Akut böbrek hasarı: Etiyoloji ve hastalık seyri
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Tarih
2025
Yazarlar
Dergi Başlığı
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Cilt Başlığı
Yayıncı
Alanya Alaaddin Keykubat Üniversitesi
Erişim Hakkı
info:eu-repo/semantics/closedAccess
Özet
Akut böbrek hasarı (ABH), ani ve genellikle geri dönüşümlü böbrek fonksiyon kaybıyla karakterize ciddi bir klinik tablodur. Son yıllarda, ABH sonrası dönemde gelişebilen ve hem kısa hem de uzun vadeli sonuçlar doğurabilen akut böbrek hastalığı (ABHa) kavramı tanımlanmıştır. ABHa, ABH ile kronik böbrek hastalığı (KBH) arasında bir geçiş evresi olarak kabul edilmekte olup, prognoz üzerinde belirleyici bir rol oynamaktadır. Ancak ABHa'nın insidansı, risk faktörleri ve uzun dönem klinik sonuçları hâlâ yeterince aydınlatılamamıştır. Öte yandan, mevcut KBH zemininde gelişen ABH, yani akut-on-KBH (A-KBH) olguları da ABHa gelişimi ve kötü prognoz açısından yüksek riskli bir grubu temsil etmektedir. Bu retrospektif çalışma, 1 Ocak 2022 – 31 Aralık 2024 tarihleri arasında hastanemiz dahiliye servisinde izlenen 228 hastayı kapsamaktadır. KDIGO kılavuzları esas alınarak ABH ve A-KBH tanımlamaları yapılmış; hastalar etiyolojik olarak prerenal, intrarenal ve postrenal gruplara ayrılmıştır. ABHa tanı kriterleri olarak ABH varlığı, GFR <60 mL/dak/1,73 m², GFR'nin %35'ten fazla düşüş ya da serum kreatinin düzeyinde %50'den fazla kullanılmıştır. Risk faktörleri arasında ileri yaş, diabetes mellitus, hipertansiyon, kardiyovasküler hastalık, malignite, sepsis ve nefrotoksin maruziyeti incelenmiştir. Böbrek fonksiyonları tanıda, 7. günde (±2 gün) ve 90. günde (±15 gün) değerlendirilmiş; geçici/kalıcı diyaliz ihtiyacı, yeni tanı KBH, KBH progresyonu ve 90 günlük mortalite oranları belirlenmiştir. Çalışmaya toplam 228 hasta dahil edilmiştir; bunların 145'i (%63,6) akut böbrek hasarı (ABH), 83'ü (%36,4) kronik böbrek hastalığı (KBH) zemininde gelişen ABH (A-KBH) olgularından oluşmaktadır. Ortalama yaş 69,6±13,2 yıl olup, A-KBH grubundaki hastalar belirgin olarak daha yaşlıdır (72,7±11,0 vs. 67,7±14,4 yıl). Cinsiyet dağılımı ise %54,8 erkek (n=125) ve %45,2 kadın (n=103) şeklindedir. ABH etiyolojisinde en sık görülen neden intrarenal (%42,1; n=96) olup, bunu prerenal (%38,2; n=87) ve postrenal (%19,7; n=45) nedenler izlemiştir. KDIGO evrelemesine göre olguların %34,2'si evre 1 (n=78), %27,6'sı evre 2 (n=63) ve %38,2'si evre 3 (n=87) olarak sınıflandırılmıştır. Birincil sonlanım olan akut böbrek hastalığı (ABHa), tüm kohortta %46,1 (n=105) oranında saptanmıştır. Alt gruplar incelendiğinde, ABHa sıklığı A-KBH'de %59,0 (n=49) iken, izole ABH'de %38,6 (n=56) bulunmuş ve bu fark istatistiksel olarak anlamlıdır (p=0,003). Sekonder sonlanımlar arasında, geçici hemodiyaliz gereksinimi ABHa varlığında her iki grupta da artış göstermiştir. Kalıcı hemodiyaliz ihtiyacı, A-KBH grubunda ABH'ye göre anlamlı olarak daha yüksek bulunmuştur (%12,0 vs. %2,8; p=0,005). 90. gün takiplerinde, ABH grubunda yeni tanı KBH %42,9, A-KBH grubunda ise KBH progresyonu %72,5 oranında izlenmiştir (her ikisi için p<0,001). Ayrıca, 90 günlük mortalite, A-KBH'de %19,3, ABH'de ise %9,7 olup bu fark da istatistiksel olarak anlamlıdır (p=0,039). Bu bulgular KBH zemininde gelişen ABH, izole ABH'ye kıyasla üç aylık dönemde daha yüksek ABHa sıklığı, daha fazla kalıcı diyaliz gereksinimi ve daha yüksek mortalite ile ilişkili olduğunu ortaya koymaktadır. Özellikle ABHa gelişimi hem yeni KBH tanısı hem de KBH progresyonu için güçlü bir öngörücü faktör olarak öne çıkmaktadır. Bu nedenle, taburculuk sonrası erken dönemde (ilk hafta) ve 3. ayda yapılacak yakın nefrolojik izlemler ile nefrotoksinlerden kaçınma ve hemodinamik optimizasyonu hedefleyen ikincil korunma stratejilerinin standardize edilmesi önem arz etmektedir.
Acute kidney injury (AKI) is a serious clinical condition characterized by sudden and often reversible loss of kidney function. In recent years, the concept of acute kidney disease (AKD), which can develop in the post-AKI period and lead to both short and long-term consequences, has been defined. AKD is considered a transitional phase between AKI and chronic kidney disease (CKD) and plays a determining role in prognosis. However, the incidence, risk factors, and long-term clinical outcomes of AKD are still not fully elucidated. On the other hand, cases of AKI developing on a background of existing CKD, i.e., acute-on-chronic kidney disease (A-CKD), also represent a high-risk group for AKD development and poor prognosis. This retrospective study included 228 patients followed in the internal medicine ward of our hospital between January 1, 2022, and December 31, 2024. AKI and A-CKD were defined based on KDIGO guidelines; patients were etiologically divided into prerenal, intrarenal, and postrenal groups. The diagnostic criteria for AKD were the presence of AKI, GFR <60 mL/min/1.73 m², a greater than 35% decline in GFR, or a greater than 50% increase in serum creatinine level. Risk factors including advanced age, diabetes mellitus, hypertension, cardiovascular disease, malignancy, sepsis, and nephrotoxin exposure were examined. Kidney functions were assessed at diagnosis, on day 7 (±2 days), and on day 90 (±15 days); temporary/permanent dialysis requirement, new-onset CKD, CKD progression, and 90-day mortality rates were determined. A total of 228 patients were included in the study; 145 (63.6%) were acute kidney injury (AKI) cases, and 83 (36.4%) were AKI cases developing on a background of chronic kidney disease (A-CKD). The mean age was 69.6 ± 13.2 years, with patients in the A-CKD group being significantly older (72.7 ± 11.0 vs. 67.7 ± 14.4 years). The gender distribution was 54.8% male (n=125) and 45.2% female (n=103). The most common etiology of AKI was intrarenal (42.1%; n=96), followed by prerenal (38.2%; n=87) and postrenal (19.7%; n=45) causes. According to KDIGO staging, 34.2% of cases were stage 1 (n=78), 27.6% were stage 2 (n=63), and 38.2% were stage 3 (n=87). The primary outcome, acute kidney disease (AKD), was detected in 46.1% (n=105) of the entire cohort. When subgroups were analyzed, the frequency of AKD was 59.0% (n=49) in A-CKD, compared to 38.6% (n=56) in isolated AKI, and this difference was statistically significant (p=0.003). Among secondary outcomes, the need for temporary hemodialysis increased in the presence of AKD in both groups. The need for permanent hemodialysis was significantly higher in the A-CKD group compared to the AKI group (12.0% vs. 2.8%; p=0.005). At the 90-day follow-up, new-onset CKD was observed in 42.9% of the AKI group, while CKD progression was observed in 72.5% of the A-CKD group (p<0.001 for both). Furthermore, the 90-day mortality was 19.3% in A-CKD and 9.7% in AKI, a difference that was also statistically significant (p=0.039). These findings reveal that AKI developing on a background of CKD is associated with a higher frequency of AKD, a greater need for permanent dialysis, and higher mortality over a three-month period compared to isolated AKI. Notably, the development of AKD emerges as a strong predictive factor for both new-onset CKD and CKD progression. Therefore, standardizing secondary prevention strategies targeting close nephrological follow-up in the early post-discharge period (first week) and at the 3rd month, avoidance of nephrotoxins, and hemodynamic optimization is of great importance.
Acute kidney injury (AKI) is a serious clinical condition characterized by sudden and often reversible loss of kidney function. In recent years, the concept of acute kidney disease (AKD), which can develop in the post-AKI period and lead to both short and long-term consequences, has been defined. AKD is considered a transitional phase between AKI and chronic kidney disease (CKD) and plays a determining role in prognosis. However, the incidence, risk factors, and long-term clinical outcomes of AKD are still not fully elucidated. On the other hand, cases of AKI developing on a background of existing CKD, i.e., acute-on-chronic kidney disease (A-CKD), also represent a high-risk group for AKD development and poor prognosis. This retrospective study included 228 patients followed in the internal medicine ward of our hospital between January 1, 2022, and December 31, 2024. AKI and A-CKD were defined based on KDIGO guidelines; patients were etiologically divided into prerenal, intrarenal, and postrenal groups. The diagnostic criteria for AKD were the presence of AKI, GFR <60 mL/min/1.73 m², a greater than 35% decline in GFR, or a greater than 50% increase in serum creatinine level. Risk factors including advanced age, diabetes mellitus, hypertension, cardiovascular disease, malignancy, sepsis, and nephrotoxin exposure were examined. Kidney functions were assessed at diagnosis, on day 7 (±2 days), and on day 90 (±15 days); temporary/permanent dialysis requirement, new-onset CKD, CKD progression, and 90-day mortality rates were determined. A total of 228 patients were included in the study; 145 (63.6%) were acute kidney injury (AKI) cases, and 83 (36.4%) were AKI cases developing on a background of chronic kidney disease (A-CKD). The mean age was 69.6 ± 13.2 years, with patients in the A-CKD group being significantly older (72.7 ± 11.0 vs. 67.7 ± 14.4 years). The gender distribution was 54.8% male (n=125) and 45.2% female (n=103). The most common etiology of AKI was intrarenal (42.1%; n=96), followed by prerenal (38.2%; n=87) and postrenal (19.7%; n=45) causes. According to KDIGO staging, 34.2% of cases were stage 1 (n=78), 27.6% were stage 2 (n=63), and 38.2% were stage 3 (n=87). The primary outcome, acute kidney disease (AKD), was detected in 46.1% (n=105) of the entire cohort. When subgroups were analyzed, the frequency of AKD was 59.0% (n=49) in A-CKD, compared to 38.6% (n=56) in isolated AKI, and this difference was statistically significant (p=0.003). Among secondary outcomes, the need for temporary hemodialysis increased in the presence of AKD in both groups. The need for permanent hemodialysis was significantly higher in the A-CKD group compared to the AKI group (12.0% vs. 2.8%; p=0.005). At the 90-day follow-up, new-onset CKD was observed in 42.9% of the AKI group, while CKD progression was observed in 72.5% of the A-CKD group (p<0.001 for both). Furthermore, the 90-day mortality was 19.3% in A-CKD and 9.7% in AKI, a difference that was also statistically significant (p=0.039). These findings reveal that AKI developing on a background of CKD is associated with a higher frequency of AKD, a greater need for permanent dialysis, and higher mortality over a three-month period compared to isolated AKI. Notably, the development of AKD emerges as a strong predictive factor for both new-onset CKD and CKD progression. Therefore, standardizing secondary prevention strategies targeting close nephrological follow-up in the early post-discharge period (first week) and at the 3rd month, avoidance of nephrotoxins, and hemodynamic optimization is of great importance.
Açıklama
15.04.2026 tarihine kadar kullanımı yazar tarafından kısıtlanmıştır.
Anahtar Kelimeler
İç Hastalıkları, Internal diseases
