Acute kidney injury leading to chronic kidney disease and long-term outcomes of acute kidney injury: the best opportunity to mitigate acute kidney injury?

Acute kidney injury (AKI) has been shown to be associated with progression to chronic kidney disease (CKD). Multiple studies have shown that subsets of AKI survivors are at high risk for progression to advanced stage CKD and death. Risk factors associated with AKI survivors progressing to CKD have been identified and include advanced age, diabetes mellitus, decreased baseline glomerular filtration rate, severity of AKI and a low concentration of serum albumin. These risk factors can be utilized to identify those patients at highest risk for progression. Because progression to CKD in these AKI survivors typically occurs months after the initial AKI insult, a common injury pathway of CKD progression is probable, and therapeutic interventions that have been shown to retard CKD progression are likely to be effective in patients who survive AKI and then progress to CKD. AKI has many negative impacts across the spectrum of the disease. The 30-day mortality for patients with AKI is high, hence the preference to target AKI during the initiation phase. However, this phase is the most difficult point to treat AKI. The maintenance phase of AKI is longer in duration in comparison to the initiation phase, and thus the logistics are more amenable to study. However, the mainstay of treatment for the maintenance phase of AKI (renal replacement therapy) has been tested extensively and increasing the dose of renal replacement therapy has not been shown to improve outcome. Therefore, the recovery phase of AKI may represent the best opportunity to intervene in the negative outcomes of AKI.