The incidence and associations of acute kidney injury in trauma patients admitted to critical care: A systematic review and meta-analysis

Acute kidney injury in the acute care surgery patient: What you need to know

ABSTRACT

Acute kidney injury is associated with poor outcomes in the trauma and emergency general surgery population, and recent consensus definitions have allowed for significant advances in defining the burden of disease. The current definitions rely on overall functional measures (i.e., serum creatinine and urine output), which can be confounded by a variety of clinical factors. Biomarkers are increasingly being investigated as more direct diagnostic assays for the diagnosis of acute kidney injury and may allow earlier detection and more timely therapeutic intervention. Etiologies fall into two general categories: disorders of renal perfusion and exposure to nephrotoxic agents. Therapy is largely supportive, and prevention offers the best chance to decrease clinical impact.

Renal angioembolization vs. surgery for high-grade renal trauma: a nationwide comparative analysis

PURPOSE

Renal angioembolization (RAE) is widely employed in low-grade renal injuries and associated with improved patient outcomes, while surgery remains the mainstay for managing high-grade injuries. We compared the outcomes following surgery and RAE in high-grade renal trauma (HGRT).

METHODS

We used the ACS TQIP 2016-2020 to identify patients ≥ 16 years with HGRT who underwent RAE or surgery. Morbidity was the primary outcome, while mortality and lengths of stay were secondary outcomes. We accounted for clinically relevant characteristics using multilevel logistic regression analyses.

RESULTS

We included 591 patients, of whom 279 (47.2%) underwent RAE. After adjusting, there was no difference in morbidity, hospital LOS, or ICU LOS. The surgery cohort had increased odds of mortality (aOR 4.93; [95% CI] 1.53-15.82; p = 0.007) compared to RAE. In the penetrating injury subgroup, no associations between management and outcomes were observed. In the grade V injury subgroup, morbidity was significantly higher after surgery (aOR 4.64; [95% CI] 1.49-14.47; p = 0.008).

CONCLUSION

Overall, RAE did not significantly impact morbidity but was associated with improved mortality. RAE could safeguard renal function by augmenting the efficacy of concurrent non-operative interventions. Randomized studies are needed to further validate the utility of RAE in HGRT.

Traumatic rhabdomyolysis: rare but morbid, potentially lethal, and inconsistently monitored

PURPOSE

Although traumatic rhabdomyolysis (TR) is shown to be associated with acute kidney injury (AKI), there are no large prospective epidemiological studies, interventional trials, official guidelines outlining the appropriate investigation, monitoring, and treatment on this poorly understood condition. We aimed to establish the contemporary epidemiology and describe current practices for TR to power future higher quality studies. We hypothesised that investigation and monitoring occur in an ad hoc fashion.

MATERIAL AND METHODS

We conducted a 1-year retrospective cohort study of all patients > 16 years of age, with an ISS > 12 and, admitted to a level 1 trauma centre. Demographics, initial vital signs, admission laboratory values, and daily creatinine kinase (CK) values were collected. The primary outcome was TR (defined by CK > 5000 IU), secondary outcomes included AKI (KDIGO criteria), mortality, multiple organ failure, length of stay, and need for renal replacement therapy (RRT).

RESULTS

586 patients met inclusion criteria and 15 patients (2.56%) developed TR. CK testing occurred in 78 (13.1%) patients with 29 (37.7%) of these having values followed until downtrending. AKI occurred in 63 (10.8%) patients within the entire study population. Among those with TR, nine (60%) patients developed AKI. Patients with TR had higher ISS (median 29 vs 18) and mortality (26.7% vs 8.9%).

DISCUSSION

Whilst TR appears rare without liberal screening, it is strongly associated with AKI. Given the poor outcomes, standardised monitoring, and liberal testing of CK could be justified in trauma patients with higher injury severity. This epidemiological data can help to define study populations and power future multicentre prospective studies on this infrequent yet morbid condition.

Exploration of potential biomarkers and therapeutic targets for trauma-related acute kidney injury

PURPOSE

Acute kidney injury (AKI) is one of the most common functional injuries observed in trauma patients. However, certain trauma medications may exacerbate renal injury. Therefore, the early detection of trauma-related AKI holds paramount importance in improving trauma prognosis.

METHODS

Qualified datasets were selected from public databases, and common differentially expressed genes related to trauma-induced AKI and hub genes were identified through enrichment analysis and the establishment of protein-protein interaction (PPI) networks. Additionally, the specificity of these hub genes was investigated using the sepsis dataset and conducted a comprehensive literature review to assess their plausibility. The raw data from both datasets were downloaded using R software (version 4.2.1) and processed with the "affy" package19 for correction and normalization.

RESULTS

Our analysis revealed 585 upregulated and 629 downregulated differentially expressed genes in the AKI dataset, along with 586 upregulated and 948 downregulated differentially expressed genes in the trauma dataset. Concurrently, the establishment of the PPI network and subsequent topological analysis highlighted key hub genes, including CD44, CD163, TIMP metallopeptidase inhibitor 1, cytochrome b-245 beta chain, versican, membrane spanning 4-domains A4A, mitogen-activated protein kinase 14, and early growth response 1. Notably, their receiver operating characteristic curves displayed areas exceeding 75%, indicating good diagnostic performance. Moreover, our findings postulated a unique molecular mechanism underlying trauma-related AKI.

CONCLUSION

This study presents an alternative strategy for the early diagnosis and treatment of trauma-related AKI, based on the identification of potential biomarkers and therapeutic targets. Additionally, this study provides theoretical references for elucidating the mechanisms of trauma-related AKI.

Safety and Metabolic Tolerance of Citrate Anticoagulation in Critically Ill Polytrauma Patients with Acute Kidney Injury Requiring an Early Continuous Kidney Replacement Therapy

For severe polytrauma patients with an early AKI requiring renal replacement therapy, anticoagulation remains a great challenge. Due to a high bleeding risk, hemodynamic instability, and increased lactate levels, continuous modality (CKRT) and citrate anticoagulation seem to be the most appropriate. However, their safety with regard to the potential risk of impaired citrate metabolism is not documented. A retrospective study of 60 severe polytrauma patients admitted to the emergency department between January 2000 and December 2021 was conducted; the patients requiring CKRT during the first 72 h were treated with citrate (n. 46, group Citrate) or with heparin (n. 14, group Heparin). Out of 60 patients, 31 survived (51.7%). According to logistic regression analysis, age and SOFA score were significant predictors of mortality. The incidence of rhabdomyolysis was more common in the survivors (77.4 vs. 51.7%), and Kaplan-Meyer analysis showed a better trend towards survival at 90 days for the group Citrate than the group Heparin (p 0.0956). In the group Citrate, hemorrhagic episodes were significantly less common (0.045 vs. 0.273 episodes/day, p < 0.001); the effective duration (h/day) of CKRT was longer; and the effective net ultrafiltration rate (mL/kg/h) and blood flow rate were lower. For severe polytrauma patients, early, soft CKRT with citrate anticoagulation at a low blood flow rate and circuit citratemia showed a better safety and hemodynamic stability, suggesting that citrate should be the first choice anticoagulant in this subset of patients.

Comparing machine learning and logistic regression for acute kidney injury prediction in trauma patients: A retrospective observational study at a single tertiary medical center

Acute kidney injury (AKI) is common in patients with trauma and is associated with poor outcomes. Therefore, early prediction of AKI in patients with trauma is important for risk stratification and the provision of optimal intensive care unit treatment. This study aimed to compare 2 models, machine learning (ML) techniques and logistic regression, in predicting AKI in patients with trauma. We retrospectively reviewed the charts of 400 patients who sustained torso injuries between January 2016 and June 2020. Patients were included if they were aged > 15 years, admitted to the intensive care unit, survived for > 48 hours, had thoracic and/or abdominal injuries, had no end-stage renal disease, and had no missing data. AKI was defined in accordance with the Kidney Disease Improving Global Outcomes definition and staging system. The patients were divided into 2 groups: AKI (n = 78) and non-AKI (n = 322). We divided the original dataset into a training (80%) and a test set (20%), and the logistic regression with stepwise selection and ML (decision tree with hyperparameter optimization using grid search and cross-validation) was used to build a model for predicting AKI. The models established using the training dataset were evaluated using a confusion matrix receiver operating characteristic curve with the test dataset. We included 400 patients with torso injury, of whom 78 (19.5%) progressed to AKI. Age, intestinal injury, cumulative fluid balance within 24 hours, and the use of vasopressors were independent risk factors for AKI in the logistic regression model. In the ML model, vasopressors were the most important feature, followed by cumulative fluid balance within 24 hours and packed red blood cell transfusion within 4 hours. The accuracy score showed no differences between the 2 groups; however, the recall and F1 score were significantly higher in the ML model (.94 vs 56 and.75 vs 64, respectively). The ML model performed better than the logistic regression model in predicting AKI in patients with trauma. ML techniques can aid in risk stratification and the provision of optimal care.

Predisposing Factors and Outcome of Acute Kidney Injury After Blunt Trauma: A 10-Year Study

INTRODUCTION

Acute kidney injury (AKI) indicates an impairment of the renal function following blunt trauma. It is multifactorial and associated with an increased risk of morbidity and mortality. The incidence and risk factors of AKI in young patients with trauma are not well-described. This study aimed to evaluate the incidence, clinical characteristics, and outcomes of post-traumatic AKI. We hypothesized that AKI is associated with worse outcomes in patients with trauma.

METHODS

This was a retrospective study of all adult trauma patients admitted to a level 1 trauma center between 2011 and 2021. AKI was diagnosed on the basis of the Kidney Disease Improving Global Outcomes criteria. Data were collected and analyzed for patients with and without AKI using chi-square test and Student's t-test. Multivariate logistic regression analysis and Kaplan-Meier curves were performed.

RESULTS

A total of 17,341 patients with trauma were evaluated, of which 140 (0.8%) developed AKI. Patients with AKI were older (40 ± 20 versus 32 ± 16 y), had more comorbidities, and had a higher injury severity score (ISS) and in-hospital mortality (65% versus 3.2%) than non-AKI patients. Direct trauma to the kidney was reported in only nine (6.4%) patients in the AKI group. Among patients with AKI, nonsurvivors had a higher ISS and were more likely to have hypotension, elevated serum lactate, positive troponin, and a lower platelet-to-lymphocyte ratio than survivors. Multiple logistic regression analyses showed that age, ISS, acute respiratory distress syndrome, blood transfusion, diabetes mellitus, onadmission Glasgow coma scale score, and shock index were predictors of AKI in trauma patients, whereas ISS (odds ratio (OR) = 1.05; 95% confidence interval (CI):1.003-1.100; P = 0.03), serum lactate level (OR = 1.25; 95% CI: 1.019-1.533; P = 0.03), and hypotension (OR = 3.22; 95% CI: 1.044-9.945; P = 0.04) were independent predictors of mortality in patients with posttraumatic AKI. Kaplan-Meier survival analysis showed significant differences in mortality among the three stages of AKI (P = 0.03), with the worst outcome in stage III. However, after adjusting for age, hypotension, and ISS, the Cox regression model showed that only stage I had better survival than stages II and III, whereas no survival difference was noted between stages II and III (P = 0.06).

CONCLUSIONS

AKI in young trauma patients is uncommon and associated with a prolonged hospital course and higher mortality. This study identified factors that independently predicted the development of AKI and its outcomes in patients with trauma. However, further prospective and multicenter studies are required to minimize the incidence and complications of posttraumatic AKI.

Who Is at Risk of Death after Renal Trauma? An Analysis of Thirty-Day Mortality after 1,799 Cases of Renal Trauma

INTRODUCTION

The aim of the study was to report the 30-day mortality (30DM) after renal trauma and identify the risk factors associated with death.

METHODS

The TRAUMAFUF project was a retrospective multi-institutional study including all patients with renal trauma admitted to 17 French hospitals between 2005 and 2015. The included population focused on patients of all age groups who underwent renal trauma during the study period. The primary outcome was death within 30 days following trauma. The multivariate logistic regression model with a stepwise backward elimination was used to identify predictive factors of 30DM.

RESULTS

Data on 1,799 renal trauma were recorded over the 10-year period. There were 59 deaths within 30 days of renal trauma, conferring a 30DM rate of 3.27%. Renal trauma was directly involved in 5 deaths (8.5% of all deaths, 0.3% of all renal trauma). Multivariate stepwise logistic regression analysis revealed that age >40 years (odds ratio [OR] 2.18; 95% confidence interval [CI]: 1.20-3.99; p = 0.01), hemodynamic instability (OR 4.67; 95% CI: 2.49-9; p < 0.001), anemia (OR 3.89; 95% CI: 1.94-8.37; p < 0.001), bilateral renal trauma (OR 6.77; 95% CI: 2.83-15.61; p < 0.001), arterial contrast extravasation (OR 2.09; 95% CI: 1.09-3.96; p = 0.02), and concomitant visceral and bone injuries (OR 6.57; 95% CI: 2.41-23.14; p < 0.001) were independent predictors of 30DM.

CONCLUSION

Our large multi-institutional study supports that the 30DM of 3.27% after renal trauma is due to the high degree of associated injuries and was rarely a consequence of renal trauma alone. Age >40 years, hemodynamic instability, anemia, bilateral renal trauma, arterial contrast extravasation, and concomitant visceral and bone lesions were predictors of death. These results can help clinicians to identify high-risk patients.

Selection of appropriate reference creatinine estimate for acute kidney injury diagnosis in patients with severe trauma

BACKGROUND

In patients with severe trauma, the diagnosis of acute kidney injury (AKI) is important because it is a predictive factor for poor prognosis and can affect patient care. The diagnosis and staging of AKI are based on change in serum creatinine (SCr) levels from baseline. However, baseline creatinine levels in patients with traumatic injuries are often unknown, making the diagnosis of AKI in trauma patients difficult. This study aimed to enhance the accuracy of AKI diagnosis in trauma patients by presenting an appropriate reference creatinine estimate (RCE).

METHODS

We reviewed adult patients with severe trauma requiring intensive care unit admission between 2015 and 2019 (n=3,228) at a single regional trauma center in South Korea. AKI was diagnosed based on the current guideline published by the Kidney Disease: Improving Global Outcomes organization. AKI was determined using the following RCEs: estimated SCr75-modification of diet in renal disease (MDRD), trauma MDRD (TMDRD), admission creatinine level, and first-day creatinine nadir. We assessed inclusivity, prognostic ability, and incrementality using the different RCEs.

RESULTS

The incidence of AKI varied from 15% to 46% according to the RCE used. The receiver operating characteristic curve of TMDRD used to predict mortality and the need for renal replacement therapy (RRT) had the highest value and was statistically significant (0.797, P<0.001; 0.890, P=0.002, respectively). In addition, the use of TMDRD resulted in a mortality prognostic ability and the need for RRT was incremental with AKI stage.

CONCLUSIONS

In this study, TMDRD was feasible as a RCE, resulting in optimal post-traumatic AKI diagnosis and prognosis.

Minor injury turns into major problem in severe acute kidney injury: a propensity matched analysis

Objective

Severe acute kidney injury (sAKI) has been associated with a higher mortality in trauma patients, and severity of trauma often correlates with risk of sAKI. Whether minor to moderate trauma is associated with sAKI is less clear. The purpose of the study was to examine the outcomes of minor to moderate trauma patients who developed sAKI.

Methods

The National Trauma Database participant use files of 2017 and 2018 were accessed for the study. All patients aged 18 years old and above who sustained an Injury Severity Score (ISS) of <16 and who were brought to a level I or level II trauma center were included in the study. sAKI was defined as an abrupt decrease in kidney function either three times increase in serum creatinine (SCr) level from the baseline or increase in SCr to ≥4.0 mg/dL (≥353.6 µmol/L), initiation of renal replacement therapy, or anuria for ≥12 hours. Propensity matching analysis was performed between the groups who developed sAKI and without sAKI. Outcome of interest was in-hospital mortality.

Results

A total of 655 872 patients fulfilled the inclusion criteria with complete information, of which 1896 patients were found to have sAKI. There were significant differences between the two groups on baseline characteristics. The propensity score matching eliminated all the differences and created 1896 pairs of patients. The median hospital length of stay was longer in patients with sAKI when compared with patients who did not develop sAKI (14 (13 to 15) vs. 5 (5 to 5), days p<0.001). The overall in-hospital mortality was 20.6% in patients with sAKI compared with 2.1% without sAKI (p<0.001).

Conclusion

The occurrence of sAKI in minor to moderate trauma patients was less than 0.5%. There was a three times longer hospital stay in patients with sAKI and 10-fold increase in mortality when compared with patients who did not develop sAKI.

Level of evidence

IV.

Study type

Observational cohort study.

The Predictive Role of Systemic Inflammatory Markers in the Development of Acute Kidney Failure and Mortality in Patients with Abdominal Trauma

Background: Abdominal trauma is defined as a variety of injuries to the abdominal wall, solid or hollow intra-abdominal organs, and various intra-abdominal vessels. Recently, there has been a significant amount of interest in the establishment of a reliable biomarker that can predict the outcome in patients with an abdominal injury. The purpose of this study is to confirm the predictive role of inflammatory biomarkers and underlying risk factors and the risk of acute kidney insufficiency (AKI) developing and mortality in abdominal trauma patients; Materials and methods: The current study was intended as an observational, analytical, retrospective cohort study and included all patients over 18 years of age with a diagnosis of abdominal trauma confirmed through a CT scan admitted to the County Emergency Clinical Hospital of Targu-Mureș, Romania between January 2017, and December 2021; Results: Non-survivor patients had a greater age (p = 0.02), as well as a higher prevalence of ischemic heart disease (IHD) (p = 0.007), history of myocardial infarction (MI) (p = 0.002), peripheral arterial disease (PAD) (p = 0.01), chronic kidney disease (CKD) (p = 0.01), and all risk factors (p = 0.0004 and p < 0.0001). In terms of injured organs, we have in the second group a higher incidence of kidney injury (p = 0.003) and hemoperitoneum (p = 0.008). Multivariate analysis showed a high baseline value for all inflammatory biomarkers that are independent predictors of adverse outcomes for all recruited patients. Furthermore, for all hospitalized patients, the history of MI (p = 0.03; p = 0.001; and p = 0.003), PAD (p = 0.01; p = 0.01; and p = 0.002), obesity (for all p < 0.0001), CKD (p < 0.001; p = 0.01; and p = 0.001), and kidney injury (p = 0.02; p = 0.004; and p = 0.01) were independent predictors of all outcomes. Moreover, IHD (p = 0.008 and p = 0.02), tobacco (p < 0.0001 and p = 0.02), and hemoperitoneum (p = 0.009 and p = 0.01) were predictors of mortality and composite endpoint, but not for AKI risk, as well as atrial fibrillation [AF] (p = 0.04) as predictors of the composite endpoint Conclusions: Higher monocyte to lymphocyte ratio (MLR), platelets to lymphocyte ratio (PLR), systemic inflammatory index (SII), neutrophil to lymphocyte ratios (NLR), aggregate inflammatory systemic index (AISI), and systemic inflammatory response index (SIRI) levels at admission, according to our data, highly predict AKI risk and death.

Specificity of severe AKI aetiology and care in the elderly. The IRACIBLE prospective cohort study

INTRODUCTION

Acute Kidney Injury (AKI) is increasingly common in people over 65 years of age, but its causes and management are poorly described. The purpose of this study was to describe the causes, management and prognosis of patients over 65 hospitalised for severe acute kidney injury (AKI) in all departments of a tertiary centre.

METHOD

The prospective IRACIBLE (IRA: AKI in French; CIBLE: target in French) cohort included 480 patients hospitalised at a university hospital over 18 months for severe AKI or subgroup of AKIN3 (Acute Kidney Injury Network classification) defined by an acute creatinine increase > 354 μmol/L or managed with acute renal replacement therapy (RRT). The history, aetiology of AKI, management, and prognosis were compared in three age groups: < 65, 65-75, and > 75 years.

RESULTS

The study population included 480 subjects (73% men) with a median body mass index (BMI) of 26.6 kg/m² [23.3, 30.9], 176 (37%) diabetic patients, 124 (26%) patients < 65 years, 150 (31%) 65-75 years and 206 (43%) > 75 years. Increasing age class was associated with more comorbidities, a significantly lower median estimated glomerular filtration rate (eGFR) 6 months before inclusion (82; 62; 46 ml/min/1.73 m², p < 0.05) and aetiology of AKI, which was more often obstructive (12%; 15%; 23%, p = 0.03) or part of a cardio-renal syndrome (6%; 9%; /15%, p = 0.04). Older patients were less often managed in the intensive care unit  (54%; 47%; 24%, p < 0.0001), were less frequently treated by RRT (52%; 43%; 31%, p < 0.001) and received fewer invasive treatments  (6%; 9%; 22%, p < 0.0001). Older survivors returned home less often (80%; 73%; 62%, p = 0.05) in favour of transfers to rehabilitation services (10%; 13%; 22%) with higher mortality at 3 months (35%; 32%; 50%, p < 0.0001).

CONCLUSION

Older patients hospitalised for severe AKI have a specific profile with more comorbidities, lower baseline renal function, an aetiology of AKI of mainly extra-parenchymal causes and a complex pathway of care with an overall poor prognosis.

Incidence of Acute Kidney Injury in Polytrauma Patients and Predictive Performance of TIMP2 × IGFBP7 Biomarkers for Early Identification of Acute Kidney Injury

Background: Acute kidney injury (AKI) is a common cause of organ failure in trauma patients who survive their initial injuries. It is independently associated with increased morbidity and mortality and prolongs the length of hospital stays. The objectives of this study were to describe the incidence of early AKI and influence of risk factors in polytrauma patients and evaluate the predictive potential of TIMP2 × IGFBP7 biomarkers in this patient cohort. Methods: We conducted a retrospective cohort study of severely injured adult patients who were consecutively admitted to a multidisciplinary ICU from May 2017 to May 2019. Detailed patient data was retrieved from ICU medical records. Fluid balance, urinary output, and sCr values up to 72 h were collected. Urine samples for measuring TIMP2 × IGFBP7 concentrations were obtained and analyzed from ICU admission to 72 h. Results: Among the 153 patients eligible for analysis, 45 were included in the AKI, and 108 in the no AKI cohorts. The incidence of AKI within 72 h, based on KDIGO criteria, was 28.8%. There were no differences in ISS, type and mechanism of injury, heart rate, and systolic BP at admission between groups. Patients with early AKI were older (68 vs. 49 years, p < 0.001), obese (BMI 26.2 vs. 24.7, p < 0.048), and more likely to have previous cardiac disease (27% vs. 5.6%, p < 0.001). TIMP2 × IGFBP7 values on ICU admission were associated with subsequent AKI in patients without evidence of AKI at the time of ICU admission. They were also higher in the AKI cohort and significantly correlated with renal replacement therapy (RRT) and episodes of hypotension. Multivariable analysis confirmed age, previous cardiac disease, and NephroCheck as the variables mostly associated with AKI, with AUC 0.792. Conclusions: TIMP2 × IGFBP7 may help identify trauma patients with tubular damage that may evolve into a clinically manifested syndrome. Prospective studies of TIMP2 × IGFBP7, as a trigger for early AKI bundle care, are warranted.

Risk factors for end-stage renal disease in patients with trauma and stage 3 acute kidney injury

Research on long-term renal outcomes in patients with acute kidney injury (AKI) and trauma, especially those with traumatic brain injury (TBI), has been limited.In this study, we enrolled patients with stage 3 AKI as per the Kidney Disease Improving Global Outcomes guidelines, who initiated renal replacement therapy (RRT). These patients were divided into 2 groups depending on the presence of TBI. Comparing the baseline characteristics and management strategies of each group, we analyzed whether TBI affects the progression of kidney disease.Between January 1, 2014 and June 30, 2020, 51 patients who initiated RRT due to AKI after trauma were enrolled in this study. TBI was identified in 20 patients, and the clinical conditions were not related to TBI in the remaining 31. The study endpoint was set to determine whether the patients of each group needed RRT persistently at discharge and at the time of recent outpatient clinic. Six (30.0%) out of 20 patients with TBI and 2 (6.5%) out of 31 patients without TBI required conventional hemodialysis, as per the most recent data. No significant within-group differences were found in terms of the baseline characteristics and management strategies. In the logistic regression analysis, TBI was independently associated with disease progression to end-stage renal disease.TBI is a risk factor for end-stage renal disease in patients with trauma and stage 3 AKI who initiate RRT.

Prediction of early acute kidney injury after trauma using prehospital systolic blood pressure and lactate levels: A prospective validation study

BACKGROUND

Acute kidney injury (AKI) after trauma is a major complication independently associated with a prolonged hospital stay and increased mortality. We previously reported that the prehospital systolic blood pressure (SBP) and early hospital arterial lactate level, along with specific cut-off values, show good performance in the early prediction of AKI using AUC-ROC [1]. The purpose of this study was to prospectively validate whether or not these parameters are predictive of newly occurring AKI after trauma.

METHODS

This was a prospective review of trauma patients who were admitted to a single trauma center from January to December 2019. Patients who were <16 years old, who had burns, and who had chronic kidney disease were excluded. AKI was defined according to the Risk, Injury, Failure, Loss of the kidney function, and End-stage kidney disease (RIFLE) classification based on serum creatinine alone. Patients with a low prehospital SBP (≤126 mmHg) and high lactate levels (≥2.5 mmol/L) were defined as the high-risk group, and other patients were defined as the low-risk group.

RESULTS

A total of 489 trauma patients were admitted to our center, of whom 403 were eligible for the study. The high-risk group consisted of 38 patients, and the low-risk group consisted of 365 patients. The incidence of severe AKI in Stage Injury and Failure was significantly higher in the high-risk group (5 patients, 13.2%) than in the low-risk group (7 patients, 1.9%), with an odds ratio of 7.75 and 95% confidence interval of 2.33-25.77.

CONCLUSIONS

These predictors showed good performance in the early prediction of severe AKI after trauma. Early prediction of the high-risk groups for severe AKI after trauma prompting early treatment may help improve the prognosis of trauma patients.

Biomarkers for assessing acute kidney injury for people who are being considered for admission to critical care: a systematic review and cost-effectiveness analysis

BACKGROUND

Acute kidney injury is a serious complication that occurs in the context of an acute critical illness or during a postoperative period. Earlier detection of acute kidney injury may facilitate strategies to preserve renal function, prevent further disease progression and reduce mortality. Acute kidney injury diagnosis relies on a rise in serum creatinine levels and/or fall in urine output; however, creatinine is an imperfect marker of kidney function. There is interest in the performance of novel biomarkers used in conjunction with existing clinical assessment, such as NephroCheck^® (Astute Medical, Inc., San Diego, CA, USA), ARCHITECT^® urine neutrophil gelatinase-associated lipocalin (NGAL) (Abbott Laboratories, Abbott Park, IL, USA), and urine and plasma BioPorto NGAL (BioPorto Diagnostics A/S, Hellerup, Denmark) immunoassays. If reliable, these biomarkers may enable earlier identification of acute kidney injury and enhance management of those with a modifiable disease course.

OBJECTIVE

The objective was to evaluate the role of biomarkers for assessing acute kidney injury in critically ill patients who are considered for admission to critical care.

DATA SOURCES

Major electronic databases, conference abstracts and ongoing studies were searched up to June 2019, with no date restrictions. MEDLINE, EMBASE, Health Technology Assessment Database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Web of Science, World Health Organization Global Index Medicus, EU Clinical Trials Register, International Clinical Trials Registry Platform and ClinicalTrials.gov were searched.

REVIEW METHODS

A systematic review and meta-analysis were conducted to evaluate the performance of novel biomarkers for the detection of acute kidney injury and prediction of other relevant clinical outcomes. Random-effects models were adopted to combine evidence. A decision tree was developed to evaluate costs and quality-adjusted life-years accrued as a result of changes in short-term outcomes (up to 90 days), and a Markov model was used to extrapolate results over a lifetime time horizon.

RESULTS

A total of 56 studies (17,967 participants), mainly prospective cohort studies, were selected for inclusion. No studies addressing the clinical impact of the use of biomarkers on patient outcomes, compared with standard care, were identified. The main sources of bias across studies were a lack of information on blinding and the optimal threshold for NGAL. For prediction studies, the reporting of statistical details was limited. Although the meta-analyses results showed the potential ability of these biomarkers to detect and predict acute kidney injury, there were limited data to establish any causal link with longer-term health outcomes and there were considerable clinical differences across studies. Cost-effectiveness results were highly uncertain, largely speculative and should be interpreted with caution in the light of the limited evidence base. To illustrate the current uncertainty, 15 scenario analyses were undertaken. Incremental quality-adjusted life-years were very low across all scenarios, ranging from positive to negative increments. Incremental costs were also small, in general, with some scenarios generating cost savings with tests dominant over standard care (cost savings with quality-adjusted life-year gains). However, other scenarios generated results whereby the candidate tests were more costly with fewer quality-adjusted life-years, and were thus dominated by standard care. Therefore, it was not possible to determine a plausible base-case incremental cost-effectiveness ratio for the tests, compared with standard care.

LIMITATIONS

Clinical effectiveness and cost-effectiveness results were hampered by the considerable heterogeneity across identified studies. Economic model predictions should also be interpreted cautiously because of the unknown impact of NGAL-guided treatment, and uncertain causal links between changes in acute kidney injury status and changes in health outcomes.

CONCLUSIONS

Current evidence is insufficient to make a full appraisal of the role and economic value of these biomarkers and to determine whether or not they provide cost-effective improvements in the clinical outcomes of acute kidney injury patients.

FUTURE WORK

Future studies should evaluate the targeted use of biomarkers among specific patient populations and the clinical impact of their routine use on patient outcomes and management.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019147039.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 26, No. 7. See the NIHR Journals Library website for further project information.

Cost-effectiveness and value of information analysis of NephroCheck and NGAL tests compared to standard care for the diagnosis of acute kidney injury

BACKGROUND

Early and accurate acute kidney injury (AKI) detection may improve patient outcomes and reduce health service costs. This study evaluates the diagnostic accuracy and cost-effectiveness of NephroCheck and NGAL (urine and plasma) biomarker tests used alongside standard care, compared with standard care to detect AKI in hospitalised UK adults.

METHODS

A 90-day decision tree and lifetime Markov cohort model predicted costs, quality adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) from a UK NHS perspective. Test accuracy was informed by a meta-analysis of diagnostic accuracy studies. Clinical trial and observational data informed the link between AKI and health outcomes, health state probabilities, costs and utilities. Value of information (VOI) analysis informed future research priorities.

RESULTS

Under base case assumptions, the biomarker tests were not cost-effective with ICERs of £105,965 (NephroCheck), £539,041 (NGAL urine BioPorto), £633,846 (NGAL plasma BioPorto) and £725,061 (NGAL urine ARCHITECT) per QALY gained compared to standard care. Results were uncertain, due to limited trial data, with probabilities of cost-effectiveness at £20,000 per QALY ranging from 0 to 99% and 0 to 56% for NephroCheck and NGAL tests respectively. The expected value of perfect information (EVPI) was £66 M, which demonstrated that additional research to resolve decision uncertainty is worthwhile.

CONCLUSIONS

Current evidence is inadequate to support the cost-effectiveness of general use of biomarker tests. Future research evaluating the clinical and cost-effectiveness of test guided implementation of protective care bundles is necessary. Improving the evidence base around the impact of tests on AKI staging, and of AKI staging on clinical outcomes would have the greatest impact on reducing decision uncertainty.

Emergency angiography for trauma patients and potential association with acute kidney injury

BACKGROUND

Angiography has been conducted as a hemostatic procedure for trauma patients. While several complications, such as tissue necrosis after embolization, have been reported, little is known regarding subsequent acute kidney injury (AKI) due to contrast media. To elucidate whether emergency angiography would introduce kidney dysfunction in trauma victims, we compared the incidence of AKI between patients who underwent emergency angiography and those who did not.

METHODS

A retrospective cohort study was conducted using a nationwide trauma database (2004-2019), and adult trauma patients were included. The indication of emergency angiography was determined by both trauma surgeons and radiologists, and AKI was diagnosed by treating physicians based on a rise in serum creatinine and/or fall in urine output according to any published standard criteria. Incidence of AKI was compared between patients who underwent emergency angiography and those who did not. Propensity score matching was conducted to adjust baseline characteristics including age, comorbidities, mechanism of injury, vital signs on admission, Injury Severity Scale (ISS), degree of traumatic kidney injury, surgical procedures, and surgery on the kidney, such as nephrectomy and nephrorrhaphy.

RESULTS

Among 230,776 patients eligible for the study, 14,180 underwent emergency angiography. The abdomen/pelvis was major site for angiography (10,624 [83.5%]). Embolization was performed in 5,541 (43.5%). Propensity score matching selected 12,724 pairs of severely injured patients (median age, 59; median ISS, 25). While the incidence of AKI was rare, it was higher among patients who underwent emergency angiography than in those who did not (140 [1.1%] vs. 67 [0.5%]; odds ratio = 2.10 [1.57-2.82]; p < 0.01). The association between emergency angiography and subsequent AKI was observed regardless of vasopressor usage or injury severity in subgroup analyses.

CONCLUSIONS

Emergency angiography in trauma patients was probably associated with increased incidence of AKI. The results should be validated in future studies.

Nephrectomy After High-Grade Renal Trauma is Associated With Higher Mortality: Results From the Multi-Institutional Genitourinary Trauma Study (MiGUTS)

OBJECTIVE

To test the hypothesis that undergoing nephrectomy after high-grade renal trauma is associated with higher mortality rates.

METHODS

We gathered data from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study. Patients with high-grade renal trauma were included. We assessed the association between nephrectomy and mortality in all patients and in subgroups of patients after excluding those who died within 24 hours of hospital arrival and those with GCS≤8. We controlled for age, injury severity score (ISS), shock (systolic blood pressure <90 mmHg), and Glasgow Coma Scale (GCS).

RESULTS

A total of 1181 high-grade renal trauma patients were included. Median age was 31 and trauma mechanism was blunt in 78%. Injuries were graded as III, IV, and V in 55%, 34%, and 11%, respectively. There were 96 (8%) mortalities and 129 (11%) nephrectomies. Mortality was higher in the nephrectomy group (21.7% vs 6.5%, P <.001). Those who died were older, had higher ISS, lower GCS, and higher rates of shock. After adjusting for patient and injury characteristics nephrectomy was still associated with higher risk of death (RR: 2.12, 95% CI: 1.26-2.55).

CONCLUSION

Nephrectomy was associated with higher mortality in the acute trauma setting even when controlling for shock, overall injury severity, and head injury. These results may have implications in decision making in acute trauma management for patients not in extremis from renal hemorrhage.

Risk factors for acute kidney injury in critically ill patients with torso injury: A retrospective observational single-center study

Acute kidney injury (AKI) is common in trauma patients and associated with poor outcomes. Identifying AKI risk factors in trauma patients is important for risk stratification and provision of optimal intensive care unit (ICU) treatment. This study identified AKI risk factors in patients admitted to critical care after sustaining torso injuries.We performed a retrospective chart review involving 380 patients who sustained torso injuries from January 2016 to December 2019. Patients were included if they were aged >15 years, admitted to an ICU, survived for >48 hours, and had thoracic and/or abdominal injuries and no end-stage renal disease. AKI was defined according to the Kidney Disease Improving Global Outcomes definition and staging system. Clinical and laboratory variables were compared between the AKI and non-AKI groups (n = 72 and 308, respectively). AKI risk factors were assessed using multivariate logistic regression analysis.AKI occurred in 72 (18.9%) patients and was associated with higher mortality than non-AKI patients (26% vs 4%, P < .001). Multivariate logistic regression analysis identified bowel injury, cumulative fluid balance >2.5 L for 24 hours, lactate levels, and vasopressor use (adjusted odds ratio: 2.953, 2.058, 1.170, and 2.910; 95% confidence interval: 1.410-6.181, 1.017-4.164, 1.019-1.343, and 1.414-5.987; P = .004, .045, .026, and .004, respectively) as independent risk factors for AKI.AKI in patients admitted to the ICU with torso injury had a substantial mortality. Recognizing risk factors at an early stage could aid risk stratification and provision of optimal ICU care.

Prehospital Blood Pressure and Lactate are Early Predictors of Acute Kidney Injury After Trauma

BACKGROUND

The purpose of this study is to report the prevalence of acute kidney injury (AKI) after trauma in our center, describe the risk factors associated with AKI, and determine whether these risk factors help avoid AKI.

MATERIALS AND METHODS

We retrospectively analyzed the data which were prospectively collected from a single center trauma registry from January 2017 to December 2018. Patients who were <16 years of age, patients with burns, and patients with chronic kidney disease were excluded from the present study. AKI was defined according to the risk, injury, failure, loss of the kidney function, and end-stage kidney disease (RIFLE) classification from serum creatinine alone. A logistic regression analysis was performed to identify prehospital and early hospital risk factors for AKI.

RESULTS

There were 806 trauma patients recorded in the database. One hundred thirty cases were excluded based on the abovementioned exclusion criteria. Six hundred seventy-six patients were included in the analysis. The prevalence of AKI in the overall population was 14.5% including 10.5% of patients with stage R, 3.0% of patients with stage I and 1.0% with stage F. The incidence of AKI increased to 36.3%, 12.1% and 3.3% in the subgroup of patients with hemorrhagic shock. The multivariate analysis revealed that the minimum prehospital systolic blood pressure and arterial lactate level were independent predictors of AKI. The model showed good discrimination with an area under the receiver operating characteristic curve (AUC-ROC) of 0.867 and 0.852 in the prediction of AKI stage I or F. The cutoff values were ≤126 mmHg and ≥2.5 mmol/L, respectively.

CONCLUSION

These parameters showed good performance in the early prediction of AKI after trauma. They are associated with the early onset of AKI after trauma and may be an early predictor of the effects of treatment to prevent AKI.

Risk of in-hospital mortality in severe acute kidney injury after traumatic injuries: a national trauma quality program study

BACKGROUND

The development of acute kidney injury (AKI) in trauma patients has been associated with an almost threefold increase in overall mortality. Many risk factors of mortality in severe AKI have been reported, but majority of the studies have been performed using a single-center data or have a small sample size. The purpose of this study was to identify the risk factors of mortality in severe AKI trauma patients.

METHODS

The study was performed using 2012-2016 American College of Surgeon Trauma Quality Improvement Program data, a national database of trauma patients in the USA.All adult trauma patients aged 16 to 89 years old, admitted to the hospital and who developed a severe AKI were included in the study. A p value of <0.05 was considered statistically significant.

RESULTS

Out of 9309 trauma patients who developed severe AKI, 2641 (28.08%) died. There were significant differences found in bivariate analysis between the groups who died and who survived after developing a severe AKI. Multivariable analysis showed male sex, older age, higher Injury Severity Score, lower Glasgow Coma Scale, presence of hypotension (systolic blood pressure<90 mm Hg) and coagulopathy were all significantly associated with in-hospital mortality. The area under the curve value was 0.706 and the 95% CI was 0.68 to 0.727.

DISCUSSION

Current analysis showed certain patients' characteristics are associated with higher mortality in patients with severe AKI. Prompt identification and aggressive monitoring and management in high-risk patients may result in reduced mortality.

LEVEL OF EVIDENCE

IV.

STUDY TYPE

Observational cohort study.

Artificial Intelligence in Acute Kidney Injury: From Static to Dynamic Models

Artificial intelligence (AI) is the development of computer systems that normally require human intelligence. In the field of acute kidney injury (AKI) AI has led to an evolution of risk prediction models. In the past, static prediction models were developed using baseline (eg, preoperative) data to evaluate AKI risk. Newer models which incorporated baseline as well as evolving data collected during a hospital admission have shown improved predicative abilities. In this review, we will summarize the advances made in AKI risk prediction over the last several years, including a shift toward more dynamic, real-time, electronic medical record-based models. In addition, we will be discussing the role of electronic AKI alerts and decision support tools. Recent studies have demonstrated improved patient outcomes through the use of these tools which monitor for nephrotoxin medication exposures as well as provide kidney focused care bundles for patients at high risk for severe AKI. Finally, we will briefly discuss the pitfalls and implications of implementing these scores, alerts, and support tools.

Long-term outcomes following vehicle trauma related acute kidney injury requiring renal replacement therapy: a nationwide population study

Acute kidney injury (AKI) is a frequent complication of traumatic injury; however, long-term outcomes such as mortality and end-stage kidney disease (ESKD) have been rarely reported in this important patient population. We compared the long-term outcome of vehicle-traumatic and non-traumatic AKI requiring renal replacement therapy (AKI-RRT). This nationwide cohort study used data from the Taiwan National Health Insurance Research Database. Vehicle-trauma patients who were suffered from vehicle accidents developing AKI-RRT during hospitalization were identified, and matching non-traumatic AKI-RRT patients were identified between 2000 and 2010. The incidences of ESKD, 30-day, and long-term mortality were evaluated, and clinical and demographic associations with these outcomes were identified using Cox proportional hazards regression models. 546 vehicle-traumatic AKI-RRT patients, median age 47.6 years (interquartile range: 29.0–64.3) and 76.4% male, were identified. Compared to non-traumatic AKI-RRT, vehicle-traumatic AKI-RRT patients had longer length of stay in hospital [median (IQR):15 (5–34) days vs. 6 (3–11) days; p < 0.001). After propensity matching with non-traumatic AKI-RRT cases with similar demographic and clinical characteristics. Vehicle-traumatic AKI-RRT patients had lower rates of long-term mortality (adjusted hazard ratio (HR), 0.473; 95% CI, 0.392–0.571; p < 0.001), but similar rates of ESKD (HR, 1.166; 95% CI, 0.829–1.638; p = 0.377) and short-term risk of death (HR, 1.134; 95% CI, 0.894–1.438; p = 0.301) as non-traumatic AKI-RRT patients. In competing risk models that focused on ESKD, vehicle-traumatic AKI-RRT patients were associated with lower ESKD rates (HR, 0.552; 95% CI, 0.325–0.937; p = 0.028) than non-traumatic AKI-RRT patients. Despite severe injuries, vehicle-traumatic AKI-RRT patients had better long-term survival than non-traumatic AKI-RRT patients, but a similar risk of ESKD. Our results provide a better understanding of long-term outcomes after vehicle-traumatic AKI-RRT.

Acute kidney injury risk in orthopaedic trauma patients pre and post surgery using a biomarker algorithm and clinical risk score

Acute kidney injury (AKI) after major trauma is associated with increased mortality. The aim of this study was to assess if measurement of blood biomarkers in combination with clinical characteristics could be used to develop a tool to assist clinicians in identifying which orthopaedic trauma patients are at risk of AKI. This is a prospective study of 237 orthopaedic trauma patients who were consecutively scheduled for open reduction and internal fixation of their fracture between May 2012 and August 2013. Clinical characteristics were recorded, and 28 biomarkers were analysed in patient blood samples. Post operatively a combination of H-FABP, sTNFR1 and MK had the highest predictive ability to identify patients at risk of developing AKI (AUROC 0.885). Three clinical characteristics; age, dementia and hypertension were identified in the orthopaedic trauma patients as potential risks for the development of AKI. Combining biomarker data with clinical characteristics allowed us to develop a proactive AKI clinical tool, which grouped patients into four risk categories that were associated with a clinical management regime that impacted patient care, management, length of hospital stay, and efficient use of hospital resources.

Immunopathophysiology of trauma-related acute kidney injury

Physical trauma can affect any individual and is globally accountable for more than one in every ten deaths. Although direct severe kidney trauma is relatively infrequent, extrarenal tissue trauma frequently results in the development of acute kidney injury (AKI). Various causes, including haemorrhagic shock, rhabdomyolysis, use of nephrotoxic drugs and infectious complications, can trigger and exacerbate trauma-related AKI (TRAKI), particularly in the presence of pre-existing or trauma-specific risk factors. Injured, hypoxic and ischaemic tissues expose the organism to damage-associated and pathogen-associated molecular patterns, and oxidative stress, all of which initiate a complex immunopathophysiological response that results in macrocirculatory and microcirculatory disturbances in the kidney, and functional impairment. The simultaneous activation of components of innate immunity, including leukocytes, coagulation factors and complement proteins, drives kidney inflammation, glomerular and tubular damage, and breakdown of the blood-urine barrier. This immune response is also an integral part of the intense post-trauma crosstalk between the kidneys, the nervous system and other organs, which aggravates multi-organ dysfunction. Necessary lifesaving procedures used in trauma management might have ambivalent effects as they stabilize injured tissue and organs while simultaneously exacerbating kidney injury. Consequently, only a small number of pathophysiological and immunomodulatory therapeutic targets for TRAKI prevention have been proposed and evaluated.

Incidence and Risk Factors for Acute Kidney Injury in Severely Injured Patients Using Current Kidney Disease: Improving Global Outcomes Definitions

BACKGROUND

Acute kidney injury (AKI) is a significant cause of morbidity and mortality for critically injured trauma patients. The Kidney Disease: Improving Global Outcomes (KDIGO) practice guideline is the most up-to-date classification for AKI. The aims of this study were to determine the incidence and risk factors for AKI in critically injured trauma patients using the current KDIGO definitions.

STUDY DESIGN

A prospective cohort study was performed at our academic, level 1 trauma center, from September 2017 to August 2018. All adult trauma patients admitted to the surgical ICU were included. The primary outcome was the development of AKI, as defined by KDIGO. Secondary outcomes included hospital and ICU length of stay, ventilator days, and mortality.

RESULTS

There were 466 patients included and 314 (67%) developed AKI. Those who developed AKI were more often hypotensive on admission (7% vs 2%), had higher Injury Severity Scores (ISS) (19 vs 13), were more likely to have severe injuries to the chest (40% vs 24%) and extremities (20% vs 6%), received transfusion (41% vs 21%), sustained crush injuries (8% vs 1%), received radiocontrast (75% vs 47%), nephrotoxic medication (74% vs 60%), or vasopressors (15% vs 3%). After multivariate analysis, risk factors independently associated with AKI include age, Injury Severity Score (ISS), severe extremity injuries, radiocontrast, and vasopressors. Those who developed AKI had higher mortality (9% vs 2%).

CONCLUSIONS

Using current KDIGO criteria, the incidence of AKI in critically injured trauma patients was higher than previously reported. Older patients, with more severe injuries to their extremities and chest and who have suffered crush injuries, appear to be the most a risk. AKI in the critically injured patient results in an almost 5-fold increase in mortality.

Pain management in the orthopaedic trauma patient: Non-opioid solutions

When treating pain in the orthopaedic trauma patient opioids have classically represented the mainstay of treatment. They are relatively inexpensive and modestly effective for basic pain management. However, they are fraught with considerable side effects as well as the very high risk of addiction. Their use in pain management has been implicated in the opioid epidemic. For this reason, as well as their only moderate efficacy, alternative modes of treatment have been sought for both the patient with isolated limb trauma and the patient with poly trauma. We review alternative treatment methods in pain management for those with isolated limb trauma and poly trauma. These methods include topical agents, as well as non steroidal anti-inflammatory medications, acetaminophen, gabapetoids, intravenous agents, varying degrees of local anesthetic infiltration and peripheral nerve blocks, and the newer modality of fascial plane blocks. Often, it is a combination of these analgesic modalities that gives the most optimum treatment for the trauma patient. This also, more frequently than not, must be individually tailored to the patient, as no two patients act the same in this regard. It is therefore of importance that the physician managing such patients's pain be experienced and well-versed in all these treatment modalities. We also provide a basic stepwise algorithm we have found useful in treating those with single extremity or single site trauma versus those patients with poly trauma and resultant multiple sources as pain generators. It is hoped that this breakdown of the different modalities along with a better understanding of each modality's potential benefits and indications will aid the surgeon in providing better care to patients following orthopedic trauma.

Trauma-associated acute kidney injury

PURPOSE OF REVIEW

A summary of recent research into the epidemiology, cause, management and outcomes of trauma-associated acute kidney injury (AKI). There is an increasing focus on subtypes of AKI to better target clinical management and future research.

RECENT FINDINGS

AKI associated with trauma occurs in 20-24% of patients admitted to ICU. On the basis of creatinine and/or urine output, AKI occurs in the first few days of traumatic illness. Although various associations have been identified, shock and high-volume blood transfusion are the most consistent risks for development of trauma-associated AKI. Short-term outcomes appear worse for patients with AKI, but extent of longer term kidney function recovery remains unknown. Recent research in the general critical care population is beginning to better inform AKI management; however, currently, preventive and supportive strategies remain the mainstay of AKI management after trauma.

SUMMARY

Well-designed, prospective research is required to better understand the phenotype, pathophysiology and recovery trajectory of trauma-associated AKI. Only then can potentially unique therapeutic targets be developed for this common subtype of AKI.

Risk of severe acute kidney injury in multiple trauma patients: Risk estimation based on a national trauma dataset

INTRODUCTION

The development of acute kidney injury (AKI) in trauma patients has been associated with almost three fold increase in overall mortality. However, there is a paucity of information of early recognition of risk factors of severe AKI in trauma patients examining the patient's demography, injury characteristics and comorbidities. The purpose of the study was early identification of risk factors of severe AKI.

METHODS

This retrospective cohort study was performed using 2012-2016, American College of Surgeon Trauma Quality improvement program (ACS-TQIP) data, a national data base of trauma patients in the United State. All adult Trauma patients, age 16 to 89 years old, admitted to the hospital were included in the study. Other variables included; race, sex, initial systolic blood pressure (SBP), SBP<90 mmHg, heart rate, injury severity score (ISS), Glasgow Coma Scale Motor Score (GCSMOT), injury type and patient's comorbidities; diabetes mellitus (DM), hypertension (HTN), congestive heart failure (CHF) and history of smoking. A multiple logistic regression model was used to assess the chance of having severe AKI. The receiver-operating characteristics (ROC) curve was constructed, and the corresponding area-under-the curve (AUC) was calculated. All p values <0.05 was considered statistically significant.

RESULTS

Out of 935,402 trauma victims, 9,281 (0.99%) patients developed severe AKI. There were significant differences found between the groups (severe AKI presence vs AKI absence), regarding median age [IQR] (61[43-75] vs. 53[32-71]; p<0.001), ISS (18[10-29] vs. 12[9-17]; p<0.001), DM (25.6% vs. 13.2%; p<0.001), HTN (48.6% vs. 33.3%; p<0.001), CHF (9.8% vs. 3.4%; p<0.001) and history of smoking (16.5% vs. 21.3%; p<0.001) on univariate analysis. A multivariable analysis showed all variables above had a significant association of the development of severe AKI except history of smoking. Older age, male gender, high ISS, SBP<90 mmHg, history of DM, HTN, CHF had a higher odds of development of severe AKI. The model showed a moderate strength with area under the curve (AUC) value was 0.750 and the 95% confidence intervals were [0.740, 0.759].

CONCLUSION

Current analysis showed certain patients demography, injury characteristics, along with comorbidities are associated with risk of severe AKI.

Incidence of, Risk Factors for, and Mortality Associated With Severe Acute Kidney Injury After Gunshot Wound

IMPORTANCE

Acute kidney injury increases the risk of mortality in hospitalized patients. However, incidence of severe acute kidney injury (SAKI) and its association with mortality in civilians with gunshot wounds (GSWs) is not known.

OBJECTIVE

To determine the incidence of and risk factors associated with SAKI and acute kidney injury requiring dialysis (AKI-D) after GSWs and the association of SAKI and AKI-D with mortality among civilians in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study included civilians with GSW reported to the National Trauma Data Bank between July 1, 2010, and June 30, 2015. Torso GSWs were included in study; GSWs to the head were excluded. The data were analyzed between September and November 2018.

EXPOSURE

Civilians with GSW.

MAIN OUTCOMES AND MEASURES

Incidence of SAKI and AKI-D; association of SAKI and AKI-D with mortality.

RESULTS

Most of the 64 059 civilian GSWs affected men (57 431 [89.7%]) and racial/ethnic minorities (36 205 [56.5%] African American individuals; 9681 [15.1%] Hispanic individuals). Incidence of SAKI was 2.3% (1450 of 64 059), and incidence of AKI-D was 0.9% (588 of 64 059). On multivariate analysis, SAKI was associated with older age (odds ratio [OR], 1.02; 95% CI, 1.01-1.02; P < .001), male sex (OR, 1.37; 95% CI, 1.12-1.66; P = .002), diabetes (OR, 1.55; 95% CI, 1.20-2.00; P = .001), hypertension (OR, 1.76; 95% CI, 1.46-2.11; P < .001), Glasgow Coma Scale score (OR, 0.98; 95% CI, 0.96-0.99; P = .002), sepsis (OR, 13.83; 95% CI, 11.77-16.24; P < .001), hollow viscus injury (OR, 2.31; 95% CI, 2.05-2.59; P < .001), and injury severity score (OR, 1.02; 95% CI, 1.01-1.02; P < .001); AKI-D was associated with systolic blood pressure (OR, 0.99; 95% CI, 0.99-1.00; P < .001), sepsis (OR, 1.56; 95% CI, 1.18-2.04; P = .001), and injury severity score (OR, 1.01; 95% CI, 1.01-1.02; P = .001). Mortality was significantly higher in patients with AKI-D (167 of 588 patients [28.4%]) compared with patients with SAKI (172 of 862 [20.0%]) and no SAKI or AKI-D (5521 of 62 609 [8.8%]) (P < .001). Mortality was associated with older age (OR, 1.01; 95% CI, 1.01-1.01; P < .001), systolic blood pressure (OR, 0.997; 95% CI, 0.997-0.998; P < .001), Glasgow Coma Scale score (OR, 0.87; 95% CI, 0.87-0.88; P < .001), SAKI (OR, 2.32; 95% CI, 1.93-2.79; P < .001), AKI-D (OR, 1.46; 95% CI, 1.12-1.90; P < .001), hollow viscus injury (OR, 1.87; 95% CI, 1.76-1.98; P < .001), and higher injury severity score (OR, 1.01; 95% CI, 1.01-1.01; P < .001). After matching for variables except SAKI or AKI-D, patients with SAKI were twice as likely to die than patients without SAKI (320 of 1391 [23.0%] vs 158 of 1391 [11.4%]; P < .001).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, SAKI among civilians who experienced GSWs was associated with mortality.

Trauma induced acute kidney injury

Background

Injured patients are at risk of developing acute kidney injury (AKI), which is associated with increased morbidity and mortality. The aim of this study is to describe the incidence, timing, and severity of AKI in a large trauma population, identify risk factors for AKI, and report mortality outcomes.

Methods

A prospective observational study of injured adults, who met local criteria for trauma team activation, and were admitted to a UK Major Trauma Centre. AKI was defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression and Cox proportional hazard modelling was used to analyse parameters associated with AKI and mortality.

Results

Of the 1410 patients enrolled in the study, 178 (12.6%) developed AKI. Age; injury severity score (ISS); admission systolic blood pressure, lactate and serum creatinine; units of Packed Red Blood Cells transfused in first 24 hours and administration of nephrotoxic therapy were identified as independent risk factors for the development of AKI. Patients that developed AKI had significantly higher mortality than those with normal renal function (47/178 [26.4%] versus 128/1232 [10.4%]; OR 3.09 [2.12 to 4.53]; p<0.0001). After adjusting for other clinical prognostic factors, AKI was an independent risk factor for mortality.

Conclusions

AKI is a frequent complication following trauma and is associated with prolonged hospital length of stay and increased mortality. Future research is needed to improve our ability to rapidly identify those at risk of AKI, and develop resuscitation strategies that preserve renal function in trauma patients.