Acute‑on‑chronic kidney disease (AoCKD): a critical appraisal and call for action to define boundaries and optimize management.
- 1Nephrology Unit, Internal Medicine Department, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt.
- 2Division of Transplant Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
- 3Medical Services, Ralph H. Johnson VA Medical Centre, Charleston, SC, USA.
Abstract
Acute‑on‑chronic kidney disease (AoCKD) refers to an acute decline in renal function occurring in individuals with established CKD. Despite its major clinical impact-including increased mortality, accelerated CKD progression, and higher cardiovascular risk-AoCKD remains underrepresented within major guideline frameworks (KDIGO, ADQI, NICE). Our review aims to critically appraise existing guideline frameworks, definitions, biomarkers, imaging recommendations, and research gaps related to AoCKD, and to highlight priorities for future harmonization and clinical integration. We conducted a targeted literature search of PubMed, Embase, and the Cochrane Library, to identify guidelines, consensus reports, observational studies, and systematic reviews describing acute deterioration in CKD. Extracted data included definitional criteria, epidemiology, biomarker performance, imaging guidance, and prognostic outcomes. Current KDIGO, ADQI, and NICE frameworks were evaluated in parallel. We report marked heterogeneity in definitions describing acute deterioration in CKD, with terms including AoCKD, AKI‑on‑CKD, acute pre‑existing kidney dysfunction, and cROCK‑based definitions. Reported incidence varies widely (1-33%) due to inconsistent criteria. Creatinine‑based definitions show reduced prognostic accuracy in CKD populations, whereas cystatin‑C-based eGFR demonstrates superior discrimination for mortality and progression. We propose an operational definition of AoCKD that includes functional criteria and biomarker-based criteria. The definition reflects the increased mortality in this phenotype even before reaching the KDIGO-AKI threshold. In conclusion, AoCKD is a clinically significant but poorly defined state within the kidney disease continuum. Harmonized definitions, incorporation of cystatin‑C-based markers, structured imaging pathways, and integration of early biomarkers are urgently needed.
Related
- Deep brain stimulation and spinal cord stimulation for chronic disorders of consciousness: a decade of clinical evidence, mechanistic insights, and critical appraisal.
- Chronic Intermittent Hypoxia and MASLD in Obstructive Sleep Apnea: A Critical Appraisal of Mechanistic and Causal Evidence
- A critical appraisal of guidelines and recommendations for the management of ANCA-associated vasculitis.
- Precision targeting using machine learning to optimize medication therapy management delivery in value-based care: A quasi-experimental study using real-world evidence
- AI-Driven Hyperspectral Imaging in Clinical Medicine: A Critical Appraisal of Translational Readiness
BibTeX
@article{soliman2026acuteonchronic,
title = {{Acute‑on‑chronic kidney disease (AoCKD): a critical appraisal and call for action to define boundaries and optimize management.}},
author = {Amin R Soliman and Karim M Soliman and Salwa Ibrahim Mohamed and Mohamed Mostafa Elkhatib and Mohamed Momtaz and Mahmoud M Elnokeety and Ahmed Aly and Hoda Maamoun and Tarek S Abdelaziz and Hany Hammad and Mahmoud M Shaheen and Rasha Ahmed Darwish and Ahmed Fayed and Dina A Abdellatif and Nouran Hatem Samir and Ahmed S Hegazy and Sahier El-Khashab and Kasr Alainy Nephrology group (KANG)},
journal = {Renal failure},
year = {2026},
month = oct,
doi = {10.1080/0886022x.2026.2746268},
url = {https://europepmc.org/article/MED/42954720},
note = {CC BY},
}
RIS
TY - JOUR
TI - Acute‑on‑chronic kidney disease (AoCKD): a critical appraisal and call for action to define boundaries and optimize management.
AU - Amin R Soliman
AU - Karim M Soliman
AU - Salwa Ibrahim Mohamed
AU - Mohamed Mostafa Elkhatib
AU - Mohamed Momtaz
AU - Mahmoud M Elnokeety
AU - Ahmed Aly
AU - Hoda Maamoun
AU - Tarek S Abdelaziz
AU - Hany Hammad
AU - Mahmoud M Shaheen
AU - Rasha Ahmed Darwish
AU - Ahmed Fayed
AU - Dina A Abdellatif
AU - Nouran Hatem Samir
AU - Ahmed S Hegazy
AU - Sahier El-Khashab
AU - Kasr Alainy Nephrology group (KANG)
PY - 2026
DA - 2026/10/29
JO - Renal failure
DO - 10.1080/0886022x.2026.2746268
UR - https://europepmc.org/article/MED/42954720
AB - Acute‑on‑chronic kidney disease (AoCKD) refers to an acute decline in renal function occurring in individuals with established CKD. Despite its major clinical impact-including increased mortality, accelerated CKD progression, and higher cardiovascular risk-AoCKD remains underrepresented within major guideline frameworks (KDIGO, ADQI, NICE). Our review aims to critically appraise existing guideline frameworks, definitions, biomarkers, imaging recommendations, and research gaps related to AoCKD, and to highlight priorities for future harmonization and clinical integration. We conducted a targeted literature search of PubMed, Embase, and the Cochrane Library, to identify guidelines, consensus reports, observational studies, and systematic reviews describing acute deterioration in CKD. Extracted data included definitional criteria, epidemiology, biomarker performance, imaging guidance, and prognostic outcomes. Current KDIGO, ADQI, and NICE frameworks were evaluated in parallel. We report marked heterogeneity in definitions describing acute deterioration in CKD, with terms including AoCKD, AKI‑on‑CKD, acute pre‑existing kidney dysfunction, and cROCK‑based definitions. Reported incidence varies widely (1-33%) due to inconsistent criteria. Creatinine‑based definitions show reduced prognostic accuracy in CKD populations, whereas cystatin‑C-based eGFR demonstrates superior discrimination for mortality and progression. We propose an operational definition of AoCKD that includes functional criteria and biomarker-based criteria. The definition reflects the increased mortality in this phenotype even before reaching the KDIGO-AKI threshold. In conclusion, AoCKD is a clinically significant but poorly defined state within the kidney disease continuum. Harmonized definitions, incorporation of cystatin‑C-based markers, structured imaging pathways, and integration of early biomarkers are urgently needed.
SN - 0886-022X
SN - 1525-6049
ER -