A worldwide multicentre evaluation of the influence of deterioration or improvement of acute kidney injury on clinical outcome in critically ill patients with and without sepsis at ICU admission: results from The Intensive Care Over Nations audit

Esther Peters, Massimo Antonelli, Xavier Wittebole, Rahul Nanchal, Bruno François, Yasser Sakr, Jean-Louis Vincent, Peter Pickkers, Esther Peters, Massimo Antonelli, Xavier Wittebole, Rahul Nanchal, Bruno François, Yasser Sakr, Jean-Louis Vincent, Peter Pickkers

Abstract

Background: Acute kidney injury (AKI) is a common complication of critical illness and is associated with worse outcomes. However, the influence of deterioration or improvement in renal function on clinical outcomes is unclear. Using a large international database, we evaluated the prevalence and evolution of AKI over a 7-day period and its effects on clinical outcomes in septic and non-septic critically ill patients worldwide.

Methods: From the 10,069 adult intensive care unit (ICU) patients in the Intensive Care Over Nations database, all those with creatinine and urine output data were included in this substudy. Patients who developed sepsis during the ICU stay (≥ 2 days after admission) were excluded. AKI was evaluated within 72 hours after admission and before discharge/death up to day 7 according to the Acute Kidney Injury Network (AKIN) criteria.

Results: A total of 7970 patients were included, 59% of whom met AKIN criteria for AKI within the first 72 hours of the ICU stay. Twenty-four per cent of patients had sepsis on admission, of whom 68% had AKI, compared to 57% of those without sepsis on admission (p < 0.001). AKIN stage 3 (40% vs 24%, p < 0.001) and use of renal replacement therapy (20% vs 5%, p < 0.0001) were more prevalent in patients with sepsis. Patients with sepsis and AKIN stage 3 were less likely to improve to a lower stage during the 7-day follow-up period than non-septic patients with AKIN stage 3 (21% vs 32%, p < 0.0001). In-hospital mortality was related to severity of AKI and was reduced in patients in whom AKI improved compared to those who remained stable or deteriorated, but remained higher than in patients without AKI, even if there was apparent full recovery at day 7.

Conclusion: These findings illustrate the different kinetics of AKI in septic and non-septic ICU patients and emphasize the important impact of AKI on mortality rates even when there is apparent full renal recovery at day 7.

Keywords: Critical care outcomes; Epidemiology; Renal replacement therapy.

Conflict of interest statement

In each institution, the study was approved by the institutional research ethics committee in accordance with local ethical regulations. Informed consent was not required due to the observational and anonymous nature of data collection.

Not applicable.

The authors declare that they have no competing interests.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Change in severity of acute kidney injury (AKI) in septic and non-septic critically ill patients over 7 days. Vertical bar graphs represent AKI diagnosed at ICU admission in septic patients (left) and non-septic patients (right), according to AKIN categories: No AKI, stage 1, 2 and 3. Horizontal bar graphs (middle) represent change in AKI stage on day 7 according to AKI admission category. For example, of the 30% (n = 575) of septic patients with AKI stage 1, 27% (n = 155) remained in the AKI stage 1 group, 36% (n = 206) improved to No AKI, 8% (n = 45) worsened to stage 2 and 29% (n = 169) worsened to stage 3
Fig. 2
Fig. 2
Cumulative incidence functions of death in critically ill patients with (left) and without (right) sepsis according to acute kidney injury (AKI) stage on admission and presence of comorbid chronic renal failure (CRF)

References

    1. Lameire NH, Bagga A, Cruz D, De Maeseneer J, Endre Z, Kellum JA, Liu KD, Mehta RL, Pannu N, Van Biesen W, et al. Acute kidney injury: an increasing global concern. Lancet. 2013;382(9887):170–179. doi: 10.1016/S0140-6736(13)60647-9.
    1. Siew ED, Davenport A. The growth of acute kidney injury: a rising tide or just closer attention to detail? Kidney Int. 2015;87(1):46–61. doi: 10.1038/ki.2014.293.
    1. Murugan R, Karajala-Subramanyam V, Lee M, Yende S, Kong L, Carter M, Angus DC, Kellum JA. Acute kidney injury in non-severe pneumonia is associated with an increased immune response and lower survival. Kidney Int. 2010;77(6):527–535. doi: 10.1038/ki.2009.502.
    1. Nisula S, Kaukonen KM, Vaara ST, Korhonen AM, Poukkanen M, Karlsson S, Haapio M, Inkinen O, Parviainen I, Suojaranta-Ylinen R, et al. Incidence, risk factors and 90-day mortality of patients with acute kidney injury in Finnish intensive care units: the FINNAKI study. Intensive Care Med. 2013;39(3):420–428. doi: 10.1007/s00134-012-2796-5.
    1. Bagshaw SM, George C, Dinu I, Bellomo R. A multi-centre evaluation of the RIFLE criteria for early acute kidney injury in critically ill patients. Nephrol Dial Transplant. 2008;23(4):1203–1210. doi: 10.1093/ndt/gfm744.
    1. Ostermann M, Chang RW. Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med. 2007;35(8):1837–1843. doi: 10.1097/01.CCM.0000277041.13090.0A.
    1. Hoste EA, Clermont G, Kersten A, Venkataraman R, Angus DC, De Bacquer D, Kellum JA: RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: a cohort analysis. Crit Care 2006, 10(3):R73.
    1. Hoste EA, Bagshaw SM, Bellomo R, Cely CM, Colman R, Cruz DN, Edipidis K, Forni LG, Gomersall CD, Govil D, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med. 2015;41(8):1411–1423. doi: 10.1007/s00134-015-3934-7.
    1. Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, Moreno R, Carlet J, Le Gall JR, Payen D, et al. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med. 2006;34(2):344–353. doi: 10.1097/01.CCM.0000194725.48928.3A.
    1. Case J, Khan S, Khalid R, Khan A. Epidemiology of acute kidney injury in the intensive care unit. Crit Care Res Pract. 2013;2013:479730.
    1. Chawla LS, Amdur RL, Amodeo S, Kimmel PL, Palant CE. The severity of acute kidney injury predicts progression to chronic kidney disease. Kidney Int. 2011;79(12):1361–1369. doi: 10.1038/ki.2011.42.
    1. Zarjou A, Agarwal A. Sepsis and acute kidney injury. J Am Soc Nephrol. 2011;22(6):999–1006. doi: 10.1681/ASN.2010050484.
    1. Gomez H, Ince C, De Backer D, Pickkers P, Payen D, Hotchkiss J, Kellum JA. A unified theory of sepsis-induced acute kidney injury: inflammation, microcirculatory dysfunction, bioenergetics, and the tubular cell adaptation to injury. Shock. 2014;41(1):3–11. doi: 10.1097/SHK.0000000000000052.
    1. Mehta RL, Bouchard J, Soroko SB, Ikizler TA, Paganini EP, Chertow GM, Himmelfarb J, Program to Improve Care in Acute Renal Disease Study Group Sepsis as a cause and consequence of acute kidney injury: Program to Improve Care in Acute Renal Disease. Intensive Care Med. 2011;37(2):241–248. doi: 10.1007/s00134-010-2089-9.
    1. Vincent JL, Marshall JC, Namendys-Silva SA, Francois B, Martin-Loeches I, Lipman J, Reinhart K, Antonelli M, Pickkers P, Njimi H, et al. Assessment of the worldwide burden of critical illness: the intensive care over nations (ICON) audit. Lancet Respir Med. 2014;2(5):380–386. doi: 10.1016/S2213-2600(14)70061-X.
    1. Calandra T, Cohen J, International Sepsis Forum Definition of Infection in the ICUCC The international sepsis forum consensus conference on definitions of infection in the intensive care unit. Crit Care Med. 2005;33(7):1538–1548. doi: 10.1097/01.CCM.0000168253.91200.83.
    1. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, Levin A, Acute Kidney Injury Network Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11(2):R31. doi: 10.1186/cc5713.
    1. Cruz DN, Antonelli M, Fumagalli R, Foltran F, Brienza N, Donati A, Malcangi V, Petrini F, Volta G, Bobbio Pallavicini FM, et al. Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA. 2009;301(23):2445–2452. doi: 10.1001/jama.2009.856.
    1. Fine JP, Gray RJ. A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc. 1999;94(446):496–509. doi: 10.1080/01621459.1999.10474144.
    1. Southern DA, Faris PD, Brant R, Galbraith PD, Norris CM, Knudtson ML, Ghali WA, Investigators A. Kaplan-Meier methods yielded misleading results in competing risk scenarios. J Clin Epidemiol. 2006;59(10):1110–1114. doi: 10.1016/j.jclinepi.2006.07.002.
    1. Gray RJ. A class of K-sample tests for comparing the cumulative incidence of a competing risk. Ann Stat. 1988;16(3):1141–1154. doi: 10.1214/aos/1176350951.
    1. Hedeker D. Methods for multilevel ordinal data in prevention research. Prev Sci. 2015;16(7):997–1006. doi: 10.1007/s11121-014-0495-x.
    1. Hedeker D, Gibbons RD. Longitudinal Data Analysis. New York: Wiley; 2006.
    1. Poukkanen M, Vaara ST, Pettila V, Kaukonen KM, Korhonen AM, Hovilehto S, Inkinen O, Laru-Sompa R, Kaminski T, Reinikainen M, et al. Acute kidney injury in patients with severe sepsis in Finnish intensive care units. Acta Anaesthesiol Scand. 2013;57(7):863–872. doi: 10.1111/aas.12133.
    1. Lattanzio MR, Kopyt NP. Acute kidney injury: new concepts in definition, diagnosis, pathophysiology, and treatment. J Am Osteopath Assoc. 2009;109(1):13–19.
    1. Takasu O, Gaut JP, Watanabe E, To K. Fagley RE, Sato B, Jarman S, Efimov IR, Janks DL, Srivastava A, et al. Mechanisms of cardiac and renal dysfunction in patients dying of sepsis. Am J Respir Crit Care Med. 2013;187(5):509–517. doi: 10.1164/rccm.201211-1983OC.
    1. Ronco C, Ricci Z, De Backer D, Kellum JA, Taccone FS, Joannidis M, Pickkers P, Cantaluppi V, Turani F, Saudan P, et al. Renal replacement therapy in acute kidney injury: controversy and consensus. Crit Care. 2015;19:146. doi: 10.1186/s13054-015-0850-8.
    1. Prowle JR, Davenport A. Does early-start renal replacement therapy improve outcomes for patients with acute kidney injury? Kidney Int. 2015;88(4):670–673. doi: 10.1038/ki.2015.225.
    1. Zarbock A, Kellum JA, Schmidt C, Van Aken H, Wempe C, Pavenstadt H, Boanta A, Gerss J, Meersch M. Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: the ELAIN randomized clinical trial. JAMA. 2016;315(20):2190–2199. doi: 10.1001/jama.2016.5828.
    1. Gaudry S, Hajage D, Schortgen F, Martin-Lefevre L, Pons B, Boulet E, Boyer A, Chevrel G, Lerolle N, Carpentier D, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med. 2016;375(2):122–133. doi: 10.1056/NEJMoa1603017.
    1. Clec'h C, Darmon M, Lautrette A, Chemouni F, Azoulay E, Schwebel C, Dumenil AS, Garrouste-Orgeas M, Goldgran-Toledano D, Cohen Y, et al. Efficacy of renal replacement therapy in critically ill patients: a propensity analysis. Crit Care. 2012;16(6):R236. doi: 10.1186/cc11905.
    1. Clark EG, Bagshaw SM. Unnecessary renal replacement therapy for acute kidney injury is harmful for renal recovery. Semin Dial. 2015;28(1):6–11. doi: 10.1111/sdi.12300.
    1. Kellum JA, Chawla LS, Keener C, Singbartl K, Palevsky PM, Pike FL, Yealy DM, Huang DT, Angus DC, ProCess et al. The effects of alternative resuscitation strategies on acute kidney injury in patients with septic shock. Am J Respir Crit Care Med. 2016;193(3):281–287. doi: 10.1164/rccm.201505-0995OC.
    1. Mehta RL, Burdmann EA, Cerda J, Feehally J, Finkelstein F, Garcia-Garcia G, Godin M, Jha V, Lameire NH, Levin NW, et al. Recognition and management of acute kidney injury in the International Society of Nephrology 0by25 Global Snapshot: a multinational cross-sectional study. Lancet. 2016;387(10032):2017–2025. doi: 10.1016/S0140-6736(16)30240-9.

Source: PubMed

赞助者和合作者

医疗条件

药物干预

3
订阅