The Aftermath of Acute Kidney Injury

This thesis offers insight in the development op acute kidney injury (AKI) en its long-term sequelae

The aftermath of acute kidney injury: a narrative review of long-term mortality and renal function

Acute kidney injury (AKI) is a frequent complication of hospitalization and is associated with an increased risk of chronic kidney disease (CKD), end-stage renal disease (ESRD), and mortality. While AKI is a known risk factor for short-term adverse outcomes, more recent data suggest that the risk of mortality and renal dysfunction extends far beyond hospital discharge. However, determining whether this risk applies to all patients who experience an episode of AKI is difficult. The magnitude of this risk seems highly dependent on the presence of comorbid conditions, including cardiovascular disease, hypertension, diabetes mellitus, preexisting CKD, and renal recovery. Furthermore, these comorbidities themselves lead to structural renal damage due to multiple pathophysiological changes, including glomeruloscleroses and tubulointerstitial fibrosis, which can lead to the loss of residual capacity, glomerular hyperfiltration, and continued deterioration of renal function. AKI seems to accelerate this deterioration and increase the risk of death, CDK, and ESRD in most vulnerable patients. Therefore, we strongly advocate adequate hemodynamic monitoring and follow-up in patients susceptible to renal dysfunction. Additionally, other potential renal stressors, including nephrotoxic medications and iodine-containing contrast fluids, should be avoided. Unfortunately, therapeutic interventions are not yet available. Additional research is warranted and should focus on the prevention of AKI, identification of therapeutic targets, and provision of adequate follow-up to those who survive an episode of AKI

Long-term sequelae of severe acute kidney injury in the critically Ill patient without comorbidity: A retrospective cohort study

Background and Objectives: Acute kidney injury (AKI) necessitating renal replacement therapy (RRT) is associated with high mortality and increased risk for end stage renal disease. However, it is unknown if this applies to patients with a preliminary unremarkable medical history. The purpose of this study was to describe overall and renal survival in critically ill patients with AKI necessitating RRT stratified by the presence of comorbidity. Design, Setting, Participants, and Measurements: A retrospective cohort study was performed, between 1994 and 2010, including all adult critically ill patients with AKI necessitating RRT, stratified by the presence of comorbidity. Logistic regression, survival curve and cox proportional hazards analyses were used to evaluate overall and renal survival. Standardized mortality rate (SMR) analysis was performed to compare long-term survival to the predicted survival in the Dutch population. Results: Of the 1067 patients included only 96(9.0%) had no comorbidity. Hospital mortality was 56.6% versus 43.8% in patients with and without comorbidity, respectively. In those who survived hospitalization 10-year survival was 45.0% and 86.0%, respectively. Adjusted for age, sex and year of treatment, absence of comorbidity was not associated with hospital mortality (OR=0.74, 95%-CI=0.47-1.15), while absence of comorbidity was associated with better long-term survival (adjusted HR=0.28, 95%-CI = 0.14-0.58). Compared to the Dutch population, patients without comorbidity had a similar mortality risk (SMR=1.6, 95%-CI=0.7-3.2), while this was increased in patients with comorbidity (SMR=4.8, 95%-CI=4.1-5.5). Regarding chronic dialysis dependency, 10-year renal survival rates were 76.0% and 92.9% in patients with and without comorbidity, respectively. Absence of comorbidity was associated with better renal survival (adjusted HR=0.24, 95%-CI=0.07-0.76). Conclusions: While hospital mortality remains excessively high, the absence of comorbidity in critically ill patients with RRT-requiring AKI is associated with a relative good long-term prognosis in those who survive hospitalization

Time of injury affects urinary biomarker predictive values for acute kidney injury in critically ill, non-septic patients

Background: The predictive value of acute kidney injury (AKI) urinary biomarkers may depend on the time interval following tubular injury, thereby explaining in part the heterogeneous performance of these markers that has been reported in the literature. We studied the inf

Overall and renal survival of patients that survived hospital admission.

<p>Data are given as percentage of cumulative overall survival and renal survival at 1, 5 and 10 years stratified by the presence of comorbidity.</p><p>Overall and renal survival of patients that survived hospital admission.</p

Kaplan-Meier curves for renal survival stratified by comorbidity.

<p>Defined as years after discharge until chronic replacement therapy is initiated, censored for death.</p

Univariable and multivariable analysis of characteristics associated with hospital mortality in patients without comorbidity.

<p>CRRT: continuous renal replacement therapy; CVVH: continuous venovenous hemofiltration; ICU: intensive care unit; SOFA: sequential organ failure assessment</p><p>*Score available in 50 cases</p><p>Univariable and multivariable analysis of characteristics associated with hospital mortality in patients without comorbidity.</p

Flowchart of inclusion and hospital mortality stratified by presence of comorbidity.

<p>(C)RRT: (continuous) renal replacement therapy, ICU: intensive care unit, KT: kidney transplant.</p

Standardized mortality ratio analysis in patients that survived hospital admission.

<p>Standardized mortality ratio analysis in patients that survived hospital admission.</p

Clinical and demographical characteristics of 96 patients without comorbidity treated with CRRT in the ICU.

<p>Categorical variables are expressed as number and percentage; continuous variables are expressed as median and interquartile range. AKI: acute kidney injury; CAVHD: continuous arteriovenous haemodialysis; CRRT: continuous renal replacement therapy; CVVH: continuous venovenous hemofiltration; ICU: intensive care unit; SOFA: sequential organ failure assessment</p><p>* Score available in 50 cases</p><p>Clinical and demographical characteristics of 96 patients without comorbidity treated with CRRT in the ICU.</p