Syndrome of rapid onset end stage renal disease in incident Mayo Clinic chronic hemodialysis patient

Abstract

Despite decades of research, a full understanding of chronic kidney disease (CKD)-end stage renal disease (ESRD) progression remains elusive. The common consensus is a predictable, linear, progressive and time-dependent decline of CKD to ESRD. Acute kidney injury (AKI) on CKD is usually assumed to be transient, with recovery as the expected outcome. AKI-ESRD association in current nephrology literature is blamed on the so-called “residual confounding.” We had previously described a relationship between AKI events and rapid onset yet irreversible ESRD happening in a continuum in a high-risk CKD cohort. However, the contribution of the syndrome of rapid onset-ESRD (SORO-ESRD) to incident United States ESRD population remained conjectural. In this retrospective analysis, we analyzed serum creatinine trajectories of the last 100 consecutive ESRD patients in 4 Mayo Clinic chronic hemodialysis units to determine the incidence of SORO-ESRD. Excluding 9 patients, 31 (34%) patients, including two renal transplant recipients, had SORO-ESRD: 18 males and 13 females age 72 (range 50-92) years. Precipitating AKI followed pneumonia (8), acutely decompensated heart failure (7), pyelonephritis (4), post-operative (5), sepsis (3), contrast-induced nephropathy (2), and others (2). Time to dialysis was shortest following surgical procedures. Concurrent renin angiotensin aldosterone system blockade was higher with SORO-ESRD - 23% versus 5%, P = 0.0113. In conclusion, SORO-ESRD is not uncommon among the incident general US ESRD population. The implications for ESRD care planning, AV-fistula-first programs, general CKD care and any associations with renal ageing/senescence warrant further study.

Evidence of the syndrome of rapid onset end-stage renal disease (SORO-ESRD) in the acute kidney injury (AKI) literature – preventable causes of AKI and SORO-ESRD – a call for re-engineering of nephrology practice paradigms

“…[9][10][11][12] Our SORO-ESRD rate of 34% compares favorably with the 18.4% rate reported in 1996 by Bhandari and Turner at the Leeds General Infirmary, in the United Kingdom. [9][10][11][12]1 In our 2011 Mayo Clinic Dialysis study, AKI immediately precipitating SORO-ESRD in the 31 patients was caused by pneumonia (8), acute decompensating heart failure (ADHF) (7), pyelonephritis (4), post-operative (5), general sepsis (3), contrast nephropathy (CN) (2) and others (2). [9][10][11][12] The interval between AKI and initiation of RRT was less than one week in the patients where the AKI followed cardiac surgery.…”

“…[6][7][8][9][10][11][12] Bhandari and Turney, reporting from the United Kingdom, in 1996, referred to them as ''survivors of acute renal failure who do not recover renal function''. 17 This report constituted the largest AKI series that we examined and consisted of 1095 patients, mean age 64 years and of whom 107 (16%) developed SORO-ESRD.…”

“…Excluding nine patients with incomplete data, 91 patients, 57 males and 34 females, age 39-93 years were analyzed. [9][10][11][12] Thirty-one of 91 (34%) ESRD patients had SORO-ESRD. The 31 patients, 18 males and 13 females, had a mean age of 72 (50-92) years.…”

“…Conversely, in opposition, the syndrome of rapid onset end-stage renal disease (SORO-ESRD), which we first described in 2010, is the sudden, unanticipated, precipitate and yet irreversible ESRD rapidly following AKI superimposed in a CKD patient with an a priori otherwise stable CKD [6][7][8][9][10][11][12] ( Figure 1). SORO-ESRD is the unpredictable, nonlinear, abrupt and rapid progression to irreversible ESRD, often over a period of less than 2-4 weeks, following AKI in CKD patients with prior stable and non-progressive albeit often reduced levels of eGFR [6][7][8][9][10][11][12] ( Figure 1). It remains unclear to what extent this syndrome may have been identified in the past in the medicalnephrology literature without acknowledging the uniqueness of this form of presentation of rapid onset albeit irreversible ESRD.…”

“…It remains unclear to what extent this syndrome may have been identified in the past in the medicalnephrology literature without acknowledging the uniqueness of this form of presentation of rapid onset albeit irreversible ESRD. [6][7][8][9][10][11][12] Our working diagnosis of SORO-ESRD is any CKD patient with an otherwise a priori stable eGFR of !30 mL/min/1.73 sq m BSA, on or before the 90th day preceding the first RRT, and which patient has remained permanently on RRT for 490 d. [6][7][8][9][10][11][12] Clearly, from the foregoing, the diagnosis of SORO-ESRD can only be made retroactively, at least 90 d after the first RRT treatment session was instituted. We investigated the incidence of SORO-ESRD as could be deduced from prior publications in the AKI literature, between 1975 and 2010, using this working definition of SORO-ESRD.…”