Abstract
BackgroundLittle is known about factors associated with recovery of kidney function—and return to dialysis independence—or temporal trends in recovery after starting outpatient dialysis in the United States. Understanding the characteristics of individuals who may have the potential to recover kidney function may promote better recognition of such events. The goal of this study was to determine factors associated with recovery of kidney function in children compared with adults starting dialysis in the US.Methods and findingsWe determined factors associated with recovery of kidney function—defined as survival and discontinuation of dialysis for ≥90-day period—in children versus adults who started maintenance dialysis between 1996 and 2015 according to the United States Renal Data System (USRDS) followed through 2016 in a retrospective cohort study. We also examined temporal trends in recovery rates over the last 2 decades in this cohort. Among 1,968,253 individuals included for study, the mean age was 62.6 ± 15.8 years, and 44% were female. Overall, 4% of adults (83,302/1,953,881) and 4% of children (547/14,372) starting dialysis in the outpatient setting recovered kidney function within 1 year. Among those who recovered, the median time to recovery was 73 days (interquartile range [IQR] 43–131) in adults and 100 days (IQR 56–189) in children. Accounting for the competing risk of death, children were less likely to recover kidney function compared with adults (sub-hazard ratio [sub-HR] 0.81; 95% CI 0.74–0.89, p-value <0.001; point estimates <1 indicating increased risk for a negative outcome). Non-Hispanic black (NHB) adults were less likely to recover compared with non-Hispanic white (NHW) adults, but these racial differences were not observed in children. Of note, a steady increase in the incidence of recovery of kidney function was noted initially in adults and children between 1996 and 2010, but this trend declined thereafter. The diagnoses associated with the highest recovery rates of recovery were acute tubular necrosis (ATN) and acute interstitial nephritis (AIN) in both adults and children, where 25%–40% of patients recovered kidney function depending on the calendar year of dialysis initiation. Limitations to our study include the potential for residual confounding to be present given the observational nature of our data.ConclusionsIn this study, we observed that discontinuation of outpatient dialysis due to recovery occurred in 4% of patients with end-stage kidney disease (ESKD) and was more common among those with ATN or AIN as the cause of their kidney disease. While recovery rates rose initially, they declined starting in 2010. Additional studies are needed to understand how to best recognize and promote recovery in patients whose potential to discontinue dialysis is high in the outpatient setting.
Highlights
Patients with acute kidney injury (AKI) in the setting of illnesses or hospitalization may often require dialysis initiation acutely [1,2,3]
We observed that discontinuation of outpatient dialysis due to recovery occurred in 4% of patients with end-stage kidney disease (ESKD) and was more common among those with acute tubular necrosis (ATN) or acute interstitial nephritis (AIN) as the cause of their kidney disease
Even in patients with progressive chronic kidney disease (CKD) who do not appear to suffer any acute insults prior to dialysis initiation, the decision to start dialysis may be based on factors that are not permanent, so that even patients not thought to have an acute deterioration in kidney function may recover enough residual kidney function to maintain homeostasis and discontinue dialysis despite disease that was deemed consistent with end-stage kidney disease (ESKD) [9]
Summary
Patients with acute kidney injury (AKI) in the setting of illnesses or hospitalization may often require dialysis initiation acutely [1,2,3]. A substantial proportion of these patients will survive their initial hospitalizations and be discharged to the outpatient setting with continued dialysis requirement [4,5,6,7]. Subsets of these outpatients may have the potential to recover sufficient kidney function to eventually discontinue maintenance dialysis. Prior studies have reported that approximately 40% of patients who started dialysis after AKI and continued outpatient dialysis following hospital discharge had adequate recovery within 1 year [8]. The goal of this study was to determine factors associated with recovery of kidney function in children compared with adults starting dialysis in the US.
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