Patients with chronic kidney disease (CKD) who are more frequently hospitalized are more likely progress to end-stage kidney disease (ESKD) or die compared with patients who are rarely hospitalized, independent of traditional risk factors, a new study finds.

Among 3012 individuals with CKD stages 2 to 4 in the Chronic Renal Insufficiency Cohort (CRIC) study, 5658 hospitalizations occurred within 4 years. The high-, intermediate-, and low-utilizer groups had a mean 6.3, 2.2, and 0 all-cause hospitalizations, respectively, over the period, Anand Srivastava, MD, MPH, of Northwestern University Feinberg School of Medicine in Chicago, Illinois, and colleagues reported in Kidney International Reports. For both high and intermediate utilizers, the top 5 reasons for hospitalization were circulatory system disorders, infectious diseases, endocrine disorders, musculoskeletal system disorders, and injury and poisoning. High utilizers had a significantly longer hospital stay compared with intermediate and low utilizers: 1.6 vs 0.5 vs 0 days, respectively, according to the investigators. Patients in the high-utilizer group also were significantly more likely to be rehospitalized within 30 days: 31.4% vs 12.9% vs 0%, respectively.

After the 4 year period, 544 ESKD events and 437 ESKD-censored deaths occurred during a median follow-up duration of 5.1 years. In adjusted analyses, intermediate and high utilizers had a 1.5- and 1.8-fold higher risk of ESKD, respectively, compared with low utilizers, Dr Srivastava’s team reported. Intermediate and high utilizers also had a 1.5- and 2.6-fold higher risk of ESKD-censored death, respectively.

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Intermediate and high utilizers were more likely than low utilizers to be female and Black and have lower income, diabetes, cardiovascular disease, lower serum albumin, lower hemoglobin, higher body mass index, proteinuria, and lower estimated glomerular filtration rate. The risk estimates for ESKD and death, however, were independent of proteinuria and kidney function, the strongest determinants of risk, and other factors.

“Collectively, our results suggest that trajectories of cumulative all-cause hospitalization identify high-risk individuals with CKD who have rapidly declining health, as suggested by their need for increased health care resource utilization,” Dr Srivastava and colleagues wrote. They suggested that hospitalization trajectories could be a simple severity of illness marker that treating physicians could review in a patient’s electronic medical record.

In an accompanying editorial, Stuart L. Goldstein, MD, of the Center for Acute Care Nephrology, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine in Cincinnati, Ohio, agreed.

“Finally, and obviously, our goal should be to slow CKD progression and reduce mortality risk. The utilization groups not only identify patients who may require more clinical attention but can enrich the CKD population to direct novel interventions to the most at-risk patient.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 


Srivastava A, Cai X, Mehta R, et al for the CRIC study investigators. Hospitalization trajectories and risks of ESKD and death in individuals with CKD. Kidney Int Rep 6(6):1592-1602. doi:10.1016/j.ekir.2021.03.883

Goldstein SL. Risk of progression to ESKD or death in adults with CKD: three paths identified. Kidney Int Rep 6(6):1492-1493. doi:10.1016/j.ekir.2021.04.028