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See EJ, Toussaint ND, Bailey M, Johnson DW, Polkinghorne KR, Robbins R, Bellomo R. Risk factors for major adverse kidney events in the first year after acute kidney injury. Clin Kidney J 2019; 14:556-563. [PMID: 33623679 PMCID: PMC7886537 DOI: 10.1093/ckj/sfz169] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/08/2019] [Indexed: 01/29/2023] Open
Abstract
Background Acute kidney injury (AKI) survivors are at increased risk of major adverse kidney events (MAKEs), including chronic kidney disease (CKD), end-stage kidney disease (ESKD) and death. High-risk AKI patients may benefit from specialist follow-up, but factors associated with increased risk have not been reported. Methods We conducted a retrospective study of AKI patients admitted to a single centre between 2012 and 2016 who had a baseline estimated glomerular filtration rate (eGFR) >30 mL/min/1.73 m2 and were alive and independent of renal replacement therapy (RRT) at 30 days following discharge. AKI was identified using International Classification of Diseases, Tenth Revision codes and staged according to the Kidney Disease: Improving Global Outcomes criteria. Patients were excluded if they were kidney transplant recipients or if AKI was attributed to intrinsic kidney disease. We performed Cox regression models to examine MAKEs in the first year, defined as the composite of CKD (sustained 25% drop in eGFR), ESKD (requirement for chronic RRT or sustained eGFR <15 mL/min/1.73 m2) or death. We examined secondary outcomes (CKD, ESKD and death) using Cox and competing risk regression analyses. Results We studied 2101 patients (mean ± SD age 69 ± 15 years, baseline eGFR 72 ± 23 mL/min/1.73 m2). Of these, 767 patients (37%) developed at least one MAKE (429 patients developed CKD, 21 patients developed ESKD, 375 patients died). MAKEs occurred more frequently with older age [hazard ratio (HR) 1.16 per decade, 95% confidence interval (CI) 1.10–1.24], greater severity of AKI (Stage 2 HR 1.38, 95% CI 1.16–1.64; Stage 3 HR 1.62, 95% CI 1.31–2.01), higher serum creatinine at discharge (HR 1.04 per 10 µmol/L, 95% CI 1.03–1.06), chronic heart failure (HR 1.41, 95% CI 1.19–1.67), liver disease (HR 1.68, 95% CI 1.39–2.03) and malignancy (non-metastatic HR 1.44, 95% CI 1.14–1.82; metastatic HR 2.26, 95% CI 1.80–2.83). Traditional risk factors (e.g. diabetes and cardiovascular disease) had limited predictive value. Conclusions More than a third of AKI patients develop MAKEs within the first year. Clinical variables available at the time of discharge can help identify patients at increased risk of such events.
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Affiliation(s)
- Emily J See
- School of Medicine, University of Melbourne, Melbourne, Australia.,Department for Continuing Education, University of Oxford, Oxford, UK.,Department of Intensive Care, Austin Hospital, Heidelberg, Australia
| | - Nigel D Toussaint
- Department of Medicine, University of Melbourne, Melbourne, Australia.,Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Michael Bailey
- School of Medicine, University of Melbourne, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia.,Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia.,Australasian Kidney Trials Network, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia
| | - Kevan R Polkinghorne
- School of Medicine, Monash University, Melbourne, Australia.,Department of Nephrology, Monash Health, Clayton, Australia.,Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Raymond Robbins
- Data Analytics Research and Evaluation, The University of Melbourne and Austin Hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- School of Medicine, University of Melbourne, Melbourne, Australia.,Department of Intensive Care, Austin Hospital, Heidelberg, Australia.,Data Analytics Research and Evaluation, The University of Melbourne and Austin Hospital, Melbourne, Australia
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Pan HC, Wu PC, Wu VC, Yang YF, Huang TM, Shiao CC, Chen TC, Tarng DC, Lin JH, Yang WS, Sun CY, Lin CY, Chu TS, Wu MS, Wu KD, Chen YC, Huang CC. A nationwide survey of clinical characteristics, management, and outcomes of acute kidney injury (AKI) - patients with and without preexisting chronic kidney disease have different prognoses. Medicine (Baltimore) 2016; 95:e4987. [PMID: 27684854 PMCID: PMC5265947 DOI: 10.1097/md.0000000000004987] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Acute kidney injury (AKI) is a common complication in hospitalized patients. The International Society of Nephrology implemented the "0 by 25" initiative aimed at preventing deaths from treatable AKI worldwide by 2025 and conducted a global snapshot survey in 2014. We joined in the project and conducted this study to compare the epidemiology, risk factors, and prognosis between patients with pure AKI and those with acute-on-chronic kidney disease (ACKD). In this study, we prospectively collected demographic parameters and data on clinical characteristics, baseline comorbidities, management, and outcomes of 201 AKI patients in 18 hospitals in Taiwan from September 2014 to November 2014. The in-hospital mortality rate was 16%. AKI was mostly attributed to sepsis (52%). Multivariate logistic regression indicated that oliguria was a positive independent predictor of in-hospital mortality, whereas preexisting CKD and exposure to nephrotoxic agents were negative independent predictors. The prevalence of vasopressor use, intensive care unit care, and mortality were significantly higher in pure AKI patients than in ACKD patients. Moreover, serum creatinine (SCr) levels significantly increased within 7 days after AKI diagnosis in nonsurvivors but not in survivors in the pure AKI group. By contrast, SCr levels were persistently lower in nonsurvivors than in survivors in the ACKD group during the same period. We thus determined that the prognosis of ACKD patients differed from that of pure AKI patients. Considering the CKD history in the future AKI staging system may improve prognosis prediction.
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Affiliation(s)
- Heng-Chih Pan
- Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung
| | - Pei-Chen Wu
- Division of Nephrology, Department of Internal Medicine, Mackay Memorial Hospital
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Ya-Fei Yang
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung
| | - Tao-Min Huang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yunlin
| | - Chih-Chung Shiao
- Division of Nephrology, Department of Internal Medicine, Saint Mary's Hospital Luodong; and Saint Mary's Medicine, Nursing and Management College, Yilan
| | - Te-Chuan Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung; and Chang Gung University College of Medicine, Taoyuan
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei
| | - Jui-Hsiang Lin
- Division of Nephrology, Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan
| | - Wei-Shun Yang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital Hisn-Chu Branch, Hsin-Chu City
| | - Chiao-Yin Sun
- Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung
| | - Chan-Yu Lin
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital; and Chang Gung University College of Medicine, Taoyuan
| | - Tzong-Shinn Chu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan (R.O.C.)
| | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Yung-Chang Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital; and Chang Gung University College of Medicine, Taoyuan
- Correspondence: Yung-Chang Chen, Department of Nephrology, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei 105, Taiwan (R.O.C.) (e-mail: ); Chiu-Ching Huang, Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, No.91, Hsueh-Shih Road, Taichung 404, Taiwan (R.O.C.) (e-mail: )
| | - Chiu-Ching Huang
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung
- Correspondence: Yung-Chang Chen, Department of Nephrology, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei 105, Taiwan (R.O.C.) (e-mail: ); Chiu-Ching Huang, Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, No.91, Hsueh-Shih Road, Taichung 404, Taiwan (R.O.C.) (e-mail: )
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Chen YM, Li WY, Wu VC, Wang YC, Hwang SJ, Lin SH, Wu KD. Impact of weaning from acute dialytic therapy on outcomes of chronic kidney disease following urgent-start dialysis. PLoS One 2015; 10:e0123386. [PMID: 25856435 PMCID: PMC4391852 DOI: 10.1371/journal.pone.0123386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 02/18/2015] [Indexed: 11/18/2022] Open
Abstract
Discontinuation of acute, unplanned dialysis is always an important therapeutic goal in dialysis-requiring patients with existing chronic kidney disease. Only a limited proportion of patients could be weaned off dialysis and remained dialysis-free. Here we performed a multicenter, observational study to investigate factors associated with successful weaning from acute dialysis, and to explore the potential impact of weaning itself on outcomes of patients with chronic kidney disease following urgent-start dialysis. We recruited 440 chronic kidney disease patients with a baseline estimated glomerular filtration rate <45 ml/min per 1/73 m2, and used propensity score-adjusted Cox regression analysis to measure the effect of weaning from acute dialysis on death during the index hospitalization and death or readmission after discharge. Over 2 years, 64 of 421 (15.2%) patients who survived >1 month died, and 36 (8.6%) were removed from dialysis, with 26 (6.2%) remaining alive and dialysis-free. Logistic regression analysis found that age ≧ 65 years, ischemic acute tubular necrosis, nephrotoxic exposure, urinary obstruction, and higher predialysis estimated glomerular filtration rate and serum hemoglobin were predictors of weaning off dialysis. After adjustment for propensity scores for dialysis weaning, Cox proportional hazards models showed successful weaning from dialysis (adjusted hazard ratio 0.06; 95% confidence interval 0.01 to 0.35), along with a history of hypertension and serum albumin, were independent protectors for early death. Conversely, a history of stroke, peripheral arterial disease and cancer predicted the occurrence of early mortality. In conclusion, this prospective cohort study shows that compared to patients with chronic kidney disease who became end-stage renal disease after acute dialysis, patients who could be weaned off acute dialytic therapy were associated with reduced risk of premature death over a 2-year observation period.
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Affiliation(s)
- Yung-Ming Chen
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, Taiwan
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
- * E-mail:
| | - Wen-Yi Li
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, Taiwan
| | - Vin-Cent Wu
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Cheng Wang
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shang-Jyh Hwang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital; Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Adjunctive Investigator, Division of Geriatrics and Gerontology, Institute of Population Health Sciences, National Health Research Institutes, Taiwan
| | - Shih-Hwa Lin
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Kwan-Dun Wu
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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de Abreu KLS, da Silva Junior GB, Muniz TD, Barreto AGC, Lima RSA, Holanda MA, Pereira EDB, Libório AB, Daher EDF. Acute kidney injury in critically ill patients with lung disease: kidney-lung crosstalk. Rev Bras Ter Intensiva 2015; 25:130-6. [PMID: 23917978 PMCID: PMC4031835 DOI: 10.5935/0103-507x.20130024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 06/18/2013] [Indexed: 11/20/2022] Open
Abstract
Objective To examine the factors associated with acute kidney injury and outcome in patients
with lung disease. Methods A prospective study was conducted with 100 consecutive patients admitted to a
respiratory intensive care unit in Fortaleza (CE), Brazil. The risk factors for
acute kidney injury and mortality were investigated in a group of patients with
lung diseases. Results The mean age of the study population was 57 years, and 50% were male. The
incidence of acute kidney injury was higher in patients with
PaO2/FiO2<200 mmHg (54% versus 23.7%; p=0.02). Death was observed in
40 cases and the rate of mortality of the acute kidney injury group was higher
(62.8% versus 27.6%; p=0.01). The independent factor that was found to be
associated with acute kidney injury was PaO2/FiO2<200
mmHg (p=0.01), and the independent risk factors for death were PEEP at admission
(OR: 3.6; 95%CI: 1.3-9.6; p=0.009) and need for hemodialysis (OR: 7.9; 95%CI:
2.2-28.3; p=0.001). Conclusion There was a higher mortality rate in the acute kidney injury group. Increased
mortality was associated with mechanical ventilation, high PEEP, urea and need for
dialysis. Further studies must be performed to better establish the relationship
between kidney and lung injury and its impact on patient outcome.
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Skott M, Nørregaard R, Birke-Sørensen H, Palmfeldt J, Kwon TH, Frøkiaer J, Nielsen S. Acute kidney injury in rats with or without pre-existing chronic kidney disease: cytokine/chemokine response. Nephrology (Carlton) 2014; 19:410-9. [PMID: 24730452 DOI: 10.1111/nep.12263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2014] [Indexed: 11/28/2022]
Abstract
AIM Evidence suggests the possibility that pre-existing chronic kidney (CKD) disease may result in a more severe outcome of acute kidney injury (AKI). The aim of this study was to examine whether CKD enhances the inflammatory response in the kidney, as well as other organs, in response to AKI in rats. METHODS CKD was induced by 5/6 nephrectomy (Nx) and AKI by intestinal ischaemia and reperfusion (IIR). RESULTS For 6 weeks following Nx there was a progressive increase in serum creatinine with associated development of albuminuria. The increment in creatinine above baseline determination 90 min following IIR was comparable in 5/6 Nx and in the sham 5/6 Nx. Similarly, increased levels of serum alanine transaminase and histomorphological changes in the lungs were observed in the rats exposed to IIR compared with those exposed to sham IIR, with no additional significant impact of 5/6 Nx. In kidney tissue the levels of cytokines/chemokines were equally elevated regardless of exposure to sham IIR or IIR. In lung and liver tissue the levels of cytokines/chemokines were equally elevated in the rats that were exposed to IIR, regardless of exposure to sham Nx or Nx. CONCLUSION We conclude that the immediate severity of AKI induced by IIR in rats with CKD is similar to that induced in rats without CKD. However, the impact of Nx on the cytokine/chemokine response after AKI is not uniform in kidney, lung or liver tissue.
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Affiliation(s)
- Martin Skott
- Department of Biomedicine, Aarhus University, Aarhus, Denmark; The Water & Salt Research Center, Aarhus University, Aarhus, Denmark
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