Acute kidney injury influences mortality in lung transplantation.

Xue J ，Wang L ，Chen CM ，Chen JY ，Sun ZX ... -  《-》

Association between transient acute kidney injury and morbidity and mortality after lung transplantation: a retrospective cohort study.

Acute kidney injury (AKI) is a common occurrence after lung transplantation (LTx). Whether transient AKI or early recovery is associated with improved outcome is uncertain. Our aim was to describe the incidence, factors, and outcomes associated with transient AKI after LTx. We performed a retrospective cohort study of all adult recipients of LTx at the University of Alberta between 1990 and 2011. Our primary outcome transient AKI was defined as return of serum creatinine below Kidney Disease-Improving Global Outcome AKI stage I within 7days after LTx. Secondary outcomes included occurrence of postoperative complications, mortality, and long-term kidney function. Of 445 LTx patients enrolled, AKI occurred in 306 (68.8%) within the first week after LTx. Of these, transient AKI (or early recovery) occurred in 157 (51.3%). Transient AKI was associated with fewer complications including tracheostomy (17.2% vs 38.3%; P<.001), reintubation (16.4% vs 41.9%; P<.001), decreased duration of mechanical ventilation (median [interquartile range], 69 [41-142] vs 189 [63-403] hours; P<.001), and lower rates of chronic kidney disease at 3 months (28.5% vs 51.1%, P<.001) and 1 year (49.6% vs 66.7%, P=.01) compared with persistent AKI. Factors independently associated with persistent AKI were higher body mass index (per unit; odds ratio [OR], 0.91; 95% confidence interval, 0.85-0.98; P=.01), cyclosporine use (OR, 0.29; 0.12-0.67; P=.01), longer duration of mechanical ventilation (per hour [log transformed]; OR, 0.42; 0.21-0.81; P=.01), and AKI stages II to III (OR, 0.16; 0.08-0.29; P<.001). Persistent AKI was associated with higher adjusted hazard of death (hazard ratio, 1.77 [1.08-2.93]; P=.02) when compared with transient AKI (1.44 [0.93-2.19], P=.09) and no AKI (reference category), respectively. Transient AKI after LTx is associated with fewer complications and improved survival. Among survivors, persistent AKI portends an increased risk for long-term chronic kidney disease.

Fidalgo P ，Ahmed M ，Meyer SR ，Lien D ，Weinkauf J ，Kapasi A ，Cardoso FS ，Jackson K ，Bagshaw SM ... -  《-》

Incidence of Early Acute Kidney Injury in Lung Transplant Patients: A Single-Center Experience.

Acute kidney injury (AKI) is a common complication in the early period of lung transplantation (LTx). We aimed to describe the incidence and perioperative risk factors associated with AKI following LTx. Clinical data of 30 patients who underwent LTx were retrospectively reviewed. Primary outcomes were development of AKI and patient mortality within 30 postoperative days. Postoperative AKI is determined based on creatinine criteria from Acute Kidney Injury Network (AKIN) classification. Secondary outcomes included the association between AKI and demographic and clinical parameters of patients and treatment modalities in the pre- and postoperative periods. Of the 30 LTx recipients included, AKI occurred in 16 patients (53.4%) within the first 30 days. Length of intensive care unit (P = .06) and hospital stay (P = .008) and mechanical ventilation duration (P = .03) were significantly higher in patients with AKI compared with patients without AKI. Factors independently associated with AKI were intraoperative hypotension (odds ratio [OR] 0.500; 95% confidence interval [CI], 1.145 to 26.412, P = .02), longer duration of mechanical ventilation (OR 1.204; 95% CI 0.870 to 1.665, P = .03), and systemic infection (OR 8.067; 95% CI 1.538 to 42.318, P = .014) in the postoperative period. Short-term mortality was similar in patients with and patients without AKI. By the AKIN definition, AKI occurred in half of the patients following LTx. Several variables including intraoperative hypotension, longer duration of mechanical ventilation, and systemic infection in the postoperative period independently predict AKI in LTx recipients.

Balci MK ，Vayvada M ，Salturk C ，Kutlu CA ，Ari E ... -  《-》

Short-term and long-term outcomes of acute kidney injury after lung transplantation.

The effect of acute kidney injury (AKI) after lung transplantation has been described infrequently and with inconsistent results. Using a newly adopted and validated definition of AKI proposed by the Acute Kidney Injury Network (AKIN), we examined the incidence of AKI and associated renal morbidity and short-term and long-term mortality. We retrospectively evaluated data of 657 patients who underwent lung transplantation from 1997 to 2009. Outcomes analyzed were the incidence of AKI, as defined and categorized into 3 stages according to creatinine criteria from the AKIN classification (AKIN 1, AKIN 2, and AKIN 3), cumulative incidence of chronic kidney disease (CKD), as defined by an estimated glomerular filtration rate ≤ 29 ml/min/1.73 m(2), and/or the onset of end-stage renal disease, as defined by the need for renal replacement therapy for 8 weeks with no recovery on follow-up or need for kidney transplant, and long-term mortality. We identified 424 patients (65%) who had at least 1 AKI (309 [47%] AKIN 1 and 115 [17%] AKIN 2-3) event in the first 2 weeks after transplantation. At 1 year, the cumulative incidence of CKD was 5.8%, 12.8%, 24.5 % in the no-AKI, AKIN 1, and AKIN 2-3 patients, respectively. After a median follow-up of 2.2 years, 277 (42%) died. One-year patient survival was 91%, 82%, 66% in the no-AKI, AKIN 1, and AKIN 2-3 patients, respectively. Adjusting for age, sex, race, type and cause of lung transplant, diabetes, and hypertension, the hazard ratio for death was 1.7 (95% confidence interval, 1.2-2.2; p = 0.0002) for AKIN 1 and 2.9 (95% confidence interval, 1.7-3.7; p < 0.001) for AKIN 2-3. AKI is a common complication after lung transplantation and is associated with increased risk of CKD and all cause-mortality on long-term follow-up.

Wehbe E ，Brock R ，Budev M ，Xu M ，Demirjian S ，Schreiber MJ Jr ，Stephany B ... -  《-》

Severe acute kidney injury according to the RIFLE (risk, injury, failure, loss, end stage) criteria affects mortality in lung transplantation.

The RIFLE criteria (risk, injury, failure, loss, end stage) are new consensus definitions for acute kidney injury (AKI) associated with increased mortality; however, they have not been applied in lung transplantation (LTx). Using the RIFLE criteria, we examined the effect of AKI on outcomes and cost in LTx. We retrospectively reviewed all LTx patients at our institution since the lung allocation score (LAS) system was initiated (May 2005-August 2010). Using the Modification of Diet in Renal Disease formula, we assigned appropriate RIFLE class (R, I, F) comparing baseline creatinine to peak levels in the first 7 days after LTx. Generalized linear models assessed the effect of AKI on in-hospital and 1-year mortality. Hospital charges were used to examine the financial effect of AKI. During the study, 106 LTx were performed. Excluding patients bridged to LTx with extracorporeal membrane oxygenation, 84 (86%) lived 1 year. Median LAS was 37.1 (interquartile range, 34.1-45.2). RIFLE status was I or F in 39 (36.7%), and 14 (13.2%) required renal replacement therapy (RRT). After adjusting for LAS, RIFLE-F had an increased relative rate (RR) of in-hospital mortality (RR, 4.76, 95% confidence interval [CI], 1.65-13.7, p = 0.004) and 1-year mortality (RR, 3.17, 95% CI 1.55-6.49, p = 0.002). RIFLE-R and I were not associated with higher in-hospital or 1-year mortality. Post-operative RRT was associated with increased in-hospital (RR, 28.2; 95% CI, 6.18-128.1; p < 0.001) and 1-year mortality (RR, 4.97; 95% CI, 1.54-16.0; p < 0.001). AKI patients had higher median hospital charges of $168,146 vs $143,551 for no AKI (p = 0.02). This study shows high rates of AKI using the new RIFLE criteria in LTx. RIFLE-F is associated with higher in-hospital and 1-year mortality. Less severe degrees of AKI are not associated with increased mortality. The financial burden associated with AKI is significant.

Arnaoutakis GJ ，George TJ ，Robinson CW ，Gibbs KW ，Orens JB ，Merlo CA ，Shah AS ... -  《-》