AKIN Definitions Research Articles

The incidence and outcome of AKI in patients with sepsis in the emergency department applying different definitions of AKI and sepsis

BackgroundSepsis is often accompanied with acute kidney injury (AKI). The incidence of AKI in patients visiting the emergency department (ED) with sepsis according to the new SOFA criteria is not exactly known, because the definition of sepsis has changed and many definitions of AKI exist. Given the important consequences of early recognition of AKI in sepsis, our aim was to assess the epidemiology of sepsis-associated AKI using different AKI definitions (RIFLE, AKIN, AKIB, delta check, and KDIGO) for the different sepsis classifications (SIRS, qSOFA, and SOFA).MethodsWe retrospectively enrolled patients with sepsis in the ED in three hospitals and applied different AKI definitions to determine the incidence of sepsis-associated AKI. In addition, the association between the different AKI definitions and persistent kidney injury, hospital length of stay, and 30-day mortality were evaluated.ResultsIn total, 2065 patients were included. The incidence of AKI was 17.7–51.1%, depending on sepsis and AKI definition. The highest incidence of AKI was found in qSOFA patients when the AKIN and KDIGO definitions were applied (51.1%). Applying the AKIN and KDIGO definitions in patients with sepsis according to the SOFA criteria, AKI was present in 37.3% of patients, and using the SIRS criteria, AKI was present in 25.4% of patients. Crude 30-day mortality, prolonged length of stay, and persistent kidney injury were comparable for patients diagnosed with AKI, regardless of the definition used.ConclusionThe incidence of AKI in patients with sepsis is highly dependent on how patients with sepsis are categorised and how AKI is defined. When AKI (any definition) was already present at the ED, 30-day mortality was high (22.2%). The diagnosis of AKI in sepsis can be considered as a sign of severe disease and helps to identify patients at high risk of adverse outcome at an early stage.

Acute Kidney Injury after Liver Resection: A Systematic Review, Meta-Analysis and Metaregression of Factors Affecting It

Aim: This systematic review and meta-analysis aimed to study the incidence of acute kidney injury after liver resection and to analyze various factors affecting it by metaregression analysis. Methods: The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (2020) and MOOSE guidelines. The meta-analysis was done using Review Manager 5.4 and the JASP Team (2020). JASP (Version 0.14.1)(University of Amsterdam). Weighted percentage incidence with 95% confidence intervals were used. Univariate metaregression was done by DerSimonian-Laird methods. Factors with a p-value less than 0.05 in the univariate metaregression model were entered in the multivariate metaregression model. Heterogeneity was assessed using the Higgins I2 test. The random-effects model was used in meta-analysis. Results: Total 14 studies including 15510 patients were included in the final analysis. 1247 patients developed Acute Kidney Injury. Weighted Acute kidney injury percentage after liver resection was 15% with a 95% confidence interval of 11%-19%. On univariate metaregression analysis major hepatectomy (p=0.001), Underlying cirrhosis of liver (p=0.031), AKIN definition used (0.017), male sex (p<0.001), open surgery (p=0.032), underlying diabetes (0.026). On multivariate metaregression analysis major hepatectomy (p=0.003), underlying cirrhosis (p<0.001), male sex (p<0.001), AKIN classification used for defining acute kidney injury (p < 0.001, independently predicted heterogeneity and hence acute kidney injury. Conclusion: Liver resection is associated with a high incidence of acute kidney injury. Major hepatectomy, male sex, underlying cirrhosis were independently predicting acute kidney injury.

MO364ASSOCIATION OF AKI-EVENT DEFINED BY DIFFERENT DEFINITIONS WITH IN-HOSPITAL MORTALITY

Abstract Background and Aims Studies have shown that millions of hospitalized patients suffer from Acute Kidney Injury (AKI) per year which increases mortality risk for these patients. Different definitions for AKI have been proposed during the past years such as RIFLE (2002) and AKIN (2004). In 2012, KDIGO published a clinical practice guideline harmonizing AKIN and RIFLE into one general guideline which classifies AKI into 3 stages, where stage 1 is defined as an absolute increase of SCr ≥ 0.3 mg/dl over 48 hours or a relative increase in SCr ≥ 50% from baseline within the previous 7 days. A recent study [Sparrow et al., 2019] evaluated the impact of further categorizing AKI stage 1 into 2 stages based on SCr criteria. The study separates KDIGO AKI stage 1 and AKIN stage 1 into 2 stages (KDIGO-4 and AKIN-4) based on the different SCr criteria. Having different AKI definitions makes it challenging to analyze AKI incidence and associated outcomes among studies. The present study aimed to investigate the incidence of AKI events defined by 4 different definitions (standard AKIN and KDIGO, and modified AKIN-4 and KDIGO-4) and its association with in-hospital mortality. Method Retrospective clinical data available for all adult (≥18 years old) hospital admissions to a local health district in Athens, Greece between October 1999 and March 2019 was used in the analysis. We excluded patients whose time between admission and discharge was less than 7 days. Also, patients with less than 5 Scr measurements were omitted from the analysis resulting in the final cohort of 7242 admissions. We used the AKIN, KDIGO, AKIN-4, and KDIGO-4 definitions to check the incidence of AKI. As our second goal, we assessed associations of AKI-events with in-hospital mortality, adjusted for characteristics (age, sex, AKI staging) using multivariable logistic regression. Results The incidence of in-hospital AKI using the modified KDIGO-4 was 6.72% for stage 1a, 15.71% for stage 1b, 8.06% for stage 2, and 2.97% for stage 3; however, these percentages for AKIN-4 were 11.5%, 5.83%,1.75%, and 0.33% for stage 1a, stage 1b, stage 2, and stage 3, respectively. Using the standard KDIGO and AKIN definition, 19.08 and 14.05 % developed stage 1, respectively. To find the association between AKI stages and in-hospital mortality, we considered the most severe stage of AKI reached by a patient. Results of logistic regression models show that in-hospital mortality increased as the stage of AKI events increased for both KDIGO-4 and AKIN-4 (Table 1). Table 2 shows the same results using the original KDIGO and AKIN definitions. Conclusion The results of both definitions (AKIN-4 and KDIGO-4) show a significant association with mortality, but KDIGO-4 has a larger odds ratio meaning that AKI classification based on KDIGO-4 has a stronger association with mortality than AKI classification based on AKIN-4. However, based on our results, splitting stage 1 to stage 1a and stage 1b does not seem to make a difference; hence, using KDIGO-4 as a replacement for KDIGO would not have a significant impact on capturing AKI events.

Evaluation of two classical contrast-induced nephropathy definitions for predicting long-term mortality in patients undergoing elective percutaneous coronary intervention

Abstract Background Contrast-induced nephropathy (CIN) is a frequent complication after percutaneous coronary intervention (PCI), and is associated with poor outcome. However, the optimal definition of CIN has been debated because of its different incidence and influence on prognosis. At present, there are limited data regarding th impact of different CIN definitions on long-term mortality in patients undergoing elective PCI. Purpose To explore the influence of two classical CIN definitions on long-term mortality and identify which definition was more suitable for predicting long-term mortality in patients undergoing elective PCI.. Methods We prospectively observed 5600 consenting patients undergoing PCI from January 2012 to December 2018. Two classical CIN definitions include those defined by ESUR[Contrast-media-induced nephrotoxicity (CMN)] and AKIN[contrast induced acute kidney injury (CI-AKI)]. CMN was defined as an increase in serum creatinine (SCr) ≥25% or 0.5 mg/dLabove thebaseline level within 3 days,while CI-AKI wasdefined as an increase in SCr ≥50% or 0.3 mg/dL within 48hs after contrast medium exposure.The association of CIN with long-term mortality was investigated by Cox regression analysis.Interaction analyses were performed for long-term mortality across subgroups. Results The incidence of CIN according to ESUR (CMN) and AKIN (CI-AKI) definition were18.3% (n=1023) and 6.1% (n=342), respectively. During a median follow-up of 2 years, after adjusting other potential risk factors, multivariable cox regression analysis revealed CIN was a risk factor for long-term mortality [hazard ratio (HR): 2.021, 95% confidence interval (CI): 1.389–2.938, P&amp;lt;0.0001] according to AKIN definition, but not for ESUR definition (HR: 1.344, 95% CI: 0.982–1.838, P&amp;gt;0.05). Further interaction analysis showed that there was a significant interaction between age &amp;gt;75ys and CMN for long-term mortality (P=0.042) while no such association was observed between age &amp;gt;75ys and CI-AKI (P=0.806). Conclusions CIN defined by AKIN may be more suitable for predicting long-term mortality in patients undergoing elective PCI. However, in elderly patients, CIN defined by ESUR could also be used for predicting long-term mortality. Association Between CIN and mortality Funding Acknowledgement Type of funding source: None

Urine klotho is a potential early biomarker for acute kidney injury and associated with poor renal outcome after cardiac surgery

BackgroundCurrent paradigms of detecting acute kidney injury (AKI) are insensitive and non-specific. Klotho is a pleiotropic protein that is predominantly expressed in renal tubules. In this study, we evaluated the diagnostic and prognostic roles of urine Klotho for AKI following cardiac surgery.MethodsWe conducted a prospective study involving 91 patients undergoing cardiac surgery. AKI was defined according to the AKIN definition. The renal outcomes within 7 days after operation were evaluated. Perioperative levels of urine Klotho and urine neutrophil gelatinase-associated lipocalin (NGAL) were measured by using ELISA.ResultsOf 91 participants, 33 patients (36.26%) developed AKI. Of these AKI patients, 21 (63.64%), 8 (24.24%), and 4 (12.12%) were staged 1, 2, and 3, respectively. Serum creatinine in AKI patients began to slightly increase at first postoperative time and reached the AKI diagnostic value 1 day after operation.Postoperative urine Klotho peaked at the first postoperative time (0 h after admission to the intensive care unit (ICU)) in patients with AKI, and was higher than that in non-AKI patients up to day 3. The AUC of detecting AKI for urine Klotho was higher than urine NGAL at the first postoperative time and 4 h after admission to the ICU. In a multivariate model, increased first postoperative urine Klotho may be an independent predictor for AKI occurrence following cardiac surgery. The concentrations of first postoperative urine Klotho were higher in AKI stage 2 and 3 than those in stage 1 (p < 0.05), and were higher in patients with incomplete recovery of renal function than those with complete recovery (p < 0.05).ConclusionsUrine Klotho may serve as an early biomarker for AKI and subsequent poor short-term renal outcome in patients undergoing cardiac surgery.

Evaluation of Liver Functional Test (LFT) and Kidney Functional Test (KFT) in Dengue Patients

Background: Dengue is an acute infection caused by an arbovirus in the Flavivirus genus, and the mosquito Aedes aegypti is the vector. Case fatality ratio in India is reported to be 3 to 5 percent. One of the least studies complications occurring in dengue is acute kidney injury (AKI) and liver abnormalities are few of the least studied complications of dengue. Hence, we planned the present study to assess the LFT and KFT in Dengue patients. Methods: The present study included assessment of 100 patients out of which 50 patients were found to be sero positive for dengue while rest 50 were found to be sero negative. Assessment of levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT), the degree of hepatic involvement was done in all the patients included in the present study. AKIN definition for classification of AKI (Acute kidney injury) Stages was used for the present study. All the results were analyzed by SPSS software. Results: Total proteins level among dengue sero positive and negative subjects was found to be 7.01 and 7.89 g/dl. Significant results were obtained while comparing the total proteins levels among dengue positive and negative subjects. While comparing the albumin and globulin levels between dengue positive and negative subjects, significant results were obtained. Significant results were obtained while comparing the AST and ALT levels between both the study groups. 14.5 And 63.5 percent of the patients were AKI and AKIN- 1 AKI. Conclusions: Hepatic and renal involvement occurs in patients suffering from dengue fever.

Incidence, timing and outcome of AKI in critically ill patients varies with the definition used and the addition of urine output criteria

BackgroundAcute kidney injury (AKI) is a serious complication of critical illness with both attributed morbidity and mortality at short-term and long-term. The incidence of AKI reported in critically ill patients varies substantially with the population evaluated and the definitions used. We aimed to assess which of the AKI definitions (RIFLE, AKIN or KDIGO) with or without urine output criteria recognizes AKI most frequently and quickest. Additionally, we conducted a review on the comparison of incidence proportions of varying AKI definitions in populations of critically ill patients.MethodsWe included all patients with index admissions to our intensive care unit (ICU) from January 1st, 2014 until June 11th, 2014 to determine the incidence and onset of AKI by RIFLE, AKIN and KDIGO during the first 7 days of ICU admission. We conducted a sensitive search using PubMed evaluating the comparison of RIFLE, AKIN and KDIGO in critically ill patientsResultsAKI incidence proportions were 15, 21 and 20% respectively using serum creatinine criteria of RIFLE, AKIN and KDIGO. Adding urine output criteria increased AKI incidence proportions to 35, 38 and 38% using RIFLE, AKIN and KDIGO definitions. Urine output criteria detected AKI in patients without AKI at ICU admission in a median of 13 h (IQR 7–22 h; using RIFLE definition) after admission compared to a median of 24 h using serum creatinine criteria (IQR24-48 h). In the literature a large heterogeneity exists in patients included, AKI definition used, reference or baseline serum creatinine used, and whether urine output in the staging of AKI is used.ConclusionAKIN and KDIGO criteria detect more patients with AKI compared to RIFLE criteria. Addition of urine output criteria detect patients with AKI 11 h earlier than serum creatinine criteria and may double AKI incidences in critically ill patients. This could explain the large heterogeneity observed in literature.

Defining and treating acute kidney injury patients in Brazilian intensive care units: Results from a cross-sectional nationwide survey

PurposeThe purpose of the study is to characterize the practices of Brazilian intensivists toward acute kidney injury (AKI) definition and management. MethodsA cross-sectional survey was conducted among 36 Brazilian hospitals. ResultsOf 731 ICU physicians invited to participate, 310 (42%) responded to the survey. Nearly half of the intensive care unit (ICU) physicians (146/310) do not apply AKIN and/or RIFLE definitions to their ICU patients. Most of the respondents prescribe intravenous fluids as a first-line therapeutic intervention for AKI patients. Although 38% of the surveyed physicians considered worsening of respiratory parameters to be the main criterion for stopping fluid infusion, only 15% considered daily net fluid balance as a criterion. Most of the respondents believed in the benefits of early renal replacement therapy (RRT) and considered worsening acidosis the most important criteria for starting early RRT. The main reason for a nephrologist referral was an urgently needed RRT. ConclusionsDespite recent advances in AKI definition and management, most of the surveyed ICU physicians in Brazil have not incorporated them in their clinical practice. Important differences in the management of AKI patients were observed among Brazilian ICU physicians, which is relevant for educational interventions and future research.

Hypernatremia is a significant risk factor for acute kidney injury after subarachnoid hemorrhage: a retrospective analysis.

Hypertonic saline therapy is often used in critically ill subarachnoid hemorrhage (SAH) patients for indications ranging from control of intracranial hypertension to managing symptomatic hyponatremia. The risk factors for developing acute kidney injury (AKI) in this patient population are not well defined. To study the role of serum sodium in developing AKI (based on the AKIN definition) in the SAH population admitted to a large academic neurocritical care unit. This is an IRB-approved, retrospective cohort study of patients admitted to a tertiary neuro intensive care unit. We included adult (age ≥ 18 years) SAH patients admitted to the neuro intensive care unit for at least 72 h. Development of AKI after admission to the ICU was defined using the AKIN serum creatinine criteria between 72 h and 14 days following admission. A Cox proportional hazards survival model with multiple time varying covariates was developed to evaluate the effect of maximum sodium exposure on the risk of AKI. Sodium exposure was captured as the running maximum of daily maximum serum sodium concentration (mEq/L). Sodium exposure was used as a surrogate for hypertonic saline therapy. The final cohort of patients included 736 patients admitted to the neuro intensive care unit between 2006 and 2012. The number of patients who developed AKI was 64 (9 %). These patients had an increased length of stay (15.6 ± 9.4 vs. 12.5 ± 8.7 days). The odds of death were more than two fold greater among patients who developed AKI (odds ratio 2.33 95 % CI 1.27, 4.3). Sodium exposure was significantly associated with the hazard of developing AKI, adjusting for age, sex, preexisting renal disease, diabetes mellitus, radiocontrast exposure, number of days on mechanical ventilation, and admission Glasgow Coma Scale score. For each 1 mEq/L increase in the running maximum daily serum sodium, the hazard of developing AKI was increased by 5.4 % (95 % CI 1.4, 9.7). The maximum daily sodium is a significant risk factor for developing AKI in patients with SAH.

Renal Perfusion Assessment by Renal Doppler During Fluid Challenge in Sepsis

To assess renal resistive index variations in response to fluid challenge. Prospective cohort study. Three ICUs in French teaching hospitals. Consecutive patients receiving mechanical ventilation and requiring a fluid challenge. Resistive index measurement before and after fluid challenge. Renal Doppler was used to measure resistive index and esophageal Doppler to monitor aortic blood flow. Of the 35 included patients, 17 (49%) met our definition for fluid challenge responsiveness, that is, had at least a 10% increase in aortic blood flow. After fluid challenge, mean arterial pressure increased from 73 mm Hg (interquartile range 68-79) to 80 mm Hg (75-86; p < 0.0001) and stroke volume from 50 mL (30-77) to 55 mL (39-84; p < 0.0001). Stroke volume changes after fluid challenge were +28.6% (+18.8% to +38.8%) in fluid challenge responders and +3.1% (-1.6% to 7.4%) in fluid challenge nonresponders. Renal resistive index was unchanged after fluid challenge in both nonresponders (0.72 [0.67-0.75] before and 0.71 [0.67-0.75] after fluid challenge; p = 0.62) and responders (0.70 [0.65-0.75] before and 0.72 [0.68-0.74] after fluid challenge; p = 0.11). Stroke volume showed no correlations with resistive index changes after fluid challenge in the overall population (r² = 0.04, p = 0.25), in fluid challenge responders (r² = -0.02, p = 0.61), or in fluid challenge nonresponders (r² = 0.08, p = 0.27). Stroke volume did not correlate with resistive index changes after fluid challenge in the subgroups without acute kidney injury (AKIN definition), with transient acute kidney injury, or with persistent acute kidney injury. Systemic hemodynamic changes induced by fluid challenge do not translate into resistive index variations in patients without acute kidney injury, with transient acute kidney injury, or with persistent acute kidney injury.

735 Acute kidney injury in neonates following post cardiac surgery utilizing the akin definition: A retrospective study

Acute kidney injury (AKI) is common in the newborn period, but there is little known about the epidemiology and the incidence of AKI, especially in high-risk groups such as post heart surgery patients. The incidence of AKI in neonates varies widely between 3.4 to 61% based on the use of various AKI definitions. Since the launch of standardized AKI definitions such as AKIN (Acute Kidney Injury Network), there have been no studies applying them to the neonatal population. AKIN criteria consists of three stages: 1 (mild), 2 (moderate), and 3 (severe), which are based on specified changes in serum creatinine and/or urine output. Our objective was to describe the clinical characteristics of neonates with AKI following congenital heart surgery, utilizing the AKIN definition. Retrospective, single center observational design. We included all post heart surgery neonates admitted to PICU at our hospital between January 1st 2006 and May 30th 2009 with AKI as defined by their maximal AKIN stage. Patient data was collected from a PICU database and medical charts. Table 1 describes patients' characteristics. We identified 76 (54% males) out of 122 neonates who underwent heart surgery and developed AKI over the study period. Overall, the mean age was 8.4 ± 7.6 days with 90% of them being term gestation. However, younger patients were observed in AKIN stage 3 with a mean age of 6.03 ± 5.37 days. Twenty two (29%) patients had closed heart and 54 (71%) had open heart surgical procedures. AKIN stage 3 patients underwent mostly open heart procedures (82.9%). Twenty-six (34%) had Risk Adjustment in Congenital Heart Surgery-1 score > 3. Most of these patients (69%) were in AKIN stage 3. Regarding cardiac diagnosis, majority of patients had transposition of the great arteries (39.5%). The overall incidence of AKI was 62%. AKI occurred early as 57 of 76 neonates reached their maximal AKIN stage within 24 hours following surgery (Figure1). Eleven neonates died after AKI, 8 were after open heart (72%) and 9 within the first 10 days post AKI. All deaths occurred in AKIN stage 3.Tabled 1View Large Image Figure ViewerDownload Hi-res image Download (PPT) AKI is common in post-heart surgery neonates. Our incidence of 62% is high, but is explained in part by the sensitivity of the AKIN definition. AKI occurs early in the post-operative course with an overall mortality of 14.5%. All deaths occurred with AKIN stage 3. Open heart surgery and younger age showed a trend of increased mortality.

Early Blood Biomarkers Predict Organ Injury and Resource Utilization Following Complex Cardiac Surgery

Patients undergoing complex cardiac surgery (thoracic aorta and valve) are at risk for organ failure and increased resource utilization. Neutrophil gelatinase-associated lipocalin (NGAL) has been found to be an early biomarker for renal injury. Multiplex cytokine immunoassays allow the evaluation of the early inflammatory response. We examined the relationship between early biomarker appearance (NGAL and multiplex cytokines) and organ injury and resource utilization. NGAL and multiplex cytokine immunoassays were performed at baseline, 1, 6, and 24 h following surgery on 38 patients undergoing thoracic aorta and valve operations. The mean age was 65 y with 26 males and 12 females. Acute kidney injury (AKIN definition), pulmonary failure (>24 h ventilation), and intensive care unit and hospital stays were examined. One hour following complex cardiac surgery, the quartile of patients with the greatest IL-6 response had higher serum NGAL levels compared with the lowest quartile (347 versus 145 ng/mL, P=0.002), and 70% of these patients progressed to clinical kidney injury. Six hours following surgery, the quartile of patients with the greatest IL-10 response had higher serum NGAL compared with the lowest quartile (271 versus 160, P =0.04), more pulmonary failure (60% versus 10%, P =0.01), and longer ICU and hospital stays (P =0.001). Patients with early elevated biomarkers of inflammation exhibited higher NGAL, more pulmonary failure, and greater resource utilization. Earlier identification of patients at risk for organ injury may allow for earlier intervention and reduce resource utilization.

Early blood biomarkers predict organ injury and resource utilization following complex cardiac surgery

Kim, Tad MD; Arnaoutakis, George J. MD; Bihorac, Azra MD; Martin, Tomas D. MD; Hess, Phillip J. Jr MD; Klodell, Charles T. MD; Tribble, Curtis G. MD; Ejaz, Ahsan A. MD; Moldawer, Lyle L. PhD; Beaver, Thomas M. MD, MPH Author Information