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Greenberg JH, Zappitelli M, Jia Y, Thiessen-Philbrook HR, de Fontnouvelle CA, Wilson FP, Coca S, Devarajan P, Parikh CR. Biomarkers of AKI Progression after Pediatric Cardiac Surgery. J Am Soc Nephrol 2018; 29:1549-1556. [PMID: 29472416 DOI: 10.1681/asn.2017090989] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 01/25/2018] [Indexed: 12/13/2022] Open
Abstract
Background As children progress to higher stages of AKI, the risk for adverse outcomes dramatically increases. No reliable methods exist to predict AKI progression in hospitalized children. To determine if biomarkers of inflammation and kidney injury can predict AKI progression, we conducted a three-center prospective cohort study of children undergoing cardiopulmonary bypass.Methods On the first day of serum creatinine-defined AKI, we measured urine biomarkers (neutrophil gelatinase-associated lipocalin [NGAL], IL-18, kidney injury molecule 1, liver fatty acid binding protein [L-FABP], albumin, and cystatin C) and plasma biomarkers (IFN, IL-1, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, IL-13, TNF-α, NGAL, and cystatin C). We defined AKI progression as a worsening of AKI stage or persisting stage 3 AKI (≥2 consecutive days).Results In all, 176 of 408 (43%) children developed postoperative AKI. Among the children with AKI, we diagnosed stages 1, 2, and 3 AKI in 145 (82.5%), 25 (14%), and six (3.5%) children, respectively, on the first day of AKI; 28 (7%) children had AKI progression. On the first day of AKI, nine of 17 biomarkers were significantly higher in patients with than without AKI progression. Urine L-FABP (among injury biomarkers) and plasma IL-8 (among inflammatory biomarkers) had the highest discrimination for AKI progression: optimism-corrected area under the curve, 0.70; 95% confidence interval, 0.58 to 0.81 and optimism-corrected area under the curve, 0.80; 95% confidence interval, 0.69 to 0.91, respectively.Conclusions If validated in additional cohorts, plasma IL-8 could be used to improve clinical care and guide enrollment in therapeutic trials of AKI.
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Affiliation(s)
- Jason H Greenberg
- Departments of Pediatrics and.,Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut
| | - Michael Zappitelli
- Department of Pediatrics, Division of Pediatric Nephrology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Yaqi Jia
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut
| | | | | | - F Perry Wilson
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut.,Internal Medicine, Section of Nephrology and.,Department of Internal Medicine, Section of Nephrology, Veterans Affairs Medical Center, West Haven, Connecticut
| | - Steven Coca
- Department of Internal Medicine, Section of Nephrology, Mount Sinai School of Medicine, New York, New York; and
| | - Prasad Devarajan
- Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Chirag R Parikh
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut; .,Internal Medicine, Section of Nephrology and.,Department of Internal Medicine, Section of Nephrology, Veterans Affairs Medical Center, West Haven, Connecticut
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102
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Bansal N, Matheny ME, Greevy RA, Eden SK, Perkins AM, Parr SK, Fly J, Abdel-Kader K, Himmelfarb J, Hung AM, Speroff T, Ikizler TA, Siew ED. Acute Kidney Injury and Risk of Incident Heart Failure Among US Veterans. Am J Kidney Dis 2017; 71:236-245. [PMID: 29162339 DOI: 10.1053/j.ajkd.2017.08.027] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 08/29/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is common and associated with poor outcomes. Heart failure is a leading cause of cardiovascular disease among patients with chronic kidney disease. The relationship between AKI and heart failure remains unknown and may identify a novel mechanistic link between kidney and cardiovascular disease. STUDY DESIGN Observational study. SETTING & PARTICIPANTS We studied a national cohort of 300,868 hospitalized US veterans (2004-2011) without a history of heart failure. PREDICTOR AKI was the predictor and was defined as a 0.3-mg/dL or 50% increase in serum creatinine concentration from baseline to the peak hospital value. Patients with and without AKI were matched (1:1) on 28 in- and outpatient covariates using optimal Mahalanobis distance matching. OUTCOMES Incident heart failure was defined as 1 or more hospitalization or 2 or more outpatient visits with a diagnosis of heart failure within 2 years through 2013. RESULTS There were 150,434 matched pairs in the study. Patients with and without AKI during the index hospitalization were well matched, with a median preadmission estimated glomerular filtration rate of 69mL/min/1.73m2. The overall incidence rate of heart failure was 27.8 (95% CI, 19.3-39.9) per 1,000 person-years. The incidence rate was higher in those with compared with those without AKI: 30.8 (95% CI, 21.8-43.5) and 24.9 (95% CI, 16.9-36.5) per 1,000 person-years, respectively. In multivariable models, AKI was associated with 23% increased risk for incident heart failure (HR, 1.23; 95% CI, 1.19-1.27). LIMITATIONS Study population was primarily men, reflecting patients seen at Veterans Affairs hospitals. CONCLUSIONS AKI is an independent risk factor for incident heart failure. Future studies to identify underlying mechanisms and modifiable risk factors are needed.
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Affiliation(s)
- Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, WA.
| | - Michael E Matheny
- Geriatrics Research Education and Clinical Center, Tennessee Valley Health System, Veteran's Health Administration, Nashville, TN; Vanderbilt University Medical Center, Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research, Nashville, TN; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Robert A Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Svetlana K Eden
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Amy M Perkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Sharidan K Parr
- Geriatrics Research Education and Clinical Center, Tennessee Valley Health System, Veteran's Health Administration, Nashville, TN; Vanderbilt University Medical Center, Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research, Nashville, TN
| | - James Fly
- Geriatrics Research Education and Clinical Center, Tennessee Valley Health System, Veteran's Health Administration, Nashville, TN
| | - Khaled Abdel-Kader
- Geriatrics Research Education and Clinical Center, Tennessee Valley Health System, Veteran's Health Administration, Nashville, TN; Vanderbilt University Medical Center, Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research, Nashville, TN
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, WA
| | - Adriana M Hung
- Geriatrics Research Education and Clinical Center, Tennessee Valley Health System, Veteran's Health Administration, Nashville, TN; Vanderbilt University Medical Center, Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research, Nashville, TN
| | - Theodore Speroff
- Geriatrics Research Education and Clinical Center, Tennessee Valley Health System, Veteran's Health Administration, Nashville, TN; Vanderbilt University Medical Center, Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research, Nashville, TN
| | - T Alp Ikizler
- Geriatrics Research Education and Clinical Center, Tennessee Valley Health System, Veteran's Health Administration, Nashville, TN; Vanderbilt University Medical Center, Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research, Nashville, TN
| | - Edward D Siew
- Geriatrics Research Education and Clinical Center, Tennessee Valley Health System, Veteran's Health Administration, Nashville, TN; Vanderbilt University Medical Center, Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research, Nashville, TN.
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103
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Wald R, Kitchlu A, Harel Z, Silver S. Care of the Acute Kidney Injury Survivor. Nephron Clin Pract 2017; 137:306-309. [DOI: 10.1159/000484113] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 10/05/2017] [Indexed: 11/19/2022] Open
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He L, Wei Q, Liu J, Yi M, Liu Y, Liu H, Sun L, Peng Y, Liu F, Venkatachalam MA, Dong Z. AKI on CKD: heightened injury, suppressed repair, and the underlying mechanisms. Kidney Int 2017; 92:1071-1083. [PMID: 28890325 DOI: 10.1016/j.kint.2017.06.030] [Citation(s) in RCA: 264] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 06/13/2017] [Accepted: 06/19/2017] [Indexed: 02/07/2023]
Abstract
Acute kidney injury (AKI) and chronic kidney disease (CKD) are interconnected. Although AKI-to-CKD transition has been intensively studied, the information of AKI on CKD is very limited. Nonetheless, AKI, when occurring in patients with CKD, is known to be more severe and difficult to recover. CKD is associated with significant changes in cell signaling in kidney tissues, including the activation of transforming growth factor-β, p53, hypoxia-inducible factor, and major developmental pathways. At the cellular level, CKD is characterized by mitochondrial dysfunction, oxidative stress, and aberrant autophagy. At the tissue level, CKD is characterized by chronic inflammation and vascular dysfunction. These pathologic changes may contribute to the heightened sensitivity of, and nonrecovery from, AKI in patients with CKD.
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Affiliation(s)
- Liyu He
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qingqing Wei
- Department of Cellular Biology and Anatomy, Medical College of Georgia at Augusta University and Charlie Norwood VA Medical Center, Augusta, Georgia, USA
| | - Jing Liu
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; Department of Cellular Biology and Anatomy, Medical College of Georgia at Augusta University and Charlie Norwood VA Medical Center, Augusta, Georgia, USA
| | - Mixuan Yi
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; Department of Cellular Biology and Anatomy, Medical College of Georgia at Augusta University and Charlie Norwood VA Medical Center, Augusta, Georgia, USA
| | - Yu Liu
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hong Liu
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lin Sun
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Youming Peng
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Fuyou Liu
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Manjeri A Venkatachalam
- Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Zheng Dong
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; Department of Cellular Biology and Anatomy, Medical College of Georgia at Augusta University and Charlie Norwood VA Medical Center, Augusta, Georgia, USA.
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105
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Corona-Villalobos CP, Shlipak MG, Tin A, Parikh C, Moore RD, Vittinghoff E, Monroy-Trujillo JM, Atta MG, Estrella MM. Predictors of Acute Renal Injury Study (PARIS) among HIV-positive individuals: design and methods. BMC Nephrol 2017; 18:289. [PMID: 28882126 PMCID: PMC5590192 DOI: 10.1186/s12882-017-0696-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 08/22/2017] [Indexed: 12/29/2022] Open
Abstract
Background Acute kidney injury (AKI), which is common among HIV-positive individuals, may contribute to the excess burden of chronic kidney disease (CKD) in this patient population; however, conventional clinical methods to detect AKI do not capture kidney injury sufficiently early to prevent irreversible damage. Further, large observational and interventional studies of AKI generally exclude HIV-positive persons in spite of their disproportionate risk. Methods The Predictors of Acute Renal Injury Study (PARIS) is a prospective observational cohort study among HIV-positive individuals established to determine the ability of candidate kidney injury biomarkers to predict future hospitalized clinical AKI, to characterize hospitalized subclinical AKI, and to discern the risk of progressive kidney disease following subclinical and clinical AKI. Among the candidate kidney injury markers, we will select the most promising to translate into a clinically viable, multiplex panel of urinary biomarkers which we will integrate with clinical factors to develop a model prognostic of risks for AKI and subsequent kidney function decline. This study has a targeted enrollment of 2000 participants. The overall follow-up of participants consists of two phases: 1) a 5-year active follow-up phase which involves serial evaluations at enrollment, annual clinic visits, and among participants who are hospitalized during this period, an evaluation at index hospitalization and 3 and 12 months post-hospitalization; and 2) a subsequent passive follow-up phase for the duration that the participant receives medical care at The Johns Hopkins Hospital. Discussions This study will serve as an important resource for future studies of AKI by establishing a repository with both ambulatory and inpatient biospecimens, a resource that is currently lacking in existing HIV clinical cohorts and studies of AKI. Upon completion of this study, the resulting prognostic model which will incorporate results from the multiplex HIV-AKI Risk Pane could serve as a pharmacodynamic endpoint for early phase therapeutic candidates for AKI.
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Affiliation(s)
- Celia P Corona-Villalobos
- Department of Medicine, Johns Hopkins School of Medicine, 1830 E. Monument St., Suite 416, Baltimore, 21287, MD, USA
| | - Michael G Shlipak
- San Francisco and San Francisco VA Health Care System, Kidney Health Research Collaborative, University of California, 1450 Clement St., 111A1, San Francisco, 94121, CA, USA
| | - Adrienne Tin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Room W6017, Baltimore, 21287, MD, USA
| | - Chirag Parikh
- Department of Medicine, Division of Nephrology, Yale University School of Medicine, 60 Temple St., Suite 6C, New Haven, 06510, CT, USA
| | - Richard D Moore
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Room W6017, Baltimore, 21287, MD, USA.,Department of Medicine, Division of General Internal Medicine, Johns Hopkins School of Medicine, 1830 E. Monument St., Suite 8059, Baltimore, 21287, MD, USA
| | - Eric Vittinghoff
- San Francisco and San Francisco VA Health Care System, Kidney Health Research Collaborative, University of California, 1450 Clement St., 111A1, San Francisco, 94121, CA, USA
| | - Jose Manuel Monroy-Trujillo
- Department of Medicine, Johns Hopkins School of Medicine, 1830 E. Monument St., Suite 416, Baltimore, 21287, MD, USA
| | - Mohamed G Atta
- Department of Medicine, Johns Hopkins School of Medicine, 1830 E. Monument St., Suite 416, Baltimore, 21287, MD, USA
| | - Michelle M Estrella
- San Francisco and San Francisco VA Health Care System, Kidney Health Research Collaborative, University of California, 1450 Clement St., 111A1, San Francisco, 94121, CA, USA.
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106
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[Life after Acute Kidney Injury : Long-term consequences and implications for clinical practice]. Med Klin Intensivmed Notfmed 2017; 112:597-604. [PMID: 28875354 DOI: 10.1007/s00063-017-0340-7] [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: 08/07/2017] [Accepted: 08/08/2017] [Indexed: 01/12/2023]
Abstract
Acute kidney injury (AKI) is a common complication in critically ill patients and is accompanied by significantly increased mortality and morbidity. Those complications are not limited to the acute phase of the illness, but may also affect a patient's risk profile long after AKI. Recovery of renal function is observed in the majority of patients although this rate significantly deteriorates with increasing severity of the AKI. After an AKI episode, the long-term risk for the development of chronic kidney disease (CKD) is considerably increased, as well as the risk for cardiovascular and neurological complications. Follow-up of these patients should include general nephroprotective measures such as controlling hypertension as well as avoiding nephrotoxic drugs, as well as repeated evaluations of renal function.
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107
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Göcze I, Wiesner C, Schlitt HJ, Bergler T. Renal recovery. Best Pract Res Clin Anaesthesiol 2017; 31:403-414. [PMID: 29248146 DOI: 10.1016/j.bpa.2017.08.006] [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: 07/19/2017] [Accepted: 08/17/2017] [Indexed: 10/19/2022]
Abstract
Recovery patterns after acute kidney injury (AKI) have increasingly become the focus of research, because currently available preventive measures and specific therapeutic intervention are limited. Moreover, changes in renal functional reserve are recognized as a "hidden" indicator of kidney susceptibility to either acute kidney injury or chronic kidney disease. Understanding these phenomena and their association with outcome may enable the initiation of strategies that facilitate fast and sustained recovery during the time course of AKI and limit AKI progression towards chronic kidney disease. Different interventions may be required during various phases of AKI continuum. Early recognition and prevention of second hit by kidney stress, treatment of cause and prevention of aggravation in the early phase of AKI and facilitation of recovery in the phase of acute kidney disease may together represent the key aspects of modern AKI management.
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Affiliation(s)
- Ivan Göcze
- Department of Surgery and Operative Intensive Care, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany.
| | - Christina Wiesner
- Department of Surgery and Operative Intensive Care, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
| | - Hans J Schlitt
- Department of Surgery and Operative Intensive Care, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
| | - Tobias Bergler
- Department of Nephrology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
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108
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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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109
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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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110
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Novel insights into acute kidney injury-chronic kidney disease continuum and the role of renin-angiotensin system. J Formos Med Assoc 2017; 116:652-659. [PMID: 28615146 DOI: 10.1016/j.jfma.2017.04.026] [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] [Received: 04/18/2017] [Accepted: 04/25/2017] [Indexed: 12/11/2022] Open
Abstract
Acute kidney injury (AKI) is an independent risk factor for chronic kidney disease (CKD). If injury is mild, a repair process can be adaptive and lead to complete renal recovery. However, severe injury will be accompanied by a maladaptive repair which usually leads to nephron loss, fibrosis, vascular rarefaction, and chronic inflammation. Although various mechanisms underlying AKI-CKD transition have been explored, no intervention has been proved effective to block the transition until very recently. A lack of consensus for monitoring renal function and defining renal recovery after AKI should be the reasons for the slow advance in the discovery of a timely pharmacologic treatment to block AKI-CKD transition. Recently, animal studies have shown the activation of renin-angiotensin system (RAS) after AKI. In patients with complete renal recovery after AKI defined as the decrease of serum creatinine level to within 0.3 mg/dL above the baseline, administration of RAS inhibitor can prevent the ensuing CKD. In this review, we will discuss the renal recovery after AKI and the mechanisms underlying AKI-CKD transition. We will then highlight the promising effect of RAS inhibitor on CKD prevention in patients with complete renal recovery from AKI based on the recent clinical evidence.
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111
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Chou YH, Huang TM, Pan SY, Chang CH, Lai CF, Wu VC, Wu MS, Wu KD, Chu TS, Lin SL. Renin-Angiotensin System Inhibitor is Associated with Lower Risk of Ensuing Chronic Kidney Disease after Functional Recovery from Acute Kidney Injury. Sci Rep 2017; 7:46518. [PMID: 28406186 PMCID: PMC5390249 DOI: 10.1038/srep46518] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 03/17/2017] [Indexed: 12/17/2022] Open
Abstract
Acute kidney injury (AKI) is an independent risk factor for ensuing chronic kidney disease (CKD). Animal studies have demonstrated that renin-angiotensin system (RAS) inhibitor can reduce ensuing CKD after functional recovery from AKI. Here we study the association between ensuing CKD and use of RAS inhibitor including angiotensin converting enzyme inhibitor or angiotensin II type 1a receptor blocker starting after renal functional recovery in our prospectively collected observational AKI cohort. Adult patients who had cardiac surgery-associated AKI (CSA-AKI) are studied. Patients with CKD, unrecovered AKI, and use of RAS inhibitor before surgery are excluded. Among 587 eligible patients, 94 patients are users of RAS inhibitor which is started and continued after complete renal recovery during median follow-up period of 2.99 years. The users of RAS inhibitor show significantly lower rate of ensuing CKD (users vs. non-users, 26.6% vs. 42.2%) and longer median CKD-free survival time (users vs. non-users, 1079 days vs. 520 days). Multivariate Cox regression analyses further demonstrate that use of RAS inhibitor is independently associated with lower risk of ensuing CKD (hazard ratio = 0.46, P < 0.001). We conclude that use of RAS inhibitor in CSA-AKI patients after renal functional recovery is associated with lower risk of ensuing CKD development.
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Affiliation(s)
- Yu-Hsiang Chou
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital Jin-Shan Branch, New Taipei City, Taiwan.,Graduate Institute of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tao-Min Huang
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Szu-Yu Pan
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Chin-Hao Chang
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Fu Lai
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Vin-Cent Wu
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Shiou Wu
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kwan-Dun Wu
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzong-Shinn Chu
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shuei-Liong Lin
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Integrated Diagnostics &Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.,Research Center for Developmental Biology and Regenerative Medicine, National Taiwan University, Taipei, Taiwan
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112
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Horne KL, Packington R, Monaghan J, Reilly T, Selby NM. Three-year outcomes after acute kidney injury: results of a prospective parallel group cohort study. BMJ Open 2017; 7:e015316. [PMID: 28360257 PMCID: PMC5372023 DOI: 10.1136/bmjopen-2016-015316] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Using a prospective study design, we aimed to characterise the effect of acute kidney injury (AKI) on long-term changes in renal function in a general hospital population. PARTICIPANTS Hospitalised patients with AKI (exposed) and hospitalised patients without AKI (non-exposed), recruited at 3 months after hospital admission. DESIGN Prospective, matched parallel group cohort study, in which renal function and proteinuria were measured at 3 months, 1 year and 3 years. SETTING Single UK centre. CLINICAL END POINTS Clinical end points at 3 years were comparison of the following variables between exposed and non-exposed groups: renal function, prevalence of proteinuria and albuminuria and chronic kidney disease (CKD) progression/development at each time point. CKD progression was defined as a decrease in the estimated glomerular filtration rate (eGFR) of ≥25% associated with a decline in eGFR stage. RESULTS 300 exposed and non-exposed patients were successfully matched 1:1 for age and baseline renal function; 70% of the exposed group had AKI stage 1. During follow-up, the AKI group had lower eGFR than non-exposed patients at each time point. At 3 years, the mean eGFR was 60.7±21 mL/min/1.73 m2 in the AKI group compared with 68.4±21 mL/min/1.73 m2 in the non-exposed group, p=0.003. CKD development or progression at 3 years occurred in 30 (24.6%) of the AKI group compared with 10 (7.5%) of the non-exposed group, p<0.001. Albuminuria was more common in the AKI group, and increased with AKI severity. Factors independently associated with CKD development/progression after AKI were non-recovery at 90 days, male gender, diabetes and recurrent AKI. CONCLUSIONS AKI is associated with deterioration in renal function to 3 years, even in an unselected population with predominantly AKI stage 1. Non-recovery from AKI is an important factor determining long-term outcome.
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Affiliation(s)
- Kerry L Horne
- Department of Renal Medicine, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - Rebecca Packington
- Department of Renal Medicine, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - John Monaghan
- Department of Chemical Pathology, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - Timothy Reilly
- Department of Informatics, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - Nicholas M Selby
- Department of Renal Medicine, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
- Centre for Kidney Research and Innovation, School of Medicine, University of Nottingham, Nottingham, UK
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113
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Acute kidney disease and renal recovery: consensus report of the Acute Disease Quality Initiative (ADQI) 16 Workgroup. Nat Rev Nephrol 2017; 13:241-257. [PMID: 28239173 DOI: 10.1038/nrneph.2017.2] [Citation(s) in RCA: 883] [Impact Index Per Article: 126.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Consensus definitions have been reached for both acute kidney injury (AKI) and chronic kidney disease (CKD) and these definitions are now routinely used in research and clinical practice. The KDIGO guideline defines AKI as an abrupt decrease in kidney function occurring over 7 days or less, whereas CKD is defined by the persistence of kidney disease for a period of >90 days. AKI and CKD are increasingly recognized as related entities and in some instances probably represent a continuum of the disease process. For patients in whom pathophysiologic processes are ongoing, the term acute kidney disease (AKD) has been proposed to define the course of disease after AKI; however, definitions of AKD and strategies for the management of patients with AKD are not currently available. In this consensus statement, the Acute Disease Quality Initiative (ADQI) proposes definitions, staging criteria for AKD, and strategies for the management of affected patients. We also make recommendations for areas of future research, which aim to improve understanding of the underlying processes and improve outcomes for patients with AKD.
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Silver SA, Harel Z, McArthur E, Nash DM, Acedillo R, Kitchlu A, Garg AX, Chertow GM, Bell CM, Wald R. 30-Day Readmissions After an Acute Kidney Injury Hospitalization. Am J Med 2017; 130:163-172.e4. [PMID: 27751901 DOI: 10.1016/j.amjmed.2016.09.016] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 09/12/2016] [Accepted: 09/14/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND The risk of hospital readmission in acute kidney injury survivors is not well understood. We estimated the proportion of acute kidney injury patients who were rehospitalized within 30 days and identified characteristics associated with hospital readmission. METHODS We conducted a population-based study of patients who survived a hospitalization complicated by acute kidney injury from 2003-2013 in Ontario, Canada. The primary outcome was 30-day hospital readmission. We used a propensity score model to match patients with and without acute kidney injury, and a Cox proportional hazards model with death as a competing risk to identify predictors of 30-day readmission. RESULTS We identified 156,690 patients who were discharged from 197 hospitals after an episode of acute kidney injury. In the subsequent 30 days, 27,457 (18%) patients were readmitted; 15,988 (10%) visited the emergency department and 7480 (5%) died. We successfully matched 111,778 patients with acute kidney injury 1:1 to patients without acute kidney injury. The likelihood of 30-day readmission was higher in acute kidney injury patients than those without acute kidney injury (hazard ratio [HR] 1.53; 95% confidence interval [CI], 1.50-1.57). Factors most strongly associated with 30-day rehospitalization were the number of hospitalizations in the preceding year (adjusted HR 1.45 for ≥2 hospitalizations; 95% CI, 1.40-1.51) and receipt of inpatient chemotherapy (adjusted HR 1.44; 95% CI, 1.32-1.58). CONCLUSIONS One in 5 patients who survive a hospitalization complicated by acute kidney injury is readmitted in the next 30 days. Better strategies are needed to identify and care for acute kidney injury survivors in the community.
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Affiliation(s)
- Samuel A Silver
- Division of Nephrology, St. Michael's Hospital and the University of Toronto, Ont, Canada.
| | - Ziv Harel
- Division of Nephrology, St. Michael's Hospital and the University of Toronto, Ont, Canada; Li Ka Shing Knowledge Institute of St Michael's Hospital, University of Toronto, Ont, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ont, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, Toronto, Ont, Canada
| | - Danielle M Nash
- Institute for Clinical Evaluative Sciences, Toronto, Ont, Canada
| | - Rey Acedillo
- Division of Nephrology, London Health Sciences Centre, Western University, Ont, Canada
| | - Abhijat Kitchlu
- Division of Nephrology, St. Michael's Hospital and the University of Toronto, Ont, Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences, Toronto, Ont, Canada; Division of Nephrology, London Health Sciences Centre, Western University, Ont, Canada
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, Calif
| | - Chaim M Bell
- Institute for Clinical Evaluative Sciences, Toronto, Ont, Canada; Department of Medicine, Mount Sinai Hospital, University of Toronto, Ont, Canada; Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto, Ont, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital and the University of Toronto, Ont, Canada; Li Ka Shing Knowledge Institute of St Michael's Hospital, University of Toronto, Ont, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ont, Canada
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Tangren JS, Powe CE, Ankers E, Ecker J, Bramham K, Hladunewich MA, Karumanchi SA, Thadhani R. Pregnancy Outcomes after Clinical Recovery from AKI. J Am Soc Nephrol 2016; 28:1566-1574. [PMID: 28008002 DOI: 10.1681/asn.2016070806] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 10/04/2016] [Indexed: 11/03/2022] Open
Abstract
The effect of clinically recovered AKI (r-AKI) on future pregnancy outcomes is unknown. We retrospectively studied all women who delivered infants between 1998 and 2007 at Massachusetts General Hospital to assess whether a previous episode of r-AKI associated with subsequent adverse maternal and fetal outcomes, including preeclampsia. AKI was defined as rise in serum creatinine concentration to 1.5-fold above baseline. We compared pregnancy outcomes in women with r-AKI without history of CKD (eGFR>90 ml/min per 1.73 m2 before conception; n=105) with outcomes in women without kidney disease (controls; n=24,640). The r-AKI and control groups had similar prepregnancy serum creatinine measurements (0.70±0.20 versus 0.69±0.10 mg/dl; P=0.36). However, women with r-AKI had increased rates of preeclampsia compared with controls (23% versus 4%; P<0.001). Infants of women with r-AKI were born earlier than infants of controls (37.6±3.6 versus 39.2±2.2 weeks; P<0.001), with increased rates of small for gestational age births (15% versus 8%; P=0.03). After multivariate adjustment, r-AKI associated with increased risk for preeclampsia (adjusted odds ratio [aOR], 5.9; 95% confidence interval [95% CI], 3.6 to 9.7) and adverse fetal outcomes (aOR, 2.4; 95% CI, 1.6 to 3.7). When women with r-AKI and controls were matched 1:2 by age, race, body mass index, diastolic BP, parity, and diabetes status, r-AKI remained associated with preeclampsia (OR, 4.7; 95% CI, 2.1 to 10.1) and adverse fetal outcomes (OR, 2.1; 95% CI, 1.2 to 3.7). Thus, a past episode of AKI, despite return to normal renal function before pregnancy, associated with adverse outcomes in pregnancy.
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Affiliation(s)
| | | | | | - Jeffrey Ecker
- Department of Obstetrics and Gynecology, Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | - Kate Bramham
- Department of Renal Medicine, King's College London and King's Health Partners, London, United Kingdom
| | - Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; and
| | - S Ananth Karumanchi
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Lipworth L, Abdel-Kader K, Morse J, Stewart TG, Kabagambe EK, Parr SK, Birdwell KA, Matheny ME, Hung AM, Blot WJ, Ikizler TA, Siew ED. High prevalence of non-steroidal anti-inflammatory drug use among acute kidney injury survivors in the southern community cohort study. BMC Nephrol 2016; 17:189. [PMID: 27881100 PMCID: PMC5122006 DOI: 10.1186/s12882-016-0411-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 11/18/2016] [Indexed: 12/24/2022] Open
Abstract
Background Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used and have been linked to acute kidney injury (AKI), chronic kidney disease (CKD) and cardiovascular disease (CVD). Patients who survive an AKI episode are at risk for future adverse kidney and cardiovascular outcomes. The objective of our study was to examine the prevalence and predictors of NSAID use among AKI survivors. Methods The Southern Community Cohort Study is a prospective study of low-income adults aged 40–79 in the southeastern US. Through linkage with Centers for Medicare and Medicaid Services, 826 participants with an AKI diagnosis (ICD-9 584.5-584.9) at any age prior to cohort enrollment were identified. At baseline, data were collected on regular use of prescription and over-the-counter NSAIDs, as well as demographic, medical and other characteristics. Additional comorbidities were ascertained via linkage with CMS or the US Renal Data System. Results One hundred fifty-four AKI survivors (19%) reported regular NSAID use at cohort enrollment (52 prescription, 81 OTC, 21 both) and the percentage of NSAID users did not vary by time since AKI event. Over 58% of users were taking NSAIDS regularly both before and after their AKI event. Hypertension (83%), arthritis (71%), heart failure (44%), CKD (36%) and diabetes (35%) were prevalent among NSAID users. In a multivariable model, history of arthritis (OR: 3.00; 95% CI: 1.92, 4.68) and acetaminophen use (OR: 2.43; 95% CI: 1.50, 3.93) were significantly associated with NSAID use, while prevalent CKD (OR: 0.63; 95% CI: 0.41, 0.98) and diabetes (OR: 0.44; 95% CI: 0.29, 0.69) were significantly inversely associated. Conclusions NSAID use among AKI survivors is common and highlights the need to understand physician and patient decision-making around NSAIDs and to develop effective strategies to reduce NSAID use in this vulnerable population. Electronic supplementary material The online version of this article (doi:10.1186/s12882-016-0411-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Loren Lipworth
- Department of Medicine, Division of Epidemiology, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA
| | - Khaled Abdel-Kader
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA.,Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer Morse
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thomas G Stewart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edmond K Kabagambe
- Department of Medicine, Division of Epidemiology, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA
| | - Sharidan K Parr
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA.,Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Healthcare System (TVHS) VA Medical Center, TVHS Geriatric Research Education and Clinical Centers (GRECC), Veteran's Health Administration, Nashville, TN, USA
| | - Kelly A Birdwell
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA.,Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael E Matheny
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA.,Tennessee Valley Healthcare System (TVHS) VA Medical Center, TVHS Geriatric Research Education and Clinical Centers (GRECC), Veteran's Health Administration, Nashville, TN, USA
| | - Adriana M Hung
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA.,Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Healthcare System (TVHS) VA Medical Center, TVHS Geriatric Research Education and Clinical Centers (GRECC), Veteran's Health Administration, Nashville, TN, USA
| | - William J Blot
- Department of Medicine, Division of Epidemiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - T Alp Ikizler
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA.,Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Healthcare System (TVHS) VA Medical Center, TVHS Geriatric Research Education and Clinical Centers (GRECC), Veteran's Health Administration, Nashville, TN, USA
| | - Edward D Siew
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA. .,Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA. .,Tennessee Valley Healthcare System (TVHS) VA Medical Center, TVHS Geriatric Research Education and Clinical Centers (GRECC), Veteran's Health Administration, Nashville, TN, USA.
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Greenberg JH, Zappitelli M, Devarajan P, Thiessen-Philbrook HR, Krawczeski C, Li S, Garg AX, Coca S, Parikh CR. Kidney Outcomes 5 Years After Pediatric Cardiac Surgery: The TRIBE-AKI Study. JAMA Pediatr 2016; 170:1071-1078. [PMID: 27618162 PMCID: PMC5476457 DOI: 10.1001/jamapediatrics.2016.1532] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
IMPORTANCE Acute kidney injury (AKI) after pediatric cardiac surgery is associated with high short-term morbidity and mortality; however, the long-term kidney outcomes are unclear. OBJECTIVE To assess long-term kidney outcomes after pediatric cardiac surgery and to determine if perioperative AKI is associated with worse long-term kidney outcomes. DESIGN, SETTING, AND PARTICIPANTS This prospective multicenter cohort study recruited children between ages 1 month to 18 years who underwent cardiopulmonary bypass for cardiac surgery and survived hospitalization from 3 North American pediatric centers between July 2007 and December 2009. Children were followed up with telephone calls and an in-person visit at 5 years after their surgery. EXPOSURES Acute kidney injury defined as a postoperative serum creatinine rise from preoperative baseline by 50% or 0.3 mg/dL or more during hospitalization for cardiac surgery. MAIN OUTCOMES AND MEASURES Hypertension (blood pressure ≥95th percentile for height, age, sex, or self-reported hypertension), microalbuminuria (urine albumin to creatinine ratio >30 mg/g), and chronic kidney disease (serum creatinine estimated glomerular filtration rate [eGFR] <90 mL/min/1.73 m2 or microalbuminuria). RESULTS Overall, 131 children (median [interquartile range] age, 7.7 [5.9-9.9] years) participated in the 5-year in-person follow-up visit; 68 children (52%) were male. Fifty-seven of 131 children (44%) had postoperative AKI. At follow-up, 22 children (17%) had hypertension (10 times higher than the published general pediatric population prevalence), while 9 (8%), 13 (13%), and 1 (1%) had microalbuminuria, an eGFR less than 90 mL/min/1.73 m2, and an eGFR less than 60 mL/min/1.73 m2, respectively. Twenty-one children (18%) had chronic kidney disease. Only 5 children (4%) had been seen by a nephrologist during follow-up. There was no significant difference in renal outcomes between children with and without postoperative AKI. CONCLUSIONS AND RELEVANCE Chronic kidney disease and hypertension are common 5 years after pediatric cardiac surgery. Perioperative AKI is not associated with these complications. Longer follow-up is needed to ascertain resolution or worsening of chronic kidney disease and hypertension.
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Affiliation(s)
- Jason H. Greenberg
- Section of Nephrology, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut2Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut
| | - Michael Zappitelli
- Division of Pediatric Nephrology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
| | - Prasad Devarajan
- Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Catherine Krawczeski
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Simon Li
- Division of Critical Care, Department of Pediatrics, Maria Fareri Children’s Hospital, Valhalla, New York
| | - Amit X. Garg
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - Steve Coca
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut8Section of Nephrology, Department of Internal Medicine, Mount Sinai School of Medicine, New York, New York
| | - Chirag R. Parikh
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut9Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut10VA Medical Center, West Haven, Connecticut
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Hypertension after injury among burned combat veterans: A retrospective cohort study. Burns 2016; 43:290-296. [PMID: 28029474 DOI: 10.1016/j.burns.2016.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/03/2016] [Accepted: 10/05/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND The long-term health effects of burn are poorly understood. We sought to evaluate the relationship between burn and the subsequent development of hypertension. METHODS Retrospective cohort study of patients admitted to our burn center from 2003 to 2010. Data collected included demographic variables, burn size, injury severity score, presence of inhalation injury, serum creatinine, need for renal replacement therapy, as well as days spent in the hospital, in the intensive care unit and on mechanical ventilation. Data for the subsequent diagnosis of hypertension was obtained from medical records. Cox proportional hazard regression models were performed to determine what factors were associated with hypertension. RESULTS Of the 711 patients identified, 670 were included for analysis after exclusions. After adjustment, only age (HR 1.06 per one year increase, 95% confidence interval 1.03-1.08; p<0.001), percentage of total body surface area burned (HR 1.11 per 5% increase, 95% confidence interval 1.04-1.19; p=0.002) and acute kidney injury (HR 1.68, 95% confidence interval 1.05-2.69; p=0.03) were associated with hypertension. CONCLUSION Burn size is independently associated with the subsequent risk of hypertension in combat casualties. Clinical support for primary prevention techniques to reduce the incidence of hypertension specific to burn patients may be warranted.
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Cheng SY, Chou YH, Liao FL, Lin CC, Chang FC, Liu CH, Huang TM, Lai CF, Lin YF, Wu VC, Chu TS, Wu MS, Lin SL. Losartan reduces ensuing chronic kidney disease and mortality after acute kidney injury. Sci Rep 2016; 6:34265. [PMID: 27677327 PMCID: PMC5039710 DOI: 10.1038/srep34265] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 09/12/2016] [Indexed: 01/04/2023] Open
Abstract
Acute kidney injury (AKI) is an important risk factor for incident chronic kidney disease (CKD). Clinical studies disclose that ensuing CKD progresses after functional recovery from AKI, but the underlying mechanisms remain illusive. Using a murine model representing AKI-CKD continuum, we show angiotensin II type 1a (AT1a) receptor signaling as one of the underlying mechanisms. Male adult CD-1 mice presented severe AKI with 20% mortality within 2 weeks after right nephrectomy and left renal ischemia-reperfusion injury. Despite functional recovery, focal tubular atrophy, interstitial cell infiltration and fibrosis, upregulation of genes encoding angiotensinogen and AT1a receptor were shown in kidneys 4 weeks after AKI. Thereafter mice manifested increase of blood pressure, albuminuria and azotemia progressively. Drinking water with or without losartan or hydralazine was administered to mice from 4 weeks after AKI. Increase of mortality, blood pressure, albuminuria, azotemia and kidney fibrosis was noted in mice with vehicle administration during the 5-month experimental period. On the contrary, these parameters in mice with losartan administration were reduced to the levels shown in control group. Hydralazine did not provide similar beneficial effect though blood pressure was controlled. These findings demonstrate that losartan can reduce ensuing CKD and mortality after functional recovery from AKI.
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Affiliation(s)
- Shun-Yang Cheng
- Graduate Institute of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Hsiang Chou
- Graduate Institute of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Fang-Ling Liao
- Graduate Institute of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chi-Chun Lin
- Graduate Institute of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Fan-Chi Chang
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Renal Division, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chia-Hao Liu
- Graduate Institute of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tao-Min Huang
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Chun-Fu Lai
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Feng Lin
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Vin-Cent Wu
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzong-Shinn Chu
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Shiou Wu
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shuei-Liong Lin
- Graduate Institute of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Sprenger-Mähr H, Zitt E, Lhotta K. Acute Kidney Injury Treated with Dialysis outside the Intensive Care Unit: A Retrospective Observational Single-Center Study. PLoS One 2016; 11:e0163512. [PMID: 27673681 PMCID: PMC5038962 DOI: 10.1371/journal.pone.0163512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 09/09/2016] [Indexed: 01/19/2023] Open
Abstract
Introduction The number of patients suffering from acute kidney injury requiring dialysis (AKI-D) is increasing. Whereas causes and outcome of AKI-D in the intensive care unit (ICU) are described extensively, few data exist about AKI-D patients treated outside the ICU. Aim of this study was to identify the causes of AKI-D, determine in-depth the comorbid conditions and outcome of this particular patient group and identify possibilities for its prevention. Methods We retrospectively studied all AKI-D patients treated outside the ICU in a single nephrology referral center between January 2010 and June 2015. Data on comorbid conditions, renal function and drug therapy prior to AKI-D, and possible causal events were collected. Patients were grouped into those with renal hypoperfusion as the predominant cause of AKI-D (hemodynamic group) and those with other causes (non-hemodynamic group). Results During 66 months 128 patients (57% male, mean age 69.3 years) were treated. AKI-D was community-acquired in 70.3%. The most frequent comorbidities were hypertension (62.5%), chronic kidney disease (CKD) (58.9%), coronary artery disease (CAD) (46.1%), diabetes (35.9%) and heart failure (34.1%). Most patients were prescribed diuretics (61.7%) and inhibitors of the renin-angiotensin-aldosterone system (RASI) (57.8%); 46.1% had a combination of both. In the 88 patients with hemodynamic AKI-D (68.8%) the most frequent initiating events were diarrhea (39.8%), infections (17.0%) and acute heart failure (13.6%). In the 40 patients with non-hemodynamic AKI-D (31.2%) interstitial nephritis (n = 15) was the prominent diagnosis. Patients with hemodynamic AKI-D were older (72.6 vs. 62.1 years, p = 0.001), suffered more often from CKD (68.2% vs. 33.3%, p = 0.003), CAD (54.5% vs. 27.5%, p = 0.004) and diabetes (42.0% vs. 22.5%, p = 0.033), and were more frequently on diuretics (75.0% vs. 32.5%, p<0.001), RASI (67.0% vs. 37.5%, p = 0.002) or their combination (58.0% vs. 20.0%, p<0.001). Twenty-two (17.2%) patients died and 27 (21.1%) patients died or developed end-stage renal disease. Conclusion AKI-D treated outside the ICU is most often caused by renal hypoperfusion. It predominantly afflicts elderly patients with one or more comorbid conditions, who are treated with diuretics and RASI and have an acute illness leading to volume depletion. Early discontinuation of these drugs may be a successful strategy to avoid AKI-D in vulnerable patients.
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Affiliation(s)
- Hannelore Sprenger-Mähr
- Department of Nephrology and Dialysis, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Emanuel Zitt
- Department of Nephrology and Dialysis, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Karl Lhotta
- Department of Nephrology and Dialysis, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Teaching Hospital Feldkirch, Feldkirch, Austria
- * E-mail:
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Picken M, Long J, Williamson GA, Polichnowski AJ. Progression of Chronic Kidney Disease After Acute Kidney Injury: Role of Self-Perpetuating Versus Hemodynamic-Induced Fibrosis. Hypertension 2016; 68:921-8. [PMID: 27550923 DOI: 10.1161/hypertensionaha.116.07749] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 07/22/2016] [Indexed: 12/20/2022]
Abstract
The relative contribution of self-perpetuating versus hemodynamic-induced fibrosis to the progression of chronic kidney disease (CKD) after acute kidney injury (AKI) is unclear. In the present study, male Sprague-Dawley rats underwent right uninephrectomy and were instrumented with a blood pressure radiotelemeter. Two weeks later, separate groups of rats were subjected to 40 minutes renal ischemia-reperfusion or sham surgery and followed up for 4 or 16 weeks to determine the extent to which glomerulosclerosis and tubulointerstitial fibrosis as a result of the AKI-CKD transition (ie, at 4 weeks post AKI) change over time during the progression of CKD (ie, at 16 weeks post AKI). On average, tubulointerstitial fibrosis was ≈3-fold lower (P<0.05), whereas glomerulosclerosis was ≈6-fold higher (P<0.05) at 16 versus 4 weeks post AKI. At 16 weeks post AKI, marked tubulointerstitial fibrosis was only observed in rats exhibiting marked glomerulosclerosis, proteinuria, and kidney hypertrophy consistent with a hemodynamic pathogenesis of renal injury. Moreover, quantitative analysis between blood pressure and renal injury revealed a clear and modest blood pressure threshold (average 16-week systolic blood pressure of ≈127 mm Hg) for the development of glomerulosclerosis. In summary, modest levels of blood pressure may be playing a substantial role in the progression of renal disease after AKI in settings of preexisting CKD associated with 50% loss of renal mass. In contrast, these data do not support a major role of self-perpetuating tubulointerstitial fibrosis in the progression CKD after AKI in such settings.
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Affiliation(s)
- Maria Picken
- From the Research and Development Service, Edward Hines Jr. VA Hospital, Hines, IL (A.J.P.); Department of Medicine, (A.J.P.) and Department of Pathology (M.P.), Loyola University-Chicago, Maywood, IL; and Department of Electrical and Computer Engineering, Illinois Institute of Technology, Chicago (J.L., G.A.W.)
| | - Jianrui Long
- From the Research and Development Service, Edward Hines Jr. VA Hospital, Hines, IL (A.J.P.); Department of Medicine, (A.J.P.) and Department of Pathology (M.P.), Loyola University-Chicago, Maywood, IL; and Department of Electrical and Computer Engineering, Illinois Institute of Technology, Chicago (J.L., G.A.W.)
| | - Geoffrey A Williamson
- From the Research and Development Service, Edward Hines Jr. VA Hospital, Hines, IL (A.J.P.); Department of Medicine, (A.J.P.) and Department of Pathology (M.P.), Loyola University-Chicago, Maywood, IL; and Department of Electrical and Computer Engineering, Illinois Institute of Technology, Chicago (J.L., G.A.W.)
| | - Aaron J Polichnowski
- From the Research and Development Service, Edward Hines Jr. VA Hospital, Hines, IL (A.J.P.); Department of Medicine, (A.J.P.) and Department of Pathology (M.P.), Loyola University-Chicago, Maywood, IL; and Department of Electrical and Computer Engineering, Illinois Institute of Technology, Chicago (J.L., G.A.W.).
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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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123
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Abstract
Acute kidney injury is strongly associated with increased mortality and other adverse outcomes. Medical researchers have intensively investigated novel biomarkers to predict short- and long-term outcomes of acute kidney injury in many patient care settings, such as cardiac surgery, intensive care units, heart failure, and transplant. Future research should focus on leveraging this relationship to improve enrollment for clinical trials of acute kidney injury.
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Affiliation(s)
- Jennifer A Schaub
- Program of Applied Translational Research, Yale University, New Haven, CT, USA
| | - Chirag R Parikh
- Program of Applied Translational Research, Yale University, New Haven, CT, USA
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124
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Palant CE, Chawla LS, Faselis C, Li P, Pallone TL, Kimmel PL, Amdur RL. High serum creatinine nonlinearity: a renal vital sign? Am J Physiol Renal Physiol 2016; 311:F305-9. [PMID: 27194712 DOI: 10.1152/ajprenal.00025.2016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 05/10/2016] [Indexed: 01/20/2023] Open
Abstract
Patients with chronic kidney disease (CKD) may have nonlinear serum creatinine concentration (SC) trajectories, especially as CKD progresses. Variability in SC is associated with renal failure and death. However, present methods for measuring SC variability are unsatisfactory because they blend information about SC slope and variance. We propose an improved method for defining and calculating a patient's SC slope and variance so that they are mathematically distinct, and we test these methods in a large sample of US veterans, examining the correlation of SC slope and SC nonlinearity (SCNL) and the association of SCNL with time to stage 4 CKD (CKD4) and death. We found a strong correlation between SCNL and rate of CKD progression, time to CKD4, and time to death, even in patients with normal renal function. We therefore argue that SCNL may be a measure of renal autoregulatory dysfunction that provides an early warning sign for CKD progression.
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Affiliation(s)
- Carlos E Palant
- Department of Medicine, Veterans Affairs Medical Center, Washington, District of Columbia; Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University Medical Center, Washington, District of Columbia
| | - Lakhmir S Chawla
- Department of Medicine, Veterans Affairs Medical Center, Washington, District of Columbia; Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University Medical Center, Washington, District of Columbia; Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, Washington, District of Columbia
| | - Charles Faselis
- Department of Medicine, Veterans Affairs Medical Center, Washington, District of Columbia
| | - Ping Li
- Department of Medicine, Veterans Affairs Medical Center, Washington, District of Columbia; Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University Medical Center, Washington, District of Columbia
| | - Thomas L Pallone
- Department of Medicine, University of Maryland at Baltimore, Baltimore, Maryland
| | - Paul L Kimmel
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University Medical Center, Washington, District of Columbia; National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Richard L Amdur
- Department of Medicine, Veterans Affairs Medical Center, Washington, District of Columbia; Biostatistics Core, Veterans Affairs Medical Center, Washington, District of Columbia; Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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125
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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: 53] [Impact Index Per Article: 6.6] [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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