Kidney Disease Improving Global Outcomes Research Articles

Machine learning for prediction of chronic kidney disease progression: Validation of the Klinrisk model in the CANVAS Program and CREDENCE trial.

To validate the Klinrisk machine learning model for prediction of chronic kidney disease (CKD) progression in patients with type 2 diabetes in the pooled CANVAS/CREDENCE trials. We externally validated the Klinrisk model for prediction of CKD progression, defined as 40% or higher decline in estimated glomerular filtration rate (eGFR) or kidney failure. Model performance was assessed for prediction up to 3 years with the area under the receiver operating characteristic curve (AUC), Brier scores and calibration plots of observed and predicted risks. We compared performance of the model with standard of care using eGFR (G1-G4) and urine albumin-creatinine ratio (A1-A3) Kidney Disease Improving Global Outcomes (KDIGO) heatmap categories. The Klinrisk model achieved an AUC of 0.81 (95% confidence interval [CI] 0.78-0.83) at 1 year, and 0.88 (95% CI 0.86-0.89) at 3 years. The Brier scores were 0.020 (0.018-0.022) and 0.056 (0.052-0.059) at 1 and 3 years, respectively. Compared with the KDIGO heatmap, the Klinrisk model had improved performance at every interval (P < .01). The Klinrisk machine learning model, using routinely collected laboratory data, was highly accurate in its prediction of CKD progression in the CANVAS/CREDENCE trials. Integration of the model in electronic medical records or laboratory information systems can facilitate risk-based care.

Prevalence and risk factors for chronic kidney disease of unknown aetiology (CKDu) among industrial workers

Objectives Industrial workers are facing an occurrence of high risk factors. Exploring the frequency of CKDu and associated risk factors in industrial workers is needed. This study examined the CKDu prevalence and associated risk factors in industrial workers. Design: Cross section study. Material and Methods We enrolled 134 (83 male and 41 female) industrial workers. Modifying diet in renal disease (MDRD) equation was used to determine the estimated glomerular filtration rate (eGFR). The CKDu stages 1–5 were assessed using Kidney Disease: Improving Global Outcomes (KIDGO) guidelines. Results The mean eGFR was reported to be 99.2 for male workers and 85.2 ml/min per 1.73 m2 for female workers. The average eGFR among male workers was higher than female workers. 43.3% of workers had normal eGFR (&gt; 90), while 52.2% of workers had a mild reduction (89–60), and 4.5% of workers had a moderate loss (59–45). No cases of severe loss and kidney failure (&lt; 15) were noted. CKDu stage 2 was significantly higher in female workers than male workers. The increased odd ratio (OR) of CKDu stage 3 (&lt; 60) was noted among male workers, with an increase in age, overweight, obesity, hypertension, diabetes, habits of smoking, and alcohol consumption. Conclusion The present study noted a lower eGFR and a higher OR of CKDu in industrial workers with risk factors. To avoid the progression from moderate severe loss and kidney failure, suggested weight reduction, avoiding smoking and alcohol consumption, and controlling diabetes and hypertension.

#1816 CA 125 as a surrogate marker for plasma volume in patients with cardiorenal syndrome

Abstract Background and Aims Assessing volume status in heart failure (HF) and end-stage chronic kidney disease (CKD) is challenging. Plasma volume expansion is an early step in the pathophysiology of decompensated HF and an independent risk factor for death and HF hospitalization, and should be addressed early. Evaluating plasma volume, especially its variation with diuretic therapy, can be a useful clinical tool for guiding decongestive therapy. There's a growing need for accurate and simple tools to guide clinician decisions on patient volume management. Cancer antigen 125 (CA125), a glycoprotein produced in mesothelial cells in the pericardium, pleura, or peritoneum, is primarily associated with ovarian and gynecological malignancies. Recent studies link CA125 to inflammation and congestion. In acute HF, elevated CA125 is associated with fluid overload indicators like increased central venous and pulmonary wedge pressure. Elevated CA125 in acute HF patients is linked to worse outcomes in death and hospital stay length. Evidence supports CA125-guided therapy in acute HF, but its role in managing chronic volume overload is still uncertain. We aim to assess the relationship between CA125 levels and estimated plasma volume (ePV). Method A retrospective unicentric observational study was conducted between June 2022, and April 17, 2023, at the Renocardiac clinic of a tertiary hospital. Clinical data were extracted from electronic patient records. CKD staging was determined following the Kidney Disease Improving Global Outcomes (KDIGO) classification. ePV was calculated using the Kaplan-Hakim formula. CA125 and ePV were assessed for the same patient in 2 different visits and their variation was calculated. The correlation between CA125 and ePV, as well as CA125 and ePV variation, was evaluated using Spearman's rank correlation coefficient for bivariate analysis, conducted with IBM SPSS®. Results This study comprised 65 patients, totaling 124 hospital visits. The patient demographic was 67.7% male, with a mean age of 76.4 (±12.47) years. In terms of CKD staging, 48.5% were classified as KDIGO 5, 40.6% as KDIGO 4, 9.4% as KDIGO 3, and 1.5% as KDIGO 2. HF etiology distribution included 59% ischemic, 9.8% hypertensive, 6.5% valvular, and 24.5% other causes. The mean ejection fraction was 37.35 (±12.36)% and 19% had preserved ejection fraction; 75% of them were treated with prognostic-modifying medication, including SGLT2 inhibitors. This proportion was lower (19%) in patients with reduced ejection fraction, receiving ACE/angiotensin ± neprilysin inhibitor + mineralocorticoid receptor inhibitor + beta-blocker + SGLT2 inhibitor. During the follow-up period, 13 hospitalizations, 1 major adverse cardiovascular event (MACE), and 5 deaths were recorded. The mean CA125 level was 193.98 (±154.55) U/mL, and patients had a mean ePV of 2.41 (±1.19) L. A significant positive correlation was found between CA125 levels and ePV (r = 0.355, p = 0.000). However, there was no significant correlation between the variation of CA125 and ePV levels between visits (p = 0.535). Conclusion This study focuses on a population with limited implementation of disease-modifying therapy due to advanced CKD, complicating the clinical management of volume status, kidney function, potassium levels, and long-term prognosis in both CKD and HF. CA125 shows potential clinical utility as a marker of congestion, aiding clinicians in assessing volume status by correlating with plasma volume. However, this study found no correlation between CA125 variation and changes in plasma volume. The outpatient nature of the studied population, typically euvolemic, may hinder assessing the relationship between CA125 and ePV changes. Future studies with larger sample sizes are essential to clarify this relationship and potentially identify volume-expanded patients early.

#624 The impact of hemoadsorption in patients with borderline chronic kidney disease undergoing coronary artery bypass grafting

Abstract Background and Aims With an annual incidence of up to 30%, cardiac surgery–associated acute kidney injury (CSA-AKI) may be one of the most underappreciated yet frequent complications and renal protective adjustments are crucial. We evaluated the impact of hemoadsorption as adjunctive therapy on clinical outcome in Kidney Disease Improving Global Outcomes (KDIGO) G2/A2) patients undergoing coronary artery bypass grafting (CABG). Method During a three-year period, 40 patients undergoing CABG with borderline chronic kidney disease (KDIGO-G2/A2) were treated with adjunctive hemoadsorption therapy and were compared by propensity score-matched 40 patients (KDIGO G2/A2) (Control). Primary endpoints were the need for renal replacement therapy (RRT)/dialysis and/or worsening of KDIGO stage in the perioperative period. Secondary endpoints were the change in inflammatory biomarkers, vasopressor requirement and ICU/hospital stay. In the study group, a 300 mL hemoadsorber (Cytosorbents Inc, NJ) was used for the entire duration of cardiopulmonary bypass (CPB). All patients were prepared via enhanced recovery after surgery (ERAS) protocol and surgical procedures were performed under moderate hypothermia with pulsatile flow and ultrafiltration. Patients with septic shock, limited life expectancy and refused to give consent were excluded. Results After institutional ethics committee approval was obtained, written informed consent was received from each patient. No significant difference was noted between groups in demographic, operative data and preoperative baseline laboratory. At the end of CPB; s-Creatinine (mg/dL) (1.85 ± 0.6 vs 2.751 ± 0.6; p = 0.035), NT-proBNP (pg/L) (130 ± 30 vs 180 ± 40; p = 0.04), IL-6 (pg/mL) (8.2 ± 4 vs 22.2 ± 4; p = 0.012) and myoglobulin (pg/L) (210 ± 75 vs 310 ± 80; p = 0.04) levels were significantly lower in the study group versus control. Clinical outcome is summarized in Figure. Conclusion This pioneering study demonstrated the additional protective effects of hemoadsorption in patients with borderline chronic kidney disease (KDIGO-G2/A2) undergoing CABG. Elimination of inflammatory parameters might be a complementary mechanism resulting in lesser worsening of kidney function/need of RRT and ICU stay. These findings require validation in large, multicenter trials.

#2317 Did acute kidney injury confer greater mortality in COVID-19 hospitalized patients? A Portuguese hospital experience in the third COVID wave

Abstract Background and Aims The outbreak of coronavirus disease 2019 (COVID-19) pandemic, which originated in December 2019, had a huge impact on healthcare worldwide. Numerous studies have reported alterations in kidney function among hospitalized patients with COVID-19, such as hematuria, proteinuria, and acute kidney injury (AKI). Histopathology exams in autopsies have identified various potential causes for the presence of AKI in these patients, with reports linking AKI to unfavorable outcomes across multiple countries. However, additional data concerning hospitalized COVID patients in Portugal are essential to further understand this aspect. Method Retrospective cohort study enrolling adult patients, who attended the Emergency Department and recorded positive polymerase chain reaction (PCR) results for SARS-CoV-2 from January 1 to January 31, 2021. AKI was diagnosed using the Kidney Disease Improving Global Outcome (KDIGO) classification based on serum creatinine (sCr) criteria and using a background creatinine available in the patient record. We performed an analysis of incidence, lethality, and possible risk factors of AKI in COVID-19 patients. Results The study encompassed a cohort of 239 patients, of whom 62 (25.94%) received a diagnosis of Acute Kidney Injury (AKI) based on KDIGO criteria. Within this subgroup, the average age was 77.65 years (±12.07), with a total of 29 male patients (46.78%). Notably, 30 deaths (48.39%) occurred during the hospital stay in this group. Regarding the AKI classification, 39 patients (62.9%) were classified as KDIGO-AKI stage 1, 14 patients (22.58%) as stage 2, and 9 patients (14.52%) as stage 3. Regarding the timing of the diagnosis of AKI, 54 (87%) occurred in the moment of admission, 7 patients (11.3%) were diagnosed within the first 48 hours and a solitary case (1.6%) was diagnosed after 7 days of hospitalization. In the non-AKI group, the mean age was 69.86 years (±15.95), and approximately 55% were male. Within this group, 49 deaths (27.7%) were recorded during hospitalization. Significantly higher mortality rates were observed in the AKI group, demonstrating a statistically significant difference (p &amp;lt; 0.01) and a relative risk of 1.75 or mortality during hospitalization for AKI patients. Furthermore, the duration of hospitalization was notably prolonged in the AKI group (p &amp;lt; 0.01), with a disparity of approximately three days. Individuals who developed AKI exhibited lower scores on the Barthel-dependence scale, indicative of higher dependence (p &amp;lt; 0.01), and were significantly older (p &amp;lt; 0.01) comparing with the ones that did not develop acute kidney injury. Additionally, it was remarkable that the leukocyte count at admission was more elevated in the AKI group (p = 0.03) compared to non-AKI patients with a difference of approximately 1.62×109/L. Conclusion Respiratory infections, including COVID-19, frequently lead to emergency department admissions and hospitalizations. This study validates an elevated prevalence of acute kidney injury (AKI) both at admission and during the hospital stay in such cases. The presence of AKI is linked to adverse outcomes, including mortality and extended hospital stays, underscoring the critical importance of promptly diagnosing AKI. Larger-scale studies are warranted in this field to enhance our understanding of this entity and therefore improve the outcomes related to this prevalent condition.

#1648 Chronic kidney disease-mineral bone disorder and fractures in predialysis patients

Abstract Background and Aims Chronic Kidney Disease (CKD) patients have a complex physiopathology of bone fragility given the development of mineral bone disorder (CKD-MBD) and are at increased fracture risk [1]. Bone turnover, mineralization, and volume (TMV) classification, as proposed by Kidney Disease Improving Global Outcomes (KDIGO), defines different subtypes of renal osteodystrophy (ROD), and is evaluated through bone biopsies and respective histomorphometric analysis. The impact of these parameters and of different ROD subtypes in fracture occurrence has not been evaluated. We aim to evaluate the incidence of fractures in patients with predialysis CKD and the relationship of ROD subtypes and the impact of bone volume with the occurrence of fractures. Method We conducted a retrospective study that enrolled 54 patients (40-89 years old) followed in a predialysis clinic between 2014-2023. Blood tests, bone biopsies and histomorphometric analysis were performed at the beginning of follow-up. Data from dual x-ray absorptiometry (DXA) scan were collected if available. Information regarding clinical evident fractures was recorded from analysis of clinical registries. Radiographies of the thoracic and/or lumbar spine were evaluated to detect asymptomatic vertebral fractures. Results Median follow-up time was 7.5 ± 3 years. Mean age at the time of bone biopsy was 65.4 ± 9.8 years old and most patients were male (n = 43, 79.6%). The majority had CKD stage 4 (53.7%). During follow-up, 20 (37%) patients progressed to kidney replacement therapy and 5 (9.3%) died. DXA scan was performed in 19 patients (35.2%). Of these, 5 had osteoporosis (T-score ≤-2,5). The histomorphometric analysis showed that 40.7% (n = 22) patients had normal bone histology, 37% (n = 20) low bone turnover with normal mineralization (adynamic bone disease) and 22.3% (n = 12) high bone turnover with normal mineralization (hyperparathyroid bone disease). Two patients sustained clinical evident fractures. Radiographies of 51 patients were reviewed and asymptomatic vertebral fractures were identified in 3 (5.9%). The group that suffered fractures had higher phosphorus levels and these differences were statistically significant (4.1 mg/dL vs 3.5 mg/dL, p = 0.047). None of the patients with osteoporosis diagnosed by DXA scan fractured and bone mineral density (BMD) by DXA was similar between the groups (−1.05 vs −1.04, p = 0.530). The different histomorphometric subtypes and circulating biomarkers did not correlate with the incidence of fractures. Patients with fractures had more frequently low bone volume (40%) than patients who do not sustained fractures (25.5%) but this difference was not significant (p = 0.579). BV/TV was lower in the group that sustained fractures during follow-up (16.1 (11.9-17.2) vs 19.0 (16.2-23.6)) and this achieved borderline significance (p = 0.052). Femoral neck BMD measures in the patients who had an available DXA scan did not show any correlation with BV/TV (r = 0.039, p = 0.874). Conclusion No relationship was found between different ROD subtypes and the incidence of fractures. However, when considering bone volume isolated (but not BMD assessed by DXA), a marginally significant association was found between a low BV/TV value and the occurrence of fractures. High phosphorus levels also associated with fractures and have been previously described as a possible risk factor for fractures not only in CKD patients but also general population [2, 3]. Further studies with a larger population are needed to validate these conclusions with statistical power.

#2561 Association of acute kidney injury stage with in-hospital mortality in elderly patients with hip fractures

Abstract Background and Aims Elderly individuals often experience hip fractures and acute kidney injury (AKI), both of which are associated with higher rates of morbidity and mortality. This study aimed to evaluate whether the severity of AKI is associated with higher mortality rates in elderly patients with hip fractures. Method Patients aged 65 years and older, who underwent surgery for hip fracture between October 2015 and October 2020, were retrospectively evaluated. Those with known chronic kidney disease stages 4, 5, or end-stage kidney disease were excluded. AKI was defined and categorized into stages 1, 2, and 3 according to the Kidney Disease Improving Global Outcomes (KDIGO) guidelines. Results In the study, 780 elderly patients with hip fractures were included, with a median age of 82.0 years (interquartile range 77.0–87.0) and 22.4% of them being men. Of these, 172 patients (22.1%) experienced AKI, with 125 (72.7%), 26 (15.1%), and 21 (12.2%) of these patients categorized as having stage 1, 2, and 3 AKI, respectively. Higher AKI stages were independently associated with increased in-hospital mortality compared to patients without AKI (odds ratio [OR] 1.07, 95% confidence interval [CI] 0.18–6.55, P=0.940 for AKI stage 1; OR 14.09, 95% CI 1.47–135.52, P=0.022 for AKI stage 2; and OR 413.79, 95% CI 45.84–3735.28, P&amp;lt;0.001 for AKI stage 3). Furthermore, compared to patients without AKI, those with AKI stage 3 had a significantly increased risk of mortality (hazard ratio 15.30, 95% CI 2.65–88.48, P=0.002). Conclusion A higher stage of AKI is independently associated with increased in-hospital mortality in elderly patients with hip fractures. Prevention and prompt treatment of AKI, especially higher AKI stages, is important in elderly patients with hip fractures.

#1543 Risk factors of obstructive sleep apnea-hypopnea syndrome in patients with chronic kidney disease

Abstract Background and Aims Both obstructive sleep apnea-hypopnea syndrome (OSAHS) and chronic kidney disease (CKD) are common disease. Patients with OSAHS were evidenced to have oxidative stress, increased albuminuria and renal injury. Previous reports show high prevalence of OSAHS among CKD patients, while its risk factors are hardly investigated. The objective of this study is to assess the risk factors of OSAHS in patients with CKD. Method We selected 181 patients with CKD who were hospitalized in department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital from September 2020 to February 2023. All participants underwent full-night standard nocturnal polysomnography (PSG) monitoring in the sleep center using Alice 4, 5 or 6 devices. An apnea hypopnea index (AHI)&amp;gt;5 events/h was consistent with the diagnosis of OSA. The 181 Patients are divided into three groups based on the level of AHI to studied the differences of clinical and biochemical characteristics. According to Kidney Disease Improving Global Outcomes (KDIGO) risk categories, all patients are divided into non very high risk and very high risk group, logistic regression is used for analyzing risk factors of OSAHS in patients with CKD. Results The prevalence of OSAHS was 86.7% (157 of 181), with 29.8% mild, 30.9% moderate and 25.9% severe respectively. The urea nitrogen (P=0.039) and cystatin C (P = 0.030) levels in patients of severe OSAHS group were significantly higher than those within non or mild OSAHS group. The eGFR in non or mild OSAHS group was significantly higher than moderate OSAHS group (P = 0.036). Pearson correlation analysis showed a significant negative correlation between AHI (p = 0.022), ODI (p = 0.033), and hypopnea index (p = 0.004) of sleep parameters and eGFR, while a significant positive correlation was found between LaSO2 (p = 0.005), MaSO2 (p = 0.030), and eGFR. Stepwise linear regression analysis showed that the hypopnea index was an independent risk factor for eGFR (p = 0.033, R2: 0.215), and CT90 was an independent risk factor for UACR (p &amp;lt; 0.001, R2: 0.105). Logistic regression analysis revealed that hypopnea index (OR = 1.058) was significantly correlated with very high risk in KDIGO risk categories (p &amp;lt; 0.05). Conclusion OSAHS is high prevalence in patients with CKD. Regression analysis shows that hypopnea index is not only an independent risk factor for eGFR but also a significant predictor associated with very high risk according to KDIGO risk category.

#2977 Pregnancy-related acute kidney injury in a second level care hospital in Merida, Yucatan, Mexico

Abstract Background and Aims Pregnancy-related acute kidney injury (PRAKI) is a public health problem associated with an increased risk of adverse maternal and fetal outcomes. The causes of PRAKI varies according to the age of gestation. Mexico lacks a national acute kidney injury (AKI) registry, and the access to AKI treatment is limited due to lack of financial coverage, lack of nephrologists, and poor infrastructure. The General Hospital Dr. Agustín O'Horán is a second level unit that attends to the uninsured pregnant population from the southeast of Mexico. The aim of this study was to investigate the prevalence, clinical characteristics, and outcomes of PRAKI in a Mexican population. Method This was a retrospective study in an obstetric intensive care unit (OICU) in the General Hospital Dr. Agustín O'Horán in Merida, Yucatan, Mexico. Women during pregnancy and postpartum periods admitted to the OICU between January to December 2023 were included. Demographical, clinical and laboratory data were collected from medical records, and AKI was diagnosed according to the Kidney Disease Improving Global Outcomes (KDIGO) creatinine criteria. We evaluated the prevalence, clinical characteristics, and outcomes of PRAKI. Results During the study period, 188 women were admitted to the OICU, and the mean age was 24.9 years. Eight women presented in the first trimester, 19 in the second trimester, 21 in the third trimester, and 140 in the postpartum period. Fifty-five women met AKI creatinine criteria: 31 (56.3%) had stage 1, 15 (27.3%) had stage 2, and 9 (16.4%) had stage 3. The most common causes of PRAKI were obstetric hemorrhage (27.3%), eclampsia (21.8%), and preeclampsia (18.2%) (Table 1). There was no difference in vital signs on admission and baseline creatinine level between both groups. Women who developed PRAKI had a longer stay in the OICU (4.2 days vs 2.3 days, p &amp;lt; 0.001), and greater use of vasopressor (30.9% vs 9.0%, p &amp;lt; 0.001), and mechanical ventilation (34.5% vs 11.3%, p &amp;lt; 0.001). Women with AKI had higher mortality (9.1% vs 1.5%, p = 0.012), and perinatal mortality (9.1% vs 2.3%, p = 0.035) (Table 2). Conclusion Women during pregnancy and postpartum periods who developed PRAKI had more adverse clinical and obstetric outcomes (maternal and perinatal mortality). Hence, women in pregnancy and postpartum periods admitted to an intensive care unit should be closely monitored and implement strategies for early diagnosis and aggressive therapy of PRAKI regardless of KDIGO stage.

#1723 Genetic landscape of polycystic kidney disease in a Chinese cohort – experience using whole genome sequencing in a tertiary renal unit

Abstract Background and Aims Genetic testing has increasingly been employed to provide definitive diagnoses and prognostic information in patients with Autosomal Dominant Polycystic Kidney Disease (ADPKD). We aim to explore the genetic landscape of ADPKD in a Chinese cohort utilizing whole genome sequencing and study its real-world clinical utility. Method From 1st January 2022 to 31st March 2023, we recruited 50 adult Chinese patients who had the clinical diagnosis of ADPKD followed up at Queen Mary Hospital and consented to the study protocol. The study was approved by the University Institution Review Board and local ethics committees. Genomic DNA was isolated from samples obtained from patients per standard protocol. Whole-genome sequencing was performed and analysed through the germline analysis pipeline. Diagnostic analysis was performed per American College of Medical Genetics (ACMG) guidelines and ClinGen variant curation expert panel specifications. Diagnostic variants were defined as those classified as ‘pathogenic’ or ‘likely pathogenic’. Potential clinical utility of genetic findings were studied case-by-case based on the Kidney Disease Improving Global Outcomes (KDIGO) 2023 Clinical Practice Guideline for the Evaluation, Management and Treatment of ADPKD. Results Among the 50 unrelated probands with ADPKD, half were males and the mean age at presentation was 38. 38% patients had incidental finding of kidney cysts on abdominal imaging performed for unrelated symptoms or health screening, 32% presented for screening due to positive family history and only 30% presented with typical symptoms of ADPKD. Cystic complications were present in 30%, with cyst haemorrhage being the most common, followed by kidney stones, cyst rupture and infection. 80% patients also had liver cysts and none had a history of cerebral aneurysms. The majority of our cohort (72%) had a family history of ADPKD. We identified diagnostic variants in 35 individuals, reaching a diagnostic yield of 70%. Diagnostic variants were identified in PKD1 (20/35), PKD2 (11/35), IFT140 (3/35) and ALG9 (1/35). The majority of diagnostic variants were protein-truncating (32/35), while non-truncating variants consisted of 1 in-frame deletion and 2 missense variants in PKD1. We identified 3 copy number variation:NC_000016.10:g.2110587_2111851del,NC_000016.10:g.2132339_2137621del,NC_000016.10:g.2036427_2101117del. The genetic findings allowed physicians to make definitive diagnosis in 9 patients with negative family history of ADPKD. The genetic findings provided important prognostic information as protein-truncating variants in PKD1 or PKD2 were associated with more severe disease compared to non-truncating variants. For the 3 patients harbouring heterozygous pathogenic variants in IFT140 (NM_014714.4:c.2659G&amp;gt;T, NM_014714.4:c.3780del, NM_014714.4:c.1035_1036del), they demonstrated a milder PKD phenotype with stable kidney function, normal kidneys size and absence of liver cysts 10 years after the diagnosis. The patient with heterozygous likely pathogenic ALG9 variant (NM_024740.2:c.1225del) also had milder PKD phenotype with normal kidney function and normal sized kidneys on USG 5 years after the diagnosis. In another male patient with young hypertension who was classified as Mayo Class 1C according to kidney imaging, identifying the pathogenic protein-truncating variant in PKD1 (NM_001009944.3:c.7288C&amp;gt;T) would render him eligible to tolvaptan treatment in view of the high PROPKD score (7). Furthermore, the genetic findings enabled an earlier diagnosis in a number of family members by cascade testing and genetic results were important to identify suitable living-related kidney donors. Conclusion Genetic testing utilizing whole genome sequencing has multiple clinical utility in ADPKD patients. It could provide a definitive diagnosis in those with atypical presentation or without family history, inform prognosis, guide treatment, determine living-related donor suitability and allow earlier diagnosis in other family members.

#444 Novel MRI filtration fraction method to assess glomerular hemodynamics in diabetic kidney disease

Abstract Background and Aims Filtration fraction (FF) is the ratio of the glomerular filtration rate (GFR) to renal plasma flow (RPF) and is therefore an important measure of glomerular hemodynamics. The gold standard method to assess effective RPF is renal clearance of para-aminohippuric acid (PAH) but technical and labour-intensive difficulties limit its application [1]. Quicker and simpler assays of FF are needed, particularly to assess the renal hemodynamic dysfunction (hyper- or hypofiltration) and effects/mode of action of therapeutic interventions in chronic kidney disease (CKD). We assessed a novel magnetic resonance imaging (MRI) technique to measure FF in patients with diabetic kidney disease (DKD) and healthy controls (HC) [2]. Method This cross-sectional sub-study included 32 DKD subjects with measured GFR (mGFR) ≤ 60 ml/ min/1.73 m2 and stratified into the following GFR stages as per the Kidney Disease Improving Global Outcomes (KDIGO) classification: stage G3a (mGFR 45-59 ml/ min/1.73 m2, n = 3), G3b (mGFR 30-44 ml/ min/1.73 m2, n = 8), G4 (mGFR 15-29 ml/ min/1.73 m2, n = 15), G5 (&amp;lt;15 ml/ min/1.73 m2, n = 6), and 18 age-, gender-matched HC with mGFR ≥ 60 ml/min/1.73 m2. All subjects were 18-79 years old. mGFR was assessed using iohexol clearance. Renal blood flow (RBF) (ml/min) was measured by a 5-minute add-on phase contrast MRI of the renal artery of each kidney and then summed together. RBF was corrected for Body Surface Area. RPF and FF were calculated as below: ${\rm{RPF }} = {\rm{ RBF}} \times \ ( {1\ -{\rm{ Hematocrit}}} )$ ${\rm{FF}} = {\rm{mGFR}}/{\rm{RPF}}$ Results RBF and mGFR were highly correlated (R2 = 0.70, Fig. 1). FF was 17.1% for HC and decreased with increasing degrees of renal impairment (Fig. 2). While the difference between HC and G3a DKD group was not significant, there was highly significant difference between HC and all other DKD groups (p &amp;lt; 0.001). The standard deviation in the G3a group was relatively large with only 3 subjects in this group. Conclusion The phase contrast MRI scan can provide a quick and simple measurement of glomerular hemodynamics and therewith further insights into the pathophysiology of DKD and its progression. Given the limitations of the existing method for assessing renal plasma flow, this MRI method can facilitate the inclusion of filtration fraction in DKD clinical trials. Further, the described method could be used to identify hyperfiltration, a compensatory mechanism that can influence results in clinical trials of DKD.

#1212 Trends in real-world lipid lowering therapy use among adult patients with chronic kidney disease: 5-year single center experience in the Philippines

Abstract Background and Aims Patients with chronic kidney disease (CKD) carry an extremely high burden for atherosclerotic cardiovascular disease (ASCVD), which worsens as CKD progresses. Several international guidelines, including the 2013 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, have recommended the use of lipid-lowering therapy (LLT) in this high-risk population. To evaluate the implementation of these recommendations in real-world practice, we assessed patterns of dyslipidemia management among patients with CKD. Specific objectives include describing the prevalence and intensity of LLT prescription [stratified by estimated glomerular filtration rate (GFR) and whether requiring renal replacement therapy or not] as well as adherence to guideline recommendations on LLT use. Method We conducted a single-center, cross-sectional study covering the period of January 2019 to December 2023. A review of inpatient and outpatient medical records of the Department of Medicine, University of the Philippine—Philippine General Hospital was done. Eligible patients were at least 18 years of age, and diagnosed with CKD. Exclusion criteria included having a concomitant diagnosis of Acute Kidney Injury, and being pregnant or breastfeeding at any point in the study period. Sociodemographic, clinical, and laboratory data were based off the latest entry in each patient's medical record. No clinical data were collected beyond those that were available on the records. Classification of statin intensity was based on the 2019 American Heart Association/American College of Cardiology Guidelines on the Management of Blood Cholesterol as well as the 2020 Philippine Clinical Practice Guidelines on the Management of Dyslipidemia. All analyses were descriptive and done using STATA 18. Categorical variables were summarized as frequencies and percentages. Continuous variables were reported as measures of central tendency [i.e. mean (SD) or median (IQR), as appropriate]. Results Of the 3845 patients included in the study, 2922 (76%) were prescribed LLT. The most common LLT were statins (92%), followed by statin/ezetimibe combinations (6%), then statin/fibrate combinations (2%). None were prescribed PCKS9 inhibitors, niacin, omega-3 fatty acids, or bile acid sequestrants. Among non-dialytic patients, the distribution of LLT use was as follows: a) eGFR ≥ 60 ml/min/1.73 m2: 40% (173/431) b) eGFR 30-60 ml/min/1.73 m2: 76% (1198/1576) c) eGFR &amp;lt;30 ml/min/1.73 m2: 84% (1551/1838). Among dialytic patients, 68% (601/884) were already on LLT prior to initiation of dialysis while 35% (283/884) were started on LLT after dialysis initiation. Notably, 89% (786/884) of these dialytic patients were still on moderate-to-high-intensity statin doses. Based on recommendations from the 2013 KDIGO guidelines, only 78% (2610/3334) of eligible patients were prescribed on LLT, while 61% (312/511) of ineligible patients were prescribed on LLT. Similar rates of adherence were seen to other international guideline recommendations on the management of dyslipidemia in CKD (e.g. 2018 American Heart Association/American College of Cardiology Guideline on the Management of Blood Cholesterol, 2019 European Society of Cardiology/European Atherosclerosis Society guidelines for the management of dyslipidaemias, 2020 Clinical Practice Guidelines for the management of dyslipidemia in the Philippines). Conclusion Real-world LLT use among CKD patients remains high, even at lower eGFRs. More importantly, a large proportion of patients remain under- and over-treated, highlighting significant gaps between guideline recommendations and real-world clinical practice. Further investigation regarding the underlying reasons for these practice variations is necessary to improve quality of care, and safely reduce the burden of dyslipidemia and ASCVD among CKD patients.

#2954 A comparative view of IgA nephropathy care across four global regions

Abstract Background and Aims IgA nephropathy (IgAN) is a chronic, rare, and slow progressing glomerular disease. IgAN treatment currently consists of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB), sodium-glucose co-transporter 2 (SGLT2) inhibitors, corticosteroids, and recently approved Nefecon and sparsentan in select markets. This research compares approaches to IgAN treatment in four regions of the world. Method Data was collected in partnership with 730 nephrologists submitting chart data from 1,570 of their most recently seen IgAN patients to create a representative sample across the US, EU5 (UK, Germany, Italy, France, and Spain), Japan, and China via parallel online surveys in 2023. Results Regardless of their geographic location, audited patient charts revealed that hypertension, hyperlipidemia, obesity, and diabetes were the leading comorbid conditions among IgAN patients. Across the four regions evaluated, Japanese patients were the healthiest (44% have no comorbid conditions vs. 28% EU5, 25% China, 18% US) and Japanese nephrologists perceived 79% of their IgAN patients to be in “excellent” overall health. Comparatively, patients in the US had the highest calculated body mass index (28.2) and the most comorbid conditions reported. Audited records also revealed that patients in Japan and China were referred to nephrology care earlier in their CKD progression as measured by eGFR levels, with over 50% of patients referred to their current nephrologist in CKD Stages 1 or 2, compared to approximately 35% of patients in the US and EU5. Chinese nephrologists (59%) and those in the US (53%) were most likely to agree that it is easy to identify IgAN patients who are likely to have rapid progression (vs. 43% EU5 and 40% Japan). When treating their IgAN patients, Japanese nephrologists ordered labs on a more frequent basis compared to those in the US, EU5, and China and on average, Japanese patients had blood work and urinalysis labs conducted six times within the past twelve months (versus four in the other countries.) Most audited patients had a calculated annual eGFR decline of 1 ml/year or more. Chinese patients (77%) were most notable for their IgAN progression, while those in Japan were least likely to be progressing in their disease (41%). Due to its chronic nature, most IgAN patients will eventually need dialysis, and while still representative of the majority of their audited patients, US nephrologists projected the lowest percentage of IgAN patients to eventually progress to end stage renal disease (66% vs. 73% Japan, 75% EU5, and 85% China). Most participating nephrologists reported that they closely adhere to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines when treating their IgAN patients. Nearly all audited IgAN patients were on baseline therapy of ACE inhibitors or ARBs, while the uptake of SGLT2 inhibitors has been notable in China (44%), the US (43%), and EU5 (43%), with Japan (33%) trailing in current treatment rates. Meanwhile, the use of corticosteroid was also higher in patients in Japan (65%) and China (59%) compared to those in the EU5 (51%) and US (43%). Of note, tonsillectomies are frequently used as a treatment approach for IgAN patients in Japan, with 45% of patients having received the procedure, whereas this approach is used much less often in the other regions. Following a tonsillectomy, nearly all Japanese patients received a pulse of steroids, leading to higher overall corticosteroid use compared to other regions. At the time of fielding, Nefecon was available to prescribe in the US and Germany with 9% and 7% of patients currently on treatment, respectfully; however, sparsentan had not been approved in any regions. Conclusion The comparison of patient chart data across various regions reveals differences in perspectives and IgAN treatment approaches among nephrologists. Prognostic and predictive tools are available and utilized globally, but the reliability and correlation between results, lab values, and disease progression calls for better education and alignment of global treatment guidelines.

#807 Presepsin and procalcitonin levels are associated with acute kidney injury in sepsis patients

Abstract Background and Aims Acute kidney injury (AKI) is a leading cause of death in patients with sepsis. Presepsin is a novel biomarker which has been used to predict sepsis and the outcomes of sepsis. Presepsin was also demonstrated in a small clinical trial to be associated with AKI in sepsis patients. Procalcitonin is a biomarker which was well-studied in sepsis and AKI patients. We aimed to study the association of presepsin and procalcitonin with AKI and outcomes of AKI in sepsis patients. Method We conducted a multicenter prospective trial in eight tertiary-care hospitals in Thailand. We included suspected sepsis patients aged 18 years or older who entered the emergency room during January 2021 to July 2022. We excluded patients with pregnancy, previous trauma, and postcardiac arrest. We also excluded dialysis patients and patients with estimated glomerular filtration rate (eGFR) less than 30 ml/min/1.73 m2 from our study. We measured blood presepsin and procalcitonin at day 0, 3 and 7 along with other investigation for usual intensive care of sepsis. We calculated the level of presepsin and procalcitonin that could distinguish between sepsis patients with and without AKI. We also analyzed whether presepsin and procalcitonin were associated between severity of AKI determined by Kidney Disease: Improving Global Outcomes (KDIGO) staging of AKI. Results We recruited 621 patients who was diagnosed sepsis at emergency department. AKI was diagnosed in 246 patients (39.6%). Of these AKI patients, maximal KDIGO stage of AKI were stage 1, 2 and 3 in 140 (56.9%), 64 (26.0%) and 42 (17.1%) patients, respectively. The median age was 70.1 years with 54.6% was male patients. The median BMI was 21.9 kg/m2. The median Charlson comorbidity index (CCI) was 5 (IQR 4-7). The median presepsin level in AKI patients was 1012 pg/mL (IQR 528-1719 pg/mL), which was significantly higher (P &amp;lt; 0.001) than the median presepsin level in non-AKI patients, which was 594 pg/mL (IQR 337-1138 pg/mL). The median procalcitonin level in AKI patients was 1.24 ng/mL (IQR 0.22-6.06 ng/mL), which was significantly higher (P &amp;lt; 0.001) than the median presepsin level in non-AKI patients, which was 0.50 ng/mL (IQR 0.09-2.34 ng/mL). The cut-point of presepsin level and the procalcitonin level of ≥795 pg/mL and ≥0.9 ng/mL was associated with AKI in sepsis patients respectively. The higher level of presepsin and procalcitonin also significantly associated with higher KGIDO staging of AKI as shown in Fig. 1. However, the mortality rate in both groups were not significantly different (24.0% in AKI group vs. 21.1% in non-AKI group, P = 0.39) Conclusion To date, this is one of the largest studies to evaluate the association between presepsin level, procalcitonin level and AKI in sepsis patients. The presepsin level and the procalcitonin level of ≥795 pg/mL and ≥0.9 ng/mL was associated with AKI in sepsis patients respectively.

#1280 Temporal trends in chronic kidney disease and mortality after acute kidney injury

Abstract Background and Aims In 2015, the International Society of Nephrology formulated the “0by25” initiative, which aims to eliminate all preventable deaths due to acute kidney injury (AKI) by 2025. Numerus publications have added focus to the importance of clinical awareness and improved treatment for AKI. Ideally, this should translate to lower rates of AKI-associated adverse outcomes such as chronic kidney disease (CKD) and death. To our knowledge, there are no studies describing temporal trends in the incidence of CKD following AKI. Moreover, only a few studies have examined the temporal trends in mortality following AKI and these studies included highly selected groups of patients not representative of general hospitalized patients and to an even lesser degree the general population. Hence, further examination of the prognosis after AKI is required to understand temporal trends in the quality of care for AKI and establish a foundation for both preventive and therapeutic measures. Therefore, we examined the temporal trends in CKD and mortality after AKI in Denmark. Method We identified adult individuals with AKI from 1 January 2007 to 31 December 2018 using population-based plasma creatinine (pCr) data covering both the primary care and hospital settings. AKI was defined in accordance with the Kidney Disease: Improving Global Outcomes (KDIGO) creatinine criteria. CKD after AKI was defined as ≥2 eGFR measurements from primary care or planned outpatient hospital visits &amp;lt;60 mL/min/1.73 m2 separated by a period of ≥90 days or by a hospital diagnoses code related to chronic dialysis or kidney transplantation. Information on all-cause death was obtained from the Danish Civil Registration System. Annual crude and sex-and-age-standardized 1-year incidence rates of CKD and mortality after AKI were estimated using direct standardization. Results During the 2007-2018 period, 406,207 AKIs were identified in 274,269 distinct Danish residents. The mean age at the time of first AKI was 72 years (IQR, 61; 81) and 137,185 (50%) of first-time AKIs occurred in males. Twenty-eight percent of individuals had a Charlson Comorbidity Index (CCI) score of 0, while 42% had a CCI score of 1-2, and 30% a CCI score ≥3. The mean age, sex, and CCI score distributions were stable across the study period. The age- and sex-standardized incidence rate of CKD after AKI ranged from 102 (95% CI, 99-106) per 1000 person-years in 2018 to 126 (95% CI, 119-133) per 1000 person-years in 2014. Besides a peak in 2014, the incidence of CKD after AKI showed little variation throughout the period. The age-and sex-standardized mortality rate after AKI ranged from 317 (95% CI, 311-323) per 1000 person-years in 2018 to 392 (95% CI, 379-406) per 1000 person-years in 2007. From 2007 to 2013 there was a stable decline in the mortality rate after AKI. From 2014 to 2018 the rate showed little variation. Conclusion The rate of CKD after AKI was stable throughout the period, while there was a decline in mortality after AKI, especially in the years from 2007 to 2013. The decline in mortality after AKI is encouraging; however, the stable rate of CKD after AKI, despite increasing knowledge on AKI treatment and CKD prevention, warrants an evaluation of the contemporary quality of care for AKI in Denmark.

#976 Empagliflozin limits AKI incidence and severity following cardiac surgery: an open-label phase IV randomized pilot study

Abstract Background and Aims Cardiac surgery-associated acute kidney injury (CSA-AKI) is a frequent complication of cardiac surgery assisted by cardiopulmonary bypass (CPB). Currently, no effective preventative strategies exist to reduce the incidence of acute kidney injury (AKI). Sodium-glucose transport protein 2 (SGLT2) inhibitors are effective in reducing the incidence of AKI in studies conducted in patients with chronic kidney disease. Therefore, we hypothesized that perioperative SGLT2 inhibition could reduce the incidence of CSA-AKI. Method In this open-label phase IV, randomized, parallel-group, balanced (1:1), pilot study, adult patients undergoing elective cardiac surgery with CPB were randomized to receive 10 mg empagliflozin per os once daily three days before surgery until two days after surgery, or standard care. The primary outcome was AKI incidence according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Other outcomes included hypoxia-inducible factor 1 alpha (HIF1A) and urinary Kidney Injury Molecule (KIM-1), urinary neutrophil gelatinase associated lipocalin (NGAL) and metabolic parameters such as plasma ketone and glucose concentrations. Results Between March 2022 and April 2023, 60 patients were randomized to empagliflozin (n = 29) or control (n = 31). All patients who underwent cardiac surgery with CPB were included in the intention-to-treat analysis (n = 25; empagliflozin group, n = 30; control group). SGLT2 inhibition significantly reduced the incidence of all stages of AKI (20% vs 66.7%; absolute difference 46%, 95% CI .13 to .63, P &amp;lt; .001). This decline in AKI incidence was reflected in the kidney biomarkers. SGLT2 inhibition also significantly reduced the number of patients with postoperative hyperglycemia (28% vs 60%; absolute difference 32%, 95% CI −56.8 to −7.2, P = .029). We observed no differences in the incidence of neither ketoacidosis nor hypoglycemic events. Conclusion Perioperative SGLT2 inhibition, compared with standard of care, demonstrated a significant reduction in AKI incidence rates. These findings merit validation in a larger placebo-controlled trial which is currently ongoing. Supplementary figures:

#2982 Shifts in SGLT2 inhibitor initiation in CKD non-dialysis patients

Abstract Background and Aims KDIGO guidelines have changed since 2020 with the introduction of SGLT2 inhibitors to CKD care. As the agents have become more standard of care in CKD, this research assesses how the treatment of more than 2000 CKD non-dialysis patients in the EU5 aligns with the KDIGO guidelines. Method Data from 1062 patient charts were collected in partnership with 265 EU5 (Germany, United Kingdom, Italy, France, and Spain) nephrologists via an online survey from December 2022-February 2023. Additionally, data from 1282 patient charts were collected from 263 EU5 nephrologists from December 2021-February 2022 via an online survey. Results Nephrologists often report that they strongly rely on the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines when making treatment decisions for their patients. Globally recognized, the KDIGO guidelines are created and periodically updated based on a rigorous scientific process to create an all-encompassing set of clinical practice recommendations. Over the past several years, SGLT2 inhibitors have become a fundamental part of CKD treatment and eGFR management. While the agents are primarily used in CKD patients with diabetic kidney disease (DKD), treatment rates among non-diabetic CKD patients have increased year-over-year. According to 2023 audited patient chart data, approximately one-half of DKD patients in the EU5 are on an SGLT2 inhibitor, while there has been a notable increase in treatment rates among non-diabetic CKD patients, from 11% in 2022 to 23% in 2023. Despite the recent change in the KDIGO guideline, which lowered the recommended eGFR level for SGLT2 inhibitor initiation to 20 mL/min/1.73 m2, 71% of patients who are treated with an SGLT2 inhibitor were initiated on therapy in CKD Stage 3 (eGFR 30-50), indicating that EU5 nephrologists have not yet conformed to the revised guidelines. Notably, participating EU5 nephrologists elicit increased comfort prescribing SGLT2 inhibitors to both their DKD and non-diabetic CKD patients year-over-year. In 2023, nearly all physicians reported that they expect to increase their use of SGLT2 inhibitors in their CKD patients, regardless of their diabetes status, indicating that there is potential for further adoption of the revised KDIGO guidelines into clinical practice. Conclusion As the treatment of CKD patients continues to evolve with SGLT2 inhibitors and newer therapies, KDIGO guidelines will adjust to accommodate evolution. Increased awareness of guideline changes will be paramount in ensuring that patients are receiving top quality care based on treatment recommendations.

#3066 Long-term outcomes after AKI in hospitalized patients with COVID-19

Abstract Background and Aims Acute kidney injury (AKI) is frequent in hospitalized patients and contributes to adverse short- and long-term outcomes. We aimed to evaluate the association of AKI and long-term adverse renal events and mortality in a cohort of patients hospitalized with COVID-19. Method Single-center and retrospective study of hospitalized patients admitted to a Dedicated Unit for COVID-19 at Centro Hospitalar Universitário Lisboa Norte, Portugal, between March 2020 and October 2020. AKI was defined and classified according to the Kidney Disease: Improving Global Outcomes (KDIGO) classification, using SCr criteria. The analyzed outcomes were development of major adverse kidney events (MAKE), major adverse renal cardiovascular events (MARCE), and mortality over a two-year follow-up period. Results From the included 409 patients, AKI occurred in 60.4% (n = 247). Within two years after discharge, 31.8% (n = 130) of patients had an eGFR &amp;lt;60 mL/min/1.73 m2 and/or a 25% decrease on eGFR and 1.7% (n = 7) of patients required RRT, 6.1% (n = 25) of patients had CV events and 27.9% (n = 114) of patients died. The incidence of MAKE was 61.4% (n = 251), and MARCE was 67.5% (n = 276). On a multivariate analysis, older age (adjusted HR 1.02 (95% CI: 1.01-1.04), p = 0.008), cardiovascular disease (adjusted HR 2.22 (95% CI: 1.24-3.95), p = 0.007), chronic kidney disease (adjusted HR 5.15 (95% CI: 2.22-11.93), p &amp;lt; 0.001), and AKI (adjusted HR 1.76 (95% CI: 1.12-2.78), p = 0.015) were independent predictors of MAKE. Older age (adjusted HR 1.06 (95% CI: 1.04-1.08), p &amp;lt; 0.001) and neoplasia (adjusted HR 4.88 (95% CI: 2.37-10.04), p &amp;lt; 0.001) were independent predictors of mortality. Conclusion In this cohort of hospitalized patients with COVID-19, AKI was independently associated with the risk of long-term need for dialysis and/or renal function decline and/or mortality after hospital discharge.

#492 Ten-year experience treating osteoporosis with bisphosphonate in hemodialysis patients

Abstract Background and Aims The treatment of osteoporosis in patients undergoing hemodialysis (HD) has not been established, as there is insufficient evidence regarding the treatment of osteoporosis. The Kidney Disease: Improving Global Outcomes (KDIGO) 2017 guidelines suggest that determining the bone marrow density (BMD) of HD patients is useful. In 2011, we began treating HD patients' osteoporosis with alendronate. Herein, we describe the effects of the treatment based on our 10-year experience. Method This was a single-center prospective observational study of 85 HD patients (age 67.8 ± 11.0 yrs; 47 females, 38 males) treated for osteoporosis with alendronate at our hospital during the 10 years 2011–2021. The average observational period was 3.9 ± 2.9 years. The patients' BMD values including those at the lumbar spine, femoral neck, and total hip were determined by dual-energy X-ray absorptiometry. The patients whose first T-score was ≤ −2.5 were treated with alendronate. We evaluated the patients' yearly BMD measurements and their yearly values of bone metabolism markers, i.e., parathyroid hormone (PTH), bone alkaline phosphatase (BAP), and tartrate-resistant acid phosphatase 5b (TRACP-5b). Results We compared the data before and after the start of alendronate treatment by dividing the patients into a responder group (the patients whose T-score had improved at 1 year after treatment started; n=44) and a non-responder group (the patients whose T-score had not improved; n=32). The mean observational period of the responder group was significantly longer than that of the non-responder group (p&amp;lt;0.01). In a multiple regression analysis, a longer observational period was significantly associated with the improvement of T-scores (p=0.02). Only the mean T-score of the lumbar spine gradually improved during the study period; those of the femoral neck and total hip did not. Conclusion A long-term use of alendronate for the treatment of osteoporosis may be effective in hemodialysis patients, especially for the lumbar spine. Decisions regarding the effect of alendronate treatment for osteoporosis patients undergoing HD should not be made within only a year after the treatment initiation; rather, a longer observation period is necessary.

Acute kidney injury after out-of-hospital cardiac arrest

BackgroundAcute kidney injury (AKI) is a significant risk factor associated with reduced survival following out-of-hospital cardiac arrest (OHCA). Whether the severity of AKI simply serves as a surrogate measure of worse peri-arrest conditions, or represents an additional risk to long-term survival remains unclear.MethodsThis is a sub-study derived from a randomized trial in which 789 comatose adult OHCA patients with presumed cardiac cause and sustained return of spontaneous circulation (ROSC) were enrolled. Patients without prior dialysis dependent kidney disease and surviving at least 48 h were included (N = 759). AKI was defined by the kidney disease: improving global outcome (KDIGO) classification, and patients were divided into groups based on the development of AKI and the need for continuous kidney replacement therapy (CKRT), thus establishing three groups of patients—No AKI, AKI no CKRT, and AKI CKRT. Primary outcome was overall survival within 365 days after OHCA according to AKI group. Adjusted Cox proportional hazard models were used to assess overall survival within 365 days according to the three groups.ResultsIn the whole population, median age was 64 (54–73) years, 80% male, 90% of patients presented with shockable rhythm, and time to ROSC was median 18 (12–26) min. A total of 254 (33.5%) patients developed AKI according to the KDIGO definition, with 77 requiring CKRT and 177 without need for CKRT. AKI CKRT patients had longer time-to-ROSC and worse metabolic derangement at hospital admission. Overall survival within 365 days from OHCA decreased with the severity of kidney injury. Adjusted Cox regression analysis found that AKI, both with and without CKRT, was significantly associated with reduced overall survival up until 365 days, with comparable hazard ratios relative to no AKI (HR 1.75, 95% CI 1.13–2.70 vs. HR 1.76, 95% CI 1.30–2.39).ConclusionsIn comatose patients who had been resuscitated after OHCA, patients developing AKI, with or without initiation of CKRT, had a worse 1-year overall survival compared to non-AKI patients. This association remains statistically significant after adjusting for other peri-arrest risk factors.Trial registration: The BOX trial is registered at ClinicalTrials.gov: NCT03141099.