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.
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.
Summary Background Low values of estimated glomerular filtration rate (eGFR) predispose to acute kidney injury, and proteinuria is a marker of kidney disease. We aimed to investigate how eGFR and ...proteinuria jointly modified the risks of acute kidney injury and subsequent adverse clinical outcomes. Methods We did a cohort study of 920 985 adults residing in Alberta, Canada, between 2002 and 2007. Participants not needing chronic dialysis at baseline and with at least one outpatient measurement of both serum creatinine concentration and proteinuria (urine dipstick or albumin-creatinine ratio) were included. We assessed hospital admission with acute kidney injury with validated administrative codes; other outcomes were all-cause mortality and a composite renal outcome of end-stage renal disease or doubling of serum creatinine concentration. Findings During median follow-up of 35 months (range 0–59 months), 6520 (0·7%) participants were admitted with acute kidney injury. In those with eGFR 60 mL/min per 1·73 m2 or greater, the adjusted risk of admission with this disorder was about 4 times higher in those with heavy proteinuria measured by dipstick (rate ratio 4·4 vs no proteinuria, 95% CI 3·7–5·2). The adjusted rates of admission with acute kidney injury and kidney injury needing dialysis remained high in participants with heavy dipstick proteinuria for all values of eGFR. The adjusted rates of death and the composite renal outcome were also high in participants admitted with acute kidney injury, although the rise associated with this injury was attenuated in those with low baseline eGFR and heavy proteinuria. Interpretation These findings suggest that information on proteinuria and eGFR should be used together when identifying people at risk of acute kidney injury, and that an episode of acute kidney injury provides further long-term prognostic information in addition to eGFR and proteinuria. Funding The study was funded by an interdisciplinary team grant from Alberta Heritage Foundation for Medical Research.
Recognition is increasing for the effect of AKI on patients, and the resulting societal burden from its long-term effects, including development of chronic kidney disease and end-stage renal disease ...needing dialysis or transplantation.2 Few systematic efforts to manage (prevent, diagnose, and treat) AKI have been put in place and few resources have been allocated to inform health-care professionals and the public of the importance of AKI as a preventable and treatable disease.
Abstract Background Identification of patients at risk of contrast-induced acute kidney injury (CI-AKI) is valuable for targeted prevention strategies accompanying cardiac catheterization. Methods We ...searched MedLine and EMBASE for articles that developed or validated a clinical prediction model for CI-AKI or dialysis after angiography or percutaneous coronary intervention. Random effects meta-analysis was used to pool c-statistics of models. Heterogeneity was explored using stratified analyses and meta-regression. Results We identified 75 articles describing 74 models predicting CI-AKI, 10 predicting CI-AKI and dialysis, and 1 predicting dialysis. Sixty-three developed a new risk model whereas 20 articles reported external validation of previously developed models. Thirty models included sufficient information to obtain individual patient risk estimates; 9 using only preprocedure variables whereas 21 included preprocedural and postprocedure variables. There was heterogeneity in the discrimination of CI-AKI prediction models (median total range in c-statistic 0.78 0.57-0.95; I2 = 95.8%, Cochran Q-statistic P < 0.001). However, there was no difference in the discrimination of models using only preprocedure variables compared with models that included postprocedural variables ( P = 0.868). Models predicting dialysis had good discrimination without heterogeneity (median total range c-statistic: 0.88 0.87-0.89; I2 = 0.0%, Cochran Q-statistic P = 0.981). Seven prediction models were externally validated; however, 2 of these models showed heterogeneous discriminative performance and 2 others lacked information on calibration in external cohorts. Conclusions Three published models were identified that produced generalizable risk estimates for predicting CI-AKI. Further research is needed to evaluate the effect of their implementation in clinical care.
Background The buttonhole technique is an alternative method of cannulating the arteriovenous fistula (AVF) in hemodialysis (HD), frequently used for home HD patients. However, the balance of risks ...and benefits of the buttonhole compared with the rope-ladder technique is uncertain. Study Design A systematic review of randomized trials and observational studies (case reports, case series, studies without a control group, non-English studies, and abstracts were excluded). Setting & Population HD patients (both in-center conventional HD and home HD) using an AVF for vascular access. Selection Criteria for Studies We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL from the earliest date in the databases to March 2014 for studies comparing clinical outcomes of the buttonhole versus rope-ladder technique. Intervention Buttonhole versus rope-ladder cannulation technique. Outcomes The primary outcomes of interest were patient-reported cannulation pain and rates of AVF-related local and systemic infections. Secondary outcomes included access survival, intervention, hospitalization, and mortality, as well as hematoma and aneurysm formation, time to hemostasis, and all-cause hospitalization and mortality. Results Of 1,044 identified citations, 23 studies were selected for inclusion. There was equivocal evidence with respect to cannulation pain: pooled observational studies yielded a statistical reduction in pain with buttonhole cannulation (standardized mean difference, −0.76 95% CI, −1.38 to −0.15 standard deviations), but no difference in cannulation pain was found among randomized controlled trials (standardized mean difference, 0.34 95% CI, −0.76 to 1.43 standard deviations). Buttonhole, as compared to rope-ladder, technique appeared to be associated with increased risk of local and systemic infections. Limitations Overall poor quality and substantial heterogeneity among studies precluded pooling of most outcomes. Conclusions Evidence does not support the preferential use of buttonhole over rope-ladder cannulation in either facility-based conventional HD or home HD. This does not preclude buttonhole cannulation as being appropriate for some patients with difficult-to-access AVFs.
Background Although there is a strong economic rationale in favor of peritoneal dialysis (PD) over hemodialysis (HD), the potentially costly effect of PD technique failure is an important ...consideration in PD program promotion that is unknown. Study Design Incident dialysis patients were categorized by initial and subsequent modality changes during the first year of dialysis and tracked for inpatient and outpatient costs, physician claims, and medication costs for 3 years using merged administrative data sets. We determined unadjusted and adjusted total cumulative costs for each modality group using multivariable linear regression models. Setting & Participants All incident dialysis patients from Alberta in 1999-2003. Outcomes 3-year mean adjusted total cumulative costs. Measurements Mean direct health care costs by modality group determined using patient-level resource utilization data. Results 3-year adjusted total cumulative costs for patients in the PD-only and HD-to-PD groups were $58,724 (95% CI, $44,123-$73,325) and $114,503 (95% CI, $96,318-$132,688), respectively, compared with $175,996 (95% CI, $134,787-$217,205) for HD only. PD technique failure was associated with lower costs by $11,466 (95% CI, $248-$22,964) at 1 year compared with HD only; however, costs were similar at 3 years. Costs drivers in PD technique failure arose primarily from costs of dialysis provision, hospitalization, medications, and physician fees. Limitations This analysis is taken from the perspective of the health payer, and costs that are outside the health care system are not measured. Conclusions Compared with patients who receive only HD, those who received PD only and those who transitioned from HD to PD therapy had significantly lower total health care costs at 1 and 3 years. Patients experiencing PD technique failure had costs similar and not in excess of HD-only patients at 3 years, further supporting the economic rationale for a PD-first policy in all eligible patients.
Background In the nontransplant setting, acute kidney injury (AKI) may lead to chronic kidney disease (CKD) and end-stage renal disease, but the epidemiology of AKI in transplant recipients has not ...been characterized. The purpose of this study was to determine the incidence and consequences of AKI in kidney transplant recipients outside the peritransplant period and unrelated to acute rejection. Study Design Retrospective longitudinal cohort study. Setting & Participants 27,232 adult Medicare-insured transplant recipients with transplant survival of 6 months or longer in the US Renal Data System in 1995-2000. Predictors International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM ) hospital discharge diagnostic codes were used to identify AKI during the first 3 posttransplant years. Outcomes Transplant loss from any cause, mortality (death with a functioning transplant), and death-censored transplant loss. Measurements Estimated glomerular filtration rate calculated by the MDRD (Modification of Diet in Renal Disease) Study equation 6 months posttransplant. Results 3,066 (11.3%) patients had 4,181 hospitalizations with AKI, of which 14.8% required dialysis therapy. The incidence of AKI more than doubled during the study, and AKI was more frequent in patients with lower levels of transplant function. AKI was associated independently with increased risk of transplant loss from any cause (HR, 2.74; 95% CI, 2.56-2.92), death with a functioning transplant (HR, 2.36; 95% CI, 2.14-2.60), and death-censored transplant loss (HR, 3.17; 95% CI, 2.91-3.46). However, AKI-associated risks paradoxically were higher in patients with earlier CKD stage. Limitations Because of the limited sensitivity of ICD-9-CM codes for non–dialysis-requiring AKI events, the overall incidence of AKI likely is underestimated in this study. Conclusions We conclude that AKI is increasingly common and associated with transplant failure and death. Later CKD stage increases the risk of AKI, but AKI-associated risks of transplant failure were greater in those with higher levels of kidney function (earlier CKD stage).
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