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Summary
Background Acute kidney injury (AKI) has become a worldwide public health problem, but little information is
available about the disease burden in China. We aimed to evaluate the burden of AKI and assess the availability of
diagnosis and treatment in China.
Methods We launched a nationwide, cross-sectional survey of adult patients who were admitted to hospital in 2013
in academic or local hospitals from 22 provinces in mainland China. Patients with suspected AKI were screened
out on the basis of changes in serum creatinine by the Laboratory Information System, and we reviewed medical
records for 2 months (January and July) to conrm diagnoses. We assessed rates of AKI according to
two identication criteria: the 2012 Kidney Disease: Improving Global Outcomes (KDIGO) AKI denition and an
increase or decrease in serum creatinine by 50% during hospital stay (expanded criteria). We estimated national
rates with data from the 2013 report by the Chinese National Health and Family Planning Commission and
National Bureau of Statistics.
Findings Of 2 223 230 patients admitted to the 44 hospitals screened in 2013, 154 950 (70%) were suspected of
having AKI by electronic screening, of whom 26 086 patients (from 374 286 total admissions) were reviewed with
medical records to conrm the diagnosis of AKI. The detection rate of AKI was 099% (3687 of 374 286) by KDIGO
criteria and 203% (7604 of 374 286) by expanded criteria, from which we estimate that 1429 million people with
AKI were admitted to hospital in China in 2013. The non-recognition rate of AKI was 742% (5608 of 7555 with
available data). Renal referral was done in 214% (1625 of 7604) of the AKI cases, and renal replacement therapy was
done in 593% (531 of 896) of those who had the indications. Delayed AKI recognition was an independent risk
factor for in-hospital mortality, and renal referral was an independent protective factor for AKI under-recognition
and mortality
Interpretation AKI has become a huge medical burden in China, with substantial underdiagnosis and undertreatment.
Nephrologists should take the responsibility for leading the battle against AKI.
Funding National 985 Project of China, National Natural Science Foundation of China, Beijing Training Program for
Talents, International Society of Nephrology Research Committee, and Bethune Fund Management Committee.
Introduction
Acute kidney injury (AKI) is a common disorder with a
high risk of mortality and development of chronic kidney
disease, although information from developing countries
is scarce.13 In 2013, the International Society of
Nephrology launched a global target of 0by25no
patient deaths due to untreated acute kidney failure by
2025to improve the diagnosis and treatment of AKI
globally.4 An important step to meet this target is to
measure and identify the burden and present situation of
AKI worldwide, for which data from China, the worlds
largest developing country, will provide valuable
information. Up to now, data about the prevalence of AKI
in China have been sparse. Single-centre studies have
reported that AKI complicates 241319% of all hospital
admissions,5,6 which is much lower than what is reported
by developed countries (718%).711
Methods
Study design and participants
We did a cross-sectional survey in mainland China. We
included 22 of the 31 provinces, municipalities, and
autonomous regions in China in our survey, covering
82% of the countrys population and the four
geographical regions of China (north, northwest,
southeast, and southwest; appendix). In each region we
enrolled an academic hospital in the regions capital
city and a local hospital from a smaller city or rural
county. The appendix contains details on hospital
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Survey design
The survey for AKI was designed to have three steps.
First, we screened adult patients who were admitted to
hospital with suspected AKI on the basis of changes in
their serum creatinine reported by the Laboratory
Information System (a software-based laboratory and
information management system that can track and
analyse laboratory data in hospitals). We used the 2012
Kidney Disease: Improving Global Outcomes (KDIGO)
denition of AKI as the major screening criteria.12 For
patients who had repeated serum creatinine assay with
intervals longer than 7 days and those who had recovering
44 study hospitals
Identify AKI
Investigate AKI
Cause
Comorbidity
Recognition
Treatment
Short-term outcome
Procedures
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Exclusion criteria:
Chronic kidney disease stage 5
Nephrectomy
Kidney transplantation
Peak serum creatinine <53 mol/L
Serum creatinine change could not
be attributed to AKI
Articles
Statistical analysis
We calculated detection rates of AKI (number of detected
AKI cases per number of admission) at the hospital level
(academic or local) and by geographical regions in two
categories according to the identication criteria for AKI.
We used data from the 2013 report by the Chinese
National Health and Family Planning Commission and
National Bureau of Statistics as the standard population.
We present continuous data as mean (SD) or median
(IQR) as appropriate and categorical variables as n (%).
We described characteristics of patients and the statues
of recognition and treatment of AKI, stratied by
hospital level, geographical region, and level of
economic development. We compared groups using
one-way ANOVA or Kruskal-Wallis test for continuous
variables and test for categorical variables.
We analysed relevant covariates that might associate
with under-recognition of AKI (non-recognition and
delayed recognition; yes vs no) with multivariable
logistic regression and report odds ratios with 95% CIs
and p values of Wald test. Covariates included in the
analysis were age (change by 10 years), sex (male vs
female), chronic kidney disease (yes vs no), renal referral
(yes vs no), AKI stages at detection and at peak, hospital
Total
Results
We assessed 2 223 230 adult patients (aged 18 years)
admitted to 44 study hospitals in the survey: 1 541 151 from
academic hospitals and 682 079 from local hospitals.
In three regions, we were not able to enrol local hospitals
because of research recourse limitations and enrolled
additional local hospitals in the adjacent regions instead.
Of the 2 223 230 patients treated in hospital in 2013 who
were screened, 562 191 (253%) had serum creatinine
North
Northwest
Southeast
Southwest
135513
47167
9842
58926
14007
4676
1176
6024
2131
Population (million)16
Hospital admissions (million)17
Screened cases*
19578
374 286
119 284
46 099
162 973
Academic hospital
257 498
86 721
42 372
101 313
45 930
27 092
Local hospital
116 788
32 563
3727
61 660
18 838
7 (019%; 005033)
Local hospital
Academic hospital
Local hospital
24 (064%; 039090)
AKI=acute kidney injury. KDIGO=Kidney Disease: Improving Global Outcomes. *Percentage is screened cases per total hospital admissions.
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Age (years)
Academic hospitals
(N=5662)
Local hospitals
(N=1942)
616 (174)
607 (174)
640 (172)
876 (115%)
686 (121%)
2341 (308%)
1831 (323%)
510 (263%)
3120 (410%)
2277 (402%)
843 (434%)
Age group
Aged 80 years
p value
<00001
<00001
190 (98%)
1267 (167%)
868 (153%)
399 (205%)
Men
4955 (652%)
3685 (651%)
1270 (654%)
080
CA-AKI
4136 (544%)
2859 (505%)
1277 (658%)
<00001
601 (79%)
409 (72%)
192 (99%)
<00001
Surgical
1639 (216%)
1231 (217%)
408 (210%)
Medicinal
3195 (420%)
2266 (400%)
929 (478%)
Intensive-care unit
2169 (285%)
1756 (310%)
413 (213%)
Pre-renal
3936 (518%)
2866 (506%)
1070 (551%)
00007
Intrinsic-renal
2100 (276%)
1632 (288%)
468 (241%)
<00001
AKI classication
Post-renal
670 (88%)
472 (83%)
198 (102%)
00126
Unclassied
898 (118%)
692 (122%)
206 (106%)
006
Renal hypoperfusion
5914 (778%)
4400 (777%)
1514 (780%)
082
Nephrotoxic drugs
5444 (716%)
4087 (722%)
1357 (699%)
005
Injury factors
Environmental toxins
191 (25%)
129 (23%)
62 (32%)
Sepsis
483 (64%)
328 (58%)
155 (80%)
00006
3224 (424%)
2484 (439%)
740 (381%)
<00001
Surgery
1629 (214%)
1406 (248%)
223 (115%)
<00001
3483 (458%)
2613 (461%)
870 (448%)
1950 (256%)
1422 (251%)
528 (272%)
2171 (286%)
1627 (287%)
544 (280%)
RRT indication
896 (118%)
732 (129%)
164 (84%)
Mortality*
927 (124%)
727 (131%)
200 (105%)
00027
18 (1029)
18 (1131)
16 (927)
<00001
AKI stage
00263
020
6497 (2984
14 294)
2795 (15225609)
<00001
<00001
Comorbidity
Pre-existing CKD
1847 (243%)
1431 (253%)
416 (214%)
00006
Hypertension
3190 (420%)
2408 (425%)
782 (403%)
008
Cardiovascular disease*
2666 (351%)
1923 (340%)
743 (383%)
00006
Diabetes
1404 (185%)
1065 (188%)
339 (175%)
018
Malignancy
1418 (186%)
1144 (202%)
274 (141%)
<00001
Data are mean (SD), n (%), or median (IQR), unless stated otherwise. AKI=acute kidney injury.
CA-AKI=community-acquired AKI. RRT=renal replacement therapy. CKD=chronic kidney disease. *Data missing for
mortality in 129 cases (100 in academic hospitals vs 29 in local hospitals), for days of hospital stay in ve cases (5 vs 0), for
hospital cost in 1411 cases (1132 vs 279), and for cardiovascular disease comorbidity in one case (1 vs 0). Hospital cost is
equal to the entire cost of the hospital admission of a patient with AKI.
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Discussion
Non-recognised Delayed
AKI
recognition of
AKI
Timely
recognition of
AKI
p value*
5608 (742%)
343 (46%)
1604 (212%)
NA
4199 (748%)
237 (42%)
1180 (210%)
1409 (727%)
106 (55%)
424 (219%)
Tertile 1 (n=2245)
1712 (763%)
125 (56%)
408 (182%)
Tertile 2 (n=2729)
2061 (755%)
90 (33%)
578 (212%)
Tertile 3 (n=2581)
1835 (711%)
128 (50%)
618 (239%)
594 (680%)
29 (33%)
251 (287%)
Total (N=7555)
Hospital level
00431
<00001
Age (years)
1839 (n=874)
<00001
4059 (n=2321)
1715 (739%)
93 (40%)
513 (221%)
6079 (n=3101)
2354 (759%)
132 (43%)
615 (198%)
945 (751%)
89 (71%)
225 (179%)
1150 (626%)
121 (66%)
566 (308%)
Non-CKD (n=1837)
4458 (780%)
222 (39%)
1038 (182%)
80 (n=1259)
Disease factors
<00001
Data are %, unless stated otherwise. AKI=acute kidney injury. GDP=gross domestic product. CKD=chronic kidney
disease. *The p value represents the general statistical dierence between the three groups of AKI recognition.
49 cases had no information on their AKI recognition status.
Expanded criteria*
OR (95% CI)
OR (95% CI)
p value
135 (127142)
<00001
133 (125142)
<00001
121 (102143)
00307
121 (099149)
006
120 (102142)
00302
125 (103153)
00263
113 (093137)
023
111 (088139)
039
085 (070105)
013
081 (063103)
009
145 (104203)
00298
129 (089189)
018
525 (436631)
<00001
484 (386606)
<00001
189 (153232)
<00001
189 (146244)
205 (154274)
<00001
195 (138275)
00001
165 (132207)
<00001
187 (142247)
<00001
169 (134213)
<00001
146 (113190)
00042
066 (053082)
00003
061 (047080)
00002
117 (097141)
009
114 (091143)
026
<00001
All variables listed in the table were included in the logistic regression model and adjusted for hospital-acquired or
community-acquired patients. AKI=acute kidney injury. KDIGO=Kidney Disease: Improving Global Outcomes.
OR=odds ratio. RRT=renal replacement therapy. *7431 cases were included in the analysis after excluding 129 cases,
which were missing the information for all-cause in-hospital mortality, one for history of cardiovascular disease, and
49 for delayed or timely recognition of AKI. 3591 cases were included in the analysis after excluding 73 cases
missing the information for all-cause in-hospital mortality and 26 for delayed or timely recognition of AKI.
Reference value.
Table 4: Multivariate logistic regression analysis for factors associated with all-cause in-hospital
mortality in AKI
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Contributors
Li Yang (Peking University First Hospital) conceived, designed, and
organised the study, interpreted the results, and drafted the manuscript.
Jinwei Wang analysed the data. All authors contributed to collecting the
data on site. Minghui Zhao obtained funding, helped organise the study,
and revised the manuscript. Haiyan Wang conceived, organised, and
supervised the study, interpreted the results, and revised the manuscript.
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Declaration of interests
We declare no competing interests.
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Acknowledgments
This study was supported by National Project 985 to Peking University
for Clinical Study on Cooperation; Beijing Training Program for Talents
(20110009001000002); National Natural Science Foundation of China
(81270777); International Society of Nephrology Research Committee;
Bethune Fund Management Committee; and Fresenius Medical Care.
We thank Haixia Li for the technical support in setting up the Laboratory
Information System laboratory screening system. We would like to
dedicate this Article to our respectable Prof Haiyan Wang.
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