Acute Kidney Injury and Emergent Dialysis

Do Children With Acute Kidney Injury Require Long-term Evaluation for CKD?

Purpose To compare the rates of acute kidney injury (AKI), emergent dialysis, and short-term mortality between patients who underwent intravenous administration of the iso-osmolar contrast material (IOCM) iodixanol 320 and patients who underwent a noncontrast computed tomography (CT) examination. Materials and Methods Study design and implementation were overseen by an institutional review board and conformed to HIPAA guidelines on patient data integrity. All patients who underwent an iodixanol-enhanced (IOCM group) or a noncontrast (noncontrast group) CT examination from January 2003 to December 2014 were identified. Patients were subdivided into subgroups of those with stage 1-2 chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR], ≥ 60 mL/min/1.73 m2), those with stage 3 CKD (eGFR, 30-59 mL/min/1.73 m2), and those with stage 4-5 CKD (eGFR < 30 mL/min/1.73 m2) and separately underwent propensity score stratification and matching. Rates of AKI, emergent dialysis, and mortality were compared between IOCM and noncontrast groups. Additional analyses incorporating intravenous fluid administration, including additional CT studies at other sites within a single institution, and a paired analysis of patients who underwent both IOCM and noncontrast CT studies during the study time frame, were also performed. Results A total of 5758 patients (1538 with stage 1-2 CKD, 2899 with stage 3 CKD, and 1321 with stage 4-5 CKD) were included in the study. After propensity score adjustment, rates of AKI, dialysis, and mortality were not significantly higher in the IOCM group compared with the noncontrast group for all CKD subgroups (AKI odds ratios [ORs], 0.74-0.91, P = .16-0.69; dialysis ORs, 0.74-2.00, P = .42-.76; mortality ORs, 0.98-1.24, P = .39-.88). Sensitivity analyses yielded similar results. Conclusion Among patients at the highest perceived risk of postcontrast AKI, intravenous administration of iodixanol for contrast material enhanced CT was not an independent risk factor for AKI, dialysis, or mortality. © RSNA, 2017 Online supplemental material is available for this article.

Although computed tomography (CT) is a useful tool for exploring occult infection in patients with sepsis in the emergency department, the potential nephrotoxicity of contrast media is a major concern. Our study aimed to investigate the association between use of contrast-enhanced CT and the risks of acute kidney injury and other adverse outcomes in patients with sepsis. In total, 587 patients with sepsis who underwent CT scan (enhanced CT group: 105, non-enhanced CT group: 482) from January 2012 to December 2016 at a tertiary referral centre were enrolled in this retrospective analysis, and propensity score matching was performed to minimise the selection bias. The length of stay, incidences of acute kidney injury and emergent dialysis, and short-term mortality were compared between the two groups. Compared with patients in the non-enhanced CT group, patients in the contrast-enhanced CT group did not have increased risks of acute kidney injury (odds ratio [OR]=1.38, 95% confidence interval [CI]=0.55-3.43; P=0.489), emergent dialysis (OR=1.31, 95% CI=0.47-3.68; P=0.602), or short-term mortality (OR=0.90, 95% CI=0.48-1.69; P=0.751). In addition, there was no significant difference in the median length of hospital stay between survivors in the two groups (20 vs 19 days, P=0.742). Intravenous contrast administration during CT scanning was not associated with prolonged length of hospital stay in patients with sepsis in an emergency setting. Moreover, the use of contrast-enhanced CT was not associated with increased risks of acute kidney injury, emergent dialysis, or short-term mortality.

World Kidney Day 2013: Acute Kidney Injury—Global Health Alert

Risk of Acute Kidney Injury, Dialysis, and Mortality in Patients With Chronic Kidney Disease After Intravenous Contrast Material Exposure

Long-term Outcomes After Acute Kidney Injury: Where We Stand and How We Can Move Forward

Acute kidney injury (AKI) occurs in 7% to 18% of hospitalized patients and complicates the course of 50% to 60% of those admitted to the intensive care unit, carrying both significant mortality and morbidity.[1][1] Even though many cases of AKI are reversible within days to weeks of occurrence, data

Use of Relative Blood Volume Monitoring to Reduce Intradialytic Hypotension in Hospitalized Patients Receiving Dialysis

Background: Information is limited regarding the outcomes of patients with preexisting chronic kidney disease (CKD) who develop dialysis-requiring acute kidney injury. Methods: 131 adult patients with advanced CKD who received emergent hemodialysis from January to June in 2002 were recruited and monitored for all-cause mortality and end-stage renal disease until the end of 2007. Results: Among patients investigated, 21 (16%) were successfully withdrawn from acute hemodialysis after an average of 8 sessions of dialysis therapy (range: 1–44). Multivariate analysis revealed that larger kidney size (odds ratio, OR = 1.755, p = 0.018), lower predialysis creatinine (OR = 0.722, p = 0.002), and non-diabetes (OR = 0.271, p = 0.037) were predictors for withdrawal. After 5 years, all patients in the non-withdrawal group remained on chronic dialysis, whereas only 8/21 (38%) patients in the withdrawal group developed end-stage renal disease. Cox’s analysis showed that age (hazard ratio, HR = 1.043, p < 0.0001), prerenal azotemia (HR = 1.040, p = 0.002), and adjusted propensity score for assigning to dialysis withdrawal (HR = 6.819, p = 0.008) were associated with mortality. Withdrawal from acute dialysis was not related to long-term mortality (p = 0.34). Conclusions: Among the advanced CKD patients, predictors of the successful weaning from acute dialysis were non-diabetes, larger kidney size and lower serum creatinine levels. The strategy of removal from emergent dialysis was not related to long-term mortality.

EVERY YEAR MORE THAN 1 MILLION HOSPITALIZATIONS in the United States are complicated by acute kidney injury, accounting for an estimated $10 billion in excess costs to the health care system. Acute kidney injury has been shown to be a potent predictor of excess length of stay, morbidity, and mortality in a number of clinical settings. The incidence of acute kidney injury has increased more than 4-fold since 1988 and is estimated to have a yearly population incidence of more than 500 per 100 000 population—higher than the yearly incidence of stroke. Survival from an episode of acute kidney injury may be increasing by virtue of advances in critical care medicine and dialysis technologies. In short, more hospitalized patients are being discharged alive after an episode of acute kidney injury. The report by Wald and colleagues in this issue of JAMA provides valuable insights into the complex complications faced by survivors of an episode of severe acute kidney injury. Using linked administrative health databases covering the entire province of Ontario, Canada, the authors addressed the long-term risks of death and dialysis dependence among individuals who developed acute kidney injury requiring acute temporary dialysis during hospitalization. During a 10-year period between 1996 and 2006, they identified 18 551 individuals with acute kidney injury requiring dialysis, which corresponds to an approximate yearly incidence of 19 per 100 000 population—lower than the estimate of 24.4 per 100 000 population reported in Northern California between 1996 and 2003. After excluding 3321 individuals who had previous acute kidney injury, dialysis, or kidney transplantation in the preceding 5 years, and 202 who had extreme lengths of hospital stay, the authors identified 15 028 patients with a first hospitalization for acute kidney injury requiring dialysis. More than 40% of these individuals died during hospitalization, in keeping with previous reports of the grave implications of severe acute kidney injury. Nearly half of these patients recovered kidney function for at least 30 days following hospitalization, attesting to the remarkable ability of the kidneys to repair and regenerate even after severe, dialysis-requiring injury. Another 23% of patients required further dialysis within 30 days of discharge, but it is not reported how many of those required chronic dialysis. The final study cohort included 4066 survivors, 3769 (92.7%) of whom were matched to control patients and observed for a median of 3 years after discharge. Even among this selected cohort of survivors, mortality rates exceeded 10% per year. One of every 12 survivors of acute kidney injury requiring acute dialysis required subsequent initiation of chronic dialysis despite being dialysis-free at 30 days after discharge. These findings are noteworthy even without considering the next step in the analysis, which was to compare this incidence rate against that of matched individuals without acute kidney injury. From the perspective of a clinician caring for an individual with severe acute kidney injury, the findings by Wald et al provide an important quantitative estimate that can be shared with affected patients and their families: even in the best of circumstances—meaning survival during hospitalization and recovery of kidney function sufficient to stop dialysis for a month—there is almost a 10% chance of requiring chronic dialysis in the next few years. The chronic dialysis incidence rate reported by Wald et al is 72 times higher than that reported for the general population in the United States in 2006 (366/1 million person-years). This finding has important implications for the postdischarge care of patients successfully treated with acute temporary dialysis: follow-up care with a nephrologist for secondary prevention is absolutely necessary. These findings also highlight the magnitude of the problem of acute kidney injury as a cause of end-stage renal disease (ESRD): extrapolating from the data of Wald et al, a rough estimate of the yearly incidence of ESRD due to acute kidney injury is 0.3 per 100 000 population, which is approximately onethird of the incidence of ESRD secondary to cystic kidney disease. The true magnitude is even higher because this estimate does not consider the 3481 individuals excluded from the final cohort because of the need for dialysis during the

Long-Term Outcomes of Acute Kidney Injury

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Immunosuppression in liver transplant recipients with renal impairment

Perioperative Acute Kidney Injury