Recovery from acute kidney injury (AKI) in hospitalized patients is variable and persistent impairment of renal function at discharge has been associated with increased mortality, resource utilization, progression to CKD, ESRD, and cardiovascular events. Even small changes in kidney function in hospitalized patients are associated with significant changes in short and long-term outcomes (1,22). Therefore, identifying risk factors leading to incomplete recovery after AKI, maximizing recovery, reducing the burden of CKD, and ESKD in the community should be the goal of any AKI prevention and treatment strategies (20,23).
This study, the first in Ethiopia, found a high prevalence (32%) of non-recovery AKI at hospital discharge. The degree of non-recovery was higher than findings from other studies, 15.2% in Cameroon(24), and 20.2% in South Africa(25). The high prevalence of non-recovery observed in this study could be due to the variation with these studies in criteria used for renal recovery (dialysis independent vs return to baseline Scr), and difference in point in time of evaluation of recovery (at hospital discharge vs post-discharge). Studies defining recovery as independent from dialysis show higher rates of recovery than those defining recovery from AKI as a return to baseline serum creatinine (26). The rate of non-recovery in our study was lower than the results reported from previous studies, 47.3% in southwest Nigeria(27), 52.8% in Malawi(28), 60.7% in Cleveland, Ohio(29), and 61% in South Korea(30). The variation could be due to differences in sample size, length of follow-up, study design, study setting, patient population (surgical, medical, or mixed), and the inclusion/exclusion of patients with CKD. In addition, since our study is limited only to survivors at discharge, the exclusion of patients who died in the hospital may contribute to the low prevalence of non-recovery in this study. However, due to the absence of a uniform definition of renal recovery and the difference in the timing of assessment of recovery, the rate of renal non-recovery is different in studies published in the literature. Therefore, it is difficult to compare findings directly across studies (31,21).
Patients discharged with non-recovery AKI had a more severe stage of the disease and a higher mean discharge creatinine value, and mean duration of anuria and oliguria. Likewise, previous studies revealed that a more severe stage of AKI, a higher mean discharge creatinine, and a mean duration of anuria are common in patients with incomplete recovery (23,28,32,33). Interestingly, the severity of AKI was significantly associated with an increased likelihood of non-renal recovery. This is consistent with previous studies that demonstrated a significant association between the severity of AKI and incomplete recovery (19,29,30,34). Furthermore, declined renal function at hospital discharge and severity of AKI are found to be associated with the progression of AKI to CKD and mortality. Therefore, physicians should identify patients with a more severe stage of the disease and manage accordingly to enhance recovery and prevent these adverse outcomes. It is recommended that the intensity of therapeutic and preventive measures should be performed based on the severity of AKI (1,35).
Many studies found an association between exposure to nephrotoxic drugs and the risk of non-renal recovery after AKI. Prescription of nephrotoxic drugs is usually evaluated semi-quantitatively and thus associated with subsequent AKI and CKD, and worsening of lower severity of disease, morbidity, and mortality (36,37,38). This study found that the use of nephrotoxic drugs was associated with a significantly higher chance of non-renal recovery at discharge. The study highlights the need to minimize patients’ exposure to nephrotoxic drugs to avoid persistent injury to the kidney, improve renal recovery and prevent subsequent poor short and long-term outcomes AKI. Measures taken to prevent AKI and protect kidney function, such as avoiding nephrotoxins and drug use monitoring can prevent persistent acute kidney injury(19).
One of the main findings of this study found a significant association between proteinuria with non-recovery AKI. As reported in previous studies preadmission proteinuria before an episode of AKI and in-hospital positive urine dipstick test are independent predictors of non-recovery at discharge(21,32,39). Therefore, close monitoring of proteinuria during the period of hospitalization may help to identify patients with persistent AKI and subsequent progressive kidney disease and initiate specific interventions to improve recovery.
The recovery of kidney function following AKI is shown to be an important determinant of morbidity and mortality. Even after distinct recovery, AKI is shown to be associated with long-term risk for CKD, even for less severe forms. Patients with one episode of mild AKI have significantly lower long-term survival rates than patients with no AKI. As a result, close medical follow-up of these patients is warranted (22,40,41). However, due to the lack of routine renal function tests in many hospitals in the country and periodic follow-up of patients post-discharge (42), the long-term outcomes include mortality, CKD, ESRD, and other adverse outcomes of AKI in our settings are not known.
Our study has some limitations. Firstly, this was a single-center study and exclude patients with underlying CKD. Secondly, urine output assessment was not done for some patients. Moreover, there was no monitoring of the patients after discharge. Therefore, the outcomes of AKI after discharge are not known. Despite these limitations, this is the first prospective observational study of adult medical admissions, which shed some light on the clinical features and recovery status of patients after AKI in resource-limited settings.