Risk factors for major adverse kidney events in the first year after acute kidney injury

Emily J See, Nigel D Toussaint, Michael Bailey, David W Johnson, Kevan R Polkinghorne, Raymond Robbins, Rinaldo Bellomo, Emily J See, Nigel D Toussaint, Michael Bailey, David W Johnson, Kevan R Polkinghorne, Raymond Robbins, Rinaldo Bellomo

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.

Keywords: risk factors; acute kidney injury; chronic kidney disease; death; end-stage kidney disease; major adverse kidney events.

© The Author(s) 2019. Published by Oxford University Press on behalf of ERA-EDTA.

Figures

FIGURE 1
FIGURE 1
Study flow diagram.
FIGURE 2
FIGURE 2
Multivariable Cox regression analysis of MAKEs within the first year in 2101 hospitalized adults with AKI. Estimates shown include adjusted HR with 95% CI.
FIGURE 3
FIGURE 3
Cumulative incidence of MAKEs, CKD, ESKD and death occurring between 30 and 365 days following discharge in 2101 hospitalized adults with AKI.

References

    1. Australian Institute of Health and Welfare. Acute Kidney Injury in Australia: A First National Snapshot. Canberra: AIHW, 2015
    1. Li PKT, Burdmann EA, Mehta RL. Acute kidney injury: a global alert. J Bras Nefrol 2013; 35: 1–5
    1. Silver SA, Long J, Zheng Y et al. Cost of acute kidney injury in hospitalized patients. J Hosp Med 2017; 12: 70–76
    1. See EJ, Jayasinghe K, Glassford N et al. Long-term risk of adverse outcomes after acute kidney injury: a systematic review and meta-analysis of cohort studies using consensus definitions of exposure. Kidney Int 2019; 95: 160–172
    1. Stads S, Fortrie G, van Bommel J et al. Impaired kidney function at hospital discharge and long-term renal and overall survival in patients who received CRRT. Clin J Am Soc Nephrol 2013; 8: 1284–1291
    1. Bucaloiu ID, Kirchner HL, Norfolk ER et al. Increased risk of death and de novo chronic kidney disease following reversible acute kidney injury. Kidney Int 2012; 81: 477–485
    1. James MT, Pannu N, Hemmelgarn BR et al. Derivation and external validation of prediction models for advanced chronic kidney disease following acute kidney injury. JAMA 2017; 318: 1787.
    1. Ishani A, Xue JL, Himmelfarb J et al. Acute kidney injury increases risk of ESRD among elderly. J Am Soc Nephrol 2009; 20: 223–228
    1. Bagshaw SM, Laupland KB, Doig CJ et al. Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: a population-based study. Crit Care 2005; 9: R700.
    1. Sawhney S, Mitchell M, Marks A et al. Long-term prognosis after acute kidney injury (AKI): what is the role of baseline kidney function and recovery? A systematic review. BMJ Open 2015; 5: e006497
    1. Lee P-H, Wu V-C, Hu F-C et al. Outcomes following dialysis for acute kidney injury among different stages of chronic kidney disease. Am J Nephrol 2011; 34: 95–103
    1. De Corte W, Dhondt A, Vanholder R et al. Long-term outcome in ICU patients with acute kidney injury treated with renal replacement therapy: a prospective cohort study. Crit Care 2016; 20: 256.
    1. Harel Z, Wald R, Bargman JM et al. Nephrologist follow-up improves all-cause mortality of severe acute kidney injury survivors. Kidney Int 2013; 83: 901–908
    1. Palevsky PM. Endpoints for clinical trials of acute kidney injury. Nephron 2018; 140: 111–115
    1. Jin K, Murugan R, Sileanu FE et al. Intensive monitoring of urine output is associated with increased detection of acute kidney injury and improved outcomes. Chest 2017; 152: 972–979
    1. von Elm E, Altman DG, Egger M et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61: 344–349
    1. Waikar SS, Wald R, Chertow GM et al. Validity of International Classification of Diseases, Ninth Revision, clinical modification codes for acute renal failure. J Am Soc Nephrol 2006; 17: 1688–1694
    1. Kellum J, Lameire N, Aspelin P et al. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl 2012; 2: 1–138
    1. Quan H, Sundararajan V, Halfon P et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005; 43: 1130–1139
    1. Levin A, Stevens PE, Bilous RW et al. Kidney disease: improving global outcomes (KDIGO) CKD work group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 2013; 3: 1–150
    1. Dunne L Measuring Remoteness: Accessibility/Remoteness Index of Australia (ARIA) Report. Department of Health and Aged Care, Canberra: 2001; 18–19
    1. Siew ED, Alp Ikizler T, Matheny ME et al. Estimating baseline kidney function in hospitalized patients with impaired kidney function. Clin J Am Soc Nephrol 2012; 7: 712–719
    1. Levey AS, Stevens LA, Schmid CH et al. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009; 150: 604–612
    1. Chawla LS, Amdur RL, Faselis C et al. Impact of acute kidney injury in patients hospitalized with pneumonia. Crit Care Med 2017; 45: 600–606
    1. Chawla LS, Amdur RL, Shaw AD et al. Association between AKI and long-term renal and cardiovascular outcomes in United States veterans. Clin J Am Soc Nephrol 2014; 9: 448–456
    1. Billings FT, Shaw AD. Clinical trial endpoints in acute kidney injury. Nephron Clin Pract 2014; 127: 89–93
    1. Zhou B, Fine J, Laird G. Goodness-of-fit test for proportional subdistribution hazards model. Statist Med 2013; 32: 3804–3811
    1. Chawla LS, Amdur RL, Amodeo S et al. The severity of acute kidney injury predicts progression to chronic kidney disease. Kidney Int 2011; 79: 1361–1369
    1. Silver SA, Harel Z, McArthur E et al. Causes of death after a hospitalization with AKI. J Am Soc Nephrol 2018; 29: 1001–1010

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi