1 Epidemiology of Acute Kidney Injury

Das akute
Nierenversagen:
Nierenversagen:
Ursache für
CNI/
DialysepflichtigDialysepflichtigkeit nach ICU
Prof. Dr. Wilfred Druml
Abteilung fü
für Nephrologie und Dialyse
Medizinische Universitä
Universitätsklinik III
Allgemeines Krankenhaus Wien
Österreich
F-1818-11
KurzKurz- und Langezeitkomplikationen
der Akuten Nierenschädigung (ANS)
Wir waren naiv und haben geglaubt, dass….
1. kleine Schwankungen der Nierenfunktion bzw. KreatininKreatininÄnderungen vernachlässigbar sind..
2. das ANV eine „harmlose“ Komplikation darstellet, das die
Nierenfunktion beliebig lange durch RRT ersetzt werden
kann
3. Patienten „im“ ANV aber nicht „am“ ANV versterben
4. Bei Patienten, die eine ANS überleben, die Nierenfunktion
sich vollständig erholt
5. Patienten, die ein ANV überleben, alles so ist wie vorher…
[email protected]
Epidemiology of
Acute Kidney Injury
Cerda J et al.
Clin J Am Soc Nephrol. 2008; 3:881-6
Natural history of AKI.
Patients who develop AKI
may experience
(1) complete recovery
of renal function,
(2) development of
progressive chronic
kidney disease (CKD),
(3) exacerbation of the
rate of progression of
preexisting CKD; A-o-C
(4) irreversible loss of
kidney function and evolve
into ESRD
DialysisDialysis-requiring acute renal failure
increases the risk of progressive
chronic kidney disease
Lo LJ. et al.
Kidney int 2009; 76: 893-99.
Kaplan–Meier curves
showing long-term risk
of progressive chronic
kidney disease (CKD)
(stage 4 or higher)
among patients who did
(dashed line) or did not
(solid line) suffer acute
renal failure.
Epidemiology of renal recovery
after acute renal failure
Bagshaw SM et al . Curr Opin Crit Care 2006; 12:544-50
Summary of studies of critically ill patients reporting renal
recovery to independence from renal replacement therapy at
hospital discharge
Evolution of chronic renal impairment
and longlong-term mortality after de novo
acute kidney injury in the critically ill;
ill;
a Swedish multimulti-centre cohort study
RimesRimes-Stigare C. et al.
Crit Care 2015; 19: 221
Estimates of survival, end-stage renal disease (ESRD) and
chronic kidney disease (CKD) three years after ICU admission in
patients with AKI and patients with no AKI. Kaplan-Meier curves
for cumulative mortality (A), ESRD (B), and CKD (C).
1
Long-term risk of chronic kidney disease
and mortality in children after acute
kidney injury: a systematic review
Greenberg JH. et al.
BMC Nephrol 2014; 15: 184
Cumulative long-term rates of renal outcomes and mortality
Chronic kidney disease after acute
kidney injury:
injury: a systematic review
and metameta-analysis
Coca SG. et al.
Kidney Int 2012;
81: 442442-48
LongLong-term risk of mortality and acute
kidney injury during hospitalization
after major surgery
Bihorac A. et al.
Ann Surg 2009; 249: 851-59
Long-term survival of patients with and without an episode of AKI
during hospitalization, stratified by degree of renal recovery.
Nonrecovery of kidney function
and death after
„acute on chronic“
chronic“ renal failure
Hsu CY et al.
Clin J Am Soc Nephrol. 2009;4:891-8.
Long-term ESRD-free
survival (absence of
death or ESRD) among
patients who had CKD
and who did not develop
ESRD or death within 30
d of discharge from
index hospitalization.
Dashed line represents
those who experienced
superimposed ARF (n
= 213);
Solid line represents
those who did not (n =
34,721).
Meta-analysis of
chronic kidney
disease (CKD)
and end-stage
renal disease
(ESRD) associated
with AKI.
(a)Pooled adjusted
hazard ratios
(HRs) for CKD
after AKI.
(b)(b) Pooled
adjusted HRs for
ESRD after AKI
Nonrecovery of kidney function
and death after acute on chronic
renal failure
Hsu CY et al.
Clin J Am Soc Nephrol. 2009;4:891-8.
Outcomes during and immediately after hospitalization for patients who
had CKD and did or did not experience an episode of superimposed ARF,
stratified by level of preadmission eGFR
LongLong-term mortality and risk factors for
development of endend-stage renal disease in
critically ill patients with and without
chronic kidney disease
Rimes-Cigare C. et al.
Crit Care 2015; 19:383-387
Kaplan-Meier curves showing a 5-year survival and b 3-year risk
of developing ESRD according to renal disease status.
2
Altersverteilung von Patienten mit
Akutem Nierenversagen auf der ICU
Mittleres Alter
fast 70 Jahre!!
AKUTES NIERENVERSAGEN
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Risikofaktoren „chronisch“
„susceptibility factors“
Nicht modifizierbar
Vorbestehende Niereninsuffizienz
fortgeschrittenes Alter
Hypertonie
Diabetes mellitus I / II
Herzinsuffizienz
Leberinsuffizienz
Nephrotisches Syndrom
.....
Komorbiditäten
aus der ASDI-Datenbank – Österreichische Intensivstationen im Jahr 2014
Beachte : Das ANV trifft selten „Nieren-naive“
Patienten !
Acute kidney injury increases risk of
ESRD among elderly
LongLong-Term Sequelae of Severe Acute
Kidney Injury in the Critically Ill Patient
without Comorbidity:
Comorbidity:
A Retrospective Cohort Study
Ishani A. et al.
JASN 2009; 20:223-28
Fortrie G. et al.
Likelihood of
initiating ESRD
treatment after
acute kidney
injury (AKI).
Renal recovery after severe
acute renal failure
Bagshaw,
Bagshaw, SM et al.
Int J Art Organ 2006; 29:102329:1023-31
PLoS One 2015; 892–900
Kaplan-Meier curves for overall survival after hospital discharge
stratified by comorbidity
Acute kidney injury and chronic
kidney disease as interconnected
syndromes
Chawla LS. et al.
N Engl J Med 2014;
371: 5858-66
Multivariate logistic regression model of factors independently
associated with RENAL RECOVERY at 90 days among critically ill
patients with severe ACUTE RENAL FAILURE
Pathophysiological
Features of Acute Kidney
Injury Leading to Chronic
Kidney Disease
3
Hypoxia as a key player in the
AKIAKI-toto-CKD transition
Renale Inflammation macht
interstitielle Fribrose
The role of macrophages in renal fibrosis
Meng XM. et al.
Nat Rev Nephrol
2010; 14: 493493-503
Tanaka S. et al.
Am J Physiol
2014;
307:F1187307:F1187-95
Renal hypoxia in the pathophysiology of the acute kidney injury
(AKI)-to-chronic kidney disease (CKD) transition.
Nierenfunktion nach akuter
Nierenschädigung
Renal injury can lead to the accumulation of classicallyactivated M1 proinflammatory macrophages in the kidney.
Elevated BP after AKI
Hsu CY. et al.
J Am Soc Nephrol 2015; e-pub
BEACHTE:
Cumulative incidence of
elevated BP (systolic
BP>140 mmHg and/or
diastolic BP>90 mmHg)
during the first 2 years
after discharge among
patients with and
without AKI.
Eine Normalisierung des Serum-Kreatinin bedeutet
nicht eine komplette Erholung der
Nierenfunktion…
We conclude that AKI is an independent risk factor for
subsequent development of elevated BP.
LongLong-term risk of coronary events
after AKI
Wu VC. et al.
J Am Soc Nephrol 2014; 25: 595-605
The Impact of Acute Kidney Injury
on the LongLong-term Risk of Stroke
Wu VC. et al.
Am J Heart Assoc 2014; 3: e0000933
Kaplan–Meier curves of
being free from stroke in
the AKI-recovery and
non-AKI groups
(P=0.0025).
AKI indicates acute
kidney injury
(A) Adjusted HRs for long-term risk of coronary events stratified by status
of DM and AKI *P<0.005; #P<0.001.
(B) Conditional effect plot showing the relationships of age, DM, and AKI
with the incidence of coronary events during follow-up with adjustment for
propensity score, sex, premorbid risk, and comorbidities
..patients who recovered from AKI had a higher incidence
of developing incident stroke and mortality than the
patients without AKI,
4
Risk of developing severe sepsis
after acute kidney injury:
injury: a
populationpopulation-based cohort study
Wu VC. et al.
Crit Care 2013: 17: R231
LongLong-term risk of upper
gastrointestinal hemorrhage after
advanced AKI
Wu RC. et al.
Clin J Am Soc Nephrol. 2015;10: 353-62
Future 10-year
probability of freedom
from upper
gastrointestinal bleeding
was lower among
patients with worse
renal status during
follow-up.
Kaplan–Meier curve for
incidence of severe sepsis
after discharge for patients
with or without acute kidney
injury
.. AKI is an independent risk factor for severe sepsis. Even patients who
recovered from AKI had a high risk of long-term severe sepsis
Haben auch Studien zum Frakturrisiko, Malignität und TBS (Wu V-C)
Langzeitfolgen des AKI
Conclusions: Recovery from dialysis-requiring AKI was
associated with future UGIB and mortality.
Acute kidney injury in nonnon-severe
pneumonia is associated with an increased
immune response and lower survival
Murugan R. et al.
Kidney int 2010; 77: 527
Auch bei
Patienten, bei
denen sich
Nierenfunktion
„normalisiert“
hatte
One-year mortality in patients with and without AKI in the overall
cohort (a) Kaplan–Meier failure plots by maximum RIFLE stage for
probability of death in the entire CAP cohort (at 1 year was higher
in patients with AKI than in patients without AKI (P<0.001)).
Temporal Changes in Incidence
of DialysisDialysis-Requiring AKI
Hsu RK. et al.
JASN 2013; 24: 3737-42
Population
incidence of dialysisrequiring AKI in the
US from 2000 to 2009
(absolute and
incidence rate/ million
person-years).
The number of
dialysis-requiring AKI
increased from 63,000
in 2000 to 164,000 in
2009; the population
incidence increased at
10% per year from
222 to 533 cases/
Acute kidney injury: global health alert million person-years.
CNI nach AKI
Was können wir tun?
 Prävention der ANS !!!
 Volumenmanagement optimieren (Hypervolämie
(Hypervolämie
vermeiden)
 Methode des Nierenersatzes (kontinuierlich vs.
intermittierend)
 Art der Membran, Form der Antikoagulation
 medikamentöse Interventionen
RAASRAAS- Blockade, ACEACE-Hemmer,
Hemmer, Spironolakton etc.
Antiinflammatorische Strategien: Statine ?
 PostPost-ICUICU-Care,
Care, Nachbetreuung von Intensivpatienten
Wir auf der ICU sind verantwortlich für die
Zukunft der Patienten!
5
Früherkennung des AKI
Neue Biomarker nach Ludwig Wagner
Nephrocheck developed by Astute Medical
Continuous renal replacement therapy is
associated with less chronic renal failure
than intermittent haemodialysis after ARF
Impact of realreal-time electronic alerting of
acute kidney injury on therapeutic
intervention and progression of RIFLE class
Colpaert K. et al.
Crit Care Med 2012; 40: 11641164-70
Kaplan-Meier curve for proportion of therapeutic
interventions. Y-axis = percentage of
admissions with therapeutic interventions within
60 mins after AKI alert in 3 study phases
„AKI sniffer"
Patient and kidney survival by dialysis
modality in critically ill patients with
acute kidney injury
Uchino S et
Int J Artif Org 2007; 30: 281-92
Bell M. et al.
Intensive Care Med
2007; 33; 773-80
Cumulative incidence of
permanent renal failure
among patients
surviving 90 days
The association between renal replacement
therapy modality and longlong-term outcomes
among critically ill adults with acute kidney
injury:
injury: a retrospective cohort study
Wald R. et al.
Crit Care Med 2014; 42: 868-77
Cumulative risk of chronic dialysis among critically ill patients with AKI
surviving to day 90 after commencement of RRT who were initially
treated with CRRT (dashed line) vs intermittent HD (IHD) (solid line).
Inverted Kaplan-Meier product limit plot for dialysis dependence
among survivors of acute renal failure.
Outcome of Acute Kidney Injury with
Different Treatment Options:
Options:
LongLong-Term FollowFollow-up
Van Berendoncks AM et al.
ClinJASN 2010; 5:1755-62
Two-year survival
according to
treatment option.
A general
comparison showed
no difference in longterm survival
according to different
treatment options
6
Citrate anticoagulation for
continuous venovenous
hemofiltration
Oudemans-van Straaten H. et al. Crit Care Med 2009; 37: 545-52
Effect of Hemodialysis Before
Transplant Surgery on Renal
Allograft Function - A Pair of RCTs
Kikic Z. et al.
Transplantation 2009; 88:137288:1372-85
125
Safety,
Safety, efficacy,
efficacy, and clinical outcomes
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P=
0.3
0.8
0.9
0.9
eGFR ( ml/min)
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0.6
0.5
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75
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0.03
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25
0.1
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50
0.3
36 vs. 47 ml/min, p < 0.03
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1
2
3
4
5
6
7
30
365
Days after transplantation
Effect of pretransplant dialysis mode on glomerular filtration rate.
Comparison of preoperative dialysis with systemic heparin anticoagulation
(open plots) versus dialysis with citrate anticoagulation (hatched plots).
Renal PostPost-ICUICU-Care
The Acute Kidney Injury (AKI) Follow-up
Clinic at St. Michael’s Hospital
Did you know???
• AKI survivors have a 40% increased risk of dying in the 2
years after the initial hospitalization
• AKI is associated with the development of new or
accelerated chronic kidney disease
• the association of AKI with long-term mortality is present
even in patients with rapidly reversible AKI
After an episode of AKI…
Refer to the AKI Follow-up Clinic
• Fax: 416-867-3709
• Tel: 416-867-7460 (ext. 8209)
• Email: [email protected]
nach Silver SA. et al. Can J Kidney Health Dis 2015; 2: 36
Nephrologist followfollow-up improves allallcause mortality of severe acute
kidney injury survivors
Harel Z. et al.
Kidney Int 2013; 83: 901
Risk of all-cause
mortality in
survivors of severe
acute kidney injury
(AKI). Renal PostPost-ICUICU-Care
All patients with an episode of AKI should be
considered for post-discharge nephrology care
Referral criteria (even if partially or completely recovered
kidney function):
• doubling of serum creatinine during hospitalization or from known
pre-admission baseline
• creatinine over 354µmol/L during an AKI episode
• requirement for any dialysis to manage AKI
Exclusion criteria:
• kidney transplant recipients
• severe pre-existing CKD (baseline eGFR<30mL/min/1.73m2)
• diagnosis of glomerulonephritis, vasculitis, HUS/TTP, polycystic
kidney disease, myeloma
• palliation as primary goal of care
• patients with previously established nephrology follow-up
(including need for dialysis post-discharge)
nach Silver SA. et al. Can J Kidney Health Dis 2015; 2: 36
Das akute
Nierenversagen
hat massive
LangzeitLangzeitkomplikationen;
komplikationen;
darunter auch
CNI/ ESRD
Prof. Dr. Wilfred Druml
Abteilung fü
für Nephrologie und Dialyse
Medizinische Universitä
Universitätsklinik III
Allgemeines Krankenhaus Wien
Österreich
[email protected]
7