Predictors of Outpatient Kidney Function Recovery Among Patients Who Initiate Hemodialysis in the Hospital

Abstract

Background Recent policy clarifications by the Centers for Medicare and Medicaid Services have changed access to outpatient dialysis care at end stage renal disease (ESRD) facilities for individuals with acute kidney injury in the United States. Tools to predict “ESRD” and “acute” status in terms of kidney function recovery among patients who previously initiated dialysis in the hospital could help inform patient management decisions. Study Design Historical cohort study Setting & Participants Incident hemodialysis patients in the Mayo Clinic Health System who initiated in-hospital RRT and continued outpatient dialysis following hospital dismissal (2006 to 2009) Predictor Baseline estimated glomerular filtration rate (eGFR), sepsis/surgery acute tubular necrosis (ATN), heart failure, intensive care unit, and dialysis access. Outcomes Kidney function recovery defined as sufficient kidney function for outpatient hemodialysis discontinuation. Results Cohort consisted of 281 patients with mean age 64 years, 63% men, 45% heart failure, and baseline eGFR ≥30 mL/min/1.73m2 in 46%. Over a median 8 months, 52 (19%) recovered, most (94%) within 6 months. Higher baseline eGFR (Hazard Ratio 1.27 per 10 ml/min/1.73m2; 95% CI 1.16–1.39; p<0.001), ATN from sepsis or surgery (HR 3.34; CI 1.83- 6.24; p<0.001), and heart failure (HR 0.40; CI 0.19–0.78, p=0.007) were independent predictors of recovery within 6 months while first RRT in the intensive care unit and a catheter dialysis access were not. There was a positive interaction between absence of heart failure and eGFR≥30 ml/min/1.73m2 for predicting kidney function recovery (p<0.001). Limitations Sample size. Conclusions Kidney function recovery in the outpatient hemodialysis unit following in-hospital RRT initiation is not rare. As expected, higher baseline eGFR is an important determinant of recovery. However, patients with heart failure are less likely to recover even with higher baseline eGFR. Consideration of these factors at hospital discharge informs decisions on “ESRD” status designation and long-term hemodialysis care.

Sepse em pacientes com lesão renal aguda severa

“…The mortality of patients with severe AKI, ie requiring hemodialysis, reaches high levels from 45% to 70%. 7,16 In this study, a mortality rate of 79.5% was found, above what is verified in the literature. This result can be explained by the profile of severe patients received in the ICU, since the SOFA mortality score presented a high index and association with mortality (p = 0.0021).…”

Predictors of Recurrent AKI

“…Preventing recurrent AKI in this population may also be important given literature indicating a lower likelihood of renal recovery following AKI. 25 We also found that patients with AKI in the setting of acute coronary syndrome were at risk for recurrent AKI. These findings may help explain the observations made by others that some patients who experience AKI following coronary angiography appear to be at risk for long-term decline in kidney function.…”

Predictors and Outcomes of Post-Hospitalization Dialysis Dependent Acute Kidney Injury

“…A recent article by Cerda et al [19] discussed results from available reports indicating at most a 20% outpatient recovery for D-AKI (depending on the percentage of CKD in the population reported). Similarly, Hickson et al [20], studied incident outpatient HD patients treated at Mayo Clinic Dialysis Services over 4 years (January 1, 2006-December 31, 2009). This study was done prior to the CMS clarification.…”