AKI in Acute Dialysis Units outside ICU across Finland Mikko Haapio, MD Consulting Nephrologist Helsinki University Central Hospital Department of Nephrology mikko.haapio@hus.fi
FINNAKI-Nephro In conjunction with the main FINNAKI Study First Finnish study to explore acute RRT outside ICUs aims: - Incidence - Characteristics of patients and therapy - Prognosis relating to - RRT modalities - Duration of RRT - Diagnoses - AKI biomarkers
FINNAKI-Nephro Inclusion Patients treated in nephrological units, outside ICUs - Acute renal replacement therapy started, or - Indication for acute RRT existed, but a conservative approach was chosen (e.g. high age, multiple comorbidity, etc.)
FINNAKI in Nephrological Units (outside ICUs) - 17 (14) centres - 11 with patient recruitment Patient recruitment 1.9.2011 1.2.2012
Centres with patient recruitment patient-% of all 60 50 40 30 20 10 0 Helsinki University Hospital Tampere University Hospital Oulu University Hospital Jyväskylä Central Hospital Kuopio University Hospital Turku University Hospital Pori Cental Hospital Lappeenranta Central Hospital Joensuu Central Hospital Kokkola Central Hospital Vaasa Central Hospital
60 50 40 30 20 10 0 AKI Non-AKI Number of patients Helsinki University Hospital Oulu University Hospital Jyväskylä Central Hospital Tampere University Hospital Kuopio University Hospital Turku University Hospital Pori Cental Hospital Lappeenranta Central Hospital Joensuu Central Hospital Kokkola Central Hospital Vaasa Central Hospital
Basic characteristics All patients (n=137) Patients with AKI (n=93) Gender, males n (%) 77 (56) 52 (56) Age, males, median (IQR) 66 (49-77) 64 (49-74) Age, females, median (IQR) 66 (55-77) 68 (59-77) Plasma crea within recent year, median (IQR), µmol/l Plasma crea within recent year, mean (SEM), µmol/l 130 (88-215) 129 (89-205) 181 (14.7) 180 (17.3) Chronic kidney disease, n (%) 75 (55) 56 (60)
RIFLE Urine, % of AKI patients 60 50 40 30 20 10 All AKI patients AKI patients on RRT 0 Risk Injury Failure
Comorbidities, % of AKI patients 70 60 50 40 30 20 10 0 Hypertension Heart failure Atherosclerotic disease Type 2 diabetes Type 1 diabetes Connective tissue disease Kidney transplant Non-metastatic cancer COPD Chronic liver disease Transplant other than kidney
40 35 30 25 20 15 10 5 0 Infection suspected Infection diagnosed Predisposing factors, Hypovolemia % of AKI patients Rhabdomyolysis Hypotension Operation within 1wk Infection in 71%! IV contrast media Cardiogenic shock Resuscitation Acute liver failure Renal artery obstruction Urine flow obstruction Intoxication Massive blood transfusion
Predisposing drugs, % of AKI patients 70 60 50 40 30 20 10 0 Diuretic ACEi or ARB NSAID Nephrotoxic antibiotic Colloid
RRT decision, all patients (n=137)
First RRT modality, all patients treated (n=107)
RRT decisions, patients with AKI (n=93)
First RRT modality, AKI patients treated (n=71)
Alive at hospital discharge or day 28 all patients (data for 129 of 137) 100 90 80 70 60 50 40 30 20 10 0 99 76 77 76 55 44 All Males Females n %
Alive at hospital discharge or day 28 all AKI patients (n=93) 100 90 80 70 60 50 40 30 20 10 0 74 73 76 69 38 31 All Males Females n %
Alive at hospital discharge or day 28 AKI patients with RRT (n=71) 100 90 80 70 60 50 40 30 20 10 0 86 86 86 61 37 24 All Males Females n %
Alive on day 90 all patients (data for 129 of 137) 100 90 80 70 60 50 40 30 20 10 0 83 64 65 64 46 37 All Males Females n %
Alive on day 90 all AKI patients (n=93) 100 90 80 70 60 50 40 30 20 10 0 57 61 62 61 32 25 All Males Females n %
Alive on day 90 AKI patients with RRT (n=71) 100 90 80 70 60 50 40 30 20 10 0 75 75 75 53 32 21 All Males Females n %
Dialysis dependence and outcome AKI patients with RRT (n=71)
Conclusions Acute renal replacement therapy unevenly given across Finland - Local resources and hospital procedures Of acute patients in Finnish Nephrological Units: - About two thirds have AKI - 20-25% of AKI patients do not enter RRT - Mortality of AKI patients on RRT: - hospital 14% - 90-day 25%
Centres in FINNAKI-Nephro Helsinki Unversity Hospital Lohja: Terhi Martikainen, Mervi Haapala Porvoo: Karri Helin Tammisaari: Maija Heiro, Marja Stenborg, Kaj Metsärinne Meilahti: Mikko Haapio Kuopio University Hospital Arto Pulkkinen, Pauli Karhapää Oulu University Hospital Päivi Lepistö, Jutta Huhti, Minna Tamminen Tampere University Hospital Jukka Sauranen, Martti Metso Turku University Hospital Niina Koivuviita, Risto Tertti Lappeenranta Central Hospital Jari Hartman, Johanna Sinkko Kokkola Central Hospital Stefan Anderson Jyväskylä Central Hospital Marja Miettinen, Kari Vääräniemi Rovaniemi Central Hospital Tapani Salonen, Hellevi Lohi Kemi Central Hospital Pirkko Nyländen, Mari Lantto Joensuu Central Hospital Kirsti Jääskeläinen Pori Central Hospital Kaisa Laine, Maarit Vainiotalo Savonlinna Central Hospital Mika Taskinen Vaasa Central Hospital S Anna Salmela Research coordinator: Hillevi Boman
Non-critically ill patients 5-fold risk to be admitted to ICU 8-fold risk of hospital mortality (AKI = crea-increase > 26 µmol/l) Barrantes F et al. Mayo Clin Proc 2009;84.
Patients with acute congestive heart failure (sub)acutely progressing to dialysis-dependent renal failure survival from RRT start: 95 days (median) to 444 days (mean) Patients > 60 years with acute renal failure RRT for 40%, 26% outside ICUs, 3-year follow-up crea > 124/115 males/females mortality 59% (hospital-acquired ARF) Lindner G ym. Wien Klin Wochenschr. 2009;121. Sesso R ym. AJKD 2004;44.
n 83 000 No renal replacement therapy Elderly - AKI 66 ± 12 yrs After hospital discharge: - All: 17,4% died - AKI: 29,8% AKI - Non-AKI: 16,1% Adjusted mortality risk increased according to worsening AKIN stage Lafrance JP, Miller DR, JASN 2010.