Chronic kidney disease (CKD) remains one of the most potent predictors of acute kidney injury (AKI); however, recent epidemiologic studies have demonstrated a complex interplay between these two ...clinical entities. A growing body of evidence supports a bidirectional relationship: AKI leads to CKD, and the presence of CKD increases the risk of AKI. Additionally, several studies suggest that the presence of underlying CKD does modify the relation between AKI and adverse outcomes. In this article, we will review recent studies supporting the hypothesis that AKI leads to CKD and will explore the role of CKD as an effect modifier for AKI.
A recent meta-analysis confirms the association between AKI and the development of CKD and end-stage renal disease. Patient survival and renal outcomes after AKI are influenced by the presence of underlying CKD. AKI survivors with complete recovery of renal function remain at elevated risk of developing de-novo CKD, which may influence long-term survival; however, recovery of kidney function after AKI is associated with better long-term survival and renal function.
Recent findings support a strong association between AKI and CKD. There is uncertainty as to whether this relationship is causal. CKD is an effect modifier in AKI.
Acute kidney injury (AKI), once viewed predominantly as a self-limited and reversible condition, is now recognized as a growing problem associated with significant risks of adverse long-term health ...outcomes. Many cohort studies have established important relationships between AKI and subsequent risks of recurrent AKI, hospital re-admission, morbidity and mortality from cardiovascular disease and cancer, as well as the development of chronic kidney disease and end-stage kidney disease. In both high-income countries (HICs) and low-income or middle-income countries (LMICs), several challenges exist in providing high-quality, patient-centered care following AKI. Despite advances in our understanding about the long-term risks following AKI, large gaps in knowledge remain about effective interventions that can improve the outcomes of patients. Therapies for high blood pressure, glycaemic control (for patients with diabetes), renin-angiotensin inhibition and statins might be important in improving long-term cardiovascular and kidney outcomes after AKI. Novel strategies that incorporate risk stratification approaches, educational interventions and new models of ambulatory care following AKI have been described, and some of these are now being implemented and evaluated in clinical studies in HICs. Care for AKI in LMICs must overcome additional barriers due to limited resources for diagnosis and management.
Acute kidney injury: an increasing global concern Lameire, Norbert H, Prof; Bagga, Arvind, Prof; Cruz, Dinna, MD ...
The Lancet (British edition),
07/2013, Letnik:
382, Številka:
9887
Journal Article
Recenzirano
Despite an increasing incidence of acute kidney injury in both high-income and low-income countries and growing insight into the causes and mechanisms of disease, few preventive and therapeutic ...options exist. Even small acute changes in kidney function can result in short-term and long-term complications, including chronic kidney disease, end-stage renal disease, and death. Presence of more than one comorbidity results in high severity of illness scores in all medical settings. Development or progression of chronic kidney disease after one or more episode of acute kidney injury could have striking socioeconomic and public health outcomes for all countries. Concerted international action encompassing many medical disciplines is needed to aid early recognition and management of acute kidney injury.
IMPORTANCE: Contrast-associated acute kidney injury (AKI) is a common complication of coronary angiography and percutaneous coronary intervention (PCI) that has been associated with high costs and ...adverse long-term outcomes. OBJECTIVE: To determine whether a multifaceted intervention is effective for the prevention of AKI after coronary angiography or PCI. DESIGN, SETTING, AND PARTICIPANTS: A stepped-wedge, cluster randomized clinical trial was conducted in Alberta, Canada, that included all invasive cardiologists at 3 cardiac catheterization laboratories who were randomized to various start dates for the intervention between January 2018 and September 2019. Eligible patients were aged 18 years or older who underwent nonemergency coronary angiography, PCI, or both; who were not undergoing dialysis; and who had a predicted AKI risk of greater than 5%. Thirty-four physicians performed 7820 procedures among 7106 patients who met the inclusion criteria. Participant follow-up ended in November 2020. INTERVENTIONS: During the intervention period, cardiologists received educational outreach, computerized clinical decision support on contrast volume and hemodynamic-guided intravenous fluid targets, and audit and feedback. During the control (preintervention) period, cardiologists provided usual care and did not receive the intervention. MAIN OUTCOMES AND MEASURES: The primary outcome was AKI. There were 12 secondary outcomes, including contrast volume, intravenous fluid administration, and major adverse cardiovascular and kidney events. The analyses were conducted using time-adjusted models. RESULTS: Of the 34 participating cardiologists who were divided into 8 clusters by practice group and center, the intervention group included 31 who performed 4327 procedures among 4032 patients (mean age, 70.3 SD, 10.7 years; 1384 were women 32.0%) and the control group included 34 who performed 3493 procedures among 3251 patients (mean age, 70.2 SD, 10.8 years; 1151 were women 33.0%). The incidence of AKI was 7.2% (310 events after 4327 procedures) during the intervention period and 8.6% (299 events after 3493 procedures) during the control period (between-group difference, −2.3% 95% CI, −0.6% to −4.1%; odds ratio OR, 0.72 95% CI, 0.56 to 0.93; P = .01). Of 12 prespecified secondary outcomes, 8 showed no significant difference. The proportion of procedures in which excessive contrast volumes were used was reduced to 38.1% during the intervention period from 51.7% during the control period (between-group difference, −12.0% 95% CI, −14.4% to −9.4%; OR, 0.77 95% CI, 0.65 to 0.90; P = .002). The proportion of procedures in eligible patients in whom insufficient intravenous fluid was given was reduced to 60.8% during the intervention period from 75.1% during the control period (between-group difference, −15.8% 95% CI, −19.7% to −12.0%; OR, 0.68 95% CI, 0.53 to 0.87; P = .002). There were no significant between-group differences in major adverse cardiovascular events or major adverse kidney events. CONCLUSIONS AND RELEVANCE: Among cardiologists randomized to an intervention including clinical decision support with audit and feedback, patients undergoing coronary procedures during the intervention period were less likely to develop AKI compared with those treated during the control period, with a time-adjusted absolute risk reduction of 2.3%. Whether this intervention would show efficacy outside this study setting requires further investigation. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03453996
IntroductionIncremental dialysis is a personalised dialysis prescription based on residual kidney function that allows for the initial use of shorter duration, less frequent and less intense ...dialysis. It has been associated with enhanced quality of life and decreased healthcare costs when compared with conventional dialysis. While nephrologists report prescribing incremental dialysis, few dialysis programmes offer a systematic approach in offering and evaluating its use. To move evidence into practice, and in order to improve the safety and quality of providing incremental dialysis care, we have designed an implementation study. This study aims to evaluate the systematic assessment of patients starting facility-based haemodialysis for eligibility for incremental dialysis, and the prescription and monitoring of incremental dialysis treatment.Methods and analysisA hybrid effectiveness and implementation study design is being used to evaluate the implementation of the programme at dialysis sites in Alberta, Canada. The Reach, Effectiveness, Adoption, Implementation and Maintenance framework will be used to capture individual-level and organisational-level impact of the project. Clinical outcomes related to kidney function will be monitored on an ongoing basis, and patient-reported outcomes and experience measures will be collected at baseline and then quarterly throughout the first year of dialysis.Ethics and disseminationThe study was approved by the Health Research Ethics Board of the University of Alberta. The study is funded by the Strategic Clinical Networks of Alberta Health Services. The study will help answer important questions on the effectiveness of incremental dialysis, and inform the acceptability, adoption, feasibility, reach and sustainability of incremental dialysis within provision of haemodialysis care.
This study aimed to determine if recovery of kidney function after AKI modifies the association between AKI during hospitalization and adverse outcomes after discharge.
The effect of renal recovery ...after AKI was evaluated in a population-based cohort study (n=190,714) with participants identified from a provincial claims registry in Alberta, Canada, between November 1, 2002 and December 31, 2007. AKI was identified by a two-fold increase between prehospital and peak in-hospital serum creatinine (SCr). Recovery was assessed using SCr drawn closest to 90 days after the AKI event. All-cause mortality and a combined renal outcome of sustained doubling of SCr or progression to kidney failure were evaluated.
Overall, 3.7% of the participants (n=7014) had AKI, 62.7% of whom (n=4400) survived 90 days. In the 3231 patients in whom recovery could be assessed over a median follow-up of 34 months, 30.8% (n=1268) of AKI survivors died and 2.1% (n=85) progressed to kidney failure. Participants who did not recover kidney function had a higher risk for mortality and adverse renal outcomes when AKI participants who recovered to within 25% of baseline SCr were used as the reference group (adjusted mortality hazard ratio (HR), 1.26; 95% confidence interval, 1.10, 1.43) (adjusted renal outcomes HR, 4.13; 95% confidence interval, 3.38, 5.04). Mortality HR was notably higher when participants failed to recover within 55% of baseline.
Renal recovery after AKI is associated with a lower risk of death or adverse renal outcomes after hospital discharge.
Kidney involvement in patients with coronavirus disease 2019 (COVID-19) is common, and can range from the presence of proteinuria and haematuria to acute kidney injury (AKI) requiring renal ...replacement therapy (RRT; also known as kidney replacement therapy). COVID-19-associated AKI (COVID-19 AKI) is associated with high mortality and serves as an independent risk factor for all-cause in-hospital death in patients with COVID-19. The pathophysiology and mechanisms of AKI in patients with COVID-19 have not been fully elucidated and seem to be multifactorial, in keeping with the pathophysiology of AKI in other patients who are critically ill. Little is known about the prevention and management of COVID-19 AKI. The emergence of regional 'surges' in COVID-19 cases can limit hospital resources, including dialysis availability and supplies; thus, careful daily assessment of available resources is needed. In this Consensus Statement, the Acute Disease Quality Initiative provides recommendations for the diagnosis, prevention and management of COVID-19 AKI based on current literature. We also make recommendations for areas of future research, which are aimed at improving understanding of the underlying processes and improving outcomes for patients with COVID-19 AKI.
Summary The global nephrology community recognises the need for a cohesive plan to address the problem of chronic kidney disease (CKD). In July, 2016, the International Society of Nephrology hosted a ...CKD summit of more than 85 people with diverse expertise and professional backgrounds from around the globe. The purpose was to identify and prioritise key activities for the next 5–10 years in the domains of clinical care, research, and advocacy and to create an action plan and performance framework based on ten themes: strengthen CKD surveillance; tackle major risk factors for CKD; reduce acute kidney injury—a special risk factor for CKD; enhance understanding of the genetic causes of CKD; establish better diagnostic methods in CKD; improve understanding of the natural course of CKD; assess and implement established treatment options in patients with CKD; improve management of symptoms and complications of CKD; develop novel therapeutic interventions to slow CKD progression and reduce CKD complications; and increase the quantity and quality of clinical trials in CKD. Each group produced a prioritised list of goals, activities, and a set of key deliverable objectives for each of the themes. The intended users of this action plan are clinicians, patients, scientists, industry partners, governments, and advocacy organisations. Implementation of this integrated comprehensive plan will benefit people who are at risk for or affected by CKD worldwide.
Summary Background Diabetes is regarded as a coronary heart disease risk equivalent—ie, people with the disorder have a risk of coronary events similar to those with previous myocardial infarction. ...We assessed whether chronic kidney disease should be regarded as a coronary heart disease risk equivalent. Methods We studied a population-based cohort with measures of estimated glomerular filtration rate (eGFR) and proteinuria from Alberta, Canada. We used validated algorithms based on hospital admission and medical-claim data to classify participants with baseline history of myocardial infarction or diabetes and to ascertain which patients were admitted to hospital for myocardial infarction during follow-up (the primary outcome). For our primary analysis, we defined baseline chronic kidney disease as eGFR 15–59·9 mL/min per 1·73 m2 (stage 3 or 4 disease). We used Poisson regression to calculate unadjusted rates and relative rates of myocardial infarction during follow-up for five risk groups: people with previous myocardial infarction (with or without diabetes or chronic kidney disease), and (of those without previous myocardial infarction), four mutually exclusive groups defined by the presence or absence of diabetes and chronic kidney disease. Findings During a median follow-up of 48 months (IQR 25–65), 11 340 of 1 268 029 participants (1%) were admitted to hospital with myocardial infarction. The unadjusted rate of myocardial infarction was highest in people with previous myocardial infarction (18·5 per 1000 person-years, 95% CI 17·4–19·8). In people without previous myocardial infarction, the rate of myocardial infarction was lower in those with diabetes (without chronic kidney disease) than in those with chronic kidney disease (without diabetes; 5·4 per 1000 person-years, 5·2–5·7, vs 6·9 per 1000 person-years, 6·6–7·2; p<0·0001). The rate of incident myocardial infarction in people with diabetes was substantially lower than for those with chronic kidney disease when defined by eGFR of less than 45 mL/min per 1·73 m2 and severely increased proteinuria (6·6 per 1000 person-years, 6·4–6·9 vs 12·4 per 1000 person-years, 9·7–15·9). Interpretation Our findings suggest that chronic kidney disease could be added to the list of criteria defining people at highest risk of future coronary events. Funding Alberta Heritage Foundation for Medical Research.
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