Sepsis-Associated Acute Kidney Disease Incidence, Trajectory, and Outcomes

Rationale & Objective Systematic evaluation of the prognosis from sepsis-associated acute kidney disease (SA-AKD) using real-world data is limited. This study aimed to use data algorithms on the electronic health records to trace the SA-AKD trajectory from acute kidney injury (AKI) to chronic kidney disease (CKD). Study Design A retrospective cohort study. Setting & Participants Adult inpatients with first sepsis episode surviving 90 days after AKD in a quaternary referral medical center. Exposure We defined SA-AKD as having sustained ≥1.5-fold increased serum creatinine levels or initiating kidney replacement therapy after the SA-AKI, and we classified SA-AKD into recovery, relapse, and persistent SA-AKD subgroups. Outcomes All-cause mortality, kidney replacement therapy (KRT), de novo nondialysis dependent CKD (CKD-ND), and late-recovery AKD during 1-year follow-up. Analytical Approach A multivariable Cox proportional hazards models. Results Of 24,038 eligible inpatients with sepsis, 42.2% had SA-AKI, and 17.6% progressed to SA-AKD (43.6% recovery, 8.3% relapse, 32.2% persistent, and 15.9% unclassified). Compared with the recovery subgroup, the 1-year mortality risk for the relapse, persistent, and unclassified SA-AKD subgroups were 1.57 (adjusted hazard ratios [aHRs]; 95% CI, 1.22-2.01), 1.36 (1.13-1.63), and 0.65 (0.48-0.89), respectively. Risks of KRT initiation were 3.27 (2.14-4.98), 6.01 (4.41-8.19), and 0.98 (0.55-1.74), respectively, and corresponding aHRs for de novo CKD-ND were 3.84 (2.82-5.22), 3.35 (2.61-4.29), and 0.48 (0.30-0.77), respectively. Patients with relapse SA-AKD had a higher likelihood of late recovery (aHR, 3.62; 95% CI, 2.52-5.21) than the persistent SA-AKD. Limitations Selection bias and information bias could be present because of limiting population to sepsis survivors and because of no standardized follow-up protocol for kidney function. Conclusions SA-AKD without recovery is associated with increased and long-term risks of KRT initiation, mortality, and increased risk of de novo CKD-ND for patients initially free of CKD. Further studies are warranted for managing AKI to AKD to CKD in real-world settings. Plain Language Summary Systematic evaluation of the prognosis for sepsis-associated acute kidney injury (AKI) and sepsis-associated acute kidney disease (AKD) using real-world data remain limited. We applied standard definitions of sepsis and AKI/AKD and comprehensively profiled the AKI-AKD-chronic kidney disease (CKD) trajectory among sepsis survivors in a large, longitudinal hospital-based cohort. Our study showed that sepsis-associated AKD without recovery is associated with elevated and long-term risks of progressing to kidney replacement therapy, mortality, and new onset of CKD. These findings advocate for a paradigm shift toward digital therapies for managing the transition from AKI to AKD to CKD among patients with sepsis.