Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study.

World Kidney Day 2013: Acute Kidney Injury—Global Health Alert

This study was to investigate the association between albumin-corrected anion gap (AG) (ACAG) levels and the risk of acute kidney injury (AKI) in intensive care unit (ICU) patients. The ICU patients of this retrospective cohort study were collected from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database between 2008 and 2019. ACAG = AG + {4.4-[albumin (g/dl)]} × 2.5. The incidence of AKI was determined using the Kidney Disease: Improving Global Outcomes (KDIGO) definition. The logistic regression model was used to evaluate the association between ACAG levels and the risk of AKI. Subgroup analyses were applied based on age, gender, mechanical ventilation, vasopressors, the Charlson comorbidity index (CCI), and the Simplified Acute Physiology Score II (SAPS II). Totally, 5586 patients were enrolled, of which 1929 patients (34.53%) occurred AKI. The higher levels of ACAG were associated with the risk of AKI in ICU patients, with the odds ratio (OR) value being 1.23 [95% confidence interval (CI): 1.22-1.24, P = 0.005] in ACAG level between 16.5 and 19.5, and OR value being 1.20 (95% CI 1.16-1.24, P = 0.016) in ACAG level > 19.5. A higher ACAG level was associated with a higher risk of AKI in ICU patients aged < 65years, in ICU patients of female gender, in ICU patients who used mechanical ventilation, in ICU patients who did not use vasopressors, in patients without cardiogenic shock, and in ICU patients with CCI ≥ 2, and SAPS II > 31 (all P < 0.05). There is an association between ACAG level and the risk of AKI in ICU patients. A higher ACAG value in ICU patients should therefore receive more attention.

Survival outcomes in older patients with different stages of acute kidney injury defined by the addition of urine output criteria.

Perioperative Acute Kidney Injury

Epidemiology and outcomes of acute kidney injury in cardiac intensive care unit patients.

Dear Editor, We thank Dr. Valette and Dr. du Cheyron [1] for their thoughtful comments on our recently published article [2]. We appreciate that they support our hypothesis that acute kidney injury (AKI) in this specific setting is likely caused by multiple factors. Many indications or clinical scenarios for performing a contrastenhanced computed tomography (CT) scan or angiography, such as septic or hemorrhagic shock, may also a contribute to the development of AKI. Therefore, for this specific cohort of intensive care unit (ICU) patients, we chose to use the term contrast-associated AKI (CA-AKI), rather than the generally accepted term contrastinduced AKI. Dr. Valette and Dr. du Cheyron stated that some of our patients probably already had AKI before the administration of contrast agent. This view is supported by the increase in serum creatinine levels between ICU admission and the administration of contrast agent in CA-AKI patients. Following their suggestion, we analyzed the evolution of serum creatinine between the day preceding contrast administration and the day of contrast administration and found that the serum creatinine level actually decreased in patients who developed CA-AKI just before contrast exposure (Table 1). In other words, we did not observe the ‘‘natural evolution of ongoing AKI’’, and contrast exposure most probably played a major role in the pathophysiology of AKI in these patients. Finally, Dr. Valette and Dr. du Cheyron suggested a comparison to a control group of patients who had not been not exposed to contrast agent. For a control group to provide meaningful information, it should have the same characteristics as the intervention group. However, the addition of the suggested control group of patients, namely, those who had undergone a CT scan without contrast agent, would introduce a major bias into the study as there would be a clinical reason why these patients were not administered contrast agent. The two most likely of these would be these patients already had AKI and, therefore, contrast was not administered, or the patients were less severely ill and there was no need to administer the contrast agent. In other words, the control patients would have completely different baseline characteristics. Also, the addition of a control group would exclude 16% of the included patients who underwent an angiography. Finally, there are many roads that will lead to AKI in ICU patients. A certain number of patients in a control group will develop AKI secondary to other reasons. Up to twothirds of ICU patients actually do develop AKI in the ICU [3, 4], and the majority of these patients did so without previous contrast exposure. In other words, the addition of a control group would dilute the signal and lead to false negative results.

Background:Acute kidney injury (AKI) is the most common cause of organ dysfunction in intensive care unit (ICU) patients. There is no consensus definition of AKI in ICU patients. Therefore, we aimed to evaluate the incidence rate, risk factors and clinical outcome of AKI using the RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) classification in ICU patients.Methods:We performed a retrospective cohort study, on 900 patients admitted to the ICU during a one year period at Imam Khomeini Hospital in Ardebil, Iran from 2014 to 2015. AKI was defined by the consensus RIFLE criteria.Results:The overall incidence rate of AKI was 37%. The patients with AKI were also classified according to RIFLE as follows: Risk (8.2%), Injury (13.4%), Failure (13.2%), Loss of kidney function (1.3%), and End-stage kidney disease (0.8%). The mortality rate was 58.3% for AKI patients, and 13.4% for non-AKI patients (P<0.001). Patients in RIFLE-R (Risk) had a mortality rate of 37.8% compared with 48.8% for those in RIFLE-I (Injury) and 76.5% for RIFLE-F (Failure) patients (P<0.0001). Significant risk factors to the development of AKI were included: age more than 60 yr, increased length of hospital stay, systolic blood pressure less than 100 mm Hg, requirement of mechanical ventilation, relevant comorbidities, anemia, thrombocytopenia, increased serum bilirubin and liver enzymes, and serum sodium abnormalities.Conclusion:The RIFLE classification is a useful and suitable clinical tool to evaluate the incidence and mortality rate of AKI. In ICU patients, AKI is associated with increased mortality rate.

Background: Acute kidney injury (AKI) is associated with increased mortality in patients with acute respiratory distress syndrome (ARDS). However, the epidemiological features and outcomes of AKI among COVID-19 patients with ARDS are unknown. Methods: We retrospectively recruited consecutive adult COVID-19 patients who were diagnosed with ARDS according to Berlin definition from 13 designated intensive care units in the city of Wuhan, China. Potential risk factors of AKI as well as the relation between AKI and in-hospital mortality were investigated. Results: A total of 275 COVID-19 patients with ARDS were included in the study, and 49.5% of them developed AKI during their hospital stay. In comparison with patients without AKI, patients who developed AKI were older, tended to have chronic kidney disease, had higher Sepsis-Related Organ Failure Assessment score on day 1, and were more likely to receive invasive ventilation and develop acute organ dysfunction. Multivariate analysis showed that age, history of chronic kidney disease, neutrophil-to-lymphocyte ratio, and albumin level were independently associated with the occurrence of AKI. Importantly, increasing AKI severity was associated with increased in-hospital mortality when adjusted for other potential variables: odds ratio of stage 1 = 5.374 (95% CI: 2.147–13.452; p < 0.001), stage 2 = 6.216 (95% CI: 2.011–19.210; p = 0.002), and stage 3 = 34.033 (95% CI: 9.723–119.129; p < 0.001). Conclusion: In this multicenter retrospective study, we found that nearly half of COVID-19 patients with ARDS experienced AKI during their hospital stay. The coexistence of AKI significantly increased the mortality of these patients.

BackgroundTo construct and validate a risk assessment model for acute kidney injury (AKI) in patients with acute pancreatitis (AP) in the intensive care unit (ICU).MethodsA total of 963 patients diagnosed with acute pancreatitis (AP) from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database was included. These patients were randomly divided into training set (N = 674) and validation set (N = 289) at a ratio of 7:3. Clinical characteristics were utilized to establish a nomogram for the prediction of AKI during ICU stay. These variables were selected by the least absolute shrinkage and selection operation (LASSO) regression and included in multivariate logistic regression analysis. Variables with P-values less than 0.05 were included in the final model. A nomogram was constructed based on the final model. The predicted accuracy of the nomogram was assessed by calculating the receiver operating characteristic curve (ROC) and the area under the curve (AUC). Moreover, calibration curves and Hosmer-Lemeshow goodness-of-fit test (HL test) were performed to evaluate model performance. Decision curve analysis (DCA) evaluated the clinical net benefit of the model.ResultsA multivariable model that included 6 variables: weight, SOFA score, white blood cell count, albumin, chronic heart failure, and sepsis. The C-index of the nomogram was 0.82, and the area under the receiver operating characteristic curve (AUC) of the training set and validation set were 0.82 (95% confidence interval:0.79–0.86) and 0.76 (95% confidence interval: 0.70–0.82), respectively. Calibration plots showed good consistency between predicted and observed outcomes in both the training and validation sets. DCA confirmed the clinical value of the model and its good impact on actual decision-making.ConclusionWe identified risk factors associated with the development of AKI in patients with AP. A risk prediction model for AKI in ICU patients with AP was constructed, and improving the treatment strategy of relevant factors in the model can reduce the risk of AKI in AP patients.

Long-Term Outcomes of Acute Kidney Injury

1.1.Background: Acute kidney injury (AKI) considered as a major public health problem that affects millions of patients worldwide and leads to decreased survival and increased progression of chronic kidney disease (CKD). 1.2.Aim of study: Epidemiology, clinical characteristics and outcome of acute kidney injury in patients admitted to main Alexandria university hospitals over six months. 1.3.Methods:All patients who were admittedto intensive care units (ICUs) at Alexandria University Hospitals wereprospectively studied. Patients whodeveloped ICU-acquired acute renalfailure were collected in the period over six months. 1.4.Results:Our study included 500 patients in general ICU. General ICU patients classified according to renal impairment: 303 cases (no AKI) 60.6%, 74 cases (CKD) 14.8%, 55 cases (AKI) 11%, 38 cases (acute on top of CKD) 7.6%, 28 cases (ESRD) 5.6%, 2 cases (obstructive uropathy) 0.4%. Bimodal distribution of age in patients developed AKI at (18-30y) & (62-85y). 75 Toxicological cases, 3 developed AKI (2 organo phosphorus & 1 scorpion bite). The most common cause of AKI in our study was septic AKI 60% & among 128 cases of sepsis 32% not developed AKI/ 25.8% developed septic AKI 32% acute on top of CKD/10.2% ESRD. Mortality rate allover general ICU patients was 140/500 (28%) while allover AKI patients in general ICU 30/55(54%) and allover septic AKI 26/33(79%). 1.5.Conclusion:AKI is a worsening problem, but its true incidence is in need of huge work, our work was 1st up to our knowledge in Alexandria to check its incidence hence planning for better outcome.

Acute kidney injury (AKI) is one of the most common and significant problems in patients with Coronavirus Disease 2019 (COVID-19). However, little is known about the incidence and impact of AKI occurring in the community or early in the hospital admission. The traditional Kidney Disease Improving Global Outcomes (KDIGO) definition can fail to identify patients for whom hospitalisation coincides with recovery of AKI as manifested by a decrease in serum creatinine (sCr). We hypothesised that an extended KDIGO (eKDIGO) definition, adapted from the International Society of Nephrology (ISN) 0by25 studies, would identify more cases of AKI in patients with COVID-19 and that these may correspond to community-acquired AKI (CA-AKI) with similarly poor outcomes as previously reported in this population. All individuals recruited using the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC)-World Health Organization (WHO) Clinical Characterisation Protocol (CCP) and admitted to 1,609 hospitals in 54 countries with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection from February 15, 2020 to February 1, 2021 were included in the study. Data were collected and analysed for the duration of a patient's admission. Incidence, staging, and timing of AKI were evaluated using a traditional and eKDIGO definition, which incorporated a commensurate decrease in sCr. Patients within eKDIGO diagnosed with AKI by a decrease in sCr were labelled as deKDIGO. Clinical characteristics and outcomes-intensive care unit (ICU) admission, invasive mechanical ventilation, and in-hospital death-were compared for all 3 groups of patients. The relationship between eKDIGO AKI and in-hospital death was assessed using survival curves and logistic regression, adjusting for disease severity and AKI susceptibility. A total of 75,670 patients were included in the final analysis cohort. Median length of admission was 12 days (interquartile range [IQR] 7, 20). There were twice as many patients with AKI identified by eKDIGO than KDIGO (31.7% versus 16.8%). Those in the eKDIGO group had a greater proportion of stage 1 AKI (58% versus 36% in KDIGO patients). Peak AKI occurred early in the admission more frequently among eKDIGO than KDIGO patients. Compared to those without AKI, patients in the eKDIGO group had worse renal function on admission, more in-hospital complications, higher rates of ICU admission (54% versus 23%) invasive ventilation (45% versus 15%), and increased mortality (38% versus 19%). Patients in the eKDIGO group had a higher risk of in-hospital death than those without AKI (adjusted odds ratio: 1.78, 95% confidence interval: 1.71 to 1.80, p-value < 0.001). Mortality and rate of ICU admission were lower among deKDIGO than KDIGO patients (25% versus 50% death and 35% versus 70% ICU admission) but significantly higher when compared to patients with no AKI (25% versus 19% death and 35% versus 23% ICU admission) (all p-values <5 × 10-5). Limitations include ad hoc sCr sampling, exclusion of patients with less than two sCr measurements, and limited availability of sCr measurements prior to initiation of acute dialysis. An extended KDIGO definition of AKI resulted in a significantly higher detection rate in this population. These additional cases of AKI occurred early in the hospital admission and were associated with worse outcomes compared to patients without AKI.

Case Scenario: Hemodynamic Management of Postoperative Acute Kidney Injury

While considerable information is available on acute kidney injury (AKI) in North America and Europe, large comprehensive epidemiologic studies on AKI from Latin America and Asia are still lacking. The present study aimed to evaluate the epidemiology and outcomes of AKI in patients evaluated by nephrologists in a Brazilian teaching hospital. We performed a large retrospective observational study that looked into the epidemiology of AKI and its effect on patient outcomes across time periods. For comparison purposes, patients were divided into two groups according to the year of follow up: 2011-2014 and 2015-2018. We enrolled 7976 AKI patients and, after excluding patients with chronic kidney disease stages 4 and 5, kidney transplant recipients and those with incomplete data, 5428 AKI patients were included (68%). The maximum AKI stage was 3 (50.6%), and there was a mortality rate of 34.3% (1865 patients). Dialysis treatment was indicated in 928 patients (17.1%). Patient survival improved along the study periods, and patients treated in 2015-2018 had a relative risk death reduction of 0.89 (95% CI 0.81-0.98, p = 0.02). The independent risk factors for mortality were sepsis, > 65years of age, admission to the intensive care unit, AKI-KDIGO 3, recurrent AKI, no metabolic and fluid demand to capacity imbalance (as a dialysis indication), and the period of treatment. We observed an improvement in AKI patient survival over the years, even after correction for several confounders and using a competing risk approach. Identification of risk factors for mortality can help in decision-making for timely intervention, leading to better clinical outcomes.

Epidemiology and Outcomes of Acute Kidney Injury Among Patients in the Intensive Care Units in Laos: A Nationwide Multicenter, Prospective, and Observational Study