Meri Poukkanen 30.5.2012Division of Anaesthesia

and Intensive Care Medicine,Lapland Central Hospital, Rovaniemi

Incidence and outcome ofIncidence and outcome ofseptic AKI in Finlandseptic AKI in Finland

Acute kidney injury in critically ill patients with severe sepsis in Finnish ICUs

Meri Poukkanen1, Sari Karlsson2, Kirsi-Maija Kaukonen3, Anna-Maija Korhonen3, SuviVaara3, Seppo Hovilehto4, Outi Inkinen5, Raili Laru-Sompa6, Tadeusz Kaminski7, VillePettilä3 and the FINNAKI study investigators

To be submitted in 2012

HH

In study

Not in study

• 1.9.2011 - 1.2.2012

(5 months)

• Prospective multicenterstudy

• 17 ICUs from Finland• Covered 85% of the Finnish

adult population

ObjectObjectivesObjectObjectives

• Acute kidney injury (AKI):Incidence, risk factors, and outcome

• Renal replacement therapy (RRT):Characteristics of RRT treatment, factors associatedwith 90-d mortality

• Septic AKI:Incidence, outcome

AKIN criteriaAKIN criteria

Mehta et al, 2007

Inclusion and Exclusion CriteriaInclusion and Exclusion Criteria

Under 18 yearsPreviously in study with RRTElective admission < 24hOn chronic RRTOrgan donorInitiation of chronic RRTDeclined / No consentForeignerOver 5 days in study already in another ICUIntermediate careOther/unknown

Emergency admission

Elective admission >24 h

InclusionInclusion ExclusionsExclusions

5853 Admissions 2728Exclusion criteria140 <18 years26 Previously in study with RRT1182 Elective admission < 24h59 On chronic RRT28 Organ donor5 Initiation of chronic RRT174 Declined36 Foreigner160 No consent39 > 5 days in study already660 Intermediate care219 Other/unknown

1760 No AKI(60.7%)

32 Transfers192 Multiple admissions

3125 Admissions

2901 Patients

1141 AKI(39.3%)

232 AKIN stage 2(8.0%)

410 AKIN stage 3(14.1%)

499 AKIN stage 1(17.2%)

296 RRT (10.2%)

Population-based incidence of ICU-treated AKI:

746 / million adult population / year

Reference population: 3 671 14385% of the Finnish adult population

AKI incidence (95% CI): 39.3% (37.5 - 41.1 %)

• A predetermined sub-study of the FINNAKIstudy

• Sepsis criteria:– ACCP/SCCM (Crit Care Med 1992)

• AKI criteria– AKIN stages (Mehta Crit Care 2007)

• Aim: to evaluate the incidence of severesepsis associated AKI and its associationwith 90-d mortality

2901 FINNAKIstudy patients

97 AKIN stage 2(10.6 %)

197 AKIN stage 3(21.5 %)

194 AKIN stage 1(21.1 %)

918 severe sepsispatients

488 AKI patients(53.2 %)

142 RRT (15.5%)

Population-based incidence of ICU-treatedsevere sepsis associated AKI (95%CI):

319/ million adult population / year (300-338)

Reference population: 3 671 14385% of the Finnish adult population

Incidence of severe sepsis associated AKI(95% CI): 53.2 % (49.9-56.4%)

IncideIncide Incidence of septic AKI inICU patients

AKIcriteria

Study patients(n)

Septic AKIpatients(n)

Bagshaw 2008 RIFLE 120,123 ICU 11.7%(14,039)

Lopes 2009 AKIN,RIFLE

315 sepsis 31.4% (99)

Bagshaw 2009 RIFLE 4532 septic shock 64.4% (2918)Plataki 2011 RIFLE 390 severe sepsis 61.0% (237)

IncideIncideIncidence of septic AKI in

ICU patients

AKIcriteria

Study patients(n)

AKI patients(n)

Bagshaw 2008 RIFLE 33,375 sepsis 42.1%(14,039)

Lopes 2009 AKIN,RIFLE

315 sepsis 31.4% (99)

Bagshaw 2009 RIFLE 4532 septic shock 64.4% (2918)

Plataki 2011 RIFLE 390 severe sepsis 61.0% (237)

IncideIncideIncidence of severe sepsis associatedAKI in ICU patients

AKIcriteria

Study patients(n)

AKI patients(n)

Bagshaw2009

RIFLE 4532 septicshock

64.4% (2918)

Plataki2011

RIFLE 390 severe sepsis 61.0% (237)

FINNAKI2012

AKIN 918 severe sepsis 53.2 % (488)

IncideIncideAKI stages of severe sepsis associated AKI

Study patients(n)

AKIpatients (n)

AKI stages(n)

Bagshaw2009

4532 septic shock 64.4%(2918)

Risk 16.3% (739)Injury 29.4% (1332)Failure 18.7% (847)

Plataki2011

390 severe sepsis 61.0% (237) Risk 12.3% (48)Injury 32.0% (76)Failure 48.0% (114)

FINNAKI2012

918 severe sepsis 53.2 % (488) Stage 1 21.1% (194)Stage 2 10.6% (97)Stage 3 21.5% (197)

Severe sepsis patientsNo AKI(n=430)

AKI (n=488) -value

Age (y) 63.0 (52.0-73.3) 66.0 (56.0-76.0) 0.002

Gender (male) 66.3% (285) 62.3% (304)

BMI (kg/m2) 25.9 (20.0-31.8) 27.4 (20.3-34.5) <0.001

Co-morbities

Atherosclerosis 12.6% (54) 16.0% (78) 0.3

Chronic kidney disease 2.8% (12) 9.8% (48) <0.001

Chronic liver failure 5.1% (22) 5.1% (25) 0.9

Hypertension 2.8% (12) 9.8% (48) 0.07

COPD 13.0% (56) 11.3% (55) 0.6

Diabetes 19.8% (85) 29.3% (143) 0.01

Systolic heart failure 10.7% (46) 10.7% (52) 0.8Values are expressed as median (IQR) or percentage and count

Severe sepsis patients

No AKI (n=430) AKI (n=488) -value

Admission

Emergency 97.4% (419) 97.3% (475) 0.2

Operative 23.7% (102) 24.8% (121) 0.6

SAPS II ( 0-163) 38 (30-46) 48 (38-61) <0.001

SOFAmax (0-24) 7 (5-9) 10 (8-13) <0.001

SOFAmax (without renalpoints) (0-20)

7 (5-9) 8 (6-11) <0.001

Values are expressed as median (IQR) or percentage and count

Severe sepsis patients

-value Other studies

Age 0.002 Bagshaw, Plataki,Yegenaga,Lopes

BMI (kg/m2) <0.001 Bagshaw, Plataki

Co-morbities

Chronic kidney disease <0.001 Plataki, Lopes

Diabetes 0.01 Bagshaw, Yegenaga

Blood cultures

Source of infection

No AKI %(n)

AKI % (n) -value

Lung 56.5 % (243) 44.9% (219) 0.002

Abdominal 19.5% (84) 26.4% (129) 0.05

Soft tissue 8.6% (37) 9.4% (46) 0.8

Genitourinarytract

4.4% (19) 8.0% (39) 0.08

Lenght of stay (=LOS)

Severesepsiswithout AKI(n=430)

Severesepsis withAKI(n=488)

-value

ICU (d) 3.8 (1.8-7.0) 4.2 (2.4-8.2) 0.01

Hospital (d) 14.0 (8.0-24.0)

14.0 (7.0-23.0)

0.18

Values are expressed as median (IQR) or percentage and count

Lenght of staySevere sepsiswithout AKI

Severesepsis withAKI

ICU (d)PlatakiBagshaw

3.83.07.0*

4.24.08.0*

Hospital (d)PlatakiBagshaw

14.08.526.0*

14.09.030.0*

* LOS in ICU and hospital for survivorst

MortalityAKI (n=488) No AKI (n=430) -value

ICU 18.6 % (91) 6.5 % (28) <0.001

Hospital 29.3 % (143) 18.1 % (78) <0.001

90-d 38.1 % (186) 24.7 % (106) <0.001

Mortality by AKIN stagesM

orta

lity

n=430 n=194

Conclusions I

• AKI was associated in 53.2% of severe sepsispatients

• Advanced age, higher BMI, pre-existing chronickidney disease, and diabetes were risk factors forseptic AKI

• Patients with severe sepsis associated AKI hadmore often positive blood culture

Conclusions II

• Mortality of patients with severe sepsisassociated AKI increased by increasingseverity of AKI

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East Savo Central Hospital: Markku Suvela, Katrine Pesola, Pekka Saastamoinen, Sirpa KauppinenHelsinki University Central Hospital: Ville Pettilä, Kirsi-Maija Kaukonen, Anna-Maija Korhonen, Sara Nisula, Suvi Vaara,

Raili Suojaranta-Ylinen, Leena Mildh, Mikko Haapio, Laura Nurminen, Sari Sutinen, Leena Pettilä, Helinä Laitinen,Heidi Syrjä, Kirsi Henttonen, Elina Lappi, Hillevi Boman

Jorvi Central Hospital: Tero Varpula, Päivi Porkka, Mirka Sivula Mira Rahkonen, Anne Tsurkka, Taina Nieminen, NiinaPrittinen.

Kanta-Häme Central hospital: Ari Alaspää, Hanna Juntunen, Teija SanisaloKuopio University Hospital: Ilkka Parviainen, Ari Uusaro, Esko Ruokonen, Stepani Bendel, Niina Rissanen, Maarit Lång,

Sari Rahikainen, Saija Rissanen, Merja Ahonen, Elina Halonen, Eija VaskelainenLapland Central Hospital: Meri Poukkanen, Esa Lintula, Sirpa SuominenLänsi Pohja Central Hospital: Jorma Heikkinen, Timo Lavander, Kirsi Heinonen, Anne-Mari Juopperi,Middle Ostrobothnia Central Hospital: Tadeusz Kaminski, Fiia Gäddnäs, Tuija Kuusela, Jane RoikoNorth Karelia Central Hospital: Sari Karlsson, Matti Reinikainen, Tero Surakka, Helena Jyrkönen, Tanja Eiserbeck, Jaana

KallinenSatakunta Hospital district: Vesa Lund, Päivi Tuominen, Pauliina Perkola, Riikka Tuominen, Marika Hietaranta, Satu

JohanssonSouth Karelia Central Hospital: Seppo Hovilehto, Anne Kirsi, Pekka Tiainen, Tuija Myllärinen, Pirjo Leino, Anne

ToropainenTampere University Hospital: Anne Kuitunen, Jyrki Tenhunen, Ilona Leppänen, Markus Levoranta, Sanna Hoppu, Jukka

Sauranen, Atte Kukkurainen, Samuli Kortelainen, Simo VarilaTurku University Hospital: Outi Inkinen, Niina Koivuviita, Jutta Kotamäki, Anu LaineOulu University Hospital: Tero Ala-Kokko, Jouko Laurila, Sinikka SälkiöVaasa Central Hospital: Simo-Pekka Koivisto, Raku Hautamäki, Maria Skinnar

Study GroupStudy Group

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