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Original ArticlesAcute Kidney Injury /Acute Renal Failure
You have accessRestricted Access

World Incidence of AKI: A Meta-Analysis

Paweena Susantitaphong, Dinna N. Cruz, Jorge Cerda, Maher Abulfaraj, Fahad Alqahtani, Ioannis Koulouridis and Bertrand L. Jaber
CJASN September 2013, 8 (9) 1482-1493; DOI: https://doi.org/10.2215/CJN.00710113
Paweena Susantitaphong
*Kidney and Dialysis Research Laboratory, Division of Nephrology, Department of Medicine, St. Elizabeth’s Medical Center, Boston, Massachusetts;
†Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts;
‡Extracorporeal Multiorgan Support Dialysis Center, Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand;
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Dinna N. Cruz
§Division of Nephrology, University of San Diego, San Diego, California; and
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Jorge Cerda
‖Albany Medical College, Albany, New York
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Maher Abulfaraj
*Kidney and Dialysis Research Laboratory, Division of Nephrology, Department of Medicine, St. Elizabeth’s Medical Center, Boston, Massachusetts;
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Fahad Alqahtani
*Kidney and Dialysis Research Laboratory, Division of Nephrology, Department of Medicine, St. Elizabeth’s Medical Center, Boston, Massachusetts;
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Ioannis Koulouridis
*Kidney and Dialysis Research Laboratory, Division of Nephrology, Department of Medicine, St. Elizabeth’s Medical Center, Boston, Massachusetts;
†Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts;
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Bertrand L. Jaber
*Kidney and Dialysis Research Laboratory, Division of Nephrology, Department of Medicine, St. Elizabeth’s Medical Center, Boston, Massachusetts;
†Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts;
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    Figure 1.

    Literature search and selection. KDIGO, Kidney Disease Improving Global Outcomes.

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    Figure 2.

    Pooled incidence rate of AKI in studies that used KDIGO-equivalent serum creatinine-based AKI definition and staging system, or dialysis requirement. Some studies and patients are included in more than one category. KDIGO, Kidney Disease Improving Global Outcomes; 95% CI, 95% confidence interval.

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    Figure 3.

    Pooled incidence rate of AKI by world zones in studies that used a KDIGO-equivalent serum creatinine-based AKI definition. Some studies and patients are included in more than one category. KDIGO, Kidney Disease Improving Global Outcomes.

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    Figure 4.

    Pooled AKI-associated mortality rate in studies that used a KDIGO-equivalent serum creatinine-based AKI definition and staging system, or dialysis requirement. Some studies and patients are included in more than one category. KDIGO, Kidney Disease Improving Global Outcomes; 95% CI, 95% confidence interval.

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    Figure 5.

    Pooled unadjusted odds ratio for all-cause mortality in patients with AKI relative to patients without AKI in studies that used a KDIGO-equivalent serum creatinine-based AKI definition and staging system, or dialysis requirement. Some studies and patients are included in more than one category. KDIGO, Kidney Disease Improving Global Outcomes; 95% CI, 95% confidence interval.

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    Table 1.

    Characteristics of the 154 studies that used a KDIGO-equivalent AKI definition

    All StudiesStudies of AdultsStudies of Children
    No. of studies15413024
    Sample size22,220 (95–1,126,636)26,240 (509–1,126,636)593 (95–3396)
    Percentage of male participants63 (28–100)65 (28–100)56 (49–79)
    Age of participants (yr)51.6 (0.0–80.3)a60.6 (25.5–80.3)4.7 (0.0–11.4)a
    Studies by clinical setting
     Community acquired7 (5)6 (5)1 (4)
     Critical care41 (27)32 (25)9 (38)
     Cardiac surgery42 (27)35 (27)7 (29)
     Trauma4 (2)4 (3)0 (0)
     Heart failure1 (1)1 (1)0 (0)
     Hematology/oncology3 (2)3 (2)0 (0)
     Nephrotoxins4 (2)2 (1)2 (8)
     Hospital acquired, unspecified52 (34)47 (36)5 (21)
    Studies by continent
     Australia and New Zealand9 (6)9 (7)0 (0)
     Asia21 (14)18 (14)3 (13)
     Europe51 (33)45 (35)6 (25)
     America70 (45)55 (42)15 (62)
     Africa0 (0)0 (0)0 (0)
     Multiple continents3 (2)3 (2)0 (0)
    Studies by world zoneb
     Australia and New Zealand9 (6)9 (7)0 (0)
     Eastern Asia17 (11)15 (12)2 (8)
     Western Asia2 (1)1 (1)1 (4)
     Southern Asia2 (1)2 (2)0 (0)
     South East Asia0 (0)0 (0)0 (0)
     Eastern Europe2 (1)1 (1)1 (4)
     Western Europe15 (10)13 (10)2 (8)
     Northern Europe12 (8)10 (8)2 (8)
     Southern Europe18 (11)17 (13)1 (4)
     Multi-zone Europe4 (3)4 (3)0 (0)
     North America64 (42)50 (38)14 (60)
     South America6 (4)5 (3)1 (4)
     North Africa0 (0)0 (0)0 (0)
     Western Africa0 (0)0 (0)0 (0)
     Multiple zones3 (2)3 (2)0 (0)
    Studies by latitude
     North138 (89)115 (88)23 (96)
     South15 (10)14 (11)1 (4)
     North and South1 (1)1 (1)0 (0)
    Country income classificationc
     Low income1 (1)1 (1)0 (0)
     Lower middle income1 (1)1 (1)0 (0)
     Upper middle income20 (13)16 (12)4 (17)
     High income130 (84)110 (85)20 (83)
     Not available2 (1)2 (1)0 (0)
    Country total health expenditure (% of GDP)d
     <58 (5)7 (5)1 (4)
     5–1068 (45)58 (45)10 (42)
     >1076 (49)63 (48)13 (54)
     Not available2 (1)2 (2)0 (0)
    • Data are presented as the mean (range) or n (%). KDIGO, Kidney Disease Improving Global Outcomes; GDP, gross domestic product.

    • ↵a A zero value indicates newborns.

    • ↵b According to the United Nations geo-scheme classification (11).

    • ↵c According to the World Bank's classification of income of countries (12).

    • ↵d According to the World Health Organization (14).

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    Table 2.

    Pooled incidence rate of AKI according to the KDIGO-equivalent definition

    SubgroupStudies (n)Patients (n)Patients with AKI (n)AKI Incidence Rate (%)95% Confidence IntervalTest for Heterogeneity
    I2 IndexQ Test P Value
    All1543,585,911573,42423.221.0 to 25.799.9<0.001
    Age category
     Adults1303,571,691569,86121.619.3 to 24.199.9<0.001
     Children2414,220356333.726.9 to 41.398.3<0.001
    Clinical setting
     Community acquired7548,39848978.31.6 to 33.099.9<0.001
     Critical care41888,604272,58031.728.6 to 35.099.9<0.001
     Cardiac surgery42164,33333,15724.320.4 to 28.899.7<0.001
     Trauma414,947255719.913.6 to 28.298.7<0.001
     Heart failure168222132.429.0 to 36.0——
     Hematology/oncology3240145321.37.5 to 47.699.2<0.001
     Nephrotoxins417,786168112.26.2 to 22.798.7<0.001
     Hospital acquired, unspecified521,948,760257,87820.917.2 to 25.299.9<0.001
    Continent
     Australia and New Zealand9523,715182,40525.622.3 to 29.399.9<0.001
     Asia21286,37717,35815.68.7 to 26.499.9<0.001
     Europe51918,06872,39023.118.0 to 29.299.9<0.001
     America701,847,689296,65524.922.1 to 27.899.9<0.001
     Multiple continents310,062461649.422.9 to 76.399.9<0.001
    World zonea
     Australia and New Zealand9523,715182,40525.622.3 to 29.399.9<0.001
     Eastern Asia17258,16114,79414.77.0 to 28.299.9<0.001
     Western Asia225,989200616.73.3 to 54.399.3<0.001
     South Asia2222755823.77.5 to 54.499.4<0.001
     Eastern Europe2260063922.09.5 to 43.398.9<0.001
     Western Europe15161,19814,72520.112.1 to 31.599.9<0.001
     Northern Europe12607,956889414.75.5 to 33.699.9<0.001
     Southern Europe1824,080654631.523.1 to 41.399.5<0.001
     Multi-zone Europe4122,2344158632.528.3 to 37.099.6<0.001
     North America641,843,814295,55424.521.7 to 27.599.9<0.001
     South America63875110129.619.1 to 42.798.3<0.001
     Multiple zones310,062461649.422.9 to 76.399.9<0.001
    Latitude
     North1383,057,543389,45422.620.2 to 25.299.9<0.001
     South15527,590183,50627.024.2 to 30.099.8<0.001
     North and South177846459.656.2 to 63.0——
    Country income classificationb
     Low income1104739938.135.2 to 41.1——
     Lower middle income1118015913.511.6 to 15.5——
     Upper middle income20248,71814,33519.510.4 to 33.799.9<0.001
     High income1303,313,430553,20323.821.4 to 26.499.9<0.001
     Not available221,536532825.123.6 to 26.780.40.02
    Country total health expenditure (% of GDP)c
     <58222,178782314.57.2 to 26.999.8<0.001
     5–10681,406,796258,63622.319.6 to 25.399.9<0.001
     >10761,935,401301,63725.222.3 to 28.399.9<0.001
     Not available221,536532825.123.6 to 26.780.4<0.001
    • KDIGO, Kidney Disease Improving Global Outcomes; GDP, gross domestic product.

    • ↵a According to the United Nations geo-scheme classification (11).

    • ↵b According to the World Bank's classification of income of countries (12).

    • ↵c According to the World Health Organization (14).

    • View popup
    Table 3.

    Pooled AKI-associated mortality rate in studies that adopted a KDIGO-equivalent AKI definition

    Subgroup Studies (n)Patients with AKI (n)Deaths (n)Pooled Mortality Rate95% Confidence IntervalTest for Heterogeneity
    I2 IndexQ Test P Value
    All110429,535107,43323.021.3 to 24.899.3<0.001
    Age category
     Adults99427,804107,16723.922.1 to 25.799.4<0.001
     Children11173126613.88.8 to 21.091.3<0.001
    Clinical setting
     Community acquired54349201532.820.8 to 47.598.1<0.001
     Critical care31198,64553,78333.129.8 to 36.699.5<0.001
     Cardiac surgery2321,81118718.36.6 to 10.495.3<0.001
     Trauma3238759332.213.0 to 60.199.1<0.001
     Heart failure12214721.316.4 to 27.2——
     Hematology/oncology22787625.716.1 to 38.373.9<0.001
     Nephrotoxins1811214.88.6 to 24.3——
     Hospital acquired, unspecified44201,76349,03625.722.5 to 29.199.2<0.001
    Continent
     Australia and New Zealand7137,11633,28124.423.2 to 25.693.9<0.001
     Asia1314,718408930.221.9 to 40.198.9<0.001
     Europe4065,20021,15723.520.6 to 26.798.8<0.001
     America48209,12046,99218.816.1 to 21.899.3<0.001
     Multiple continents23381191449.029.3 to 69.098.6<0.001
    World zonea
     Australia and New Zealand7137,11633,28124.423.2 to 25.693.9<0.001
     Eastern Asia912,154368836.925.7 to 49.799.2<0.001
     Western Asia2200633323.610.1 to 46.093.1<0.001
     South Asia25586813.84.6 to 34.395.2<0.001
     Eastern Europe263911121.43.6 to 66.898.8<0.001
     Western Europe108769195121.317.4 to 25.893.3<0.001
     Northern Europe108712145117.29.9 to 28.298.9<0.001
     Southern Europe145494165026.319.2 to 34.997.6<0.001
     Multi-zone Europe441,58615,99438.335.9 to 40.896.2<0.001
     North America42208,01946,56516.614.0 to 19.599.3<0.001
     South America6110142738.919.0 to 63.397.9<0.001
     Multiple zones23381191449.029.3 to 69.098.6<0.001
    Latitude
     North96290,85473,54721.419.3 to 23.699.4<0.001
     South13138,21733,70830.728.4 to 33.197.5<0.001
     North and South146417838.434.0 to 42.9——
    Country income classificationb
     Low income1399328.05.7 to 11.1——
     Lower middle income11593622.616.8 to 29.8——
     Upper middle income1412,697399241.430.8 to 52.998.9<0.001
     High income93412,187101,88420.919.2 to 22.699.3<0.001
     Not available14093148936.434.9 to 37.9——
    Country total health expenditure (% of GDP)c
     <546554157136.117.3 to 60.299.2<0.001
     5–1053208,68957,06426.624.1 to 29.399.3<0.001
     >1052210,19947,30918.415.9 to 21.299.2<0.001
     Not available14093148936.434.9 to 37.9——
    Duration of follow-up (mo)
     <395413,487102,16922.120.4 to 23.999.3<0.001
     3–664831210131.518.6 to 48.098.6<0.001
     >6911,217316327.722.2 to 33.997.3<0.001
    • KDIGO, Kidney Disease Improving Global Outcomes; GDP, gross domestic product.

    • ↵a According to the United Nations geo-scheme classification (11).

    • ↵b According to the World Bank's classification of income of countries (12).

    • ↵c According to the World Health Organization (14).

    • View popup
    Table 4.

    Meta-regression analyses examining the association of AKI incidence rate according to the KDIGO-equivalent definition and its associated mortality rate with aggregate study- and country-level characteristics

    CharacteristicRate Change (%)95% Confidence IntervalP Value
    AKI incidence rate
     Country percentage GDP spent on total health expenditure (per 1% ↑)0.540.07 to 1.020.03
     Country gross national income per capita (per $10,000 ↑)0.18−0.90 to 1.270.74
     Year of study publication (per year ↑)−2.02−2.83 to −1.22<0.001
    AKI-associated mortality rate
     Country percentage GDP spent on total health expenditure (per 1% ↑)−1.36−1.97 to −0.75<0.001
     Country gross national income per capita (per $10,000 ↑)−3.43−4.63 to −2.23<0.001
     Year of study publication (per year ↑)−1.46−2.69 to −0.240.02
    • GDP, gross domestic product.

    • View popup
    Table 5.

    Pooled odds ratio for mortality in patients with AKI relative to patients without AKI in studies that adopted a KDIGO-equivalent AKI definition

    SubgroupStudies (n)Patients with AKI (n)Deaths (n)Patients without AKI (n)Deaths (n)Pooled Odds Ratio95% Confidence IntervalP ValueTest for Heterogeneity
    I2 IndexQ Test
P Value
    Age category
     Adults81403,88098,3481,760,31191,9154.924.07 to 5.93<0.00199.6<0.001
     Children11173626052631585.573.49 to 8.89<0.00154.7<0.001
    Clinical setting
     Community acquired438751,72417,20269782.561.31 to 5.010.0195.9<0.001
     Critical care24182,39346,880269,61328,9233.933.12 to 4.96<0.00199.28<0.001
     Cardiac surgery2221,402185264,77611186.314.81 to 8.28<0.00187.3<0.001
     Trauma3238759311,9898946.621.75 to 24.990.0198.9<0.001
     Heart failure122147461522.131.38 to 3.270.001——
     Hematology/oncology22787616042715.508.40 to 28.60<0.00137.50.21
     Nephrotoxins1811221121402.451.30 to 4.630.01——
     Hospital acquired, unspecified35194,97947,4241,397,81753,9415.153.86 to 6.87<0.00199.4<0.001
    Continent
     Australia and New Zealand6136,88833,190210,28921,4133.342.14 to 5.22< 0.00199.8<0.001
     Asia1013,7023424208,45753748.104.78 to 13.71<0.00198.3<0.001
     Europe3344,52513,743150,66710,7765.214.39 to 6.18<0.00195.0<0.001
     America41207,12046,3371,194,23253,8324.573.30 to 6.33<0.00199.5<0.001
     Multiple continents23381191419296782.121.42 to 3.16<0.00182.80.02
    World zonea
     Australia and New Zealand6136,88833,190210,28921,4133.342.14 to 5.22<0.00199.8<0.001
     Eastern Asia611,1333023182,81050626.733.41 to 13.29<0.00198.9<0.001
     Western Asia2201133323,9783039.182.95 to 28.62<0.00187.20.01
     South Asia2558681669949.450.57 to 4275.160.0989.50.002
     Eastern Europe263911119611316.063.896 to 9.43<0.00136.20.21
     Western Europe94473111416,7329556.253.93 to 9.94<0.00190.9<0.001
     Northern Europe87764100568,55420085.703.95 to 8.24<0.00185.6<0.001
     Southern Europe1146391410937114104.733.23 to 6.92<0.00190.2<0.001
     Multi-zone Europe327,01010,10354,04962724.342.84 to 6.64<0.00199.2<0.001
     North America38206,46046,2041,193,39753,7694.493.21 to 6.29<0.00199.5<0.001
     South America3660133835635.642.18 to 14.62<0.00165.60.06
     Multiple zones23381191419296782.121.42 to 3.16<0.00182.80.02
    Latitude
     North82267,60465,1071,554,13670,5125.154.29 to 6.19<0.00199.2<0.001
     South9137,54833,323211,12421,4763.712.50 to 5.51<0.00199.7<0.001
     North and South1464178314851.681.23 to 2.290.001——
    Country income classificationb
     Low income13993264896.192.92 to 13.11<0.001——
     Lower middle income11593610210597.3736.43 to 9796.52<0.001——
     Upper middle income911,3363064181,13550516.573.68 to 11.74<0.00198.2<0.001
     High income80389,62993,9871,570,07985,3834.733.89 to 5.75<0.00199.6<0.001
     Not available14093148912,69116303.883.57 to 4.21<0.001——
    Country total health expenditure (% of GDP)c
     <5362011379175,079413313.858.76 to 21.89<0.00187.4<0.001
     5–1042191,21349,672401,89432,6564.693.83 to 5.74<0.00199.1<0.001
     >1046204,10946,0681,175,91053,6544.833.54 to 6.59<0.00199.4<0.001
     Not available14093148912,69116303.883.57 to 4.21<0.001——
    Duration of follow-up (mo)
     <379390,22193,7501,725,37682,0925.584.60 to 6.76<0.00199.5<0.001
     3–634178169516,94769132.251.09 to 4.680.0394.8<0.001
     >61011,217316323,25130682.742.09 to 3.58<0.00193.9<0.001
    • KDIGO, Kidney Disease Improving Global Outcomes; GDP, gross domestic product.

    • ↵a According to the United Nations geo-scheme classification (11).

    • ↵b According to the World Bank's classification of income of countries (12).

    • ↵c According to the World Health Organization (14).

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Clinical Journal of the American Society of Nephrology: 8 (9)
Clinical Journal of the American Society of Nephrology
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September 06, 2013
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World Incidence of AKI: A Meta-Analysis
Paweena Susantitaphong, Dinna N. Cruz, Jorge Cerda, Maher Abulfaraj, Fahad Alqahtani, Ioannis Koulouridis, Bertrand L. Jaber
CJASN Sep 2013, 8 (9) 1482-1493; DOI: 10.2215/CJN.00710113

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World Incidence of AKI: A Meta-Analysis
Paweena Susantitaphong, Dinna N. Cruz, Jorge Cerda, Maher Abulfaraj, Fahad Alqahtani, Ioannis Koulouridis, Bertrand L. Jaber
CJASN Sep 2013, 8 (9) 1482-1493; DOI: 10.2215/CJN.00710113
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Acute Kidney Injury /Acute Renal Failure

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  • B Lymphocyte-Derived CCL7 Augments Neutrophil and Monocyte Recruitment, Exacerbating Acute Kidney Injury
  • Murine models of renal ischaemia reperfusion injury: An opportunity for refinement using non-invasive monitoring methods
  • Kidney Disease, Race, and GFR Estimation
  • Long-Term Outcomes in Patients with Acute Kidney Injury
  • Sirtuin 5 Regulates Proximal Tubule Fatty Acid Oxidation to Protect against AKI
  • Iron Chelation as a Potential Therapeutic Strategy for AKI Prevention
  • Theophylline and aminophylline for prevention of acute kidney injury in neonates and children: a systematic review
  • TRAIL, OPG, and TWEAK in kidney disease: biomarkers or therapeutic targets?
  • Proximal Tubule {beta}2-Adrenergic Receptor Mediates Formoterol-Induced Recovery of Mitochondrial and Renal Function after Ischemia-Reperfusion Injury
  • An Organizational-Level Program of Intervention for AKI: A Pragmatic Stepped Wedge Cluster Randomized Trial
  • Complement Inhibitor CRIg/FH Ameliorates Renal Ischemia Reperfusion Injury via Activation of PI3K/AKT Signaling
  • Acute Kidney Injury among Hospitalized Children in China
  • A High-Throughput Screen Identifies DYRK1A Inhibitor ID-8 that Stimulates Human Kidney Tubular Epithelial Cell Proliferation
  • Incidence, Etiology, and Outcomes of Community-Acquired Acute Kidney Injury in Pediatric Admissions in Malawi
  • A New Criterion for Pediatric AKI Based on the Reference Change Value of Serum Creatinine
  • Peritoneal Dialysis for AKI in Cameroon: Commercial vs Locally-Made Solutions
  • Caspase-3 Is a Pivotal Regulator of Microvascular Rarefaction and Renal Fibrosis after Ischemia-Reperfusion Injury
  • What insights do patients and caregivers have on acute kidney injury and posthospitalisation care? A single-centre qualitative study from Toronto, Canada
  • Cross-sectional survey on adult acute kidney injury in Chinese ICU: the study protocol (CARE-AKI)
  • Causes of Death after a Hospitalization with AKI
  • Risk of Hypoglycemia Following Hospital Discharge in Patients With Diabetes and Acute Kidney Injury
  • Infrequent Provision of Palliative Care to Patients with Dialysis-Requiring AKI
  • Health Care Costs Associated with AKI
  • Biomarkers for Early Detection of Acute Kidney Injury
  • Systematic review of prognostic prediction models for acute kidney injury (AKI) in general hospital populations
  • ELABELA and an ELABELA Fragment Protect against AKI
  • NLRX1 dampens oxidative stress and apoptosis in tissue injury via control of mitochondrial activity
  • Proteinuria as an independent risk factor for contrast-induced acute kidney injury and mortality in patients with stroke undergoing cerebral angiography
  • Three-year outcomes after acute kidney injury: results of a prospective parallel group cohort study
  • Clinical Outcomes of Remote Ischemic Preconditioning Prior to Cardiac Surgery: A Meta-Analysis of Randomized Controlled Trials
  • Acute Kidney Outreach to Reduce Deterioration and Death (AKORDD) trial: the protocol for a large pilot study
  • Mineralocorticoid Receptor Antagonism in AKI: A New Hope?
  • Risk of postoperative acute kidney injury in patients undergoing orthopaedic surgery--development and validation of a risk score and effect of acute kidney injury on survival: observational cohort study
  • Outpatient Dialysis for Patients with AKI: A Policy Approach to Improving Care
  • Epidemiology and Clinical Correlates of AKI in Chinese Hospitalized Adults
  • A Prospective International Multicenter Study of AKI in the Intensive Care Unit
  • The Furosemide Stress Test and Predicting AKI Outcomes
  • AKI in Hospitalized Children: Comparing the pRIFLE, AKIN, and KDIGO Definitions
  • Correction
  • Epidemiology and Outcomes in Community-Acquired Versus Hospital-Acquired AKI
  • ASN Presidential Address 2013: Innovation and Individualization--The Path Forward for Nephrology
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