Non-recovery from dialysis-requiring acute kidney injury and short-term mortality and cardiovascular risk: a cohort study

Abstract

Background: The high mortality and cardiovascular disease (CVD) burden in patients with end-stage renal disease (ESRD) is well-documented. Recent literature suggests that acute kidney injury is also associated with CVD. It is unknown whether patients with incident ESRD due to dialysis-requiring acute kidney injury (AKI-D) are at higher short-term risk for death and CVD events, compared with incident ESRD patients without preceding AKI-D. Few studies have examined the impact of recovery from AKI-D on subsequent CVD risk.

Methods: In this retrospective cohort study, we evaluated adult members of Kaiser Permanente Northern California who initiated dialysis from January 2009 to September 2015. Preceding AKI-D and subsequent outcomes of death and CVD events (acute coronary syndrome, heart failure, ischemic stroke or transient ischemic attack) were identified from electronic health records. We performed multivariable Cox regression models adjusting for demographics, comorbidities, medication use, and laboratory results.

Results: Compared to incident ESRD patients who experienced AKI-D (n = 1865), patients with ESRD not due to AKI-D (n = 3772) had significantly lower adjusted rates of death (adjusted hazard ratio [aHR] 0.56, 95% CI: 0.47-0.67) and heart failure hospitalization (aHR 0.45, 0.30-0.70). Compared to AKI-D patients who did not recover and progressed to ESRD, AKI-D patients who recovered (n = 1347) had a 30% lower adjusted relative rate of death (aHR 0.70, 0.55-0.88).

Conclusions: Patients who transition to ESRD via AKI-D are a high-risk subgroup that may benefit from aggressive monitoring and medical management, particularly for heart failure. Recovery from AKI-D is independently associated with lower short-term mortality.

Keywords: Cardiovascular events; Dialysis-requiring acute kidney injury; End-stage renal disease; Mortality; Renal recovery.

Conflict of interest statement

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki and was approved by the KPNC and University of California, San Francisco institutional review boards. We obtained a waiver of informed consent given the nature of the study.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

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Figures

Fig. 1

Multivariable association of all-cause mortality and cardiovascular events after dialysis initiation among patients with incident end-stage renal disease (ESRD) due to dialysis-requiring acute kidney injury (AKI-D), patients with incident ESRD not due to AKI-D, and patients with AKI-D who recovered. Models are adjusted for the following baseline covariates: age, gender, race, Hispanic ethnicity, smoking status, acute myocardial infarction, heart failure, ischemic stroke or transient ischemic attack, peripheral artery disease, mitral and/or aortic valvular disease, atrial flutter or fibrillation, venous thromboembolism, other thromboembolic events, coronary artery bypass surgery, percutaneous coronary intervention, diabetes mellitus, hypertension, dyslipidemia, hyperthyroidism, hypothyroidism, cirrhosis, chronic lung disease, diagnosed dementia, diagnosed depression, hospitalized bleed, body mass index, systolic blood pressure, eGFR, dipstick proteinuria, hemoglobin level, HDL cholesterol level, LDL cholesterol level, and pre-admission receipt of the following medications: ACE inhibitor, angiotensin II receptor blocker, antiarrhythmic drug, beta blocker, calcium channel blocker, diuretic, alpha blocker, any anti-hypertensive agent, aldosterone receptor antagonist, nitrates, vasodilators, statin, other lipid-lowering agent, non-aspirin antiplatelet agent, low molecular weight heparin, non-steroidal anti-inflammatory drug, and diabetic therapy