External validation of a risk stratification model to assist shared decision making for patients starting renal replacement therapy

BACKGROUND: Shared decision making is nowadays acknowledged as an essential step when deciding on starting renal replacement therapy. Valid risk stratification of prognosis is, besides discussing quality of life, crucial in this regard. We intended to validate a recently published risk stratification model in a large cohort of incident patients starting renal replacement therapy in Flanders. METHODS: During 3 years (2001-2003), the data set collected for the Nederlandstalige Belgische Vereniging voor Nefrologie (NBVN) registry was expanded with parameters of comorbidity. For all incident patients, the abbreviated REIN score(aREIN), being the REIN score without the parameter "mobility", was calculated, and prognostication of mortality at 3, 6 and 12 month after start of renal replacement therapy (RRT) was evaluated. RESULTS: Three thousand four hundred seventy-two patients started RRT in Flanders during the observation period (mean age 67.6 ± 14.3, 56.7 % men, 33.6 % diabetes). The mean aREIN score was 4.1 ± 2.8, and 56.8, 23.1, 12.6 and 7.4 % of patients had a score of ≤4, 5-6, 7-8 or ≥9 respectively. Mortality at 3, 6 and 12 months was 8.6, 14.1 and 19.6 % in the overall and 13.2, 21.5 and 31.9 % in the group with age >75 respectively. In RoC analysis, the aREIN score had an AUC of 0.74 for prediction of survival at 3, 6 and 12 months. There was an incremental increase in mortality with the aREIN score from 5.6 to 45.8 % mortality at 6 months for those with a score ≤4 or ≥9 respectively. CONCLUSION: The aREIN score is a useful tool to predict short term prognosis of patients starting renal replacement therapy as based on comorbidity and age, and delivers meaningful discrimination between low and high risk populations. As such, it can be a useful instrument to be incorporated in shared decision making on whether or not start of dialysis is worthwhile

Prevention and conservative management of acute kidney injury

The incidence of acute kidney injury (AKI) is increasing steadily. This can be attributed to a growing prevalence of risk factors for AKI, such as aging, diabetes, underlying cardiovascular disease and the escalating application of more complex procedures. Currently, there is no treatment for established AKI, except for renal replacement therapy in case of life-threatening conditions. The focus should thus be shifted towards AKI prevention rather than treatment. Several promising pharmacological and non-pharmacological interventions for prevention of AKI in animal models did not fulfill the expectations when applied in humans. There are multiple reasons why these interventions prove to be disappointing. The pathophysiology of AKI in different settings has not been fully elucidated, the underlying cause of AKI in the clinical setting is often multifactorial, and animal AKI models often do not mimic human AKI very well. Ischemia-reperfusion models are representative for human AKI in the setting of aortic clamping or in case of delayed graft function after kidney transplantation, but are not suited to study AKI in many other conditions such as sepsis. Moreover, several drugs for AKI prevention are associated with deleterious adverse events in humans as they lack selectivity. In this review, an overview of the strategies that can be used in the clinical setting for AKI prevention will be presented. Potential preventive strategies in certain specific clinical conditions will also be reviewed