Syndrome of rapid-onset end-stage renal disease: a new unrecognized pattern of CKD progression to ESRD

Abstract

By most estimates, we have an increasing worldwide end-stage renal disease (ESRD) epidemic. This is despite at least two decades of intensified reno-protection strategies, including attempts at optimal hypertension management, optimization of diabetic control, smoking cessation efforts, and the extensive application of renin-angiotensin-aldosterone system (RAAS) blockade in both diabetic and nondiabetic chronic nephropathies. The current consensus is that chronic kidney disease (CKD) progression to ESRD is a continuous, progressive, and predictable loss of estimated glomerular filtration rate (eGFR) in CKD patients, inexorably leading to ESRD. Our recent experience in a Mayo Health System Hypertension Clinic, as well as new reports associating ESRD development in CKD patients with episodes of acute kidney injury (AKI), led us to hypothesize that CKD to ESRD progression may not be that predictable, after all. Among a 100 high-risk CKD patient cohort that we have followed up prospectively since 2002, we demonstrated that in 15 of 17 (88%) patients who progressed to ESRD, progression from CKD to ESRD was unpredictable, nonlinear, abrupt, and rapid, and this followed AKI secondary to medical and surgical events. We have coined a new term, the syndrome of rapid-onset end-stage renal disease (SORO-ESRD), to represent this unrecognized syndrome. Larger studies are warranted to confirm our single-center findings. If confirmed to represent a significant proportion of the ESRD population, at least here in the United States, this finding will demand major paradigm shifts in the current concepts of reno-protection and "A-V Fistula first" programs.

Evidence of the syndrome of rapid onset end-stage renal disease (SORO-ESRD) in the acute kidney injury (AKI) literature – preventable causes of AKI and SORO-ESRD – a call for re-engineering of nephrology practice paradigms

“…The 31 patients, 18 males and 13 females, had a mean age of 72 (50-92) years. [9][10][11][12] Our SORO-ESRD rate of 34% compares favorably with the 18.4% rate reported in 1996 by Bhandari and Turner at the Leeds General Infirmary, in the United Kingdom. [9][10][11][12]1 In our 2011 Mayo Clinic Dialysis study, AKI immediately precipitating SORO-ESRD in the 31 patients was caused by pneumonia (8), acute decompensating heart failure (ADHF) (7), pyelonephritis (4), post-operative (5), general sepsis (3), contrast nephropathy (CN) (2) and others (2).…”

“…[6][7][8][9][10][11][12] Bhandari and Turney, reporting from the United Kingdom, in 1996, referred to them as ''survivors of acute renal failure who do not recover renal function''. 17 This report constituted the largest AKI series that we examined and consisted of 1095 patients, mean age 64 years and of whom 107 (16%) developed SORO-ESRD.…”

“…Excluding nine patients with incomplete data, 91 patients, 57 males and 34 females, age 39-93 years were analyzed. [9][10][11][12] Thirty-one of 91 (34%) ESRD patients had SORO-ESRD. The 31 patients, 18 males and 13 females, had a mean age of 72 (50-92) years.…”

“…Conversely, in opposition, the syndrome of rapid onset end-stage renal disease (SORO-ESRD), which we first described in 2010, is the sudden, unanticipated, precipitate and yet irreversible ESRD rapidly following AKI superimposed in a CKD patient with an a priori otherwise stable CKD [6][7][8][9][10][11][12] ( Figure 1). SORO-ESRD is the unpredictable, nonlinear, abrupt and rapid progression to irreversible ESRD, often over a period of less than 2-4 weeks, following AKI in CKD patients with prior stable and non-progressive albeit often reduced levels of eGFR [6][7][8][9][10][11][12] ( Figure 1). It remains unclear to what extent this syndrome may have been identified in the past in the medicalnephrology literature without acknowledging the uniqueness of this form of presentation of rapid onset albeit irreversible ESRD.…”

“…It remains unclear to what extent this syndrome may have been identified in the past in the medicalnephrology literature without acknowledging the uniqueness of this form of presentation of rapid onset albeit irreversible ESRD. [6][7][8][9][10][11][12] Our working diagnosis of SORO-ESRD is any CKD patient with an otherwise a priori stable eGFR of !30 mL/min/1.73 sq m BSA, on or before the 90th day preceding the first RRT, and which patient has remained permanently on RRT for 490 d. [6][7][8][9][10][11][12] Clearly, from the foregoing, the diagnosis of SORO-ESRD can only be made retroactively, at least 90 d after the first RRT treatment session was instituted. We investigated the incidence of SORO-ESRD as could be deduced from prior publications in the AKI literature, between 1975 and 2010, using this working definition of SORO-ESRD.…”