Sepsis-associated acute kidney injury: consensus report of the 28th Acute Disease Quality Initiative workgroup (original) (raw)
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Kidney International, 2019
Sepsis-associated acute kidney injury (S-AKI) is a frequent complication of the critically ill patient and is associated with unacceptable morbidity and mortality. Prevention of S-AKI is difficult because by the time patients seek medical attention, most have already developed acute kidney injury. Thus, early recognition is crucial to provide supportive treatment and limit further insults. Current diagnostic criteria for acute kidney injury has limited early detection; however, novel biomarkers of kidney stress and damage have been recently validated for risk prediction and early diagnosis of acute kidney injury in the setting of sepsis. Recent evidence shows that microvascular dysfunction, inflammation, and metabolic reprogramming are 3 fundamental mechanisms that may play a role in the development of S-AKI. However, more mechanistic studies are needed to better understand the convoluted pathophysiology of S-AKI and to translate these findings into potential treatment strategies and add to the promising pharmacologic approaches being developed and tested in clinical trials.
Sepsis-Associated Acute Kidney Injury
Acute kidney injury (AKI) is an epidemic problem. Sepsis has long been recognized as a foremost precipitant of AKI. Sepsis-associated AKI (SA-AKI) portends a high burden of morbidity and mortality in both children and adults with critical illness. Although our understanding of its pathophysiology is incomplete, SA-AKI likely represents a distinct subset of AKI contributed to by a unique constellation of hemodynamic, inflammatory, and immune mechanisms. SA-AKI poses significant clinical challenges for clinicians. To date, no singular effective therapy has been developed to alter the natural history of SA-AKI. Rather, current strategies to alleviate poor outcomes focus on clinical risk identification, early detection of injury, modifying clinician behavior to avoid harm, early appropriate antimicrobial therapy, and surveillance among survivors for the longer-term sequelae of kidney damage. Recent evidence has confirmed that patients no longer die with AKI, but from AKI. To improve the care and outcomes for sufferers of SA-AKI, clinicians need a robust appreciation for its epidemiology and current best-evidence strategies for prevention and treatment. Semin Nephrol 35:2-11 C 2015 Elsevier Inc. All rights reserved.
Sepsis-induced acute kidney injury revisited
Current Opinion in Critical Care, 2014
Purpose of review Acute kidney injury (AKI) is a common complication in critically ill patients and is associated with increased morbidity and mortality. Sepsis is the most common cause of AKI. Considerable evidence now suggests that the pathogenic mechanisms of sepsis-induced AKI are different from those seen in other causes of AKI. This review focuses on the recent advances in this area and discusses possible therapeutic interventions that might derive from these new insights into the pathogenesis of sepsis-induced AKI.
New insights in prevention and treatment of sepsis-induced acute kidney injury
Journal of Translational Internal Medicine, 2013
Sepsis-induced acute kidney injury (SAKI) remains an important challenge for intensive care unit clinicians. We reviewed current available evidence regarding prevention and treatment of SAKI thereby incorporating some major recent advances and developments. Prevention includes early and ample administration of "balanced" crystalloid solutions such as Ringer's lactate. For monitoring of renal function during resuscitation, lactate clearance rate is preferred above S cv O 2 or renal Doppler. Aiming at high central venous pressures seems to be deleterious in light of the novel "kidney afterload" concept. Noradrenaline is the vasopressor of choice for preventing SAKI. Intra-abdominal hypertension, a potent trigger of acute kidney injury in postoperative and trauma patients, should not be neglected in sepsis. Renal replacement therapy (RRT) must be started early in fluid-overloaded patients refractory to diuretics. Continuous RRT (CRRT) is the preferred modality in hemodynamically unstable SAKI but its use in more stable SAKI is increasing. In the absence of hypervolemia, diuretics should be avoided. Antimicrobial dosing during CRRT needs to be thoroughly reconsidered to assure adequate infection control.
Sepsis and Acute Kidney Injury
Journal of the American Society of Nephrology, 2011
Sepsis develops when the initial, appropriate host response to an infection becomes amplified and then dysregulated. Because of very high mortality rates, it is fundamental to promptly recognize sepsis-induced AKI and to choose the most appropriate therapeutic modality. This task, however, is still far from certain because of a lack of general consensus and conflicting data. It is well established that
Intensive Care Medicine, 2011
Purpose: Sepsis commonly contributes to acute kidney injury (AKI); however, the frequency with which sepsis develops as a complication of AKI and the clinical consequences of this sepsis are unknown. This study examined the incidence of, and outcomes associated with, sepsis developing after AKI. Methods: We analyzed data from 618 critically ill patients enrolled in a multicenter observational study of AKI (PICARD). Patients were stratified according to their sepsis status and timing of incident sepsis relative to AKI diagnosis. Results: We determined the associations among sepsis, clinical characteristics, provision of dialysis, in-hospital mortality, and length of stay (LOS), comparing outcomes among patients according to their sepsis status. Among the 611 patients with data on sepsis status, 174 (28%) had sepsis before AKI, 194 (32%) remained sepsis-free, and 243 (40%) developed sepsis a median of 5 days after AKI. Mortality rates for patients with sepsis developing after AKI were higher than in sepsis-free patients (44 vs. 21%; p \ 0.0001) and similar to patients with sepsis preceding AKI (48 vs. 44%; p = 0.41). Compared with sepsis-free patients, those with sepsis developing after AKI were also more likely to be dialyzed (70 vs. 50%; p \ 0.001) and had longer LOS (37 vs. 27 days; p \ 0.001). Oliguria, higher fluid accumulation and severity of illness scores, non-surgical procedures after AKI, and provision of dialysis were predictors of sepsis after AKI. Conclusions: Sepsis frequently develops after AKI and portends a poor prognosis, with high mortality rates and relatively long LOS. Future studies should evaluate techniques to monitor for and manage this complication to improve overall prognosis.
Outcomes in Sepsis-Induced Acute Kidney Injury: A Prospective Observational Study
International Journal of Contemporary Medical Research [IJCMR]
Introduction: Acute Kidney injury (AKI) is often multifactorial, with sepsis being only one of the factors in its pathogenesis particularly in critically ill patients. It often leads to worse clinical outcomes, increased duration of hospitalization, need for intensive care and mortality. Our objective in the current study was to analyze the various factors associated with sepsis-related AKI and clinical outcome. Material and Methods: The study included all patients with sepsis admitted to medical Intensive care unit (ICU). These patients were subjected to laboratory investigations and radiological imaging. The APACHE II score was assessed and patients were grouped by RIFLE categories for risk, injury, and failure. Course in the hospital was observed for a period of 28 days or till discharge/death of the patients. Results: Of the 320 patients with sepsis, 31.2% developed AKI due to sepsis. The overall mortality rate of AKI patients with sepsis was 58%. The mortality rate increased significantly as renal function deteriorated (p=0.020). It was also observed that the mortality increased significantly with increase in the severity of sepsis (p<0.005). Multivariate logistic regression analysis revealed sepsis severity, RIFLE class, high APACHE II score were the independent predictors of mortality. Conclusion: The present study revealed high overall mortality rate. Males sex, sepsis severity, RIFLE class, high APACHE II score, and Vasopressor Use were the independent predictors of mortality in sepsis-induced AKI, while age had no independent prognostic value.
Critical Care
Background: Acute kidney injury (AKI) is a common complication of critical illness and is associated with worse outcomes. However, the influence of deterioration or improvement in renal function on clinical outcomes is unclear. Using a large international database, we evaluated the prevalence and evolution of AKI over a 7-day period and its effects on clinical outcomes in septic and non-septic critically ill patients worldwide. Methods: From the 10,069 adult intensive care unit (ICU) patients in the Intensive Care Over Nations database, all those with creatinine and urine output data were included in this substudy. Patients who developed sepsis during the ICU stay (≥ 2 days after admission) were excluded. AKI was evaluated within 72 hours after admission and before discharge/death up to day 7 according to the Acute Kidney Injury Network (AKIN) criteria. Results: A total of 7970 patients were included, 59% of whom met AKIN criteria for AKI within the first 72 hours of the ICU stay. Twenty-four per cent of patients had sepsis on admission, of whom 68% had AKI, compared to 57% of those without sepsis on admission (p < 0.001). AKIN stage 3 (40% vs 24%, p < 0.001) and use of renal replacement therapy (20% vs 5%, p < 0.0001) were more prevalent in patients with sepsis. Patients with sepsis and AKIN stage 3 were less likely to improve to a lower stage during the 7-day follow-up period than non-septic patients with AKIN stage 3 (21% vs 32%, p < 0.0001). In-hospital mortality was related to severity of AKI and was reduced in patients in whom AKI improved compared to those who remained stable or deteriorated, but remained higher than in patients without AKI, even if there was apparent full recovery at day 7. Conclusion: These findings illustrate the different kinetics of AKI in septic and non-septic ICU patients and emphasize the important impact of AKI on mortality rates even when there is apparent full renal recovery at day 7.
Journal of Evolution of Medical and Dental Sciences, 2019
BACKGROUND A rising trend has been reported in Acute Kidney Injury (AKI) in both developed and developing countries and there is an independent association with increased morbidity and mortality with sepsis being the most common predisposing factor. Sepsis and cardiovascular causes resulted in a high incidence of AKI, and older age was also an important risk factor. Our study aims to determine the incidence, outcome and comorbidities associated with AKI in sepsis patients. Sepsis is a serious medical condition characterized by a whole-body inflammatory state (systemic inflammatory-response syndrome) and the presence of a known or suspected infection that has severe consequences, including multiple organ failure. METHODS We did a retrospective observational study in 497 sepsis patients admitted in MDICU. Acute kidney injury in these patients was identified and studied using RIFLE criteria between June 2016 and May 2017. RESULTS A total of 497 patients were studied. Mean age was 60 yrs. 59.8% were males and 40.2% were females. 279 have acute kidney injury; so, incidence of AKI in our study is 56.1%. Significant comorbidities associated with AKI are diabetes mellitus 61.6% (p= 0.001), hypertension 76.7% (p= 0.001), CKD 43.3% (p= 0.001), CAD 28.3% (p 0.020). Out of 279 AKI cases, 167 (59.9%) were under RISK, 94 (33.7%) were under kidney injury, 18 (6.5%) under renal failure. 246 (88.1%) received conservative management and 33 (11.9%) received renal replacement therapy. Out of 33 patients receiving RRT, 18 patients (54.5%) expired during the study period (p value 0.011). 14 patients (50%) of those who received early RRT died and 14 patients (50%) survived, whereas in late RRT 4 (80%) died and 1 patient (20%) survived. There is no statistically significant (p= 0.25) association between mortality and early or late initiation of RRT. CONCLUSIONS As the incidence of AKI is 56.1% and there is significant association between sepsis patients with AKI and comorbidity, high RIFLE score and mortality, RRT and mortality. So Specific goals for reducing incidence and mortality of acute kidney injury has to be formulated and uniform guidelines regarding initiating RRT should be formed.