KDIGO - PDF Document

Presentation Transcript

  1. Acute Kidney Injury as a risk factor for Chronic Kidney Disease KDIGO Alan Cass, MBBS FRACP PhD Menzies School of Health Research Darwin, Australia

  2. Global burden of kidney disease KDIGO Jha et al – Lancet 2013 Kidney  Disease:  Improving  Global  Outcomes  

  3. Globalization and kidney disease KDIGO White et al – WHO Bulletin 2008 Kidney  Disease:  Improving  Global  Outcomes  

  4. Kidney disease – winning the war? KDIGO Is incidence falling in high-income countries? Kidney  Disease:  Improving  Global  Outcomes  

  5. Ageing population KDIGO 1970 Kidney  Disease:  Improving  Global  Outcomes  

  6. Ageing population KDIGO 2010 Kidney  Disease:  Improving  Global  Outcomes  

  7. Ageing population KDIGO 2050 Kidney  Disease:  Improving  Global  Outcomes  

  8. Ageing across Asia-Pacific region 2009 2050 15-59:60+ Rank Country KDIGO Country 15-59:60+ Rank Japan 1.92 1 Japan 1.01 1 Australia 3.24 2 USA 3.45 3 Hong Kong 3.97 4 Singapore 4.51 5 S. Korea 4.51 6 Taiwan 4.75 7 China 5.71 8 Vietnam 7.63 9 Kidney  Disease:  Improving  Global  Outcomes  

  9. Ageing across Asia-Pacific region 2009 2050 15-59:60+ Rank Country KDIGO Country 15-59:60+ Rank Japan 1.92 1 Japan 1.01 1 Australia 3.24 2 Taiwan 1.14 2 USA 3.45 3 S. Korea 1.17 3 Hong Kong 3.97 4 Singapore 1.24 4 Singapore 4.51 5 Hong Kong 1.25 5 S. Korea 4.51 6 China 1.73 6 Taiwan 4.75 7 Australia 1.82 7 China 5.71 8 USA 2.03 8 Vietnam 7.63 9 Vietnam 2.13 9 Kidney  Disease:  Improving  Global  Outcomes  

  10. Increasing burden of diabetes KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  11. Coming wave of obesity in children KDIGO WHO 2010 Kidney  Disease:  Improving  Global  Outcomes  

  12. Who is at risk of CKD? KDIGO Typically previous episode of AKI not featured amongst risk factors Kidney Health Australia 2012 Kidney  Disease:  Improving  Global  Outcomes  

  13. KDIGO – AKI definition 2.1.1: AKI is defined as any of the following: §  Increase in SCr by ≥ 0.3 mg/dl (≥ 26.5 µmol/l) within 48 hours; or KDIGO §  Increase in SCr to ≥ 1.5 times baseline, which is known or presumed to have occurred within the prior 7 days; or §  Urine volume <0.5 ml/kg/h for 6 hours Kidney  Disease:  Improving  Global  Outcomes  

  14. KDIGO – AKI staging/ severity KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  15. KDIGO – AKI causes KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  16. Traditional concept of AKI recovery •  Pre-renal phase •  Acute kidney injury that is reversible KDIGO •  Predictable and complete recovery •  No long-term sequelae Kidney  Disease:  Improving  Global  Outcomes  

  17. Acute Kidney Injury •  Increasing incidence, especially KDIGO in hospitalized elderly patients •  Prolongs hospital stay •  Often requires ICU transfer/dialysis support •  In hospital mortality remains high Kidney  Disease:  Improving  Global  Outcomes  

  18. Patients with at least one recognized AKI event KDIGO Medicare patients age 66 & older. USRDS 2013 Kidney  Disease:  Improving  Global  Outcomes  

  19. Rate  of  first  AKI  -­‐  2011   KDIGO USRDS 2013 Kidney  Disease:  Improving  Global  Outcomes  

  20. Probability of a recurrent AKI hospitalization in next 12 months KDIGO 34% 11% Months following AKI discharge USRDS 2013 Kidney  Disease:  Improving  Global  Outcomes  

  21. AKI and CKD - Interplay •  Accept that CKD is a risk factor for AKI KDIGO •  Concentrate on AKI as a risk factor for CKD •  Long-term follow-up of survivors RCT of intense vs standard CRRT for severe AKI •  Is there any evidence to suggest that modality of treatment for severe AKI affects dialysis dependence in survivors? Kidney  Disease:  Improving  Global  Outcomes  

  22. CKD as a risk factor for AKI Alberta Kidney Disease Network study KDIGO •  920,985 adults living in Alberta •  Followed median 35 months •  6520 (0.7%) admitted with AKI •  Stratified by eGFR and proteinuria •  Examined risk for hospitalization with AKI James et al – Lancet 2010 Kidney  Disease:  Improving  Global  Outcomes  

  23. Risk factors for AKI admission Reference group eGFR ≥60mLs/min/1.73m2 and no proteinuria KDIGO •  eGFR ≥60mLs/min/1.73m2 and heavy proteinuria Ø AKI admission ARR 4.4, needing dialysis ARR 7.7 •  eGFR 45.0 – 59.9 mLs/min/1.73m2 and no proteinuria Ø AKI admission ARR 2.3, needing dialysis ARR 1.9 •  eGFR 30.0 – 44.9 mLs/min/1.73m2 and no proteinuria Ø AKI admission ARR 5.6, needing dialysis ARR 4.6 •  eGFR 15.0 – 29.9 mLs/min/1.73m2 and no proteinuria Ø AKI admission ARR 13, needing dialysis ARR 15 James et al – Lancet 2010 Kidney  Disease:  Improving  Global  Outcomes  

  24. CKD after AKI – meta-analysis and SR •  SR comparing risk for death, CKD and ESRD KDIGO in patients with and without AKI •  13 studies with long-term renal and non-renal outcomes selected •  11 followed more than 3,000 patients •  1 in HIV, 2 included stem cell Tx recipients •  8 cardiac surgery, ICU, coronary angiography, post MI, hospitalized cohort Coca et al – KI 2012 Kidney  Disease:  Improving  Global  Outcomes  

  25. Mortality after AKI KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  26. CKD after AKI KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  27. ESKD after AKI KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  28. Outcomes in CA vs HA-AKI •  Electronic record review of 15,976 patients admitted KDIGO two district general hospitals in UK •  Baseline SCr established from blood tests taken 12 months prior to admission •  No baseline available in 49 and used upper limit of normal range SCr •  CA = AKI apparent on admission blood test •  HA = AKI occurred during hospitalization Wonnacott et al – cJASN 2012 Kidney  Disease:  Improving  Global  Outcomes  

  29. Outcomes in CA vs HA-AKI •  No dedicated onsite renal service or cardiothoracic KDIGO surgery •  1020 (6.4%) admission with AKI •  686 or approx 2/3 AKI cases were CA •  334 or approx 1/3 were HA •  CA mean age 74.4 vs 76.8, admitted to ICU 4.7% vs 9.9%, median LOS 7 vs 15 days Wonnacott et al – cJASN 2012 Kidney  Disease:  Improving  Global  Outcomes  

  30. Mortality after AKI Adjusted HR mortality HA-AKI 1.75 (1.44 to 2.13) KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  31. AKI - renal and CV outcomes •  Patients in VA database with discharge Dx of AKI or MI KDIGO •  36,980 patients admitted (and discharged) 1999 to 2005 analysed •  Known CKD and baseline eGFR <45mLs/min excluded •  Outcomes for people with MI, AKI, MI + AKI compared •  Median follow-up 1.4 years •  Outcomes death, kidney (dialysis, loss >25% eGFR or died), cardiac (CVA, MI or CHF admission) and combined kidney and cardiac Chawla et al – cJASN 2014 Kidney  Disease:  Improving  Global  Outcomes  

  32. Mortality after AKI KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  33. Poor outcomes with reversible AKI? •  Propensity matched cohort study of patients admitted to a US KDIGO medical center •  Excluded patients with eGFR < 60 in preceding 12 months, known CKD or receiving RRT •  “Recovery” of renal function defined as eGFR of at least 90% of baseline within 90 days of AKI •  Cohort 1610 with reversible AKI •  Median follow-up 3.3 years •  De novo CKD = occurrence of two eGFR measures <60mLs/ min/1.73m2 separated 90 days Bucaloiu et al – KI 2012 Kidney  Disease:  Improving  Global  Outcomes  

  34. De novo CKD after “reversible” AKI KDIGO Adjusted HR for de novo CKD 1.95 (1.75 to 2.09) Kidney  Disease:  Improving  Global  Outcomes  

  35. Renal Study KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  36. Renal Study KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  37. Renal Study KDIGO 37 Kidney  Disease:  Improving  Global  Outcomes  

  38. Renal Study KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  39. Post-RENAL Study •  Extended follow-up of survivors from 90 days to 4 years KDIGO •  Primary and secondary outcomes – death and commencement RRT – ascertained for 1464 (97%) of original participants at median of 43.9 months •  Tertiary outcomes assessed in 350 participants included eGFR and spot ACR More than 40% of participants seen at follow-up had micro or macroalbuminuria Gallagher et al – PLoS Med 2014 Kidney  Disease:  Improving  Global  Outcomes  

  40. Mortality KDIGO 40 Kidney  Disease:  Improving  Global  Outcomes  

  41. Death and dialysis after Day 90 KDIGO Low rates progression to ESKD Ongoing high death rate 41 Kidney  Disease:  Improving  Global  Outcomes  

  42. Modality and renal recovery KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  43. Modality and renal recovery OBJECTIVES: To compare recovery to RRT independence in AKI survivors according to initial RRT modality. DATA SOURCES: We searched MEDLINE and EMBASE for the keywords “renal replacement therapy” and “acute kidney injury” and their equivalents. STUDY SELECTION: We retrieved all English language studies (2000 to 2010) reporting renal recovery to RRT independence after adult AKI. DATA EXTRACTION: Two authors independently assessed study quality and extracted data. We used pooled analyses and the chi-square test for comparison. We performed sensitivity analyses with stratification by study type, size, pre-morbid chronic kidney disease, and illness severity. Secondarily, studies were pooled into Low (<50% exposed) or High- exposure (>50% exposed) according to the percentage of patients exposed to intermittent RRT (IRRT) (essentially intermittent HD). KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  44. Dialysis dependence in AKI survivors KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  45. Dialysis dependence in AKI survivors KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  46. Dialysis dependence in AKI survivors KDIGO Kidney  Disease:  Improving  Global  Outcomes  

  47. Summary •  AKI is common •  CKD is a risk factor for AKI •  AKI is a risk factor for development of CKD, progression to ESKD and death •  Need to identify high-risk patients - elderly, diabetes, people with CKD, undergoing major surgery •  Need to improve clinical follow-up after hospital discharge •  Further research necessary to examine whether modality of dialysis for severe AKI affects long-term dialysis dependence KDIGO Kidney  Disease:  Improving  Global  Outcomes