Sepsis-Associated Acute Kidney Disease

Peerapornratana, Sadudee; Priyanka, P.; Shu, Wang; Angus, Derek C.; Chawla, Lakhmir S.; Huang, Defeng; Keener, Christopher; Kellum, John A.; Lucko, Nicole; Palevsky, Paul M.; Pike, Francis; Singbartl, Kai; Smith, A.J. Conrad; Yealy, Donald M.; Yende, Sachin; Barnato, Amber E.; Eaton, Tammy L.; Gimbel, Elizabeth; Landis, Kyle; Stapleton, Diana K.; Weissfeld, Lisa A.; Willochell, Michael; Wofford, Kourtney A.; Kulstad, Erik; Watts, Hannah; Venkatv, Arvind; Hou, Peter C.; Massaro, Anthony F.; Parmar, Siddharth; Limkakeng, Alexander T.; Brewer, Kori L.; Delbridge, Theodore R.; Mainhart, Allison; Miner, James R.; Allen, Todd L.; Grissom, Colin K.; Swadron, Stuart P.; Conrad, Steven A.; Carlson, Richard; LoVecchio, Frank; Bajwa, Ednan; Filbin, Michael R.; Parry, Blair A.; Ellender, Timothy J.; Sama, Andrew E.; Fine, Jonathan; Nafeei, Soheil; Terndrup, Thomas E.; Wojnar, Margaret; Pearl, Ronald G.; Wilber, Scott T.; Sinert, Richard; Orban, David J.; Wilson, Jason; Ufberg, Jacob W.; Albertson, Timothy; Panacek, Edward A.; Parekh, Sohan; Gunn, Scott R.; Rittenberger, Jon S.; Wadas, Richard J.; Edwards, Andrew R.; Kelly, Matthew; Wang, Henry E.; Holmes, T.; McCurdy, Michael T.; Weinert, Craig R.; Harris, Estelle S.; Self, Wesley H.; Dubinski, Diane; Phillips, Carolyn; Migues, Ronald M.

doi:10.1016/j.ekir.2020.03.005

Cited by 40 publications

(42 citation statements)

References 36 publications

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“…This is the first report in a large population of pediatric population, to our knowledge, to incorporate contemporary recommendations for clinical adjudication of AKI diagnosis. Although our findings validate the findings in adult septic patients, 1 , 2 , 4 , 10 , 25 we demonstrate unique downstream sequelae based on AKI duration and severity. Significant differences in the associations with mortality and ICU resource utilization exist between mild forms of S-AKI and severe forms of AKI.…”

Section: Discussionsupporting

confidence: 82%

Clinical phenotypes of acute kidney injury are associated with unique outcomes in critically ill septic children

et al. 2021

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Background Assessment of acute kidney injury (AKI) in septic patients remains imprecise. In adults, the classification of septic patients by clinical AKI phenotypes (severity and timing) demonstrates unique associations with patient outcome vs. broadly defined AKI. Methods In a multinational prospective observational study, AKI diagnosis in critically ill septic children was stratified by duration (transient vs. persistent) and severity (mild vs. severe by creatinine change and urine output). The outcomes of interest were mortality and intensive care unit resource complexity at 28 days. Results Seven hundred and fifty-seven septic children were studied (male 52.7%, age 4.6 years (1.5–11.9)). Mortality (overall 12.1%) was different between severe AKI and mild AKI (18.3 vs. 4.4%, p < 0.001) as well as intensive care unit (ICU) complexity (overall 34.5%, 45 vs. 21.7%, p < 0.001). Patients with Persistent AKI had fewer ICU-free days (17 (7, 21) vs. 24 (17, 26), p < 0.001) and higher ICU complexity (52.8 vs. 22.9%, p = 0.002) than transient AKI, even after exclusion of patients with early mortality. AKI phenotypes incorporating temporal and severity data correlate with unique survival (range 4.4–21.6%) and ICU-free days (range of 15–25 days) Conclusions The outcome of septic children with AKI changes by clinical phenotype. Our findings underscore the importance of prognostic enrichment in sepsis and AKI for the purpose of trial design and patient management. Impact Although AKI occurs commonly in patients with sepsis (S-AKI), outcomes for children with S-AKI varies based on the severity and timing of the AKI. Existing S-AKI pediatric data utilize a broad singular definition of kidney injury. Increasing the precision of AKI classification results in a new understanding of how S-AKI associates with patient outcome. A refined classification of S-AKI identifies subgroups of children, making possible a targeted and a personalized medicine approach to S-AKI study and management.

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Section: Discussionsupporting

confidence: 82%

Clinical phenotypes of acute kidney injury are associated with unique outcomes in critically ill septic children

et al. 2021

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“…16 , 33 Patients with AKI that evolves into acute kidney disease show greater long-term eGFR decreases than patients with AKI who do not develop acute kidney disease. 34 Older age, male sex, Black race, underlying CKD, and AKI severity are known risk factors for AKI progression to acute kidney disease 35 , 36 ; however, the accelerated eGFR decrease following COVID-19–associated AKI persisted after adjusting for these covariates. As in acute tubular necrosis, where patients with acute tubular necrosis due to mixed causes are at higher risk for future CKD than patients with acute tubular necrosis due to a single cause, such as ischemia or nephrotoxins, 37 the multiple concurrent mechanisms of COVID-19–associated AKI may be contributing to the increased eGFR decrease after discharge.…”

Section: Discussionmentioning

confidence: 99%

Assessment of Acute Kidney Injury and Longitudinal Kidney Function After Hospital Discharge Among Patients With and Without COVID-19

et al. 2021

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IMPORTANCE Acute kidney injury (AKI) occurs in up to half of patients hospitalized with coronavirus disease 2019 (COVID-19). The longitudinal effects of COVID-19-associated AKI on kidney function remain unknown. OBJECTIVE To compare the rate of change in estimated glomerular filtration rate (eGFR) after hospital discharge between patients with and without COVID-19 who experienced in-hospital AKI. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted at 5 hospitals in Connecticut and Rhode Island from March 10 to August 31, 2020. Patients who were tested for COVID-19 and developed AKI were screened, and those who survived past discharge, did not require dialysis within 3 days of discharge, and had at least 1 outpatient creatinine level measurement following discharge were included. EXPOSURES Diagnosis of COVID-19. MAIN OUTCOMES AND MEASURES Mixed-effects models were used to assess the association between COVID-19-associated AKI and eGFR slope after discharge. The secondary outcome was the time to AKI recovery for the subgroup of patients whose kidney function had not returned to the baseline level by discharge. RESULTS A total of 182 patients with COVID-19-associated AKI and 1430 patients with AKI not associated with COVID-19 were included. The population included 813 women (50.4%); median age was 69.7 years (interquartile range, 58.9-78.9 years). Patients with COVID-19-associated AKI were more likely to be Black (73 [40.1%] vs 225 [15.7%]) or Hispanic (40 [22%] vs 126 [8.8%]) and had fewer comorbidities than those without COVID-19 but similar rates of preexisting chronic kidney disease and hypertension. Patients with COVID-19-associated AKI had a greater decrease in eGFR in the unadjusted model (−11.3; 95% CI,-22.1 to −0.4 mL/min/1.73 m 2 /y; P = .04) and after adjusting for baseline comorbidities (−12.4; 95% CI,-23.7 to −1.2 mL/min/1.73 m 2 /y; P = .03). In the fully adjusted model controlling for comorbidities, peak creatinine level, and in-hospital dialysis requirement, the eGFR slope difference persisted (−14.0; 95% CI,-25.1 to −2.9 mL/min/1.73 m 2 /y; P = .01). In the subgroup of patients who had not achieved AKI recovery by discharge (n = 319), COVID-19-associated AKI was associated with decreased kidney recovery during outpatient follow-up (adjusted hazard ratio, 0.57; 95% CI, 0.35-0.92). CONCLUSIONS AND RELEVANCE In this cohort study of US patients who experienced in-hospital AKI, COVID-19-associated AKI was associated with a greater rate of eGFR decrease after discharge compared with AKI in patients without COVID-19, independent of underlying comorbidities or AKI (continued) Key Points Question What is the association between coronavirus disease 2019 (COVID-19) in patients with acute kidney injury and the longitudinal trajectory of estimated glomerular filtration rate? Findings In this cohort study of 1612 patients with acute kidney injury monitored after their index hospitalization, estimated glomerular filtration rate declined by 11.3 mL/min/ 1.73 m 2 per year faster in patients ...

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“…[5][6][7] Sepsis-associated AKI has high potential to lead to acute kidney disease (AKD), or persistently reduced kidney function for at least 7 but less than 90 days. [8][9][10] J o u r n a l P r e -p r o o f Despite the prevalence of sepsis-associated AKI, long-term follow-up examination of kidney function in this patient population remains understudied. Given the large number of patients with sepsis-associated AKI cared for annually, and many that will develop AKD, risk stratification of these patients either at hospital discharge or shortly thereafter will be critical to aid in prognostication as well as to target interventions that reduce post-AKI morbidity and the development of kidney [11][12][13] and non-kidney related complications such as cardiovascular disease.…”

Section: Introductionmentioning

confidence: 99%