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CME

Acute Kidney Injury in Elderly May Increase Risk for End-Stage Renal Disease

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Désirée Lie, MD, MSEd
  • CME Released: 11/25/2008
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 11/25/2009
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Target Audience and Goal Statement

This article is intended for primary care clinicians, geriatricians, nephrologists, urologists, endocrinologists, and other specialists who care for elderly patients with acute kidney injury.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Describe the risk for end-stage renal disease associated with acute kidney injury in older adults.
  2. Describe the risk for end-stage renal disease associated with chronic kidney disease alone and in combination with acute kidney injury in older adults.


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Author(s)

  • Laurie Barclay, MD

    Laurie Barclay, MD is a freelance reviewer and writer for Medscape.

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Editor(s)

  • Brande Nicole Martin

    Brande Nicole Martin is the News CME editor for Medscape Medical News.

    Disclosures

    Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

CME Author(s)

  • Désirée Lie, MD, MSEd

    Clinical Professor, Family Medicine, University of California, Orange; Director, Division of Faculty Development, UCI Medical Center, Orange, California

    Disclosures

    Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.


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CME

Acute Kidney Injury in Elderly May Increase Risk for End-Stage Renal Disease

Authors: News Author: Laurie Barclay, MD CME Author: Désirée Lie, MD, MSEdFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME Released: 11/25/2008

Valid for credit through: 11/25/2009

processing....

November 25, 2008 — Elderly patients with acute kidney injury (AKI) have an increased risk for end-stage renal disease (ESRD), according to the results of a cohort study reported in the November 19 Online First issue and will be published in the January 2009 print issue of the Journal of the American Society of Nephrology.

"Although short-term consequences of...AKI have been extensively studied, the rate of development of...ESRD after AKI has been poorly defined in a representative sample," write Areef Ishani, from the United States Renal Data System Coordinating Center, University of Minnesota Medical School in Minneapolis, and colleagues. "Moreover, the potential linkage between patients with AKI, chronic kidney disease (CKD), and ESRD has been poorly studied and remains ill defined, particularly among elderly individuals, who represent the fastest growing segment of the ESRD population."

The goal of this study was to examine incidence rates and hazard ratios for the development of ESRD in elderly individuals, with and without CKD. Medicare claims were used to identify clinical data from a 5% random sample of Medicare beneficiaries in 2000. Data regarding treatment for ESRD during 2 years of follow-up were obtained from ESRD registration.

The study cohort consisted of 233,803 patients who were hospitalized in 2000, who were at least aged 67 years at discharge, did not have previous ESRD or AKI, and were entitled to Medicare benefits for at least 2 years before discharge. Among this cohort, 3.1% of those who survived to discharge had a diagnosis of AKI, and ESRD developed in 5.3 per 1000. Of patients treated for ESRD, 25.2% had a history of AKI.

For patients with AKI and CKD, the hazard ratio (HR) for the development of ESRD, relative to those without kidney disease, was 41.2 (95% confidence interval [CI], 34.6 - 49.1), after adjustment for age, sex, race, diabetes, and hypertension. HR was 13.0 (95% CI, 10.6 - 16.0) for patients with AKI and without previous CKD and 8.4 (95% CI, 7.4 - 9.6) for patients with CKD and without AKI.

"Physicians should be especially vigilant in monitoring these patients over time to ensure that they receive proper and prompt care if their kidney function continues to decline," senior author Allan J. Collins said in a news release. "Physicians should take advantage of relatively simple lab tests to check kidney function."

Limitations of this study include low sensitivity of International Classification of Diseases, Ninth Revision, Clinical Modification, codes to identify both AKI and CKD; lack of data on the severity of AKI; lack of generalizability to younger populations or to the US population as a whole; and a large number of patients with AKI who did not survive the index hospitalization and were therefore not included in the study cohort.

"Elderly individuals with AKI, particularly those with previously diagnosed CKD, are at significantly increased risk for ESRD, suggesting that episodes of AKI may accelerate progression of renal disease," the study authors write. "The impact of AKI on the development of ESRD suggests that AKI may be an important factor contributing to the high incidence of ESRD in the United States. The findings from this study may be helpful in developing novel strategies to reduce the incidence of ESRD and also suggest that close medical follow-up of kidney function in elderly patients who have experienced AKI is warranted."

The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, supported this study. The study authors have disclosed no relevant financial relationships.

J Am Soc Nephrol. Published online November 19, 2008.

Clinical Context

The rate of ESRD associated with AKI is not well described in the literature. AKI may be an additional risk factor for ESRD to CKD, especially in older adults.

This is a Medicare claims study in adults older than 65 years to examine the association between ESRD and previous AKI and CKD and to assess the association between these risk factors.

Study Highlights

  • US renal dialysis units and transplant facilities are required to complete information on a database for services related to ESRD.
  • Participants 67 years or older who survived a hospitalization in 2000 and who had a diagnosis of ESRD consisted of a 5% random sample from the Medicare claims database.
  • Participants included inpatients, outpatients, and those from skilled nursing facilities.
  • Patients with AKI were required to survive the episode of AKI.
  • Excluded were patients with a previous diagnosis of AKI or who already had ESRD at the time of AKI.
  • In this study, claims data were extracted from 233,803 patients in the Medicare database with use of International Classification of Diseases, Ninth Revision, Clinical Modification, codes.
  • These patients represented 66.3% of the 5% random sample.
  • A history of AKI and CKD was extracted as primary or secondary diagnoses.
  • Follow-up was for 2 years.
  • Mean age of participants was 79.2 years, 38.8% were men, 89% were white, and two thirds had hypertension or heart disease, with 27.2% having diabetes mellitus.
  • The incidence of AKI was 3.1%, and baseline CKD was present in 12.0% of participants.
  • In patients with AKI, the proportion with CKD was 34.3%.
  • Of those who survived their index hospitalizations, those with AKI and CKD had a higher 2-year mortality rate vs those with AKI alone.
  • The likelihood of initiating ESRD treatment was higher in those with AKI vs those without AKI and increased steadily with time after discharge from the hospital.
  • The likelihoods of initiating ESRD treatment for patients with AKI alone were 0.96% after 30 days, 2.69% after 180 days, 4.08% within 365 days, and 6.96% at the end of 2 years of follow-up.
  • For those without AKI, the corresponding likelihoods were 0.04%, 0.14%, 0.25%, and 0.49%, respectively.
  • For patients with CKD without AKI, the likelihoods were 0.26%, 0.86%, 1.43%, and 2.54%, respectively.
  • For patients with both AKI and CKD, the likelihoods were 1.61%, 4.76%, 7.91%, and 14.29%, respectively.
  • Thus, the combination of AKI and CKD produced higher likelihoods of ESRD than either condition alone.
  • The HR for ESRD in those with AKI as a primary diagnosis without CKD was 15.04.
  • The HR for ESRD in those with both AKI and CKD was 41.19.
  • The rate of development of ESRD in those with both conditions was 101.5 per 1000 patients.
  • After adjustment for age, sex, race, hypertension, and diabetes, the rate of ESRD was 55.36 higher in patients with AKI and CKD vs patients without either condition.
  • The authors concluded that AKI, especially combined with CKD, was a risk factor for ESRD and may accelerate the progression of CKD or unmask previously undiagnosed kidney disease.

Pearls for Practice

  • US renal dialysis units and transplant facilities are required to complete information on a database for services related to ESRD.
  • Participants 67 years or older who survived a hospitalization in 2000 and who had a diagnosis of ESRD consisted of a 5% random sample from the Medicare claims database.
  • Participants included inpatients, outpatients, and those from skilled nursing facilities.
  • Patients with AKI were required to survive the episode of AKI.
  • Excluded were patients with a previous diagnosis of AKI or who already had ESRD at the time of AKI.
  • In this study, claims data were extracted from 233,803 patients in the Medicare database with use of International Classification of Diseases, Ninth Revision, Clinical Modification, codes.
  • These patients represented 66.3% of the 5% random sample.
  • A history of AKI and CKD was extracted as primary or secondary diagnoses.
  • Follow-up was for 2 years.
  • Mean age of participants was 79.2 years, 38.8% were men, 89% were white, and two thirds had hypertension or heart disease, with 27.2% having diabetes mellitus.
  • The incidence of AKI was 3.1%, and baseline CKD was present in 12.0% of participants.
  • In patients with AKI, the proportion with CKD was 34.3%.
  • Of those who survived their index hospitalizations, those with AKI and CKD had a higher 2-year mortality rate vs those with AKI alone.
  • The likelihood of initiating ESRD treatment was higher in those with AKI vs those without AKI and increased steadily with time after discharge from the hospital.
  • The likelihoods of initiating ESRD treatment for patients with AKI alone were 0.96% after 30 days, 2.69% after 180 days, 4.08% within 365 days, and 6.96% at the end of 2 years of follow-up.
  • For those without AKI, the corresponding likelihoods were 0.04%, 0.14%, 0.25%, and 0.49%, respectively.
  • For patients with CKD without AKI, the likelihoods were 0.26%, 0.86%, 1.43%, and 2.54%, respectively.
  • For patients with both AKI and CKD, the likelihoods were 1.61%, 4.76%, 7.91%, and 14.29%, respectively.
  • Thus, the combination of AKI and CKD produced higher likelihoods of ESRD than either condition alone.
  • The HR for ESRD in those with AKI as a primary diagnosis without CKD was 15.04.
  • The HR for ESRD in those with both AKI and CKD was 41.19.
  • The rate of development of ESRD in those with both conditions was 101.5 per 1000 patients.
  • After adjustment for age, sex, race, hypertension, and diabetes, the rate of ESRD was 55.36 higher in patients with AKI and CKD vs patients without either condition.
  • The authors concluded that AKI, especially combined with CKD, was a risk factor for ESRD and may accelerate the progression of CKD or unmask previously undiagnosed kidney disease.

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