Five-year risk of end-stage renal disease among intensive care patients surviving dialysis-requiring acute kidney injury: a nationwide cohort study

Abstract

IntroductionDialysis-requiring acute kidney injury (D-AKI) is common among intensive care unit (ICU) patients. However, follow-up data on the risk of end-stage renal disease (ESRD) among these patients remain sparse. We assessed the short-term and long-term risk of ESRD after D-AKI, compared it with the risk in other ICU patients, and examined the risk within subgroups of ICU patients.MethodsWe used population-based medical registries to identify all adult patients admitted to an ICU in Denmark from 2005 through 2010, who survived for 90 days after ICU admission. D-AKI was defined as needing acute dialysis at or after ICU admission. Subsequent ESRD was defined as a need for chronic dialysis for more than 90 days or a kidney transplant. We computed the cumulative ESRD risk for patients with D-AKI and for other ICU patients, taking into account death as a competing risk, and computed hazard ratios (HRs) using a Cox model adjusted for potential confounders.ResultsWe identified 107,937 patients who survived for 90 days after ICU admission. Of these, 3,062 (2.8%) had an episode of D-AKI following ICU admission. The subsequent risk of ESRD up to 180 days after ICU admission was 8.5% for patients with D-AKI, compared with 0.1% for other ICU patients. This corresponds to an adjusted HR of 105.6 (95% confidence interval (CI): 78.1 to 142.9). Among patients who survived 180 days after ICU admission without developing ESRD (n = 103,996), the 181-day to 5-year ESRD risk was 3.8% for patients with D-AKI, compared with 0.3% for other ICU patients, corresponding to an adjusted HR of 6.2 (95% CI: 4.7 to 8.1). During the latter period, the impact of AKI was most pronounced in the youngest patients, aged 15 to 49 years (adjusted HR = 12.8, 95% CI: 6.5 to 25.4) and among patients without preexisting chronic kidney disease (adjusted HR = 11.9, 95% CI: 8.5 to 16.8).ConclusionD-AKI is an important risk factor for ESRD for up to five years after ICU admission.

Acute Kidney Injury After Coronary Artery Bypass Grafting and Long-Term Risk of End-Stage Renal Disease

“…The 5-year risk of ESRD in these patients was 3.8% compared with 0.3% in patients who did not require dialysis. 22 Even though the setting was different in the Danish study, the risk of ESRD was similar to that in our cohort. In the Danish study, the association between AKI and ESRD was stronger in patients with normal kidney function than in those with chronic kidney disease.…”

“…Several previous epidemiological studies in various clinical settings reported an association between AKI and ESRD. 10,11,[22][23][24] AKI requiring dialysis in the immediate postoperative period is an independent risk factor for mortality. 5 Even though only ≈0.6% of patients need dialysis during the postoperative period, this is an important prognostic factor for both all-cause mortality and long-term dialysis.…”

“…Several previous epidemiological studies in various clinical settings reported an association between AKI and ESRD. 10,11,[22][23][24] AKI requiring dialysis in the immediate postoperative period is an independent risk factor for mortality.5 Even though only ≈0.6% of patients need dialysis during the postoperative period, this is an important prognostic factor for both all-cause mortality and long-term dialysis.6 A previous study reported that 8% of patients who survived >3 months after postoperative dialysis developed ESRD during 5.5 years of follow-up. 6 In another cohort of patients who underwent coronary angiography and developed AKI, the risk of ESRD was >4-fold higher in patients in AKIN stage 1 and almost 12-fold higher in patients in AKIN stage 2 to 3 compared with patients without AKI.…”

Inflammation in AKI

“…57 It is now known that AKI acquired in the ICU has important long-term sequelae, including an increased risk for ESRD. 58 However, both the number of patients and the duration of follow-up required to address end points, such as ESRD, make it unlikely that pharmacologic interventional trials with sufficient statistical power to show effects on these long-term consequences of ICUacquired AKI will be conducted in the near future. Therefore, the primary aim of clinical research in AKI should be to determine whether a new intervention actually ameliorates inflammationassociated kidney tissue damage during the patient's clinical stay.…”

Diagnostic accuracy of urinary neutrophil gelatinase-associated lipocalin in patients with septic acute kidney injury

“…18 Worsening AKI was defined as an increase in RIFLE category (from RISK to INJURY, RISK to FAILURE, or INJURY to FAILURE) in the 48 hours after enrollment or renal replacement therapy (RRT) initiation, as previously defined. 19 Baseline serum creatinine was defined as the lowest creatinine value in the last 6 months before AKI or, for those without this measurement, the lowest value achieved during hospitalization in the absence of dialysis. 20 Day 0 was defined as the calendar day of admission and thus its length varied depending on the time of presentation.…”