Acute Kidney Injury Requiring Dialysis and Incident Dialysis Patient Outcomes in US Outpatient Dialysis Facilities

Nephroprotective Potential of Lyophilized Grewia asiatica Powder Against Renal Biomarkers and Inflammation In Vivo

Introduction: Phalsa (Grewia asiatica) fruit is known for its rich nutritional profile and diverse pharmacological properties such as antioxidants, anti-inflammatory, and anti-cancer, making it a promising contender for preventive measures against cisplatin-induced acute kidney injury (AKI) in living organisms. Material and Methods: In the present study, rats were provided with different levels of lyophilized Grewia asiatica, i.e., 200, 300, and 400 mg/kg body weight along with control, fed on the basal diet. After trial completion, blood serum samples of rats subjected to renal biomarkers, hematology, and liver function tests, interleukin-6 (IL-6), whereas enzymes (alanine aminotransferase (ALT); sodium oxide dismutase, and glutathione) for kidney tissues along with photomicrographs for kidney tissue damage were measured. Results: The findings revealed that lyophilized Grewia asiatica provision effectively reduced renal biomarkers, blood urea nitrogen, and creatinine with AKI in the rats as well as treatments demonstrated significant improvements in antioxidant activity by reducing malonaldehyde levels and increasing the activity of glutathione, catalase, and superoxide dismutase in groups treated with dosages of 300 and 400 mg/kg powder. Conclusion: Grewia asiatica exhibited remarkable hepatoprotective properties by decreasing ALT and displayed anti-inflammatory properties, as evidenced by a substantial decrease in interleukin-6 serum levels. The study findings also added valuable insight into the multiform nephroprotective reverberation of lyophilized phalsa powder, emphasizing its plausible protective use in reducing cisplatin-induced nephrotoxicity.

Outcomes following acute kidney injury requiring dialysis: A cohort study

OBJECTIVE

Retrospective study to examine the outcomes of acute kidney injury requiring dialysis (AKI-D) patients that received outpatient hemodialysis as part of continued AKI-D care and explore factors associated with recovery of kidney function and discontinuation of dialysis.

METHODS

Records of all admissions to Emory Dialysis centers between January 2010 to December 2021 were reviewed to include patients with confirmed diagnosis of AKI-D. Basic demographics, comorbidities, duration of hospitalization and cause of AKI were extracted from hospital records and cross-referenced with the dialysis center electronic health record. Patients were followed starting from the day of the first outpatient hemodialysis up to 180 days. All hemodialysis sessions and laboratory data were analyzed. Logistic regression models were used to examine factors associated with recovery of kidney function, defined as survival free of dialysis.

RESULTS

132 patients were analyzed, corresponding to 12,662 patient-day of outpatient AKI-D care. Among those, 19 (14 %) patients died during the observation period. 54 % of patients were male and 70 % were Black race. Median Age was 64 years (IQR 49-79). 42 patients (32 %) recovered enough kidney function to discontinue dialysis. Median time to kidney recovery was 31 days (IQR: 19-75), and the cumulative probability of kidney recovery at 6 months was 39 %. Patients who discontinued dialysis were younger (58 vs 66 years), had higher estimated glomerular filtration rate (eGFR) at time of admission (69 vs 46 ml/min/1.73m2) to the hospital, and were less likely to have a history of hypertension (61 % vs 82 %). Intra-dialytic hypotension was more common in patients who did not recover kidney function.

CONCLUSIONS

39 % of patients with AKI-D recovered kidney function within 180 days of outpatient HD start. The median time to recovery was 31 days. Younger age, higher e-GFR at time of hospital admission, and absence of hypertension were predictors of kidney recovery. Patients who recover kidney function experienced episodes of intradialytic hypotension less frequently.

Unraveling the Epidemiology of Acute Kidney Injury Recovery

Acute kidney injury (AKI) is a common complication among hospitalized patients and is associated with significant long-term morbidity, including the development of major adverse kidney events such as kidney failure. By definition, AKI holds the promise of potential kidney recovery, yet clearly not all patients will recover, and some will develop worsening kidney function even after initial recovery. Being able to identify which patients with AKI will recover vs have persistent or future kidney complications is a critically important question, both for counseling patients and for determining appropriate care of AKI survivors. In this article, we review and describe the key factors associated with kidney function nonrecovery after AKI, some of which are modifiable and may be future targets for intervention. We also describe recent studies developing clinical risk scores to predict post-AKI kidney outcomes and their potential role in the clinical setting. Despite progress, there remains significant opportunity to improve our understanding of the epidemiology of AKI recovery.

Management of Patients With Acute Kidney Injury Undergoing Dialysis After Hospital Discharge

Acute kidney injury is a common diagnosis in hospitalized patients and can range in severity from a minor, reversible rise in creatinine to a more severe kidney injury with resultant complications. In a small but significant percentage of patients with acute kidney injury, renal replacement therapy is required for supportive care. Patients who require renal replacement therapy and survive to hospital discharge face major challenges in recovering from acute illness while adapting to an outpatient dialysis system that was not designed for patients with acute kidney injury. In addition, treating clinicians must navigate complex transitions of care and remain cognizant of signs of renal recovery. This review describes the current evidence in postdischarge acute kidney injury requiring dialysis management. We discuss risk factors for dialysis dependency, markers of kidney recovery, transitions of care, dialysis customization, and quality of life.

Hospital readmission for acute kidney injury is independently associated with de novo end-stage renal disease after liver transplantation

End-stage renal disease (ESRD) after liver transplantation (LT) is associated with high morbidity and mortality. The consequences of hospitalizations for post-LT acute kidney injury (AKI) are poorly understood. Using linked Medicare claims and transplant registry data, we analyzed adult liver alone recipients not receiving pretransplant dialysis between January 1, 2007, and December 31, 2016. Covariate-adjusted Cox proportional hazards models stratified by center evaluated factors associated with AKI readmission during the first post-LT year, and whether AKI readmission was associated with de novo early (<1 y) or late (≥1 y) ESRD post-LT. The cohort included 10,559 patients and was 64.5% male, 72.5% White, 8.1% Black, and 14.0% Hispanic with median age 62 years. Overall, 2875 (27.2%) patients had ≥1 AKI hospitalization during the first year. Estimated glomerular filtration rate at LT was associated with AKI readmission (adjusted HR: 1.16 per 10 mL/min/1.73m 2 decrease; p <0.001). The adjusted HR for early ESRD in patients with ≥1 AKI readmission <90 days post-LT was 1.90 ( p <0.001). The adjusted HRs for late ESRD with 1 and ≥2 prior AKI readmissions were 1.57 and 2.80, respectively ( p <0.001). AKI readmissions in the first post-LT year impact over one-quarter of recipients. These increase the risk of subsequent ESRD, but may represent an opportunity to intervene and mitigate further renal dysfunction.

Cumulative impact of hypotension during intermittent hemodialysis on kidney recovery in critically ill patients with AKI-D

BACKGROUND

Intermittent hemodialysis (IHD) is commonly implemented in patients with AKI-D, irrespective of the initial kidney replacement therapy (KRT) modality. However, concerns remain regarding the hemodynamic instability during IHD. This study aimed to assess the association between hypotensive episodes during IHD and kidney recovery in AKI-D patients.

METHODS

We retrospectively enrolled AKI-D survivors who received IHD in the intensive care units of a tertiary care hospital in Korea from January 2018 to February 2024.

RESULTS

A total of 1791 IHD sessions from 209 AKI-D survivors were analyzed. The patients underwent a median of 7 IHD sessions (interquartile range [IQR] 3-11), with an incidence of intradialytic hypotension (IDH) of 16.8 % per patient. Of these, 43.1 % were dialysis-dependent at hospital discharge. The number of IDH was a significant predictor of dialysis dependence (odds ratio [OR] 1.56; 95 % confidence interval [CI] 1.16-2.22). Patients experiencing ≥3 IDH episodes had a substantially higher risk of dialysis dependence compared to those without IDH (OR 9.41; 95 % CI 2.41-41.69). In per-session analysis, the target ultrafiltration rate was identified as an independent risk factor for IDH occurrence.

CONCLUSIONS

Our study revealed that IHD-related hypotension during hospitalization has a cumulative negative impact on kidney recovery in AKI-D survivors.

Health Care Access, Socioeconomic Status, and Acute Kidney Injury Outcomes: A Prospective National Study

Rationale & Objectives

Acute kidney injury (AKI) incidence and outcome in Kuwait are unknown. Moreover, non-Kuwaitis, who represent 66% of the population, have lower income, and their access to public health services is restricted compared with Kuwaitis who have free full access.

Study Design

Observational prospective multicenter cohort study.

Setting & Participants

Adult inpatients with AKI in 7 public hospitals from January 1 to December 31, 2021.

Exposure

AKI identified using Kidney Disease: Improving Global Outcomes serum creatinine-based criteria.

Outcomes

For hospitalized patients with AKI, the outcomes included 30-day outcomes of mortality, need for dialysis, kidney recovery rates, and differences in outcomes between Kuwaitis and non-Kuwaitis.

Analytical Approach

A backward stepwise multiple logistic regression analysis was performed to assess possible independent risk factors for the outcomes.

Results

We recruited 3,744 patients (mean age: 63 years; mean baseline estimated glomerular filtration rate [eGFR]: 66.7 mL/min; non-Kuwaitis: 42.3%), representing 3.2% of hospitalizations and 19.5% of intensive care unit (ICU) admissions. Non-Kuwaitis were significantly younger (57.6 vs 66.9 years), with higher baseline eGFR (73.1 vs. 62 mL/min), more frequent community acquired AKI (53.8% vs 46.7%), and AKI in summer (34.7% vs 26.9%). Dialysis was provided to 33.5% of patients, with a higher need for non-Kuwaitis (35.5% vs 32.1%). At 30 days, 34.4% of patients died, representing 24.8% of hospital mortality and 59.8% of ICU mortality. No differences in mortality or kidney recovery were noted between Kuwaitis and non-Kuwaitis. Low eGFR did not affect the mortality rate.

Limitations

Observational nature and short follow-up period of 30 days only.

Conclusions

AKI was associated with high dialysis need and mortality. Non-Kuwaitis accounted for less cases despite representing 66% of the population because they were younger with higher baseline eGFR and fewer comorbid conditions. Non-Kuwaitis had higher rates of community acquired AKI and AKI in summer and a higher need for dialysis but had similar mortality and complete kidney recovery rates.

Acute Kidney Injury Receiving Dialysis and Dialysis Care after Hospital Discharge

The number of patients with AKI receiving outpatient hemodialysis (AKI-D) is increasing. At present, on the basis of limited data, approximately one third of patients with AKI-D who receive outpatient dialysis after hospital discharge survive and regain sufficient kidney function to discontinue dialysis. Data to inform dialysis management strategies that promote kidney function recovery and processes of care among patients with AKI-D receiving outpatient dialysis are lacking. In this article, we detail current trends in the incidence, risk factors, clinical outcomes, proposed management, and health policy landscape for patients with AKI-D receiving outpatient dialysis and identify areas for further research.

Challenges in the Care of Patients with AKI Receiving Outpatient Dialysis: AKINow Recovery Workgroup Report

BACKGROUND

Up to one third of survivors of AKI that required dialysis (AKI-D) during hospitalization remain dialysis dependent at hospital discharge. Of these, 20%-60%, depending on the clinical setting, eventually recover enough kidney function to stop dialysis, and the remainder progress to ESKD.

METHODS

To describe the challenges facing those still receiving dialysis on discharge, the AKINow Committee conducted a group discussion comprising 59 participants, including physicians, advanced practitioners, nurses, pharmacists, and patients. The discussion was framed by a patient who described gaps in care delivery at different transition points and miscommunication between care team members and the patient.

RESULTS

Group discussions collected patient perspectives of ( 1 ) being often scared and uncertain about what is happening to and around them and ( 2 ) the importance of effective and timely communication, a comfortable physical setting, and attentive and caring health care providers for a quality health care experience. Provider perspectives included ( 1 ) the recognition of the lack of evidence-based practices and quality indicators, the significant variability in current care models, and the uncertain reimbursement incentives focused on kidney recovery and ( 2 ) the urgency to address communication barriers among hospital providers and outpatient facilities.

CONCLUSIONS

The workgroup identified key areas for future research and policy change to ( 1 ) improve communication among hospital providers, dialysis units, and patients/care partners; ( 2 ) develop tools for risk classification, subphenotyping, and augmented clinical decision support; ( 3 ) improve education to providers, staff, and patients/care partners; ( 4 ) identify best practices to improve relevant outcomes; ( 5 ) validate quality indicators; and ( 6 ) assess the effect of social determinants of health on outcomes. We urge all stakeholders involved in the process of AKI-D care to align goals and work together to fill knowledge gaps and optimize the care to this highly vulnerable patient population.

Pathophysiology of Red Blood Cell Trapping in Ischemic Acute Kidney Injury

Red blood cell (RBC) trapping describes the accumulation of RBCs in the microvasculature of the kidney outer medulla that occurs following ischemic acute kidney injury (AKI). Despite its prominence in human kidneys following AKI, as well as evidence from experimental models demonstrating that the severity of RBC trapping is directly correlated with renal recovery, to date, RBC trapping has not been a primary focus in understanding the pathogenesis of ischemic kidney injury. New evidence from rodent models suggests that RBC trapping is responsible for much of the tubular injury occurring in the initial hours after kidney reperfusion from ischemia. This early injury appears to result from RBC cytotoxicity and closely reflects the injury profile observed in human kidneys, including sloughing of the medullary tubules and the formation of heme casts in the distal tubules. In this review, we discuss what is currently known about RBC trapping. We conclude that RBC trapping is likely avoidable. The primary causes of RBC trapping are thought to include rheologic alterations, blood coagulation, tubular cell swelling, and increased vascular permeability; however, new data indicate that a mismatch in blood flow between the cortex and medulla where medullary perfusion is maintained during cortical ischemia is also likely critical. The mechanism(s) by which RBC trapping contributes to renal functional decline require more investigation. We propose a renewed focus on the mechanisms mediating RBC trapping, and RBC trapping-associated injury is likely to provide important knowledge for improving AKI outcomes. © 2024 American Physiological Society. Compr Physiol 14:5325-5343, 2024.

Unsupervised clustering identifies sub-phenotypes and reveals novel outcome predictors in patients with dialysis-requiring sepsis-associated acute kidney injury

INTRODUCTION

Heterogeneity exists in sepsis-associated acute kidney injury (SA-AKI). This study aimed to perform unsupervised consensus clustering in critically ill patients with dialysis-requiring SA-AKI.

PATIENTS AND METHODS

This prospective observational cohort study included all septic patients, defined by the Sepsis-3 criteria, with dialysis-requiring SA-AKI in surgical intensive care units in Taiwan between 2009 and 2018. We employed unsupervised consensus clustering based on 23 clinical variables upon initializing renal replacement therapy. Multivariate-adjusted Cox regression models and Fine-Gray sub-distribution hazard models were built to test associations between cluster memberships with mortality and being free of dialysis at 90 days after hospital discharge, respectively.

RESULTS

Consensus clustering among 999 enrolled patients identified three sub-phenotypes characterized with distinct clinical manifestations upon renal replacement therapy initiation (n = 352, 396 and 251 in cluster 1, 2 and 3, respectively). They were followed for a median of 48 (interquartile range 9.5-128.5) days. Phenotypic cluster 1, featured by younger age, lower Charlson Comorbidity Index, higher baseline estimated glomerular filtration rate but with higher severity of acute illness was associated with an increased risk of death (adjusted hazard ratio of 3.05 [95% CI, 2.35-3.97]) and less probability to become free of dialysis (adjusted sub-distribution hazard ratio of 0.55 [95% CI, 0.38-0.8]) than cluster 3. By examining distinct features of the sub-phenotypes, we discovered that pre-dialysis hyperlactatemia ≥3.3 mmol/L was an independent outcome predictor. A clinical model developed to determine high-risk sub-phenotype 1 in this cohort (C-static 0.99) can identify a sub-phenotype with high in-hospital mortality risk (adjusted hazard ratio of 1.48 [95% CI, 1.25-1.74]) in another independent multi-centre SA-AKI cohort.

CONCLUSIONS

Our data-driven approach suggests sub-phenotypes with clinical relevance in dialysis-requiring SA-AKI and serves an outcome predictor. This strategy represents further development toward precision medicine in the definition of high-risk sub-phenotype in patients with SA-AKI.Key messagesUnsupervised consensus clustering can identify sub-phenotypes of patients with SA-AKI and provide a risk prediction.Examining the features of patient heterogeneity contributes to the discovery of serum lactate levels ≥ 3.3 mmol/L upon initializing RRT as an independent outcome predictor.This data-driven approach can be useful for prognostication and lead to a better understanding of therapeutic strategies in heterogeneous clinical syndromes.

Initial Management and Potential Opportunities to Deprescribe Dialysis among Patients with AKI-D Patients after Hospital Discharge

SIGNIFICANCE STATEMENT

Dialysis-requiring AKI (AKI-D) now accounts for more than 15% of outpatient hemodialysis initiations; over 30% of these patients with AKI-D may have potential to recover. However, little is known about strategies currently used to treat outpatient AKI-D and screen for recovery. In this study of 1754 patients with AKI-D, we found that ( 1 ) the initial dialysis orders were similar to those of patients with contemporary incident ESKD, despite different treatment goals; ( 2 ) timed urine collections were completed in only a minority of patients; and ( 3 ) most patients with AKI-D who recovered discontinued dialysis without ever having been weaned from their initial dialysis prescription, suggesting there may be substantial opportunity to wean dialysis sooner.

Associations between abrupt transition, dialysis-requiring AKI, and early mortality in ESKD among U.S. veterans

BACKGROUND

Mortality is high within the first few months of starting chronic dialysis. Pre-ESKD trajectory of kidney function has been shown to be predictive of early death after dialysis initiation. We aim to better understand how two key aspects of pre-dialysis kidney function-an abrupt transition pattern and an episode of dialysis-requiring AKI (AKI-D) leading directly to ESKD-are associated with early mortality after dialysis initiation.

METHODS

We extracted national data from U.S. Veterans Health Administration cross-linked with the United States Renal Data System (USRDS) to identify patients who initiated hemodialysis during 2009-2013. We defined abrupt transition as having a mean outpatient eGFR ≥ 30 ml/min/1.73m2 within 1 year prior to ESKD. AKI-D was identified using inpatient serum creatinine measurements (serum Cr increase by at least 50% from baseline) along with billing codes for inpatient receipt of dialysis for AKI within 30 days prior to the ESKD start date. We used multivariable proportional hazards models to examine the association between patterns of kidney function prior to ESKD and all-cause mortality within 90 days after ESKD.

RESULTS

Twenty-two thousand eight hundred fifteen patients were identified in the final analytic cohort of Veterans who initiated hemodialysis and entered the USRDS. We defined five patterns of kidney function decline. Most (68%) patients (N = 15,484) did not have abrupt transition and did not suffer an episode of AKI-D prior to ESKD (reference group). The remaining groups had abrupt transition, AKI-D, or both. Patients who had an abrupt transition with (N = 503) or without (N = 3611) AKI-D had the highest risk of early mortality after ESKD onset after adjustment for demographics and comorbidities (adjusted HR 2.10, 95% CI 1.66-2.65 for abrupt transition with AKI-D; adjusted HR 2.10, 95% CI 1.90-2.33 for abrupt transition without AKI-D). In contrast, patients who experienced AKI-D without an abrupt transition pattern (N =  2141 had only a modestly higher risk of early death (adjusted HR 1.19, 95% CI 1.01-1.40).

CONCLUSIONS

An abrupt decline in kidney function within 1 year prior to ESKD occurred in nearly 1 in 5 incident hemodialysis patients (18%) in this national cohort of Veterans and was strongly associated with higher early mortality after ESKD onset.

Early Comprehensive Kidney Care in Dialysis-Requiring Acute Kidney Injury Survivors: A Populational Study

Background

For patients with Acute Kidney Injury (AKI), a strong and graded relationship exists between AKI severity and mortality. One of the most severe entities of AKI is Dialysis-Requiring Acute Kidney Injury (D-AKI), which is associated with high rates of mortality and end-stage renal disease (ESRD). For this high-risk population group, there is a lack of evidence regarding optimal post-AKI care. We propose that post-AKI care through the combined efforts of the nephrologist and the multidisciplinary care team may improve outcomes. Our aim here is to study for survivors of dialysis-requiring acute kidney injury, the effects of implementing early comprehensive kidney care.

Methods

This is a retrospective longitudinal cohort study of Taiwanese through analyzing the National Health Insurance Research Database (NHIRD). We included patients with acute dialysis during hospitalization from January 1, 2015 to December 31, 2018. Propensity match was done at 1:1, including estimated glomerular filtration rate (eGFR) based on CKD-EPI which was performed due to large initial disparities between these two cohorts.

Results

After the propensity match, each cohort had 4,988 patients. The mean eGFR based on CKD-EPI was 27.5 ml/min/1.73 m2, and the mean follow-up period was 1.4 years.

The hazard ratio for chronic dialysis or ESRD was 0.55 (95% CI, 0.49–0.62; p &lt; 0.001). The hazard ratio for all-cause mortality was 0.79 (95% CI, 0.57–0.88; p &lt; 0.001). Both outcomes favored early comprehensive kidney care.

Conclusions

For survivors of dialysis-requiring acute kidney injury, early comprehensive kidney care significantly lowered risks of chronic dialysis and all-cause mortality.