Acute Renal Failure in Critically Ill Patients: A Multinational, Multicenter Study
TL;DR: In this article, the period prevalence of acute renal failure (ARF) requiring renal replacement therapy (RRT) was found to be between 5% and 6% and was associated with a high hospital mortality rate.
Abstract: ContextAlthough acute renal failure (ARF) is believed to be common in the setting
of critical illness and is associated with a high risk of death, little is
known about its epidemiology and outcome or how these vary in different regions
of the world.ObjectivesTo determine the period prevalence of ARF in intensive care unit (ICU)
patients in multiple countries; to characterize differences in etiology, illness
severity, and clinical practice; and to determine the impact of these differences
on patient outcomes.Design, Setting, and PatientsProspective observational study of ICU patients who either were treated
with renal replacement therapy (RRT) or fulfilled at least 1 of the predefined
criteria for ARF from September 2000 to December 2001 at 54 hospitals in 23
countries.Main Outcome MeasuresOccurrence of ARF, factors contributing to etiology, illness severity,
treatment, need for renal support after hospital discharge, and hospital mortality.ResultsOf 29 269 critically ill patients admitted during the study period,
1738 (5.7%; 95% confidence interval [CI], 5.5%-6.0%) had ARF during their
ICU stay, including 1260 who were treated with RRT. The most common contributing
factor to ARF was septic shock (47.5%; 95% CI, 45.2%-49.5%). Approximately
30% of patients had preadmission renal dysfunction. Overall hospital mortality
was 60.3% (95% CI, 58.0%-62.6%). Dialysis dependence at hospital discharge
was 13.8% (95% CI, 11.2%-16.3%) for survivors. Independent risk factors for
hospital mortality included use of vasopressors (odds ratio [OR], 1.95; 95%
CI, 1.50-2.55; P<.001), mechanical ventilation
(OR, 2.11; 95% CI, 1.58-2.82; P<.001), septic
shock (OR, 1.36; 95% CI, 1.03-1.79; P = .03),
cardiogenic shock (OR, 1.41; 95% CI, 1.05-1.90; P = .02),
and hepatorenal syndrome (OR, 1.87; 95% CI, 1.07-3.28; P = .03).ConclusionIn this multinational study, the period prevalence of ARF requiring
RRT in the ICU was between 5% and 6% and was associated with a high hospital
mortality rate.
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TL;DR: The guidelines focused on 4 key domains: (1) AKI definition, (2) prevention and treatment of AKI, (3) contrastinduced AKI (CI-AKI) and (4) dialysis interventions for the treatment ofAKI.
Abstract: tion’, implying that most patients ‘should’ receive a particular action. In contrast, level 2 guidelines are essentially ‘suggestions’ and are deemed to be ‘weak’ or discretionary, recognising that management decisions may vary in different clinical contexts. Each recommendation was further graded from A to D by the quality of evidence underpinning them, with grade A referring to a high quality of evidence whilst grade D recognised a ‘very low’ evidence base. The overall strength and quality of the supporting evidence is summarised in table 1 . The guidelines focused on 4 key domains: (1) AKI definition, (2) prevention and treatment of AKI, (3) contrastinduced AKI (CI-AKI) and (4) dialysis interventions for the treatment of AKI. The full summary of clinical practice statements is available at www.kdigo.org, but a few key recommendation statements will be highlighted here.
6,247 citations
TL;DR: The Acute Kidney Injury Network (AKI Network) as discussed by the authors is a multidisciplinary collaborative network focused on AKI, which was established to improve care for patients with or at risk for AKI.
Abstract: Acute kidney injury (AKI) is a complex disorder for which currently there is no accepted definition. Having a uniform standard for diagnosing and classifying AKI would enhance our ability to manage these patients. Future clinical and translational research in AKI will require collaborative networks of investigators drawn from various disciplines, dissemination of information via multidisciplinary joint conferences and publications, and improved translation of knowledge from pre-clinical research. We describe an initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI. Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a two day conference in Amsterdam, The Netherlands, in September 2005 and were assigned to one of three workgroups. Each group's discussions formed the basis for draft recommendations that were later refined and improved during discussion with the larger group. Dissenting opinions were also noted. The final draft recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. Participating societies endorsed the recommendations and agreed to help disseminate the results. The term AKI is proposed to represent the entire spectrum of acute renal failure. Diagnostic criteria for AKI are proposed based on acute alterations in serum creatinine or urine output. A staging system for AKI which reflects quantitative changes in serum creatinine and urine output has been developed. We describe the formation of a multidisciplinary collaborative network focused on AKI. We have proposed uniform standards for diagnosing and classifying AKI which will need to be validated in future studies. The Acute Kidney Injury Network offers a mechanism for proceeding with efforts to improve patient outcomes.
5,669 citations
01 Mar 2007
TL;DR: An initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI is described.
Abstract: Acute kidney injury (AKI) is a complex disorder for which currently there is no accepted definition. Having a uniform standard for diagnosing and classifying AKI would enhance our ability to manage these patients. Future clinical and translational research in AKI will require collaborative networks of investigators drawn from various disciplines, dissemination of information via multidisciplinary joint conferences and publications, and improved translation of knowledge from pre-clinical research. We describe an initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI. Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a two day conference in Amsterdam, The Netherlands, in September 2005 and were assigned to one of three workgroups. Each group's discussions formed the basis for draft recommendations that were later refined and improved during discussion with the larger group. Dissenting opinions were also noted. The final draft recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. Participating societies endorsed the recommendations and agreed to help disseminate the results. The term AKI is proposed to represent the entire spectrum of acute renal failure. Diagnostic criteria for AKI are proposed based on acute alterations in serum creatinine or urine output. A staging system for AKI which reflects quantitative changes in serum creatinine and urine output has been developed. We describe the formation of a multidisciplinary collaborative network focused on AKI. We have proposed uniform standards for diagnosing and classifying AKI which will need to be validated in future studies. The Acute Kidney Injury Network offers a mechanism for proceeding with efforts to improve patient outcomes.
5,467 citations
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TL;DR: Evidence suggests that patients who have had acute kidney injury are at increased risk of subsequent chronic kidney disease, and new diagnostic techniques (eg, renal biomarkers) might help with early diagnosis.
1,840 citations
Research Foundation - Flanders1, University of Pittsburgh2, Ghent University3, University of Alberta4, Austin Hospital5, University of Miami6, University of California, San Diego7, University of Surrey8, The Chinese University of Hong Kong9, Medanta10, University of Bordeaux11, University of Helsinki12, Pontifical Catholic University of Chile13, Jikei University School of Medicine14, University of Western Australia15
TL;DR: This is the first multinational cross-sectional study on the epidemiology of AKI in ICu patients using the complete KDIGO criteria and found that AKI occurred in more than half of ICU patients.
Abstract: Current reports on acute kidney injury (AKI) in the intensive care unit (ICU) show wide variation in occurrence rate and are limited by study biases such as use of incomplete AKI definition, selected cohorts, or retrospective design. Our aim was to prospectively investigate the occurrence and outcomes of AKI in ICU patients. The Acute Kidney Injury–Epidemiologic Prospective Investigation (AKI-EPI) study was an international cross-sectional study performed in 97 centers on patients during the first week of ICU admission. We measured AKI by Kidney Disease: Improving Global Outcomes (KDIGO) criteria, and outcomes at hospital discharge. A total of 1032 ICU patients out of 1802 [57.3 %; 95 % confidence interval (CI) 55.0–59.6] had AKI. Increasing AKI severity was associated with hospital mortality when adjusted for other variables; odds ratio of stage 1 = 1.679 (95 % CI 0.890–3.169; p = 0.109), stage 2 = 2.945 (95 % CI 1.382–6.276; p = 0.005), and stage 3 = 6.884 (95 % CI 3.876–12.228; p < 0.001). Risk-adjusted rates of AKI and mortality were similar across the world. Patients developing AKI had worse kidney function at hospital discharge with estimated glomerular filtration rate less than 60 mL/min/1.73 m2 in 47.7 % (95 % CI 43.6–51.7) versus 14.8 % (95 % CI 11.9–18.2) in those without AKI, p < 0.001. This is the first multinational cross-sectional study on the epidemiology of AKI in ICU patients using the complete KDIGO criteria. We found that AKI occurred in more than half of ICU patients. Increasing AKI severity was associated with increased mortality, and AKI patients had worse renal function at the time of hospital discharge. Adjusted risks for AKI and mortality were similar across different continents and regions.
1,704 citations
References
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TL;DR: The SAPS II, based on a large international sample of patients, provides an estimate of the risk of death without having to specify a primary diagnosis, and is a starting point for future evaluation of the efficiency of intensive care units.
Abstract: Objective. —To develop and validate a new Simplified Acute Physiology Score, the SAPS II, from a large sample of surgical and medical patients, and to provide a method to convert the score to a probability of hospital mortality. Design and Setting. —The SAPS II and the probability of hospital mortality were developed and validated using data from consecutive admissions to 137 adult medical and/or surgical intensive care units in 12 countries. Patients. —The 13 152 patients were randomly divided into developmental (65%) and validation (35%) samples. Patients younger than 18 years, burn patients, coronary care patients, and cardiac surgery patients were excluded. Outcome Measure. —Vital status at hospital discharge. Results. —The SAPS II includes only 17 variables: 12 physiology variables, age, type of admission (scheduled surgical, unscheduled surgical, or medical), and three underlying disease variables (acquired immunodeficiency syndrome, metastatic cancer, and hematologic malignancy). Goodness-of-fit tests indicated that the model performed well in the developmental sample and validated well in an independent sample of patients (P=.883 andP=.104 in the developmental and validation samples, respectively). The area under the receiver operating characteristic curve was 0.88 in the developmental sample and 0.86 in the validation sample. Conclusion. —The SAPS II, based on a large international sample of patients, provides an estimate of the risk of death without having to specify a primary diagnosis. This is a starting point for future evaluation of the efficiency of intensive care units. (JAMA. 1993;270:2957-2963)
5,836 citations
TL;DR: Mortality among critically ill patients with acute renal failure was high, but increase in the rate of ultrafiltration improved survival significantly, and it is recommended thatUltrafiltration should be prescribed according to patient's bodyweight and should reach at least 35 mL h(-1) kg(-1).
1,433 citations
TL;DR: This study gives, for the first time, the incidence of all forms of ARF in a developed country and shows that ARF is iatrogenically induced at a high rate by modern medicine and prevention strategies are needed to decrease its impact.
938 citations
TL;DR: To assess the causes, the prognostic factors, and the outcome of patients with severe acute renal failure, a multicenter study is conducted in French multidisciplinary intensive care units.
Abstract: ObjectiveTo assess the causes, the prognostic factors, and the outcome of patients with severe acute renal failure.DesignProspective, multicenter study.SettingTwenty French multidisciplinary intensive care units (ICUs).PatientsAll patients with severe acute renal failure were prospectively enrolled
839 citations
TL;DR: The high mortality rate among critically ill patients with acute renal failure who require renal-replacement therapy is related to both coexisting conditions and uremic damage to other organ systems.
Abstract: Background Intermittent hemodialysis is widely used as renal-replacement therapy in patients with acute renal failure, but an adequate dose has not been defined. We performed a prospective study to determine the effect of daily intermittent hemodialysis, as compared with conventional (alternate-day) intermittent hemodialysis, on survival among patients with acute renal failure. Methods A total of 160 patients with acute renal failure were assigned to receive daily or conventional intermittent hemodialysis. Survival was the primary end point of the study. The duration of acute renal failure and the frequency of therapy-related complications were secondary end points. Results The two study groups were similar with respect to age, sex, cause and severity of acute renal failure, medical or surgical intensive care setting, and the score on the Acute Physiology, Age, and Chronic Health Evaluation. Daily hemodialysis resulted in better control of uremia, fewer hypotensive episodes during hemodialysis, and more r...
779 citations