Acute kidney injury after aneurysmal subarachnoid hemorrhage and its effect on patient outcome: an exploratory analysis

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Acute kidney injury (AKI) is associated with death in critically ill patients, but this complication has not been well characterized after aneurysmal subarachnoid hemorrhage (aSAH). The purpose of this study was to determine the incidence of AKI after aSAH and to identify risk factors for renal dysfunction. Secondary objectives were to examine what effect AKI has on patient mortality and functional outcome at 12 weeks post-aSAH.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors performed a post hoc analysis of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1) trial data set (clinical trial registration no.: NCT00111085, <jats:ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="https://clinicaltrials.gov">https://clinicaltrials.gov</jats:ext-link>). The primary outcome of interest was the development of AKI, which was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Secondary outcomes of interest were death and a modified Rankin Scale score greater than 2 at 12 weeks post-aSAH. Propensity score matching was used to assess for a significant treatment effect related to clazosentan administration and AKI. Univariate analysis, locally weighted scatterplot smoothing (LOWESS) curves, and stepwise logistic regression models were used to evaluate for associations between baseline or disease-related characteristics and study outcomes.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>One hundred fifty-six (38%) of the 413 patients enrolled in the CONSCIOUS-1 trial developed AKI during their ICU stay. A history of hypertension (p &lt; 0.001) and the number of nephrotoxic medications administered (p = 0.029) were independent predictors of AKI on multivariate analysis. AKI was an independent predictor of death (p = 0.028) but not a poor functional outcome (p = 0.21) on multivariate testing. Unresolved renal dysfunction was the strongest independent predictor of death in this cohort (p &lt; 0.001).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>AKI is a common complication following aSAH. Patients with premorbid hypertension and those treated with nephrotoxic medications may be at greater risk for renal dysfunction. AKI appears to confer an increased probability of death after aSAH.</jats:p></jats:sec>

Lessons from the CONSCIOUS-1 Study

“…The effect on fluctuations in sodium in patients with aSAH in CONSCIOUS-1 are consistent with this concept of the negative effects of nonphysiologic conditions after aSAH [64]. Changes in daily sodium were associated with poor outcome, and the absolute daily difference in sodium during the DCI window trended toward significance as an independent predictor of DCI.…”

“…Acute kidney injury has seldom been studied in aSAH. Eagles et al analyzed acute kidney injury and outcome in CONSCIOUS-1 [ 64 ]. History of hypertension and nephrotoxic medications were independent predictors of developing acute kidney injury.…”

Low-chloride- versus high-chloride-containing hypertonic solution for the treatment of subarachnoid hemorrhage–related complications: The ACETatE (A low ChloriE hyperTonic solution for brain Edema) randomized trial

“…Aside from CNS-related complications such as hydrocephalus, cerebral edema, or delayed cerebral ischemia, systemic complications account for up to 40% of all deteriorations during inpatient care [3]. Acute kidney injury in aSAH patients is associated with a greater than four-fold increase in hospital mortality, along with less favorable neurological recovery in patients who survive [4][5][6].…”

Early Serum Creatinine Levels after Aneurysmal Subarachnoid Hemorrhage Predict Functional Neurological Outcome after 6 Months

“…Previous studies reported that even marginal increases in the sCr levels in ICU patients relevantly worsened the outcome [ 22 ]. Investigations that used the RIFLE and AKIN guidelines for AKI also proved that even moderate AKI raised the mortality risk [ 17 , 23 ]. However, Tujjar et al and Eagles et al reported that AKI did not independently influence the outcome [ 16 , 23 ].…”

“…Investigations that used the RIFLE and AKIN guidelines for AKI also proved that even moderate AKI raised the mortality risk [ 17 , 23 ]. However, Tujjar et al and Eagles et al reported that AKI did not independently influence the outcome [ 16 , 23 ]. Eagles et al could not elucidate why AKI was independently associated with mortality, but not with functional outcome [ 23 ].…”