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Malbrain MLNG, Tantakoun K, Zara AT, Ferko NC, Kelly T, Dabrowski W. Urine output is an early and strong predictor of acute kidney injury and associated mortality: a systematic literature review of 50 clinical studies. Ann Intensive Care 2024; 14:110. [PMID: 38980557 PMCID: PMC11233478 DOI: 10.1186/s13613-024-01342-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 06/22/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND Although the present diagnosis of acute kidney injury (AKI) involves measurement of acute increases in serum creatinine (SC) and reduced urine output (UO), measurement of UO is underutilized for diagnosis of AKI in clinical practice. The purpose of this investigation was to conduct a systematic literature review of published studies that evaluate both UO and SC in the detection of AKI to better understand incidence, healthcare resource use, and mortality in relation to these diagnostic measures and how these outcomes may vary by population subtype. METHODS The systematic literature review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Data were extracted from comparative studies focused on the diagnostic accuracy of UO and SC, relevant clinical outcomes, and resource usage. Quality and validity were assessed using the National Institute for Health and Care Excellence (NICE) single technology appraisal quality checklist for randomized controlled trials and the Newcastle-Ottawa Quality Assessment Scale for observational studies. RESULTS A total of 1729 publications were screened, with 50 studies eligible for inclusion. A majority of studies (76%) used the Kidney Disease: Improving Global Outcomes (KDIGO) criteria to classify AKI and focused on the comparison of UO alone versus SC alone, while few studies analyzed a diagnosis of AKI based on the presence of both UO and SC, or the presence of at least one of UO or SC indicators. Of the included studies, 33% analyzed patients treated for cardiovascular diseases and 30% analyzed patients treated in a general intensive care unit. The use of UO criteria was more often associated with increased incidence of AKI (36%), than was the application of SC criteria (21%), which was consistent across the subgroup analyses performed. Furthermore, the use of UO criteria was associated with an earlier diagnosis of AKI (2.4-46.0 h). Both diagnostic modalities accurately predicted risk of AKI-related mortality. CONCLUSIONS Evidence suggests that the inclusion of UO criteria provides substantial diagnostic and prognostic value to the detection of AKI.
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Affiliation(s)
- Manu L N G Malbrain
- First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland.
- International Fluid Academy, Lovenjoel, Belgium.
- Medical Data Management, Medaman, Geel, Belgium.
| | - Krista Tantakoun
- Value & Evidence Division, Marketing and Market Access, EVERSANA™, Burlington, ON, Canada
| | - Anthony T Zara
- Value & Evidence Division, Marketing and Market Access, EVERSANA™, Burlington, ON, Canada
| | - Nicole C Ferko
- Value & Evidence Division, Marketing and Market Access, EVERSANA™, Burlington, ON, Canada
| | - Timothy Kelly
- Becton, Dickinson and Company, Franklin Lakes, NJ, USA
| | - Wojciech Dabrowski
- First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
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2
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Bianchi NA, Altarelli M, Monard C, Kelevina T, Chaouch A, Schneider AG. Identification of an optimal threshold to define oliguria in critically ill patients: an observational study. Crit Care 2023; 27:207. [PMID: 37254158 DOI: 10.1186/s13054-023-04505-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/23/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND The relevance of current consensus threshold to define oliguria has been challenged by small observational studies. We aimed to determine the optimal threshold to define oliguria in critically-ill patients. METHODS Cohort study including adult patients admitted within a multi-disciplinary intensive care unit between January 1st 2010 and June 15th 2020. Patients on chronic dialysis or who declined consent were excluded. We extracted hourly urinary output (UO) measurements along with patient's characteristics from electronic medical records and 90-day mortality from the Swiss national death registry. We randomly split our data into a training (80%) and a validation (20%) set. In the training set, we developed multivariable models to assess the relationship between 90-day mortality and the minimum average UO calculated over time windows of 3, 6, 12 and 24 h. Optimal thresholds were determined by visually identifying cut-off values for the minimum average UO below which predicted mortality increased substantially. We tested models' discrimination and calibration on the entire validation set as well as on a subset of patients with oliguria according to proposed thresholds. RESULTS Among the 15,500 patients included in this analysis (training set: 12,440, validation set: 3110), 73.0% (95% CI [72.3-73.8]) presented an episode of oliguria as defined by consensus criteria (UO < 0.5 ml/kg/h for 6 h). Our models had excellent (AUC > 85% for all time windows) discrimination and calibration. The relationship between minimum average UO and predicted 90-day mortality was nonlinear with an inflexion point at 0.2 ml/kg/h for 3 and 6 h windows and 0.3 ml/kg/h for 12 and 24 h windows. Considering a threshold of < 0.2 ml/kg/h over 6 h, the proportion of patients with an episode of oliguria decreased substantially to 24.7% (95% CI [24.0-25.4]). Contrary to consensus definition, this threshold identified a population with a higher predicted 90-day mortality. CONCLUSIONS The widely used cut-off for oliguria of 0.5 ml/kg/h over 6 h may be too conservative. A cut-off of 0.2 ml/kg/h over 3 or 6 h is supported by the data and should be considered in further definitions of oliguria.
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Affiliation(s)
- Nathan Axel Bianchi
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), 46, Avenue du Bugnon, 1011, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Marco Altarelli
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), 46, Avenue du Bugnon, 1011, Lausanne, Switzerland
| | - Céline Monard
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), 46, Avenue du Bugnon, 1011, Lausanne, Switzerland
| | - Tatiana Kelevina
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), 46, Avenue du Bugnon, 1011, Lausanne, Switzerland
| | - Aziz Chaouch
- Department of Epidemiology and Health Systems, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Antoine Guillaume Schneider
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), 46, Avenue du Bugnon, 1011, Lausanne, Switzerland.
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
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3
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Fu J, Kosaka J, Morimatsu H. Impact of Different KDIGO Criteria on Clinical Outcomes for Early Identification of Acute Kidney Injury after Non-Cardiac Surgery. J Clin Med 2022; 11:jcm11195589. [PMID: 36233456 PMCID: PMC9571209 DOI: 10.3390/jcm11195589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
The Kidney Disease Improving Global Outcomes (KDIGO) guidelines are currently used in acute kidney injury (AKI) diagnosis and include both serum creatinine (SCR) and urine output (UO) criteria. Currently, many AKI-related studies have inconsistently defined AKI, which possibly affects the comparison of their results. Therefore, we hypothesized that the different criteria in the KDIGO guidelines vary in measuring the incidence of AKI and its association with clinical outcomes. We retrospectively analyzed that data of patients admitted to the intensive care unit after non-cardiac surgery in 2019. Three different criteria used to define AKI were included: UOmean, mean UO < 0.5 mL/kg/h over time; UOcont, hourly UO < 0.5 mL/kg/h over time; or SCR, KDIGO guidelines SCR criteria. A total of 777 patients were included, and the incidence of UOmean-AKI was 33.1%, the incidence of UOcont-AKI was 7.9%, and the incidence of SCR-AKI was 2.0%. There were differences in the length of ICU stay and hospital stay between AKI and non-AKI patients under different criteria. We found differences in the incidence and clinical outcomes of AKI after non-cardiac surgery when using different KDIGO criteria.
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Affiliation(s)
| | - Junko Kosaka
- Correspondence: ; Tel.: +81-86-235-7327; Fax: +81-86-235-7329
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4
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Brothers TN, Strock J, LeMasters TJ, Pawasauskas J, Reed RC, Al-Mamun MA. Survival and recovery modeling of acute kidney injury in critically ill adults. SAGE Open Med 2022; 10:20503121221099359. [PMID: 35652035 PMCID: PMC9150243 DOI: 10.1177/20503121221099359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/21/2022] [Indexed: 11/15/2022] Open
Abstract
Objectives: Acute kidney injury is common among the critically ill. However, the incidence, medication use, and outcomes of acute kidney injury have been variably described. We conducted a single-center, retrospective cohort study to examine the risk factors and correlates associated with acute kidney injury in critically ill adults with a particular focus on medication class usage. Methods: We reviewed the electronic medical records of all adult patients admitted to an intensive care unit between 1 February and 30 August 2020. Acute kidney injury was defined by the 2012 Kidney Disease: Improving Global Outcomes guidelines. Data included were demographics, comorbidities, symptoms, laboratory parameters, interventions, and outcomes. The primary outcome was acute kidney injury incidence. A Least Absolute Shrinkage and Selection Operator regression model was used to determine risk factors associated with acute kidney injury. Secondary outcomes including acute kidney injury recovery and intensive care unit mortality were analyzed using a Cox regression model. Results: Among 226 admitted patients, 108 (47.8%) experienced acute kidney injury. 37 (34.3%), 39 (36.1%), and 32 patients (29.6%) were classified as acute kidney injury stages I–III, respectively. Among the recovery and mortality cohorts, analgesics/sedatives, anti-infectives, and intravenous fluids were significant (p-value < 0.05). The medication classes IV-fluid electrolytes nutrition (96.7%), gastrointestinal (90.2%), and anti-infectives (81.5%) were associated with an increased odds of developing acute kidney injury, odd ratios: 1.27, 1.71, and 1.70, respectively. Cox regression analyses revealed a significantly increased time-varying mortality risk for acute kidney injury-stage III, hazard ratio: 4.72 (95% confidence interval: 1–22.33). In the recovery cohort, time to acute kidney injury recovery was significantly faster in stage I, hazard ratio: 9.14 (95% confidence interval: 2.14–39.06) cohort when compared to the stage III cohort. Conclusion: Evaluation of vital signs, laboratory, and medication use data may be useful to determine acute kidney injury risk stratification. The influence of particular medication classes further impacts the risk of developing acute kidney injury, necessitating the importance of examining pharmacotherapeutic regimens for early recognition of renal impairment and prevention.
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Affiliation(s)
- Todd N Brothers
- College of Pharmacy, The University of Rhode Island, Kingston, RI, USA
| | - Jacob Strock
- Graduate School of Oceanography, The University of Rhode Island, Narragansett, RI, USA
| | - Traci J LeMasters
- School of Pharmacy, University of West Virginia, Morgantown, WV, USA
| | - Jayne Pawasauskas
- College of Pharmacy, The University of Rhode Island, Kingston, RI, USA
| | - Ronald C Reed
- Graduate School of Oceanography, The University of Rhode Island, Narragansett, RI, USA
| | - Mohammad A Al-Mamun
- Graduate School of Oceanography, The University of Rhode Island, Narragansett, RI, USA
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5
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Birkelo BC, Pannu N, Siew ED. Overview of Diagnostic Criteria and Epidemiology of Acute Kidney Injury and Acute Kidney Disease in the Critically Ill Patient. Clin J Am Soc Nephrol 2022; 17:717-735. [PMID: 35292532 PMCID: PMC9269585 DOI: 10.2215/cjn.14181021] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Since the description ischuria renalis by William Heberden (1), AKI has remained a prominent complication of critical illness. Beyond KRT, treatment has been limited by the capacity to phenotype this condition. Here, we chronicle the evolution of attempts to classify AKI, including the adoption of consensus definitions, the expansion of diagnosis and prognosis with novel biomarkers, and emerging tools such as artificial intelligence (AI).
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Affiliation(s)
- Bethany C. Birkelo
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neesh Pannu
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Edward D. Siew
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
- Health Services Research and Development, Veterans Affairs Tennessee Valley, Nashville, Tennessee
- Veterans Affairs Geriatrics Research Education and Clinical Center (GRECC), Tennessee Valley Health System (THVS), Veteran’s Health Administration, Nashville, Tennessee
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Dong GY, Qin JP, An Y, Kang Y, Yu X, Zhao M, Ma X, Ai Y, Xu Y, Xi X, Qian C, Wu D, Sun R, Li S, Hu Z, Cao X, Zhou F, Jiang L, Lin J, Chen E, Qin T, He Z, Zhu J, Du B. Utilizing reclassification to explore characteristics and prognosis of KDIGO SCr AKI subgroups: a retrospective analysis of a multicenter prospective cohort study. Ren Fail 2021; 43:1569-1576. [PMID: 34860139 PMCID: PMC8648037 DOI: 10.1080/0886022x.2021.1997761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is widespread in the intensive care unit (ICU) and affects patient prognosis. According to Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, the absolute and relative increases of serum creatinine (Scr) are classified into the same stage. Whether the prognosis of the two types of patients is similar in the ICU remains unclear. METHODS According to the absolute and relative increase of Scr, AKI stage 1 and stage 3 patients were divided into stage 1a and 1b, stage 3a and 3b groups, respectively. Their demographics, laboratory results, clinical characteristics, and outcomes were analyzed retrospectively. RESULTS Of the 345 eligible cases, we analyzed stage 1 because stage 3a group had only one patient. Using 53 or 61.88 µmol/L as the reference Scr (Scrref), no significant differences were observed in ICU mortality (P53=0.076, P61.88=0.070) or renal replacement therapy (RRT) ratio, (P53=0.356, P61.88=0.471) between stage 1a and 1b, but stage 1b had longer ICU length of stay (LOS) than stage 1a (P53<0.001, P61.88=0.032). In the Kaplan-Meier survival analysis, no differences were observed in ICU mortality between stage 1a and 1b (P53=0.378, P61.88=0.255). In a multivariate analysis, respiratory failure [HR = 4.462 (95% CI 1.144-17.401), p = 0.031] and vasoactive drug therapy [HR = 4.023 (95% CI 1.584-10.216), p = 0.003] were found to be independently associated with increased risk of death. CONCLUSION ICU LOS benefit was more prominent in KDIGOSCr AKI stage 1a patients than in stage 1 b. Further prospective studies with a larger sample size are necessary to confirm the effectiveness of reclassification.
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Affiliation(s)
- Gui-Ying Dong
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China.,Trauma Intensive Care Unit, Peking University People's Hospital, Key Laboratory of Trauma and Neural Regeneration (Peking University); Ministry of Education, Beijing, China
| | - Jun-Ping Qin
- Department of Critical Care Medicine, Tsinghua changgung Hospital, Beijing, China
| | - Youzhong An
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Xiangyou Yu
- Department of Critical Care Medicine, First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Mingyan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Xiaochun Ma
- Department of Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Yuhang Ai
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Yuan Xu
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Xiuming Xi
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
| | - Chuanyun Qian
- Department of Emergency Medicine, The First Affiliated Hospital of Kunming Medical College, Kunming, China
| | - Dawei Wu
- Department of Critical Care Medicine, Qilu Hospital, Shandong University, Jinan, China
| | - Renhua Sun
- Department of Critical Care Medicine, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Shusheng Li
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Zhenjie Hu
- Department of Critical Care Medicine, Hebei Medical University Fourth Hospital, Shijiazhuang, China
| | - Xiangyuan Cao
- Department of Critical Care Medicine, Affiliated Hospital of Ningxia Medical University, Yinchuan, China
| | - Fachun Zhou
- Department of Critical Care Medicine, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Li Jiang
- Department of Critical Care Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jiandong Lin
- Department of Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Erzhen Chen
- Department of Emergency Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Tiehe Qin
- Department of Critical Care Medicine, Guangdong General Hospital, Guangzhou, China
| | - Zhenyang He
- Department of Critical Care Medicine, Hainan Provincial People's Hospital, Haikou, China
| | - Jihong Zhu
- Department of Emergency Medicine, Peking University People's Hospital, Beijing, China
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
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7
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Bianchi NA, Stavart LL, Altarelli M, Kelevina T, Faouzi M, Schneider AG. Association of Oliguria With Acute Kidney Injury Diagnosis, Severity Assessment, and Mortality Among Patients With Critical Illness. JAMA Netw Open 2021; 4:e2133094. [PMID: 34735011 PMCID: PMC8569487 DOI: 10.1001/jamanetworkopen.2021.33094] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/06/2021] [Indexed: 12/21/2022] Open
Abstract
Importance The current definition and staging of acute kidney injury (AKI) considers alterations in serum creatinine (sCr) level and urinary output (UO). However, the relevance of oliguria-based criteria is disputed. Objective To determine the contribution of oliguria, as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria, to AKI diagnosis, severity assessment, and short- and long-term outcomes. Design, Setting, and Participants This cohort study included adult patients admitted to a multidisciplinary intensive care unit from January 1, 2010, to June 15, 2020. Patients receiving long-term dialysis and those who declined consent were excluded. Daily sCr level and hourly UO measurements along with sociodemographic characteristics and severity scores were extracted from electronic medical records. Long-term mortality was assessed by cross-referencing the database with the Swiss national death registry. The onset and severity of AKI according to the KDIGO classification was determined using UO and sCr criteria separately, and their agreement was assessed. Main Outcomes and Measures Using a multivariable model accounting for baseline characteristics, severity scores, and sCr stages, the association of UO criteria with 90-day mortality was evaluated. Sensitivity analyses were conducted to assess how missing sCr, body weight, and UO values, as well as different sCr baseline definitions and imputations methods, would affect the main results. Results Among the 15 620 patients included in the study (10 330 men [66.1%] with a median age of 65 [IQR, 53-75] years, a median Simplified Acute Physiology Score II score of 40.0 [IQR, 30.0-53.0], and a median follow-up of 67.0 [IQR, 34.0-100.0] months), 12 143 (77.7%) fulfilled AKI criteria. Serum creatinine and UO criteria had poor agreement on AKI diagnosis and staging (Cohen weighted κ, 0.36; 95% CI, 0.35-0.37; P < .001). Compared with the isolated use of sCr criteria, consideration of UO criteria enabled identification of AKI in 5630 patients (36.0%). Those patients had a higher 90-day mortality than patients without AKI (724 of 5608 [12.9%] vs 288 of 3462 [8.3%]; P < .001). On multivariable analysis accounting for sCr stage, comorbidities, and illness severity, UO stages 2 and 3 were associated with a higher 90-day mortality (odds ratios, 2.4 [95% CI, 1.6-3.8; P < .001] and 6.2 [95% CI, 3.7-10.5; P < .001], respectively). These results remained significant in all sensitivity analyses. Conclusions and Relevance The findings of this cohort study suggest that oliguria lasting more than 12 hours (KDIGO stage 2 or 3) has major AKI diagnostic implications and is associated with outcomes irrespective of sCr elevations.
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Affiliation(s)
- Nathan Axel Bianchi
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Louis Léon Stavart
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Marco Altarelli
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Tatiana Kelevina
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Mohamed Faouzi
- Division of Biostatistics, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Antoine Guillaume Schneider
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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8
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Vodovar D, Peyre H, Mégarbane B. Relationship between acute kidney injury and mortality in poisoning - a systematic review and metanalysis. Clin Toxicol (Phila) 2021; 59:771-779. [PMID: 34080503 DOI: 10.1080/15563650.2021.1928161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
RATIONALE Three consensus classifications of acute kidney injury have been published. These are RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease published by the Acute Dialysis Quality Initiative workgroup), AKIN (published by the Acute Kidney Injury Network) and KDIGO (published by the Kidney Disease Improving Global Outcome workgroup). Acute kidney injury has been reported consistently as associated with worsened outcomes. However, toxicant-related acute kidney injury has been excluded from the studies used to validate the classifications of acute kidney injury. OBJECTIVE To study whether poisoned patients who develop acute kidney injury, as defined by consensus definitions/classifications, have higher mortality compared to those who did not. METHODS Databases were searched from 2004 to 2019 using the following keywords (KDIGO OR "Kidney Disease: Improving Global Outcomes" OR "Kidney Disease Improving Global Outcomes" OR AKIN OR "AKI network" OR "Acute kidney Injury Network" OR ADQI OR RIFLE OR "Acute dialysis quality initiative") AND (intoxication OR poisoning OR overdose OR ingestion) AND (AKI OR kidney OR renal OR ARF). If data were available, we used a random-effects meta-analysis model and Fisher's exact test to compare mortality in patients according to kidney function definitions (acute kidney injury vs not) and stages (stages vs no acute kidney injury), respectively. If data were available, we assessed the correlation between mortality and renal function (no acute kidney injury, risk/stage 1, injury/stage 2 and failure/stage 3) using the Spearman correlation. If available, we collected the results of statistical analyses in studies that have used acute kidney injury to predict mortality. RESULTS Study selection. Thirty-three relevant studies were found, 22/33 retrospective studies (67%) and 11/33 prospective studies (33%). Paraquat was the most frequent toxicant involved (13/33, 39%). We found a disparity between studies regarding the timeframe during which mortality was assessed, the temporality of the renal function considered to predict mortality (initial/worst) and the criteria used to define/grade acute kidney injury across studies. Univariate association between acute kidney injury definitions/stages and mortality. Consensus definitions/staging of acute kidney injury were associated with higher mortality, using univariate analyses, in twenty-eight (RIFLE = 7; AKIN = 12; KDIGO = 9) studies included but not in five (AKIN = 4, KDIGO = 1). When available data were pooled, RIFLE (5 studies), AKIN (16 studies) and KDIGO definitions (8 studies) of acute kidney injury were associated with a higher mortality (Log unadjusted Odds ratios [95%-confidence interval], 2.60 [2.23; 2.97], 2.02 [1.48; 2,52] and 3.22 [2,65; 3.78], respectively). However, we found high heterogeneity (I2=54,7%) and publication bias among studies using AKIN. In ten studies with available data, the correlation between renal function (no acute kidney injury, risk/stage 1, injury/stage 2, failure/stage 3) and mortality was significant in 5 studies (RIFLE = 2; AKIN = 3), but not in five studies (RIFLE = 1; AKIN = 3; KDIGO = 1).Multivariate association between acute kidney injury definitions/stages and mortality. The definitions of acute kidney injury were associated with higher mortality in two studies (RIFLE = 2), but not in four studies (AKIN = 1 and KDIGO = 3. The stages of acute kidney injury (including one or more stages) were associated with higher mortality in four (RIFLE = 1, AKIN = 1 and KDIGO = 2). CONCLUSIONS All three consensus definitions/classifications were associated independently with increased mortality in poisoning but with disparity between studies reporting acute kidney injury.
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Affiliation(s)
- Dominique Vodovar
- Paris Poison Control Centre, Federation of Toxicology APHP, Fernand Widal Hospital, Paris, France.,University of Paris, Inserm UMRS 1144, Paris, France.,University of Paris, Medical school, Paris, France
| | - Hugo Peyre
- University of Paris, Medical school, Paris, France.,Neurodiderot. INSERM UMR 1141, Paris Diderot University, Paris, France.,Department of Child and Adolescent Psychiatry, Robert Debré Hospital, APHP, Paris, France
| | - Bruno Mégarbane
- University of Paris, Inserm UMRS 1144, Paris, France.,University of Paris, Medical school, Paris, France.,Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France
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9
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Zaky A, Younan DS, Meers B, Davies J, Pereira S, Melvin RL, Kidd B, Morgan C, Tolwani A, Pittet JF. End-of-Procedure Volume Responsiveness Defined by the Passive Leg Raise Test Is Not Associated With Acute Kidney Injury After Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2020; 35:1299-1306. [PMID: 33317887 DOI: 10.1053/j.jvca.2020.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Renal hypoperfusion is a common mechanism of cardiac surgery-related acute kidney injury (CS-AKI). However, the optimal amount of volume resuscitation to correct systemic hypoperfusion and prevent the postoperative development of CS-AKI has been a subject of debate. The goal of this study was to assess the association of volume responsiveness determined by stroke volume variation using the passive leg raise test (PLRT) at chest closure, with the development of CS-AKI according to the Kidney Disease Improving Global Outcomes criteria. DESIGN Single-center, prospective observational study. SETTING Tertiary hospital. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 131 patients were studied from January 2015 until May 2017. All patients underwent cardiac surgery that required cardiopulmonary bypass. Volume responsiveness was assessed at chest closure using the PRLT. Stroke volume variation from the sitting to the recumbent positions was measured by transesophageal echocardiography. Fluid responsiveness was defined as an increase of >12% of stroke volume from sitting to recumbent positions. A total of 82 (68.3%) patients were fluid-responsive versus 38 (31.6%) who were fluid-unresponsive. CS-AKI occurred in 30% of patients. There was no difference in CS-AKI between fluid-responsive and fluid-nonresponsive groups. However, CS-AKI was associated independently with an increases in body mass index and preoperative diastolic blood pressure. CS-AKI also was associated with prolonged intensive care unit length of stay. CONCLUSION End-of-procedure volume responsiveness is not associated with a high risk for postoperative CS-AKI.
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Affiliation(s)
- Ahmed Zaky
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL.
| | - Duraid S Younan
- Department of Surgery, Cleveland University Hospitals, Cleveland, OH
| | - Bradley Meers
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - James Davies
- Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Sara Pereira
- Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Ryan L Melvin
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Brent Kidd
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Charity Morgan
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
| | - Ashita Tolwani
- Department of Nephrology, University of Alabama at Birmingham, Birmingham, AL
| | - Jean Francois Pittet
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
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10
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Abstract
Acute kidney injury (AKI) is a common and critical clinical disorder with non-negligible morbidity and mortality and remains a large public health problem. Asia, as the world's largest and most populous continent, is crucial in eliminating unsatisfactory outcomes of AKI. The diversities in climate, customs, and economic status lead to various clinical features of AKI across Asia. In this review, we focus on the epidemiologic data and clinical features of AKI in different Asian countries and clinical settings, and we show the huge medical and economic burden of AKI in Asian countries. Drugs and sepsis are the most common etiologies for AKI, however, an adequate surveillance system has not been well established. There is significant undertreatment of AKI in many regions, and medical resources for renal replacement therapy are not universally available. Although substantial improvement has been achieved, health care for AKI still needs improvement, especially in developing regions.
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Affiliation(s)
- Junwen Huang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China; Peking University Institute of Nephrology, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Damin Xu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China; Peking University Institute of Nephrology, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Li Yang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China; Peking University Institute of Nephrology, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.
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11
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Lionaki S, Liapis G, Boletis JN. Pathogenesis and Management of Acute Kidney Injury in Patients with Nephrotic Syndrome Due to Primary Glomerulopathies. ACTA ACUST UNITED AC 2019; 55:medicina55070365. [PMID: 31336742 PMCID: PMC6681356 DOI: 10.3390/medicina55070365] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 07/03/2019] [Accepted: 07/08/2019] [Indexed: 01/10/2023]
Abstract
Acute kidney injury in the context of nephrotic syndrome is a serious and alarming clinical problem. Largely, acute kidney injury is a relatively frequent complication among patients with comorbidities while it has been independently associated with an increased risk of adverse outcomes, including death and chronic kidney disease. Nephrotic syndrome, without hematuria or with minimal hematuria, includes a list of certain glomerulopathies; minimal change disease, focal segmental glomerulosclerosis and membranous nephropathy. In the light of primary nephrotic syndrome, pathophysiology of acute kidney injury is differentiated by the nature of the primary disease and the severity of the nephrotic state. This review aims to explore the clinical circumstances and pathogenetic mechanisms of acute kidney injury in patients with nephrotic syndrome due to primary glomerulopathies, focusing on newer perceptions regarding the pathogenesis and management of this complicated condition, for the prompt recognition and timely initiation of appropriate treatment in order to restore renal function to its baseline level. Prompt recognition of the precise cause of acute kidney injury is crucial for renal recovery. Clinical characteristics, laboratory and serological findings along with histopathological findings, if required, will reveal the implicated pathway leading to individualized approach and management.
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Affiliation(s)
- Sophia Lionaki
- Nephrology Department & Transplantation Unit, Laiko Hospital, Faculty of Medicine, National & Kapodistrian University of Athens, 11527 Athens, Greece.
| | - George Liapis
- Department of Pathology, Laiko Hospital, Faculty of Medicine, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - John N Boletis
- Nephrology Department & Transplantation Unit, Laiko Hospital, Faculty of Medicine, National & Kapodistrian University of Athens, 11527 Athens, Greece
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12
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Ju XF, Wang F, Wang L, Wu X, Jiang TT, You DL, Yang BH, Xia JJ, Hu SY. Dynamic Change of Red Cell Distribution Width Levels in Prediction of Hospital Mortality in Chinese Elderly Patients with Septic Shock. Chin Med J (Engl) 2018; 130:1189-1195. [PMID: 28485319 PMCID: PMC5443025 DOI: 10.4103/0366-6999.205858] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background: The normal range of red cell distribution width (RDW) level is <15%. Several studies have indicated that a high RDW level was associated with mortality in critically ill patients, and the patients with a high RDW level need increased focus in clinical practice. In view of the difficulty in defining the specific value of high RDW level, the key is to focus on the patient with the level beyond the normal upper limit. This study aimed to determine whether dynamic change of RDW levels, rather than the level itself, is predictive of death in elderly patients with septic shock when RDW level is beyond 15%. Methods: Between September 2013 and September 2015, the elderly septic shock patients with RDW level beyond 15% were enrolled in this study. The RDW levels were measured at enrollment (day 1), and days 4 and 7 after enrollment. Sequential Organ Failure Assessment (SOFA) scores were recorded simultaneously. Results: A total of 45 patients, including 32 males and 13 females, were included in the final analysis. Based on their hospital outcomes, these patients were divided into the survivor group (n = 26) and the nonsurvivor group (n = 19). There were no significant differences in age, gender, body mass index, initial level of RDW, Acute Physiology and Chronic Health Evaluation II scores, and SOFA scores between survivors and nonsurvivors. At days 4 and 7 measurement, both RDW level (median [interquartile range]: day 4: 15.8 [2.0]% vs. 16.7 [2.0]%, P = 0.011; and day 7: 15.6 [1.8]% vs. 17.7 [2.5]%, P = 0.001) and SOFA scores (day 4: 7.0 [4.0] vs. 16.0 [5.0], P < 0.001, day 7: 5.5 [4.0] vs. 17.0 [5.0], P < 0.001) were significantly lower in survivors than those in nonsurvivors. Dynamic changes of RDW and SOFA scores in survivor group were significantly different from those in nonsurvivor group (all P < 0.05). Continuous increase in RDW level was observed in 10 of the 13 nonsurvivors, but only in 3 of the 26 survivors. The level of RDW7 and dynamic changes significantly correlated with their counterparts of SOFA scores (all P < 0.05), whereas the levels of RDW1 and RDW4 had no significant correlation with their counterparts of SOFA scores (all P > 0.05). Conclusions: Continuous increase in RDW level, rather than the level of RDW itself, was more useful in predicting hospital death in elderly patients with septic shock when the level of RDW was >15%. The dynamic changes of RDW were highly correlated with the SOFA score in the patients.
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Affiliation(s)
- Xue-Feng Ju
- Department of Emergency Medicine, Shanghai Jiading District Central Hospital, Shanghai 201800, China
| | - Fei Wang
- Department of Critical Care Medicine, Shanghai Jiading District Central Hospital, Shanghai 201800, China
| | - Li Wang
- Department of Emergency Medicine, Shanghai Jiading District Central Hospital, Shanghai 201800, China
| | - Xiao Wu
- Department of Emergency Medicine, Shanghai Jiading District Central Hospital, Shanghai 201800, China
| | - Ting-Ting Jiang
- Department of Critical Care Medicine, Shanghai Jiading District Central Hospital, Shanghai 201800, China
| | - Da-Li You
- Department of Critical Care Medicine, Shanghai Jiading District Central Hospital, Shanghai 201800, China
| | - Bing-Hua Yang
- Department of Emergency Medicine, Shanghai Jiading District Central Hospital, Shanghai 201800, China
| | - Jian-Jun Xia
- Department of Emergency Medicine, Shanghai Jiading District Central Hospital, Shanghai 201800, China
| | - Shan-You Hu
- Department of Critical Care Medicine, Shanghai Jiading District Central Hospital, Shanghai 201800, China
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13
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Glassford NJ, Bellomo R. The Role of Oliguria and the Absence of Fluid Administration and Balance Information in Illness Severity Scores. Korean J Crit Care Med 2017; 32:106-123. [PMID: 31723625 PMCID: PMC6786718 DOI: 10.4266/kjccm.2017.00192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/05/2017] [Indexed: 01/18/2023] Open
Abstract
Urinary examination has formed part of patient assessment since the earliest days of medicine. Current definitions of oliguria are essentially arbitrary, but duration and intensity of oliguria have been associated with an increased risk of mortality, and this risk is not completely attributable to the development of concomitant acute kidney injury (AKI) as defined by changes in serum creatinine concentration. The increased risk of death associated with the development of AKI itself may be modified by directly or indirectly by progressive fluid accumulation, due to reduced elimination and increased fluid administration. None of the currently extant major illness severity scoring systems or outcome prediction models use modern definitions of AKI or oliguria, or any values representative of fluid volumes variables. Even if a direct relationship with mortality is not observed, then it is possible that fluid balance or fluid volume variables mediate the relationship between illness severity and mortality in the renal and respiratory physiological domains. Fluid administration and fluid balance may then be an important, easily modifiable therapeutic target for future investigation. These relationships require exploration in large datasets before being prospectively validated in groups of critically ill patients from differing jurisdictions to improve prognostication and mortality prediction.
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Affiliation(s)
- Neil J Glassford
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Australia.,School of Medicine, The University of Melbourne, Melbourne, Australia
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