Effects of Mean Artery Pressure and Blood pH on Survival Rate of Patients with Acute Kidney Injury Combined with Acute Hypoxic Respiratory Failure: A Retrospective Study.

Chi-Hua Ko,Chia-Wen Kuo,Tien-Tsai Cheng,Chih-Ching Yen,Yu-Hsien Liu,Abdulkadir Cidem,Chuan-Mu Chen,Wei Chen,Ying-Wei Lan,Shan-Fu Yu,Ying-Chou Chen

doi:10.3390/medicina57111243

Abstract

Background and Objectives: In the intensive care unit (ICU), renal failure and respiratory failure are two of the most common organ failures in patients with systemic inflammatory response syndrome (SIRS). These clinical symptoms usually result from sepsis, trauma, hypermetabolism or shock. If this syndrome is caused by septic shock, the Surviving Sepsis Campaign Bundle suggests that vasopressin be given to maintain mean arterial pressure (MAP) > 65 mmHg if the patient is hypotensive after fluid resuscitation. Nevertheless, it is important to note that some studies found an effect of various mean arterial pressures on organ function; for example, a MAP of less than 75 mmHg was associated with the risk of acute kidney injury (AKI). However, no published study has evaluated the risk factors of mortality in the subgroup of acute kidney injury with respiratory failure, and little is known of the impact of general risk factors that may increase the mortality rate. Materials and Methods: The objective of this study was to determine the risk factors that might directly affect survival in critically ill patients with multiple organ failure in this subgroup. We retrospectively constructed a cohort study of patients who were admitted to the ICUs, including medical, surgical, and neurological, over 24 months (2015.1 to 2016.12) at Chiayi Chang Gung Memorial Hospital. We only considered patients who met the criteria of acute renal injury according to the Acute Kidney Injury Network (AKIN) and were undergoing mechanical ventilator support due to acute respiratory failure at admission. Results: Data showed that the overall ICU and hospital mortality rate was 63.5%. The most common cause of ICU admission in this cohort study was cardiovascular disease (31.7%) followed by respiratory disease (28.6%). Most patients (73%) suffered sepsis during their ICU admission and the mean length of hospital stay was 24.32 ± 25.73 days. In general, the factors independently associated with in-hospital mortality were lactate > 51.8 mg/dL, MAP ≤ 77.16 mmHg, and pH ≤ 7.22. The risk of in-patient mortality was analyzed using a multivariable Cox regression survival model. Adjusting for other covariates, MAP ≤ 77.16 mmHg was associated with higher probability of in-hospital death [OR = 3.06 (1.374–6.853), p = 0.006]. The other independent outcome predictor of mortality was pH ≤ 7.22 [OR = 2.40 (1.122–5.147), p = 0.024]. Kaplan-Meier survival curves were calculated and the log rank statistic was highly significant. Conclusions: Acute kidney injury combined with respiratory failure is associated with high mortality. High mean arterial pressure and normal blood pH might improve these outcomes. Therefore, the acid–base status and MAP should be considered when attempting to predict outcome. Moreover, the blood pressure targets for acute kidney injury in critical care should not be similar to those recommended for the general population and might prevent mortality.

Highlights

In intensive care units (ICUs), multiple organ failure is associated with increased mortality and prolonged hospital stay, and renal failure and respiratory failure are the two most common organ failures in critically ill patients [1,2]
There are many recognized risk factors associated with death in ICU with renal failure, including old age, prolonged hospitalization, high Acute Physiology, and Chronic Health Evaluation (APACHE II) score, comorbidities, sepsis, invasive mechanical ventilation, etc. [3]; risk factors for respiratory failure, including old age, immune responses, or coagulation dysfunction have been reported to be associated with death [4]
The main findings in our study were that (a) the ICU mortality rate in acute kidney injury combined with respiratory failure were higher than reported in several other studies [1,2,26]; and (b) the two most important risk factors for death in the ICU were hypotension and acidosis

Summary

Introduction

In intensive care units (ICUs), multiple organ failure is associated with increased mortality and prolonged hospital stay, and renal failure and respiratory failure are the two most common organ failures in critically ill patients [1,2]. Mounting evidence has indicated that the body can tolerate hypotension in this situation and that a high blood pressure target does not result in significant differences in mortality [5,10] It is clearly stated in the sepsis guidelines that it is only necessary to maintain the mean arterial pressure (MAP) above 65 mmHg [11]. In the intensive care unit (ICU), renal failure and respiratory failure are two of the most common organ failures in patients with systemic inflammatory response syndrome (SIRS) These clinical symptoms usually result from sepsis, trauma, hypermetabolism or shock. The blood pressure targets for acute kidney injury in critical care should not be similar to those recommended for the general population and might prevent mortality

Objectives

Results

Discussion

Conclusion