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Long-term health care utilization and associated costs after dialysis-treated acute kidney injury in children

Robinson CH, Klowak JA, Jeyakumar N, Luo B, Wald R, Garg AX, Nash DM, McArthur E, Greenberg JH, Askenazi D, Mammen C, Thabane L, Goldstein S, Silver SA, Parekh RS, Zappitelli M, Chanchlani R. Am J Kidney Dis. 2022; Aug 16 [Epub ahead of print]. DOI:

Rationale and Objective — Acute kidney injury (AKI) is common among hospitalized children and is associated with increased hospital length of stay and costs. However, there are limited data on post-discharge healthcare utilization after AKI hospitalization. Our objectives were to evaluate healthcare utilization and physician follow-up patterns after pediatric dialysis-treated AKI.

Study Design — Retrospective cohort study, using provincial health administrative databases.

Setting and Participants — All hospitalized children (0-18yr) between 1996-2017 in Ontario, Canada. Exclusions: Non-Ontario residents, metabolic disorders or poisoning, and dialysis or kidney transplant (pre-admission or by 3mo post-discharge).

Exposure — Episodes of dialysis-treated AKI, identified using validated health administrative codes. AKI survivors were matched to four hospitalized controls without dialysis-treated AKI by age, sex, and admission year.

Outcomes — Our primary outcome was post-discharge hospitalizations, emergency department, and outpatient physician visits. Secondary outcomes included outpatient visits by physician type and composite healthcare costs.

Analytical Approach — Proportions with ≥1 event and rates (per 1,000 person-years). Total and median composite healthcare costs. Adjusted rate ratios (aRR) using negative binomial regression models.

Results — We included 1688 pediatric dialysis-treated AKI survivors and 6752 matched controls. Dialysis-treated AKI survivors had higher re-hospitalization and emergency department visit rates (0-1yr, 0-5yr, 0-10yr, and throughout follow-up), and outpatient visit rates (0-1yr). The overall aRR for re-hospitalization was 1.46 (95% confidence interval (CI) 1.25-1.69, p<0.0001) and outpatient visits was 1.16 (95%CI 1.09-1.23, p=0.01). Dialysis-treated AKI survivors also had higher healthcare costs. Nephrologist follow-up was infrequent among dialysis-treated AKI survivors (18.6% by 1yr post-discharge).

Limitations — Potential miscoding of study exposures or outcomes. Residual uncontrolled confounding. Data for healthcare costs and emergency department visits was unavailable prior to 2006 and 2001, respectively.

Conclusions — Dialysis-treated AKI survivors had greater post-discharge healthcare utilization and costs vs. hospitalized controls. Strategies are needed to improve follow-up care for children after dialysis-treated AKI to prevent long-term complications.