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Published on: February 2, 2021
Post-Acute Kidney Injury Proteinuria and Subsequent Kidney Disease Progression: The Assessment, Serial Evaluation,
Chi-Yuan Hsu1,2, Vernon M Chinchilli3, Steven Coca4
1Division of Nephrology, University of California School of Medicine, San Francisco, San Francisco.
Insights
Proteinuria measured after acute kidney injury (AKI) predicts future kidney function loss. Routine urine tests post-AKI can identify high-risk patients for better follow-up and management of kidney disease progression.
Area of Science:
- Nephrology
- Internal Medicine
- Clinical Epidemiology
Background:
- Acute kidney injury (AKI) hospitalization increases risk for subsequent kidney function decline.
- Improved risk prediction models are needed to identify AKI patients requiring closer monitoring.
- Proteinuria is a known marker for kidney damage, but its role post-AKI needs further evaluation.
Purpose of the Study:
- To assess the association between proteinuria after AKI and the risk of long-term kidney function loss.
- To determine if urine albumin-to-creatinine ratio (ACR) can effectively predict kidney disease progression post-AKI.
- To compare the predictive performance of ACR in patients with and without a history of AKI.
Main Methods:
- Prospective cohort study (ASSESS-AKI) of 1538 patients discharged from hospital.
- Urine albumin-to-creatinine ratio (ACR) measured 3 months post-discharge.
- Kidney disease progression defined as eGFR halving or end-stage renal disease, followed for a median of 4.7 years.
Main Results:
- Higher post-AKI urine ACR levels significantly correlated with increased risk of kidney disease progression (HR 1.53 per doubling).
- Urine ACR demonstrated strong discrimination for predicting kidney disease progression in AKI patients (C-statistic 0.82).
- A model including ACR and clinical factors showed improved prediction (C-statistic 0.85) for AKI patients compared to non-AKI patients (C-statistic 0.76).
Conclusions:
- Proteinuria, specifically urine ACR, is a valuable tool for risk stratification in the period following AKI.
- Routine measurement of proteinuria after hospitalization for AKI is recommended.
- These findings support enhanced monitoring and intervention strategies for patients identified as high-risk post-AKI.
Importance:
Among patients who had acute kidney injury (AKI) during hospitalization, there is a need to improve risk prediction such that those at highest risk for subsequent loss of kidney function are identified for appropriate follow-up.
Objective:
To evaluate the association of post-AKI proteinuria with increased risk of future loss of renal function.
Design, Setting, And Participants:
The Assessment, Serial Evaluation, and Subsequent Sequelae in Acute Kidney Injury (ASSESS-AKI) Study was a multicenter prospective cohort study including 4 clinical centers in North America included 1538 patients enrolled 3 months after hospital discharge between December 2009 and February 2015.
Exposures:
Urine albumin-to-creatinine ratio (ACR) quantified 3 months after hospital discharge.
Main Outcomes And Measures:
Kidney disease progression defined as halving of estimated glomerular filtration rate (eGFR) or end-stage renal disease.
Results:
Of the 1538 participants, 769 (50%) had AKI durring hospitalization. The baseline study visit took place at a mean (SD) 91 (23) days after discharge. The mean (SD) age was 65 (13) years; the median eGFR was 68 mL/min/1.73 m2; and the median urine ACR was 15 mg/g. Overall, 547 (37%) study participants were women and 195 (13%) were black. After a median follow-up of 4.7 years, 138 (9%) participants had kidney disease progression. Higher post-AKI urine ACR level was associated with increased risk of kidney disease progression (hazard ratio [HR], 1.53 for each doubling; 95% CI, 1.45-1.62), and urine ACR measurement was a strong discriminator for future kidney disease progression (C statistic, 0.82). The performance of urine ACR was stronger in patients who had had AKI than in those who had not (C statistic, 0.70). A comprehensive model of clinical risk factors (eGFR, blood pressure, and demographics) including ACR provided better discrimination for predicting kidney disease progression after hospital discharge among those who had had AKI (C statistic, 0.85) vs those who had not (C statistic, 0.76). In the entire matched cohort, after taking into account urine ACR, eGFR, demographics, and traditional chronic kidney risk factors determined 3 months after discharge, AKI (HR, 1.46; 95% CI, 0.51-4.13 for AKI vs non-AKI) or severity of AKI (HR, 1.54; 95% CI, 0.50-4.72 for AKI stage 1 vs non-AKI; HR, 0.56; 95% CI, 0.07-4.84 for AKI stage 2 vs non-AKI; HR, 2.24; 95% CI, 0.33-15.29 for AKI stage 3 vs non-AKI) was not independently associated with more rapid kidney disease progression.
Conclusions And Relevance:
Proteinuria level is a valuable risk-stratification tool in the post-AKI period. These results suggest there should be more widespread and routine quantification of proteinuria after hospitalized AKI.
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