acute kidney injury in critically ill patients in the new millenium: definition and epidemiology....

ACUTE KIDNEY INJURY IN CRITICALLY ILL PATIENTS IN THE NEW MILLENIUM: DEFINITION AND EPIDEMIOLOGY

JOSÉ ANTÓNIO LOPES, MD, PhD

Assistant Professor of NephrologyFaculty of Medicine, University of Lisbon

Department of Nephrology and Renal TransplantationCentro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal

jalopes93@hotmail.com

Barcelona, 4th March 2014

DEFINITION AND CLASSIFICATION OF AKI

≠ DEFINITIONS

≠ INCIDENCE

≠ MORTALITY≠ MORTALITY

DEFINITION OF AKIINCIDENCE AND MORTALITY

Chertow GM et al. J Am Soc Nephrol 2005

N=9.210

DEFINITION OF AKI

1. Easy to use

2. High sensitivity and specificity in ≠ settings

3. Consider variations in baseline SCr

4. Determine AKI severity

5. Identifiy early and late AKI

RIFLE ClassificationRisk, Injury, Failure, Loss, End-stage kidney disease

Bellomo R et al. Crit Care 2004

Risk Injury Failure

Ricci Z et al. Kidney Int 2008

VALIDATION OF THE RIFLE IN THE ICU

RIFLE CLASSIFICATION

INCIDENCE AND STRATIFICATION OF AKI

Lopes JA et al. Clin Kidney J 2013

67%

36%

11%

36%

18%

SAPS II RIFLE

AKI IN CRITICALLY ILL SEPTIC PATIENTS

Lopes JA et al. Crit Care 2007

0.778 0.750

Hoste E et al. Crit Care 2006

CRITICALLY ILL PATIENTS

Mehta RL et al. Crit Care 2007

AKIN CLASSIFICATIONAcute Kidney Injury Network

Chertow GM et al. J Am Soc Nephrol 2005

sCr ≥ 0.3 mg/dl - IN-HOSPITAL MORTALITY

N=9.210

COMPARISON BETWEEN RIFLE AND AKIN

INCIDENCE OF AKI AND PREDICTION OF MORTALITY

Lopes JA et al. Crit Care 2008

P = 0.018

N=662

Lopes JA et al. Crit Care 2008

N=662

Acute kidney injury in critically ill patients classified by AKIN versus RIFLE using the SAPS 3 database

Joannidis M et al. Intensive Care Med 2009

N=16.784

RIFLE2004

AKIN2009

LIMITATIONS STRENGTHS

KDIGO2012

KDIGO Clinical Practice Guideline for AKI. Kidney Int 2012

KDIGO CLASSIFICATION

LIMITATIONS OF CLINICAL CLASSIFICATIONS

URINE OUTPUT

Sensitivity and specificity Hourly basis register (+++ ICU)

SCr

variability in endogenous production and S releaseMultiple factors can interfer with SCr determination HemodilutionSepsis productionCKD late in SCr Marker of renal function and not of lesion

BIOMARKERS IN AKI

Murray PT et al. Kidney Int 2013

Coca SG et al. Kidney Int 2008

BIOMARKERS IN AKI

FRAMEWORK FOR EVALUATING AKI BASED ON BIOMARKERS

Murray PT et al. Kidney Int 2013

BIOMARKERS IN AKI FUTURE DIRECTIONS

Confirm that the proposed expansion of the diagnostic criteria for AKI to include the isolated presence of damage biomarkers, with preserved function, is clinically relevant.

Determine the mechanistic pathways that are involved in the development of AKI and its natural course.

Define the prognostic value of the combined use of functional and damage markers in sequential measurements to confirm the prognostic significance of these categories.

Ascertain how well the combination of damage and functional markers can improve recognition of AKI in the setting of CKD.

Murray PT et al. Kidney Int 2013

BIOMARKERS IN AKI FUTURE DIRECTIONS

Large population-based studies would be required across multiple centers enrolling patients in the wide spectrum of AKI and different disease states, to determine whether operationalizing the approach to AKI with a simple 2x2 table to mechanistically define AKI cases and their evolution usefully influences patient management and ultimately improves outcomes.

Discover and confirm the sensitivity and specificity of damage and functional markers for specific situations.

Establish standard techniques for collection, handling, and presentation of biomarker data that permit appropriate interpretation across settings.

Murray PT et al. Kidney Int 2013

EPIDEMIOLOGY OF AKI IN THE ICUINCIDENCE

Bagshaw SM et al. Crit Care 2007

N=91.254

Lopes JA et al. Clin Kidney J 2013

67%

36%

11%

36%

INCIDENCE OF AKI IN THE ICU

Uchino S et al. JAMA 2005

EPIDEMIOLOGY OF AKI IN THE ICUPATIENT CHARACTERISTICS AND RISK FACTORS

N=29.269

EPIDEMIOLOGY OF AKI IN THE ICUSHORT- AND LONG-TERM OUTCOMES

Bagshaw SM et al. Nephrol Dial Transplant 2008

N=120.123

A multi-centre evaluation of the RIFLE criteria for early acute kidney injury in critically ill patients

Long-term risk of mortality after acute kidney injury in patients with sepsis: a contemporary analysis

Lopes JA et al. BMC Nephrol 2010

N=234

Bihorac A et al. Ann Surg 2009

N=10.518

Gammelager et al. Crit Care 2012

N=30.762

Bagshaw SM et al. Crit Care 2005

Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: a population-based study

Hobson CE et al. Circulation 2009

N=2.973

Ishani A et al. J Am Soc Nephrol 2009

N= 233.803

Acute kidney injury increases risk of ESRD among elderly

Lai CF et al. Crit Care 2012

N=634

Ponte B et al. Nephrol Dial Transplant 2008

Hansen et al. Crit Care 2013

N=1.030

SEPSIS

HEMORRHAGE

FLUID OVERLOAD

ACUTE KIDNEY INJURY

• INFLAMMATION• OXIDATIVE STRESS

• APOPTOSIS

Xiang Li et al. Curr Opin Crit Care 2010

SUMMARY

The KDIGO work group has made the fusion of the RIFLE and AKIN classifications in order to establish one classification of AKI for practice, research, and public health.

The conceptual framework of functional and damage biomarkers will need to be validated through future studies, and additional evidence will be required to establish their best combinations for utilization in clinical practice.

SUMMARY

AKI is an increasingly common complication in ICU patients.

Patients with AKI have higher ICU and in-hospital mortality and longer lengths of stay, and AKI survivors are more likely to be discharged to an extended care facility.

Patients who survive AKI have a greater rate of long-term mortality and other adverse outcomes (i.e. progression to or acceleration of CKD and cardiovascular disease) than patients who survive hospitalization without AKI.