Letter to the Editor: Early identification of mortality risk in emergency patients with chronic kidney disease - insights from India with global implications

Abstract

Chronic kidney disease (CKD), has emerged as a global public health challenge, with persistently high mortality rates among patients presenting to the emergency department, particularly in resource-limited low- and middle-income countries. I read with great interest the recent article published in the World Journal of Nephrology by Prabhahar et al, conducting a retrospective analysis from a large tertiary referral center in northern India and identifying three independent predictors of in-hospital mortality at emergency department admission: Decreased Glasgow coma scale score, hyperglycemia, and low serum albumin. The significance of this study lies in underscoring the prognostic value of dynamic physiological parameters, which appear to more accurately reflect acute illness severity than traditional measures such as CKD stage or long-term comorbidity indices. This editorial highlight three key implications for clinical practice: First, it is crucial for emergency and nephrology teams to recognize high-risk patients early; Second, implementing standardized risk stratification within the emergency guideline is essential; Third, future multicenter prospective studies could help validate these predictive markers across diverse populations. In conclusion, early identification and systematic risk assessment of high-risk CKD patients in the emergency department are important steps toward improving in-hospital outcomes.

Key Words: Chronic kidney disease; Emergency treatment; In-hospital morbidity indexes; Hyperglycemia; Hypoalbuminemia; Glasgow coma scale score

Core Tip: Three valuable prognostic markers: Low Glasgow coma scale, hyperglycemia, and hypoalbuminemia-can effectively predict mortality in chronic kidney disease patients presenting to the emergency department, supporting early risk stratification in resource-limited settings.

TO THE EDITOR

Chronic kidney disease (CKD), a progressive disorder affecting more than 10% of the global population, has emerged as one of the leading causes of mortality worldwide[1]. Leiner et al[2] pointed out that patients with CKD often encounter complex challenges when presenting to the emergency department (ED), including atypical clinical symptoms, heavy burden of comorbidities, and substantial demands on healthcare resources. Consequently, mortality rates among CKD patients requiring emergency care remain persistently high. This problem is particularly severe in low- and middle-income countries (LMICs), where delayed referral times and limited access to specialized care pathways further worsen outcomes.

In this context, evidence regarding baseline predictors of short-term mortality in CKD patients admitted through the ED remains limited. Building on this background, Prabhahar et al[3] published a study in World Journal of Nephrology, provides valuable insights by identifying three simple yet effective prognostic markers—reduced Glasgow coma scale (GCS) score, hyperglycemia, and hypoalbuminemia—for predicting short-term mortality in CKD patients presenting to the ED. Moreover, these findings underscore the importance of leveraging routinely available clinical and laboratory data for early risk stratification in CKD patients.

IMPORTANT FINDINGS AND STUDY HIGHLIGHTS

This retrospective study included 354 adult patients with CKD admitted to the ED of a large tertiary hospital in northern India. The in-hospital mortality rate was strikingly high at 29.1%. The study by Prabhahar et al[3] identified three simple predictors-low GCS, hyperglycemia, and hypoalbuminemia—that are clinically accessible and relevant in healthcare-limited developing regions. These three indicators represent three diagnostic approaches. (1) Neurological status – A GCS < 15 at admission emerged as the strongest indicator of mortality risk in CKD patients presenting to the ED. This finding reflects the severity of acute metabolic or infectious encephalopathy and underscores the prognostic value of neurological assessment; (2) Metabolic dysregulation – hyperglycemia at admission was associated with poorer survival in CKD patients, highlighting the critical role of diabetes and acute metabolic stress in determining prognosis; and (3) Nutritional and inflammatory status – Lim et al[4] suggested that hypoalbuminemia is independently associated with mortality in CKD patients presenting to the ED, suggesting its utility as an important marker of the malnutrition–inflammation–atherosclerosis syndrome, a condition frequently observed in advanced CKD. However, their retrospective design and lack of inflammatory biomarkers [e.g., C-reactive protein (CRP) and ferritin] and diagnostic examinations (e.g., echocardiography and chest computed tomography) may limit mechanistic interpretation[5,6]. In the future, additional dimensions of testing and diagnostic indicators should be incorporated, based on these three diagnostic directions, to better evaluate the mortality risk in emergency CKD patients.

CLINICAL AND PUBLIC HEALTH IMPLICATIONS

The findings of this study’s findings exhibited important implications for both clinical practice and public health: (1) For clinicians in developing regions: Rapid identification of low GCS, hyperglycemia, and hypoalbuminemia at the time of ED admission can guide early triage, escalation of care, and delivery targeted interventions for patients with CKD; (2) For health systems: Incorporating these simple prognostic indicators into standardized ED workflows may optimize the allocation of limited emergency resources, particularly in LMICs where dialysis and critical care capacity is often insufficient; and (3) For global nephrology: The results highlight the urgent need for integrated strategies that bridge preventive nephrology with acute care, ensuring that CKD patients at risk of death are identified earlier and stabilized more effectively in ED.

While the incorporation of these indicators into ED workflows is meaningful, their applicability across different healthcare settings remains uncertain. Validation in diverse populations and regions, particularly in non-Indian cohorts, is recommended. Moreover, predictive models integrating neurological status, metabolic, and inflammatory factors could outperform single-parameter models and further enhance individualized risk stratification.

LIMITATIONS AND PERSPECTIVES

Although this study showed important clinical implications, it also had some limitations. Its single-center, retrospective design may limit the generalizability of the findings, and certain potential prognostic markers-such as CRP, serum N-terminal proBNP, and echocardiographic data—were unavailable. In addition, Zoccali et al[6] pointed out that several other inflammatory markers, including interleukin-6, tumor necrosis factor-alpha, and neutrophil-to-lymphocyte ratio, are associated with early CKD development. These indicators reflect systemic inflammation and have been correlated with renal function even in apparently healthy individuals. Incorporating such inflammatory markers into future research could enhance early detection for CKD[7]. In addition, as a tertiary referral center, referral bias may have influenced the study population; for instance, patients with acute myocardial infarction might have been transferred earlier, potentially resulting in a higher proportion of advanced CKD and dialysis-dependent cases, which could in turn affect outcomes.

We believe that future work may focus on: (1) Conducting multicenter, prospective validation across diverse populations and healthcare systems; (2) Developing risk prediction models that integrate these markers into ED protocols; and (3) Performing interventional studies to examine whether early correction of hyperglycemia or proactive management of hypoalbuminemia can translate into improved survival

CONCLUSION

This study conducted by Prabhahar et al[3] makes an important contribution to understanding the mortality risk of CKD patients admitted through ED. The results demonstrated that low GCS, hyperglycemia, and hypoalbuminemia can serve as independent predictors of in-ED death in CKD patients. With the global burden of CKD continuing to rise, particularly in LMICs, this evidence underscores the need to complement long-term preventive strategies with timely acute-phase assessment and intervention. Early recognition and individualized management in the ED may represent a pivotal step in reducing preventable deaths among this vulnerable population.