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Rangaswamy D, Sud K. Acute kidney injury and disease: Long-term consequences and management. Nephrology (Carlton) 2019; 23:969-980. [PMID: 29806146 DOI: 10.1111/nep.13408] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2018] [Indexed: 01/31/2023]
Abstract
With increasing longevity and the presence of multiple comorbidities, a significant proportion of hospitalized patients, and an even larger population in the community, is at increased risk of developing an episode of acute kidney injury (AKI). Because of improvements in short-term outcomes following an episode of AKI, survivors of an episode of AKI are now predisposed to develop its long-term sequel. The identification of risk for progression to chronic kidney disease (CKD) is complicated by the absence of good biomarkers that identify this risk and the variability of risk associated with clinical factors including, but not limited to, the number of AKI episodes, severity, duration of previous AKI and pre-existing CKD that has made the prediction for long-term outcomes in survivors of AKI more difficult. Being a significant contributor to the growing incidence of CKD, there is a need to implement measures to prevent AKI in both the community and hospital settings, target interventions to treat AKI that are also associated with better long-term outcomes, accurately identify patients at risk of adverse consequences following an episode of AKI and institute therapeutic strategies to improve these long-term outcomes. We discuss the lasting renal and non-renal consequences following an episode of AKI, available biomarkers and non-invasive testing to identify ongoing intra-renal pathology and review the currently available and future treatment strategies to help reduce these adverse long-term outcomes.
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Affiliation(s)
- Dharshan Rangaswamy
- Department of Nephrology, Kasturba Medical College and Hospital, Manipal Academy of Higher Education, Karnataka, India.,Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Kamal Sud
- Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Renal Medicine, Nepean Hospital, New South Wales, Australia.,Nepean Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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52
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Jaswanth C, Priyamvada PS, Zachariah B, Haridasan S, Parameswaran S, Swaminathan RP. Short-term Changes in Urine Beta 2 Microglobulin Following Recovery of Acute Kidney Injury Resulting From Snake Envenomation. Kidney Int Rep 2019; 4:667-673. [PMID: 31080921 PMCID: PMC6506712 DOI: 10.1016/j.ekir.2019.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/15/2019] [Accepted: 01/21/2019] [Indexed: 01/19/2023] Open
Abstract
Introduction Urine β2 microglobulin (β2m) is a validated marker to diagnose sepsis and toxin-related acute kidney injury (AKI). In the current study, we used urine β2m as a potential marker to identify persistent tubular dysfunction following a clinical recovery from snake venom–related AKI. Methods A total of 42 patients who developed AKI following hemotoxic envenomation were followed up for a period of 6 months. Urine albumin excretion, estimated glomerular filtration rate (eGFR), and urine β2m levels were measured at 2 weeks, 3 months, and 6 months following discharge. Results At the end of 6 months of follow-up, 6 patients (14.3 %) progressed to chronic kidney disease (CKD) (eGFR < 60 ml and/or urine albumin excretion > 30 mg/d). The urine β2m levels were 1590 μg/l (interquartile range [IQR] 425–5260), 610 μg/l (IQR 210–1850), 850 μg/l (IQR 270–2780) at 2 weeks, 3 months, and 6 months, respectively (P = 0.020). The levels of urine β2m in the study population at the end of 6 months remained significantly higher compared with the levels in healthy control population (850 μg/l [IQR 270–2780] vs. 210 μg/l [IQR 150–480]; P = 0.001). The proportion of patients with urine β2m levels exceeding the 95th percentile of control population (>644 µg/l) during the 3 follow-up visits were 70.7% (n = 29), 48.8 % (n = 20), and 51.2% (n = 21). Similar trends were noticed in a sensitivity analysis, after excluding patients with CKD. Conclusions Urine β2m levels remain persistently elevated in approximately half of the individuals who recover from AKI due to snake envenomation.
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Affiliation(s)
- Challa Jaswanth
- Department of Nephrology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - P S Priyamvada
- Department of Nephrology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Bobby Zachariah
- Department of Biochemistry, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Sathish Haridasan
- Department of Nephrology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Sreejith Parameswaran
- Department of Nephrology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - R P Swaminathan
- Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
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53
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Fortrie G, de Geus HRH, Betjes MGH. The aftermath of acute kidney injury: a narrative review of long-term mortality and renal function. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:24. [PMID: 30678696 PMCID: PMC6346585 DOI: 10.1186/s13054-019-2314-z] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 01/07/2019] [Indexed: 12/21/2022]
Abstract
Acute kidney injury (AKI) is a frequent complication of hospitalization and is associated with an increased risk of chronic kidney disease (CKD), end-stage renal disease (ESRD), and mortality. While AKI is a known risk factor for short-term adverse outcomes, more recent data suggest that the risk of mortality and renal dysfunction extends far beyond hospital discharge. However, determining whether this risk applies to all patients who experience an episode of AKI is difficult. The magnitude of this risk seems highly dependent on the presence of comorbid conditions, including cardiovascular disease, hypertension, diabetes mellitus, preexisting CKD, and renal recovery. Furthermore, these comorbidities themselves lead to structural renal damage due to multiple pathophysiological changes, including glomeruloscleroses and tubulointerstitial fibrosis, which can lead to the loss of residual capacity, glomerular hyperfiltration, and continued deterioration of renal function. AKI seems to accelerate this deterioration and increase the risk of death, CDK, and ESRD in most vulnerable patients. Therefore, we strongly advocate adequate hemodynamic monitoring and follow-up in patients susceptible to renal dysfunction. Additionally, other potential renal stressors, including nephrotoxic medications and iodine-containing contrast fluids, should be avoided. Unfortunately, therapeutic interventions are not yet available. Additional research is warranted and should focus on the prevention of AKI, identification of therapeutic targets, and provision of adequate follow-up to those who survive an episode of AKI.
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Affiliation(s)
- Gijs Fortrie
- Department of Internal Medicine, Division of Nephrology, and Transplantation, Erasmus Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Hilde R H de Geus
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Michiel G H Betjes
- Department of Internal Medicine, Division of Nephrology, and Transplantation, Erasmus Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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54
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Abstract
Sepsis is defined as organ dysfunction resulting from the host's deleterious response to infection. One of the most common organs affected is the kidneys, resulting in sepsis associated acute kidney injury (SA-AKI) that contributes to the morbidity and mortality of sepsis. A growing body of knowledge has illuminated the clinical risk factors, pathobiology, response to treatment, and elements of renal recovery that have advanced our ability to prevent, detect, and treat SA-AKI. Despite these advances, SA-AKI remains an important concern and clinical burden, and further study is needed to reduce the acute and chronic consequences. This review summarizes the relevant evidence, with a focus on the risk factors, early recognition and diagnosis, treatment, and long term consequences of SA-AKI. In addition to literature pertaining to SA-AKI specifically, pertinent sepsis and acute kidney injury literature relevant to SA-AKI was included.
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Affiliation(s)
- Jason T Poston
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago
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55
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Hall IE, Akalin E, Bromberg JS, Doshi MD, Greene T, Harhay MN, Jia Y, Mansour SG, Mohan S, Muthukumar T, Reese PP, Schröppel B, Singh P, Thiessen-Philbrook HR, Weng FL, Parikh CR. Deceased-donor acute kidney injury is not associated with kidney allograft failure. Kidney Int 2018; 95:199-209. [PMID: 30470437 DOI: 10.1016/j.kint.2018.08.047] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/17/2018] [Accepted: 08/30/2018] [Indexed: 12/12/2022]
Abstract
Deceased-donor acute kidney injury (AKI) is associated with organ discard and delayed graft function, but data on longer-term allograft survival are limited. We performed a multicenter study to determine associations between donor AKI (from none to severe based on AKI Network stages) and all-cause graft failure, adjusting for donor, transplant, and recipient factors. We examined whether any of the following factors modified the relationship between donor AKI and graft survival: kidney donor profile index, cold ischemia time, donation after cardiac death, expanded-criteria donation, kidney machine perfusion, donor-recipient gender combinations, or delayed graft function. We also evaluated the association between donor AKI and a 3-year composite outcome of all-cause graft failure or estimated glomerular filtration rate ≤ 20 mL/min/1.73 m2 in a subcohort of 30% of recipients. Among 2,430 kidneys transplanted from 1,298 deceased donors, 585 (24%) were from donors with AKI. Over a median follow-up of 4.0 years, there were no significant differences in graft survival by donor AKI stage. We found no evidence that pre-specified variables modified the effect of donor AKI on graft survival. In the subcohort, donor AKI was not associated with the 3-year composite outcome. Donor AKI was not associated with graft failure in this well-phenotyped cohort. Given the organ shortage, the transplant community should consider measures to increase utilization of kidneys from deceased donors with AKI.
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Affiliation(s)
- Isaac E Hall
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Enver Akalin
- Division of Nephrology, Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jonathan S Bromberg
- Division of Transplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA; Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mona D Doshi
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Tom Greene
- Division of Biostatistics and Epidemiology, Department of Internal Medicine and Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Meera N Harhay
- Division of Nephrology and Hypertension, Department of Internal Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA; Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania, USA
| | - Yaqi Jia
- Division of Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sherry G Mansour
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut, USA; Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sumit Mohan
- The Columbia University Renal Epidemiology Group, New York, New York, USA; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA; Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA; Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Pooja Singh
- Division of Nephrology, Department of Medicine, Sydney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | | | - Chirag R Parikh
- Division of Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
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Sigurjonsdottir VK, Chaturvedi S, Mammen C, Sutherland SM. Pediatric acute kidney injury and the subsequent risk for chronic kidney disease: is there cause for alarm? Pediatr Nephrol 2018; 33:2047-2055. [PMID: 29374316 DOI: 10.1007/s00467-017-3870-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/03/2017] [Accepted: 12/04/2017] [Indexed: 02/02/2023]
Abstract
Acute kidney injury (AKI) is characterized clinically as an abrupt decline in renal function marked by reduced excretion of waste products, disordered electrolytes, and disrupted fluid homeostasis. The recent development of a standardized AKI definition has transformed our understanding of AKI epidemiology and outcomes. We now know that in the short term, children with AKI experience greater morbidity and mortality; additionally, observational studies have established that chronic renal sequelae are far more common after AKI events than previously realized. Many of these studies suggest that patients who develop AKI are at greater risk for the subsequent development of chronic kidney disease (CKD). The goal of this review is to critically evaluate the data regarding the association between AKI and CKD in children. Additionally, we describe best practice approaches for future studies, including the use of consensus AKI criteria, the application of rigorous definitions for CKD and renal sequelae, and the inclusion of non-AKI comparator groups. Finally, based upon existing data, we suggest an archetypal approach to follow-up care for the AKI survivors who may be at greater CKD risk, including children with more severe AKI, those who endure repeated AKI episodes, patients who do not experience full recovery, and those with pre-existing CKD.
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Affiliation(s)
- Vaka K Sigurjonsdottir
- Department of Pediatrics, Division of Nephrology, Stanford University School of Medicine, 300 Pasteur Drive, Room G-306, Stanford, CA, USA
| | | | - Cherry Mammen
- Division of Paediatric Nephrology, Department of Paediatrics, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Scott M Sutherland
- Department of Pediatrics, Division of Nephrology, Stanford University School of Medicine, 300 Pasteur Drive, Room G-306, Stanford, CA, USA.
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57
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Honarpisheh M, Foresto-Neto O, Steiger S, Kraft F, Koehler P, von Rauchhaupt E, Potempa J, Adamowicz K, Koziel J, Lech M. Aristolochic acid I determine the phenotype and activation of macrophages in acute and chronic kidney disease. Sci Rep 2018; 8:12169. [PMID: 30111809 PMCID: PMC6093867 DOI: 10.1038/s41598-018-30628-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 08/03/2018] [Indexed: 01/12/2023] Open
Abstract
Acute and chronic kidney injuries are multifactorial traits that involve various risk factors. Experimental animal models are crucial to unravel important aspects of injury and its pathophysiological mechanisms. Translating knowledge obtained from experimental approaches into clinically useful information is difficult; therefore, significant attention needs to be paid to experimental procedures that mimic human disease. Herein, we compared aristolochic acid I (AAI) acute and chronic kidney injury model with unilateral ischemic-reperfusion injury (uIRI), cisplatin (CP)- or folic acid (FA)-induced renal damage. The administration of AAI showed significant changes in serum creatinine and BUN upon CKD. The number of neutrophils and macrophages were highly increased as well as AAI-induced CKD characterized by loss of tubular epithelial cells and fibrosis. The in vitro and in vivo data indicated that macrophages play an important role in the pathogenesis of AA-induced nephropathy (AAN) associated with an excessive macrophage accumulation and an alternative activated macrophage phenotype. Taken together, we conclude that AA-induced injury represents a suitable and relatively easy model to induce acute and chronic kidney injury. Moreover, our data indicate that this model is appropriate and superior to study detailed questions associated with renal macrophage phenotypes.
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Affiliation(s)
- Mohsen Honarpisheh
- Klinikum der Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, Department of Nephrology, LMU Munich, Germany
| | - Orestes Foresto-Neto
- Klinikum der Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, Department of Nephrology, LMU Munich, Germany
| | - Stefanie Steiger
- Klinikum der Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, Department of Nephrology, LMU Munich, Germany
| | - Franziska Kraft
- Klinikum der Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, Department of Nephrology, LMU Munich, Germany
| | - Paulina Koehler
- Klinikum der Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, Department of Nephrology, LMU Munich, Germany
| | - Ekaterina von Rauchhaupt
- Klinikum der Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, Department of Nephrology, LMU Munich, Germany
| | - Jan Potempa
- Departments of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | - Karina Adamowicz
- Departments of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | - Joanna Koziel
- Departments of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | - Maciej Lech
- Klinikum der Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, Department of Nephrology, LMU Munich, Germany. .,Departments of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland.
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58
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Abou‐Arkoub R, Worrall JC, Clark EG. Emergency Department Patients With Acute Kidney Injury: Appropriately Discharged but Inadequately Followed-Up? Acad Emerg Med 2018; 25:815-818. [PMID: 29360211 DOI: 10.1111/acem.13379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Rima Abou‐Arkoub
- Division of Nephrology Department of Medicine The Ottawa Hospital and University of Ottawa Ottawa Ontario
| | - James C. Worrall
- Department of Emergency Medicine The Ottawa Hospital and University of Ottawa Ottawa Ontario
| | - Edward G. Clark
- Division of Nephrology Department of Medicine The Ottawa Hospital and University of Ottawa Ottawa Ontario
- Kidney Research Centre Ottawa Hospital Research Institute Ottawa Ontario Canada
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Silver SA, Saragosa M, Adhikari NK, Bell CM, Harel Z, Harvey A, Kitchlu A, Neyra JA, Wald R, Jeffs L. What insights do patients and caregivers have on acute kidney injury and posthospitalisation care? A single-centre qualitative study from Toronto, Canada. BMJ Open 2018; 8:e021418. [PMID: 29909373 PMCID: PMC6009618 DOI: 10.1136/bmjopen-2017-021418] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 03/23/2018] [Accepted: 05/18/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Hospitalisation with acute kidney injury (AKI) is associated with short-term and long-term adverse events, but patient and caregiver experiences with AKI are not well described. We sought to better understand patient and caregiver perspectives after a hospitalisation with AKI to inform discharge strategies that may improve outcomes for this high-risk population. DESIGN Qualitative study with semistructured interviews. SETTING Tertiary care hospital in Toronto, Ontario, Canada. PARTICIPANTS Adult patients (n=15) who survived a hospitalisation with Kidney Disease Improving Global Outcomes stage 2 or 3 AKI from May to December 2016. We also interviewed five patient caregivers. We required patients to have no previous evidence of severe chronic kidney disease (ie, prior receipt of dialysis, previous kidney transplantation or pre-existing estimated glomerular filtration rate (eGFR) under 30 mL/min/1.73 m2). RESULTS We identified three over-arching themes: (1) prioritisation of conditions other than AKI, reflected by the importance placed on other comorbidities and the omission of AKI as part of the ongoing medical history; (2) variability in comprehension of the significance of AKI, represented by minimal knowledge of the causes and symptoms associated with AKI, along with misinformation on the kidneys' ability to self-repair; and (3) anxiety from discharge planning and competing health demands, illustrated by complicated discharge plans involving multiple specialist appointments. CONCLUSIONS Patients and caregivers view AKI as a short-term and reversible condition, giving it little thought during the postdischarge period. As a result, reliance on patients and caregivers to report an episode of AKI to their outpatient physicians is unlikely to be successful. Patient-centred tools and decision aids are needed to bridge the gap between a hospitalisation with AKI and the safe transition to the outpatient setting.
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Affiliation(s)
- Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, Ontario, Canada
| | - Marianne Saragosa
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Neill K Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chaim M Bell
- Department of Medicine, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Ziv Harel
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Harvey
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Abhijat Kitchlu
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Javier A Neyra
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Ron Wald
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Lianne Jeffs
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
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60
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Liu L, Wu X, Xu H, Yu L, Zhang X, Li L, Jin J, Zhang T, Xu Y. Myocardin-related transcription factor A (MRTF-A) contributes to acute kidney injury by regulating macrophage ROS production. Biochim Biophys Acta Mol Basis Dis 2018; 1864:3109-3121. [PMID: 29908908 DOI: 10.1016/j.bbadis.2018.05.026] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 05/11/2018] [Accepted: 05/31/2018] [Indexed: 11/17/2022]
Abstract
A host of pathogenic factors induce acute kidney injury (AKI) leading to insufficiencies of renal function. In the present study we evaluated the role of myocardin-related transcription factor A (MRTF-A) in the pathogenesis of AKI. We report that systemic deletion of MRTF-A or inhibition of MRTF-A activity with CCG-1423 significantly attenuated AKI in mice induced by either ischemia-reperfusion or LPS injection. Of note, MRTF-A deficiency or suppression resulted in diminished renal ROS production in AKI models with down-regulation of NAPDH oxdiase 1 (NOX1) and NOX4 expression. In cultured macrophages, MRTF-A promoted NOX1 transcription in response to either hypoxia-reoxygenation or LPS treatment. Interestingly, macrophage-specific MRTF-A deletion ameliorated AKI in mice. Mechanistic analyses revealed that MRTF-A played a role in regulating histone H4K16 acetylation surrounding the NOX gene promoters by interacting with the acetyltransferase MYST1. MYST1 depletion repressed NOX transcription in macrophages. Finally, administration of a MYST1 inhibitor MG149 alleviated AKI in mice. Therefore, we data illustrate a novel epigenetic pathway that controls ROS production in macrophages contributing to AKI. Targeting the MRTF-A-MYST1-NOX axis may yield novel therapeutic strategies to combat AKI.
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Affiliation(s)
- Li Liu
- Key Laboratory of Targeted Intervention of Cardiovascular Disease and Collaborative Innovation Center for Cardiovascular Translational Medicine, Department of Pathophysiology, Nanjing Medical University, Nanjing, China
| | - Xiaoyan Wu
- Key Laboratory of Targeted Intervention of Cardiovascular Disease and Collaborative Innovation Center for Cardiovascular Translational Medicine, Department of Pathophysiology, Nanjing Medical University, Nanjing, China
| | - Huihui Xu
- Key Laboratory of Targeted Intervention of Cardiovascular Disease and Collaborative Innovation Center for Cardiovascular Translational Medicine, Department of Pathophysiology, Nanjing Medical University, Nanjing, China
| | - Liming Yu
- Key Laboratory of Targeted Intervention of Cardiovascular Disease and Collaborative Innovation Center for Cardiovascular Translational Medicine, Department of Pathophysiology, Nanjing Medical University, Nanjing, China
| | - Xinjian Zhang
- Key Laboratory of Targeted Intervention of Cardiovascular Disease and Collaborative Innovation Center for Cardiovascular Translational Medicine, Department of Pathophysiology, Nanjing Medical University, Nanjing, China
| | - Luyang Li
- Key Laboratory of Targeted Intervention of Cardiovascular Disease and Collaborative Innovation Center for Cardiovascular Translational Medicine, Department of Pathophysiology, Nanjing Medical University, Nanjing, China
| | - Jianliang Jin
- Department of Anatomy and Histology, Nanjing Medical University, Nanjing, China
| | - Tao Zhang
- Key Laboratory of Targeted Intervention of Cardiovascular Disease and Collaborative Innovation Center for Cardiovascular Translational Medicine, Department of Pathophysiology, Nanjing Medical University, Nanjing, China; Department of Renal Medicine, Jiangsu Remin Hospital affiliated to Nanjing Medical University, Nanjing, China.
| | - Yong Xu
- Key Laboratory of Targeted Intervention of Cardiovascular Disease and Collaborative Innovation Center for Cardiovascular Translational Medicine, Department of Pathophysiology, Nanjing Medical University, Nanjing, China.
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61
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Lim SY, Ko YS, Lee HY, Yang JH, Kim MG, Jo SK, Cho WY. The Impact of Preexisting Chronic Kidney Disease on the Severity and Recovery of Acute Kidney Injury. Nephron Clin Pract 2018; 139:254-268. [PMID: 29649832 DOI: 10.1159/000487492] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 02/07/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Recent observational studies have shown that in chronic kidney disease (CKD) patients, a significantly smaller percentage of patients with an episode of acute kidney injury (AKI) have full recovery of renal function compared to those without CKD. However, precise mechanisms involved in the incomplete repair after AKI with preexisting CKD have not been completely ascertained. Here, we assessed the impact of preexisting CKD on the severity and recovery of AKI in a mouse model of 5/6 nephrectomy. METHODS Male CD-1 mice underwent 5/6 nephrectomy (Nx). Six weeks post surgery, ischemia reperfusion injury (IRI) or a sham operation was performed and functional, histological, and various molecular parameters were compared between them. RESULTS Serum creatinine level on day 1 after IRI was comparable between control and Nx mice. However, serum creatinine remained significantly higher throughout the recovery phase in Nx mice compared to control mice. mRNA and protein expression of the cell cycle regulatory proteins were persistently elevated in Nx mice and this was associated with significantly increased levels of the G1 cell cycle arrest markers. Treatment with a p53 inhibitor following IRI resulted in not only decreased expression of G1 arrest markers but also decreased fibrosis, suggesting that prolonged epithelial G1 cell cycle arrest might be partially responsible for impaired recovery from superimposed AKI on CKD. CONCLUSION Taken together, reduced nephron mass have a negative effect on the repair process that is partially mediated by the disruption of the cell cycle regulation.
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62
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Saxena A, Meshram SV. Predictors of Mortality in Acute Kidney Injury Patients Admitted to Medicine Intensive Care Unit in a Rural Tertiary Care Hospital. Indian J Crit Care Med 2018; 22:231-237. [PMID: 29743761 PMCID: PMC5930526 DOI: 10.4103/ijccm.ijccm_462_17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Acute kidney injury (AKI) is a challenging problem faced by intensive care clinicians worldwide, and it is associated with high morbidity and mortality, especially in critically ill patients. Materials and Methods: A hospital-based prospective, observational study was conducted in patients of AKI admitted to the Intensive Care Unit (ICU) of the Department of Medicine in a rural tertiary care hospital located in central India. Data of all consecutive AKI inpatients related to demographic variables, clinical profile, and laboratory investigations were collected from patient's medical records. Results: Of the total 229 AKI patients enrolled in this study, 65 (28.4%) patients died during their hospital stay. The presence of metabolic acidosis, hypotension, Glasgow coma scale (GCS) and Acute Physiologic Assesment and Chronic Health Evaluation (APACHE 2) score, advanced AKI stage, higher serum creatinine and blood urea levels on diagnosis of AKI and the peak rise in their level within 48 h of diagnosis of AKI, the use of mechanical ventilator, leukocytosis, and hyperkalemia were significantly associated with in-hospital mortality in AKI patients (P < 0.05). Conclusion: The overall in-hospital mortality in patients of AKI admitted to medicine-ICU was 28.4%. Sepsis was the most common cause of AKI (24.5%). The presence of metabolic acidosis, hypotension, GCS and APACHE 2 score, advanced AKI stage, higher serum creatinine, and blood urea levels on diagnosis of AKI and the peak rise in their level within 48 h of diagnosis of AKI, use of mechanical ventilator, leukocytosis, and hyperkalemia were associated with in-hospital mortality in AKI patients.
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Affiliation(s)
- Amrish Saxena
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Shrikant V Meshram
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
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63
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Patel SS, Palant CE, Mahajan V, Chawla LS. Sequelae of AKI. Best Pract Res Clin Anaesthesiol 2017; 31:415-425. [PMID: 29248147 DOI: 10.1016/j.bpa.2017.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 08/17/2017] [Indexed: 12/28/2022]
Abstract
Large epidemiologic studies in a variety of patient populations reveal increased morbidity and mortality that occur months to years after an episode of acute kidney injury (AKI). Even milder forms of AKI have increased associated morbidity and mortality. Residual confounding may account for these findings, but considering the huge number of individuals afflicted with AKI, the sequelae of AKI may be a very large public health burden. AKI may simply be a marker for increased risk, but there is increasing evidence that it is part of the causal pathway to chronic kidney disease. These studies have upended the traditional view that AKI survivors who returned to baseline, or near baseline renal function, do not suffer additional long-term consequences. Recovery of renal function after AKI, short of independence from renal replacement therapy, is yet to be clearly defined but may be of significant importance in the management of AKI survivors. The association between AKI in patients who undergo cardiac surgery and clinical outcomes is of considerable importance to clinicians, surgeons, and anesthesiologists alike and is a major focus of this review.
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Affiliation(s)
- Samir S Patel
- The Veterans Affairs Medical Center, Washington, DC, USA; George Washington University Medical Center, Washington, DC, USA
| | - Carlos E Palant
- The Veterans Affairs Medical Center, Washington, DC, USA; George Washington University Medical Center, Washington, DC, USA
| | - Vrinda Mahajan
- Georgetown University Medical Center, Washington, DC, USA
| | - Lakhmir S Chawla
- The Veterans Affairs Medical Center, Washington, DC, USA; George Washington University Medical Center, Washington, DC, USA
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64
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Acute Kidney Injury in Burn Patients: Clinically Significant Over the Initial Hospitalization and 1 Year After Injury: An Original Retrospective Cohort Study. Ann Surg 2017; 266:376-382. [PMID: 27611620 DOI: 10.1097/sla.0000000000001979] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To examine the development of acute kidney injury (AKI) after burn injury as an independent risk factor for increased morbidity and mortality over initial hospitalization and 1-year follow-up. BACKGROUND Variability in fluid resuscitation and difficulty recognizing early sepsis are major barriers to preventing AKI after burn injury. Expanding our understanding of the burden AKI has on the clinical course of burn patients would highlight the need for standardized protocols. METHODS We queried the Healthcare Cost and Utilization Project State Inpatient Databases in the states of Florida and New York during the years 2009 to 2013 for patients over age 18 hospitalized with a primary diagnosis of burn injury using ICD-9 codes. We identified and grouped 18,155 patients, including 1476 with burns >20% total body surface area, by presence of AKI. Outcomes were compared in these cohorts via univariate analysis and multivariate logistic regression models. RESULTS During initial hospitalization, AKI was associated with increased pulmonary failure, mechanical ventilation, pneumonia, myocardial infarction, length of stay, cost, and mortality, and also a lower likelihood of being discharged home. One year after injury, AKI was associated with development of chronic kidney disease, conversion to chronic dialysis, hospital readmission, and long-term mortality. CONCLUSIONS AKI is associated with a profound and severe increase in morbidity and mortality in burn patients during initial hospitalization and up to 1 year after injury. Consensus protocols for initial burn resuscitation and early sepsis recognition and treatment are crucial to avoid the consequences of AKI after burn injury.
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Parikh CR, Puthumana J, Shlipak MG, Koyner JL, Thiessen-Philbrook H, McArthur E, Kerr K, Kavsak P, Whitlock RP, Garg AX, Coca SG. Relationship of Kidney Injury Biomarkers with Long-Term Cardiovascular Outcomes after Cardiac Surgery. J Am Soc Nephrol 2017; 28:3699-3707. [PMID: 28808078 DOI: 10.1681/asn.2017010055] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 07/05/2017] [Indexed: 01/08/2023] Open
Abstract
Clinical AKI, measured by serum creatinine elevation, is associated with long-term risks of adverse cardiovascular (CV) events and mortality in patients after cardiac surgery. To evaluate the relative contributions of urine kidney injury biomarkers and plasma cardiac injury biomarkers in adverse events, we conducted a multicenter prospective cohort study of 968 adults undergoing cardiac surgery. On postoperative days 1-3, we measured five urine biomarkers of kidney injury (IL-18, NGAL, KIM-1, L-FABP, and albumin) and five plasma biomarkers of cardiac injury (NT-proBNP, H-FABP, hs-cTnT, cTnI, and CK-MB). The primary outcome was a composite of long-term CV events or death, which was assessed via national health care databases. During a median 3.8 years of follow-up, 219 (22.6%) patients experienced the primary outcome (136 CV events and 83 additional deaths). Compared with patients without postsurgical AKI, patients who experienced AKI Network stage 2 or 3 had an adjusted hazard ratio for the primary composite outcome of 3.52 (95% confidence interval, 2.17 to 5.71). However, none of the five urinary kidney injury biomarkers were significantly associated with the primary outcome. In contrast, four out of five postoperative cardiac injury biomarkers (NT-proBNP, H-FABP, hs-cTnT, and cTnI) strongly associated with the primary outcome. Mediation analyses demonstrated that cardiac biomarkers explained 49% (95% confidence interval, 1% to 97%) of the association between AKI and the primary outcome. These results suggest that clinical AKI at the time of cardiac surgery is indicative of concurrent CV stress rather than an independent renal pathway for long-term adverse CV outcomes.
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Affiliation(s)
- Chirag R Parikh
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut; .,Department of Internal Medicine, Veterans Affairs Medical Center, West Haven, Connecticut
| | - Jeremy Puthumana
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Michael G Shlipak
- Division of General Internal Medicine, San Francisco Veteran Affairs Medical Center, San Francisco, California
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Pritzker School of Medicine, Chicago, Illinois
| | - Heather Thiessen-Philbrook
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Kathleen Kerr
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Peter Kavsak
- Departments of Pathology and Molecular Medicine and
| | | | - Amit X Garg
- Division of Nephrology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Institute for Clinical Evaluative Services, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Steven G Coca
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Sawhney S, Marks A, Fluck N, Levin A, McLernon D, Prescott G, Black C. Post-discharge kidney function is associated with subsequent ten-year renal progression risk among survivors of acute kidney injury. Kidney Int 2017; 92:440-452. [PMID: 28416224 PMCID: PMC5524434 DOI: 10.1016/j.kint.2017.02.019] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/01/2017] [Accepted: 02/16/2017] [Indexed: 11/29/2022]
Abstract
The extent to which renal progression after acute kidney injury (AKI) arises from an initial step drop in kidney function (incomplete recovery), or from a long-term trajectory of subsequent decline, is unclear. This makes it challenging to plan or time post-discharge follow-up. This study of 14651 hospital survivors in 2003 (1966 with AKI, 12685 no AKI) separates incomplete recovery from subsequent renal decline by using the post-discharge estimated glomerular filtration rate (eGFR) rather than the pre-admission as a new reference point for determining subsequent renal outcomes. Outcomes were sustained 30% renal decline and de novo CKD stage 4, followed from 2003-2013. Death was a competing risk. Overall, death was more common than subsequent renal decline (37.5% vs 11.3%) and CKD stage 4 (4.5%). Overall, 25.7% of AKI patients had non-recovery. Subsequent renal decline was greater after AKI (vs no AKI) (14.8% vs 10.8%). Renal decline after AKI (vs no AKI) was greatest among those with higher post-discharge eGFRs with multivariable hazard ratios of 2.29 (1.88-2.78); 1.50 (1.13-2.00); 0.94 (0.68-1.32) and 0.95 (0.64-1.41) at eGFRs of 60 or more; 45-59; 30-44 and under 30, respectively. The excess risk after AKI persisted over ten years of study, irrespective of AKI severity, or post-episode proteinuria. Thus, even if post-discharge kidney function returns to normal, hospital admission with AKI is associated with increased renal progression that persists for up to ten years. Follow-up plans should avoid false reassurance when eGFR after AKI returns to normal.
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Affiliation(s)
- Simon Sawhney
- University of Aberdeen, Aberdeen, UK; NHS Grampian, Aberdeen, UK.
| | - Angharad Marks
- University of Aberdeen, Aberdeen, UK; NHS Grampian, Aberdeen, UK
| | | | - Adeera Levin
- University of British Columbia, British Columbia, Canada
| | | | | | - Corri Black
- University of Aberdeen, Aberdeen, UK; NHS Grampian, Aberdeen, UK
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Liu Y, Ma X, Zheng J, Liu X, Yan T. Pregnancy outcomes in patients with acute kidney injury during pregnancy: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2017; 17:235. [PMID: 28720086 PMCID: PMC5516395 DOI: 10.1186/s12884-017-1402-9] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 07/03/2017] [Indexed: 11/29/2022] Open
Abstract
Background Presently, the matter of pregnancy outcomes of patients with pregnancy related AKI (PR-AKI) were disputed. Thus, we conducted a meta-analysis to evaluate the impact of PR-AKI on pregnancy outcomes. Method We systematically searched MEDLINE, Embase, VIP, CNKI and Wanfang Databases for cohort or case-control studies in women with PR-AKI and those without AKI as a control group to assess the influence of PR-AKI on pregnancy outcomes and kidney outcome. Reduction of odd ratio (OR) was calculated by a random-effects model. Results One thousand one hundred fifty two articles were systematically reviewed, of those 11 studies were included, providing data of 845 pregnancies in 834 women with PR-AKI and 5387 pregnancies in 5334 women without AKI. In terms of maternal outcomes, women with PR-AKI had a greater likelihood of cesarean delivery (OR, 1.49; 95% confidence interval [CI], 1.37 to 1.61), hemorrhage (1.26; 1.02 to 1.56), HELLP syndrome (1.86; 1.41 to 2.46), placental abruption (3.13; 1.96 to 5.02), DIC (3.41; 2.00 to 5.84), maternal death (4.50; 2.73 to 7.43), but had a lower risk of eclampsia (0.53; 0.34 to 0.83). Women with PR-AKI also had a longer stay in ICU (weighted mean difference, 2.13 day [95% CI 1.43 to 2.83 day]) compared with those without PR-AKI. As for fetal outcomes, higher incidence of stillbirth/perinatal death (3.39, 2.76 to 4.18), lower mean gestational age at delivery (−0.70 week [95% CI -1.21 to −0.19 week]) and lower birth weight (−740 g [95% CI -1180 to 310 g]) were observed in women with PR-AKI. The occurrence of kidney outcome, defined as ESRD requiring dialysis, in women with PR-AKI was 2.4% (95% CI 1.3% to 4.2%). Conclusions PR-AKI remains a grave complication and has been associated with increased maternal and fetal mortality. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1402-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Youxia Liu
- Department of Nephrology, General Hospital of Tianjin Medical University, NO. 154, Anshan road, Heping District, Tianjin, China
| | - Xinxin Ma
- Division of Nephrology, Department of Medicine, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jie Zheng
- Radiology Department, General Hospital of Tianjin Medical University, Tianjin, China
| | - Xiangchun Liu
- Department of Nephrology, The Second Hospital of Shandong University, Shandong University, Jinan, China
| | - Tiekun Yan
- Department of Nephrology, General Hospital of Tianjin Medical University, NO. 154, Anshan road, Heping District, Tianjin, China.
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68
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Nie S, Tang L, Zhang W, Feng Z, Chen X. Are There Modifiable Risk Factors to Improve AKI? BIOMED RESEARCH INTERNATIONAL 2017; 2017:5605634. [PMID: 28744467 PMCID: PMC5514336 DOI: 10.1155/2017/5605634] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 04/26/2017] [Accepted: 05/23/2017] [Indexed: 02/07/2023]
Abstract
Acute kidney injury (AKI) is a common critical syndrome, with high morbidity and mortality. Patients with AKI typically have an adverse prognosis, from incident chronic kidney disease (CKD), progression to end-stage renal disease (ESRD), subsequent cardiovascular disease, and ultimately death. However, there is currently no effective therapy for AKI. Early detection of risk factors for AKI may offer a good approach to prevention or early intervention. Traditional risk factors include extreme age, many common comorbid diseases, such as preexisting CKD, some specific exposures, such as sepsis, and exposure to some nephrotoxic agents. Recently, several novel risk factors for AKI, such as hyperuricemia, hypoalbuminemia, obesity, anemia, and hyperglycemia, have been identified. The underlying mechanisms between these nontraditional risk factors and AKI and whether their correction can reduce AKI occurrence remain to be clarified. This review describes the current epidemiology of AKI, summarizes its outcome, outlines the traditional risk profile, and finally highlights some recently identified novel risk factors.
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Affiliation(s)
- Sasa Nie
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing 100853, China
| | - Li Tang
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing 100853, China
| | - Weiguang Zhang
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing 100853, China
| | - Zhe Feng
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing 100853, China
| | - Xiangmei Chen
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing 100853, China
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69
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Abstract
Large observational databases linking kidney function and other routine patient health data are increasingly being used to study acute kidney injury (AKI). Routine health care data show an apparent rise in the incidence of population AKI and an increase in acute dialysis. Studies also report an excess in mortality and adverse renal outcomes after AKI, although with variation depending on AKI severity, baseline, definition of renal recovery, and the time point during follow-up. However, differences in data capture, AKI awareness, monitoring, recognition, and clinical practice make comparisons between health care settings and periods difficult. In this review, we describe the growing role of large databases in determining the incidence and prognosis of AKI and evaluating initiatives to improve the quality of care in AKI. Using examples, we illustrate this use of routinely collected health data and discuss the strengths, limitations, and implications for researchers and clinicians.
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70
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Silver SA, Adu D, Agarwal S, Gupta K, Lewington AJ, Pannu N, Bagga A, Chakravarthi R, Mehta RL. Strategies to Enhance Rehabilitation After Acute Kidney Injury in the Developing World. Kidney Int Rep 2017. [PMCID: PMC5678669 DOI: 10.1016/j.ekir.2017.04.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Acute kidney injury (AKI) is independently associated with new-onset chronic kidney disease (CKD), end-stage kidney disease, cardiovascular disease, and all-cause mortality. However, only a minority of patients receive follow-up care after an episode of AKI in the developing world, and the optimal strategies to promote rehabilitation after AKI are ill-defined. On this background, a working group of the 18th Acute Dialysis Quality Initiative applied the consensus-building process informed by a PubMed review of English-language articles to address questions related to rehabilitation after AKI. The consensus statements propose that all patients should be offered follow-up within 3 months of an AKI episode, with more intense follow-up (e.g., <1 month) considered based on patient risk factors, characteristics of the AKI event, and the degree of kidney recovery. Patients should be monitored for renal and nonrenal events post-AKI, and we suggest that the minimum level of monitoring consist of an assessment of kidney function and proteinuria within 3 months of the AKI episode. Care should be individualized for higher risk patients, particularly patients who are still dialysis dependent, to promote renal recovery. Although evidence-based treatments for survivors of AKI are lacking and some outcomes may not be modifiable, we recommend simple interventions such as lifestyle changes, medication reconciliation, blood pressure control, and education, including the documentation of AKI in the patient’s medical record. In conclusion, survivors of AKI represent a high-risk population, and these consensus statements should provide clinicians with guidance on the care of patients after an episode of AKI.
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71
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Abstract
Acute kidney injury (AKI) is an increasingly common condition that is associated with long-term health outcomes. Recent studies have demonstrated that AKI, particularly when severe or persistent, is associated with all-cause mortality, CKD, ESRD, cardiovascular events, and reduced quality of life. However, data from multiple health care systems indicate that most patients do not see a nephrologist, although 1 study has suggested patients with AKI requiring dialysis may benefit from doing so. These observations raise the greater questions of what are the elements of care that may improve outcomes in survivors of AKI and which survivors need to be seen. Potential opportunities to improve care include appropriate risk stratification, closer monitoring of kidney function, management of CKD complications, blood pressure control, medication reconciliation, and education. Nephrologists are in an ideal position to lead and advocate for outpatient care pathways for survivors of AKI. In this article, we review the evidence supporting patient follow-up after AKI, describe the current state of follow-up care, and examine strategies to improve long-term outcomes for this high-risk population.
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72
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Martin-Sanchez D, Poveda J, Fontecha-Barriuso M, Ruiz-Andres O, Sanchez-Niño MD, Ruiz-Ortega M, Ortiz A, Sanz AB. Targeting of regulated necrosis in kidney disease. Nefrologia 2017. [PMID: 28647049 DOI: 10.1016/j.nefro.2017.04.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The term acute tubular necrosis was thought to represent a misnomer derived from morphological studies of human necropsies and necrosis was thought to represent an unregulated passive form of cell death which was not amenable to therapeutic manipulation. Recent advances have improved our understanding of cell death in acute kidney injury. First, apoptosis results in cell loss, but does not trigger an inflammatory response. However, clumsy attempts at interfering with apoptosis (e.g. certain caspase inhibitors) may trigger necrosis and, thus, inflammation-mediated kidney injury. Second, and most revolutionary, the concept of regulated necrosis emerged. Several modalities of regulated necrosis were described, such as necroptosis, ferroptosis, pyroptosis and mitochondria permeability transition regulated necrosis. Similar to apoptosis, regulated necrosis is modulated by specific molecules that behave as therapeutic targets. Contrary to apoptosis, regulated necrosis may be extremely pro-inflammatory and, importantly for kidney transplantation, immunogenic. Furthermore, regulated necrosis may trigger synchronized necrosis, in which all cells within a given tubule die in a synchronized manner. We now review the different modalities of regulated necrosis, the evidence for a role in diverse forms of kidney injury and the new opportunities for therapeutic intervention.
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Affiliation(s)
- Diego Martin-Sanchez
- Research Institute-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain; IRSIN, Madrid, Spain; REDINREN, Madrid, Spain
| | - Jonay Poveda
- Research Institute-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain; IRSIN, Madrid, Spain; REDINREN, Madrid, Spain
| | - Miguel Fontecha-Barriuso
- Research Institute-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain; IRSIN, Madrid, Spain; REDINREN, Madrid, Spain
| | - Olga Ruiz-Andres
- Research Institute-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain; IRSIN, Madrid, Spain; REDINREN, Madrid, Spain
| | - María Dolores Sanchez-Niño
- Research Institute-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain; IRSIN, Madrid, Spain; REDINREN, Madrid, Spain
| | - Marta Ruiz-Ortega
- Research Institute-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain; IRSIN, Madrid, Spain; REDINREN, Madrid, Spain
| | - Alberto Ortiz
- Research Institute-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain; IRSIN, Madrid, Spain; REDINREN, Madrid, Spain
| | - Ana Belén Sanz
- Research Institute-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain; IRSIN, Madrid, Spain; REDINREN, Madrid, Spain.
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Reducing the costs of chronic kidney disease while delivering quality health care: a call to action. Nat Rev Nephrol 2017; 13:393-409. [PMID: 28555652 DOI: 10.1038/nrneph.2017.63] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The treatment of chronic kidney disease (CKD) and of end-stage renal disease (ESRD) imposes substantial societal costs. Expenditure is highest for renal replacement therapy (RRT), especially in-hospital haemodialysis. Redirection towards less expensive forms of RRT (peritoneal dialysis, home haemodialysis) or kidney transplantation should decrease financial pressure. However, costs for CKD are not limited to RRT, but also include nonrenal health-care costs, costs not related to health care, and costs for patients with CKD who are not yet receiving RRT. Even if patients with CKD or ESRD could be given the least expensive therapies, costs would decrease only marginally. We therefore propose a consistent and sustainable approach focusing on prevention. Before a preventive strategy is favoured, however, authorities should carefully analyse the cost to benefit ratio of each strategy. Primary prevention of CKD is more important than secondary prevention, as many other related chronic diseases, such as diabetes mellitus, hypertension, cardiovascular disease, liver disease, cancer, and pulmonary disorders could also be prevented. Primary prevention largely consists of lifestyle changes that will reduce global societal costs and, more importantly, result in a healthy, active, and long-lived population. Nephrologists need to collaborate closely with other sectors and governments, to reach these aims.
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74
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Wyatt CM, Camargo M, Coca SG. Prophylactic hydration to prevent contrast-induced nephropathy: much ado about nothing? Kidney Int 2017; 92:4-6. [PMID: 28528129 DOI: 10.1016/j.kint.2017.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 04/13/2017] [Indexed: 10/19/2022]
Abstract
Clinical guidelines recommend prophylactic hydration to reduce the risk of contrast-induced nephropathy in high-risk patients, including those with chronic kidney disease. A recent single-center randomized trial showed no significant difference in the incidence of contrast-induced nephropathy in ambulatory patients with stage 3 chronic kidney disease who were randomized to no prophylactic hydration versus normal saline hydration. While these results may identify patients who are less likely to benefit from prophylactic hydration, nephrologists and interventionalists should carefully consider the generalizability of these results to individual patients.
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Affiliation(s)
- Christina M Wyatt
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Marianne Camargo
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Steven G Coca
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, USA
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Abstract
Patients with chronic kidney disease (CKD) are at risk for complications both inherent to the disease and as a consequence of its treatment. The dangers that CKD patients face change across the spectrum of the disease. Providers who are well-versed in these safety threats are best poised to safeguard patients as their CKD progresses.
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Affiliation(s)
- Lee-Ann Wagner
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Jeffrey C Fink
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD.
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Chavez-Iñiguez JS, Garcia-Garcia G, Briseño-Ramirez J, Medina-Gonzalez R, Jimenez-Cornejo M. The effect of resolution time of acute kidney injury on clinical outcomes. Indian J Nephrol 2017; 27:99-103. [PMID: 28356659 PMCID: PMC5358167 DOI: 10.4103/0971-4065.200514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute kidney injury (AKI) is a frequent and complex disease. It is not clearly defined whether its duration is related to adverse outcomes. We determined the effect of AKI resolution time on patient's clinical outcomes. A prospective cohort of hospitalized patients with AKI by AKI network (AKIN) creatinine criteria was included. Variables for prognosis and follow-up were analyzed. One hundred and thirteen patients were included in the study. Seventy-seven (68.1%) were males, mean age 55 years (range, 16-76 years), and 48 (42.5%) were diabetic. The most common cause of AKI was sepsis (31%). AKI resolution time ≤2 days and >2 days was seen in 47 (41.6%) and 66 (58.4%) of the cases, respectively. AKI resolution time >2 days was common in older patients (66.24 ± 17.6 year vs. 47.16 ± 12.32 year, P = 0.004), with the use of mechanical ventilation (27% vs. 4%, P = 0.02) and vasopressors (41% vs. 11%, P ≤ 0.01); it was associated with increased mortality (47% vs. 4%, P ≤ 0.01), and a discharge estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 (52% vs. 2%, P = 0.01), than in patients with resolution time ≤2 days. Survival rate was significantly worse in patients with a resolution time >2 days. By multivariate logistic step-wise regression analysis, AKI >2days, vasopressor use, and AKIN stage 2-3 were independently associated with higher mortality. AKI >2 days and vasopressor utilization were independently associated to an eGFR <60 ml/min/1.73 m2 at the time of discharge. We conclude that AKI resolution time >2 days is linked to adverse clinical outcomes.
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Affiliation(s)
- J S Chavez-Iñiguez
- University of Guadalajara Health Sciences Center, Hospital Civil de Guadalajara "Fray Antonio Alcalde," Guadalajara, Jalisco, Mexico
| | - G Garcia-Garcia
- University of Guadalajara Health Sciences Center, Hospital Civil de Guadalajara "Fray Antonio Alcalde," Guadalajara, Jalisco, Mexico
| | - J Briseño-Ramirez
- Nephrology and Internal Medicine Services, Hospital Civil de Guadalajara "Fray Antonio Alcalde," Guadalajara, Jalisco, Mexico
| | - R Medina-Gonzalez
- University of Guadalajara Health Sciences Center, Hospital Civil de Guadalajara "Fray Antonio Alcalde," Guadalajara, Jalisco, Mexico
| | - M Jimenez-Cornejo
- University of Guadalajara Health Sciences Center, Hospital Civil de Guadalajara "Fray Antonio Alcalde," Guadalajara, Jalisco, Mexico
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77
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Ahmed LI, Mansour HH, Hussen A, Zaki MS, Mohammed RR, Goda AT. Clinical evaluation of acute kidney injury in Al-Zahraa University Hospital, Cairo, Egypt. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2017. [DOI: 10.4103/ejim.ejim_3_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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78
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Pickkers P, Ostermann M, Joannidis M, Zarbock A, Hoste E, Bellomo R, Prowle J, Darmon M, Bonventre JV, Forni L, Bagshaw SM, Schetz M. The intensive care medicine agenda on acute kidney injury. Intensive Care Med 2017; 43:1198-1209. [PMID: 28138736 DOI: 10.1007/s00134-017-4687-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 01/16/2017] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) is a common complication in the critically ill. Current standard of care mainly relies on identification of patients at risk, haemodynamic optimization, avoidance of nephrotoxicity and the use of renal replacement therapy (RRT) in established AKI. The detection of early biomarkers of renal tissue damage is a recent development that allows amending the late and insensitive diagnosis with current AKI criteria. Increasing evidence suggests that the consequences of an episode of AKI extend long beyond the acute hospitalization. Citrate has been established as the anticoagulant of choice for continuous RRT. Conflicting results have been published on the optimal timing of RRT and on the renoprotective effect of remote ischaemic preconditioning. Recent research has contradicted that acute tubular necrosis is the common pathology in AKI, that septic AKI is due to global kidney hypoperfusion, that aggressive fluid therapy benefits the kidney, that vasopressor therapy harms the kidney and that high doses of RRT improve outcome. Remaining uncertainties include the impact of aetiology and clinical context on pathophysiology, therapy and prognosis, the clinical benefit of biomarker-driven interventions, the optimal mode of RRT to improve short- and long-term patient and kidney outcomes, the contribution of AKI to failure of other organs and the optimal approach for assessing and promoting renal recovery. Based on the established gaps in current knowledge the trials that must have priority in the coming 10 years are proposed together with the definition of appropriate clinical endpoints.
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Affiliation(s)
- Peter Pickkers
- Department of Intensive Care Medicine (710), Radboud University Medical Centre, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marlies Ostermann
- Department of Critical Care, Guy's and St Thomas' Hospital, King's College London, London, SE1 9RT, UK
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alexander Zarbock
- Department of Anesthesiology, Critical Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer Campus 1, Building A1, 48149, Münster, Germany
| | - Eric Hoste
- Department of Intensive Care Medicine, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.,Research Foundation-Flanders, Brussels, Belgium
| | - Rinaldo Bellomo
- School of Medicine, The University of Melbourne, Melbourne, VIC, Australia.,Department of Intensive Care, Austin Hospital Heidelberg, Melbourne, VIC, 3084, Australia
| | - John Prowle
- William Harvey Research Institute, Queen Mary University of London, London, UK.,Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Michael Darmon
- Medical-Surgical ICU, Saint-Etienne University Hospital and Jacques Lisfranc Medical School, Saint-Etienne, 42000, France
| | - Joseph V Bonventre
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Lui Forni
- Surrey Perioperative Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey County Hospital, NHS Foundation Trust and School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, UK.,Intensive Care Unit, Royal Surrey County Hospital, NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX, UK
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Sciences Building, 8440-112 ST NW, Edmonton, AB, T6G2B7, Canada
| | - Miet Schetz
- Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven University, Herestraat 49, B3000, Louvain, Belgium.
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79
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Meersch M, Schmidt C, Hoffmeier A, Van Aken H, Wempe C, Gerss J, Zarbock A. Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial. Intensive Care Med 2017; 43:1551-1561. [PMID: 28110412 PMCID: PMC5633630 DOI: 10.1007/s00134-016-4670-3] [Citation(s) in RCA: 560] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 12/28/2016] [Indexed: 12/13/2022]
Abstract
Purpose Care bundles are recommended in patients at high risk for acute kidney injury (AKI), although they have not been proven to improve outcomes. We sought to establish the efficacy of an implementation of the Kidney Disease Improving Global Outcomes (KDIGO) guidelines to prevent cardiac surgery-associated AKI in high risk patients defined by renal biomarkers. Methods In this single-center trial, we examined the effect of a “KDIGO bundle” consisting of optimization of volume status and hemodynamics, avoidance of nephrotoxic drugs, and preventing hyperglycemia in high risk patients defined as urinary [TIMP-2]·[IGFBP7] > 0.3 undergoing cardiac surgery. The primary endpoint was the rate of AKI defined by KDIGO criteria within the first 72 h after surgery. Secondary endpoints included AKI severity, need for dialysis, length of stay, and major adverse kidney events (MAKE) at days 30, 60, and 90. Results AKI was significantly reduced with the intervention compared to controls [55.1 vs. 71.7%; ARR 16.6% (95 CI 5.5–27.9%); p = 0.004]. The implementation of the bundle resulted in significantly improved hemodynamic parameters at different time points (p < 0.05), less hyperglycemia (p < 0.001) and use of ACEi/ARBs (p < 0.001) compared to controls. Rates of moderate to severe AKI were also significantly reduced by the intervention compared to controls. There were no significant effects on other secondary outcomes. Conclusion An implementation of the KDIGO guidelines compared with standard care reduced the frequency and severity of AKI after cardiac surgery in high risk patients. Adequately powered multicenter trials are warranted to examine mortality and long-term renal outcomes. Electronic supplementary material The online version of this article (doi:10.1007/s00134-016-4670-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine University, Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Christoph Schmidt
- Department of Anesthesiology, Intensive Care and Pain Medicine University, Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Andreas Hoffmeier
- Department of Cardiac Surgery, University of Münster, Münster, Germany
| | - Hugo Van Aken
- Department of Anesthesiology, Intensive Care and Pain Medicine University, Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Carola Wempe
- Department of Anesthesiology, Intensive Care and Pain Medicine University, Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine University, Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
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80
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Porter CJ, Moppett IK, Juurlink I, Nightingale J, Moran CG, Devonald MAJ. Acute and chronic kidney disease in elderly patients with hip fracture: prevalence, risk factors and outcome with development and validation of a risk prediction model for acute kidney injury. BMC Nephrol 2017; 18:20. [PMID: 28088181 PMCID: PMC5237525 DOI: 10.1186/s12882-017-0437-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 01/04/2017] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Hip fracture is a common injury in older people with a high rate of postoperative morbidity and mortality. This patient group is also at high risk of acute kidney injury (AKI) and chronic kidney disease (CKD), but little is known of the impact of kidney disease on outcome following hip fracture. METHODS An observational cohort of consecutive patients with hip fracture in a large UK secondary care hospital. Predictive modelling of outcomes using development and validation datasets. Inclusion: all patients admitted with hip fracture with sufficient serum creatinine measurements to define acute kidney injury. Main outcome measures - development of acute kidney injury during admission; mortality (in hospital, 30-365 day and to follow-up); length of hospital stay. RESULTS Data were available for 2848 / 2959 consecutive admissions from 2007-2011; 776 (27.2%) male. Acute kidney injury occurs in 24%; development of acute kidney injury is independently associated with male sex (OR 1.48 (1.21 to 1.80), premorbid chronic kidney disease stage 3B or worse (OR 1.52 (1.19 to 1.93)), age (OR 3.4 (2.29 to 5.2) for >85 years) and greater than one major co-morbidities (OR 1.61 (1.34 to 1.93)). Acute kidney injury of any stage is associated with an increased hazard of death, and increased length of stay (Acute kidney injury: 19.1 (IQR 13 to 31) days; no acute kidney injury 15 (11 to 23) days). A simplified predictive model containing Age, CKD stage (3B-5), two or more comorbidities, and male sex had an area under the ROC curve of 0.63 (0.60 to 0.67). CONCLUSIONS Acute kidney injury following hip fracture is common and associated with worse outcome and greater hospital length of stay. With the number of people experiencing hip fracture predicted to rise, recognition of risk factors and optimal perioperative management of acute kidney injury will become even more important.
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Affiliation(s)
- Christine J. Porter
- Renal and Transplant Unit, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB UK
| | - Iain K. Moppett
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, University of Nottingham, Nottingham, NG7 2RD UK
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
| | - Irene Juurlink
- Information and Computer Technology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jessica Nightingale
- Department of Orthopaedic Trauma, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Christopher G. Moran
- Department of Orthopaedic Trauma, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mark A. J. Devonald
- Renal and Transplant Unit, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB UK
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81
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Dehnadi A, Benedict Cosimi A, Neal Smith R, Li X, Alonso JL, Means TK, Arnaout MA. Prophylactic orthosteric inhibition of leukocyte integrin CD11b/CD18 prevents long-term fibrotic kidney failure in cynomolgus monkeys. Nat Commun 2017; 8:13899. [PMID: 28071653 PMCID: PMC5234083 DOI: 10.1038/ncomms13899] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 11/10/2016] [Indexed: 12/21/2022] Open
Abstract
Ischaemic acute kidney injury (AKI), an inflammatory disease process, often progresses to chronic kidney disease (CKD), with no available effective prophylaxis. This is in part due to lack of clinically relevant CKD models in non-human primates. Here we demonstrate that inhibition of the archetypal innate immune receptor CD11b/CD18 prevents progression of AKI to CKD in cynomolgus monkeys. Severe ischaemia-reperfusion injury of the right kidney, with subsequent periods of the left ureter ligation, causes irreversible right kidney failure 3, 6 or 9 months after AKI. Moreover, prophylactic inactivation of CD11b/CD18, using the orthosteric CD11b/CD18 inhibitor mAb107, improves microvascular perfusion and histopathology, reduces intrarenal pro-inflammatory mediators and salvages kidney function long term. These studies reveal an important early role of CD11b+ leukocytes in post-ischaemic kidney fibrosis and failure, and suggest a potential early therapeutic intervention to mitigate progression of ischaemic AKI to CKD in humans.
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Affiliation(s)
- Abbas Dehnadi
- Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | - A Benedict Cosimi
- Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.,Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Rex Neal Smith
- Harvard Medical School, Boston, Massachusetts 02115, USA.,Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | - Xiangen Li
- Harvard Medical School, Boston, Massachusetts 02115, USA.,Leukocyte Biology and Inflammation Program, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.,Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | - José L Alonso
- Harvard Medical School, Boston, Massachusetts 02115, USA.,Leukocyte Biology and Inflammation Program, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.,Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | - Terry K Means
- Harvard Medical School, Boston, Massachusetts 02115, USA.,Division of Rheumatology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | - M Amin Arnaout
- Harvard Medical School, Boston, Massachusetts 02115, USA.,Leukocyte Biology and Inflammation Program, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.,Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.,Center For Regenerative Medicine, Medical Services, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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82
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Makris K, Spanou L. Acute Kidney Injury: Diagnostic Approaches and Controversies. Clin Biochem Rev 2016; 37:153-175. [PMID: 28167845 PMCID: PMC5242479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Acute kidney injury (AKI) is a significant independent risk factor for morbidity and mortality. In the last ten years a large number of publications have highlighted the limitations of traditional approaches and the inadequacies of conventional biomarkers to diagnose and monitor renal insufficiency in the acute setting. A great effort was directed not only to the discovery and validation of new biomarkers aimed to detect AKI more accurately but also to standardise the definition of AKI. Despite the advances in both areas, biomarkers have not yet entered into routine clinical practice and the definition of this syndrome has many areas of uncertainty. This review will discuss the controversies in diagnosis and the potential of novel biomarkers to improve the definition of the syndrome.
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Affiliation(s)
- Konstantinos Makris
- Clinical Biochemistry Department, KAT General Hospital, Kifissia, Athens, 14561, Greece
| | - Loukia Spanou
- Clinical Biochemistry Department, KAT General Hospital, Kifissia, Athens, 14561, Greece
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83
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Trinh E, Alam A, Tchervenkov J, Cantarovich M. Impact of acute kidney injury following liver transplantation on long-term outcomes. Clin Transplant 2016; 31. [DOI: 10.1111/ctr.12863] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2016] [Indexed: 12/31/2022]
Affiliation(s)
- Emilie Trinh
- Division of Nephrology; Multi-Organ Transplant Program; McGill University Health Center; Montreal QC Canada
| | - Ahsan Alam
- Division of Nephrology; Multi-Organ Transplant Program; McGill University Health Center; Montreal QC Canada
| | - Jean Tchervenkov
- Division of General Surgery; Multi-Organ Transplant Program; McGill University Health Center; Montreal QC Canada
| | - Marcelo Cantarovich
- Division of Nephrology; Multi-Organ Transplant Program; McGill University Health Center; Montreal QC Canada
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84
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Bielopolski D, Kalantar-Zadeh K. Conservatism strikes back: later is better than earlier dialysis for acute kidney injury. J Thorac Dis 2016; 8:2415-2419. [PMID: 27746991 DOI: 10.21037/jtd.2016.09.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Dana Bielopolski
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA;; Department of Nephrology, Rabin Medical Center, Petah-Tikva, Israel
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA;; Veterans Affairs Long Beach Healthcare System, Long Beach, CA, USA;; Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA;; Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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85
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Impact of feline AIM on the susceptibility of cats to renal disease. Sci Rep 2016; 6:35251. [PMID: 27731392 PMCID: PMC5059666 DOI: 10.1038/srep35251] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 09/27/2016] [Indexed: 12/12/2022] Open
Abstract
Renal failure is one of the most important social problems for its incurability and high costs for patients’ health care. Through clarification of the underlying mechanism for the high susceptibility of cats to renal disease, we here demonstrates that the effective dissociation of serum AIM protein from IgM is necessary for the recovery from acute kidney injury (AKI). In cats, the AIM-IgM binding affinity is 1000-fold higher than that in mice, which is caused by the unique positively-charged amino-acid cluster present in feline AIM. Hence, feline AIM does not dissociate from IgM during AKI, abolishing its translocation into urine. This results in inefficient clearance of lumen-obstructing necrotic cell debris at proximal tubules, thereby impairing AKI recovery. Accordingly, mice whose AIM is replaced by feline AIM exhibit higher mortality by AKI than in wild-type mice. Recombinant AIM administration into the mice improves their renal function and survival. As insufficient recovery from AKI predisposes patients to chronic, end-stage renal disease, feline AIM may be involved crucially in the high mortality of cats due to renal disease. Our findings could be the basis of the development of novel AKI therapies targeting AIM-IgM dissociation, and may support renal function in cats and prolong their lives.
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86
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Leaf DE, Waikar SS. End Points for Clinical Trials in Acute Kidney Injury. Am J Kidney Dis 2016; 69:108-116. [PMID: 27599630 DOI: 10.1053/j.ajkd.2016.05.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/25/2016] [Indexed: 01/09/2023]
Abstract
Acute kidney injury (AKI) is an increasingly common and feared complication in hospitalized patients. The selection of appropriate primary and secondary end points is critical to the design and eventual success of clinical trials aimed at preventing and treating AKI. In this article, we provide an overview of AKI definitions and suggestions on the rational selection of end points for clinical trials in various settings, including the prevention of contrast-induced AKI, prevention of cardiac surgery-associated AKI, treatment of established AKI, and treatment of dialysis-requiring AKI.
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Affiliation(s)
- David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sushrut S Waikar
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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87
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Jung HY, Lee JH, Park YJ, Kim SU, Lee KH, Choi JY, Park SH, Kim CD, Kim YL, Cho JH. Duration of anuria predicts recovery of renal function after acute kidney injury requiring continuous renal replacement therapy. Korean J Intern Med 2016; 31:930-7. [PMID: 26867084 PMCID: PMC5016271 DOI: 10.3904/kjim.2014.290] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 06/30/2015] [Accepted: 07/04/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Little is known regarding the incidence rate of and factors associated with developing chronic kidney disease after continuous renal replacement therapy (CRRT) in acute kidney injury (AKI) patients. We investigated renal outcomes and the factors associated with incomplete renal recovery in AKI patients who received CRRT. METHODS Between January 2011 and November 2013, 408 patients received CRRT in our intensive care unit. Of them, patients who had normal renal function before AKI and were discharged without maintenance renal replacement therapy (RRT) were included in this study. We examined the incidence of incomplete renal recovery with an estimated glomerular filtration rate < 60 mL/min/1.73 m(2) and factors that increased the risk of incomplete renal recovery after AKI. RESULTS In total, 56 AKI patients were discharged without further RRT and were followed for a mean of 8 months. Incomplete recovery of renal function was observed in 20 of the patients (35.7%). Multivariate analysis revealed old age and long duration of anuria as independent risk factors for incomplete renal recovery (odds ratio [OR], 1.231; 95% confidence interval [CI], 1.041 to 1.457; p = 0.015 and OR, 1.064; 95% CI, 1.001 to 1.131; p = 0.047, respectively). In a receiver operating characteristic curve analysis, a cut-off anuria duration of 24 hours could predict incomplete renal recovery after AKI with a sensitivity of 85.0% and a specificity of 66.7%. CONCLUSIONS The renal outcome of severe AKI requiring CRRT was poor even in patients without further RRT. Long-term monitoring of renal function is needed, especially in severe AKI patients who are old and have a long duration of anuria.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Jang-Hee Cho
- Correspondence to Jang-Hee Cho, M.D. Division of Nephrology, Department of Internal Medicine, Kyungpook National University School of Medicine, 680 Gukchaebosang-ro, Jung-gu, Daegu 41944, Korea Tel: +82-53-420-6314 Fax: +82-53-423-7583 E-mail:
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88
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Yamada M, Nishi H, Sekiya N, Horikawa K, Takahashi T, Sawa Y. The efficacy of tolvaptan in the perioperative management of chronic kidney disease patients undergoing open-heart surgery. Surg Today 2016; 47:498-505. [DOI: 10.1007/s00595-016-1406-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/18/2016] [Indexed: 10/21/2022]
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89
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Hougardy JM, Revercez P, Pourcelet A, Oumeiri BE, Racapé J, Le Moine A, Vanden Eynden F, De Backer D. Chronic kidney disease as major determinant of the renal risk related to on-pump cardiac surgery: a single-center cohort study. Acta Chir Belg 2016; 116:217-224. [PMID: 27426658 DOI: 10.1080/00015458.2016.1156929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication and is associated with the poorest outcomes. Therefore, early prediction of CSA-AKI remains a major issue. Severity scores such as the STS score could estimate the risk of AKI preoperatively. The main objective of this study was to evaluate the risk factors of on-pump CSA-AKI and to assess the performance of the STS score in order to predict CSA-AKI. PATIENTS We identified 252 patients with on-pump cardiac surgery, and the STS score was defined retrospectively. RESULTS AKI occurred in 14.6% (n = 37/252) of patients and renal replacement therapy was required in 21.6% of AKI (n = 8/37). CSA-AKI was associated with 35.1% in-hospital mortality (vs. 1.4%) and nearly doubled length of stay (14.5 vs. 8.0 d). The risk of CSA-AKI was mainly determined by preoperative morbidities such as chronic kidney disease, peripheral vascular disease, and severe congestive heart failure. Long cardio-pulmonary bypass time was also a determinant. CSA-AKI + patients exhibited higher STS renal risk (5.6% vs. 2.0%; p < 0.0001), resulting in a good discrimination between AKI + and AKI - patients (area under curve [AUC] 0.80). Interestingly, a basal renal function ≤55 ml/min/1.73m2 was as good as the STS score to predict CSA-AKI (AUC 0.75; P 0.26). CONCLUSIONS On-pump CSA-AKI was observed in nearly 15% of cases and was associated with poorer outcomes. Interestingly, the risk of CSA-AKI could be estimated preoperatively, thanks to the basal renal function, which exhibited an equal performance to the STS score.
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90
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Abstract
There is increasing recognition that acute kidney injury (AKI) and chronic kidney disease (CKD) are closely linked and likely promote one another. Underlying CKD now is recognized as a clear risk factor for AKI because both decreased glomerular filtration rate and increased proteinuria have been shown to be associated strongly with AKI. A growing body of literature also provides evidence that AKI accelerates the progression of CKD. Individuals who suffered dialysis-requiring AKI are particularly vulnerable to worse long-term renal outcomes, including end-stage renal disease. The association between AKI and subsequent renal function decline is amplified by pre-existing severity of CKD, higher stage of AKI, and the cumulative number of AKI episodes. However, residual confounding and ascertainment bias may partly explain the epidemiologic association between AKI and CKD in observational studies. As the number of AKI survivors increases, we need to better understand other clinically important outcomes after AKI, identify those at highest risk for the most adverse sequelae, and develop strategies to optimize their care.
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Affiliation(s)
- Raymond K Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
| | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California.
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91
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Grams ME, Sang Y, Coresh J, Ballew S, Matsushita K, Molnar MZ, Szabo Z, Kalantar-Zadeh K, Kovesdy CP. Acute Kidney Injury After Major Surgery: A Retrospective Analysis of Veterans Health Administration Data. Am J Kidney Dis 2016; 67:872-80. [PMID: 26337133 PMCID: PMC4775458 DOI: 10.1053/j.ajkd.2015.07.022] [Citation(s) in RCA: 223] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/11/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Few trials of acute kidney injury (AKI) prevention after surgery have been conducted, and most observational studies focus on AKI following cardiac surgery. The frequency of, risk factors for, and outcomes after AKI following other types of major surgery have not been well characterized and may present additional opportunities for trials in AKI. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS 3.6 million US veterans followed up from 2004 to 2011 for the receipt of major surgery (cardiac; general; ear, nose, and throat; thoracic; vascular; urologic; and orthopedic) and postoperative outcomes. FACTORS Demographics, health characteristics, and type of surgery. OUTCOMES Postoperative AKI defined by the KDIGO creatinine criteria, postoperative length of stay, end-stage renal disease, and mortality. RESULTS Postoperative AKI occurred in 11.8% of the 161,185 major surgery hospitalizations (stage 1, 76%; stage 2, 15%, stage 3 [without dialysis], 7%; and AKI requiring dialysis, 2%). Cardiac surgery had the highest postoperative AKI risk (relative risk [RR], 1.22; 95% CI, 1.17-1.27), followed by general (reference), thoracic (RR, 0.92; 95% CI, 0.87-0.98), orthopedic (RR, 0.70; 95% CI, 0.67-0.73), vascular (RR, 0.68; 95% CI, 0.64-0.71), urologic (RR, 0.65; 95% CI, 0.61-0.69), and ear, nose, and throat (RR, 0.32; 95% CI, 0.28-0.37) surgery. Risk factors for postoperative AKI included older age, African American race, hypertension, diabetes mellitus, and, for estimated glomerular filtration rate < 90mL/min/1.73m(2), lower estimated glomerular filtration rate. Participants with postoperative AKI had longer lengths of stay (15.8 vs 8.6 days) and higher rates of 30-day hospital readmission (21% vs 13%), 1-year end-stage renal disease (0.94% vs 0.05%), and mortality (19% vs 8%), with similar associations by type of surgery and more severe stage of AKI relating to poorer outcomes. LIMITATIONS Urine output was not available to classify AKI; cohort included mostly men. CONCLUSIONS AKI was common after major surgery, with similar risk factor and outcome associations across surgery type. These results can inform the design of clinical trials in postoperative AKI to the noncardiac surgery setting.
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Affiliation(s)
- Morgan E Grams
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Josef Coresh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Shoshana Ballew
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Zoltan Szabo
- Department of Cardiothoracic Surgery and Cardiothoracic Anesthesia, Linköping University Hospital, Linköping, Sweden; Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research & Epidemiology, University of California Irvine Medical Center, Irvine, CA; Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN
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92
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The spectrum of onset of acute kidney injury in premature infants less than 30 weeks gestation. J Perinatol 2016; 36:474-80. [PMID: 26796125 DOI: 10.1038/jp.2015.217] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 10/05/2015] [Accepted: 11/25/2015] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To determine risk factors for acute kidney injury (AKI) in preterm infants as a function of time of onset. STUDY DESIGN In this 5 1/2-year, single-center, retrospective study, incidence and timing of AKI was determined using modified Acute Kidney Injury Network criteria. Characteristics of newborns with and without AKI were compared by chi square and t-tests. Logistic regression was used to examine risk factors for AKI as a function of time of onset and potential confounders. RESULT AKI occurred in 30.3% of 357 neonates; 72.2% was stage 1. Gestational ages (GA), initial Cr, maternal magnesium and volume resuscitation were associated with early AKI (days 0 to 1). Volume resuscitation, umbilical arterial line and receipt of non-steroidal anti-inflammatory drug (NSAID) for patent ductus arteriosus were associated with intermediate AKI (days 2 to 5). GA, steroids for early hypotension, necrotizing enterocolitis and sepsis were associated with late AKI (⩾day 6). CONCLUSION Stage 1 AKI is a common morbidity in our population. Risk factors for AKI in our population differed with time of onset.
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93
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Parr SK, Siew ED. Delayed Consequences of Acute Kidney Injury. Adv Chronic Kidney Dis 2016; 23:186-94. [PMID: 27113695 PMCID: PMC4849427 DOI: 10.1053/j.ackd.2016.01.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 01/22/2016] [Indexed: 11/11/2022]
Abstract
Acute kidney injury (AKI) is an increasingly common complication of hospitalization and acute illness. Experimental data indicate that AKI may cause permanent kidney damage through tubulointerstitial fibrosis and progressive nephron loss, while also lowering the threshold for subsequent injury. Furthermore, preclinical data suggest that AKI may also cause distant organ dysfunction. The extension of these findings to human studies suggests long-term consequences of AKI including, but not limited to recurrent AKI, progressive kidney disease, elevated blood pressure, cardiovascular events, and mortality. As the number of AKI survivors increases, the need to better understand the mechanisms driving these processes becomes paramount. Optimizing care for AKI survivors will require understanding the short- and long-term risks associated with AKI, identifying patients at highest risk for poor outcomes, and testing interventions that target modifiable risk factors. In this review, we examine the literature describing the association between AKI and long-term outcomes and highlight opportunities for further research and potential intervention.
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Affiliation(s)
- Sharidan K Parr
- Tennessee Valley Healthcare System (TVHS), Geriatric Research Education and Clinical Centers (GRECC), Nashville, TN; TVHS, Veterans Administration (VA) Medical Center, Veterans Health Administration, Nashville, TN; Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; and Vanderbilt Center for Kidney Disease (VCKD), Nashville, TN
| | - Edward D Siew
- Tennessee Valley Healthcare System (TVHS), Geriatric Research Education and Clinical Centers (GRECC), Nashville, TN; TVHS, Veterans Administration (VA) Medical Center, Veterans Health Administration, Nashville, TN; Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; and Vanderbilt Center for Kidney Disease (VCKD), Nashville, TN.
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94
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Bandak G, Grams ME. Kidney-Related Outcomes After Hospital-Associated Acute Kidney Injury: Even the Mildest Episodes Count. Am J Kidney Dis 2016; 67:716-8. [PMID: 27091012 DOI: 10.1053/j.ajkd.2016.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/03/2016] [Indexed: 11/11/2022]
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95
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Helanterä I, Koljonen V, Finne P, Tukiainen E, Gissler M. The risk for end-stage renal disease is increased after burn. Burns 2016; 42:316-21. [DOI: 10.1016/j.burns.2015.10.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 09/27/2015] [Accepted: 10/26/2015] [Indexed: 11/29/2022]
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96
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Incidence of acute kidney injury among patients with chronic kidney disease: a single-center retrospective database analysis. Clin Exp Nephrol 2016; 21:43-48. [PMID: 26879775 DOI: 10.1007/s10157-016-1243-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 02/01/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a serious complication among hospitalized individuals and is closely associated with chronic kidney disease (CKD). METHODS This retrospective cohort study evaluated the incidences of AKI according to CKD stage at Kochi Medical School hospital during 1981-2011. AKI was defined and staged according to the kidney disease improving global outcomes criteria, using serum creatinine levels. RESULTS We analyzed data from 122,653 Japanese patients (57,105 men, 46.6 %). The incidence of AKI was 7.8 % (95 % confidence interval 7.7-8.0 %). Compared to non-AKI patients, patients with stage 1-2 AKI were more likely to be men. Patients with stage 1-2 AKI were significantly older than non-AKI or stage 3 AKI patients. The incidences of AKI were 6.7, 5.9, 10.4, 18.4, 30.0, and 48.8 % among individuals with estimated glomerular filtration rates of ≥90, 60-89, 45-59, 30-44, 15-29, and <15 mL/min/1.73 m2, respectively; these were significantly different from the incidence for the baseline eGFR. The proportions of inpatients with AKI exhibited step-wise increases with more severe pre-existing reduced kidney function, and the proportions among outpatients exhibited step-wise increases with milder pre-existing reduced kidney function. CONCLUSIONS CKD was a risk factor for AKI, and the incidence of AKI was positively associated with pre-existing reduced kidney function (CKD stage). We also found that the prevalence of AKI at early-stage CKD among outpatients was higher than expected. We suggest that outpatients should be monitored for AKI, given its unexpected incidence in that population.
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97
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Grams ME, Sang Y, Coresh J, Ballew SH, Matsushita K, Levey AS, Greene TH, Molnar MZ, Szabo Z, Kalantar-Zadeh K, Kovesdy CP. Candidate Surrogate End Points for ESRD after AKI. J Am Soc Nephrol 2016; 27:2851-9. [PMID: 26857682 DOI: 10.1681/asn.2015070829] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 01/06/2016] [Indexed: 11/03/2022] Open
Abstract
AKI, a frequently transient condition, is not accepted by the US Food and Drug Association as an end point for drug registration trials. We assessed whether an intermediate-term change in eGFR after AKI has a sufficiently strong relationship with subsequent ESRD to serve as an alternative end point in trials of AKI prevention and/or treatment. Among 161,185 United States veterans undergoing major surgery between 2004 and 2011, we characterized in-hospital AKI by Kidney Disease Improving Global Outcomes creatinine criteria and decline in eGFR from prehospitalization to postdischarge time points and quantified associations of these values with ESRD and mortality over a median of 3.8 years. An eGFR decline of ≥30% at 30, 60, and 90 days after discharge occurred in 3.1%, 2.5%, and 2.6%, of survivors without AKI and 15.9%, 12.2%, and 11.7%, of survivors with AKI. For patients with in-hospital AKI compared with those with no AKI and stable eGFR, a 30% decline in eGFR at 30, 60, and 90 days after discharge demonstrated adjusted hazard ratios (95% confidence intervals) of ESRD of 5.60 (4.06 to 7.71), 6.42 (4.76 to 8.65), and 7.27 (5.14 to 10.27), with corresponding estimates for 40% decline in eGFR of 6.98 (5.21 to 9.35), 8.03 (6.11 to 10.56), and 10.95 (8.10 to 14.82). Risks for mortality were smaller but consistent in direction. A 30%-40% decline in eGFR after AKI could be a surrogate end point for ESRD in trials of AKI prevention and/or treatment, but additional trial evidence is needed.
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Affiliation(s)
- Morgan E Grams
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Departments of Epidemiology and
| | | | - Josef Coresh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Departments of Epidemiology and Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Tom H Greene
- Division of Clinical Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Zoltan Szabo
- Department of Cardiothoracic Surgery and Cardiothoracic Anesthesia, Linköping University Hospital, Linköping, Sweden; Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology and Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, California; and
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee; Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
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98
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Shiao CC, Wu PC, Huang TM, Lai TS, Yang WS, Wu CH, Lai CF, Wu VC, Chu TS, Wu KD. Long-term remote organ consequences following acute kidney injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:438. [PMID: 26707802 PMCID: PMC4699348 DOI: 10.1186/s13054-015-1149-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Acute kidney injury (AKI) has been a global health epidemic problem with soaring incidence, increased long-term risks for multiple comorbidities and mortality, as well as elevated medical costs. Despite the improvement of patient outcomes following the advancements in preventive and therapeutic strategies, the mortality rates among critically ill patients with AKI remain as high as 40–60 %. The distant organ injury, a direct consequence of deleterious systemic effects, following AKI is an important explanation for this phenomenon. To date, most evidence of remote organ injury in AKI is obtained from animal models. Whereas the observations in humans are from a limited number of participants in a relatively short follow-up period, or just focusing on the cytokine levels rather than clinical solid outcomes. The remote organ injury is caused with four underlying mechanisms: (1) “classical” pattern of acute uremic state; (2) inflammatory nature of the injured kidneys; (3) modulating effect of AKI of the underlying disease process; and (4) healthcare dilemma. While cytokines/chemokines, leukocyte extravasation, oxidative stress, and certain channel dysregulation are the pathways involving in the remote organ damage. In the current review, we summarized the data from experimental studies to clinical outcome studies in the field of organ crosstalk following AKI. Further, the long-term consequences of distant organ-system, including liver, heart, brain, lung, gut, bone, immune system, and malignancy following AKI with temporary dialysis were reviewed and discussed.
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Affiliation(s)
- Chih-Chung Shiao
- Division of Nephrology, Department of Internal Medicine, Saint Mary's Hospital Luodong, 160 Chong-Cheng South Road, Luodong, Yilan, 265, Taiwan.,Saint Mary's Medicine, Nursing and Management College, 160 Chong-Cheng South Road, Luodong, Yilan, 265, Taiwan
| | - Pei-Chen Wu
- Division of Nephrology, Department of Internal Medicine, MacKay Memorial Hospital, 92, Sec. 2, Zhongshan N. Road, Taipei, 10449, Taiwan
| | - Tao-Min Huang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, 579, Sec. 2, Yunlin Road, Douliu City, Yunlin County, 640, Taiwan
| | - Tai-Shuan Lai
- Department of Internal Medicine, National Taiwan University Hospital, Bei-Hu Branch, 87 Neijiang Street, Taipei, 108, Taiwan
| | - Wei-Shun Yang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Hisn-Chu Branch, No.25, Lane 442, Sec. 1, Jingguo Road, Hsin-Chu City, 300, Taiwan
| | - Che-Hsiung Wu
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chun-Fu Lai
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhong-Zheng District, Taipei, 100, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhong-Zheng District, Taipei, 100, Taiwan.
| | - Tzong-Shinn Chu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhong-Zheng District, Taipei, 100, Taiwan
| | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhong-Zheng District, Taipei, 100, Taiwan
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Heung M, Steffick DE, Zivin K, Gillespie BW, Banerjee T, Hsu CY, Powe NR, Pavkov ME, Williams DE, Saran R, Shahinian VB. Acute Kidney Injury Recovery Pattern and Subsequent Risk of CKD: An Analysis of Veterans Health Administration Data. Am J Kidney Dis 2015; 67:742-52. [PMID: 26690912 DOI: 10.1053/j.ajkd.2015.10.019] [Citation(s) in RCA: 257] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 10/14/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND Studies suggest an association between acute kidney injury (AKI) and long-term risk for chronic kidney disease (CKD), even following apparent renal recovery. Whether the pattern of renal recovery predicts kidney risk following AKI is unknown. STUDY DESIGN Retrospective cohort. SETTING & PARTICIPANTS Patients in the Veterans Health Administration in 2011 hospitalized (> 24 hours) with at least 2 inpatient serum creatinine measurements, baseline estimated glomerular filtration rate > 60 mL/min/1.73 m², and no diagnosis of end-stage renal disease or non-dialysis-dependent CKD: 17,049 (16.3%) with and 87,715 without AKI. PREDICTOR Pattern of recovery to creatinine level within 0.3 mg/dL of baseline after AKI: within 2 days (fast), in 3 to 10 days (intermediate), and no recovery by 10 days (slow or unknown). OUTCOME CKD stage 3 or higher, defined as 2 outpatient estimated glomerular filtration rates < 60 mL/min/1.73m² at least 90 days apart or CKD diagnosis, dialysis therapy, or transplantation. MEASUREMENTS Risk for CKD was modeled using modified Poisson regression and time to death-censored CKD was modeled using Cox proportional hazards regression, both stratified by AKI stage. RESULTS Most patients' AKI episodes were stage 1 (91%) and 71% recovered within 2 days. At 1 year, 18.2% had developed CKD (AKI, 31.8%; non-AKI, 15.5%; P < 0.001). In stage 1, the adjusted relative risk ratios for CKD stage 3 or higher were 1.43 (95% CI, 1.39-1.48), 2.00 (95% CI, 1.88-2.12), and 2.65 (95% CI, 2.51-2.80) for fast, intermediate, and slow/unknown recovery. A similar pattern was observed in subgroup analyses incorporating albuminuria and sensitivity analysis of death-censored time to CKD. LIMITATIONS Variable timing of follow-up and mostly male veteran cohort may limit generalizability. CONCLUSIONS Patients who develop AKI during a hospitalization are at substantial risk for the development of CKD by 1 year following hospitalization and timing of AKI recovery is a strong predictor, even for the mildest forms of AKI.
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Affiliation(s)
| | | | - Kara Zivin
- Department of Psychology, University of Michigan, Ann Arbor, MI; Ann Arbor Veteran Affairs Medical Center, Ann Arbor, MI
| | | | - Tanushree Banerjee
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Chi-Yuan Hsu
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Neil R Powe
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | | | | | - Rajiv Saran
- Kidney Epidemiology and Cost Center, Ann Arbor, MI
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100
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Stewart IJ, Sosnov JA, Howard JT, Orman JA, Fang R, Morrow BD, Zonies DH, Bollinger M, Tuman C, Freedman BA, Chung KK. Retrospective Analysis of Long-Term Outcomes After Combat Injury: A Hidden Cost of War. Circulation 2015; 132:2126-33. [PMID: 26621637 DOI: 10.1161/circulationaha.115.016950] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 08/28/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND During the conflicts in Iraq and Afghanistan, 52,087 service members have been wounded in combat. The long-term sequelae of these injuries have not been carefully examined. We sought to determine the relation between markers of injury severity and the subsequent development of hypertension, coronary artery disease, diabetes mellitus, and chronic kidney disease. METHODS AND RESULTS Retrospective cohort study of critically injured US military personnel wounded in Iraq or Afghanistan from February 1, 2002 to February 1, 2011. Patients were then followed until January 18, 2013. Chronic disease outcomes were assessed by International Classification of Diseases, 9th edition codes and causes of death were confirmed by autopsy. From 6011 admissions, records were excluded because of missing data or if they were for an individual's second admission. Patients with a disease diagnosis of interest before the injury date were also excluded, yielding a cohort of 3846 subjects for analysis. After adjustment for other factors, each 5-point increment in the injury severity score was associated with a 6%, 13%, 13%, and 15% increase in incidence rates of hypertension, coronary artery disease, diabetes mellitus, and chronic kidney disease, respectively. Acute kidney injury was associated with a 66% increase in rates of hypertension and nearly 5-fold increase in rates of chronic kidney disease. CONCLUSIONS In Iraq and Afghanistan veterans, the severity of combat injury was associated with the subsequent development of hypertension, coronary artery disease, diabetes mellitus, and chronic kidney disease.
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Affiliation(s)
- Ian J Stewart
- From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.).
| | - Jonathan A Sosnov
- From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.)
| | - Jeffrey T Howard
- From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.)
| | - Jean A Orman
- From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.)
| | - Raymond Fang
- From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.)
| | - Benjamin D Morrow
- From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.)
| | - David H Zonies
- From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.)
| | - Mary Bollinger
- From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.)
| | - Caroline Tuman
- From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.)
| | - Brett A Freedman
- From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.)
| | - Kevin K Chung
- From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.)
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