What factors worsen kidney disease progression in hospitalized patients with impaired renal function?

Factors That Worsen Kidney Disease Progression in Hospitalized Patients

Inadequate dialysis clearance is the most significant factor worsening kidney disease progression in hospitalized patients, with low creatinine clearance directly associated with prolonged hospitalization and increased mortality. 1

Key Modifiable Risk Factors

Inadequate Dialysis and Treatment Factors

• Low creatinine clearance is associated with increased overall hospitalization rates and prolonged hospital stays in patients with kidney disease 1
• Inadequate dialysis is directly related to uremic symptoms such as nausea, vomiting, and gastrointestinal bleeding, which can worsen kidney function 1
• Suboptimal ultrafiltration (related to transport characteristics) and total solute clearance negatively impact technique survival in peritoneal dialysis patients 1

Metabolic Disturbances

• Metabolic acidosis contributes to malnutrition and protein depletion, accelerating kidney function decline 1
• Hyperglycemia and insulin resistance are associated with increased risk of complications in critically ill patients with acute kidney injury/disease 1
• In diabetic patients, lower calcium levels and elevated parathyroid hormone levels at baseline are associated with CKD progression 2
• Elevated phosphorus levels are significantly associated with increased renal events, even after adjustment for baseline GFR 3

Cardiovascular Factors

• Hypertension borders on significance as a progression factor in non-diabetic patients with kidney disease 2
• Cardiovascular disease is the most frequent cause for hospitalizations among hemodialysis patients (33.68%) and a major cause in peritoneal dialysis patients (28.77%) 1
• Elevated blood pressure is a key modifiable risk factor for CKD progression 1

Proteinuria and Albuminuria

• Increased proteinuria is consistently associated with an increased risk for adverse renal outcomes, even at low levels 3
• Proteinuria is a significant perpetuating factor for progression from late-stage CKD to end-stage renal disease (ESRD) with a hazard ratio of 1.64 4
• The KDIGO guidelines recommend assessing albuminuria at least annually in people with CKD, and more often for individuals at higher risk of progression 1

Non-Modifiable Risk Factors

Demographic Factors

• Male sex is a significant perpetuating factor for progression from late-stage CKD to ESRD with a hazard ratio of 1.37 4
• Age, race/ethnicity, and genetic factors influence kidney disease progression 1
• Baseline GFR <40 ml/min is associated with adverse renal outcomes 3

Comorbidities

• Diabetes may play a role in progression to ESRD among patients with later stages of CKD (hazard ratio 1.16) 4
• History of cardiovascular disease increases risk of CKD progression 1
• Patients with diabetes have a higher prevalence among peritoneal dialysis patients (33.33%) compared to hemodialysis patients (25.71%) 1

Hospital-Related Factors

Medication Management

• Ongoing exposure to nephrotoxic agents accelerates kidney disease progression 1
• Inappropriate use of renin-angiotensin-aldosterone system inhibitors in volume-depleted patients can cause acute renal failure 5
• Inadequate monitoring of serum potassium levels while on medications that increase potassium may lead to hyperkalemia 5

Nutritional Status

• Malnutrition is prevalent in 11-54% of patients with non-dialysis CKD stages 3-5, and between 28-54% in patients undergoing chronic hemodialysis 1
• Progressive depletion of protein and/or energy stores is often observed in CKD patients, with prevalence rates increasing along with declining kidney function 1
• Medical nutrition therapy should be provided to any patient with acute kidney injury/disease or CKD staying in the ICU for more than 48 hours 1

Prevention Strategies

Medication Interventions

• Angiotensin receptor blockers (ARBs) or angiotensin-converting enzyme inhibitors (ACE-Is) should be used in both diabetic and non-diabetic adults with CKD and urine albumin excretion >300 mg/24h 1
• Losartan treatment resulted in a 16% risk reduction in the composite endpoint of doubling of serum creatinine, ESRD, or death in patients with type 2 diabetes with nephropathy 5
• Statin therapy (atorvastatin) in addition to ACE inhibitors or ARBs may reduce proteinuria and slow the rate of kidney disease progression 6

Monitoring and Management

• Monitor renal function periodically in patients whose renal function may depend on the activity of the renin-angiotensin system 5
• Define CKD progression based on decline in GFR category, a 25% or greater drop in eGFR from baseline, or a sustained decline in eGFR of ≥5 ml/min per 1.73 m²/year 1
• Categorize hospitalizations according to whether they are related to ESRD or not for better analysis and management 1

Multidisciplinary Approach

• A multidisciplinary CKD clinic program produces the greatest increases in time to renal replacement therapy compared to standard nephrology care 7
• Early identification of patients, modification of risk factors, and implementation of best interventions are key strategies to delay CKD progression 7
• Medical nutrition therapy should be considered for any patient with acute kidney injury/disease, acute kidney injury on CKD, or CKD with or without kidney failure requiring hospitalization 1

Pitfalls and Caveats

• Small fluctuations in GFR are common and not necessarily indicative of progression 1
• Changes in eGFR may be due to true change in GFR or due to changes in the non-GFR determinants of creatinine concentrations 1
• It is important to differentiate between progression of chronic disease and acute injury, as their definitions and management differ 1
• Serum creatinine is an unreliable marker of kidney dysfunction; clinicians should focus on GFR or other markers of true kidney function 7
• Modest increases in creatinine in the setting of effective decongestion therapy for acute heart failure are not necessarily associated with worsened outcomes 1