Risk Factors for AKI Dr Itır Yeğanağa KOU Tıp Fakültesi.

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1 Risk Factors for AKI Dr Itır Yeğanağa KOU Tıp Fakültesi

2 Incidence of ARF: 1%-25%; depends on the definition Mortality of ARF: 28%-90% Schaefer JH…Intensive Care Med 1991, 17:19-24 Brivet FG… Crit Care Med 1996, 24:192-198 Baldaya AP… Am J Kidney Dis 1996, 28 (suppl):s81-89 De Mendoca A… Intensive Care Med 2000, 26:915-921

3 E Hoste..Crit Care Med 2008,36suppl4:146-151

4 In the community setting; 17 per milion per year age <50, 620 per milion per year age age 80-89 1% hospital admission in the USA Hospital aquired AKI 5-7% Community aquired less then X 5-10 R Pisoni..Nephron Clin Practice 2008,109:188-191

5 Hospital-aquired ARF University hospitals in the USA (2002) Incidence of ARF: 7.2% Overall Mortality:19.4%, Required Dialysis 2.7% Regain normal RF:38.6% Higher serum creatinine, older age, sepsis risk for higher mortality Pre-exist. of CKD threefold risk for ARF Nash K… Am J Kidney Dis 2002,39:930-936

6 Medicare Analysis ARF increases 11% per year 1979-2001 Mort. Decreases 38.8% to 32.2% Required Dialysis mort. 45.7% to 44.6% Risk factor: Older age, male gender, black race.. Secondary ARF; having sepsis, ICU stay, other organ dysfunction CA Block… The Epidemiology and outcome of acute renal failure and the impact on chronic kidney disease Semianars in Dialysis 2006,19:6,450-454

7 Brivet study (prospective, multicenter) (French Study Group on Acute Renal Failure) C rit Care Med 1996,24:2,192-198 360 patients, (in 20 ICU) Age,(OR:1.55;1.32-1.81) previous health status,(2.35;1.37-4.07) Severity of illness(SAPS) (1.54;1.36-1.75) disease characteristics; initial or delayed ARF, oliguria,(2.22;1.28-3.84) sepsis(48%)(higher mort.rate 73%/45%) (2.32;1.37-3.93)

8 ARF in Critically Ill PICARD study-618 patients (1999-2001) with ARF in USA (5 academic center) overall mortality 37% non-recovery of renal function 50% ARF on CKD mort.lower (31%/41%) Mort. increases in relation of the number of organ failure Require dialysis; 64% RL Mehta…Kidney Int 2004 66:1613-1621

9 PICARD study Comorbities are more common then before; 1. 30% CKD 2. 37% Coronary arter disease 3. 29% DM 4. 21%chronic liver disease

10 RL Mehta…Kidney Int 2004 66:1613-1621

11 ARF in Critically Ill BEST Study; multicenter,54center, 23country multinational (Europe+ABD+far east ) 29,269 critcall ill patients 1,738 (5.7%), ARF mort.:60.30% Septic shock; most common 47.50% Pre-existing CKD; 30% RRT requir.; 2/3 of patients RRT at discharge; 13.8% S Uchino…JAMA 2005,294:813-818

12 ARF in Critically Ill BEST Study Mechanical ventilation Bilirubin Age Hypotension Sepsis Platetelet Oliguria Multivariate logistic regression analysis signifcant for hospital mortality S Uchino…JAMA 2005,294:813-818

13 “BEST Kidney” Çalışma gurubunun sonuçları (Hastane ölüm oranı için bağımsız risk faktörleri) (S Uchino…JAMA 2005,294:813-818) Vasopressör Risk oranı 1.95 %95güvenirlilik 1.50-2.55 Mekanik vent.2.111.58-2.82 Septik şok1.361.03-1.79 Kardiyojenik şok1.411.05-1.90 Hepatorenal sendrom 1.871.07-3.28

14 (Europian Sociaty of Intensive Care Medicine) SOFA study group 40 ICU, 16 country (europian) ; 1411 patients Acute circulatory or respiratory failure Age>65 Presence of infection Chronic heart failure history Lymphoma, leukemia Cirrhosis A De Mendonça…Intensive Care Med 2000.26:915-921

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17 Risk factors for developing ARF(SOFAstudy) Acute circulatory or respiratory failure Age>65 Presence of infection Chronic heart failure history Lymphoma, leukemia Cirrhosis A De Mendonça…Intense Care Med 2000.26:915-921

18 A De Mendonça…Intensive Care Med 2000.26:915-921

19 Lower creatinine level with increased mortality;dose manner J Cerda…Nephrol Dial Transplant 2007,22:2781-2784 R Cartin-Ceba… Crit Care Med 2007,35:2420-2423 Higher creatinine level higher mortality MM O’Brian…Kidney Int 2002,62:585-591 SG Coca… Am J Kidney Dis 2007,50:712-720

20 Low serum albumin/risk for ARF GN Cloritides…Ren Failure 2000,22:235-244 MM Ward…Arch Int Med 1988,148:1553-1557

21 ARF major complication of cardiopulmonary bypass op.(CPB) Poor cardiac performance baseline renal insuffiency PJ Conlon…Nephrol Dial Trans 1999,14:1158-1162

22 ARF Risk for trauma patient Age, ISS>17 Hemoperitoneum Shock Hypotension rabdomyolysis; CPK>10000, Acute lung injury;mechanical ventilation GCS<10 G Vivino… Intensiv Care Med 1998,24:808-814

23 Common variables in 12 AKI severity scores S Uchino.. Nephron Clin Pract 2008,109:217-223

24 Risk factors for developing ARF 257 (sepsis/SIRS)hastanın 29’unda ABY ortaya çıktı(%11) Bu oran genel anlamda çeşitli çalışmalarda %1-31 olarak bildirilmiştir. Yegenaga et al Am J Kidney Dis 2004, 43:817-824.

25 Gent YBÜ’de 2001 yılında ABY ve sepsisden ölüm oranları Yüzde oranı Yegenaga et al Am J Kidney Dis 2004, 43:817-824.

26 Yoğun Bakımda sepsis’de ABY gelişme risk faktörleri Hastaların yaşı, Serum krt.düzeylerinin normalin üst düzeyinde olması MVB yüksek olması İdrar miktarının azalmış olması Asidozun derin ve tedaviye dirençli olması Ortalama arter basınçlarının tedaviye rağmen düşük seyretmesi Siroz öyküsü varlığı Yegenaga et al Am J Kidney Dis 2004, 43:817-824

27 Sepsiste ABY gelişiminin klinik göstergeleri Göstergeler ABYyokABY Yaş (yıl) 55.1  17.465.2  13.3* S.alb (mg%) 2.7  1.42.1  0.6* CVP day 1 (mmHg) CVP day 2 (mmHg) 5.2  2.3 5.0  4.1 9.6  4.3* 8.3  3.9* Kolloid sıvı 3days (ml) 1116  12202037  1681* S.kr gün 1(mg%) S.kr artışı; mg% (d1-d2) 1.0  0.33 -0.31  0.45 1.3  0.39* +0.30  0.58* Diures d1 (ml) 1852  9131347  649* Diyastol KB mm Hg (g1) 50.7  10.048.2  8.7 OAB mm Hg (g1) 67.9  12.464.5  12.4 Yegenaga et al Am J Kidney Dis 2004, 43: 817-824.

28 Multivariate logistic regression Coef.βExp.β95%conf.interv.p Bilirubin>1.52.39.71.65-60.30.018 Age0.0741.11.03-1.130.003 Crt.mg/dl0.0231.021.007-1.040.005 CVP (cmH2O) 0.411.51.26-1.800.0001 Constant-12.90.000.0001 Yegenaga et al Am J Kidney Dis 2004, 43: 817-824

29 Yoğun Bakımda ABY gelişme risk faktörleri 185 patients, retrospective CVP with ARF:8mm/Hg; without ARF:5mm/Hg, p=0.008 pH 1mg/dl ise ABY gelişme riski 6 kat daha fazla Hoste ve ark. J.Am Soc Nephrol, 2003,14:1022-1030

30 EVALUATION OF SEPSIS/SIRS, ACUTE KIDNEY INJURY AND RIFLE CRITERA IN TWO TERTIARY HOSPITAL ICU OF TURKEY (unpublished data) 109 patients (Kocaeli), 30 patients (Marmara) Sepsis/SIRS, 2006-2008 Definition of AKI based on RIFLE

31 Clinical characteristic of patients AKI (n=79)Non-AKI (n=60)p Age(year)58.7±15.7749.82±19.12 0.003 SOFA score10.07±2.079.15±1.71 0.006 Diabetes Mellitus22(27.5%)7(11.7%) 0.034 Day-1 Lowest Syst.BP(mmHg) 92.61±21.82100.83±22.76 0.032 Day-1 Lowest CVP(cmH2O) 9.25±3.836.95±3.73 0.007 Fluid balance (intake/output) (ml/24h) 1778.31±2849.96724.21±1699.39 0.015 No of patients on vasopressors 50(62.5%)19(31.7%) 0.000 Died in Hosp52(65%)21(35%)0.001

32 Biochemical parameters of cases AKINo-AKIp Lowest Hct value(%)29.24±6.4132.20±7.000.011 Urea(mg/dL)64.41±47.9439.14±18.800.000 Creatinine(mg/dL)1.26±0.590.73±0.240.000 Prothrombin time(%)18.19±8.4415.59±3.160.028 pH lowest7.31±0.157.38±0.080.033 Bicarbonate lowest19.96±7.0523.37±5.180.003

33 Multivariate Logistic Regression Coeficient βExpβ95% confident interval p SOFA0.4241.5291.022-2.2870.039 Creatinine (mg/dL6.460638.94429.664-13762.360.000 Lowest systolicBP ( if<80mmHg-yes or no)(mmHg) 1.7535.7720.973-34.2430.054 Difference between input/output(mL/24h) 0.0001.0001.000-1.0010.053 Constant-11.4100.0000.001

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37 S Bagshow.. Critical Care 2008,12:R47 ANZIKS Database 33,375 sepsis included 14,039(27.8%) septic AKI

38 S Bagshow.. Critical Care 2008,12:R47 ANZIKS Database

39 Positive fluid balance an unfavorable outcome JP Mitchel…Am Rev Respir Dis 1992,145:990-998 Mean fluid balance, for per Liter OR 1,21(1,13- 1,28) p=0.001 D Payen.. Critical Care 2008,12:3

40 Failing to achieve a negative fluid balance within 3 days of treatment mort. increases RR=5.0 (CI 2,3-10,9) F Alsous… Chest 2000, 117:1749-1754

41 Kalp yetmezliği

42 Solunum Yetmezliği

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