A Prospective International Multicenter Study of AKI in the Intensive Care Unit

Abstract

Background and objectives AKI is frequent and is associated with poor outcomes. There is limited information on the epidemiology of AKI worldwide. This study compared patients with AKI in emerging and developed countries to determine the association of clinical factors and processes of care with outcomes.Design, setting, participants, & measurements This prospective observational study was conducted among intensive care unit patients from nine centers in developed countries and five centers in emerging countries. AKI was defined as an increase in creatinine of $0.3 mg/dl within 48 hours.Results Between 2008 and 2012, 6647 patients were screened, of whom 1275 (19.2%) developed AKI. A total of 745 (58% of those with AKI) agreed to participate and had complete data. Patients in developed countries had more sepsis (52.1% versus 38.0%) and higher Acute Physiology and Chronic Health Evaluation (APACHE) scores (mean6SD, 61.1627.5 versus 51.1625.2); those from emerging countries had more CKD (54.3% versus 38.3%), GN (6.3% versus 0.9%), and interstitial nephritis (7.0% versus 0.6%) (all P,0.05). Patients from developed countries were less often treated with dialysis (15.5% versus 30.2%; P,0.001) and started dialysis later after AKI diagnosis (2.0 [interquartile range, 0.75-5.0] days versus 0 [interquartile range, 0-5.0] days; P=0.02). Hospital mortality was 22.0%, and 13.3% of survivors were dialysis dependent at discharge. Independent risk factors associated with hospital mortality included older age, residence in an emerging country, use of vasopressors (emerging countries only), dialysis and mechanical ventilation, and higher APACHE score and cumulative fluid balance (developed countries only). A lower probability of renal recovery was associated with residence in an emerging country, higher APACHE score (emerging countries only) and dialysis, while mechanical ventilation was associated with renal recovery (developed countries only).Conclusions This study contrasts the clinical features and management of AKI and demonstrates worse outcomes in emerging than in developed countries. Differences in variations in care may explain these findings and should be considered in future trials.

Risk Factor Analysis for AKI Including Laboratory Indicators: a Nationwide Multicenter Study of Hospitalized Patients

“…The results showed that the mortality risks increased with the increase of the APACHE II or SOFA score. Similarly, two international multicenter prospective studies separated by 10 years confirmed a similar effect of the APACHE II score for predicting mortality risk [24, 25]. These results indicate that APACHE II and SOFA scores can accurately predict critical illness and mortality risk in AKI patients.…”

Sepsis associated acute kidney injury

“…Although the pathophysiologic mechanism remains incompletely understood, it seems evident that the deleterious inflammatory cascade characteristic of sepsis contributes to the AKI as well 30. Patients with sepsis complicated by AKI have a significantly increased mortality relative to patients without AKI 263132. Furthermore, patients with AKI associated with sepsis have a significantly increased mortality relative to those with AKI of another etiology 31…”

Acute Kidney Injury in Western Countries

“…In high-income countries, patients are older and have more comorbidities, such as diabetes mellitus, cardiovascular disease, malignancy, and possibly chronic kidney disease (CKD) [1,16]. The most common causes for AKI in high-income countries are sepsis, hypovolemia, drugs, and ischemia [1,16,17], and AKI is often associated with other acute organ failures [16,17]. …”

“…Other causes of AKI, such as glomerulonephritis and acute interstitial nephritis, are more often diagnosed in intensive care units in LMICs than in high-income countries [16]. However, it is unclear whether these represent real differences or whether they reflect variations in practice patterns regarding kidney biopsies.…”

“…However, it is unclear whether these represent real differences or whether they reflect variations in practice patterns regarding kidney biopsies. In one multicenter international study on AKI in critically ill patients, no kidney biopsy was done in developed countries, while 5.2% of patients from emerging countries had a biopsy performed [16]. …”