1Department of Medicine, Brigham and Women's Hospital, Boston, MA. 2Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Boulder, CO. 3Renal Division, Brigham and Women's Hospital, Boston, MA. 4Department of Medicine, Hokubu Prefectural Hospital, Okinawa, Japan. 5Pulmonary Division, Massachusetts General Hospital, Boston, MA. 6The Nathan E. Hellman Memorial Laboratory, Renal Division, Brigham and Women's Hospital, Boston, MA.
Crit Care Med. 2015 Feb;43(2):354-64. doi: 10.1097/CCM.0000000000000706.
Hospital readmissions contribute significantly to the cost of inpatient care and are targeted as a marker for quality of care. Little is known about risk factors associated with hospital readmission in survivors of critical illness. We hypothesized that acute kidney injury in patients who survived critical care would be associated with increased risk of 30-day postdischarge hospital readmission, postdischarge mortality, and progression to end-stage renal disease.
Two center observational cohort study.
Medical and surgical ICUs at the Brigham and Women's Hospital and the Massachusetts General Hospital in Boston, Massachusetts.
We studied 62,096 patients, 18 years old and older, who received critical care between 1997 and 2012 and survived hospitalization.
None
: All data was obtained from the Research Patient Data Registry at Partners HealthCare. The exposure of interest was acute kidney injury defined as meeting Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease Risk, Injury or Failure criteria occurring 3 days prior to 7 days after critical care initiation. The primary outcome was hospital readmission in the 30 days following hospital discharge. The secondary outcome was mortality in the 30 days following hospital discharge. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both acute kidney injury and readmission status. Adjustment included age, race (white vs nonwhite), gender, Deyo-Charlson Index, patient type (medical vs surgical) and sepsis. Additionally, long-term progression to End Stage Renal Disease in patients with acute kidney injury was analyzed with a risk-adjusted Cox proportional hazards regression model. The absolute risk of 30-day readmission was 12.3%, 19.0%, 21.2%, and 21.1% in patients with No Acute Kidney Injury, Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Risk, Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Injury, and Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Failure, respectively. In patients who received critical care and survived hospitalization, acute kidney injury was a robust predictor of hospital readmission and post-discharge mortality and remained so following multivariable adjustment. The odds of 30-day post-discharge hospital readmission in patients with Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Risk, Injury, or Failure fully adjusted were 1.44 (95% CI, 1.25-1.66), 1.98 (95% CI, 1.66-2.36), and 1.55 (95% CI, 1.26-1.91) respectively, relative to patients without acute kidney injury. Further, the odds of 30-day post-discharge mortality in patients with Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Risk, Injury, or Failure fully adjusted per our primary analysis were 1.39 (95% CI, 1.28-1.51), 1.46 (95% CI, 1.30-1.64), and 1.42 (95% CI, 1.26-1.61) respectively, relative to patients without acute kidney injury. The addition of the propensity score to the multivariable model did not change the point estimates significantly. Finally, taking into account age, gender, race, Deyo-Charlson Index, and patient type, we observed a relationship between acute kidney injury and development of end-stage renal disease. Patients with Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Risk, Injury, Failure experienced a significantly higher risk of end-stage renal disease during follow-up than patients without acute kidney injury (hazard ratio, 2.03; 95% CI, 1.56-2.65; hazard ratio, 3.99; 95% CI, 3.04-5.23; hazard ratio, 10.40; 95% CI, 8.54-12.69, respectively).
Patients who suffer acute kidney injury are among a high-risk group of ICU survivors for adverse outcomes. In patients treated with critical care who survive hospitalization, acute kidney injury is a robust predictor of subsequent unplanned hospital readmission. In critical illness survivors, acute kidney injury is also associated with the odds of 30-day postdischarge mortality and the risk of subsequent end-stage renal disease.
医院再入院对住院治疗的成本有重大影响，并且是作为护理质量的一个指标。关于危重病幸存者与医院再入院相关的风险因素知之甚少。我们假设，在接受重症监护的患者中发生急性肾损伤与 30 天出院后再入院、出院后死亡率以及进展为终末期肾病的风险增加有关。
两个中心观察性队列研究。
马萨诸塞州波士顿的布莱根妇女医院和麻省总医院的内科和外科重症监护病房。
我们研究了 1997 年至 2012 年间接受重症监护并存活住院的 62096 名 18 岁及以上的患者。
无。
所有数据均来自合作伙伴健康保健研究患者数据注册中心。感兴趣的暴露是急性肾损伤，定义为在重症监护开始前 3 天至 7 天后符合风险、损伤、衰竭、肾脏功能丧失和终末期肾病风险、损伤或衰竭标准。主要结局是出院后 30 天内的医院再入院。次要结局是出院后 30 天内的死亡率。通过多变量逻辑回归模型估计调整后的优势比，包括可能与急性肾损伤和再入院状态合理相互作用的协变量项。调整包括年龄、种族（白种人 vs 非白种人）、性别、Deyo-Charlson 指数、患者类型（内科 vs 外科）和败血症。此外，还通过风险调整的 Cox 比例风险回归模型分析了急性肾损伤患者的长期进展为终末期肾病。在没有急性肾损伤、风险、损伤、衰竭、肾脏功能丧失和终末期肾病风险、风险、损伤、衰竭、肾脏功能丧失和终末期肾病损伤以及风险、损伤、衰竭、肾脏功能丧失和终末期肾病衰竭的患者中，30 天再入院的绝对风险分别为 12.3%、19.0%、21.2%和 21.1%。在接受重症监护并存活住院的患者中，急性肾损伤是医院再入院和出院后死亡率的有力预测指标，并且在多变量调整后仍然如此。在完全调整的风险、损伤、衰竭、肾脏功能丧失和终末期肾病风险、损伤或衰竭患者中，30 天出院后医院再入院的几率为 1.44（95%CI，1.25-1.66）、1.98（95%CI，1.66-2.36）和 1.55（95%CI，1.26-1.91），相对无急性肾损伤患者。此外，在完全调整的主要分析中，在有风险、损伤、衰竭、肾脏功能丧失和终末期肾病风险、损伤或衰竭的患者中，30 天出院后死亡率的几率分别为 1.39（95%CI，1.28-1.51）、1.46（95%CI，1.30-1.64）和 1.42（95%CI，1.26-1.61），相对无急性肾损伤患者。将倾向评分添加到多变量模型中并没有显著改变点估计值。最后，考虑到年龄、性别、种族、Deyo-Charlson 指数和患者类型，我们观察到急性肾损伤与终末期肾病的发展之间存在关系。在风险、损伤、衰竭、肾脏功能丧失和终末期肾病风险、损伤、衰竭的患者中，与无急性肾损伤患者相比，在随访期间发生终末期肾病的风险显著增加（风险比，2.03；95%CI，1.56-2.65；风险比，3.99；95%CI，3.04-5.23；风险比，10.40；95%CI，8.54-12.69）。
患有急性肾损伤的患者是 ICU 幸存者中发生不良结局的高危人群。在接受重症监护并存活住院的患者中，急性肾损伤是随后计划外医院再入院的有力预测指标。在危重病幸存者中，急性肾损伤也与 30 天出院后死亡率的几率和随后发生终末期肾病的风险相关。
