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Duration of Anuria Predicts Recovery of Renal Function After Acute Kidney Injury Requiring Continuous Renal Replacement Therapy

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Duration of Anuria Predicts Recovery of Renal Function After Acute Kidney Injury Requiring Continuous Renal Replacement Therapy ORIGINAL ARTICLE Korean J Intern Med 2016;31:930-937 http://dx.doi.org/10.3904/kjim.2014.290 Duration of anuria predicts recovery of renal function after acute kidney injury requiring continuous renal replacement therapy Hee-Yeon Jung*, Jong-Hak Lee*, Young-Jae Park, Sang-Un Kim, Kyung-Hee Lee, Ji-Young Choi, Sun-Hee Park, Chan-Duck Kim, Yong-Lim Kim, and Jang-Hee Cho Department of Internal Medicine, Background/Aims: Little is known regarding the incidence rate of and factors Kyungpook National University associated with developing chronic kidney disease after continuous renal re- School of Medicine, and Clinical Research Center for End Stage Renal placement therapy (CRRT) in acute kidney injury (AKI) patients. We investigated Disease, Daegu, Korea renal outcomes and the factors associated with incomplete renal recovery in AKI patients who received CRRT. Methods: Between January 2011 and November 2013, 408 patients received CRRT in our intensive care unit. Of them, patients who had normal renal function be- fore AKI and were discharged without maintenance renal replacement therapy (RRT) were included in this study. We examined the incidence of incomplete renal recovery with an estimated glomerular filtration rate < 60 mL/min/1.73 m2 and factors that increased the risk of incomplete renal recovery after AKI. Received : September 25, 2014 Results: In total, 56 AKI patients were discharged without further RRT and were Revised : June 30, 2015 followed for a mean of 8 months. Incomplete recovery of renal function was ob- Accepted : July 4, 2015 served in 20 of the patients (35.7%). Multivariate analysis revealed old age and long Correspondence to duration of anuria as independent risk factors for incomplete renal recovery (odds Jang-Hee Cho, M.D. ratio [OR], 1.231; 95% confidence interval [CI], 1.041 to 1.457;p = 0.015 and OR, 1.064; Division of Nephrology, Department of Internal Medicine, 95% CI, 1.001 to 1.131; p = 0.047, respectively). In a receiver operating characteristic Kyungpook National University curve analysis, a cut-off anuria duration of 24 hours could predict incomplete re- School of Medicine, 680 Gukchae- nal recovery after AKI with a sensitivity of 85.0% and a specificity of 66.7%. bosang-ro, Jung-gu, Daegu 41944, Conclusions: The renal outcome of severe AKI requiring CRRT was poor even in Korea Tel: +82-53-420-6314 patients without further RRT. Long-term monitoring of renal function is needed, Fax: +82-53-423-7583 especially in severe AKI patients who are old and have a long duration of anuria. E-mail: [email protected] *These authors contributed equal- Keywords: Acute kidney injury; Anuria; Chronic kidney disease; Continuous re- ly to this work. nal replacement therapy; Renal recovery INTRODUCTION anuric kidney injury, requiring renal replacement ther- apy (RRT) [1,2]. Among patients with AKI undergoing Acute kidney injury (AKI) is a common clinical disorder, RRT, those who are hemodynamically unstable require defined by an abrupt increase in serum creatinine or a continuous renal replacement therapy (CRRT) rather decreased urine output. Clinical manifestations of AKI than intermittent hemodialysis, regardless of the pres- vary from an asymptomatic decline in renal function to ence of pre-existing comorbid conditions. The number Copyright © 2016 The Korean Association of Internal Medicine pISSN 1226-3303 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ eISSN 2005-6648 by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.kjim.org Jung HY, et al. Anuria duration as a predictor of renal recovery after AKI requiring CRRT of critically ill patients with AKI requiring CRRT is in- (Cr), eGFR, average mean arterial pressure (MAP), and creasing, and the mortality of patients with severe AKI is volume balance, were retrieved from electronic medical as high as 80%, despite advances in renal replacement records. Causes of AKI included ischemic acute tubular techniques and critical care medicine [3]. necrosis (ATN), infection-related ATN, and other ATN. Aside from mortality, renal outcomes after AKI are Ischemic ATN was defined as AKI induced by hypovole- also important. Previous reports demonstrated that sur- mia, heart failure, or major surgery, all of which are as- vivors after AKI have an increased risk of end-stage renal sociated with hypoperfusion. Cases occurring from both disease (ESRD), although any causal relationship and the sepsis and AKI were defined as infection-related ATN. pathogenesis remain unclear [4,5]. A recent study showed All other cases that triggered ATN were classified as that renal recovery status after AKI was also associated ‘other’ ATN. Volume balance was calculated as the sum with progression to chronic kidney disease (CKD) and of input and output during the CRRT period. Serum Cr ESRD, as well as patient survival [6]. Moreover, while and eGFR were measured during the follow-up period AKI leads to CKD and ESRD, large retrospective cohort after discharge. studies have also reported that CKD is a risk factor for The duration of anuria was defined as the period the development of AKI [4,7]. in which urine output was less than 0.5 mL/kg/hr. In- Although concerns regarding the bidirectional rela- complete renal recovery was defined as eGFR < 60 mL/ tionship between AKI and CKD are increasing, the inci- min/1.73 m2 in the 3 months after discharge. In this dence rate of and the factors predicting persistent renal study, eGFR was calculated using the simplified ‘Modi- injury in critically ill patients with AKI receiving CRRT fication of Diet in Renal Disease Study’ equation. are not well known. Identifying risk factors leading to incomplete renal recovery after AKI is crucial for pre- Continuous renal replacement therapy protocol dicting outcomes in survivors of AKI and reducing the Vascular access for CRRT was gained via the femo- burden of CKD in the general population. In this study, ral or internal jugular vein. In all patients, continuous we investigated renal outcomes and the factors associat- venovenous hemodiafiltration was performed using ed with incomplete renal recovery in AKI patients who the PRISMA platform (Gambro, Hechingen, Germa- received CRRT. ny). CRRT was initiated with a blood flow rate of 100 mL/min, which was increased gradually to 150 mL/min. CRRT was prescribed at a dose of more than 35 mL/kg/ METHODS hr, and Hemosol (Gambro) was replaced by the predilu- tion method. Patients and data collection We investigated retrospectively all patients who received Statistical analysis CRRT in our intensive care unit between January 2011 All enrolled patients were divided into complete and in- and November 2013. Patients with a pre-existing diagno- complete recovery groups, according to their eGFR val- sis of CKD (estimated glomerular filtration rate [eGFR] < ues in the 3 months after discharge. Data are expressed 60 mL/min/1.73 m2) or ESRD before CRRT were exclud- as medians with ranges. Differences between groups ed from the study. Other exclusion criteria were death were tested using independent-sample t tests and chi- and transfer to another medical center during CRRT. square tests, as appropriate. Factors that increased the Only survivors with normal renal function prior to AKI risk of incomplete renal recovery after AKI were investi- who were discharged without maintenance RRT were gated by univariate logistic regression. Afterwards, mul- included in this study. Normal renal function was de- tivariate logistic regression was performed in two mod- fined as an eGFR > 60 mL/min/1.73 m2 in this study. els. In the adjusted model, all variables with a univariate Patient data, including age, gender, baseline comor- p < 0.1 were used in the logistic regression analysis to bidities, cause of AKI, duration of CRRT, duration of anu- assess their independent influences on the clinical end- ria, body mass index (BMI), baseline serum hemoglobin point of “incomplete renal recovery.” The fully adjusted (Hb), serum C-reactive protein (CRP), serum creatinine model included all explanatory variables, such as age, http://dx.doi.org/10.3904/kjim.2014.290 www.kjim.org 931 The Korean Journal of Internal Medicine Vol. 31, No. 5, September 2016 gender, hypertension, diabetes mellitus, cause of AKI, 408 CRRT total duration of CRRT, anuria duration, initial serum Hb, 273 Death initial serum CRP, initial eGFR, average MAP, and vol- 27 Loss to follow-up ume balance, in the multiple logistic regression model. 108 Survivors The ability of anuria duration to predict incomplete re- nal recovery was further analyzed with receiver operat- 50 ESRD or CKD 58 AKI ing characteristic (ROC) curves. Statistical analyses were performed using the SPSS version 18.0 (SPSS Inc., Chi- 2 Mainatenance dialysis 56 Recovery cago, IL, USA). The p values of < 0.05 were considered to indicate statistical significance. 20 Incomplete recovery 36 Complete recovery Figure 1. Study selection diagram. In total, 408 patients treated with continuous renal replacement therapy (CRRT) RESULTS were initially enrolled. In the final analysis, 56 patients were divided into two groups (complete vs. incomplete renal re- In total, 408 patients were treated with CRRT during the covery) based on their final estimated glomerular filtration rate values. ESRD, end-stage renal disease; CKD, chronic study period. We excluded 300 patients who died during kidney disease; AKI, acute kidney injury. hospitalization or were lost to follow-up. Among the 108 surviving patients (26.5%), 50 were diagnosed with CKD or ESRD. Of the 58 AKI patients without previous CKD 0.013), and anuria duration (OR, 1.038; CI, 1.010 to 1.066; or ESRD, 36 (62.1%) showed complete recovery to base- p = 0.007) were significant risk factors for incomplete line renal function or an eGFR > 60 mL/min/1.73 m2.
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