Acute Kidney Injury and Septic Shock—Defined by Updated Sepsis-3 Criteria in Critically Ill Patients

Abstract

Sepsis is commonly associated with acute kidney injury (AKI), particularly in those requiring dialysis (AKI-D). To date, Sepsis-3 criteria have not been applied to AKI-D patients. We investigated sepsis prevalence defined by Sepsis-3 criteria and evaluated the outcomes of septic-associated AKI-D among critically ill patients. Using the data collected from a prospective multi-center observational study, we applied the Sepsis-3 criteria to critically ill AKI-D patients treated in intensive care units (ICUs) in 30 hospitals between September 2014 and December 2015. We described the prevalence, outcomes, and characteristics of sepsis as defined by the screening Sepsis-3 criteria among AKI-D patients, and compared the outcomes of AKI-D patients with or without sepsis using the Sepsis-3 criteria. A total of 1078 patients (median 70 years; 673 (62.4%) men) with AKI-D were analyzed. The main etiology of AKI was sepsis (71.43%) and the most frequent indication for acute dialysis was oliguria (64.4%). A total of 577 (53.3% of 1078 patients) met the Sepsis-3 criteria, and 206 among the 577 patients (19.1%) had septic shock. Having sepsis and septic shock were independently associated with 90-day mortality among these ICU AKI-D patients (hazard ratio (HR) 1.23 (p = 0.027) and 1.39 (p = 0.004), respectively). Taking mortality as a competing risk factor, AKI-D patients with septic shock had a significantly reduced chance of weaning from dialysis at 90 days than those without sepsis (HR 0.65, p = 0.026). The combination of the Sepsis-3 criteria with the AKI risk score led to better performance in forecasting 90-day mortality. Sepsis affects more than 50% of ICU AKI patients requiring dialysis, and one-fifth of these patients had septic shock. In AKI-D patients, coexistent with or induced by sepsis (as screened by the Sepsis-3 criteria), there is a significantly higher mortality and reduced chance of recovering sufficient renal function, when compared to those without sepsis.

Distinct Subtyping of Successful Weaning from Acute Kidney Injury Requiring Renal Replacement Therapy by Consensus Clustering in Critically Ill Patients

“…Of note, the patients in the worst cluster (cluster 2) had the best renal function parameters, including higher baseline eGFR, lower BUN and SCr before initiating RRT, higher eGFR and bicarbonate level when weaning off RRT, as well as lower BUN and SCr at 24 h after weaning off RRT. These features have been associated with a good prognosis [ 17 , 26 , 32 ]. However, the patients in cluster 2 also had more severe illness in terms of higher qSOFA score and lower bicarbonate level before initiating RRT, which have been associated with a poor prognosis [ 26 , 33 ].…”

“…These features have been associated with a good prognosis [ 17 , 26 , 32 ]. However, the patients in cluster 2 also had more severe illness in terms of higher qSOFA score and lower bicarbonate level before initiating RRT, which have been associated with a poor prognosis [ 26 , 33 ]. The results showed that clustering analysis could cluster baseline characteristics with a temporal change in disease severity into distinct phenotypes.…”

“…The RRT modality in each patient was initially chosen by the attending physician and adjusted accordingly based on disease evolution by a critical care nephrologist. The indication for RRT included one or more of the following: (1) azotemia (blood urea nitrogen (BUN) > 80 mg/dL and sCr > 2 mg/dL) with overt uremic symptoms (encephalopathy, pericarditis, or pleuritis); (2) refractory hyperkalemia with serum potassium level > 5.5 mmol/L; (3) oliguria (urine output < 400 mL/24 h) or anuria (<100 mL/24 h) refractory to diuretics; (4) fluid overload refractory to diuretics along with a central venous pressure > 12 mmHg or pulmonary edema with PaO2/FiO2 < 300 mmHg; and (5) metabolic acidosis (pH < 7.2 in arterial blood) [ 16 , 26 ].…”

“…(3) oliguria (urine output < 400 mL/24 h) or anuria (<100 mL/24 h) refractory to diuretics; (4) fluid overload refractory to diuretics along with a central venous pressure > 12 mmHg or pulmonary edema with PaO2/FiO2 < 300 mmHg; and (5) metabolic acidosis (pH < 7.2 in arterial blood) [16,26].…”

Urine Output Is Associated With In-hospital Mortality in Intensive Care Patients With Septic Shock: A Propensity Score Matching Analysis

“…A study showed that 3–5 h consecutive oliguria in patients with septic shock may be an indicator to measure the risk of AKI ( 13 ). Meanwhile, the most frequent indication for acute dialysis was oliguria ( 14 ). In general, whether patients are complicated with AKI and whether to undergo RRT or diuretic therapy are significantly related to UO theoretically.…”