Acute Kidney Injury in the ICU: Increasing Prevalence

Q: In 10 years as a hospitalist advanced practitioner, I've been seeing more and more AKI in our ICU. Is this true everywhere, or are we doing something wrong?
AKI is on the rise nationwide (see hospitalization data in figure), and it carries grim implications for patient outcomes.^1-3 AKI with a rise in serum creatinine (SCr) as modest as 0.3 mg/dL is associated with a 70% increase in mortality risk. A rise in SCr exceeding 0.5 mg/dL has been associated with a 6.5-fold rise in the risk for death, even when adjusted for age and gender.⁴ This is higher than the mortality rate for inpatients admitted with cardiovascular disease or cancer, and just slightly more favorable than the mortality risk associated with sepsis (odds ratios, 6.6 and 7.5, respectively). AKI management in the non-ICU setting incurs the third highest median direct hospital cost, after acute MI and stroke.³

A recent retrospective analysis of hospital admissions nationwide from 2000 to 2009 shows a 10% annual increase in the incidence of AKI requiring dialysis, with at least doubling of the incidence and the number of deaths during that 10-year time period.⁵ Analyzing the incidence of AKI not requiring dialysis over time is more challenging because the criteria to define AKI have not been static; however, the rise in AKI requiring dialysis has mirrored the rise in AKI not requiring dialysis—suggesting that there is in fact an increased incidence of AKI, independent of variability in the defining criteria.³

Researchers reported in 2012 that during the previous year, the incidence of AKI among all hospitalized patients was 1 in 5.⁶ In the ICU, incidence of AKI has been reported at 39%, with a mortality rate of 25%.⁷ Based on the RIFLE criteria (a recently revised classification system whose name refers to Risk, Injury, Failure; Loss and End-stage kidney disease),⁸ as many as two-thirds of patients admitted to the ICU meet criteria for a diagnosis of AKI.

Predictors for AKI include advancing age, baseline SCr below 1.2 mg/dL, the presence of diabetes, use of IV contrast, acute coronary syndromes, sepsis, liver or heart failure, and use of nephrotoxic medications.³

It is important for clinicians to recognize the implications of AKI, even when it manifests as a relatively minor rise in SCr. In addition to its association with poor outcomes in hospitalized patients, AKI increases the risk for chronic kidney disease and for readmissions within six months after hospital discharge.⁹ Unfortunately, our increased awareness of the implications of AKI in the inpatient setting has yet to translate into significant improvement in outcomes.

The evolution and availability of epidemiologic and outcome data, we can only hope, will serve to direct more resources and further study toward this issue. Clinicians' efforts to prevent and treat AKI can have profound implications for many of our nation's most chronically and critically ill patients. —AC

REFERENCES
1. National Institute of Diabetes and Digestive and Kidney Diseases, NIH. US Renal Data System, 2010 Annual Data Report. www.usrds.org/2010/view/default.asp. Accessed March 5, 2013.

2. National Institute of Diabetes and Digestive and Kidney Diseases, NIH. US Renal Data System, 2011 Annual Data Report. www.usrds.org/2011/view/v2_00_appx.asp. Accessed March 5, 2013.

3. Waikar SS, Liu KD, Chertow GM. Diagnosis, epidemiology and outcomes of acute kidney injury. Clin J Am Soc Nephrol. 2008;3:844-861.

4. Chertow GM, Burdick E, Honour M, et al. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005;16:3365-3370.

5. Hsu RK, McCulloch CE, Dudley RA, et al. Temporal changes in incidence of dialysis-requiring AKI. J Am Soc Nephrol. 2012;24:37-42.

6. Wang HE, Muntner P, Chertow GM, Warnock DG. Acute kidney injury and mortality in hospitalized patients. Am J Nephrol. 2012;35:349-355.

7. Nisula S, Kaukonen KM, Vaara ST, et al. 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;39:420-428.

8. Hoste EA, Clermont G, Kersten A, 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.

9. Coca SG, Yusuf B, Shlipak MG, et al. Long-term risk of mortality and other adverse outcomes after acute kidney injury: a systematic review and meta-analysis. Am J Kidney Dis. 2009;53:961-973.

10. Matzke GR, Aronoff GR, Atkinson AJ Jr, et al. Drug dosing consideration in patients with acute and chronic kidney disease: a clinical update from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2011;80:1122-1137.

11. Vilay AM, Churchwell MD, Mueller BA. Clinical review: drug metabolism and nonrenal clearance in acute kidney injury. Crit Care. 2008;12:235.

Q: In 10 years as a hospitalist advanced practitioner, I've been seeing more and more AKI in our ICU. Is this true everywhere, or are we doing something wrong?
AKI is on the rise nationwide (see hospitalization data in figure), and it carries grim implications for patient outcomes.^1-3 AKI with a rise in serum creatinine (SCr) as modest as 0.3 mg/dL is associated with a 70% increase in mortality risk. A rise in SCr exceeding 0.5 mg/dL has been associated with a 6.5-fold rise in the risk for death, even when adjusted for age and gender.⁴ This is higher than the mortality rate for inpatients admitted with cardiovascular disease or cancer, and just slightly more favorable than the mortality risk associated with sepsis (odds ratios, 6.6 and 7.5, respectively). AKI management in the non-ICU setting incurs the third highest median direct hospital cost, after acute MI and stroke.³

A recent retrospective analysis of hospital admissions nationwide from 2000 to 2009 shows a 10% annual increase in the incidence of AKI requiring dialysis, with at least doubling of the incidence and the number of deaths during that 10-year time period.⁵ Analyzing the incidence of AKI not requiring dialysis over time is more challenging because the criteria to define AKI have not been static; however, the rise in AKI requiring dialysis has mirrored the rise in AKI not requiring dialysis—suggesting that there is in fact an increased incidence of AKI, independent of variability in the defining criteria.³

Researchers reported in 2012 that during the previous year, the incidence of AKI among all hospitalized patients was 1 in 5.⁶ In the ICU, incidence of AKI has been reported at 39%, with a mortality rate of 25%.⁷ Based on the RIFLE criteria (a recently revised classification system whose name refers to Risk, Injury, Failure; Loss and End-stage kidney disease),⁸ as many as two-thirds of patients admitted to the ICU meet criteria for a diagnosis of AKI.

Predictors for AKI include advancing age, baseline SCr below 1.2 mg/dL, the presence of diabetes, use of IV contrast, acute coronary syndromes, sepsis, liver or heart failure, and use of nephrotoxic medications.³

It is important for clinicians to recognize the implications of AKI, even when it manifests as a relatively minor rise in SCr. In addition to its association with poor outcomes in hospitalized patients, AKI increases the risk for chronic kidney disease and for readmissions within six months after hospital discharge.⁹ Unfortunately, our increased awareness of the implications of AKI in the inpatient setting has yet to translate into significant improvement in outcomes.

The evolution and availability of epidemiologic and outcome data, we can only hope, will serve to direct more resources and further study toward this issue. Clinicians' efforts to prevent and treat AKI can have profound implications for many of our nation's most chronically and critically ill patients. —AC

REFERENCES
1. National Institute of Diabetes and Digestive and Kidney Diseases, NIH. US Renal Data System, 2010 Annual Data Report. www.usrds.org/2010/view/default.asp. Accessed March 5, 2013.

2. National Institute of Diabetes and Digestive and Kidney Diseases, NIH. US Renal Data System, 2011 Annual Data Report. www.usrds.org/2011/view/v2_00_appx.asp. Accessed March 5, 2013.

3. Waikar SS, Liu KD, Chertow GM. Diagnosis, epidemiology and outcomes of acute kidney injury. Clin J Am Soc Nephrol. 2008;3:844-861.

4. Chertow GM, Burdick E, Honour M, et al. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005;16:3365-3370.

5. Hsu RK, McCulloch CE, Dudley RA, et al. Temporal changes in incidence of dialysis-requiring AKI. J Am Soc Nephrol. 2012;24:37-42.

6. Wang HE, Muntner P, Chertow GM, Warnock DG. Acute kidney injury and mortality in hospitalized patients. Am J Nephrol. 2012;35:349-355.

7. Nisula S, Kaukonen KM, Vaara ST, et al. 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;39:420-428.

8. Hoste EA, Clermont G, Kersten A, 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.

9. Coca SG, Yusuf B, Shlipak MG, et al. Long-term risk of mortality and other adverse outcomes after acute kidney injury: a systematic review and meta-analysis. Am J Kidney Dis. 2009;53:961-973.

10. Matzke GR, Aronoff GR, Atkinson AJ Jr, et al. Drug dosing consideration in patients with acute and chronic kidney disease: a clinical update from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2011;80:1122-1137.

11. Vilay AM, Churchwell MD, Mueller BA. Clinical review: drug metabolism and nonrenal clearance in acute kidney injury. Crit Care. 2008;12:235.

Q: In 10 years as a hospitalist advanced practitioner, I've been seeing more and more AKI in our ICU. Is this true everywhere, or are we doing something wrong?
AKI is on the rise nationwide (see hospitalization data in figure), and it carries grim implications for patient outcomes.^1-3 AKI with a rise in serum creatinine (SCr) as modest as 0.3 mg/dL is associated with a 70% increase in mortality risk. A rise in SCr exceeding 0.5 mg/dL has been associated with a 6.5-fold rise in the risk for death, even when adjusted for age and gender.⁴ This is higher than the mortality rate for inpatients admitted with cardiovascular disease or cancer, and just slightly more favorable than the mortality risk associated with sepsis (odds ratios, 6.6 and 7.5, respectively). AKI management in the non-ICU setting incurs the third highest median direct hospital cost, after acute MI and stroke.³

A recent retrospective analysis of hospital admissions nationwide from 2000 to 2009 shows a 10% annual increase in the incidence of AKI requiring dialysis, with at least doubling of the incidence and the number of deaths during that 10-year time period.⁵ Analyzing the incidence of AKI not requiring dialysis over time is more challenging because the criteria to define AKI have not been static; however, the rise in AKI requiring dialysis has mirrored the rise in AKI not requiring dialysis—suggesting that there is in fact an increased incidence of AKI, independent of variability in the defining criteria.³

Researchers reported in 2012 that during the previous year, the incidence of AKI among all hospitalized patients was 1 in 5.⁶ In the ICU, incidence of AKI has been reported at 39%, with a mortality rate of 25%.⁷ Based on the RIFLE criteria (a recently revised classification system whose name refers to Risk, Injury, Failure; Loss and End-stage kidney disease),⁸ as many as two-thirds of patients admitted to the ICU meet criteria for a diagnosis of AKI.

Predictors for AKI include advancing age, baseline SCr below 1.2 mg/dL, the presence of diabetes, use of IV contrast, acute coronary syndromes, sepsis, liver or heart failure, and use of nephrotoxic medications.³

It is important for clinicians to recognize the implications of AKI, even when it manifests as a relatively minor rise in SCr. In addition to its association with poor outcomes in hospitalized patients, AKI increases the risk for chronic kidney disease and for readmissions within six months after hospital discharge.⁹ Unfortunately, our increased awareness of the implications of AKI in the inpatient setting has yet to translate into significant improvement in outcomes.

The evolution and availability of epidemiologic and outcome data, we can only hope, will serve to direct more resources and further study toward this issue. Clinicians' efforts to prevent and treat AKI can have profound implications for many of our nation's most chronically and critically ill patients. —AC

REFERENCES
1. National Institute of Diabetes and Digestive and Kidney Diseases, NIH. US Renal Data System, 2010 Annual Data Report. www.usrds.org/2010/view/default.asp. Accessed March 5, 2013.

2. National Institute of Diabetes and Digestive and Kidney Diseases, NIH. US Renal Data System, 2011 Annual Data Report. www.usrds.org/2011/view/v2_00_appx.asp. Accessed March 5, 2013.

3. Waikar SS, Liu KD, Chertow GM. Diagnosis, epidemiology and outcomes of acute kidney injury. Clin J Am Soc Nephrol. 2008;3:844-861.

4. Chertow GM, Burdick E, Honour M, et al. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005;16:3365-3370.

5. Hsu RK, McCulloch CE, Dudley RA, et al. Temporal changes in incidence of dialysis-requiring AKI. J Am Soc Nephrol. 2012;24:37-42.

6. Wang HE, Muntner P, Chertow GM, Warnock DG. Acute kidney injury and mortality in hospitalized patients. Am J Nephrol. 2012;35:349-355.

7. Nisula S, Kaukonen KM, Vaara ST, et al. 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;39:420-428.

8. Hoste EA, Clermont G, Kersten A, 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.

9. Coca SG, Yusuf B, Shlipak MG, et al. Long-term risk of mortality and other adverse outcomes after acute kidney injury: a systematic review and meta-analysis. Am J Kidney Dis. 2009;53:961-973.

10. Matzke GR, Aronoff GR, Atkinson AJ Jr, et al. Drug dosing consideration in patients with acute and chronic kidney disease: a clinical update from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2011;80:1122-1137.

11. Vilay AM, Churchwell MD, Mueller BA. Clinical review: drug metabolism and nonrenal clearance in acute kidney injury. Crit Care. 2008;12:235.