KDIGO-based acute kidney injury criteria operate differently in hospitals and the community-findings from a large population cohort

Abstract

Background: Early recognition of acute kidney injury (AKI) is important. It frequently develops first in the community. KDIGO-based AKI e-alert criteria may help clinicians recognize AKI in hospitals, but their suitability for application in the community is unknown.

Methods: In a large renal cohort (n = 50 835) in one UK health authority, we applied the NHS England AKI 'e-alert' criteria to identify and follow three AKI groups: hospital-acquired AKI (HA-AKI), community-acquired AKI admitted to hospital within 7 days (CAA-AKI) and community-acquired AKI not admitted within 7 days (CANA-AKI). We assessed how AKI criteria operated in each group, based on prior blood tests (number and time lag). We compared 30-day, 1- and 5-year mortality, 90-day renal recovery and chronic renal replacement therapy (RRT).

Results: In total, 4550 patients met AKI e-alert criteria, 61.1% (2779/4550) with HA-AKI, 22.9% (1042/4550) with CAA-AKI and 16.0% (729/4550) with CANA-AKI. The median number of days since last blood test differed between groups (1, 52 and 69 days, respectively). Thirty-day mortality was similar for HA-AKI and CAA-AKI, but significantly lower for CANA-AKI (24.2, 20.2 and 2.6%, respectively). Five-year mortality was high in all groups, but followed a similar pattern (67.1, 64.7 and 46.2%). Differences in 5-year mortality among those not admitted could be explained by adjusting for comorbidities and restricting to 30-day survivors (hazard ratio 0.91, 95% confidence interval 0.80-1.04, versus hospital AKI). Those with CANA-AKI (versus CAA-AKI) had greater non-recovery at 90 days (11.8 versus 3.5%, P < 0.001) and chronic RRT at 5 years (3.7 versus 1.2%, P < 0.001).

Conclusions: KDIGO-based AKI criteria operate differently in hospitals and in the community. Some patients may not require immediate admission but are at substantial risk of a poor long-term outcome.

Keywords: acute kidney injury; delivery of health care; epidemiology; primary health care; survival analysis.

FIGURE 1:

Flowchart of GLOMMS II cohort including AKI subgroups. AKI, acute kidney injury; HA-AKI, hospital AKI; CAA-AKI, community AKI admitted within 7 days; CANA-AKI, community AKI not admitted within 7 days. In sensitivity analysis, the proportions after multiplying out the sampled fraction were 61.0% HA-AKI, 22.1% CAA-AKI and 16.8% CANA-AKI.

FIGURE 2:

Number of patients with newly detected acute kidney injury (AKI) each day of admission and subsequent 30-day mortality (%). *Number of days in brackets represents as a denominator the median of number of days exposed in the group during that admission period. Error bars represent 95% confidence intervals (CI).

FIGURE 3:

Kaplan–Meier survival in patients with HA-AKI, CAA-AKI and CANA-AKI (A) unadjusted; (B) limited to 30-day survivors; (C) adjusted (for age, baseline eGFR and all Charlson comorbidities as in Table 5) and limited to 30-day survivors. CAA-AKI, community AKI admitted within 7 days; CANA-AKI, community AKI not admitted within 7 days; HA-AKI, hospital acquired AKI. Note that survival curves in (B) and (C) start to fall from 0 years + 30 days. Mortality for CANA-AKI was significantly reduced in (B) but not in (C), as reported in Table 5.