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Original Investigation
January 27, 2020

Post–Acute Kidney Injury Proteinuria and Subsequent Kidney Disease Progression: The Assessment, Serial Evaluation, and Subsequent Sequelae in Acute Kidney Injury (ASSESS-AKI) Study

Author Affiliations
  • 1Division of Nephrology, University of California School of Medicine, San Francisco, San Francisco
  • 2Division of Research, Kaiser Permanente Northern California, Oakland, California
  • 3Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey
  • 4Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
  • 5Cincinnati Children's Hospital, Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, Ohio
  • 6Division of Nephrology, Department of Medicine, Pennsylvania State University College of Medicine, Hershey
  • 7Vanderbilt Center for Kidney Disease, Division of Nephrology & Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
  • 8Renal Section, Veterans Affairs New York Harbor Health Care System, New York University School of Medicine, New York
  • 9Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
  • 10University of Texas, Long School of Medicine, San Antonio
  • 11Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle
  • 12Hospital for Sick Children, Division of Nephrology, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
  • 13Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
  • 14Tennessee Valley Health Services, Nashville Veterans Affairs Hospital, Nashville, Tennessee
JAMA Intern Med. 2020;180(3):402-410. doi:10.1001/jamainternmed.2019.6390
Key Points

Question  Among patients who had acute kidney injury (AKI) during hospitalization, is proteinuria quantified after hospital discharge associated with future loss of renal function?

Findings  In this matched cohort study of 1538 participants, half of whom had AKI during hospitalization, higher urine albumin-to-creatinine ratio quantified 3 months after discharge from a hospitalization with AKI was associated with increased risk of kidney disease progression and served as a risk discriminator.

Meaning  More widespread quantification of proteinuria after hospitalized AKI should be considered to better evaluate the risk of future kidney disease progression.


Importance  Among patients who had acute kidney injury (AKI) during hospitalization, there is a need to improve risk prediction such that those at highest risk for subsequent loss of kidney function are identified for appropriate follow-up.

Objective  To evaluate the association of post-AKI proteinuria with increased risk of future loss of renal function.

Design, Setting, and Participants  The Assessment, Serial Evaluation, and Subsequent Sequelae in Acute Kidney Injury (ASSESS-AKI) Study was a multicenter prospective cohort study including 4 clinical centers in North America included 1538 patients enrolled 3 months after hospital discharge between December 2009 and February 2015.

Exposures  Urine albumin-to-creatinine ratio (ACR) quantified 3 months after hospital discharge.

Main Outcomes and Measures  Kidney disease progression defined as halving of estimated glomerular filtration rate (eGFR) or end-stage renal disease.

Results  Of the 1538 participants, 769 (50%) had AKI durring hospitalization. The baseline study visit took place at a mean (SD) 91 (23) days after discharge. The mean (SD) age was 65 (13) years; the median eGFR was 68 mL/min/1.73 m2; and the median urine ACR was 15 mg/g. Overall, 547 (37%) study participants were women and 195 (13%) were black. After a median follow-up of 4.7 years, 138 (9%) participants had kidney disease progression. Higher post-AKI urine ACR level was associated with increased risk of kidney disease progression (hazard ratio [HR], 1.53 for each doubling; 95% CI, 1.45-1.62), and urine ACR measurement was a strong discriminator for future kidney disease progression (C statistic, 0.82). The performance of urine ACR was stronger in patients who had had AKI than in those who had not (C statistic, 0.70). A comprehensive model of clinical risk factors (eGFR, blood pressure, and demographics) including ACR provided better discrimination for predicting kidney disease progression after hospital discharge among those who had had AKI (C statistic, 0.85) vs those who had not (C statistic, 0.76). In the entire matched cohort, after taking into account urine ACR, eGFR, demographics, and traditional chronic kidney risk factors determined 3 months after discharge, AKI (HR, 1.46; 95% CI, 0.51-4.13 for AKI vs non-AKI) or severity of AKI (HR, 1.54; 95% CI, 0.50-4.72 for AKI stage 1 vs non-AKI; HR, 0.56; 95% CI, 0.07-4.84 for AKI stage 2 vs non-AKI; HR, 2.24; 95% CI, 0.33-15.29 for AKI stage 3 vs non-AKI) was not independently associated with more rapid kidney disease progression.

Conclusions and Relevance  Proteinuria level is a valuable risk-stratification tool in the post-AKI period. These results suggest there should be more widespread and routine quantification of proteinuria after hospitalized AKI.

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