Association Between Early Recovery of Kidney Function After Acute Kidney Injury and Long-term Clinical Outcomes
Association Between Early Recovery of Kidney Function After Acute Kidney Injury and Long-term Clinical Outcomes
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急性肾损伤后早期肾功能恢复与远期临床预后的关系
DOI：
10.1001/jamanetworkopen.2020.2682
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发表时间：
2020-04-13
影响因子：
13.8
通讯作者：
Wurfel, Mark M.
中科院分区：
文献类型：
--
作者：
Bhatraju, Pavan K.;Zelnick, Leila R.;Wurfel, Mark M.
这项队列研究评估急性肾损伤后72小时内肾功能恢复的轨迹是否与临床结局的长期风险相关。问题急性肾损伤后72小时内肾功能恢复的轨迹是否与5年临床结局相关，如慢性肾脏疾病、透析和死亡？在这项前瞻性多中心队列研究的1538名参与者中，急性肾损伤后的早期恢复模式与长期结局相关。在校正分析中，与急性肾损伤恢复模式正在消退的患者相比，急性肾损伤恢复模式未消退的患者发生复合肾脏特异性临床结局的风险高51%，与急性肾损伤患者风险分层的传统标准无关。本研究的发现表明，急性肾损伤后的急性恢复模式应考虑在评估的长期临床outcome.Importance的风险急性肾损伤（阿基）的严重程度通常是根据最大血清肌酐浓度确定。然而，肾功能恢复的轨迹可能是阿基严重程度的另一个重要方面。目的评估急性肾损伤（阿基）后72小时内肾功能恢复的轨迹是否与临床结局的长期风险相关。设计、设置和参与者这项前瞻性、多中心队列研究招募了1538名在2009年12月1日至2015年2月28日期间出院后3个月患有或不患有阿基的成人。统计分析于2018年11月1日完成。根据人口统计学特征、研究中心、合并症和住院前估计的肾小球滤过率对有或无阿基的参与者进行匹配。根据先前发表的定义，将阿基受试者分为正在消退或未消退的阿基。阿基消退定义为阿基诊断后前72小时内血清肌酐浓度较最大值降低0.3 mg/dL或更多或25%或更多。未消退阿基定义为不符合阿基消退定义的阿基。主要结局和测量主要结局是主要肾脏不良事件（MAKE）的复合，MAKE定义为研究随访期间发生或进行性慢性肾脏疾病、长期透析或全因死亡。结果在1538例受试者中（964例男性;平均[SD]年龄，64.6 [12.7]岁），769例（50%）无阿基，475例（31%）阿基模式缓解，294例（19%）阿基模式未缓解。在中位随访4.7年后，所有参与者中有550人（36%）发生了MAKE的结局。与未发生阿基的受试者相比，AKI缓解患者（调整后风险比，1.52; 95% CI，1.01-2.29; P = 0.04）和阿基未缓解患者（调整后风险比2.30; 95% CI，1.52-3.48; P <0.001）的MAKE调整后风险比更高。在阿基患者人群中，与正在消退的阿基患者相比，未消退的阿基患者发生MAKE的风险高51%（95% CI，22%-88%; P <0.001）。阿基未消退患者中MAKE风险较高，这可以通过较高的慢性肾脏疾病发生和进展风险来解释。结论和相关性本研究表明，阿基后72小时内可区分临床重要肾脏特异性长期结局的风险。识别不同的阿基恢复模式可以改善患者风险分层，促进临床试验中的预后富集，并能够识别可能受益于肾病咨询的患者。
This cohort study assesses whether the trajectory of kidney function recovery within 72 hours after acute kidney injury is associated with long-term risk of clinical outcomes.Question Is the trajectory of kidney function within 72 hours after acute kidney injury associated with 5-year clinical outcomes, such as chronic kidney disease, dialysis, and death? Findings Among 1538 participants in this prospective multicenter cohort study, the early recovery pattern after acute kidney injury was associated with long-term outcomes. In adjusted analyses, patients with a nonresolving recovery pattern after acute kidney injury had a 51% greater risk for the composite kidney-specific clinical outcome compared with patients with a resolving acute kidney injury recovery pattern, independent of traditional criteria to risk stratify patients with acute kidney injury. Meaning This study's finding suggest that the acute recovery pattern after development of acute kidney injury should be considered in evaluating the risk of long-term clinical outcomes.Importance The severity of acute kidney injury (AKI) is usually determined based on the maximum serum creatinine concentration. However, the trajectory of kidney function recovery could be an additional important dimension of AKI severity. Objective To assess whether the trajectory of kidney function recovery within 72 hours after AKI is associated with long-term risk of clinical outcomes. Design, Setting, and Participants This prospective, multicenter cohort study enrolled 1538 adults with or without AKI 3 months after hospital discharge between December 1, 2009, and February 28, 2015. Statistical analyses were completed November 1, 2018. Participants with or without AKI were matched based on demographic characteristics, site, comorbidities, and prehospitalization estimated glomerular filtration rate. Participants with AKI were classified as having resolving or nonresolving AKI based on previously published definitions. Resolving AKI was defined as a decrease in serum creatinine concentration of 0.3 mg/dL or more or 25% or more from maximum in the first 72 hours after AKI diagnosis. Nonresolving AKI was defined as AKI not meeting the definition for resolving AKI. Main Outcomes and Measures The primary outcome was a composite of major adverse kidney events (MAKE), defined as incident or progressive chronic kidney disease, long-term dialysis, or all-cause death during study follow-up. Results Among 1538 participants (964 men; mean [SD] age, 64.6 [12.7] years), 769 (50%) had no AKI, 475 (31%) had a resolving AKI pattern, and 294 (19%) had a nonresolving AKI pattern. After a median follow-up of 4.7 years, the outcome of MAKE occurred in 550 (36%) of all participants. The adjusted hazard ratio for MAKE was higher for patients with resolving AKI (adjusted hazard ratio, 1.52; 95% CI, 1.01-2.29; P = .04) and those with nonresolving AKI (adjusted hazard ratio 2.30; 95% CI, 1.52-3.48; P < .001) compared with participants without AKI. Within the population of patients with AKI, nonresolving AKI was associated with a 51% greater risk of MAKE (95% CI, 22%-88%; P < .001) compared with resolving AKI. The higher risk of MAKE among patients with nonresolving AKI was explained by a higher risk of incident and progressive chronic kidney disease. Conclusions and Relevance This study suggests that the 72-hour period immediately after AKI distinguishes the risk of clinically important kidney-specific long-term outcomes. The identification of different AKI recovery patterns may improve patient risk stratification, facilitate prognostic enrichment in clinical trials, and enable recognition of patients who may benefit from nephrology consultation.