Acute kidney injury subphenotypes based on creatinine trajectory identifies patients at increased risk of death

Pavan K Bhatraju, Paramita Mukherjee, Cassianne Robinson-Cohen, Grant E O'Keefe, Angela J Frank, Jason D Christie, Nuala J Meyer, Kathleen D Liu, Michael A Matthay, Carolyn S Calfee, David C Christiani, Jonathan Himmelfarb, Mark M Wurfel, Pavan K Bhatraju, Paramita Mukherjee, Cassianne Robinson-Cohen, Grant E O'Keefe, Angela J Frank, Jason D Christie, Nuala J Meyer, Kathleen D Liu, Michael A Matthay, Carolyn S Calfee, David C Christiani, Jonathan Himmelfarb, Mark M Wurfel

Abstract

Background: Acute kidney injury (AKI) is common among intensive care unit (ICU) patients. AKI is highly heterogeneous, with variable links to poor outcomes. Current approaches to classify AKI severity and identify patients at highest risk for poor outcomes focus on the maximum change in serum creatinine (SCr) values. However, these scores are hampered by the need for a reliable baseline SCr value and the absence of a component differentiating transient from persistent rises in SCr. We hypothesized that identification of resolving or nonresolving AKI subphenotypes based on the early trajectory of SCr values in the ICU would better differentiate patients at risk of hospital mortality.

Methods: We performed a secondary analysis of two prospective studies of ICU patients admitted to a trauma ICU (group 1; n = 1914) or general medical-surgical ICUs (group 2; n = 1867). In group 1, we tested definitions for resolving and nonresolving AKI subphenotypes and selected the definitions resulting in subphenotypes with the greatest separation in risk of death relative to non-AKI controls. We applied this definition to group 2 and tested whether the subphenotypes were independently associated with hospital mortality after adjustment for AKI severity.

Results: AKI occurred in 46% and 69% of patients in groups 1 and 2, respectively. In group 1, a resolving AKI subphenotype (defined as a decrease in SCr of 0.3 mg/dl or 25% from maximum in the first 72 h of study enrollment) was associated with a low risk of death. A nonresolving AKI subphenotype (defined as all AKI cases not meeting the "resolving" definition) was associated with a high risk of death. In group 2, the resolving AKI subphenotype was not associated with increased mortality (relative risk [RR] 0.86, 95% CI 0.63-1.17), whereas the nonresolving AKI subphenotype was associated with higher mortality (RR 1.68, 95% CI 1.15-2.44) even after adjustment for AKI severity stage.

Conclusions: The trajectory of SCr levels identifies AKI subphenotypes with different risks for death, even among AKI cases of similar severity. These AKI subphenotypes might better define the patients at risk for poor outcomes who might benefit from novel interventions.

Keywords: Acute kidney injury; Critical care; Intensive care unit; Mortality; Subphenotypes; Trajectory.

Figures

Fig. 1
Fig. 1
Diagram of the trajectory of patients with acute kidney injury (AKI) in the resolving and nonresolving subphenotype groups. Graphical representation of serum creatinine (SCr) trajectory in AKI subphenotypes. Spaghetti plots with trend lines of serial SCr values obtained over the first 72–96 h of admission in subjects exhibiting a resolving AKI subphenotype and b nonresolving AKI subphenotype

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