Journal of Critical Care xxx (2014) xxx–xxx

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Epidemiology and outcomes of acute kidney injury in critically ill surgical patients☆,☆☆,★ Donald G. Harris, MD a,⁎, Michelle P. McCrone, BS a, Grace Koo, BS a, Adam S. Weltz, MD a, William C. Chiu, MD, FACS b, Thomas M. Scalea, MD, FACS b, Jose J. Diaz, MD, FACS b, Matthew E. Lissauer, MD, FACS b, c a b c

Division of General Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD Department of Surgery, Rutgers – Robert Wood Johnson Medical School, New Brunswick, NJ

a r t i c l e

i n f o

Keywords: Acute kidney injury Organ failure Surgical critical care Renal replacement therapy Outcomes

a b s t r a c t Purpose: Acute kidney injury (AKI) is common in critically ill patients but is poorly defined in surgical patients. We studied AKI in a representative cohort of critically ill surgical patients. Methods: This was a retrospective 1-year cohort study of general surgical intensive care unit patients. Patients were identified from a prospective database, and clinical data were reviewed. Acute kidney injury events were defined by risk, injury, failure, loss, and end-stage renal classification criteria. Outcomes were inpatient and 1year mortality, inpatient lengths of stay, and discharge renal function. Risk factors for AKI and outcomes were compared by univariate and multivariate analyses. Results: Of 624 patients, 296 (47%) developed AKI. Forty-two percent of events were present upon admission, whereas 36% occurred postoperatively. Risk, injury, failure, loss, and end-stage renal classification distributions by grade were as follows: risk, 152 (51%); injury, 69 (23%); and failure, 75 (25%). Comorbid diabetes, emergency admission, major surgery, sepsis, and illness severity were independently associated with renal dysfunction. Patients with AKI had significantly worse outcomes, including increased inpatient and 1-year mortality. Acute kidney injury starting before admission was associated with worse renal dysfunction and greater renal morbidity than de novo inpatient events. Conclusions: Acute kidney injury is common in critically ill surgical patients and is associated with increased mortality, persisting renal impairment and greater resource use. © 2014 Elsevier Inc. All rights reserved.

1. Introduction Acute kidney injury (AKI) affects approximately 20% of hospitalized patients and up to 67% of those admitted to an intensive care unit (ICU), making it among the most common organ dysfunctions among the critically ill [1-7]. Depending on severity, AKI contributes to short-term mortality rates between 40% and 70% [8-14], and survivors are at increased risk for chronic kidney disease (CKD) and late death [9-11,15-18]. Acute kidney injury is associated with significantly increased resource utilization and health care costs [3-5]. Because surgical care and perioperative events and comorbidities interact to contribute to renal dysfunction in different ☆ Society presentation: Association for Academic Surgery, Academic Surgical Congress. Oral presentation, San Diego, CA, February 2014. ☆☆ Disclosures: The authors have no conflicts of interest to declare. ★ Funding: n/a, unfunded. ⁎ Corresponding author at: Division of General Surgery, University of Maryland Medical Center, 22 S. Greene Street, Baltimore, MD 21201-1590. Tel.: +1 443 875 6305; fax: +1 410 328 8118 (c/o Sarah Kidd-Romero). E-mail address: [email protected] (D.G. Harris).

patterns than in nonsurgical patients [19-26], surgical patients have unique risk factors for renal dysfunction. Although the patterns and burden of AKI among select surgical subgroups have been reported [19-23,27], few investigations have studied it in a general surgical cohort [23,25]. Indeed, one potentially valuable resource to study perioperative AKI, the American College of Surgeons–National Surgical Quality Improvement Program database, has limited sensitivity for renal dysfunction because it only includes renal events with serum creatinine greater than or equal to 2 mg/dL or requiring dialysis [24,28]. Other studies have been limited to postoperative renal dysfunction and have excluded other manifestations such as events starting before surgery or occurring in the late postoperative period [19,24-26,28]. As such, further research is required to better understand broader general surgical populations at risk for AKI, especially critically ill surgical patients. The purpose of this study was to benchmark the epidemiology and outcomes of AKI in a cohort of critically ill surgical patients. We hypothesized that renal dysfunction in this population is common and is associated with a significantly higher burden of morbidity, mortality, and resource utilization.

http://dx.doi.org/10.1016/j.jcrc.2014.07.028 0883-9441/© 2014 Elsevier Inc. All rights reserved.

Please cite this article as: Harris DG, et al, Epidemiology and outcomes of acute kidney injury in critically ill surgical patients, J Crit Care (2014), http://dx.doi.org/10.1016/j.jcrc.2014.07.028

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D.G. Harris et al. / Journal of Critical Care xxx (2014) xxx–xxx

2. Methods This was a retrospective 1-year cohort study of critically ill surgical patients approved by the University of Maryland School of Medicine Institutional Review Board. This data set was designed to capture patients' first and any subsequent AKI episodes and was used for a previously published, separate study of recurrent kidney injury that selectively analyzed patients who recovered from an initial episode of AKI [29]. This report is intended to serve as a separate, distinct analysis of primary AKI among critically ill surgical patients. The setting was the 19-bed surgical ICU (SICU) at the University of Maryland Medical Center, a quaternary care academic hospital. As previously described, it is the primary ICU for acute care, general, vascular, transplant, thoracic, orthopedic, otolaryngology, and oralmaxillofacial surgery patients requiring critical care [30]. It also serves as an ancillary ICU for neurosurgical patients and admits medical patients on an emergency basis when nonsurgical ICUs have reached maximum capacity. Cardiac surgery and trauma patients are admitted to separate, dedicated units. The unit is run as a semiclosed, collaborative unit with multidisciplinary input on patient management, with all orders and critical care decisions made by the dedicated ICU service. Renal replacement therapy (RRT) is primarily provided as continuous venovenous hemodiafiltration using a Prismaflex system (Gambro, Lund, Sweden). Consecutive adult SICU admissions between January 1 and December 31, 2012, were identified from a prospective Acute Physiology and Chronic Health Evaluation (APACHE) IV database (Cerner) [31-34]. To determine unique patients, the first SICU admission per hospitalization per patient was included. Clinical and renal data were abstracted both from the APACHE IV database and by individual chart review. One-year postdischarge survival was obtained from the Social Security Death Index, which was queried 15 months after the final discharge. Patients on chronic dialysis, who had documented previous AKI, nephrectomy, organ transplant, or with only 1 inpatient creatinine value, were excluded. Outcomes included inpatient and 1-year mortality (overall and censored for inpatient deaths); renal morbidity, as discharge renal function and recurrent kidney injury; and SICU and hospital lengths of stay as measures of resource utilization. Using a previously described method [7,29], baseline serum creatinine was defined as the lowest of within 1 year before admission, at hospital or SICU admission, or, for patients without CKD, the Modification of Diet in Renal Disease equation solved for creatinine assuming a glomerular filtration rate of 75 mL/min per 1.73 m 2 [35]. A calculated value to estimate baseline creatinine in selected cases ensured patients admitted with AKI in progress were not assigned an artificially poor baseline renal function. The primary end point was inpatient AKI as diagnosed and staged by risk, injury, failure, loss and end-stage renal classification (RIFLE) creatinine criteria (by increase from baseline creatinine: risk ≥1.5×, injury ≥2×, and failure ≥3×) [36]; because postdischarge renal function was not routinely available, the RIFLE Loss and End-stage renal disease outcome criteria were not assessed. Adapting the definition proposed by Bellomo et al [36], recovery from AKI was 2 or more serial creatinine values below a patient's RIFLE-Risk threshold, as a sustained improving trend without RRT for more than 24 hours [29]. Acute kidney injury exposure was calculated as the total time with renal dysfunction meeting AKI definition, regardless of recovery, whereas AKI duration was the time from onset to recovery. The primary analysis was between patients with or without AKI. Subgroup analysis of AKI patients was performed between those admitted to the hospital with AKI in progress vs patients who developed de novo inpatient renal dysfunction. Groups were compared by 2-sided Pearson χ2 or Fisher exact test as appropriate for categorical data. Normally distributed continuous data were compared by independent Student t test and reported as mean ± SD, whereas nonnormally distributed data were analyzed using Mann-Whitney U test and

Table 1 Cohort and subgroup characteristics

Age, years ± SD Male, n (%) Black, n (%) Hypertension, n (%) Diabetes, n (%) CKD, n (%) Baseline creatinine, mg/dL ± SD APACHE III ± SD APACHE sepsis diagnosis, n (%) Emergency status,a n (%) Mechanical ventilation, n (%) Median duration, days (IQR) Operative management, n (%) Laparotomy, n (%)

All patients (n = 624)

No AKI (n = 328)

AKI (n = 296)

P

59 ± 15 369 (59) 199 (32) 288 (46) 165 (26) 42 (7) 0.84 ± 0.52 54 ± 28 42 (7) 236 (38) 474 (76) 2 (1-5) 519 (83) 181 (29)

57 ± 17 199 (61) 105 (32) 139 (42) 66 (20) 18 (5) 0.83 ± 0.58 44 ± 19 7 (2) 98 (30) 225 (69) 1 (0-3) 271 (83) 63 (19)

62 ± 14 .0001 170 (57) .41 94 (32) .95 149 (50) b.05 99 (33) .0001 24 (8) .19 0.86 ± 0.45 .63 66 ± 32 .0001 35 (12) .0001 138 (47) .0001 249 (84) .0001 3 (1-9) .0001 248 (84) .70 118 (40) .0001

a Emergency status defined as admission from the emergency department or to the emergency general surgery service or need for emergency surgical intervention for the primary admitting diagnosis.

reported as median and interquartile range (IQR). Variables associated with AKI or mortality with a univariate P b .10 were included in multivariate logistic regression. Significance was set at P b .05. 3. Results From January to December 2012, there were 886 unique SICU admissions. A total of 262 patients (30%) were excluded: 167 transplant recipients, 40 on chronic dialysis, 39 with prior AKI, 25 after nephrectomy, and 3 with single creatinine values. For the cohort of 624 patients, 369 (59%) were male, mean age was 59 ± 15 years, APACHE III score was 54 ± 28, and 76% of patients required mechanical ventilation (Table 1). General surgery specialty patients accounted for most admissions (52%) (acute care, 22%; vascular, 22%; and general surgery, 8%), and 83% of patients received surgical management for their primary diagnosis. The breakdown of creatinine values used to define patients' baseline renal function was as follows: 114 (18%) preadmission, 252 (40%) hospital admission, 130 (21%) SICU admission, and 128 (21%) calculated. Nearly half (296, 47%) of the cohort developed AKI (Table 2). A total of 124 patients (42%) had AKI that started before hospitalization and was present upon admission, whereas 172 (58%) occurred as de novo inpatient events. Of these, 107 (62%) occurred postoperatively at a median of 3 (IQR, 1-10) days after surgery. The RIFLE distributions Table 2 Summary of AKI events AKI events (n = 296) Present upon admission, n (%) De novo inpatient AKI, n (%) Postoperative, n (%) Interval, days (IQR) Baseline creatinine, mg/dL ± SD Peak creatinine, mg/dL ± SD Peak:baseline creatinine ± SD Maximum RIFLE grade Risk, n (%) Injury, n (%) Failure, n (%) RRT, n (%) Duration, days (IQR) AKI exposure, days (IQR) Recovery,a n (%) Duration before recovery, days (IQR) Recovery to baseline,b n (%) Death with AKI in progress, n (%) a b

124 (42) 172 (58) 107 (36) 3 (1-10) 0.86 ± 0.45 2.17 ± 1.54 2.58 ± 1.67 152 (51) 69 (23) 75 (25) 35 (12) 8 (4-14) 4 (2-10) 216 (73) 3 (2-6) 79 (27) 33 (11)

Recovery defined as return of creatinine to less than 1.5× baseline. Recovery to baseline defined as creatinine returning to less than or equal to baseline.

Please cite this article as: Harris DG, et al, Epidemiology and outcomes of acute kidney injury in critically ill surgical patients, J Crit Care (2014), http://dx.doi.org/10.1016/j.jcrc.2014.07.028

D.G. Harris et al. / Journal of Critical Care xxx (2014) xxx–xxx Table 3 Patient outcomes associated with AKI

Inpatient mortality, n (%) Overall 1-y mortality, n (%) Postdischarge mortality,a n (%) Discharge creatinine, mg/dL ± SD Discharge:baseline creatinine ± SD SICU LOS, days (IQR) Hospital LOS, days (IQR)

3

Table 4 Comparison of patients with AKI present upon hospital admission vs de novo inpatient AKI No AKI (n = 328)

AKI (n = 296)

P

14 (4) 45 (14) 31 (10) 0.79 ± 0.59 0.98 ± 0.19 3 (2-5) 9 (5-16)

56 (19) 105 (35) 49 (20) 1.33 ± 1.23 1.56 ± 1.10 6 (3-10) 19 (10-30)

.0001 .0001 .0001 .0001 .0001 .0001 .0001

LOS indicates length of stay. a For patients discharged alive from the hospital.

by grade were risk 152 (51%), injury 69 (23%), and failure 75 (25%), and the median AKI exposure was 4 (IQR, 2-10) days. A total of 216 (73%) of patients recovered from AKI after a median episode duration of 3 (IQR, 2-6) days, but only 79 (36%) recovered to their actual baseline renal function. Thirty-three patients (11%) died with AKI in progress, and the remaining patients were discharged without full renal recovery. Renal replacement therapy was used for 35 patients (12%) with median treatment duration of 7 (IQR, 5-12) days. Baseline renal function was similar between AKI and non-AKI patients, and development of renal dysfunction was multifactorial (Table 1). Factors associated with AKI on univariate analysis included elderly age, cardiovascular comorbidities, emergency status, increasing illness severity, major surgery, sepsis, and need for and duration of mechanical ventilation. On multivariate analysis, APACHE III score greater than 50 (odds ratio [OR], 1.4; 95% confidence interval, 1.3-1.5), APACHE sepsis diagnosis (OR, 1.3; 1.1-1.4), laparotomy (OR, 1.2; 1.1-1.3), diabetes (OR, 1.1; 1.0-1.2), and emergency status (OR, 1.1; 1.1-1.2) remained independently associated with renal dysfunction (Table S1). Neither black ethnicity nor CKD was associated with AKI in this cohort, whereas elderly age and mechanical ventilation were not significant after multivariate analysis. Acute kidney injury was associated with significantly worse outcomes (Table 3). Acute kidney injury patients had higher inpatient (19% vs 4%; P b .0001) and 1-year mortality rates (35% vs 14%; P b .0001). Although hospital mortality for non-AKI patients was similar to the median APACHE IV–predicted rate (4% vs 3%; P = .68), AKI was associated with higher-than-predicted mortality (19% vs 11%; P = .005). Renal dysfunction was independently associated with short- and longterm mortality after adjusting for other risk factors for death (Table S1). Although mortality was highest among patients with RIFLE-Failure AKI (inpatient, 33%; 1 year, 43%), even RIFLE-Risk patients had increased mortality vs those without AKI (inpatient, 15% vs 4%; 1 year, 31% vs 14%; P b .0001 each). Acute kidney injury patients had worse discharge renal function; when normalized to baseline, the average discharge creatinine from the AKI group had not return to a references range, and only 25% of survivors had complete recovery to their baseline renal function. Finally, reflecting greater resource utilization, AKI patients had significantly longer SICU (6 [3-10] vs 3 [2-5] days; P b .001) and inpatient (19 [10-30] vs 9 [5-16] days; P b .0001) lengths of stay. To determine if prehospital AKI was associated with different clinical characteristics and outcomes than de novo inpatient AKI, patients with AKI in progress on admission were compared with those presenting with normal renal function (Table 4). Patients presenting with AKI were more likely to be male or have diabetes and had higher illness severity upon SICU admission. Admission with AKI resulted in more severe renal dysfunction, as manifested by a higher peak/baseline creatinine ratio, greater proportion of patients with RIFLE-Injury or Failure events, need for RRT, and episode duration. Although outcomes were similar between these subgroups, patients presenting with AKI were more likely to develop recurrent kidney injury, which has recently been associated with increased mortality [29].

Age, years ± SD Male, n (%) Black, n (%) Hypertension, n (%) Diabetes, n (%) Baseline creatinine, mg/dL ± SD APACHE III ± SD APACHE sepsis diagnosis, n (%) Operative management, n (%) Peak creatinine, mg/dL ± SD Peak:baseline creatinine ± SD RIFLE grade Risk, n (%) Injury, n (%) Failure, n (%) RRT, n (%) AKI exposure, days (IQR) Recovery,a n (%) Duration to recovery, days (IQR) Recovery to baseline,b n (%) Recurrent inpatient AKI, n (%) Discharge creatinine, mg/dL ± SD Inpatient mortality, n (%) 1-y mortality, n (%) SICU LOS, days (IQR) Hospital LOS, days (IQR) a b

AKI on admission (n = 124)

Inpatient AKI (n = 172)

P

62 ± 13 84 (68) 40 (32) 67 (54) 52 (42) 0.91 ± 0.44 73 ± 35 19 (15) 102 (82) 2.46 ± 1.67 2.84 ± 1.98

62 ± 14 86 (50) 54 (31) 82 (48) 47 (27) 0.83 ± 0.45 61 ± 28 16 (9) 146 (85) 1.96 ± 1.41 2.38 ± 1.38

.55 .002 .88 .28 .009 .16 .001 .11 .54 .0005 .004

52 (42) 34 (27) 38 (31) 22 (18) 5 (2-12) 91 (73) 4 (2-9) 32 (26) 36 (29) 1.39 ± 1.18 25 (20) 46 (37) 5 (2-10) 16 (9-29)

100 (58) 35 (20) 37 (22) 13 (8) 3 (2-7) 125 (73) 3 (2-5) 44 (26) 32 (19) 1.28 ± 1.27 31 (18) 59 (34) 5 (3-11) 20 (11-31)

.006 .16 .08 .007 .01 .89 .01 .97 .04 .04 .64 .62 .51 .08

Recovery defined as return of creatinine to less than 1.5× baseline. Recovery to baseline defined as creatinine returning to less than or equal to baseline.

4. Discussion To the best of our knowledge, this is one of the first studies to investigate AKI in a broad surgical cohort representing a balanced spectrum of surgical critical care practice. Importantly, renal dysfunction occurs throughout the perioperative period and is common among critically ill surgical patients. Acute kidney injury is associated with substantially worse outcomes, including greater short- and long-term mortality regardless of AKI severity. As such, this study provides early insight into the clinical significance of AKI among surgical patients. Acute kidney injury is common among critically ill surgical patients and occurred in nearly half (47%) of this cohort. This was similar to the incidence among surgical patients reported by Hoste et al [5] in a large, mixed-ICU study but higher than the 32% to 37% in other studies of AKI in surgical patients [24,25]. This difference is likely due to the inclusion of all inpatient renal events in this study, rather than a focus on postoperative AKI. Indeed, only 36% of AKI events in this cohort were postoperative, and 42% of AKI patients had significant renal dysfunction upon hospital admission. As such, the true burden of perioperative AKI among this population is higher than suggested by previous studies. Although some patients admitted with AKI were transferred to our facility from other hospitals, many of these cases likely represent a significant incidence of “community-acquired” AKI. Acute kidney injury episodes that are in progress upon admission or develop de novo during hospitalization may represent different processes. For example, although we did not investigate the primary cause of AKI events in this study, there are fewer potential causes of out-of-hospital vs inpatient renal dysfunction. Indeed, critically ill hospitalized surgical patients are exposed to multiple potential causes of AKI such as nephrotoxic agents, surgery, and perioperative complications—often in combination [22,24,26,38]. Furthermore, AKI events that start before admission appear to be associated with greater worse overall illness severity and higher renal morbidity, including greater and more prolonged renal dysfunction and risk for recurrent kidney injury. Indeed, because these events started before

Please cite this article as: Harris DG, et al, Epidemiology and outcomes of acute kidney injury in critically ill surgical patients, J Crit Care (2014), http://dx.doi.org/10.1016/j.jcrc.2014.07.028

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hospitalization, their exposure and duration times were likely underestimated in this study. Additional investigation may be required to better define important clinical differences between outof-hospital and de novo inpatient AKI. Risk factors for AKI in this cohort were similar to those reported for critically ill patients in general [3,5,39] and for surgical patients in particular [20,25,28]. In contrast to prior studies [3,5,6,39-41], advanced age, black ethnicity, and CKD were not independently associated with development of AKI. Although these findings are partly consistent with other studies of AKI in broad cohorts and surgical patients [18,20,22,25], our results could reflect effects from patient selection for surgery, perioperative management, or differences in confounding comorbidities or risk factors. In other studies, emergency surgery was associated with postoperative renal dysfunction [19,26,28]. However, our data indicate that the plurality of AKI events among surgical patients is present upon hospital admission. As such, emergency presentation rather than emergency intervention may be the critical contributor to AKI in patients undergoing nonelective surgery, especially if performed for source control of a septic focus that is primarily causing renal dysfunction [42]. Consistent with prior research, renal dysfunction was associated with substantially increased short- and long-term mortality [5,12,14,15,17,18]. Although AKI clearly serves as a marker of increased illness severity or the presence of a primary process such as severe sepsis [1,2,22], it can directly contribute to multiorgan dysfunction and subsequent mortality by increasing systemic inflammation and inducing distant organ injury [2,43,44]. Indeed, reflecting a direct doseresponse relationship, the risk of death associated with AKI increases with its severity, a trend observed in this study [3,5,12,25]. However, even patients with RIFLE-Risk AKI had substantially higher mortality than patients without renal dysfunction, a finding supported by other studies linking relatively mild renal dysfunction with worse short- and long-term mortality [3,21,37,39,45]. As such, AKI is a clinically significant event regardless of severity, and even relatively minor renal events should be recognized as defining a high-risk group. Limitations of this study include its retrospective, single-ICU design. Because RIFLE creatinine criteria were used to define and stage AKI, patients meeting RIFLE urine output criteria alone may have been missed or misclassified. Although critically ill patients have the greatest risk for renal dysfunction, we may have missed a significant burden of AKI among patients not requiring SICU admission. Finally, this study lacks granular surgical and real-time illness severity data that could be used to better correlate clinical and renal events and better define risk factors among this population. Future work will investigate these interactions. 5. Conclusions Inpatient AKI is common among critically ill surgical patients. Acute kidney injury is not strictly a postoperative phenomenon among surgical patients, as presentation with significant renal dysfunction was common in this broad cohort. Regardless of timing, AKI is an independent risk factor for inpatient and 1-year mortality and is associated with greater resource utilization. Because RIFLE-Risk AKI is associated with worse outcomes, even minor renal dysfunction is an important marker for adverse outcomes in this population. As such, renal dysfunction of any severity should be recognized as a highrisk clinical feature that identifies patients at significantly increased risk for adverse events and outcomes. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.jcrc.2014.07.028. Acknowledgments Special thanks to Deborah M. Stein, MD, MPH, FACS, and Kenji Inaba, MD, FRCSC, FACS, for constructive feedback and suggestions at critical phases of this project.

References [1] Gaieski DF, Edwards JM, Kallan MJ, Carr BG. Benchmarking the incidence and mortality of severe sepsis in the United States. Crit Care Med 2013;41:1167–74. [2] Wohlauer MV, Sauaia A, Moore EE, Burlew CC, Banerjee A, Johnson J. Acute kidney injury and posttrauma multiple organ failure: the canary in the coal mine. J Trauma Acute Care Surg 2012;72:373–80. [3] Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol 2005;16:3365–70. [4] Li PKT, Burdmann EA, Mehta RL. Acute kidney injury: global health alert. Kidney Int 2013;83:372–6. [5] Hoste EAJ, Clermont G, Kersten A, Venkataraman R, Angus DC, Bacquer D De, et al. RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: a cohort analysis. Crit Care 2006;10:R73. [6] De Mendonca A, Vincent JL, Suter PM, Moreno R, Dearden NM, Antonelli M, et al. Acute renal failure in the ICU: risk factors and outcome evaluated by the SOFA score. Intensive Care Med 2000;26:915–21. [7] Hoste EAJ, Schurgers M. Epidemiology of acute kidney injury: how big is the problem? Crit Care Med 2008;36:S146–51. [8] Schiffl H. Renal recovery from acute tubular necrosis requiring renal replacement therapy: a prospective study in critically ill patients. Nephrol Dial Transplant 2006;21:1248–52. [9] Ponte B, Felipe C, Muriel A, Tenorio MT, Liaño F. Long-term functional evolution after an acute kidney injury: a 10-year study. Nephrol Dial Transplant 2008;23:3859–66. [10] Lo LJ, Go AS, Chertow GM, McCulloch CE, Fan D, Ordonez JD, et al. Dialysisrequiring acute renal failure increases the risk of progressive chronic kidney disease. Kidney Int 2009;76:893–9. [11] Wald R, Quinn RR, Luo J, Li P, Scales DC, Mamdani MM, et al. Chronic dialysis and death among survivors of acute kidney injury requiring dialysis. JAMA 2009;302:1179–85. [12] Cruz DN, Bolgan I, Perazella MA, Bonello M, Cal M, Corradi V, et al. North East Italian prospective hospital renal outcome survey on acute kidney injury (NEiPHROS-AKI): targeting the problem with the RIFLE criteria. Clin J Am Soc Nephrol 2007;2:418–25. [13] Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 2005;294:813–8. [14] Bellomo R, Cass A, Cole L, Finfer S, Gallagher M, Lo S, et al. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med 2009;361:1627–38. [15] Gallaher M, Cass A, Bellomo R, Finfer S, Gattas D, Lee J. Long-term survival and dialysis dependency following acute kidney injury in intensive care: extended follow-up of a randomized controlled trial. PLoS Med 2014;11:e1001601. [16] Brinkman S, de Jonge E, Abu-Hanna A, Arbous MS, de Lange DW, de Keizer NF. Mortality after hospital discharge in ICU patients. Crit Care Med 2013;41:1229–36. [17] Schiffl H, Fischer R. Five-year outcomes of severe acute kidney injury requiring renal replacement therapy. Nephrol Dial Transplant 2008;23:2235–41. [18] Thakar CV, Christianson A, Himmelfarb J, Leonard AC. Acute kidney injury episodes and chronic kidney disease risk in diabetes mellitus. Clin J Am Soc Nephrol 2011;6:2567–72. [19] Abelha F, Botelho M, Fernandes V, Barros H. Determinants of postoperative acute kidney injury. Crit Care 2009;13:R79. [20] Hobson CE, Yavas S, Segal MS, Schold JD, Tribble CG, Layon AJ, et al. Acute kidney injury is associated with increased long-term mortality after cardiothoracic surgery. Circulation 2009;119:2444–53. [21] Lassnigg A, Schmidlin D, Mouhieddine M, Bachmann LM, Druml W, Bauer P, et al. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol 2004;15:1597–605. [22] White LE, Hassoun HT, Bihorac A, Moore LJ, Sailors RM, McKinley BA, et al. Acute kidney injury is surprisingly common and a powerful predictor of mortality in surgical sepsis. J Trauma Acute Care Surg 2013;75:432–8. [23] Borthwick E, Ferguson A. Perioperative acute kidney injury: risk factors, recognition, management, and outcomes. BMJ 2010;341:85–91. [24] Bihorac A, Brennan M, Ozrazgat-Baslanti T, Bozorgmehri S, Efron PA, Moore FA, et al. National surgical quality improvement program underestimates the risk associated with mild and moderate postoperative acute kidney injury. Crit Care Med 2013;41:2570–83. [25] Bihorac A, Yavas S, Subbiah S, Hobson CE, Schold JD, Gabrielli A, et al. Long-term risk of mortality and acute kidney injury during hospitalization after major surgery. Ann Surg 2009;249:851–8. [26] Kheterpal S, Tremper KK, Englesbe MJ, O'Reilly M, Shanks AM, Fetterman DM, et al. Predictors of postoperative acute renal failure after noncardiac surgery in patients with previously normal renal function. Anesthesiology 2007;107:892–902. [27] Skinner D, Hardcastle T, Rodseth R, Muckart D. The incidence and outcomes of acute kidney injury amongst patients admitted to a level I trauma unit. Injury 2013;45:259–64. [28] Kheterpal S, Tremper KK, Heung M, Rosenberg AL, Englesbe M, Shanks AM, et al. Development and validation of an acute kidney injury risk index for patients undergoing general surgery: results from a national data set. Anesthesiology 2009;110:505–15. [29] Harris DG, Koo G, McCrone MP, Scalea TM, Chiu WC, Diaz JJ, et al. Recurrent kidney injury in critically ill surgical patients is common and associated with worse outcomes. J Trauma Acute Care Surg 2014;76:1397–401. [30] Lissauer ME, Galvagno SM, Rock P, Narayan M, Shah P, Spencer H, et al. Increased ICU resource needs for an academic emergency general surgery service. Crit Care Med 2013;42:910–7. [31] Knaus WA, Wagner DP, Zimmerman JE, Draper EA. Variations in mortality and length of stay in intensive care units. Ann Intern Med 1993;118:753–61.

Please cite this article as: Harris DG, et al, Epidemiology and outcomes of acute kidney injury in critically ill surgical patients, J Crit Care (2014), http://dx.doi.org/10.1016/j.jcrc.2014.07.028

D.G. Harris et al. / Journal of Critical Care xxx (2014) xxx–xxx [32] Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, Bastos PG, et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991;100:1619–36. [33] Zimmerman JE, Kramer AA, McNair DS, Malila FM. Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today's critically ill patients. Crit Care Med 2006;34:1297–310. [34] Zimmerman JE, Wagner DP, Draper EA, Wright L, Alzola C, Knaus WA. Evaluation of Acute Physiology and Chronic Health Evaluation III predictions of hospital mortality in an independent database. Crit Care Med 1998;26:1317–26. [35] Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003;139:137–47. [36] Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P. Acute renal failure— definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004;8:R204–12. [37] Uchino S, Bellomo R, Bagshaw SM, Goldsmith D. Transient azotaemia is associated with a high risk of death in hospitalized patients. Nephrol Dial Transplant 2010;25:1833–9. [38] Bellomo R, Kellum JA, Ronco C. Acute kidney injury. Lancet 2012;380:756–66.

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[39] Goldberg A, Kogan E, Hammerman H, Markiewicz W, Aronson D. The impact of transient and persistent acute kidney injury on long-term outcomes after acute myocardial infarction. Kidney Int 2009;76:900–6. [40] Shashaty MGS, Meyer NJ, Localio AR, Gallop R, Bellamy SL, Holena DN, et al. African American race, obesity, and blood product transfusion are risk factors for acute kidney injury in critically ill trauma patients. J Crit Care 2012;27:496–504. [41] Venkatachalam MA, Griffin KA, Lan R, Geng H, Saikumar P, Bidani AK. Acute kidney injury: a springboard for progression in chronic kidney disease. Am J Physiol Renal Physiol 2010;298:F1078–94. [42] Marshall JC, Maier RV, Jimenez M, Dellinger EP. Source control in the management of severe sepsis and septic shock: an evidence-based review. Crit Care Med 2004; 32:S513–26. [43] Grigoryev DN, Liu M, Hassoun HT, Cheadle C, Barnes KC, Rabb H. The local and systemic inflammatory transcriptome after acute kidney injury. J Am Soc Nephrol 2008;19:547–58. [44] White LE, Chaudhary R, Moore LJ, Moore FA, Hassoun HT. Surgical sepsis and organ crosstalk: the role of the kidney. J Surg Res 2011;167:306–15. [45] Goldenberg I, Chonchol M, Guetta V. Reversible acute kidney injury following contrast exposure and the risk of long-term mortality. Am J Nephrol 2008;29:136–44.

Please cite this article as: Harris DG, et al, Epidemiology and outcomes of acute kidney injury in critically ill surgical patients, J Crit Care (2014), http://dx.doi.org/10.1016/j.jcrc.2014.07.028

Epidemiology and outcomes of acute kidney injury in critically ill surgical patients.

Acute kidney injury (AKI) is common in critically ill patients but is poorly defined in surgical patients. We studied AKI in a representative cohort o...
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