Abstract
IntroductionKnowledge of the association of hemodynamics with progression of septic acute kidney injury (AKI) is limited. However, some recent data suggest that mean arterial pressure (MAP) exceeding current guidelines (60–65 mmHg) may be needed to prevent AKI. We hypothesized that higher MAP during the first 24 hours in the intensive care unit (ICU), would be associated with a lower risk of progression of AKI in patients with severe sepsis.MethodsWe identified 423 patients with severe sepsis and electronically recorded continuous hemodynamic data in the prospective observational FINNAKI study. The primary endpoint was progression of AKI within the first 5 days of ICU admission defined as new onset or worsening of AKI by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. We evaluated the association of hemodynamic variables with this endpoint. We included 53724 10-minute medians of MAP in the analysis. We analysed the ability of time-adjusted MAP to predict progression of AKI by receiver operating characteristic (ROC) analysis.ResultsOf 423 patients, 153 (36.2%) had progression of AKI. Patients with progression of AKI had significantly lower time-adjusted MAP, 74.4 mmHg [68.3-80.8], than those without progression, 78.6 mmHg [72.9-85.4], P < 0.001. A cut-off value of 73 mmHg for time-adjusted MAP best predicted the progression of AKI. Chronic kidney disease, higher lactate, higher dose of furosemide, use of dobutamine and time-adjusted MAP below 73 mmHg were independent predictors of progression of AKI.ConclusionsThe findings of this large prospective multicenter observational study suggest that hypotensive episodes (MAP under 73 mmHg) are associated with progression of AKI in critically ill patients with severe sepsis.
Highlights
Knowledge of the association of hemodynamics with progression of septic acute kidney injury (AKI) is limited
Patients We identified all patients with severe sepsis and electronically recorded continuous hemodynamic data from the prospective observational FINNAKI study that was conducted in 17 Finnish intensive care unit (ICU) between 1 September 2011 and 1 February 2012 [16]
We could not assess the association of the use of colloids, nor on the use of different colloids, particular hydroxyethyl starch (HES), with progression of AKI. In this large prospective study of patients with severe sepsis, we found that time-adjusted mean arterial pressure (MAP) was significantly lower and independently associated with progression of AKI in these patients
Summary
Knowledge of the association of hemodynamics with progression of septic acute kidney injury (AKI) is limited. We hypothesized that higher MAP during the first 24 hours in the intensive care unit (ICU), would be associated with a lower risk of progression of AKI in patients with severe sepsis. Both the incidence of severe sepsis and acute kidney injury (AKI) are increasing [1,2,3]. The reduction in renal blood flow has been proposed to be essential for the establishment of AKI [9]. A recent study reported that the autoregulation of renal blood flow is deranged in critical illness prior to and during AKI, and varies with cardiac output [12]
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