The AKI care bundle: all bundle components are created equal—are they?

Groote, Thilo von; Ostermann, Marlies; Forni, Lui G.; Meersch-Dini, Melanie; Zarbock, Alexander; Schmidt, Christoph; Hoffmeier, A.; Aken, Hugo Van; Wempe, Carola; Küllmar, Mira; Lucchese, Gianluca; Baig, Kamran; Cennamo, Armando; Rajani, Ronak; McCorkell, Stuart; Arndt, Christian; Wulf, Hinnerk; Irqsusi, Marc; Monaco, Fabrizio; Prima, Ambra Licia Di; Álvarez, M. García; Italiano, Stefano; Bagán, Jordi Miralles; Kunst, Gudrun; Nair, Shrijit; L’Acqua, Camilla; Hoste, Eric A. J.; Vandenberghe, Wim; Honoré, Patrick M.; Kellum, John A.; Grieshaber, Philippe; Massoth, Christina; Weis, Raphael

doi:10.1007/s00134-021-06601-0

Cited by 21 publications

(15 citation statements)

References 5 publications

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“…Patients who received the 2 most important measures of the bundle, 12 avoidance of hypotensive episodes and avoidance of nephrotoxic agents, showed better outcomes compared to patients in whom these 2 bundle criteria were not completed (Table 2). Especially renal outcomes, incidence of moderate and severe AKI (18.7% vs 11.33%), progression of AKI (35.4% vs 31.1%), renal replacement therapy (6.8% vs 2.2%) as well as the composite outcome consisting of AKI progression and death (42.6% vs 35.8%) were improved (Table 2).…”

Section: Resultsmentioning

confidence: 99%

Implementation of Nephroprotective Measures to Prevent Acute Kidney Injury in Septic Patients: A Retrospective Cohort Study

Sadjadi

Porschen

Groote

et al. 2023

Anesthesia &Amp; Analgesia

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BACKGROUND: Sepsis remains the leading cause of mortality in critically ill patients, and mortality is increased when acute kidney injury (AKI) occurs. The Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommends the implementation of supportive measures in patients at high risk for AKI. However, it remains unclear to what extent these nephroprotective measures are implemented in daily clinical practice in critically ill patients, especially those with high-risk exposures such as sepsis. METHODS: We analyzed the Medical Information Mart for Intensive Care IV (MIMIC-IV) database to identify septic patients with and without AKI. The primary outcome of interest was the adherence to the KDIGO bundle consisting of avoidance of nephrotoxic agents, implementation of a functional hemodynamic monitoring, optimization of perfusion pressure and volume status, close monitoring of renal function, avoidance of hyperglycemia, and avoidance of radiocontrast agents. Secondary outcomes included the development of AKI, progression of AKI, the use of renal replacement therapy (RRT), mortality, and a composite end point consisting of progression of AKI and mortality within 7 days. RESULTS: Our analysis included 34,679 patients with sepsis with 1.6% receiving the complete bundle (10% received 5, 42.3% 4, 35.4% 3, and 9.8% 2 bundle components). In 56.4%, nephrotoxic agents were avoided, and hemodynamic optimization was reached in 86.5%. Secondary end points were improved in patients with bundle adherence. Avoidance of nephrotoxic drugs and optimization of hemodynamics were significantly associated with lower rates of AKI and improved patient outcomes, including 30-day mortality. CONCLUSIONS: Implementation of the KDIGO bundle is poor in patients with sepsis but may be associated with improved outcomes.

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Section: Resultsmentioning

confidence: 99%

Implementation of Nephroprotective Measures to Prevent Acute Kidney Injury in Septic Patients: A Retrospective Cohort Study

Sadjadi

Porschen

Groote

et al. 2023

Anesthesia &Amp; Analgesia

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“…However, a recent analysis of the combined data of the PrevAKI single-centre and the PrevAKI multicentre trials, including 554 randomised patients at high risk of AKI identified by biomarkers, weighted some measures as more important than others. The results of a univariate logistic regression analysis identified the combination of hypotension and a low cardiac index (<3 l min −1 m −2 ) along with the use of nephrotoxic drugs as the key determinants for the development and worsening of AKI 23 . Further outcome studies are needed to assess whether a condensation of the bundle to the measures ‘avoidance of nephrotoxic drugs’ and ‘application of functional haemodynamic monitoring’ to optimise not only mean arterial blood pressure but also cardiac index might be sufficient to prevent AKI.…”

Section: Discussionmentioning

confidence: 99%

“…The results of a univariate logistic regression analysis identified the combination of hypotension and a low cardiac index (<3 l min À1 m À2 ) along with the use of nephrotoxic drugs as the key determinants for the development and worsening of AKI. 23 Further outcome studies are needed to assess whether a condensation of the bundle to the measures 'avoidance of nephrotoxic drugs' and 'application of functional haemodynamic monitoring' to optimise not only mean arterial blood pressure but also cardiac index might be sufficient to prevent AKI. Our study assessed the KDIGO bundle application and found the overall adherence to be very low.…”

Section: Discussionmentioning

confidence: 99%

Implementation of the Kidney Disease Improving Global Outcomes guidelines for the prevention of acute kidney injury after cardiac surgery

Massoth

Küllmar

Moncho

et al. 2023

European Journal of Anaesthesiology

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BACKGROUNDIncreasing evidence from randomised controlled trials supports the implementation of a six-measure care bundle proposed by the Kidney Disease Improving Global Outcomes (KDIGO) guidelines in patients at high risk for acute kidney injury (AKI) to reduce its incidence after cardiac surgery.OBJECTIVETo assess compliance with the KDIGO bundle in clinical practice.DESIGNProspective observational multinational study.SETTINGSix international tertiary care centres, from February 2021 to November 2021.PATIENTSFive hundred and thirty-seven consecutive patients undergoing cardiac surgery during a 1-month observational period.INTERVENTIONSAll patients were assessed for the postoperative implementation of the following measures: avoidance of nephrotoxic medication and radiocontrast agents whenever possible, strict glycaemic control, close monitoring of renal function, optimisation of haemodynamic and volume status and functional monitoring of haemodynamic status.MAIN OUTCOME MEASURESThe primary endpoint was the proportion of patients receiving fully compliant care. Secondary outcomes were occurrence of AKI and major adverse kidney event rate at day 30.RESULTSThe full care bundle was applied to 0.4% of patients. There was avoidance of nephrotoxic drugs in 15.6%, radiocontrast agents in 95.3% and hyperglycaemia in 39.6%. Close monitoring of urine output and serum creatinine was achieved in 6.3%, 57.4% underwent optimisation of volume and haemodynamic status, and 43.9% received functional haemodynamic monitoring. 27.2% developed AKI within 72 h after surgery. The average number of implemented measures was 2.6 ± 1.0 and did not differ between AKI or non-AKI patients (P = 0.854).CONCLUSIONAdherence with the KDIGO bundle was very low in cardiac surgery patients. Initiatives to improve guideline compliance might provide a strategy to mitigate the burden of AKI.TRIAL REGISTRATIONwww.drks.de DRKS00024204.

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“…As an increased vasopressor use is associated with a worse outcome, balancing organ perfusion pressure against the increased risk of complications due to use of vasopressors is a challenging task for anesthetists and intensivists caring for cardiac surgery patients. In a recent posthoc analysis of the combined data of the two PrevAKI trials, the influence of postoperative hemodynamics on AKI rates was investigated [20 ▪▪ ]. In this study, hypotension (defined as MAP < 65mmHg) and low cardiac index (defined as cardiac index below 3.0 l/m 2 ) were significantly associated with AKI.…”

Section: Introductionmentioning

confidence: 92%

Acute kidney injury after cardiac surgery

von Groote,

Sadjadi,

Zarbock

2023

Current Opinion in Anaesthesiology

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Purpose of review Patients undergoing cardiac surgery are at high risk to develop cardiac surgery-associated acute kidney injury (CS-AKI) postoperatively. CS-AKI is associated with an increased risk for persistent renal dysfunction, morbidity and mortality. This review summarizes the epidemiology and pathophysiology of CS-AKI, as well as current treatment and prevention strategies. Recent findings As AKI is a syndrome with complex pathophysiology, no causative treatment strategies exist. Recent advances in the field of AKI biomarkers offer new perspectives on the issue and the implementation of biomarker-guided preventive strategies may reduce rates of CS-AKI. Finally, nephroprotective treatments and angiotensin II as a novel vasopressor may offer new opportunities for high-risk patients undergoing cardiac surgery. Summary Based on the described novel approaches for early detection, prevention and management of CS-AKI, a precision-medicine approach should be implemented in order to prevent the development of AKI in patients undergoing cardiac surgery.

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The AKI care bundle: all bundle components are created equal—are they?

Cited by 21 publications

References 5 publications

Implementation of Nephroprotective Measures to Prevent Acute Kidney Injury in Septic Patients: A Retrospective Cohort Study

Implementation of Nephroprotective Measures to Prevent Acute Kidney Injury in Septic Patients: A Retrospective Cohort Study

Implementation of the Kidney Disease Improving Global Outcomes guidelines for the prevention of acute kidney injury after cardiac surgery

Acute kidney injury after cardiac surgery

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