title: Renoprevention: A new concept for reengineering nephrology care--an economic impact and patient outcome analysis of two hypothetical patient management paradigms in the CCU.
abstract: BACKGROUND
  The impact of acute kidney injury (AKI) on chronic kidney disease (CKD) progression remains uncertain; the common belief is that AKI in CKD is short-lived with subsequent full recovery. However 25.2% of end-stage renal disease (ESRD) Medicare patients all experienced antecedent AKI. We recently described a new syndrome of ESRD following AKI, the syndrome of rapid-onset end-stage renal disease (SORO-ESRD). Renoprevention, which we described in 2009, is the application of preventative measures to reduce AKI incidence.
  
  
  METHODS
  This is a descriptive study based on real clinical experience. Two hypothetical 69-year-old Caucasian male patients, A and B, with symptomatic coronary artery disease (CAD) presented for elective cardiac catheterization and subsequent coronary artery bypass graft procedures; renoprevention was applied in patient A but not in B.
  
  
  RESULTS
  Aggressive fluid repletion, withholding Lisinopril 40 mg once daily (QD) 1 week before hospitalization (hydralazine substituted) in A-earlier discharge after 6 days, transient minimal change in serum creatinine. Patient B continued on Lisinopril 40 mg QD, experienced prolonged hypotension needing pressors-severe oliguric AKI, volume overload, daily RRT for 6 days, recovered kidney function, was discharged after 20 days. Hospital charges were $68,580 (A) versus $154,650 (B). If patient B had developed ESRD (SORO-ESRD), the savings would be humongous.
  
  
  CONCLUSIONS
  A more forceful and pragmatic application of renoprevention strategies in the coronary care unit (CCU)-preemptive withholding of nephrotoxics including renin angiotensin aldosterone system (RAAS) blockers, aggressive prevention of perioperative hypotension, avoiding nephrotoxic exposure as contrast, and antibiotics-leads to less AKI, potentially less SORO-ESRD, better patient outcomes, and massive dollar savings. Such paradigm shifts would constitute major rethinking in current nephrology practice, a form of nephrology practice reengineering.
authors.affiliation: College of Medicine, Mayo Clinic, Rochester, MN 54702, USA. onuigbo.macaulay@mayo.edu
authors.forename: Macaulay A C
authors.initials: MA
authors.lastname: Onuigbo
mesh_terms: D058186:Acute Kidney Injury / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use; D003324:Coronary Artery Disease / Q000150:complications / Q000628:therapy; D003325:Coronary Care Units / Q000191:economics*; D003404:Creatinine / Q000097:blood; D018450:Disease Progression; D004305:Dose-Response Relationship, Drug; D005919:Glomerular Filtration Rate; D017722:Hospital Charges; D006801:Humans; D015994:Incidence; D017706:Lisinopril / Q000008:administration & dosage* / Q000627:therapeutic use; D008297:Male; D009398:Nephrology / Q000458:organization & administration*; D011379:Prognosis; D051436:Renal Insufficiency, Chronic / Q000150:complications* / Q000191:economics / Q000503:physiopathology; D012107:Research Design; D012307:Risk Factors; D014922:Wisconsin / Q000453:epidemiology
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D003404:Creatinine; D017706:Lisinopril