Dialysis-requiring AKI Research Articles

Acute Kidney Disease Staging Based on Estimated Glomerular Filtration Rate Predicts Outcomes Better than Staging Based on Serum Creatinine in Patients with Dialysis-Requiring AKI

Acute Kidney Disease Staging Based on Estimated Glomerular Filtration Rate Predicts Outcomes Better than Staging Based on Serum Creatinine in Patients with Dialysis-Requiring AKI

Associations between abrupt transition, dialysis-requiring AKI, and early mortality in ESKD among U.S. veterans

BackgroundMortality is high within the first few months of starting chronic dialysis. Pre-ESKD trajectory of kidney function has been shown to be predictive of early death after dialysis initiation. We aim to better understand how two key aspects of pre-dialysis kidney function—an abrupt transition pattern and an episode of dialysis-requiring AKI (AKI-D) leading directly to ESKD—are associated with early mortality after dialysis initiation.MethodsWe extracted national data from U.S. Veterans Health Administration cross-linked with the United States Renal Data System (USRDS) to identify patients who initiated hemodialysis during 2009–2013. We defined abrupt transition as having a mean outpatient eGFR ≥ 30 ml/min/1.73m2 within 1 year prior to ESKD. AKI-D was identified using inpatient serum creatinine measurements (serum Cr increase by at least 50% from baseline) along with billing codes for inpatient receipt of dialysis for AKI within 30 days prior to the ESKD start date. We used multivariable proportional hazards models to examine the association between patterns of kidney function prior to ESKD and all-cause mortality within 90 days after ESKD.ResultsTwenty-two thousand eight hundred fifteen patients were identified in the final analytic cohort of Veterans who initiated hemodialysis and entered the USRDS. We defined five patterns of kidney function decline. Most (68%) patients (N = 15,484) did not have abrupt transition and did not suffer an episode of AKI-D prior to ESKD (reference group). The remaining groups had abrupt transition, AKI-D, or both. Patients who had an abrupt transition with (N = 503) or without (N = 3611) AKI-D had the highest risk of early mortality after ESKD onset after adjustment for demographics and comorbidities (adjusted HR 2.10, 95% CI 1.66–2.65 for abrupt transition with AKI-D; adjusted HR 2.10, 95% CI 1.90–2.33 for abrupt transition without AKI-D). In contrast, patients who experienced AKI-D without an abrupt transition pattern (N = 2141 had only a modestly higher risk of early death (adjusted HR 1.19, 95% CI 1.01–1.40).ConclusionsAn abrupt decline in kidney function within 1 year prior to ESKD occurred in nearly 1 in 5 incident hemodialysis patients (18%) in this national cohort of Veterans and was strongly associated with higher early mortality after ESKD onset.

Initial Management and Potential Opportunities to Deprescribe Dialysis among Patients with AKI-D Patients after Hospital Discharge.

Dialysis-requiring AKI (AKI-D) now accounts for more than 15% of outpatient hemodialysis initiations; over 30% of these patients with AKI-D may have potential to recover. However, little is known about strategies currently used to treat outpatient AKI-D and screen for recovery. In this study of 1754 patients with AKI-D, we found that ( 1 ) the initial dialysis orders were similar to those of patients with contemporary incident ESKD, despite different treatment goals; ( 2 ) timed urine collections were completed in only a minority of patients; and ( 3 ) most patients with AKI-D who recovered discontinued dialysis without ever having been weaned from their initial dialysis prescription, suggesting there may be substantial opportunity to wean dialysis sooner.

Outpatient Dialysis Prescription as Predictor and Modifiable Factor for Outcomes of Patients with Dialysis-Requiring AKI

Outpatient Dialysis Prescription as Predictor and Modifiable Factor for Outcomes of Patients with Dialysis-Requiring AKI

Risk of Renal Recovery Post Dialysis-Requiring AKI in Critically Ill Transplant Patients Receiving Calcineurin Inhibitors

Risk of Renal Recovery Post Dialysis-Requiring AKI in Critically Ill Transplant Patients Receiving Calcineurin Inhibitors

Association of Antiplatelet and Anticoagulation Therapy with Dialysis-Requiring AKI in Critically Ill Patients with COVID-19

Association of Antiplatelet and Anticoagulation Therapy with Dialysis-Requiring AKI in Critically Ill Patients with COVID-19

Rhabdomyolysis and High Catabolic State in Patients with COVID-19 Who Develop Dialysis-Requiring AKI

Rhabdomyolysis and High Catabolic State in Patients with COVID-19 Who Develop Dialysis-Requiring AKI

Association between regional economic status and renal recovery of dialysis-requiring acute kidney injury among critically ill patients

The association between regional economic status and the probability of renal recovery among patients with dialysis-requiring AKI (AKI-D) is unknown. The nationwide prospective multicenter study enrolled critically ill adult patients with AKI-D in four sampled months (October 2014, along with January, April, and July 2015) in Taiwan. The regional economic status was defined by annual disposable income per capita (ADIPC) of the cities the hospitals located. Among the 1,322 enrolled patients (67.1 ± 15.5 years, 36.2% female), 833 patients (63.1%) died, and 306 (23.1%) experienced renal recovery within 90 days following discharge. We categorized all patients into high (n = 992) and low economic status groups (n = 330) by the best cut-point of ADIPC determined by the generalized additive model plot. By using the Fine and Gray competing risk regression model with mortality as a competing risk factor, we found that the independent association between regional economic status and renal recovery persisted from model 1 (no adjustment), model 2 (adjustment to basic variables), to model 3 (adjustment to basic and clinical variables; subdistribution hazard ratio, 1.422; 95% confidence interval, 1.022–1.977; p = 0.037). In conclusion, high regional economic status was an independent factor for renal recovery among critically ill patients with AKI-D.

Acute kidney injury following percutaneous mechanical thrombectomy of subclavian artery stent graft thrombosis: a case report

BackgroundPercutaneous mechanical thrombectomy (PMT) is a well-established technique for treatment of acute arterial and venous thrombosis which inevitably leads to intravascular erythrocyte hemolysis, resulting in hemoglobinuria.Case presentationWe present a case of 66-year-old Caucasian female with subclavian artery aneurysm causing distal embolization and hand ischemia. The aneurysm was treated with stent graft, but with a subsequent graft thrombosis 3 months later. After graft recanalisation, AngioJet PMT was performed which resulted in dialysis-requiring acute kidney injury.ConslusionOnly several cases of acute kidney injury following AngioJet PMT have been published in literature. To our knowledge, this is the first reported case of dialysis-requiring AKI after PMT for peripheral arterial thrombosis. Until there is sufficient evidence and recommendation on preventing AKI in this setting, we believe that by being aware of the risk and by monitoring of patient, one might minimize the damage in case it occurs.

Infrequent Provision of Palliative Care to Patients with Dialysis-Requiring AKI.

The use of palliative care in AKI is not well described. We sought to better understand palliative care practice patterns for hospitalized patients with AKI requiring dialysis in the United States. Using the 2012 National Inpatient Sample, we identified patients with AKI and palliative care encounters using validated International Classification of Diseases, Ninth Revision, Clinical Modification codes. We compared palliative care encounters in patients with AKI requiring dialysis, patients with AKI not requiring dialysis, and patients without AKI. We described the provision of palliative care in patients with AKI requiring dialysis and compared the frequency of palliative care encounters for patients with AKI requiring dialysis with that for patients with other illnesses with similarly poor prognoses. We used logistic regression to determine factors associated with the provision of palliative care, adjusting for demographics, hospital-level variables, and patient comorbidities. We identified 3,031,036 patients with AKI, of whom 91,850 (3%) received dialysis. We observed significant patient- and hospital-level differences in the provision of palliative care for patients with AKI requiring dialysis; adjusted odds were 26% (95% confidence interval, 12% to 38%) lower in blacks and 23% (95% confidence interval, 3% to 39%) lower in Hispanics relative to whites. Lower provision of palliative care was observed for rural and urban nonteaching hospitals relative to urban teaching hospitals, small and medium hospitals relative to large hospitals, and hospitals in the Northeast compared with the South. After adjusting for age and sex, there was low utilization of palliative care services for patients with AKI requiring dialysis (8%)-comparable with rates of utilization by patients with other illnesses with poor prognosis, including cardiogenic shock (9%), intracranial hemorrhage (10%), and acute respiratory distress syndrome (10%). The provision of palliative care varied widely by patient and facility characteristics. Palliative care was infrequently used in hospitalized patients with AKI requiring dialysis, despite its poor prognosis and the regular application of life-sustaining therapy.

Dialysis-Requiring Acute Kidney Injury in Denmark 2000-2012: Time Trends of Incidence and Prevalence of Risk Factors-A Nationwide Study.

IntroductionDialysis-requiring acute kidney injury is a severe illness associated with poor prognosis. However, information pertaining to incidence rates and prevalence of risk factors remains limited in spite of increasing focus. We evaluate time trends of incidence rates and changing patterns in prevalence of comorbidities, concurrent medication, and other risk factors in nationwide retrospective cohort study.Materials and MethodsAll patients with dialysis-requiring acute kidney injury were identified between January 1st 2000 and December 31st 2012. By cross-referencing data from national administrative registries, the association of changing patterns in dialysis treatment, comorbidity, concurrent medication and demographics with incidence of dialysis-requiring acute kidney injury was evaluated.ResultsA total of 18,561 adult patients with dialysis-requiring AKI were identified between 2000 and 2012. Crude incidence rate of dialysis-requiring AKI increased from 143 per million (95% confidence interval, 137–144) in 2000 to 366 per million (357–375) in 2006, and remained stable hereafter. Notably, incidence of continuous veno-venous hemodialysis (CRRT) and use of acute renal replacement therapy in elderly >75 years increased substantially from 23 per million (20–26) and 328 per million (300–355) in 2000, to 213 per million (206–220) and 1124 per million (1076–1172) in 2012, respectively. Simultaneously, patient characteristics and demographics shifted towards increased age and comorbidity.ConclusionsAlthough growth in crude incidence rate of dialysis-requiring AKI stabilized in 2006, continuous growth in use of CRRT, and acute renal replacement therapy of elderly patients >75 years, was observed. Our results indicate an underlying shift in clinical paradigm, as opposed to unadulterated growth in incidence of dialysis-requiring AKI.

Exploring Potential Reasons for the Temporal Trend in Dialysis-Requiring AKI in the United States.

The population incidence of dialysis-requiring AKI has risen substantially in the last decade in the United States, and factors associated with this temporal trend are not well known. We conducted a retrospective cohort study using data from the Nationwide Inpatient Sample, a United States nationally representative database of hospitalizations from 2007 to 2009. We used validated International Classification of Diseases, Ninth Revision codes to identify hospitalizations with dialysis-requiring AKI and then, selected the diagnostic and procedure codes most highly associated with dialysis-requiring AKI in 2009. We applied multivariable logistic regression adjusting for demographics and used a backward selection technique to identify a set of diagnoses or a set of procedures that may be a driver for this changing risk in dialysis-requiring AKI. From 2007 to 2009, the population incidence of dialysis-requiring AKI increased by 11% per year (95% confidence interval, 1.07 to 1.16; P<0.001). Using backward selection, we found that the temporal trend in the six diagnoses, septicemia, hypertension, respiratory failure, coagulation/hemorrhagic disorders, shock, and liver disease, sufficiently and fully accounted for the temporal trend in dialysis-requiring AKI. In contrast, temporal trends in 15 procedures most commonly associated with dialysis-requiring AKI did not account for the increasing dialysis-requiring AKI trend. The increasing risk of dialysis-requiring AKI among hospitalized patients in the United States was highly associated with the changing burden of six acute and chronic conditions but not with surgeries and procedures.

Long-term risk of upper gastrointestinal hemorrhage after advanced AKI.

There are few reports on temporary dialysis-requiring AKI as a risk factor for future upper gastrointestinal bleeding (UGIB). This study sought to explore the long-term association between dialysis-requiring AKI and UGIB. This nationwide cohort study used data from the Taiwan National Health Insurance Research Database. Patients who recovered from dialysis-requiring AKI and matched controls were selected from hospitalized patients age ≥18 years between 1998 and 2006. The cumulative incidences of long-term de novo UGIB were calculated, and the risk factors of UGIB and mortality were identified using time-varying Cox proportional hazard models adjusted for subsequent CKD and ESRD after AKI. A total of 4565 AKI-recovery patients and the same number of matched patients without AKI were analyzed. After a median follow-up time of 2.33 years (interquartile range, 0.97-4.81 years), the incidence rates of UGIB were 50 (by stringent criterion) and 69 (by lenient criterion) per 1000 patient-years in the AKI-recovery group and 31 (by stringent criterion) and 48 (by lenient criterion) per 1000 patient-years in the non-AKI group (both P<0.001). When compared with patients in the non-AKI group, the multivariate hazard ratio (HR) for UGIB was 1.30 (95% confidence interval [95% CI], 1.14 to 1.48) for dialysis-requiring AKI, 1.83 (95% CI, 1.53 to 2.20) for time-varying CKD, and 2.31 (95% CI, 1.92 to 2.79) for time-varying ESRD (all P<0.001). Finally, the risk for long-term mortality increased after UGIB (HR, 1.24; 95% CI, 1.12 to 1.38) and dialysis-requiring AKI (HR, 1.66; 95% CI, 1.54 to 1.78). Recovery from dialysis-requiring AKI was associated with future UGIB and mortality.

Cardiovascular Events after AKI

Cardiovascular Events after AKI

Long-Term Risk of Coronary Events after AKI

The incidence rate of AKI in hospitalized patients is increasing. However, relatively little attention has been paid to the association of AKI with long-term risk of adverse coronary events. Our study investigated hospitalized patients who recovered from de novo dialysis-requiring AKI between 1999 and 2008 using patient data collected from inpatient claims from Taiwan National Health Insurance. We used Cox regression with time-varying covariates to adjust for subsequent CKD and ESRD after discharge. Results were further validated by analysis of a prospectively constructed database. Among 17,106 acute dialysis patients who were discharged, 4869 patients recovered from dialysis-requiring AKI (AKI recovery group) and were matched with 4869 patients without AKI (non-AKI group). The incidence rates of coronary events were 19.8 and 10.3 per 1000 person-years in the AKI recovery and non-AKI groups, respectively. AKI recovery associated with higher risk of coronary events (hazard ratio [HR], 1.67; 95% confidence interval [95% CI], 1.36 to 2.04) and all-cause mortality (HR, 1.67; 95% CI, 1.57 to 1.79) independent of the effects of subsequent progression to CKD and ESRD. The risk levels of de novo coronary events after hospital discharge were similar in patients with diabetes alone and patients with AKI alone (P=0.23). Our results reveal that AKI with recovery associated with higher long-term risks of coronary events and death in this cohort, suggesting that AKI may identify patients with high risk of future coronary events. Enhanced postdischarge follow-up of renal function of patients who have recovered from temporary dialysis may be warranted.

Recovery from AKI by KDIGO criteria

Data on recovery of AKI are mainly limited to persistent dialysis dependency in patients with dialysis-requiring AKI. The aim of this analysis is to evaluate recovery from different stages of AKI.

Regional Variation in the Incidence of Dialysis-Requiring AKI in the United States

Little is known about geographic differences in the incidence of AKI. The objective of this study was to determine if regional variation exists in the population incidence of dialysis-requiring AKI in the United States. Data from the Nationwide Inpatient Sample, a US nationally representative sample of hospitalizations, were used to determine the incidence rates of dialysis-requiring AKI between 2007 and 2009 among the four US Census-designated regions. Cases were identified using validated discharge codes. Poisson regression models were used to estimate overall regional rates, accounting for the data's sampling scheme. In 2007-2009, the population incidence rates of dialysis-requiring AKI differed across the four Census-designated regions (P=0.04). Incidence was highest in the Midwest (523 cases/million person-yr, 95% confidence interval=483 to 568) and lowest in the Northeast (457 cases/million person-yr, 95% confidence interval=426 to 492). The pattern of regional variation in the incidence of dialysis-requiring AKI was not the same as the pattern of regional variation in the incidence of renal replacement therapy-requiring ESRD (obtained from the US Renal Data System). In-hospital mortality associated with dialysis-requiring AKI differed across the four regions, with the highest case fatality in the Northeast (25.9%) and the lowest case fatality in the Midwest (19.4%). Significant regional variation exists in the population incidence of dialysis-requiring AKI in the United States, and additional investigation is warranted to uncover potential causes behind these geographic differences.

Piecewise Analysis of Patient Survival after Onset of AKI

AKI affects approximately 2%-7% of hospitalized patients and >35% of critically ill patients. Survival after AKI may be described as having an acute phase (including an initial hyperacute component) followed by a convalescent phase, which may itself have early and late components. Data from the Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network (ATN) study was used to model mortality risk among patients with dialysis-requiring AKI. This study assumed that the mortality hazard can be described by a piecewise log-linear function with change points. Using an average likelihood method, the authors tested for the number of change points in a piecewise log-linear hazard model. The maximum likelihood approach to locate the change point(s) was then adopted, and associated parameters and standard errors were estimated. There were 1124 ATN participants with follow-up to 1 year. The mortality hazard of AKI decreased over time with inflections in the rate of decrease at days 4, 42, and 148, with the sharpest change at day 42. The daily rate of decline in the log of the hazard for death was 0.220 over the first 4 days, 0.046 between day 4 and day 42, 0.017 between day 42 and day 148, and 0.003 between day 148 and day 365. There appear to be two major phases of mortality risk after AKI: an early phase extending over the first 6 weeks and a late phase from 6 weeks to 1 year. Within the first 42 days, this can be further divided into hyperacute (days 1-4) and acute (days 4-42) phases. After 42 days, there appear to be early (days 42-148) and late (after day 148) convalescent phases. These findings may help to inform the design of AKI clinical trials and assist critical care physicians in prognostic stratification.

The Impact of Dialysis-Requiring Acute Kidney Injury on Long-Term Prognosis of Patients Requiring Prolonged Mechanical Ventilation: Nationwide Population-Based Study

BackgroundProlonged mechanical ventilation (PMV) is increasingly common worldwide, consuming enormous healthcare resources. Factors that modify PMV outcome are still obscure.MethodsWe selected patients without preceding mechanical ventilation within the one past year and who developed PMV during index admission in Taiwan's National Health Insurance (NHI) system during 1998–2007 for comparison of mortality and resource use. They were divided into three groups: (1) patients with end-stage renal diseases (ESRD) before the index admission for PMV onset; (2) patients with dialysis-requiring acute kidney injury (AKI-dialysis) during the hospitalization course; and (3) patients without AKI or with non dialysis-requiring AKI during the hospitalization course (non-AKI). We used a random-effects logistic regression model to identify factors associated with mortality.ResultsCompared with the other two groups, patients with AKI-dialysis had significantly longer mechanical ventilation, more frequent use of vasopressors, longer intensive care unit/hospital stay and higher inpatient expenditures during the index admission. Relative to non-AKI patients, patients with AKI-dialysis had an elevated mortality hazard; the adjusted relative risk ratios were 1.51 (95% confidence interval [CI]:1.46–1.56), 1.27 (95% CI: 1.23–1.32), and 1.10 (95% CI: 1.08–1.12) for mortality rates at discharge, 3 months, and 4 years after PMV, respectively. Patients with AKI-dialysis also consumed significantly higher total in-patient expenditure than the other two patient groups (p<0.001).ConclusionsAmong patients that need PMV care during an admission, the presence of de novo AKI requiring dialysis significantly increased short and long term mortality, and demand for health care resources.

Temporal Changes in Incidence of Dialysis-Requiring AKI

The population epidemiology of AKI is not well described. Here, we analyzed data from the Nationwide Inpatient Sample, a nationally representative dataset, to identify cases of dialysis-requiring AKI using validated International Classification of Diseases, Ninth Revision (ICD-9) codes. From 2000 to 2009, the incidence of dialysis-requiring AKI increased from 222 to 533 cases per million person-years, averaging a 10% increase per year (incidence rate ratio=1.10, 95% CI=1.10-1.11 per year). Older age, male sex, and black race associated with higher incidence of dialysis-requiring AKI. The rapid increase in incidence was evident in all age, sex, and race subgroups examined. Temporal changes in the population distribution of age, race, and sex as well as trends of sepsis, acute heart failure, and receipt of cardiac catheterization and mechanical ventilation accounted for about one third of the observed increase in dialysis-requiring AKI among hospitalized patients. The total number of deaths associated with dialysis-requiring AKI rose from 18,000 in 2000 to nearly 39,000 in 2009. In conclusion, the incidence of dialysis-requiring AKI increased rapidly in all patient subgroups in the past decade in the United States, and the number of deaths associated with dialysis-requiring AKI more than doubled.