Risk factors of prognosis after acute kidney injury in hospitalized patients
Sasa Nie1, Zhe Feng1, Lihua Xia1, Jiuxu Bai1, Fenglin Xiao1, Jian Liu1, Li Tang1(), Xiangmei Chen1()
1. Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing 100853, China
The risk factors, especially laboratory indicators, of prognosis after acute kidney injury (AKI) remain unclear. We conducted a retrospective survey of Chinese People’s Liberation Army General Hospital from January 1, 2012 to December 31, 2012 according to the AKI diagnosis standard issued by Kidney Disease Improving Global Outcomes. The epidemiological features and factors influencing hospital mortality and renal function recovery were evaluated through logistic regression analysis. Among 77 662 cases of hospitalized patients, 1387 suffered from AKI. The incidence rate and mortality of AKI were 1.79% and 14.56%, respectively. Multivariate logistic regression analysis revealed that high AKI stage, age greater than 80 years, neoplastic disease, low cardiac output, increased white blood cell count, and decreased platelet count and serum albumin levels were the risk factors affecting the mortality of AKI patients. Conversely, body mass index between 28 and 34.9 was a protective factor. Increased AKI stage, tumor disease, post-cardiopulmonary resuscitation, and RRT were the risk factors of renal function recovery upon discharge. In addition to traditional risk factors, white blood cell count, platelet count, albumin, and BMI were the predictors of the mortality of AKI patients. No laboratory indicators were found to be the risk factors of renal function recovery in AKI patients.
1.5?1.9 times baselineb or≥0.3 mg/dl (≥26.5 mmol/L) increase
<0.5 ml/(kg·h) for 6?12h
2
2.0?2.9 times baseline
<0.5 ml/(kg·h) for≥12 h
3
3.0 times baseline or increase in serum creatinine to≥4.0 mg/dl (≥353.6 mmol/L) or decrease in eGFR to<35 ml/(min·1.73 m2) in patients<18 years
<0.3 ml/(kg·h) for≥24 h or anuria for≥12 h
Tab.1
Fig.1
Survival condition at discharge
Total (n = 1387)
P value
Survival (n = 1185)
Death (n = 202)
Age (year)
61 (48,73)
74 (59,82)
63 (49,74)
<0.001a
Age group
<0.001a
12?19 years
32 (2.7%)
2 (1.0%)
34 (2.5%)
20?39 years
142 (12.0%)
13 (6.4%)
155 (11.2%)
40?59 years
387 (32.7%)
40 (19.8%)
427 (30.8%)
60?79 years
505 (42.6%)
74 (36.6%)
579 (41.7%)
≥80 years
119 (10.0%)
73 (36.1%)
192 (13.8%)
Men
814 (68.7%)
148 (73.3%)
962 (69.4%)
0.192
AKI stage
<0.001a
1
618 (52.2%)
51 (25.3%)
669 (48.2%)
2
283 (23.9%)
48 (23.8%)
331 (23.9%)
3
284 (24.0%)
103 (51.0%)
387 (27.9%)
BMI
24.3±4.2
22.3±4.0
24.0±4.2
<0.001a
<18.5
80 (6.8%)
33 (16.9%)
113 (8.2%)
18.5?23.9
493 (41.9%)
97 (49.7%)
590 (43.0%)
24?27.9
407 (34.6%)
53 (27.2%)
460 (33.6%)
28?34.9
183 (15.6%)
11 (5.6%)
194 (14.2%)
≥35
13 (1.1%)
1 (0.5%)
14 (1.0%)
AKI classification
0.151
Pre-renal
641 (54.1%)
122 (60.4%)
763 (55.0%)
Intrinsic-renal
498 (42.0%)
76 (37.6%)
574 (41.4%)
Post-renal
46 (3.9%)
4 (2.0%)
50 (3.6%)
Underlying disease
Hypertension
550 (46.4%)
111 (55.0%)
661 (47.7%)
0.025a
Malignancy
326 (27.5%)
82 (40.6%)
408 (29.4%)
<0.001a
CHD
317 (26.8%)
80 (39.6%)
397 (28.6%)
<0.001a
Diabetes
276 (23.3%)
52 (25.7%)
328 (23.7%)
0.449
CKD
222 (18.7%)
38 (18.8%)
260 (18.8%)
0.979
Cirrhosis
55 (4.6%)
8 (4.0%)
63 (4.5%)
0.667
MODS
41 (3.5%)
15 (7.4%)
56 (4.0%)
0.008a
COPD
32 (2.7%)
14 (6.9%)
46 (3.3%)
0.002a
Sepsis
22 (1.9%)
8 (4.0%)
30 (2.2%)
0.101
Numberb
1 (0,1)
2 (1,2)
2 (1,2)
<0.001a
Injury factors
Infection
690 (58.2%)
155 (76.7%)
845 (60.9%)
<0.001a
Antibiotics
683 (57.6%)
124 (61.4%)
807 (58.2%)
0.318
Diuretics
539 (45.5%)
120 (59.4%)
659 (47.5%)
<0.001a
Colloid infusion
439 (37.1%)
86 (42.6%)
525 (37.9%)
0.134
NSAID
305 (23.9%)
51 (25.1%)
356 (24.1%)
0.089
Low cardiac output
151 (12.7%)
53 (26.2%)
204 (14.7%)
<0.001a
Post-CPR
26 (2.2%)
8 (4.0%)
34 (2.5%)
0.210
Numberb
3 (1,5)
4 (2,5)
3 (1,5)
0.139
APACHE II
10.6±6.0
19.5±8.9
11.9±7.2
<0.001a
SOFA
4 (2,7)
9 (5,14)
4 (2,8)
<0.001a
Laboratory examinationa
Hb (g/L)
108.9±26.0
100.7±30.0
107.7±26.7
<0.001a
WBC (× 109/L)
10.0 (6.9,14.0)
11.8 (7.6,18.4)
10.3 (7.1,14.4)
<0.001a
PLT (× 109/L)
168.5 (107.0,230.0)
126.0 (66.0,203.0)
163.0 (100.0,228.0)
<0.001a
ALB (g/L)
32.5±6.8
30.0±6.4
32.1±6.8
<0.001a
TBil (mmol/L)
11.2 (6.8,20.9)
16.6 (8.5,43.0)
11.8 (7.0,22.1)
<0.001a
Baseline SCr (mmol/L)
85.2 (68.6,115.7)
79.0 (58.7,102.2)
84.1 (67.2,114.7)
<0.001a
SCr on diagnosis (mmol/L)
157.9 (125.8,229.5)
157.9 (119.6,224.2)
157.9 (125.4,227.7)
0.184
Peak SCr (mmol/L)
166.2 (131.2,244.9)
196.7 (145.8,279.3)
170.0 (132.7,254.6)
0.004a
SUA ( mmol/L)
418.9 (315.9,540.8)
434.4 (325.0,596.1)
422.3 (317.3,548.5)
0.063
LDHc(U/L)
235.7 (177.6,380.3)
485.0 (261.5,1033.0)
248.5 (181.6,443.2)
<0.001a
RRT
121 (10.2%)
40 (19.8%)
161 (11.6%)
<0.001a
Hospital stay (day)
18.0 (10.5,29.0)
18.5 (9.0,35.5)
18.0 (10.0,30.0)
0.597
Hospital costcd(CNY)
77 889 (36 756, 131 609)
95 394 (48 949, 181 141)
79 475 (37 784, 135 837)
<0.001a
Tab.2
Causes
Patients, n (%)
Surgery-related AKI
226 (16.29%)
Decreased cardiac output
179 (12.91%)
Systemic vascular dilatation
147 (10.60%)
Drug-related AKI
197 (14.20%)
Infection-related AKI
145 (10.45%)
Renal ischemia-related AKI
110 (7.93%)
Glomerular AKI
62 (4.47%)
Urethral obstruction-related AKI
50 (3.60%)
Tab.3
Fig.2
Variables
P value
OR (95% CI)
AKI stage
1
?
1a
2
0.03b
1.78 (1.06,3.00)
3
<0.001b
4.21 (2.44,7.24)
Age
12?19 years
?
1a
20?39 years
0.54
1.68 (0.32,8.77)
40?59 years
0.71
1.35 (0.28,6.53)
60?79 years
0.42
1.90 (0.39,9.12)
≥80 years
0.02b
7.14 (1.43,35.53)
BMI
<18.5
?
1a
18.5?23.9
0.39
0.77 (0.42,1.40)
24?27.9
0.08
0.56 (0.29,1.08)
28?34.9
<0.001b
0.19 (0.07,0.50)
≥35
0.26
0.27 (0.03,2.73)
Underlying disease
Number of underlying disease (yes vs. no)
0.38
1.19 (0.81,1.74)
Hypertension
0.56
1.19 (0.66,2.14)
CHD
0.25
1.46 (0.77,2.77)
Tumor
0.01b
2.19 (1.23,3.90)
MODS
0.57
1.31 (0.52,3.25)
CKD
0.94
1.03 (0.53,1.98)
COPD
0.62
1.26 (0.50,3.16)
Injury factors (yes vs. no)
DIC
0.07
4.06 (0.88,18.66)
Hypovolemia
0.61
1.14 (0.68,1.92)
Low cardiac output
<0.001b
2.62 (1.55,4.42)
Contrast medium
0.17
0.51 (0.20,1.34)
ACEI/ARBs
0.16
0.54 (0.23,1.28)
Diuretic
0.55
1.13 (0.76,1.68)
Laboratory indexes
Hb (1 g/L)
0.91
1.00 (0.99,1.01)
WBC (1 × 109/L)
<0.001b
1.04 (1.01,1.06)
PLT (1 × 109/L)
0.01b
1.00 (1.00,1.00)
ALB (1 g/L)
0.03b
0.96 (0.93,1.00)
TBil (1 mmol/L)
0.08
1.00 (1.00,1.00)
Peak SCr (1 mmol/L)
0.14
1.00 (1.00,1.00)
LDH (1 U/L)
0.17
1.00 (1.00,1.00)
RRT (yes vs. no)
0.48
1.23 (0.69,2.21)
Tab.4
Variables
P value
OR (95% CI)
AKI stage
<0.001a
1
?
1b
2
<0.001a
1.85 (1.30,2.63)
3
<0.001a
2.78 (1.82,4.23)
Underlying disease (yes vs. no)
Hypertension
0.16
0.80 (0.59,1.09)
Sepsis
0.10
2.46 (0.84,7.17)
CHD
0.40
1.17 (0.81,1.71)
Tumor
0.01a
1.63 (1.16,2.28)
MODS
0.55
0.79 (0.35,1.74)
CKD
0.17
0.74 (0.49,1.13)
Injury factors (yes vs. no)
Post-CPR
0.03a
2.66 (1.11,6.35)
Hypovolemia
0.25
1.27 (0.85,1.90)
Antibiotics
0.39
1.16 (0.83,1.63)
Colloid
0.41
1.15 (0.82,1.62)
Antineoplastic drug
0.10
1.52 (0.92,2.51)
Laboratory index
Hb (1 g/L)
0.57
1.00 (0.99,1.00)
PLT (1 × 109/L)
0.94
1.00 (1.00,1.00)
ALB (1 g/L)
0.29
0.99 (0.97,1.01)
Peak SCr (1 mmol/L)
0.88
1.00 (1.00,1.00)
LDH (1 U/L)
0.36
1.00 (1.00,1.00)
RRT (yes vs. no)
<0.001a
5.18 (3.00,8.95)
Tab.5
1
Kidney DOQI. KDIGO clinical practice guidelines for acute kidney injury. Kidney Int Suppl 2012; 2: 1–138
2
Mehta RL, Cerdá J, Burdmann EA, Tonelli M, García-García G, Jha V, Susantitaphong P, Rocco M, Vanholder R, Sever MS, Cruz D, Jaber B, Lameire NH, Lombardi R, Lewington A, Feehally J, Finkelstein F, Levin N, Pannu N, Thomas B, Aronoff-Spencer E, Remuzzi G. International Society of Nephrology’s 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): a human rights case for nephrology. Lancet 2015; 385(9987): 2616–2643 https://doi.org/10.1016/S0140-6736(15)60126-X
3
Lameire NH, Bagga A, Cruz D, De Maeseneer J, Endre Z, Kellum JA, Liu KD, Mehta RL, Pannu N, Van Biesen W, Vanholder R. Acute kidney injury: an increasing global concern. Lancet 2013; 382(9887): 170–179 https://doi.org/10.1016/S0140-6736(13)60647-9
4
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(11): 3365–3370 https://doi.org/10.1681/ASN.2004090740
5
Chawla LS, Amdur RL, Amodeo S, Kimmel PL, Palant CE. The severity of acute kidney injury predicts progression to chronic kidney disease. Kidney Int 2011; 79(12): 1361–1369 https://doi.org/10.1038/ki.2011.42
6
Wald R, Quinn RR, Luo J, Li P, Scales DC, Mamdani MM, Ray JG, University OTAK. Chronic dialysis and death among survivors of acute kidney injury requiring dialysis. JAMA 2009; 302(11): 1179–1185 https://doi.org/10.1001/jama.2009.1322
7
Ali T, Khan I, Simpson W, Prescott G, Townend J, Smith W, MacLeod A. Incidence and outcomes in acute kidney injury: a comprehensive population-based study. J Am Soc Nephrol 2007; 18(4): 1292–1298 https://doi.org/10.1681/ASN.2006070756
8
Nisula S, Kaukonen K, Vaara ST, Korhonen A, Poukkanen M, Karlsson S, Haapio M, Inkinen O, Parviainen I, Suojaranta-Ylinen R, Laurila JJ, Tenhunen J, Reinikainen M, Ala-Kokko T, Ruokonen E, Kuitunen A, Pettilä V. Incidence, risk factors and 90-day mortality of patients with acute kidney injury in Finnish intensive care units: the FINNAKI study. Intensive Care Med 2013; 39(3): 420–428 https://doi.org/10.1007/s00134-012-2796-5
9
Levey AS, Eckardt K, Tsukamoto Y, Levin A, Coresh J, Rossert JDE, Zeeuw D, Hostetter TH, Lameire N, Eknoyan G. Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2005; 67(6): 2089–2100 https://doi.org/10.1111/j.1523-1755.2005.00365.x
10
Machado MN, Nakazone MA, Maia LN. Prognostic value of acute kidney injury after cardiac surgery according to Kidney Disease: Improving Global Outcomes definition and staging (KDIGO) criteria. PLoS One 2014; 9(5): e98028 https://doi.org/10.1371/journal.pone.0098028
11
Loef BG, Epema AH, Smilde TD, Henning RH, Ebels T, Navis G, Stegeman CA. Immediate postoperative renal function deterioration in cardiac surgical patients predicts in-hospital mortality and long-term survival. J Am Soc Nephrol 2005; 16(1): 195–200 https://doi.org/10.1681/ASN.2003100875
12
Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, GibneyN, TolwaniA, RoncoC, Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Investigators. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 2005; 294(7): 813–818 https://doi.org/10.1001/jama.294.7.813
13
Liano F, Pascual J, The Madrid Acute Renal Failure Study Group. Epidemiology of acute renal failure: a prospective, multicenter, community-based study. Kidney Int 1996; 50(3): 811–818 https://doi.org/10.1038/ki.1996.380
14
İnal S, Altuntaş A, Kidir V, Özorak A, İlgin Y, Sezer MT. Utility of serum creatinine/cystatin C ratio in diagnosis of postrenal acute kidney injury. J Res Med Sci 2014; 19(11): 1086‒1089
15
Lewington AJ, Cerdá J, Mehta RL. Raising awareness of acute kidney injury: a global perspective of a silent killer. Kidney Int 2013; 84(3): 457–467 https://doi.org/10.1038/ki.2013.153
16
Yang L, Xing G, Wang L, Wu Y, Li S, Xu G, He Q, Chen J, Chen M, Liu X, Zhu Z, Yang L, Lian X, Ding F, Li Y, Wang H, Wang J, Wang R, Mei C, Xu J, Li R, Cao J, Zhang L, Wang Y, Xu J, Bao B, Liu B, Chen H, Li S, Zha Y, Luo Q, Chen D, Shen Y, Liao Y, Zhang Z, Wang X, Zhang K, Liu L, Mao P, Guo C, Li J, Wang Z, Bai S, Shi S, Wang Y, Wang J, Liu Z, Wang F, Huang D, Wang S, Ge S, Shen Q, Zhang P, Wu L, Pan M, Zou X, Zhu P, Zhao J, Zhou M, Yang L, Hu W, Wang J, Liu B, Zhang T, Han J, Wen T, Zhao M, Wang H. ISN AKF 0by25 China Consortiums. Acute kidney injury in China: a cross-sectional survey. Lancet 2015; 386(10002): 1465–1471 https://doi.org/10.1016/S0140-6736(15)00344-X
17
Zeng X, McMahon GM, Brunelli SM, Bates DW, Waikar SS. Incidence, outcomes, and comparisons across definitions of AKI in hospitalized individuals. Clin J Am Soc Nephrol 2014; 9(1): 12–20 https://doi.org/10.2215/CJN.02730313
18
Ricci Z, Cruz D, Ronco C. The RIFLE criteria and mortality in acute kidney injury: a systematic review. Kidney Int 2008; 73(5): 538–546 https://doi.org/10.1038/sj.ki.5002743
19
Levin NW, Handelman GJ, Coresh J, Port FK, Kaysen GA. Reverse epidemiology: a confusing, confounding, and inaccurate term. Seminars in dialysis. Semin Dial 2007; 20(6): 586–592 https://doi.org/10.1111/j.1525-139X.2007.00366.x
20
Druml W, Metnitz B, Schaden E, Bauer P, Metnitz PG. Impact of body mass on incidence and prognosis of acute kidney injury requiring renal replacement therapy. Intensive Care Med 2010; 36(7): 1221–1228 https://doi.org/10.1007/s00134-010-1844-2
21
Abelha FJ, Botelho M, Fernandes V, Barros H. Determinants of postoperative acute kidney injury. Crit Care 2009; 13(3): R79 https://doi.org/10.1186/cc7894
22
De Labry LO, Campion EW, Glynn RJ, Vokonas PS. White blood cell count as a predictor of mortality: results over 18 years from the Normative Aging Study. J Clin Epidemiol 1990; 43(2): 153–157 https://doi.org/10.1016/0895-4356(90)90178-R
Kertai MD, Zhou S, Karhausen JA, Cooter M, Jooste E, Li Y, White WD, Aronson S, Podgoreanu MV, Gaca J, Welsby IJ, Levy JH, Stafford-Smith M, Mathew JP, Fontes ML. Platelet counts, acute kidney injury, and mortality after coronary artery bypass grafting surgery. Anesthesiology 2016; 124(2): 339–352 https://doi.org/10.1097/ALN.0000000000000959
25
Bieger R, Vreeken J, Stibbe J, Loeliger EA. Arterial aneurysm as a cause of consumption coagulopathy. N Engl J Med 1971; 285(3): 152–154 https://doi.org/10.1056/NEJM197107152850306
26
Zoellner H, Hofler M, Beckmann R, Hufnagl P, Vanyek E, Bielek E, Wojta J, Fabry A, Lockie S, Binder BR. Serum albumin is a specific inhibitor of apoptosis in human endothelial cells. J Cell Sci 1996; 109(10): 2571–2580
27
Karas PL, Goh SL, Dhital K. Is low serum albumin associated with postoperative complications in patients undergoing cardiac surgery? Interact Cardiovasc Thorac Surg 2015; 21(6): 777–786
28
Xu X, Nie S, Liu Z, Chen C, Xu G, Zha Y, Qian J, Liu B, Han S, Xu A, Hou FF. Epidemiology and clinical correlates of AKI in Chinese hospitalized adults. Clin J Am Soc Nephrol 2015; 10(9): 1510–1518 https://doi.org/10.2215/CJN.02140215
