Gomes Conrado Lysandro R, Cleto-Yamane Thais Lyra, da Silva Fucuta Patricia, Farias Heitor Blesa, Ruzany Frederico, Rocco Suassuna José Hermógenes
Clinical and Academic Unit of Nephrology, Faculty of Medical Sciences, Hospital Universitario Pedro Ernesto, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil.
Kidney Assistance Ltd., Rio de Janeiro, Brazil.
Clin J Am Soc Nephrol. 2024 Nov 1;19(11):1382-1394. doi: 10.2215/CJN.0000000000000530. Epub 2024 Sep 12.
Comprehensive analysis of 17,158 patients with dialysis-requiring AKI in Brazil, uncovering intricate etiological patterns and outcomes across all age groups. Detailed latent class analysis reveals four distinct phenotypes for patients with dialysis-requiring AKI, each with unique clinical characteristics and mortality risks. The study underscores the necessity of age-specific AKI management strategies, informed by diverse etiologies and survival outcomes across the lifespan.
AKI is a complex syndrome typically classified into strict categories. Alternatively, it may be more accurate to consider it as an intermediate event between an initiating cause and its outcome. Therefore, we investigated the burden of clinical scenarios associated with dialysis-requiring AKI using latent class analysis (LCA) and examined the etiological spectrum and clinical phenotypes across different life stages.
We analyzed 17,158 patients with dialysis-requiring AKI from 170 medical facilities in Rio de Janeiro, Brazil (2002–2012). Using survival curves and mixed-effects Cox regression for survival estimation, LCA classified patients on the basis of clinical characteristics and outcomes, focusing on etiological variation over the human lifespan.
The median age was 75 years (interquartile range, 59–83). Infections were the most common cause (44.2%), particularly community-acquired pneumonia (23.8%). Cardiovascular issues, especially ischemic heart disease (9.0%) and acute heart failure (8.1%), were also significant. LCA identified four distinct patient classes with varying clinical and outcome profiles. Class 1 patients were younger (median age, 66 years), predominantly male, with lower intensive care unit admission rates and higher rates of community-acquired AKI (60.8%). They had the lowest mortality (39.5%) and highest recovery rates. Class 2 had intermediate mortality (67.4%) and the highest comorbidity burden (mean Charlson score, 3.39). Classes 3 and 4 had the highest mortality (82.8% and 78.6%, respectively), requiring more mechanical ventilation and vasopressor use. Class 3 had a high prevalence of sepsis (92.7%) with lower comorbidities while class 4 had high chronic heart disease (76.3%) and perfusion factors (79.4%). Despite high mortality, class 3 patients recovered better than class 2 and 4 patients. Survival analyses revealed diverse outcomes across etiological groups, with liver-related conditions being the most severe.
This study highlights the complexity of AKI and utility of LCA in revealing its clinical heterogeneity. It underscores distinct etiological trends across ages, suggesting future research should integrate clinical profiles with advanced diagnostics to understand AKI's clinical and molecular phenotypes throughout life
对巴西17158例需要透析的急性肾损伤患者进行综合分析，揭示了所有年龄组复杂的病因模式和预后情况。详细的潜在类别分析揭示了需要透析的急性肾损伤患者的四种不同表型，每种表型都有独特的临床特征和死亡风险。该研究强调了根据不同病因和一生的生存结果制定针对特定年龄的急性肾损伤管理策略的必要性。
急性肾损伤是一种复杂的综合征，通常被严格分类。或者，将其视为起始原因与其结果之间的中间事件可能更准确。因此，我们使用潜在类别分析（LCA）研究了与需要透析的急性肾损伤相关的临床情况负担，并检查了不同生命阶段的病因谱和临床表型。
我们分析了来自巴西里约热内卢170个医疗机构的17158例需要透析的急性肾损伤患者（2002 - 2012年）。使用生存曲线和混合效应Cox回归进行生存估计，LCA根据临床特征和结果对患者进行分类，重点关注人类一生中的病因变化。
中位年龄为75岁（四分位间距，59 - 83岁）。感染是最常见的原因（44.2%），尤其是社区获得性肺炎（23.8%）。心血管问题也很显著，特别是缺血性心脏病（9.0%）和急性心力衰竭（8.1%）。LCA确定了四种不同的患者类别，其临床和预后特征各不相同。1类患者较年轻（中位年龄，66岁），男性居多，重症监护病房入院率较低，社区获得性急性肾损伤发生率较高（60.8%）。他们的死亡率最低（39.5%），恢复率最高。2类患者的死亡率中等（67.4%），合并症负担最高（平均Charlson评分为3.39）。3类和4类患者的死亡率最高（分别为82.8%和78.6%），需要更多的机械通气和血管活性药物使用。3类患者败血症患病率高（92.7%），合并症较少，而4类患者慢性心脏病（76.3%）和灌注因素（79.4%）患病率高。尽管死亡率高，但3类患者的恢复情况优于2类和4类患者。生存分析显示不同病因组的预后各不相同，与肝脏相关的疾病最为严重。
本研究强调了急性肾损伤的复杂性以及LCA在揭示其临床异质性方面的作用。它强调了不同年龄组不同的病因趋势，表明未来的研究应将临床特征与先进的诊断方法相结合，以了解急性肾损伤在一生中的临床和分子表型
