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Invited Commentary
April 13, 2020

Renal Recovery After Acute Kidney Injury and Long-term Outcomes: Is Time of the Essence?

Author Affiliations
  • 1Division of Nephrology, University of California, San Diego, La Jolla
JAMA Netw Open. 2020;3(4):e202676. doi:10.1001/jamanetworkopen.2020.2676

After any illness, restoration to good health results from organ functional recovery that is dependent on the prior state of health, severity of illness, and the process of care. Although the severity stage can be delineated by the magnitude of structural and functional derangement at any point in time, quantifying recovery is often difficult, as it requires knowledge of the prior condition of the organ and ongoing interventions. The course of disease, with progression or improvement, consequently represents both the nature and extent of injury and repair, the associated comorbidities, and the management. Furthermore, the association of the extent of recovery with short-term and long-term outcomes requires accurate definitions and recognition of the events during and after the illness. In acute kidney injury (AKI), it is well recognized that the stage of AKI; associated comorbidities of diabetes, heart failure, and chronic kidney disease (CKD); and dialysis requirements are associated with adverse outcomes.1 More recently, attention has focused on the duration and number of episodes of AKI as factors associated with nonrecovery from AKI and short-term and long-term mortality. Most of these data have emerged from retrospective studies from postcardiac surgery and intensive care unit settings and have not been studied prospectively in other settings. Bhatraju et al2 studied long-term major adverse kidney events (MAKE), including incidence or progression of CKD, death, or dialysis, in the prospective, multicenter Assessment, Serial Evaluation, and Subsequent Sequelae (ASSESS-AKI) cohort study. Patients with and without AKI who survived hospitalization for 3 months were enrolled and followed up for a median of 4.7 years. Patients with AKI were classified as having resolving AKI if their serum creatinine values decreased by 0.3 mg/dL or more (to convert to micromoles per liter, multiply by 88.4) or 25% or more from maximum within the first 72 hours after AKI diagnosis and as having nonresolving AKI if they failed to meet these criteria. Most patients (74%) had Stage 1 AKI, 9% had sepsis, 4% required mechanical ventilation, and less than 7% needed dialysis. Of the patients with AKI, 62% had a resolving pattern; 54% of these patients had returned to baseline creatinine concentration at hospital discharge and 51% returned to baseline creatinine concentration at 3 months, whereas only 16% of patients with nonresolving AKI had returned to baseline creatinine concentration at hospital discharge and 38% returned to baseline creatinine concentration at 3 months. Compared with patients with no AKI, those with resolving AKI had an almost 2-fold higher risk of MAKE and those with nonresolving AKI had an almost 3-fold higher risk of MAKE; these risks persisted when adjusted for underlying comorbidities and Kidney Disease: Improving Global Outcomes stage of AKI. Patients with nonresolving AKI had a higher rate of incident and progressive CKD. Patients with AKI had a higher mortality rate than those without AKI (22% vs 12%), but there were no differences between patients with resolving AKI and those with nonresolving AKI. Interestingly, the AKI severity stage did not differentiate the development of MAKE during the 4 years of follow-up.

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