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    Original Investigation
    April 13, 2020

    Association Between Early Recovery of Kidney Function After Acute Kidney Injury and Long-term Clinical Outcomes

    Author Affiliations
    • 1Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle
    • 2Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle
    • 3Penn State College of Medicine, Department of Public Health Sciences, Hershey, Pennsylvania
    • 4Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
    • 5Program of Applied Translational Research, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
    • 6Section of Nephrology, Department of Internal Medicine, Mount Sinai School of Medicine, New York, New York
    • 7Division of Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
    • 8Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
    • 9Division of Nephrology, Department of Medicine, University of California, San Francisco
    • 10Division of Research, Kaiser Permanente Northern California, Oakland
    • 11Department of Epidemiology and Biostatistics, University of California, San Francisco
    • 12Division of Critical Care, Department of Anesthesia, University of California, San Francisco
    • 13Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
    • 14Division of Nephrology, New York University School of Medicine, New York
    • 15Division of Nephrology, Veterans Affairs New York Harbor Healthcare System, New York
    • 16Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University Medical Center, Washington, DC
    JAMA Netw Open. 2020;3(4):e202682. doi:10.1001/jamanetworkopen.2020.2682
    Key Points español 中文 (chinese)

    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.