Division of Nephrology, University of California School of Medicine, San Francisco, San Francisco.
Division of Research, Kaiser Permanente Northern California, Oakland, California.
JAMA Intern Med. 2020 Mar 1;180(3):402-410. doi: 10.1001/jamainternmed.2019.6390.
Among patients who had acute kidney injury (AKI) during hospitalization, there is a need to improve risk prediction such that those at highest risk for subsequent loss of kidney function are identified for appropriate follow-up.
To evaluate the association of post-AKI proteinuria with increased risk of future loss of renal function.
DESIGN, SETTING, AND PARTICIPANTS: The Assessment, Serial Evaluation, and Subsequent Sequelae in Acute Kidney Injury (ASSESS-AKI) Study was a multicenter prospective cohort study including 4 clinical centers in North America included 1538 patients enrolled 3 months after hospital discharge between December 2009 and February 2015.
Urine albumin-to-creatinine ratio (ACR) quantified 3 months after hospital discharge.
Kidney disease progression defined as halving of estimated glomerular filtration rate (eGFR) or end-stage renal disease.
Of the 1538 participants, 769 (50%) had AKI durring hospitalization. The baseline study visit took place at a mean (SD) 91 (23) days after discharge. The mean (SD) age was 65 (13) years; the median eGFR was 68 mL/min/1.73 m2; and the median urine ACR was 15 mg/g. Overall, 547 (37%) study participants were women and 195 (13%) were black. After a median follow-up of 4.7 years, 138 (9%) participants had kidney disease progression. Higher post-AKI urine ACR level was associated with increased risk of kidney disease progression (hazard ratio [HR], 1.53 for each doubling; 95% CI, 1.45-1.62), and urine ACR measurement was a strong discriminator for future kidney disease progression (C statistic, 0.82). The performance of urine ACR was stronger in patients who had had AKI than in those who had not (C statistic, 0.70). A comprehensive model of clinical risk factors (eGFR, blood pressure, and demographics) including ACR provided better discrimination for predicting kidney disease progression after hospital discharge among those who had had AKI (C statistic, 0.85) vs those who had not (C statistic, 0.76). In the entire matched cohort, after taking into account urine ACR, eGFR, demographics, and traditional chronic kidney risk factors determined 3 months after discharge, AKI (HR, 1.46; 95% CI, 0.51-4.13 for AKI vs non-AKI) or severity of AKI (HR, 1.54; 95% CI, 0.50-4.72 for AKI stage 1 vs non-AKI; HR, 0.56; 95% CI, 0.07-4.84 for AKI stage 2 vs non-AKI; HR, 2.24; 95% CI, 0.33-15.29 for AKI stage 3 vs non-AKI) was not independently associated with more rapid kidney disease progression.
Proteinuria level is a valuable risk-stratification tool in the post-AKI period. These results suggest there should be more widespread and routine quantification of proteinuria after hospitalized AKI.
在住院期间发生急性肾损伤（AKI）的患者中，需要改进风险预测，以便识别出那些有后续肾功能丧失高风险的患者，以便进行适当的随访。
评估 AKI 后蛋白尿与未来肾功能丧失风险增加的相关性。
设计、地点和参与者：评估、连续评估和急性肾损伤后续后果（ASSESS-AKI）研究是一项多中心前瞻性队列研究，纳入了北美 4 个临床中心的 1538 例患者，这些患者在出院后 3 个月（2009 年 12 月至 2015 年 2 月）接受了评估。
出院后 3 个月时尿液白蛋白与肌酐比值（ACR）的定量。
定义为估计肾小球滤过率（eGFR）减半或终末期肾病的肾脏疾病进展。
在 1538 名参与者中，769 名（50%）在住院期间发生 AKI。基线研究访问发生在出院后平均（SD）91（23）天。平均（SD）年龄为 65（13）岁；中位 eGFR 为 68 mL/min/1.73 m2；中位数尿 ACR 为 15 mg/g。总体而言，547 名（37%）研究参与者为女性，195 名（13%）为黑人。中位随访 4.7 年后，138 名（9%）参与者出现肾脏疾病进展。较高的 AKI 后尿 ACR 水平与肾脏疾病进展风险增加相关（风险比[HR]，每增加一倍为 1.53；95%CI，1.45-1.62），并且尿 ACR 测量是预测未来肾脏疾病进展的有力指标（C 统计量，0.82）。在发生 AKI 的患者中，尿 ACR 的表现优于未发生 AKI 的患者（C 统计量，0.70）。包括 ACR 在内的临床危险因素综合模型（eGFR、血压和人口统计学因素）在预测出院后 AKI 患者的肾脏疾病进展方面提供了更好的区分度（C 统计量，0.85 对未发生 AKI 的患者为 0.76）。在整个匹配队列中，在考虑了出院后 3 个月的尿 ACR、eGFR、人口统计学和传统慢性肾脏病风险因素后，AKI（HR，1.46；95%CI，0.51-4.13，AKI 与非 AKI 相比）或 AKI 的严重程度（HR，1.54；95%CI，0.50-4.72，AKI 1 期与非 AKI 相比；HR，0.56；95%CI，0.07-4.84，AKI 2 期与非 AKI 相比；HR，2.24；95%CI，0.33-15.29，AKI 3 期与非 AKI 相比）与更快速的肾脏疾病进展无关。
蛋白尿水平是 AKI 后时期的一种有价值的风险分层工具。这些结果表明，应该更广泛和常规地对住院 AKI 后的蛋白尿进行定量。
