Parikh, Chirag R.

Key Points Nonimmunologic AKI-related rehospitalizations post–kidney transplant are associated with poorer long-term allograft and recipient outcomes. These data are not reported to United Network for Organ Sharing, and there are no datasets highlighting this important association; thus, our findings are valuable to clinicians. We hope to help the community create a cohort of higher risk transplant patients who need closer monitoring to potentially increase graft longevity Background AKI is associated with an increased risk of CKD and ESKD. However, only limited studies have investigated the effect of AKI episodes on kidney transplant outcomes. This study evaluated the effect of rehospitalization associated with nonimmunologic AKI on long-term outcomes. Data on rehospitalization with AKI after kidney transplant are not reported to United Network for Organ Sharing, and thus, there are no large datasets available to study this association. Methods We completed chart reviews of 989 deceased donor kidney transplant recipients transplanted from 2010 to 2014 at 13 transplant centers in the Deceased Donor Study Consortium. Rehospitalizations up to 5 years post-transplant were included. The cause of rehospitalizations was adjudicated by a transplant nephrologist on the basis of the discharge diagnosis. Primary outcomes were the effect of AKI-related rehospitalization on death-censored graft failure and all-cause mortality. We excluded rehospitalizations because of acute rejection from the primary analysis. The cohort was linked to data from Organ Procurement and Transplantation Network supplied by United Network for Organ Sharing. Time-varying cox-proportional hazard models were used to examine the association between rehospitalization and outcomes. Results We identified 200 (20%) recipients with at least one rehospitalization associated with AKI, 516 (52%) with rehospitalizations without AKI, and 273 (28%) without a rehospitalization post-transplant. Delayed graft function, donor age, and kidney donor profile index score differed between the three groups. We found a higher risk of death censored graft failure adjusted hazard ratio (aHR) 7.5 (95% confidence interval [CI], 4.0 to 13.8), all-cause graft failure aHR 6.7 (95% CI, 4.2 to 10.8), and all-cause mortality aHR 5.7 (95% CI, 2.7 to 11.8) for rehospitalizations associated with AKI compared with no rehospitalization. The non-AKI rehospitalizations also had significantly higher rates of measured outcomes; however, the associations were not as strong. Conclusions AKI rehospitalizations were associated with a significantly increased risk of poorer graft outcomes, and thus, closer follow-up of this high-risk group is warranted.

The American Society of Nephrology has established a new initiative, AKI!Now , with the goal of promoting excellence in the prevention and treatment of AKI by building a foundational program that transforms education and delivery of AKI care, aiming to reduce morbidity and associated mortality and to improve long-term outcomes. In this article, we describe our current efforts to improve early recognition and management involving inclusive interdisciplinary collaboration between providers, patients, and their families; discuss the ongoing need to change some of our current AKI paradigms and diagnostic methods; and provide specific recommendations to improve AKI recognition and care. In the hospital and the community, AKI is a common and increasingly frequent condition that generates risks of adverse events and high costs. Unfortunately, patients with AKI may frequently have received less than optimal quality of care. New classifications have facilitated understanding of AKI incidence and its impact on outcomes, but they are not always well aligned with AKI pathophysiology. Despite ongoing research efforts, treatments to promote or hasten kidney recovery remain ineffective. To avoid progression, the current approach to AKI emphasizes the promotion of early recognition and timely response. However, a lack of awareness of the importance of early recognition and treatment among health care team members and the heterogeneity of approaches within the health care teams assessing the patient remains a major challenge. Early identification is further complicated by differences in settings where AKI occurs (the community or the hospital), and by differences in patient populations and cultures between the intensive care unit and ward environments. To address these obstacles, we discuss the need to improve education at all levels of care and to generate specific guidance on AKI evaluation and management, including the development of a widely applicable education and an AKI management toolkit, engaging hospital administrators to incorporate AKI as a quality initiative, and raising awareness of AKI as a complication of other disease processes.