Javier A. Neyra, MD, MS

Patients with cirrhosis are prone to develop acute kidney injury (AKI), a complication associated with a markedly increased in-hospital morbidity and mortality, along with a risk of progression to chronic kidney disease. Whereas patients with cirrhosis are at increased risk of developing any phenotype of AKI, hepatorenal syndrome (HRS), a specific form of AKI (HRS-AKI) in patients with advanced cirrhosis and ascites, carries an especially high mortality risk. Early recognition of HRS-AKI is crucial since administration of splanchnic vasoconstrictors may reverse the AKI and serve as a bridge to liver transplantation, the only curative option. In 2023, a joint meeting of the International Club of Ascites (ICA) and the Acute Disease Quality Initiative (ADQI) was convened to develop new diagnostic criteria for HRS-AKI, to provide graded recommendations for the work-up, management and post-discharge follow-up of patients …

PurposeReal-world comparison of RRT modality on RRT dependence at 90 days postdischarge among ICU patients discharged alive after RRT for acute kidney injury (AKI).MethodsUsing claims-linked to US hospital discharge data (Premier PINC AI Healthcare Database [PHD]), we compared continuous renal replacement therapy (CRRT) vs. intermittent hemodialysis (IHD) for AKI in adult ICU patients discharged alive from January 1, 2018 to June 30, 2021. RRT dependence at 90 days postdischarge was defined as ≥2 RRT treatments in the last 8 days. Between-group differences were balanced using inverse probability treatment weighting (IPTW).ResultsOf 34,804 patients, 3804 patients (from 382 hospitals) had claims coverage for days 83–90 postdischarge. Compared to IHD-treated patients (n = 2740), CRRT-treated patients (n = 1064) were younger; had more admission to large teaching hospitals, surgery …

Acute kidney injury (AKI) affects one in five hospitalized patients and is associated with poor short-and long-term clinical and patient-centered outcomes. Among those who survive to discharge, significant gaps in documentation, education, communication, and follow-up have been observed. The American Society of Nephrology established the AKINow taskforce to address these gaps and improve AKI care. The AKINow Recovery workgroup convened two focus groups, one each focused on dialysis-independent and dialysis-requiring AKI, to summarize the key considerations, challenges, and opportunities in the care of AKI survivors. This manuscript highlights the discussion surrounding care of AKI survivors discharged without the need for dialysis. On May 3, 2022, 48 patients and multidisciplinary clinicians from diverse settings were gathered virtually. The agenda included a patient testimonial, plenary sessions …

Acute kidney injury is a common complication of decompensated cirrhosis, frequently requires hospitalization, and carries a high short-term mortality. This population experiences several characteristic types of acute kidney injury: hypovolemic-mediated (prerenal), ischemic/nephrotoxic-mediated (acute-tubular necrosis), and hepatorenal syndrome. Prerenal acute kidney injury is treated with volume resuscitation. Acute-tubular necrosis is treated by optimizing perfusion pressure and discontinuing the offending agent. Hepatorenal syndrome, a unique physiology of decreased effective arterial circulation leading to renal vasoconstriction and ultimately acute kidney injury, is treated with plasma expansion with albumin and splanchnic vasoconstrictors such as terlipressin or norepinephrine. Common acute stressors such as bleeding, infection, and volume depletion often contribute to multifactorial acute kidney injury …

Less is more. Illustrations of the validity of this mantra in life and clinical medicine are not hard to find. Examples abound in the realm of critical care, such as with mechanical ventilation 1 and transfusion targets. 2 Perhaps the best example in critical care nephrology is in dose of continuous kidney replacement therapy (CKRT) for acute kidney injury (AKI). Early enthusiasm for the routine use of high-dose CKRT fueled by smaller single-center studies was halted by the publication in 2008 and 2009 of the VA/NIH Acute Renal Failure Trial Network (ATN) and the Randomized Evaluation of Normal vs Augmented Level (RENAL) Replacement Therapy studies. 3, 4 These landmark multicenter randomized controlled trials collectively randomized> 2,000 AKI patients to high-dose (35-40mL/kg/h) versus standard-dose (20-25mL/kg/h) CKRT and found no difference in mortality or kidney recovery. The rates of serious adverse …

Methods: The Medical Information Mart for Intensive Care (MIMIC) IV dataset is utilized to augment a decision tree model with 1200 adult ICU patients with a primary or secondary diagnosis of AKI (at or up to 1 week after ICU admission) but who have not yet started CRRT. The decision tree is constructed as a tree root with two main ‘trunks’, each terminating in a decision node. Time from ICU admission until CRRT initiation is used to define early (< 12 hours) vs late (12-72 hours) CRRT at those nodes. Each decision node then divides into smaller branches with intermediate nodes containing over 60 AKI characteristics, including patient demographics, ICU admission vitals and procedures, and laboratory values. Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression is used to filter which nodes to keep and their order (lower p-value nodes placed nearer the root). Lastly, our primary outcome …

Burn injury is associated with a high risk of acute kidney injury (AKI) with a prevalence of AKI among patients with burns of 9–50%. Despite an improvement in burn injury survival in the past decade, AKI in patients with burns is associated with an extremely poor short-term and long-term prognosis, with a mortality of >80% among those with severe AKI. Factors that contribute to the development of AKI in patients with burns include haemodynamic alterations, burn-induced systemic inflammation and apoptosis, haemolysis, rhabdomyolysis, smoke inhalation injury, drug nephrotoxicity and sepsis. Early and late AKI after burn injury differ in their aetiologies and outcomes. Sepsis is the main driver of late AKI in patients with burns and late AKI has been associated with higher mortality than early AKI. Prevention of early AKI involves correction of hypovolaemia and avoidance of nephrotoxic drugs (for example …

Dear Editor, The REVIVAL study, and accompanying editorial, offer important insights on methodologic nuances of the composite outcome major adverse kidney events (MAKE)[1, 2]. We support the standardization of MAKE and, in addition to those previously identified [2], wish to highlight points regarding MAKE as a trial endpoint. One component of MAKE is persistent kidney dysfunction, variably defined by changes in creatinine (Cr) or estimated glomerular filtration rate (eGFR) from baseline. At discharge from critical illness, it was recently shown eGFRCr over-estimated measured GFR twofold, ascribed to reduced muscle mass from critical illness independent of underlying kidney function [3]. To what extent these observed changes in Cr, and inadequacies of eGFRCr, persist to the time horizon relevant for post-discharge MAKE assessment is unknown. Cystatin C (CysC) also over-estimated GFR, but to a lesser …

Methods: Secondary analysis of a prospective study evaluating the impact of beta-lactam concentrations on clinical outcomes in medical intensive care unit patients. Patients were included if vancomycin was concurrently administered with the beta-lactam. Two groups were identified: PTZ/VAN and CEF/MEM/VAN. Urinary biomarkers were measured daily up to five days following initiation of combination therapy. Primary outcome was the change in renal biomarkers NGAL, KIM-1, and TIMP-2/IGFBP-7, from baseline to peak. Secondary outcomes were serum creatinine defined AKI, and change in urine to serum creatinine (U: S) ratio over time in non-AKI patients to evaluate for tubular creatinine secretion inhibition.Results: Eighteen patients met criteria with co-administration of vancomycin at the time of urinary biomarker collection for this analysis. Five patients (27%) received PTZ/VAN and 13 (72%) received CEF …

Acute kidney injury (AKI), a common and severe complication following burn injuries, presents a significant challenge due to its broad clinical manifestations and diverse etiologies. AKI, previously known as acute renal failure, can present abruptly following burns or thermal injuries, causing detrimental health outcomes such as progressive kidney dysfunction, increased hospital length of stay, and requirement of renal replacement therapy (RRT). AKI affects the maintenance of homeostasis of fluid and electrolytes, elimination of metabolic wastes and byproducts, and acid–base balance. Aggressive nutritional support is particularly necessitated in burn patients to prevent protein-energy wasting and a negative nitrogen balance. Understanding the pathogenesis of AKI in burns and improving its prevention and early diagnosis are active areas of research in this field. Despite the potential benefits, the optimal timing …

ObjectiveThe objective was to explore and describe the role of pharmacists in providing postdischarge care to patients with kidney disease.Data SourcesPubMed, Embase (Elsevier), CINAHL (Ebscohost), Web of Science Core Collection, and Scopus were searched on January 30, 2023. Publication date limits were not included. Search terms were identified based on 3 concepts: kidney disease, pharmacy services, and patient discharge. Experimental, quasi-experimental, observational, and qualitative studies, or study protocols, describing the pharmacist’s role in providing postdischarge care for patients with kidney disease, excluding kidney transplant recipients, were eligible.Study Selection and Data ExtractionSix unique interventions were described in 10 studies meeting inclusion criteria.Data SynthesisFour interventions targeted patients with acute kidney injury (AKI) during hospitalization and 2 evaluated …

The number of individuals with acute kidney injury receiving outpatient dialysis (AKI-D) is increasing. At present, based on limited data, approximately one third of individuals with AKI-D who receive outpatient dialysis after hospital discharge survive and regain sufficient kidney function to discontinue dialysis. Data to inform dialysis management strategies that promote kidney function recovery and processes of care among individuals with AKI-D receiving outpatient dialysis are lacking. In this article, we detail current trends in the incidence, risk factors, clinical outcomes, proposed management, and health policy landscape for individuals with AKI-D receiving outpatient dialysis and identify areas for further research.

The International Society of Nephrology Global Kidney Health Atlas charts the availability and capacity of kidney care globally. In the North America and the Caribbean region, the Atlas can identify opportunities for kidney care improvement, particularly in Caribbean countries where structures for systematic data collection are lacking. In this third iteration, respondents from 12 of 18 countries from the region reported a 2-fold higher than global median prevalence of dialysis and transplantation, and a 3-fold higher than global median prevalence of dialysis centers. The peritoneal dialysis prevalence was lower than the global median, and transplantation data were missing from 6 of the 10 Caribbean countries. Government-funded payments predominated for dialysis modalities, with greater heterogeneity in transplantation payor mix. Services for chronic kidney disease, such as monitoring of anemia and blood pressure …

Background:Up to one-third of survivors of acute kidney injury that required dialysis (AKI-D) during a hospitalization remain dialysis dependent at hospital discharge. Of these, 20 to 60%, depending on the clinical setting, eventually recover enough kidney function to stop dialysis and the remainder progress to end-stage kidney disease.Methods:To describe the challenges facing those still receiving dialysis on discharge, the AKINOW Committee conducted a group discussion composed of 59 participants including physicians, advanced practitioners, nurses, pharmacists, and patients. The discussion was framed by a patient who described gaps in care delivery at different transition points and miscommunication between care team members and the patient.Results:Group discussions collected patient perspectives of: 1) being often scared and uncertain about what is happening to and around them and 2) the …

Acute kidney injury (AKI) and intensive care unit–acquired weakness (ICU-AW) are 2 frequent complications of critical illness that, until recently, have been considered unrelated processes. The adverse impact of AKI on ICU mortality is clear, but its relationship with muscle weakness—a major source of ICU morbidity—has not been fully elucidated. Furthermore, improving ICU survival rates have refocused the field of intensive care toward improving long-term functional outcomes of ICU survivors. We begin our review with the epidemiology of AKI in the ICU and of ICU-AW, highlighting emerging data suggesting that AKI and AKI treated with kidney replacement therapy (AKI-KRT) may independently contribute to the development of ICU-AW. We then delve into human and animal data exploring the pathophysiologic mechanisms linking AKI and acute KRT to muscle wasting, including altered amino acid and protein …

Acute kidney injury (AKI) is a highly prevalent condition with multiple acute and chronic consequences. Survivors of AKI are at risk of AKI-to-chronic kidney disease (CKD) transition, which carries significant morbidity and mortality. One retrospective analysis showed increased risk of bone fracture post-AKI in humans, which was independent of CKD development. While there are several theoretical reasons for late disturbances of bone health post-AKI, no definitive data are available to date. An important question is whether there are bone sequelae from AKI that are independent of CKD, meaning bone disease prior to the onset, or in the absence of CKD–a form of “post-AKI osteopathy.” While preclinical studies examining bone health after acute stressors have focused mostly on sepsis models, multiple experimental AKI models are readily available for longitudinal bone health interrogation. Future research should be …

IntroductionAcute kidney injury requiring renal replacement therapy (AKI-RRT) is common in the intensive care unit (ICU) and is associated with significant morbidity and mortality. Continuous RRT (CRRT) non-selectively removes large amounts of amino acids from plasma, lowering serum amino acid concentrations and potentially depleting total-body amino acid stores. Therefore, the morbidity and mortality associated with AKI-RRT may be partly mediated through accelerated skeletal muscle atrophy and resulting muscle weakness. However, the impact of AKI-RRT on skeletal muscle mass and function during and following critical illness remains unknown. We hypothesise that patients with AKI-RRT have higher degrees of acute muscle loss than patients without AKI-RRT and that AKI-RRT survivors are less likely to recover muscle mass and function when compared with other ICU survivors.Methods and analysis …

Introduction: In 2017, the Centers for Medicare and Medicaid Services allowed survivors of hospitalized acute kidney injury requiring dialysis (AKI-D) who were ambulatory and still dependent on hemodialysis (HD) to receive treatment in outpatient dialysis facilities. This policy change generated the ongoing need to improve AKI-D care in the outpatient setting. Methods: Quality improvement study in adult patients admitted to an outpatient HD unit with the diagnosis of AKI-D. We developed a protocol to manage these patients that included:(a) multidisciplinary evaluations;(b) personalized 3-tier HD prescription for dose/ultrafiltration rate and frequency;(c) weekly assessment of kidney recovery; and (d) patient empowerment. Patient-and protocol-specific characteristics were described. We analyzed hourly HD data and protocol adherence, and relevant hemodynamic data were compared according to HD-free survival at …

Acute kidney injury (AKI), which is a common complication of acute illnesses, affects the health of individuals in community, acute care and post-acute care settings. Although the recognition, prevention and management of AKI has advanced over the past decades, its incidence and related morbidity, mortality and health care burden remain overwhelming. The rapid growth of digital technologies has provided a new platform to improve patient care, and reports show demonstrable benefits in care processes and, in some instances, in patient outcomes. However, despite great progress, the potential benefits of using digital technology to manage AKI has not yet been fully explored or implemented in clinical practice. Digital health studies in AKI have shown variable evidence of benefits, and the digital divide means that access to digital technologies is not equitable. Upstream research and development costs, limited …

Introduction: End-stage renal disease (ESRD) patients with concomitant heart failure often require left ventricular assist devices (LVADs), but the impact on mortality in peritoneal dialysis (PD) versus hemodialysis (HD) is unclear. This study aims to compare mortality rates in prevalent and incident ESRD patients with LVADs on PD versus HD. Hypothesis: We hypothesize differences in mortality rates and heart transplantation rates between LVAD patients on PD versus HD. Methods: A retrospective cohort analysis used data from the TriNetX Research Network database. Propensity score matching compared two cohorts: LVAD with HD (Cohort 1) and LVAD with PD (Cohort 2). Demographic data, comorbidities, and baseline laboratory values were collected. Mortality rates were assessed using risk analyses over a 3-year period following LVAD placement. Results: The study cohorts included 252 patients each after …