Acute kidney injury subphenotypes based on creatinine trajectory identifies patients at increased risk of death
Acute kidney injury subphenotypes based on creatinine trajectory identifies patients at increased risk of death
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DOI：
10.1186/s13054-016-1546-4
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发表时间：
2016-11-17
期刊：
影响因子：
15.1
通讯作者：
Wurfel, Mark M.
中科院分区：
文献类型：
--
作者：
Bhatraju, Pavan K.;Mukherjee, Paramita;Wurfel, Mark M.
背景：急性肾损伤(AKI)在重症监护病房(ICU)患者中很常见。AKI是高度异质性的，与糟糕的结果有不同的联系。目前对AKI严重程度进行分类并确定预后不良的最高风险患者的方法侧重于血肌酐(SCr)值的最大变化。然而，由于需要可靠的基线SCR值，以及缺乏区分SCR暂时性和持续性上升的成分，这些得分受到阻碍。我们假设，根据ICU中SCR值的早期轨迹识别AKI亚型的可解决或未解决将更好地区分有住院死亡风险的患者。方法：我们对入住创伤ICU(组1；n=1914)或普通内科-外科ICU(组2；n=1867)的ICU患者进行了二次分析。在第一组中，我们测试了AKI亚型分解和非分解表型的定义，并选择了与非AKI对照相比，死亡风险分离最大的亚型的定义。我们将这一定义应用于第二组，并检验在调整AKI严重程度后，亚型是否与住院死亡率独立相关。结果：第一组和第二组分别有46%和69%的患者发生AKI。在组1中，AKI亚型(定义为在研究登记的前72小时Scr下降0.3 mg/dl或从最大值下降25%)与低死亡风险相关。AKI亚型不消退(定义为所有AKI病例不符合“消退”定义)与高死亡风险相关。在第2组中，AKI亚型的消退与死亡率的增加无关(相对危险度[RR]0.86，95%可信区间0.63~1.17)，而未消退的AKI亚型与较高的死亡率相关(RR 1.68，95%CI 1.15~2.44)。结论：SCr水平的变化轨迹表明，即使在严重程度相似的AKI患者中，AKI亚型的死亡风险也不同。这些AKI亚型可能更好地定义可能受益于新干预措施的不良结局风险患者。
Background: Acute kidney injury (AKI) is common among intensive care unit (ICU) patients. AKI is highly heterogeneous, with variable links to poor outcomes. Current approaches to classify AKI severity and identify patients at highest risk for poor outcomes focus on the maximum change in serum creatinine (SCr) values. However, these scores are hampered by the need for a reliable baseline SCr value and the absence of a component differentiating transient from persistent rises in SCr. We hypothesized that identification of resolving or nonresolving AKI subphenotypes based on the early trajectory of SCr values in the ICU would better differentiate patients at risk of hospital mortality.Methods: We performed a secondary analysis of two prospective studies of ICU patients admitted to a trauma ICU (group 1; n = 1914) or general medical-surgical ICUs (group 2; n = 1867). In group 1, we tested definitions for resolving and nonresolving AKI subphenotypes and selected the definitions resulting in subphenotypes with the greatest separation in risk of death relative to non-AKI controls. We applied this definition to group 2 and tested whether the subphenotypes were independently associated with hospital mortality after adjustment for AKI severity.Results: AKI occurred in 46% and 69% of patients in groups 1 and 2, respectively. In group 1, a resolving AKI subphenotype (defined as a decrease in SCr of 0.3 mg/dl or 25% from maximum in the first 72 h of study enrollment) was associated with a low risk of death. A nonresolving AKI subphenotype (defined as all AKI cases not meeting the "resolving" definition) was associated with a high risk of death. In group 2, the resolving AKI subphenotype was not associated with increased mortality (relative risk [RR] 0.86, 95% CI 0.63-1.17), whereas the nonresolving AKI subphenotype was associated with higher mortality (RR 1.68, 95% CI 1.15-2.44) even after adjustment for AKI severity stage.Conclusions: The trajectory of SCr levels identifies AKI subphenotypes with different risks for death, even among AKI cases of similar severity. These AKI subphenotypes might better define the patients at risk for poor outcomes who might benefit from novel interventions.