• Pavan K Bhatraju, Leila R Zelnick, Jerald Herting, Ronit Katz, Carmen Mikacenic, Susanna Kosamo, Eric D Morrell, Cassianne Robinson-Cohen, Carolyn S Calfee, Jason D Christie, Kathleen D Liu, Michael A Matthay, William O Hahn, Victoria Dmyterko, Natalie S J Slivinski, Jim A Russell, Keith R Walley, David C Christiani, W Conrad Liles, Jonathan Himmelfarb, and Mark M Wurfel.
• 1 Division of Pulmonary, Critical Care, and Sleep Medicine.
• Am. J. Respir. Crit. Care Med. 2019 Apr 1; 199 (7): 863-872.

RationaleCurrently, no safe and effective pharmacologic interventions exist for acute kidney injury (AKI). One reason may be that heterogeneity exists within the AKI population, thereby hampering the identification of specific pathophysiologic pathways and therapeutic targets.ObjectiveThe aim of this study was to identify and test whether AKI subphenotypes have prognostic and therapeutic implications.MethodsFirst, latent class analysis methodology was applied independently in two critically ill populations (discovery [n = 794] and replication [n = 425]) with AKI. Second, a parsimonious classification model was developed to identify AKI subphenotypes. Third, the classification model was applied to patients with AKI in VASST (Vasopressin and Septic Shock Trial; n = 271), and differences in treatment response were determined. In all three populations, AKI was defined using serum creatinine and urine output.Measurements And Main ResultsA two-subphenotype latent class analysis model had the best fit in both the discovery (P = 0.004) and replication (P = 0.004) AKI groups. The risk of 7-day renal nonrecovery and 28-day mortality was greater with AKI subphenotype 2 (AKI-SP2) relative to AKI subphenotype 1 (AKI-SP1). The AKI subphenotypes discriminated risk for poor clinical outcomes better than the Kidney Disease: Improving Global Outcomes stages of AKI. A three-variable model that included markers of endothelial dysfunction and inflammation accurately determined subphenotype membership (C-statistic 0.92). In VASST, vasopressin compared with norepinephrine was associated with improved 90-day mortality in AKI-SP1 (27% vs. 46%, respectively; P = 0.02), but no significant difference was observed in AKI-SP2 (45% vs. 49%, respectively; P = 0.99) and the P value for interaction was 0.05.ConclusionsThis analysis identified two molecularly distinct AKI subphenotypes with different clinical outcomes and responses to vasopressin therapy. Identification of AKI subphenotypes could improve risk prognostication and may be useful for predictive enrichment in clinical trials.

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