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      Renal recovery after acute kidney injury

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          Abstract

          Acute kidney injury (AKI) is a frequent complication of critical illness and carries a significant risk of short- and long-term mortality, chronic kidney disease (CKD) and cardiovascular events. The degree of renal recovery from AKI may substantially affect these long-term endpoints. Therefore maximising recovery of renal function should be the goal of any AKI prevention and treatment strategy. Defining renal recovery is far from straightforward due in part to the limitations of the tests available to assess renal function. Here, we discuss common pitfalls in the evaluation of renal recovery and provide suggestions for improved assessment in the future. We review the epidemiology of renal recovery and of the association between AKI and the development of CKD. Finally, we stress the importance of post-discharge follow-up of AKI patients and make suggestions for its incorporation into clinical practice. Summary key points are that risk factors for non-recovery of AKI are age, CKD, comorbidity, higher severity of AKI and acute disease scores. Second, AKI and CKD are mutually related and seem to have a common denominator. Third, despite its limitations full recovery of AKI may best be defined as the absence of AKI criteria, and partial recovery as a fall in AKI stage. Fourth, after an episode of AKI, serial follow-up measurements of serum creatinine and proteinuria are warranted to diagnose renal impairment and prevent further progression. Measures to promote recovery are similar to those preventing renal harm. Specific interventions promoting repair are still experimental.

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          Most cited references85

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          Septic acute kidney injury in critically ill patients: clinical characteristics and outcomes.

          Sepsis is the most common cause of acute kidney injury (AKI) in critical illness, but there is limited information on septic AKI. A prospective, observational study of critically ill patients with septic and nonseptic AKI was performed from September 2000 to December 2001 at 54 hospitals in 23 countries. A total of 1753 patients were enrolled. Sepsis was considered the cause in 833 (47.5%); the predominant sources of sepsis were chest and abdominal (54.3%). Septic AKI was associated with greater aberrations in hemodynamics and laboratory parameters, greater severity of illness, and higher need for mechanical ventilation and vasoactive therapy. There was no difference in enrollment kidney function or in the proportion who received renal replacement therapy (RRT; 72 versus 71%; P = 0.83). Oliguria was more common in septic AKI (67 versus 57%; P < 0.001). Septic AKI had a higher in-hospital case-fatality rate compared with nonseptic AKI (70.2 versus 51.8%; P < 0.001). After adjustment for covariates, septic AKI remained associated with higher odds for death (1.48; 95% confidence interval 1.17 to 1.89; P = 0.001). Median (IQR) duration of hospital stay for survivors (37 [19 to 59] versus 21 [12 to 42] d; P < 0.0001) was longer for septic AKI. There was a trend to lower serum creatinine (106 [73 to 158] versus 121 [88 to 184] mumol/L; P = 0.01) and RRT dependence (9 versus 14%; P = 0.052) at hospital discharge for septic AKI. Patients with septic AKI were sicker and had a higher burden of illness and greater abnormalities in acute physiology. Patients with septic AKI had an increased risk for death and longer duration of hospitalization yet showed trends toward greater renal recovery and independence from RRT.
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            Incidence and outcomes in acute kidney injury: a comprehensive population-based study.

            Epidemiological studies of acute kidney injury (AKI) and acute-on-chronic renal failure (ACRF) are surprisingly sparse and confounded by differences in definition. Reported incidences vary, with few studies being population-based. Given this and our aging population, the incidence of AKI may be much higher than currently thought. We tested the hypothesis that the incidence is higher by including all patients with AKI (in a geographical population base of 523,390) regardless of whether they required renal replacement therapy irrespective of the hospital setting in which they were treated. We also tested the hypothesis that the Risk, Injury, Failure, Loss, and End-Stage Kidney (RIFLE) classification predicts outcomes. We identified all patients with serum creatinine concentrations > or =150 micromol/L (male) or > or =130 micromol/L (female) over a 6-mo period in 2003. Clinical outcomes were obtained from each patient's case records. The incidences of AKI and ACRF were 1811 and 336 per million population, respectively. Median age was 76 yr for AKI and 80.5 yr for ACRF. Sepsis was a precipitating factor in 47% of patients. The RIFLE classification was useful for predicting full recovery of renal function (P < 0.001), renal replacement therapy requirement (P < 0.001), length of hospital stay [excluding those who died during admission (P < 0.001)], and in-hospital mortality (P = 0.035). RIFLE did not predict mortality at 90 d or 6 mo. Thus the incidence of AKI is much higher than previously thought, with implications for service planning and providing information to colleagues about methods to prevent deterioration of renal function. The RIFLE classification is useful for identifying patients at greatest risk of adverse short-term outcomes.
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              Recovery after Acute Kidney Injury.

              Little is known about how acute kidney injury (AKI) resolves, and whether patterns of reversal of renal dysfunction differ among patients with respect to ultimate recovery.
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                Author and article information

                Contributors
                Marlies.Ostermann@gstt.nh.uk
                0043-512-504-24180 , michael.joannidis@i-med.ac.at
                Journal
                Intensive Care Med
                Intensive Care Med
                Intensive Care Medicine
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                0342-4642
                1432-1238
                2 May 2017
                2 May 2017
                2017
                : 43
                : 6
                : 855-866
                Affiliations
                [1 ]ISNI 0000 0001 0372 6120, GRID grid.412946.c, Intensive Care Unit and Surrey Perioperative Anaesthesia and Critical Care Collaborative Research Group, , Royal Surrey County Hospital NHS Foundation Trust, ; Egerton Road, Guildford, UK
                [2 ]ISNI 0000 0004 0407 4824, GRID grid.5475.3, Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, , University of Surrey, ; Guildford, UK
                [3 ]ISNI 0000 0004 1765 1491, GRID grid.412954.f, Medical-Surgical ICU, Hopital Nord, , CHU Saint-Etienne, ; Ave. Albert Raimon, 42270 Saint-Prient-en-Jarez, EA3065, Saint-Etienne, France
                [4 ]GRID grid.425213.3, Department of Critical Care and Nephrology, , Guy’s and St Thomas’ Hospital, ; London, SE1 9RT UK
                [5 ]ISNI 0000 0004 0435 165X, GRID grid.16872.3a, Department of Intensive Care Medicine, , VU University Medical Center Amsterdam, ; Amsterdam, The Netherlands
                [6 ]ISNI 0000 0004 0410 2071, GRID grid.7737.4, Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, , University of Helsinki and Helsinki University Hospital, ; Helsinki, Finland
                [7 ]ISNI 0000 0001 0372 5777, GRID grid.139534.9, William Harvey Research Institute, Queen Mary University of London and Adult Critical Care Unit, The Royal London Hospital, , Barts Health NHS Trust, ; Whitechapel Road, London, E1 1BB UK
                [8 ]ISNI 0000 0001 0668 7884, GRID grid.5596.f, Division of Cellular and Molecular Medicine, Clinical Department and Laboratory of Intensive Care Medicine, , KU Leuven University, ; Herestraat 49, 3000 Louvain, Belgium
                [9 ]ISNI 0000 0000 8853 2677, GRID grid.5361.1, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, , Medical University Innsbruck, ; Anichstrasse 35, 6020 Innsbruck, Austria
                Author information
                http://orcid.org/0000-0002-6996-0881
                Article
                4809
                10.1007/s00134-017-4809-x
                5487594
                28466146
                861131e8-63c8-42f5-81b3-ee1a32bf7a63
                © The Author(s) 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                : 22 February 2017
                : 17 April 2017
                Categories
                Review
                Custom metadata
                © Springer-Verlag GmbH Germany and ESICM 2017

                Emergency medicine & Trauma
                acute kidney injury,acute kidney disease,chronic kidney disease,renal replacement therapy,follow-up,biomarkers

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