Proteinuria and reduced glomerular filtration rate as risk factors for acute kidney injury

Abstract

Purpose of review: Acute kidney injury (AKI) is a major public health concern, and preexisting kidney disease may be one of the most important risk factors. We review recent epidemiologic evidence supporting baseline proteinuria and reduced glomerular filtration rate as risk factors for AKI.

Recent findings: In 2008, a case-control study of over 600 000 patients in an integrated healthcare system in California first quantified a graded association between reduced baseline estimated glomerular filtration rate (eGFR) and risk of dialysis-requiring AKI; it also showed proteinuria as an independent predictor for AKI. In 2010, a cohort study consisting of 1235 adults undergoing coronary artery bypass graft in Taiwan demonstrated that mild and heavy degrees of proteinuria detected by dipstick were associated with increasingly higher odds ratio of postoperative AKI, independent of chronic kidney disease stage. A US cohort study in 2010 of over 11 000 patients determined that elevated urine albumin-to-creatinine ratio (UACR) was an independent risk factor for hospitalizations with AKI; this association started with the submicroalbuminuric range (UACR 11-29 mg/g) and increased stepwise along severity of albuminuria, after adjustment for eGFR. A cohort study in 2010 of over 900 000 adults in Alberta demonstrated increased rates of hospital admissions with AKI for patients with mild and moderate dipstick proteinuria across all values of eGFR.

Summary: The presence of baseline proteinuria and reduced baseline eGFR are powerful independent predictors for AKI and should be taken into account in clinical practice to identify high-risk patients for receipt of aggressive preventive measures to reduce risk of AKI.

Figure 1. Multivariable association of baseline estimated glomerular filtration rate and dialysis-requiring acute kidney injury stratified by the presence or absence of diabetes mellitus

Each model adjusted for age, sex, race/ethnicity, diagnosed hypertension, and documented proteinuria. DM, diabetes mellitus. Reproduced with permission from [3].

Figure 2. Conditional effect plot of baseline chronic kidney disease stage and severity or proteinuria on estimated probability of postoperative acute kidney injury

Patients with mild or heavy proteinuria had a higher risk of postoperative acute kidney injury, even after adjusting for chronic kidney disease (CKD) stage. GFR, glomerular filtration rate. Reproduced with permission from [4^••].

Figure 3. Adjusted relative hazard ratio of acute kidney injury vs. urine albumin-to-creatinine ratio using a linear spline model

Relative hazards of acute kidney injury (AKI) increases with increasing continuous urine albumin-to-creatinine ratio, adjusted for estimated glomerular filtration rate, age, sex, race, and cardiovascular risk factors. Reproduced with permission from [5^••].