acute kidney injury in critically ill patients in the new millenium: definition and epidemiology....
DESCRIPTION
Over the last decades, more than 35 different definitions have been used to describe acute kidney injury (AKI). Multiple definitions for AKI have obviously led to a great disparity in the reported incidence and mortality of AKI making it difficult or even impossible to compare the various published studies focusing on AKI. Therefore, it became crucial to establish a consensual and accurate definition of AKI that could desirably be used worldwide. Recent consensus criteria for AKI definition and classification [the Risk Injury Failure Loss of kidney function End-stage kidney disease (RIFLE) and the Acute Kidney Injury Network (AKIN) classifications] have led to more consistent estimates of its epidemiology. This review will present and critically discuss current literature about AKI diagnosis and epidemiology.TRANSCRIPT
ACUTE KIDNEY INJURY IN CRITICALLY ILL PATIENTS IN THE NEW MILLENIUM: DEFINITION AND EPIDEMIOLOGY
JOSÉ ANTÓNIO LOPES, MD, PhD
Assistant Professor of NephrologyFaculty of Medicine, University of Lisbon
Department of Nephrology and Renal TransplantationCentro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal
Barcelona, 4th March 2014
DEFINITION AND CLASSIFICATION OF AKI
≠ DEFINITIONS
≠ INCIDENCE
≠ MORTALITY≠ MORTALITY
DEFINITION OF AKIINCIDENCE AND MORTALITY
Chertow GM et al. J Am Soc Nephrol 2005
N=9.210
DEFINITION OF AKI
1. Easy to use
2. High sensitivity and specificity in ≠ settings
3. Consider variations in baseline SCr
4. Determine AKI severity
5. Identifiy early and late AKI
RIFLE ClassificationRisk, Injury, Failure, Loss, End-stage kidney disease
Bellomo R et al. Crit Care 2004
Risk Injury Failure
Ricci Z et al. Kidney Int 2008
VALIDATION OF THE RIFLE IN THE ICU
RIFLE CLASSIFICATION
INCIDENCE AND STRATIFICATION OF AKI
Lopes JA et al. Clin Kidney J 2013
67%
36%
11%
36%
18%
SAPS II RIFLE
AKI IN CRITICALLY ILL SEPTIC PATIENTS
Lopes JA et al. Crit Care 2007
0.778 0.750
Hoste E et al. Crit Care 2006
CRITICALLY ILL PATIENTS
Mehta RL et al. Crit Care 2007
AKIN CLASSIFICATIONAcute Kidney Injury Network
Chertow GM et al. J Am Soc Nephrol 2005
sCr ≥ 0.3 mg/dl - IN-HOSPITAL MORTALITY
N=9.210
COMPARISON BETWEEN RIFLE AND AKIN
INCIDENCE OF AKI AND PREDICTION OF MORTALITY
Lopes JA et al. Crit Care 2008
P = 0.018
N=662
Lopes JA et al. Crit Care 2008
N=662
Acute kidney injury in critically ill patients classified by AKIN versus RIFLE using the SAPS 3 database
Joannidis M et al. Intensive Care Med 2009
N=16.784
RIFLE2004
AKIN2009
LIMITATIONS STRENGTHS
KDIGO2012
KDIGO Clinical Practice Guideline for AKI. Kidney Int 2012
KDIGO CLASSIFICATION
LIMITATIONS OF CLINICAL CLASSIFICATIONS
URINE OUTPUT
Sensitivity and specificity Hourly basis register (+++ ICU)
SCr
variability in endogenous production and S releaseMultiple factors can interfer with SCr determination HemodilutionSepsis productionCKD late in SCr Marker of renal function and not of lesion
BIOMARKERS IN AKI
Murray PT et al. Kidney Int 2013
Coca SG et al. Kidney Int 2008
BIOMARKERS IN AKI
FRAMEWORK FOR EVALUATING AKI BASED ON BIOMARKERS
Murray PT et al. Kidney Int 2013
BIOMARKERS IN AKI FUTURE DIRECTIONS
Confirm that the proposed expansion of the diagnostic criteria for AKI to include the isolated presence of damage biomarkers, with preserved function, is clinically relevant.
Determine the mechanistic pathways that are involved in the development of AKI and its natural course.
Define the prognostic value of the combined use of functional and damage markers in sequential measurements to confirm the prognostic significance of these categories.
Ascertain how well the combination of damage and functional markers can improve recognition of AKI in the setting of CKD.
Murray PT et al. Kidney Int 2013
BIOMARKERS IN AKI FUTURE DIRECTIONS
Large population-based studies would be required across multiple centers enrolling patients in the wide spectrum of AKI and different disease states, to determine whether operationalizing the approach to AKI with a simple 2x2 table to mechanistically define AKI cases and their evolution usefully influences patient management and ultimately improves outcomes.
Discover and confirm the sensitivity and specificity of damage and functional markers for specific situations.
Establish standard techniques for collection, handling, and presentation of biomarker data that permit appropriate interpretation across settings.
Murray PT et al. Kidney Int 2013
EPIDEMIOLOGY OF AKI IN THE ICUINCIDENCE
Bagshaw SM et al. Crit Care 2007
N=91.254
Lopes JA et al. Clin Kidney J 2013
67%
36%
11%
36%
INCIDENCE OF AKI IN THE ICU
Uchino S et al. JAMA 2005
EPIDEMIOLOGY OF AKI IN THE ICUPATIENT CHARACTERISTICS AND RISK FACTORS
N=29.269
EPIDEMIOLOGY OF AKI IN THE ICUSHORT- AND LONG-TERM OUTCOMES
Bagshaw SM et al. Nephrol Dial Transplant 2008
N=120.123
A multi-centre evaluation of the RIFLE criteria for early acute kidney injury in critically ill patients
Long-term risk of mortality after acute kidney injury in patients with sepsis: a contemporary analysis
Lopes JA et al. BMC Nephrol 2010
N=234
Bihorac A et al. Ann Surg 2009
N=10.518
Gammelager et al. Crit Care 2012
N=30.762
Bagshaw SM et al. Crit Care 2005
Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: a population-based study
Hobson CE et al. Circulation 2009
N=2.973
Ishani A et al. J Am Soc Nephrol 2009
N= 233.803
Acute kidney injury increases risk of ESRD among elderly
Lai CF et al. Crit Care 2012
N=634
Ponte B et al. Nephrol Dial Transplant 2008
Hansen et al. Crit Care 2013
N=1.030
SEPSIS
HEMORRHAGE
FLUID OVERLOAD
ACUTE KIDNEY INJURY
• INFLAMMATION• OXIDATIVE STRESS
• APOPTOSIS
Xiang Li et al. Curr Opin Crit Care 2010
SUMMARY
The KDIGO work group has made the fusion of the RIFLE and AKIN classifications in order to establish one classification of AKI for practice, research, and public health.
The conceptual framework of functional and damage biomarkers will need to be validated through future studies, and additional evidence will be required to establish their best combinations for utilization in clinical practice.
SUMMARY
AKI is an increasingly common complication in ICU patients.
Patients with AKI have higher ICU and in-hospital mortality and longer lengths of stay, and AKI survivors are more likely to be discharged to an extended care facility.
Patients who survive AKI have a greater rate of long-term mortality and other adverse outcomes (i.e. progression to or acceleration of CKD and cardiovascular disease) than patients who survive hospitalization without AKI.