儿童急性肾损伤后的长期肾脏结局
Long-Term Kidney Outcomes after Pediatric Acute Kidney Injury.
作者信息
Robinson Cal H, Jeyakumar Nivethika, Luo Bin, Askenazi David, Deep Akash, Garg Amit X, Goldstein Stuart, Greenberg Jason H, Mammen Cherry, Nash Danielle M, Parekh Rulan S, Silver Samuel A, Thabane Lehana, Wald Ron, Zappitelli Michael, Chanchlani Rahul
机构信息
Division of Paediatric Nephrology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.
Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
出版信息
J Am Soc Nephrol. 2024 Nov 1;35(11):1520-1532. doi: 10.1681/ASN.0000000000000445. Epub 2024 Jul 17.
KEY POINTS
Among 4173 children with AKI, 18% had major adverse kidney events (death, kidney failure, or CKD) during a median 10-year follow-up. AKI survivors were at 2–4 times higher risk of major adverse kidney events, hypertension, and subsequent AKI versus matched hospitalized comparators. This justifies improved surveillance after pediatric AKI to detect CKD and hypertension early and improve long-term kidney health.
BACKGROUND
AKI is common in hospitalized children. Pediatric AKI receiving acute KRT is associated with long-term CKD, hypertension, and death. We aim to determine the outcomes after AKI in children who did not receive acute KRT because these remain uncertain.
METHODS
Retrospective cohort study of all hospitalized children (0–18 years) surviving AKI without acute KRT between 1996 and 2020 in Ontario, Canada, identified by validated diagnostic codes in provincial administrative health databases. Children with prior KRT, CKD, or AKI were excluded. Cases were matched with up to four hospitalized comparators without AKI by age, neonatal status, sex, intensive care unit admission, cardiac surgery, malignancy, hypertension, hospitalization era, and a propensity score for AKI. Patients were followed until death, provincial emigration, or censoring in March 2021. The primary outcome was long-term major adverse kidney events (a composite of all-cause mortality, long-term KRT, or incident CKD).
RESULTS
We matched 4173 pediatric AKI survivors with 16,337 hospitalized comparators. Baseline covariates were well-balanced following propensity score matching. During a median 9.7-year follow-up, 18% of AKI survivors developed long-term major adverse kidney event versus 5% of hospitalized comparators (hazard ratio [HR], 4.0; 95% confidence interval [CI], 3.6 to 4.4). AKI survivors had higher rates of long-term KRT (2% versus <1%; HR, 11.7; 95% CI, 7.5 to 18.4), incident CKD (16% versus 2%; HR, 7.9; 95% CI, 6.9 to 9.1), incident hypertension (17% versus 8%; HR, 2.3; 95% CI, 2.1 to 2.6), and AKI during subsequent hospitalization (6% versus 2%; HR, 3.7; 95% CI, 3.1 to 4.5), but no difference in all-cause mortality (3% versus 3%; HR, 0.9; 95% CI, 0.7 to 1.1).
CONCLUSIONS
Children surviving AKI without acute KRT were at higher long-term risk of CKD, long-term KRT, hypertension, and subsequent AKI versus hospitalized comparators.
要点
在4173例急性肾损伤（AKI）患儿中，18%在中位10年随访期间发生了严重不良肾脏事件（死亡、肾衰竭或慢性肾脏病[CKD]）。与匹配的住院对照者相比，AKI幸存者发生严重不良肾脏事件、高血压及后续AKI的风险高出2至4倍。这证明了加强儿科AKI后的监测以早期发现CKD和高血压并改善长期肾脏健康的合理性。
背景
AKI在住院儿童中很常见。接受急性肾脏替代治疗（KRT）的儿科AKI与长期CKD、高血压和死亡相关。我们旨在确定未接受急性KRT的儿童AKI后的结局，因为这些结局仍不确定。
方法
对1996年至2020年期间在加拿大安大略省未接受急性KRT而存活的所有住院儿童（0至18岁）进行回顾性队列研究，通过省级行政卫生数据库中的有效诊断编码进行识别。排除既往有KRT、CKD或AKI的儿童。病例与多达4名无AKI的住院对照者按年龄、新生儿状态、性别、重症监护病房入住情况、心脏手术、恶性肿瘤、高血压、住院时间以及AKI倾向评分进行匹配。对患者进行随访直至死亡、省级移民或2021年3月的截尾。主要结局是长期严重不良肾脏事件（全因死亡率、长期KRT或新发CKD的复合结局）。
结果
我们将4173例儿科AKI幸存者与16337名住院对照者进行了匹配。倾向评分匹配后基线协变量平衡良好。在中位9.7年的随访期间，18%的AKI幸存者发生了长期严重不良肾脏事件，而住院对照者为5%（风险比[HR]，4.0；95%置信区间[CI]，3.6至4.4）。AKI幸存者长期KRT发生率更高（2%对<1%；HR，11.7；95%CI，7.5至18.4）、新发CKD发生率更高（16%对2%；HR，7.9；95%CI，6.9至9.1）、新发高血压发生率更高（17%对8%；HR，2.3；95%CI，2.1至2.6）以及后续住院期间AKI发生率更高（6%对2%；HR，3.7；95%CI，3.1至4.5），但全因死亡率无差异（3%对3%；HR，0.9；95%CI，0.7至1.1）。
结论
与住院对照者相比，未接受急性KRT而存活的AKI儿童发生CKD、长期KRT、高血压及后续AKI的长期风险更高。
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