Acute kidney injury in different time windows: a retrospective study of hospitalized elderly patients

Abstract

Background: To compare the differences between the Kidney Disease Improving Global Outcomes (KDIGO) criteria of the 48-hour window (early acute kidney injury [AKI], 3-5 day window [middle AKI], and 6-7 day window [late AKI]) in the diagnosis of AKI, as well as the relationship between the diagnosis time windows and 90-day mortality.

Methods: We conducted a retrospective cohort study. All elderly patients admitted to the Geriatric Department of the Chinese PLA General Hospital between 2007 and 2018 were evaluated for AKI during their hospital stay. Patients with AKI were divided into early, middle, and late AKI groups according to the time of diagnosis. Statistical analyses were performed using SPSS 21.0 statistical software. Continuous parametric variables are expressed as the means ± standard deviations (SDs), and continuous nonparametric variables are presented as the medians with interquartile ranges (25th and 75th percentiles). Categorical variables are presented as numbers (n) or percentages (%). Group comparisons were conducted using one-way analysis of variance or the Kruskal-Wallis H test for continuous variables and Pearson’s chi-square or Fisher’s exact test for categorical variables. Logistic regression analyses and a forward stepwise selection method were used to identify risk factors associated with AKI diagnosis time windows and 90-day mortality.

Results: During the follow-up period, 1847 patients were enrolled. Overall, 22.4% of the patients (413/1847) developed early AKI, 7.3% (134/1847) developed middle AKI, and 10.7% (197/1847) developed late AKI. Risk factors for early AKI included age, hypoalbuminemia, low prealbumin level, and the need for mechanical ventilation; middle AKI was significantly associated with age, low prealbumin, low hemoglobin, and the need for mechanical ventilation, whereas late AKI was closely associated with age, low baseline estimated glomerular filtration rate, low prealbumin, and low hemoglobin. In the multivariable-adjusted analysis, AKI time windows (early AKI, odds ratio [OR]: 6.069; P < 0.001; middle AKI, OR: 5.000; P < 0.001) and late AKI (OR: 2.847; P < 0.001) were more strongly associated with higher 90-day mortality than non-AKI.

Conclusion: Clinical differences and risk factors for AKI in elderly patients depend on the definition used. A better understanding of how AKI develops during different diagnostic windows may lead to improved outcomes.

Conflict of interest statement

The authors declare no conflict of interest.

Author contributions

Li Q contributed to conceptualization, data curation, formal analysis, methodology, and drafting of the initial manuscript. Li G contributed to software and methodology. Li D contributed to data collection and data management. Chen Y participated in investigation, project administration, and funding acquisition. Zhou F contributed to supervision, validation, and review and editing.

Funding

This study was supported by grants from Shandong Provincial Natural Science Foundation (ZR2021MH111 for Cui X), the Science and Technology Foundation of Jinan City (201805057 for Ling M), and Doctoral Program of Shandong Provincial Natural Science Foundation (ZR2017BH047 for Lu W).

Ethical approval of studies and informed consent

This study followed the principles of the Declaration of Helsinki as revised in 2013. This study was approved by the Ethics Committee of the Chinese PLA General Hospital (No. S2017-054-01, June 29, 2017). The requirement for written informed consent was waived by the ethics committee of the designated hospital because this was an observational, retrospective, and anonymous study. The data in this study does not involve issues related to patients’ cognitive impairment.

Acknowledgments

This manuscript has been edited for English by American Journal Experts (AJE).

References

[1] LiQ LiY, Zhou F. Association of serumpotassiumlevelwith early and late mortality in very elderly patients with acute kidney injury. J Intensive Med. 2022; 2(1):50-55. doi:10.1016/j.jointm.2021.11.005

[2] Hoste EAJ, Kellum JA, Selby NM, et al. Global epidemiology and outcomes of acute kidney injury. Nat Rev Nephrol. 2018; 14(10): 607-625. doi:10.1038/s41581-018-0052-0

[3] Li Q, Li Y, Zhou F. Duration of acute kidney injury predicts 90-day mortality and chronic kidney disease progression in elderly patients. J Intensive Med. 2022; 2(2):110-117. doi:10.1016/j.jointm.2021.11.008

[4] Pickkers P, Darmon M, Hoste E, et al. Acute kidney injury in the critically ill: an updated review on pathophysiology and management. Intensive Care Med. 2021; 47(8):835-850. doi:10.1007/s00134-021-06454-7

[5] Ikizler TA, Parikh CR, Himmelfarb J, et al. A prospective cohort study of acute kidney injury and kidney outcomes, cardiovascular events, and death. Kidney Int. 2021; 99(2):456-465. doi:10.1016/j.kint.2020.06.032

[6] Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the second international consensus conference of the acute dialysis quality initiative (ADQI) group. Crit Care. 2004; 8(4):R204-R212. doi:10.1186/cc2872

[7] Mehta RL, Kellum JA, Shah SV, et al. Acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007; 11(2):R31. doi:10.1186/cc5713

[8] Kellum JA, Lameire N, Aspelin R, et al. Kidney disease: improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012; 2(1):1-138. doi:10.1038/kisup.2012.1

[9] Sparrow HG, Swan JT, Moore LW, Gaber AO, Suki WN. Disparate outcomes observed within kidney disease: improving global outcomes (KDIGO) acute kidney injury stage 1. Kidney Int. 2019; 95(4):905-913.doi:10.1016/j.kint.2018.11.030

[10] Li S, Wang S, Priyanka P, Kellum JA. Acute kidney injury in critically ill patients after noncardiac major surgery: early versus late onset. Crit Care Med. 2019; 47(6):e437-e444. doi:10.1097/ccm.0000000000003710

[11] Singbartl K, Kellum JA. AKI in the ICU: definition, epidemiology, risk stratification, and outcomes. Kidney Int. 2012; 81(9):819-825. doi:10.1038/ki.2011.339

[12] Chao C-T, Tsai H-B, Wu C-Y, et al. The severity of initial acute kidney injury at admission of geriatric patients significantly correlates with subsequent in-hospital complications. Scientific Rep. 2015; 5(1):13925. doi:10.1038/srep13925

[13] Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009; 150(9):604-612.

[14] Yang L, Xing G, Wang L, et al. Acute kidney injury in China: a crosssectional survey. Lancet. 2015; 386(10002):1465-1471. doi:10.1016/s0140-6736(15)00344-x

[15] Sun J, Tang X, Chen D, Yu S, Yang L, Mei C. Acute kidney injury burden in different clinical units: data from nationwide survey in China. PloS One. 2017; 12(2):e0171202. doi:10.1371/journal.pone.0171202

[16] Li Q, Hu P, Kang H, Zhou F. Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit. J Nutr Health Aging. 2021; 25(4):492-500. doi:10.1007/s12603-020-1550-x

[17] Li Q, Li G, Ju H, Wang Y, Li D, Zhou F. Missed diagnosis of acute kidney injury in older patients with invasive mechanical ventilation: a multicenter retrospective study. Aging Clin Exp Res. 2022; 34(11): 2887-2895. doi:10.1007/s40520-022-02229-2

[18] Wilson FP, Martin M, Yamamoto Y, et al. Electronic health record alerts for acute kidney injury: multicenter, randomized clinical trial. BMJ. 2021;372:m4786. doi:10.1136/bmj.m4786

[19] Li Q, Zhao M, Wang X. AKI in the very elderly patients without preexisting chronic kidney disease: a comparison of 48-hour window and 7-day window for diagnosing AKI using the KDIGO criteria. Clin Interv Aging. 2018; 13:1151-1160. doi:10.2147/CIA.S162899

[20] Zeng X, McMahon GM, Brunelli SM, Bates DW, Waikar SS. Incidence, outcomes, and comparisons across definitions of AKI in hospitalized individuals. Clin J Am Soc Nephrol. 2014; 9(1):12-20. doi:10.2215/cjn.02730313

[21] Xu X, Nie S, Liu Z, et al. Epidemiology and clinical correlates of AKI in Chinese hospitalized adults. Clin J Am Soc Nephrol. 2015; 10(9): 1510-1518. doi:10.2215/cjn.02140215

[22] Liu JQ, Cai GY, Liang S, et al. Characteristics of and risk factors for death in elderly patients with acute kidney injury: a multicentre retrospective study in China. Postgrad Med J. 2018; 94(1111):249-253. doi:10.1136/postgradmedj-2017-135455

[23] Moriyama N, Ishihara M, Noguchi T, et al. Early development of acute kidney injury is an independent predictor of in-hospital mortality in patients with acute myocardial infarction. J Cardiol. 2017; 69(1):79-83.doi:10.1016/j.jjcc.2016.01.001

[24] Mosier MJ, Pham TN, Klein MB, et al. Early acute kidney injury predicts progressive renal dysfunction and higher mortality in severely burned adults. J Burn Care Res. 2010; 31(1):83-92. doi:10.1097/BCR.0b013e3181cb8c87

[25] Ronco C, Bellomo R, Kellum JA. Acute kidney injury. Lancet. 2019; 394(10212):1949-1964. doi:10.1016/s0140-6736(19)32563-2