BackgroundDespite the substantial progress in the quality of critical care, the incidence and mortality of acute kidney injury (AKI) continues to rise during hospital admissions. We conducted a national, multicenter, prospective, epidemiological survey to evaluate the importance of AKI in intensive care units (ICUs) in Hungary. The objectives of this study were to determine the incidence of AKI in ICU patients; to characterize the differences in aetiology, illness severity and clinical practice; and to determine the influencing factors of the development of AKI and the patients' outcomes.MethodsWe analysed the demographic, morbidity, treatment modality and outcome data of patients (n = 459) admitted to ICUs between October 1st, 2009 and November 30th, 2009 using a prospectively filled in electronic survey form in 7 representative ICUs.ResultsThe major reason for ICU admission was surgical in 64.3% of patients and medical in the remaining 35.7%. One-hundred-twelve patients (24.4%) had AKI. By AKIN criteria 11.5% had Stage 1, 5.4% had Stage 2 and 7.4% had Stage 3. In 44.0% of patients, AKI was associated with septic shock. Vasopressor treatment, SAPS II score, serum creatinine on ICU admission and sepsis were the independent risk factors for development of any stage of AKI. Among the Stage 3 patients (34) 50% received renal replacement therapy. The overall utilization of intermittent renal replacement therapy was high (64.8%). The overall in-hospital mortality rate of AKI was 49% (55/112). The ICU mortality rate was 39.3% (44/112). The independent risk factors for ICU mortality were age, mechanical ventilation, SOFA score and AKI Stage 3.ConclusionsFor the first time we have established the incidence of AKI using the AKIN criteria in Hungarian ICUs. Results of the present study confirm that AKI has a high incidence and is associated with high ICU and in-hospital mortality.

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Background : The incidence of postoperative acute kidney injury (AKI) is predominantly determined by renal hemodynamics. Beside arterial blood pressure, the role of factors causing a deterioration of venous congestion (intraabdominal pressure, central venous pressure, mechanical ventilation) has emerged. The value of combined hemodynamic, respiratory and intra-abdominal pressure (IAP) monitoring in predicting postoperative acute kidney injury has received only limited exploration to date. Methods : Data were collected for adult patients admitted after major abdominal surgery at nine Hungarian ICUs. Hemodynamic parameters were compared in AKI vs. no-AKI patients at the time of admission and 48 h thereafter. Regarding ventilatory support, we tested mean airway pressures (Pmean). Effective renal perfusion pressure (RPP) was calculated as MAP−(IAP + CVP + Pmean). The Mann–Whitney U and the chi-square tests were carried out for statistical analysis with forward stepwise logistic regression for AKI as a dependent outcome. Results : A total of 84 patients (34 ventilated) were enrolled in our multicenter observational study. The median values of MAP were above 70 mmHg, IAP not higher than 12 mmHg and CVP not higher than 8 mmHg at all time-points. When we combined those parameters, even those belonging to the ‘normal’ range with Pmean, we found significant differences between no-AKI and AKI groups only at 12 h after ICU admission (median and IQR: 57 (42–64) vs. 40 (36–52); p < .05). Below it’s median (40.7 mmHg) on admission, AKI developed in all patients. If above 40.7 mmHg on admission, they were protected against AKI, but only if it did not decrease within the first 12 h. Conclusions : Calculated effective RPP with the novel formula MAP−(IAP + CVP + Pmean) may predict the onset of AKI in the surgical ICU with a great sensitivity and specificity. Maintaining effective RPP appears important not only at ICU admission but during the next 12 h, as well. Additional, larger studies are needed to explore therapeutic interventions targeting this parameter.

Background: Low mean arterial pressure (MAP) is a well-known risk factor for postoperative acute kidney injury (AKI), but probably it is not the sole hemodynamic parameter that can influence the development of renal failure. There are data in cardiac patients supporting the role of renal venous congestion in the development of AKI. The aim of our study was to determine a combination of factors best predicting the development of AKI. Methods: Data were collected prospectively for adult patients admitted after major abdominal surgery to 9 Hungarian intensive care units. Hemodynamic and laboratory parameters were compared in patients with AKI vs. no-AKI at the time of admission. Renal perfusion was computed by different methods from hemodynamic measurements involving MAP, central venous pressure (CVP), intraabdominal pressure (IAP), and mean airway pressures (Pmean). Twelve different, clinically interpretable equations were tested. Statistical evaluation was performed by the Mann-Whitney U test and ROC analysis. Results: Eighty-four patients were enrolled in the study. Renal perfusion pressure was significantly lower in all equations. The equations MAP-IAP-Pmean (1-area under the curve [AUC]: 0.796; likelihood ratio [LR]+: 3.520; LR–: 0.337; p < 0.01), MAP-IAP-CVP-Pmean (1-AUC: 0.794; LR+: 2.743; LR–: 0.282; p < 0.01), and MAP-2 × IAP-CVP-Pmean (1-AUC: 0.791; LR+: 4.321; LR–: 0.262; p < 0.001) showed small to moderate effect on AKI but have better performance than severity score systems (SAPS II [AUC: 0.696; LR+: 3.143, LR–: 0.433; p < 0.01], SOFA [AUC: 0.717; LR+: 2.089; LR–: 0.528; p < 0.001]). Conclusion: We found that the best parameter predicting AKI is the MAP-2 × IAP-CVP-Pmean. Further investigation is needed to analyze the role of CVP and Pmean, and to characterize renal venous congestion and tubular pressure more in detail.