Outcomes After Post-Traumatic AKI Requiring RRT in United States Military Service Members.
OBJECTIVE
Mortality and CKD risk have not been described in military casualties with post-traumatic AKI requiring RRT suffered in the Iraq and Afghanistan wars.


METHODS
This is a retrospective case series of post-traumatic AKI requiring RRT in 51 military health care beneficiaries (October 7, 2001-December 1, 2013), evacuated to the National Capital Region, documenting in-hospital mortality and subsequent CKD. Participants were identified using electronic medical and procedure records.


RESULTS
Age at injury was 26±6 years; of the participants, 50 were men, 16% were black, 67% were white, and 88% of injuries were caused by blast or projectiles. Presumed AKI cause was acute tubular necrosis in 98%, with rhabdomyolysis in 72%. Sixty-day all-cause mortality was 22% (95% confidence interval [95% CI], 12% to 35%), significantly less than the 50% predicted historical mortality (P<0.001). The VA/NIH Acute Renal Failure Trial Network AKI integer score predicted 60-day mortality risk was 33% (range, 6%-96%) (n=49). Of these, nine died (mortality, 18%; 95% CI, 10% to 32%), with predicted risks significantly miscalibrated (P<0.001). The area under the receiver operator characteristic curve for the AKI integer score was 0.72 (95% CI, 0.56 to 0.88), not significantly different than the AKI integer score model cohort (P=0.27). Of the 40 survivors, one had ESRD caused by cortical necrosis. Of the remaining 39, median time to last follow-up serum creatinine was 1158 days (range, 99-3316 days), serum creatinine was 0.85±0.24 mg/dl, and eGFR was 118±23 ml/min per 1.73 m(2). No eGFR was <60 ml/min per 1.73 m(2), but it may be overestimated because of large/medium amputations in 54%. Twenty-five percent (n=36) had proteinuria; one was diagnosed with CKD stage 2.


CONCLUSIONS
Despite severe injuries, participants had better in-hospital survival than predicted historically and by AKI integer score. No patient who recovered renal function had an eGFR<60 ml/min per 1.73 m(2) at last follow-up, but 23% had proteinuria, suggesting CKD burden.
Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland.
Jonathan A
JA
Bolanos
Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland christina.m.yuan.civ@mail.mil.
Christina M
CM
Yuan
Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland.
Dustin J
DJ
Little
Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland.
David K
DK
Oliver
Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland.
Steven R
SR
Howard
Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland.
Kevin C
KC
Abbott
Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland.
Stephen W
SW
Olson
D058186:Acute Kidney Injury / Q000209:etiology* / Q000401:mortality* / Q000628:therapy; D000328:Adult; D055826:Afghan Campaign 2001-; D001753:Blast Injuries / Q000150:complications; D003404:Creatinine / Q000097:blood; D005260:Female; D005919:Glomerular Filtration Rate; D017052:Hospital Mortality; D006801:Humans; D054542:Iraq War, 2003-2011; D007684:Kidney Tubules / Q000473:pathology*; D008297:Male; D008889:Military Personnel; D009336:Necrosis / Q000150:complications; D011507:Proteinuria / Q000209:etiology; D012372:ROC Curve; D020127:Recovery of Function; D051436:Renal Insufficiency, Chronic / Q000209:etiology* / Q000503:physiopathology; D017582:Renal Replacement Therapy; D012189:Retrospective Studies; D012206:Rhabdomyolysis / Q000150:complications; D018570:Risk Assessment; D014481:United States; D000067398:War-Related Injuries / Q000150:complications*; D014950:Wounds, Penetrating / Q000150:complications; D055815:Young Adult
D003404:Creatinine
acute renal failure; chronic kidney disease; dialysis; military casualties; mortality risk