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      Acute Kidney Injury before Dialysis Initiation Predicts Adverse Outcomes in Hemodialysis Patients

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          Background: Acute kidney injury (AKI) is associated with increased morbidity and mortality. Mortality in end-stage renal disease (ESRD) patients is highest during the first year of dialysis. The impact of pre-ESRD AKI events on long-term outcomes in incident ESRD patients remains unknown. Methods: We evaluated a retrospective cohort of 47,341 incident hemodialysis patients from the United States Renal Data System with linked Medicare data for at least 2 years prior to hemodialysis initiation. We examined the impact of pre-ESRD AKI events in the 2-year pre-ESRD period on the type of vascular access used at hemodialysis initiation (central venous catheter (CVC) versus arteriovenous access), and 1-year all-cause mortality after initiating hemodialysis. Results: The mean age was 72 ± 11 years. Of the study cohort, 18% initiated hemodialysis with arteriovenous access, and 54% of patients had at least one pre-ESRD AKI event. One-year, all-cause mortality was 32%. Compared to 75% for patients without a pre-ESRD AKI event, 89% of patients with a pre-ESRD AKI event initiated hemodialysis with CVC than arteriovenous access ( p < 0.001). A pre-ESRD AKI event was associated with lower adjusted odds of starting hemodialysis with an arteriovenous access (OR 0.47; 95% CI 0.44–0.50, p < 0.001), and higher adjusted odds of 1-year mortality (OR 1.36; 95% CI 1.30–1.42, p < 0.001). Conclusion: An AKI event prior to initiating hemodialysis independently increases the risk of CVC use and predicts 1-year mortality. Improving processes of care after AKI events may improve dialysis outcomes in patients who progress to ESRD.

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          Author and article information

          Am J Nephrol
          American Journal of Nephrology
          S. Karger AG
          July 2018
          07 June 2018
          : 47
          : 6
          : 427-434
          aDivision of Nephrology and Hypertension, University of Alabama at Birmingham, Birmingham, Alabama, USA
          bVeterans Affairs Medical Center, Birmingham, Alabama, USA
          cDivision of Nephrology, Kidney CARE Program, University of Cincinnati, Cincinnati, Ohio, USA
          dDepartment of Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio, USA
          eDepartment of Biomedical, Industrial, and Human Factors Engineering, Wright State University, Dayton, Ohio, USA
          fVeterans Affairs Medical Center, Cincinnati, Ohio, USA
          Author notes
          *Timmy Lee, MD, MSPH, FACP, FASN, Professor of Medicine, Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham, AL 35294-0007 (USA), E-Mail
          489949 Am J Nephrol 2018;47:427–434
          © 2018 S. Karger AG, Basel

          Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

          Page count
          Figures: 4, Tables: 4, Pages: 8
          Original Report: Patient-Oriented, Translational Research

          Cardiovascular Medicine, Nephrology

          Arteriovenous access, Acute kidney injury, Hemodialysis


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