Long-term risks of adverse kidney outcomes after acute kidney injury: a systematic review and meta-analysis

Abstract

Background: Acute kidney injury (AKI) is associated with increased risks of incidence or progression of chronic kidney disease (CKD), kidney failure (KF), or major adverse kidney events (MAKE), however it remains unclear which individuals have higher risks. Hence, we systematically reviewed the literature to explore differences in kidney dysfunction risks between AKI stages, AKI durations, and clinical settings.

Methods: We performed a systematic search in PubMed and Embase to identify studies that examined at least one outcome of interest in individuals with AKI versus without AKI, with a minimum follow-up of one year. Hazard/odds ratios (HR/OR) were pooled using random effects models. Heterogeneity across patient- and disease-characteristics was examined using subgroup and meta-regression analyses.

Results: We comprised 70 studies, encompassing 1,838,668 individuals, including 165,715 with AKI. All studies were of moderate to high quality. Individuals with AKI had higher risks of CKD incidence (AKI 25.8%/no AKI 8.7%; HR 2.36 (95% confidence interval (CI) 1.77-2.94)), CKD progression (AKI 43.1%/no AKI 35.6%; HR 1.83 (95%CI 1.26-2.40)), KF (AKI 2.9%/no AKI 0.5%; HR 2.64 (95%CI 2.03-3.25)), and MAKE (AKI 59.0%/no AKI 32.7%; OR 2.77 (95%CI 2.01-3.53)). The pooled effect estimates for CKD incidence after AKI lasting <3 days remained significant (OR 2.37 (95%CI 1.68-3.07), even in individuals with AKI stage 1 only (HR 1.49 (95%CI 1.44-1.55)). Diabetes mellitus, hypertension, requiring acute dialysis, cardiovascular surgery, or coronary artery disease were associated with higher CKD incidence or progression risks.

Conclusions: Risks for kidney dysfunction were higher for all individuals with AKI. Risk estimates were heterogeneous between patient subgroups, based on AKI stage, AKI duration and clinical setting, yet even individuals with the lowest stage or shortest duration of AKI remained at higher risk for CKD incidence or progression. This highlights the need to develop tailored follow-up strategies to timely recognize kidney function decline post-AKI and initiate kidney protective measures.

Keywords: acute kidney injury; chronic kidney disease; kidney failure; long-term outcomes; major adverse kidney event.