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Long-term outcomes of acute kidney injury and strategies for improved care

Nature Reviews Nephrology volume 16, pages 193–205 (2020)Cite this article

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Abstract

Acute kidney injury (AKI), once viewed predominantly as a self-limited and reversible condition, is now recognized as a growing problem associated with significant risks of adverse long-term health outcomes. Many cohort studies have established important relationships between AKI and subsequent risks of recurrent AKI, hospital re-admission, morbidity and mortality from cardiovascular disease and cancer, as well as the development of chronic kidney disease and end-stage kidney disease. In both high-income countries (HICs) and low-income or middle-income countries (LMICs), several challenges exist in providing high-quality, patient-centered care following AKI. Despite advances in our understanding about the long-term risks following AKI, large gaps in knowledge remain about effective interventions that can improve the outcomes of patients. Therapies for high blood pressure, glycaemic control (for patients with diabetes), renin–angiotensin inhibition and statins might be important in improving long-term cardiovascular and kidney outcomes after AKI. Novel strategies that incorporate risk stratification approaches, educational interventions and new models of ambulatory care following AKI have been described, and some of these are now being implemented and evaluated in clinical studies in HICs. Care for AKI in LMICs must overcome additional barriers due to limited resources for diagnosis and management.

Key points

  • Acute kidney injury (AKI) is a common and costly clinical syndrome that affects nearly one-quarter of all hospitalized patients worldwide.

  • Although AKI was previously often perceived as a self-limited condition, it is now clear that acute changes in kidney function are associated with long-term consequences, including progression to chronic kidney disease, cardiovascular effects, sustained functional impairment and death.

  • Therapies for blood pressure control, glycaemic control (for patients with diabetes), renin–angiotensin inhibition and statins might be important in improving long-term cardiovascular and kidney outcomes after AKI.

  • Novel strategies for follow-up care, including specialized nephrology care and risk-stratified follow-up, are being evaluated in high-income countries for patients discharged following AKI.

  • Care for AKI in low-income and middle-income countries poses additional barriers due to limited resources for diagnosis and management; the International Society of Nephrology has identified approaches to addressing these challenge

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Fig. 1: Absolute risks of clinical events for patients in high-income countries in the year after hospitalization with AKI.
Fig. 2: Proposed mechanisms linking acute and chronic kidney disease with cardiovascular disease and outcomes.
Fig. 3: Potential pathophysiological mechanisms involved in repair and recovery versus progression to CKD following AKI.

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Acknowledgements

M.T.J. was supported by Canadian Institutes of Health Research (CIHR) New Investigator Award. M.T.J. and M.T. were supported by a CIHR Foundation award.

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Authors and Affiliations

  1. Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

    Matthew T. James, Meha Bhatt & Marcello Tonelli

  2. Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

    Matthew T. James & Marcello Tonelli

  3. O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

    Matthew T. James & Marcello Tonelli

  4. Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

    Matthew T. James & Marcello Tonelli

  5. Department of Medicine, University of Alberta, Edmonton, Alberta, Canada

    Neesh Pannu

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M.T.J. and M.B. researched data for the article and wrote the manuscript. N.P. and M.T. made substantial contributions to discussions of the content and reviewed or edited the manuscript before submission.

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M.T.J. has received funding from an investigator-initiated research grant from Amgen Canada. The other authors declare no competing interests.

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Nature Reviews Nephrology thanks S. Faubel and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Glossary

Propensity-matched cohort study

A statistical method of analysis of observational data that uses a statistical matching technique to estimate the effect of a treatment by matching treated and untreated study participants with a similar propensity for treatment, based on the observed covariates that predict receiving the treatment.

Stepped-wedge trial

A type of cluster randomized trial that involves the collection of observations during a baseline period in which no clusters are exposed to the intervention; following this period, clusters are randomized to receive the intervention in steps, until all clusters have received the intervention.

Medication reconciliation

The process of comparing the medication orders of a patient with the list of medications that the patient has been taking to avoid medication errors such as omissions, duplications, dosing errors or drug interactions.

‘sick day medication guidance’

Advice provided to patients about symptoms and certain drugs that should be temporarily discontinued during acute intercurrent illnesses, particularly where the fluid balance is disturbed.

Concordance statistic

A measure of model performance that assesses discrimination (the ability of the model to separate individuals who develop events from those who do not).

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James, M.T., Bhatt, M., Pannu, N. et al. Long-term outcomes of acute kidney injury and strategies for improved care. Nat Rev Nephrol 16, 193–205 (2020). https://doi.org/10.1038/s41581-019-0247-z

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