Recovery from AKI and Short- and Long-Term Outcomes after Lung Transplantation

Abstract

SummaryBackground and objectives Patients with AKI after lung transplantation are at increased risk for CKD and death. Whether patients who completely recover from AKI have improved long-term outcome compared with patients who do not completely recover remains unknown.Design, setting, participants, & measurements This study retrospectively evaluated data on 657 patients who underwent lung transplantation from 1997 to 2009. Outcomes analyzed were the incidence of renal recovery after AKI and the association of this recovery with short-and long-term mortality. AKI was defined by an absolute increase in serum creatinine of $0.3 mg/dl or a percent increase in serum creatinine of $50% from baseline at any time during the first 2 weeks after transplantation.Results Four hundred twenty-four (65%) patients experienced AKI in the first 2 weeks after transplantation. Of these patients, complete renal recovery occurred in 142 (33%) patients. The incidence of in-hospital complications was similar between patients who recovered renal function and patients without recovery. At 1 year, the cumulative incidence of CKD was 14% and 22% (P=0.10) and patient survival rate was 81% and 76% (P=0.20) Conclusions Patients who recover completely from early AKI after lung transplantation have a similar risk for CKD and long-term mortality compared with patients who do not recover.

Recovery from AKI in the critically ill: potential confounders in the evaluation

“…These results highlight the need for a clear description of the included population (inclusion or exclusion of nonsurvivors, proportion of CKD, AKI severity, method used for baseline creatinine assessment, and proportion of patients with imputed baseline) in studies on this topic. Although one could argue that kidney outcome should be assessed in all AKI patients, the inclusion of nonsurvivors (as in [16,18,19,[22][23][24]26]) not only induces bias (as patients may not have had enough time to recover before they died) but being dead with recovered kidneys also has little significance from a patient's perspective. Since mortality increases with increasing AKI severity, exclusion of non-survivors mainly affects the recovery pattern of more severe forms of AKI.…”

“…The available reports used definitions based on absence of RIFLE criteria [4,17,24], return to baseline serum creatinine (Screat) [11,19,27], or a discharge Screat that returned to a value below 1.1 or 1.25 times baseline [7,10,16,20]. Few studies reported recovery according to AKI severity [4,11,15] and none of these studies used the KDIGO criteria [28] for both diagnosis of AKI and for assessment of recovery.…”

“…The majority of the available studies reported recovery at hospital discharge [17,[19][20][21][22][23][24][25]. With the exception of studies focusing on long-term follow-up [4,5,10], recovery is mostly reported for all AKI patients (survivors and non-survivors) [15,16,18,19,[21][22][23]26]. Although inclusion of non-survivors is important from a pathophysiological point of view and essential for intervention trials, recovery of kidney function among survivors is probably more relevant from a patient's perspective and crucial for determining the burden of postdischarge nephrological follow-up.…”

“…The available clinical trials either excluded patients with an unknown baseline Screat [9,19], used an imputed baseline Screat based on the Modification of Diet in Renal Disease (MDRD) equation (as suggested by ADQI and KDIGO) [4,16,17,23,25], used the minimum Screat measured during hospitalization [5,21], or did not mention how baseline Screat was determined [18,24]. The impact of using an imputed instead of the observed baseline on the incidence of AKI has been reported [30][31][32].…”

Pharmacokinetics and Toxicity of Tacrolimus Early After Heart and Lung Transplantation

“…However, longterm morbidity and mortality are significantly jeopardized by chronic kidney disease (2,3). It has been shown that chronic kidney disease often originates from kidney injury acquired early after transplantation (2,3). The underlying mechanisms of acute kidney injury are incompletely unraveled, but shock, systemic inflammation and tacrolimus nephrotoxicity are considered the most important factors.…”