EDITORIALS www.jasn.
org
mortality and incidence on the basis of the most recent
year’s data. This approach also overestimated the incident
population but was within 10% for the prevalent popula-
tion, erring on the high side by assuming falling death rates
in the dialysis population.
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The lower end of the projection by McCullough et al.2 may
be too conservative, because the incident 90-day death rates
given in the US Renal Data System 2018 Annual Data Report
show a decline.11 As noted above, the upper end projection of
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1,259,000 does not consider the effect of the two basic modal-
ities of kidney transplantation and dialysis. Because the
authors did not use an integrated approach to project these
populations, it is difficult to assess the inter-related issues of
access to organs—which drives growth in the transplant pop-
ulation and removes healthy patients from the dialysis pool—
and changing death rates in the prevalent dialysis population.
It is important to acknowledge the inevitable uncertainties
in 15-year projections. Ongoing efforts to prevent kidney dis-
ease and slow its progression may start to have an effect.
Changes in organ availability and death rates will certainly
have an important influence. Future models should build
in a range of estimates of these possible changes. This would
allow for greater clarity of the realities facing patients and
providers today.
DISCLOSURES
A.J.C. served as Director of the US Renal Data System from 1999 to 2014
when the prior two projections were published. A.J.C. is currently the Chief
Medical Officer of NxStage Medical, Inc., a home hemodialysis and acute
dialysis product company.
REFERENCES
1. US Renal Data System: Reference tables D.6 and D.9. In: 2018 USRDS
Annual Data Report: Epidemiology of Kidney Disease in the United
States, Bethesda, MD, National Institutes of Health, National In-
stitute of Diabetes and Digestive and Kidney Diseases, 2018. Avail-
able at: https://www.usrds.org/reference.aspx. Accessed October 25,
2018
2. McCullough KP, Morgenstern H, Saran R, Herman WH, Robinson BM:
Projecting ESRD incidence and prevalence in the United States
through 2030. J Am Soc Nephrol 30: 127–135, 2019
3. Mehra MR, Jarcho JA, Cherikh W, Vaduganathan M, Lehman RR,
Smits J, et al.: The drug-intoxication epidemic and solid-organ
transplantation. N Engl J Med 378: 1943–1945, 2018
4. US Renal Data System: Reference tables E.3 and E.6. In: 2018 USRDS
Annual Data Report: Epidemiology of Kidney Disease in the United
States, Bethesda, MD, National Institutes of Health, National Institute
of Diabetes and Digestive and Kidney Diseases, 2018. Available at:
https://www.usrds.org/reference.aspx. Accessed October 25, 2018
5. Wetmore JB, Liu J, Li S, Hu Y, Peng Y, Gilbertson DT, et al.: The Healthy
People 2020 objectives for kidney disease: How far have we come, and
where do we need to go? Clin J Am Soc Nephrol 12: 200–209, 2017
6. NCD Countdown 2030 collaborators: NCD Countdown 2030: World-
wide trends in non-communicable disease mortality and progress
towards Sustainable Development Goal target 3.4. Lancet 392: 1072–
1088, 2018
7. US Renal Data System: Reference table H.4. In: 2018 USRDS Annual
Data Report: Epidemiology of Kidney Disease in the United States,
4 Journal of the American Society of Nephrology
Bethesda, MD, National Institutes of Health, National Institute of Di-
abetes and Digestive and Kidney Diseases, 2018. Available at: https://
www.usrds.org/reference.aspx. Accessed October 25, 2018
8. US Renal Data System: Reference table D.6. In: 2018 USRDS Annual
Data Report: Epidemiology of Kidney Disease in the United States,
Bethesda, MD, National Institutes of Health, National Institute of Di-
abetes and Digestive and Kidney Diseases, 2018. Available at: https://
www.usrds.org/reference.aspx. Accessed October 25, 2018
9. Xue JL, Ma JZ, Louis TA, Collins AJ: Forecast of the number of patients
with end-stage renal disease in the United States to the year 2010. J Am
Soc Nephrol 12: 2753–2758, 2001
10. Gilbertson DT, Liu J, Xue JL, Louis TA, Solid CA, Ebben JP, et al.:
Projecting the number of patients with end-stage renal disease in the
United States to the year 2015. J Am Soc Nephrol 16: 3736–3741, 2005
11. US Renal Data System: Healthy people 2020. In: 2018 USRDS Annual Data
Report: Epidemiology of Kidney Disease in the United States, Bethesda,
MD, National Institutes of Health, National Institute of Diabetes and Di-
gestive and Kidney Diseases, 2018. Available at: https://www.usrds.org/
2018/view/Default.aspx. Accessed October 25, 2018
See related article, “Projecting ESRD Incidence and Prevalence in the United
States through 2030,” on pages 127–135.
Postoperative AKI—Prevention
Is Better than Cure?
Samira Bell1,2 and John Prowle3,4
1
Renal Unit, Ninewells Hospital, Dundee, United Kingdom; 2Division
of Population Health Science and Genomics, School of Medicine,
University of Dundee, Dundee, United Kingdom; 3Adult Critical Care
Unit and Department of Renal Medicine and Transplantation, The
Royal London Hospital, Barts Health National Health Service Trust,
London, United Kingdom; and 4William Harvey Research Institute,
Queen Mary University of London, London, United Kingdom
J Am Soc Nephrol 30: 4–6, 2019.
doi: https://doi.org/10.1681/ASN.2018111127
AKI could be considered as a sentinel postoperative compli-
cation, because it is relatively common and strongly associated
with increased short- and long-term risk of death, the devel-
opment of other postoperative complications, increased length
of hospital stay, and potentially, the development of progressive
CKD.1 Consequently, patients with AKI after surgery are an
area of unmet clinical need and a major burden on health care
resources. In the absence of effective interventions to treat
established AKI, preoperative identification of patients at
high risk of AKI allows for perioperative optimization to pre-
vent or reduce the severity of AKI. A number of large
Published online ahead of print. Publication date available at www.jasn.org.
Correspondence: Dr. Samira Bell, Division of Population Health Science and
Genomics, School of Medicine, University of Dundee, Mackenzie Building, Kirsty
Semple Way, Dundee DD2 4BF, United Kingdom. Email: Samira.bell@nhs.net
Copyright © 2019 by the American Society of Nephrology
J Am Soc Nephrol 30: 1–6, 2019

retrospective studies have examined the associations of post-
operative AKI in multivariable modeling; however, few of
these have led to externally validated models that have been
operationalized to give predictions in a clinical setting, partic-
ularly in patients undergoing noncardiac surgery.2 There are
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currently several validated AKI risk scores for patients under-
going cardiac surgery, one in orthopedic surgery,3 and most
recently, a model derived through machine learning capable of
forecasting the development of a range of postoperative com-
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plications, including AKI, across a range of surgical
settings.4 In this issue of the Journal of American Society of
Nephrology, Park et al.5 address this gap in the literature
through the development of the Simple Postoperative AKI
RisK (SPARK) classification, an externally validated preoper-
ative AKI risk score for noncardiac surgery. This model was
developed in 51,041 patients and validated in 39,764 patients
from South Korea, and it uses nine preoperative variables: age,
sex, baseline eGFR, urinary albuminuria, expected surgery
duration, emergency operation, diabetes mellitus, renin-
angiotensin-aldosterone system blockade usage, hypoalbumi-
nemia, anemia, and hyponatremia. In contrast to other risk
scores, this risk score additionally considers AKI severity by
predicting a composite “critical AKI”: outcome of stage 2 or
greater AKI, need for RRT within 90 days of AKI, or death
occurring after any AKI diagnosis. By allowing preoperative
risk stratification of patients, this tool could assist clinicians
in a number of ways. It can inform discussions with patients
before surgery, allowing for a clearer and more candid quanti-
fication of the risks of an important medical complication of
surgery and the potential benefits of surgical treatment to be
better weighed against risks of complications and adverse
longer-term outcomes. As we are increasingly facing an aging,
multimorbid population, we need to carefully consider these
adverse potential consequences that can often affect organ sys-
tems remote from the site of surgical disease. In addition, iden-
tifying high-risk patients can guide preoperative planning by
influencing whether patients would benefit from more inten-
sive monitoring in the postoperative period, possibly in a crit-
ical care setting.
Nevertheless, it could be argued that risk stratification is
pointless, because it remains unclear what the proposed in-
tervention(s) should be for patients at high risk for AKI and
whether these interventions are, in fact, effective. However,
recent studies have shown that risk stratification of patients
at high risk of AKI diagnosis in the postoperative setting might
enable effective intervention with a “bundle” of AKI-directed
preventative measures. These studies examined the imple-
mentation of an AKI prevention bundle derived from recom-
mendations in the Kidney Disease Improving Global
Outcomes (KDIGO) 2012 AKI guidelines6 in patients deemed
at high risk of AKI on the basis of postoperative urinary AKI
biomarkers (IGF-binding protein 7 and tissue inhibitor of
metalloproteinases-2). These interventions were composed of
the avoidance of potentially nephrotoxic agents, close moni-
toring of serum creatinine and urine output, and optimization
J Am Soc Nephrol 30: 1–6, 2019
www.jasn.org EDITORIALS
of volume status and hemodynamic parameters. In
cardiac surgery, this approach has been shown to reduce post-
operative AKI but without evidence of benefit for longer-term
renal outcomes,7 whereas application of a similar strategy in
general surgery was overall negative but showed a signal of
benefit in a subgroup of patients with moderately elevated
AKI biomarkers, suggestive of benefit in early but not more
established AKI.8 Although preliminary, these results do sug-
gest that a KDIGO-based AKI prevention bundle would be the
obvious intervention in patients stratified as high risk for peri-
operative AKI. However, AKI biomarkers are costly, and they
are not currently routinely or widely available; they have thus
far only been used in relatively small studies with equivocal
results. The application of a risk score using readily available
preoperative parameters could provide a relatively cheap and
simple means of risk stratification that could be applicable to
postoperative AKI prevention and management of many pa-
tients in a variety of income settings. Importantly, in the set-
ting of intensive care unit admissions, AKI risk prediction
algorithms on the basis of routinely available data have been
shown to have comparable diagnostic performance to AKI
biomarkers,9 reinforcing the role of predictive models as an
alternative or complement to biomarkers in risk stratification
for clinical decision making.
The SPARK risk score is thus a promising tool that could be
investigated in prospective studies for targeted AKI preven-
tative bundled intervention either as randomized studies or
perhaps, given the established nature of the components of
bundled care, as a quality improvement intervention. Cur-
rently, this model is limited in its generalizability, because it
was both developed and validated in Korean patients; addi-
tional external validation is required to ensure its applicabil-
ity to other populations worldwide before consideration of
widespread implementation. However, the approach of
risk stratification of patients for sentinel surgical complica-
tions is likely to be an increasingly important method of
improving not just perioperative care but also, the ongoing
global health care of surgical patients and the ability of pa-
tients and doctors to make informed decisions about their
surgical treatment.
DISCLOSURES
J.P. has consultancy agreements with Medibeacon Inc., Quark Pharmaceu-
ticals Inc., GE Healthcare, and Nikkiso Europe Gmb and has received speakers’
fees and hospitality form Baxter Inc., Nikksio Europe GmbH, and Fresenius
Medical Care AG.
REFERENCES
1. Meersch M, Schmidt C, Zarbock A: Perioperative acute kidney injury: An
under-recognized problem. Anesth Analg 125: 1223–1232, 2017
2. Hodgson LE, Sarnowski A, Roderick PJ, Dimitrov BD, Venn RM, Forni
LG: Systematic review of prognostic prediction models for acute kidney
injury (AKI) in general hospital populations. BMJ Open 7: e016591,
2017
Editorials 5
 EDITORIALS www.jasn.org
3. Bell S, Dekker FW, Vadiveloo T, Marwick C, Deshmukh H, Donnan PT,
et al.: 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. BMJ
351: h5639, 2015
4. Bihorac A, Ozrazgat-Baslanti T, Ebadi A, Motaei A, Madkour M, Pardalos
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PM, et al.: MySurgeryRisk: Development and validation of a machine-
learning risk algorithm for major complications and death after surgery
[published online ahead of print February 27, 2018]. Ann Surg
5. Park S, CH, Park SW, Lee S, Kim KS, Yoon HJ, et al.: Simple postoperative
AKI risk (SPARK) classification before non-cardiac surgery: A prediction
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 05/01/2023
index development study with external validation. J Am Soc Nephrol 30:
170–181, 2019
6. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney
Injury Work Group: KDIGO clinical practice guideline for acute kidney
injury. Kidney Int Suppl 2: 1–138, 2012
7. Meersch M, Schmidt C, Hoffmeier A, Van Aken H, Wempe C, Gerss J,
et al.: Prevention of cardiac surgery-associated AKI by implementing the
6 Journal of the American Society of Nephrology
KDIGO guidelines in high risk patients identified by biomarkers: The
PrevAKI randomized controlled trial. Intensive Care Med 43: 1551–1561,
2017
8. Göcze I, Jauch D, Götz M, Kennedy P, Jung B, Zeman F, et al.: Biomarker-
guided intervention to prevent acute kidney injury after major surgery:
The prospective randomized BigpAK study. Ann Surg 267: 1013–1020,
2018
9. Flechet M, Güiza F, Schetz M, Wouters P, Vanhorebeek I, Derese I, et al.:
AKIpredictor, an online prognostic calculator for acute kidney injury in
adult critically ill patients: Development, validation and comparison to
serum neutrophil gelatinase-associated lipocalin. Intensive Care Med
43: 764–773, 2017
See related article, “Simple Postoperative AKI Risk (SPARK) Classification
before Noncardiac Surgery: A Prediction Index Development Study with
External Validation,” on pages 170–181.
J Am Soc Nephrol 30: 1–6, 2019