1. For patients with a diagnosis of Acute Kidney Injury AKI who continue to require dialysis upon hospital discharge what is the comparative effectiveness of different treatment strategies for treating clinical features of AKI. Specifically are certain strategies more likely to expedite renal recovery improve quality of life and reduce mortality For instance what are the comparative effectiveness risks and benefits of different strategies for managing fluid volume blood pressure anemia nutrition and bone mineral disease 2.Is there an optimal dialysis modality peritoneal vs. intermittent hemodialysis vs. continuous renal replacement therapy length or frequency of dialysis in this population with respect to expediting renal recovery improving quality of life and reducing mortality 3.What are early and late predictors that renal function will not recover in patients with AKI requiring dialysis and how can these be used to inform optimal timing of arteriovenous fistula and graft placement as well as kidney transplantation 4.What is the optimal frequency of laboratory monitoring and clinical assessment of patients with AKI requiring outpatient dialysis for identifying renal recovery and managing complications of acute kidney injury. How does this differ from patients with endstage renal disease ESRDRelevant patients groups include those with a diagnosis of AKI during a hospitalization who are discharged from the hospital while still requiring renal replacement therapy and who have a likelihood of renal recovery. This would include patients of all ages with a variety of comorbidities including various stages of chronic kidney disease prior to hospitalization and who are hospitalized for a variety of medical and surgical conditions. Relevant patient subgroups include1 Racial and ethnic minority populations 3 Patients of differing socioeconomic and education levels.4 Patients with terminal illness with limited life expectancy andor quality of life even if renal function recovers.5 Patients with different causes of acute kidney injury and different preAKI baseline renal function.Health related outcomes of interest includeRecovery of renal function allowing a patient to safely discontinue dialysis.Allcause mortality with subanalysis to the cause of death associated with infectious etiology respiratory gastrointestinal diseases cardiovascular disease malignancy and nephrotoxic substances drugs poisoning radiocontrast substance abuse etcPatientcentered outcomes such as quality of life patient preferences and challenges and employment.Preservation of residual renal function.Utilization of healthcare resources.

According to a recently published article about 20 of hospitalized patients develop AKI and of those 12 require dialysis. Of these individuals 1030 require dialysis after hospital discharge. 2050 of these individuals recover renal function within 90 days. Individuals are typically diagnosed with ESRD after 90 days.Cerda et al. CJASN 2015 Acute kidney injury AKI requiring dialysis therapy is increasingly common among hospitalized patients. Not infrequently patients with acute kidney injury requiring dialysis do not experience renal recovery prior to hospital discharge. When these patients are ready for hospital discharge providers must arrange for continued dialysis which can be done in one of three ways 1 The patients can remain hospitalized until renal function has recovered 2 They can receive dialysis in the hospital outpatient setting and 3 They can receive dialysis at outpatient endstage renal disease ESRD facilities. In June 2015 the U.S. Congress amended Section 1861s2F of the Social Security Act by allowing payment for Renal dialysis services furnished at outpatient dialysis facilities for persons with AKI beginning on or after January 1 2017. This makes Medicare payment consistent with many private insurers which generally reimburse for outpatient dialysis in patients with AKI in ESRD facilities.

Lack of renal function recovery after 90 days is generally accepted as meeting criteria for ESRD though some may be diagnosed with ESRD earlier based on risk factors including preexsting CKD older age and other comorbidities. Of concern is that individuals with AKI may be inappropriately perceived and managed as having ESRD which could potentially delay renal recovery. For example an approach to fluid removal consistent with ESRD management may result in episodes of hypotension due to hypovolemia and could potentially delay or prevent renal function recovery. Heung et al. CJASN 2015 As more dialysis for patients with AKI is performed in outpatient ESRD facilities due to changes in payment policies it is increasingly important to understand whether and how care for these patients should differ from care for patients with ESRD. Similar to patients with ESRD patients with AKI requiring dialysis are at a high risk for death and other health complications. However they differ from patients with ESRD because their renal function often times recovers thus they may require closer monitoring to identify improvements in renal function and to determine if and when dialysis can be discontinued. It is unknown how outpatient dialysis care for patients with AKI requiring dialysis should differ from outpatient dialysis care for patients with ESRD.

Furthermore there are no standardized predictive analytic tools based on diagnostic tests or clinical comorbidities to predict which AKI patient will recover renal function or progress to irreversible loss of renal function and require continued dialysis.

Identifying best practices for patients with AKI receiving dialysis in the outpatient setting could help these patients by reducing mortality and increasing the rate of renal recovery thereby enabling them to discontinue dialysis sooner and more often.Providing nephrologists with standardized and validated predictive modeling tools could improve the efficiency and efficacy of health care services by informing decisions about timing of arteriovenous fistula and graft placement. If patients have a high likelihood of recovering renal function these surgeries may be delayed. In contrast if patients are unlikely to recover renal function these surgeries can lead to better dialysis access thereby improving survival and reducing costs. Similarly validated predictive tools could help inform decisions about when a patient would benefit from living or deceased donor transplantation. Systematic review could identify knowledge gaps that could inform research priorities for AKI population.All information gained could help develop quality measures that are specific to this unique population.

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Dr. Indira Jevaji serves as a medical officer at the Center for Medicare and Medicaid Services Quality Improvement Group in the Division of ESRD and Population Health EPCHDr. Kevin Erikson is a practicing nephrologist who serves as a CMS consultant.

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The mission of CMS is to promote better care improve population health and lower costs through quality improvement activity and incentivizing improvement in health care and related services. Research conducted by AHRQs EHC program serves to further CMS quality improvement initiatives.

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We became aware of the AHRQ EPC program through collaborative networking between AHRQ and CMS.