849 studies, 3,476 patientsFrom: Long-term Renal Prognosis of Diarrhea-Associated Hemolytic Uremic Syndrome: A Systematic Review, Meta-analysis, and Meta-regressionJAMA. 2003;290(10): doi: /jamaFigure Legend:These studies had a higher proportion of patients with death or permanentend-stage renal disease (ESRD) at follow-up, explaining 10% of the between-studyvariability (P = .02), and a higher proportion ofpatients with a glomerular filtration rate (GFR) lower than 80 mL/min per1.73 m2, hypertension, or proteinuria at last follow-up, explaining15% of the between-study variability (P<.001).The area of each circle is proportional to the number of patients in eachstudy. Curves are best-fit lines from meta-regression. See "Methods" section.
16Summary De novo AKI is associated with Incident CKD and ESRD Precise estimates of the incidence of CKD progression after AKI in children are lacking due to incomplete follow upChildren who survive an episode of AKI requiring RRT deserve long-term follow up
17AKI 2 million 1.7 million 1.5 million 300K 170K 300K 1 Billion d d mo > 3 yrs2 million1.7 million1.5 millionAKI SurvivorsRound IIAKIDe novo and ACRFAKI SurvivorsRound IIIAKI Survivors Round I300K170K300K10-15% Mortality10% ESRD20% CKD 4
18How does AKI progress to CKD? Host Predisposition: genetics / co-morbiditiesNephron loss followed by glomerular hypertrophyFibrosis and Maladaptive repairVascular drop out as a consequence of endothelial injury
31Interventions Nephrologist (CKD clinic) See the patient? HTN controlACEiLow protein dietTGF-Beta inhibitionVEGF promotion (early post-AKI)p53 inhibition (early post-AKI)
32SummarySeverity of AKI is associated with CKD progression in AKI survivorsDecreased concentration of serum albumin is associated with progression to CKDLikely a marker if increased inflammationBreaking the vicious cycle of AKI to CKD to AKI to ESRD could have significant impacts on disease burden
33Future Directions Beta-blocker for MI allegory Primary prevention study in AKI survivors to prevent progression to CKDIdentify patients at riskEnroll, randomize2 x 2 factorial designInterventions: BP control, RAAS inhibition, anti-inflammatory agents,