Abstract
Objective
To describe the incidence and outcomes associated with early acute kidney injury (AKI) in septic shock and explore the association between duration from hypotension onset to effective antimicrobial therapy and AKI.
Design
Retrospective cohort study.
Subjects
A total of 4,532 adult patients with septic shock from 1989 to 2005.
Setting
Intensive care units of 22 academic and community hospitals in Canada, the United States and Saudi Arabia.
Measurements and main results
In total, 64.4% of patients with septic shock developed early AKI (i.e., within 24 h after onset of hypotension). By RIFLE criteria, 16.3% had risk, 29.4% had injury and 18.7% had failure. AKI patients were older, more likely female, with more co-morbid disease and greater severity of illness. Of 3,373 patients (74.4%) with hypotension prior to receiving effective antimicrobial therapy, the median (IQR) time from hypotension onset to antimicrobial therapy was 5.5 h (2.0–13.3). Patients with AKI were more likely to have longer delays to receiving antimicrobial therapy compared to those with no AKI [6.0 (2.3–15.3) h for AKI vs. 4.3 (1.5–10.8) h for no AKI, P < 0.0001). A longer duration to antimicrobial therapy was also associated an increase in odds of AKI [odds ratio (OR) 1.14, 95% CI 1.10–1.20, P < 0.001, per hour (log-transformed) delay]. AKI was associated with significantly higher odds of death in both ICU (OR 1.73, 95% CI 1.60–1.9, P < 0.0001) and hospital (OR 1.62, 95% CI, 1.5–1.7, P < 0.0001). By Cox proportional hazards analysis, including propensity score-adjustment, each RIFLE category was independently associated with a greater hazard ratio for death (risk 1.31; injury 1.45; failure 1.56).
Conclusion
Early AKI is common in septic shock. Delays to appropriate antimicrobial therapy may contribute to significant increases in the incidence of AKI. Survival was considerably lower for septic shock associated with early AKI, with increasing severity of AKI, and with increasing delays to appropriate antimicrobial therapy.
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Acknowledgment
Dr. Bagshaw is supported by a Clinical Investigator Award from the Alberta Heritage Foundation for Medical Research. Dr. Kumar received initial competitive grant support for the development of the septic shock database from Health Sciences Centre Department of Research and Health Sciences Centre Foundation. Subsequent database development was also supported through unrestricted grants from Astellas Pharma Inc., Eli-Lilly and Co., Pfizer Inc., Bayer Inc., Merck and Co., Wyeth Pharmaceuticals, Bristol-Myers Squibb Co., and Astra-Zeneca Inc.
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Appendix
Appendix
Additional members of the CATSS Database Research Group
Dan Roberts, MD, Health Sciences Centre, Winnipeg MB, Canada
Kenneth E, Wood, MD, University of Wisconsin Hospital and Clinics, Madison WI, USA
Kevin Laupland, MD, Foothills Hospital, Calgary AB, Canada
Andreas Kramer, MD, Brandon General Hospital, Brandon MB, Canada
Bruce Light, MD, Winnipeg Regional Health Authority, Winnipeg MB, Canada
Satendra Sharma, MD, Winnipeg Regional Health Authority, Winnipeg MB, Canada
Aseem Kumar, PhD, Biomolecular Sciences, Laurentian University, Sudbury ON Canada
Gourang Patel, PharmD, Rush-Presbyterian-St. Luke’s Medical Center, Chicago IL, USA
Dave Gurka, MD, Rush-Presbyterian-St. Luke’s Medical Center, Chicago IL, USA
Sergio Zanotti, MD, Cooper Hospital/University Medical Center, Camden NJ, USA
Phillip Dellinger, MD, Cooper Hospital/University Medical Center, Camden NJ, USA
Dan Feinstein, MD, St. Agnes Hospital, Baltimore MD, USA
Dave Simon, MD, Rush-Presbyterian-St. Luke’s Medical Center, Chicago IL, USA
Nehad Al Shirawi, MD, King Fahad National Guard Hospital, Saudi Arabia
Abdullah Al Shimemeri, MD, King Fahad National Guard Hospital, Saudi Arabia
Associate members of the CATSS Database Research Group
John Ronald, MD, Nanaimo Regional Hospital, Nanaimo BC, Canada
Mustafa Suleman, MD, Concordia Hospital, Winnipeg, MB
Harleena Gulati, MD, University of Manitoba, Winnipeg MB, Canada
Erica Halmarson, MD, University of Manitoba, Winnipeg MB, Canada
Robert Suppes, MD, University of Manitoba, Winnipeg MB, Canada
Cheryl Peters, University of Manitoba, Winnipeg MB, Canada
Katherine Sullivan, University of Manitoba, Winnipeg MB, Canada
Rob Bohmeier, University of Manitoba, Winnipeg MB, Canada
Sheri Muggaberg, University of Manitoba, Winnipeg MB, Canada
Laura Kravetsky, University of Manitoba, Winnipeg MB, Canada
Muhammed Wali Ahsan, MD, Winnipeg MB, Canada
Amrinder Singh, MD, Winnipeg MB Canada
Lindsey Carter, BA, Winnipeg MB, Canada
Kym Wiebe, RN, St. Boniface Hospital, Winnipeg MB, Canada
Laura Kolesar, RN, St. Boniface Hospital, Winnipeg MB, Canada
Jody Richards, Camosun College, Victoria BC, Canada
Danny Jaswal, MD, University of British Columbia, Vancouver BC, Canada
Harris Chou, BSc, of British Columbia, Vancouver BC, Canada
Tom Kosick, MD, University of British Columbia, Vancouver BC, Canada
Winnie Fu, University of British Columbia, Vancouver BC, Canada
Charlena Chan, University of British Columbia, Vancouver BC, Canada
Jia Jia Ren, University of British Columbia, Vancouver BC, Canada
Mozdeh Bahrainian, MD, Madison WI
Zial Haque, MD, Montreal QC, Canada
Heidi Paulin, University of Toronto, Toronto ON, Canada
Farah Khan, MD, Toronto ON, Canada
Runjun Kumar, University of Toronto, Toronto ON, Canada
Johanne Harvey, RN, Hôpital Maisonneuve Rosemont, Montreal QC, Canada
Christina Kim, McGill University, Montreal QC, Canada
Jennifer Li, McGill University, Montreal QC, Canada
Latoya Campbell, McGill University, Montreal QC, Canada
Leo Taiberg, MD, Rush Medical College, Chicago IL, USA
Christa Schorr, RN, Cooper Hospital/University Medical Center, Camden NJ, USA
Ronny Tchokonte, MD, Wayne State University Medical School, Detroit MI, USA
Ziad Al Memish, MD, King Fahad National Guard Hospital, Saudi Arabia
Catherine Gonzales, RN, King Fahad National Guard Hospital, Saudi Arabia
Norrie Serrano, RN, King Fahad National Guard Hospital, Saudi Arabia
Sofia Delgra, RN, King Fahad National Guard Hospital, Saudi Arabia
Special Thanks to Christine Mendez, Sheena Ablang, Debbie Friesen and Lisa Halstead for data entry
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Bagshaw, S.M., Lapinsky, S., Dial, S. et al. Acute kidney injury in septic shock: clinical outcomes and impact of duration of hypotension prior to initiation of antimicrobial therapy. Intensive Care Med 35, 871–881 (2009). https://doi.org/10.1007/s00134-008-1367-2
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DOI: https://doi.org/10.1007/s00134-008-1367-2