Recovery after Critical Illness and Acute Kidney Injury

Abstract

AKI is a common complication in hospitalized and critically ill patients. Its incidence has steadily increased over the past decade. Whether transient or prolonged, AKI is an independent risk factor associated with poor short- and long-term outcomes, even if patients do not require KRT. Most patients with early AKI improve with conservative management; however, some will require dialysis for a few days, a few weeks, or even months. Approximately 10%-30% of AKI survivors may still need dialysis after hospital discharge. These patients have a higher associated risk of death, rehospitalization, recurrent AKI, and CKD, and a lower quality of life. Survivors of critical illness may also suffer from cognitive dysfunction, muscle weakness, prolonged ventilator dependence, malnutrition, infections, chronic pain, and poor wound healing. Collaboration and communication among nephrologists, primary care physicians, rehabilitation providers, physical therapists, nutritionists, nurses, pharmacists, and other members of the health care team are essential to create a holistic and patient-centric care plan for overall recovery. Integration of the patient and family members in health care decisions, and ongoing education throughout the process, are vital to improve patient well-being. From the nephrologist standpoint, assessing and promoting recovery of kidney function, and providing appropriate short- and long-term follow-up, are crucial to prevent rehospitalizations and to reduce complications. Return to baseline functional status is the ultimate goal for most patients, and dialysis independence is an important part of that goal. In this review, we seek to highlight the varying aspects and stages of recovery from AKI complicating critical illness, and propose viable strategies to promote recovery of kidney function and dialysis independence. We also emphasize the need for ongoing research and multidisciplinary collaboration to improve outcomes in this vulnerable population.

Keywords: acute kidney injury; critical illness.

Figure 1.

Clinical course of patients who develop AKI in the hospital. Patients who develop AKI in the hospital may have complete or partial recovery of kidney function in the hospital or after discharge. Those patients who do not recover kidney function in the hospital may need ongoing KRT at an intermediary facility or outpatient dialysis facility. Patients with AKI are at risk for progression to CKD and readmission to the hospital.

Figure 2.

Coordination of care for patients with critical illness and AKI after discharge. Multidisciplinary care and coordination among multiple specialties, with close involvement of patient and family, are essential for patient recovery after prolonged hospitalization complicated by AKI.