RESUMO
BACKGROUND AND OBJECTIVES: AKI is frequent and is associated with poor outcomes. There is limited information on the epidemiology of AKI worldwide. This study compared patients with AKI in emerging and developed countries to determine the association of clinical factors and processes of care with outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This prospective observational study was conducted among intensive care unit patients from nine centers in developed countries and five centers in emerging countries. AKI was defined as an increase in creatinine of ≥0.3 mg/dl within 48 hours. RESULTS: Between 2008 and 2012, 6647 patients were screened, of whom 1275 (19.2%) developed AKI. A total of 745 (58% of those with AKI) agreed to participate and had complete data. Patients in developed countries had more sepsis (52.1% versus 38.0%) and higher Acute Physiology and Chronic Health Evaluation (APACHE) scores (mean±SD, 61.1±27.5 versus 51.1±25.2); those from emerging countries had more CKD (54.3% versus 38.3%), GN (6.3% versus 0.9%), and interstitial nephritis (7.0% versus 0.6%) (all P<0.05). Patients from developed countries were less often treated with dialysis (15.5% versus 30.2%; P<0.001) and started dialysis later after AKI diagnosis (2.0 [interquartile range, 0.75-5.0] days versus 0 [interquartile range, 0-5.0] days; P=0.02). Hospital mortality was 22.0%, and 13.3% of survivors were dialysis dependent at discharge. Independent risk factors associated with hospital mortality included older age, residence in an emerging country, use of vasopressors (emerging countries only), dialysis and mechanical ventilation, and higher APACHE score and cumulative fluid balance (developed countries only). A lower probability of renal recovery was associated with residence in an emerging country, higher APACHE score (emerging countries only) and dialysis, while mechanical ventilation was associated with renal recovery (developed countries only). CONCLUSIONS: This study contrasts the clinical features and management of AKI and demonstrates worse outcomes in emerging than in developed countries. Differences in variations in care may explain these findings and should be considered in future trials.
Assuntos
Injúria Renal Aguda/terapia , Disparidades em Assistência à Saúde , Unidades de Terapia Intensiva , Diálise Renal , APACHE , Injúria Renal Aguda/sangue , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/fisiopatologia , Adulto , Idoso , Biomarcadores/sangue , Brasil , China , Creatinina/sangue , Estado Terminal , Países em Desenvolvimento , Europa (Continente) , Feminino , Humanos , Índia , Rim/fisiopatologia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , América do Norte , Estudos Prospectivos , Recuperação de Função Fisiológica , Diálise Renal/efeitos adversos , Diálise Renal/mortalidade , Características de Residência , Respiração Artificial , Fatores de Risco , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento , Regulação para CimaRESUMO
Acute kidney injury (AKI) is associated with electrolyte and acid-base disturbances such as hyperkalemia, metabolic acidosis, hypocalcemia and hyperphosphatemia. The initiation of dialysis in AKI can efficiently treat these complications. The choice of dialysis modality can be made based on their operational characteristics to tailor the therapy according to the clinical scenario. Each dialysis modality can also trigger significant electrolyte and acid-base disorders, such as hypokalemia, hypophosphatemia and metabolic alkalosis, which may direct changes in fluid delivery and composition. Continuous techniques may be particularly useful in these situations as they allow more time for correction and to maintain balance. This review provides an overview of the electrolyte and acid-base disturbances occurring in AKI and after the initiation of dialysis and discusses therapeutic options in this setting.
Assuntos
Desequilíbrio Ácido-Base/etiologia , Desequilíbrio Ácido-Base/terapia , Injúria Renal Aguda/complicações , Injúria Renal Aguda/terapia , Terapia de Substituição Renal/métodos , Desequilíbrio Hidroeletrolítico/etiologia , Desequilíbrio Hidroeletrolítico/terapia , Acidose Respiratória/etiologia , Acidose Respiratória/terapia , Alcalose Respiratória/etiologia , Alcalose Respiratória/terapia , Anticoagulantes/uso terapêutico , Citratos/uso terapêutico , HumanosRESUMO
Oliguria is a valuable marker of kidney function and a criterion for diagnosing and staging acute kidney injury (AKI). However, the utility of urine output as a specific metric for renal dysfunction is somewhat controversial. To study this issue further we tested whether urine output is a sensitive, specific, and early measure for diagnosing and staging AKI in 317 critically ill patients in a prospective observational study. Urine output was assessed every hour and serum creatinine every 12 to 24 h. The sensitivity and specificity of different definitions of oliguria for the diagnosis of AKI were compared with the Acute Kidney Injury Network serum creatinine criterion. The incidence of AKI increased from 24%, based solely on serum creatinine, to 52% by adding the urine output as a diagnostic criterion. Oliguric patients without a change in serum creatinine had an intensive care unit mortality rate (8.8%) significantly higher than patients without AKI (1.3%), and similar to oliguric patients with an increase in serum creatinine (10.4%). The diagnosis of AKI occurred earlier in oliguric than in non-oliguric patients. Oliguria of more than 12 h and oliguria of 3 or more episodes were associated with an increased mortality rate. Thus, urine output is a sensitive and early marker for AKI and is associated with adverse outcomes in intensive care unit patients.