The FINNAKI Study -RRT in Finland Suvi Vaara, MD Intensive Care Units, Division of Anaesthesiology and Intensive Care Medicine Helsinki University Central Hospital Finland
Overview FINNAKI what & why AKI incidence & outcome RRT to whom & how RRT - outcome
The FINNAKI study Prospective, observational, multicenter study 17 Finnish ICUs 1 Sep 2011 1 Feb 2012 (five months)
Main Aims Acute kidney injury, severe sepsis - incidence - risk factors - RRT-treatment - outcome - health-related quality of life and cost-utility - novel biomarkers
Data collection I The Finnish Intensive Care Consortium - High quality clinical database - Validated prospective data Previous FINN-studies - FINNSEPSIS 2004 - FINNALI 2007 - FINNRESUSCI 2009
Extended electronic dataset - almost all laboratory and physiologic data - AKI status Data collection II Case report forms: Pre-ICU + ICU days 1-5 - Chronic diseases & medications - RRT treatment - Presence of severe sepsis
Inclusion & Exclusion Inclusion Exclusions Emergency admission Elective admission >24 h Under 18 years Previously in study with RRT Elective admission < 24h On chronic RRT Organ donor Initiation of chronic RRT Declined / No consent Foreigner Over 5 days in study already in another ICU Intermediate care Other/unknown S. Nisula
5853 Admissions 2728 Exclusion criteria 140 <18 years 26 Previously in study with RRT 1182 Elective admission < 24h 59 On chronic RRT 28 Organ donor 5 Initiation of chronic RRT 174 Declined 36 Foreigner 3125 Admissions 160 No consent 39 > 5 days in study already 660 Intermediate care 219 Other/unknown 2901 Patients 32 Transfers 192 Multiple admissions 1760 No AKI (60.7%) 1141 AKI (39.3%) 499 KDIGO stage 1 (17.2%) 232 KDIGO stage 2 (8.0%) 410 KDIGO stage 3 (14.1%) 296 RRT (10.2%) S. Nisula
AKI incidence Proportion of included ICU patients 1141 of 2901 39.3% (95% CI: 37.5-41.1%) Population-based incidence 74.6 (71.7 77.4) per 100,000 adults per year Reference population 3.67 million = 85 % of the Finnish adult population
Mortality 90-day mortality of all AKI patients 33.7% % 50 45 40 35 30 25 20 15 10 5 0 No AKI KDIGO Stage 1 KDIGO Stage 2 KDIGO Stage 3 ICU Hospital 90 Days S. Nisula
Renal Replacement Therapy
RRT for AKI Yearly population-based incidence per 100,000 (95% CI) 19.4 (17.2-21.6)
Patient characteristics I APACHE III diagnosis groups N (%) of 296 Non-operative 203 (68.6) Renal disease 51 (25.1) Sepsis 38 (18.7) Metabolic 32 (15.8) Gastrointestinal disease 32 (15.8) Cardiovascular 25 (12.3) Other 25 (12.3) Operative 93 (31.4) Cardiovascular 51 (54.8) Gastrointestinal disease 35 (37.6) Other 7 (7.5)
Elderly patients N=296 Median (IQR) 64 (55-73) years N Age (years)
Severity of illness N=296 Median (IQR) 51 (40-65) N
Patient characteristics II Characteristic N (%) Male gender 197 (67%) Emergency admission 271 (93%) Vasoactives 216 (75%) Severe sepsis 142 (48%) Diuretics prior to RRT 202 (68%) Colloids prior to RRT 208 (72%)
Indications for RRT - Median (IQR) number of indications 3 (2-4) Indication N (%) Oliguria 223 (78) High creatinine 196 (70) Acidosis 181 (65) Fluid accumulation 116 (43) Hyperkalemia 72 (26) Rhabdomyolysis 34 (13) Intoxication 19 (7) Other 16 (6) 175 (51-509) ml/24h 335 (246-529) umol/l ph 7.22(7.12-7.29) BE -11.6 (-17.3 - -8.7) mmol/l
RRT was initiated early -Median (IQR) time to RRT 14.0 (3.3-41.5) hours N=296
Initial RRT modality N=11 3.7% N=4 1.4% N=4 1.4% CRRT 215 (72.6%) N=62 20.9% N=11 3.7% -91% predilution N=111 37.5% N=93 31.4% -95% predilution
CRRT anticoagulation
Initial CRRT dose N=215 N Median (IQR) 35.3 (31.2-40.6) ml/kg/h Daily median (IQR) duration of CRRT 19.0 (9.3-24.0) h (680 treatment days) Dose after adjusting for duration ->27.9 ml/kg/h
Reasons for interruptions 51% 137 CRRT treatment days
Lenght of stay Median (IQR), days ICU 5.5 (2.2-10.9) Hospital 14.5 (6.0-27.3) N N
Mortality Hospital 96 32.4% (95% CI; 31.9-32.9%) 90-day 116 39.2% (38.6-39.8%) SAPS II standardized mortality ratio 0.64 (0.52-0.78)
Studies with 90-day mortality Retro Prosp RCT
Fluid accumulation at RRT initiation Calculated from ICU admission to RRT initiation (day of RRT initiation included) Survivors N=180 Comparison between groups: P <0.001. Data presented as median [IQR]. Non-survivors N=116 Cumulative balance (L) 3.1 [0.3-6.4] 6.2 [2.2-9.7] Fluid accumulation % of weight 3.6 [0.3-8.2] 8.0 [3.0-12.9]
Fluid accumulation & mortality P<0.001 32 44 94 67 46
Logistic regression for 90-day mortality Odds ratio (95% CI) P-value Age /year 1.05 (1.02-1.07) 0.001 SAPS II without age /point 1.05 (1.02-1.07) <0.001 Non-renal SOFA score on RRT initiation day /point 1.22 (1.08-1.38) 0.002 Fluid overload 2.63 (1.30-5.30) 0.007 Non-significant factors (P>0.01) -Time from ICU admission to RRT initiation (days) -Initial RRT modality -Severe sepsis (yes/no) -Urine output on RRT initiation day, use of diuretics or colloids prior to RRT -Lactate, Crea, BE prior to RRT
90-day survival No fluid overload Fluid overload 68.6% 40.8% Log-rank test P<0.001
Conclusions Population-based incidence /100,000 adults per year - AKI 74.6 - RRT 19.6 90-day mortality - all AKI 34% - RRT patients 39% Fluid overload at RRT initiation-> worse outcome
Conclusions - RRT RRT initiated early Oliguria, high crea, and acidosis most common indications CRRT initial modality in 72% - Regional citrate anticoagulation used in 59% - CRRT dose 28 ml/kg/h
Future directions Large data bank Blood and urine samples Health-related quality of life and cost-utility
The FINNAKI Study Group Central Finland Central Hospital: Raili Laru-Sompa, Anni Pulkkinen, Minna Saarelainen, Mikko Reilama, Sinikka Tolmunen, Ulla Rantalainen, Marja Miettinen East Savo Central Hospital: Markku Suvela, Katrine Pesola, Pekka Saastamoinen, Sirpa Kauppinen Helsinki University Central Hospital: Ville Pettilä, Kirsi-Maija Kaukonen, Anna-Maija Korhonen, Sara Nisula, Suvi Vaara, Raili Suojaranta-Ylinen, Leena Mildh, Mikko Haapio, Laura Nurminen, Sari Sutinen, Leena Pettilä, Helinä Laitinen, Heidi Syrjä, Kirsi Henttonen, Elina Lappi, Hillevi Boman Jorvi Central Hospital: Tero Varpula, Päivi Porkka, Mirka Sivula Mira Rahkonen, Anne Tsurkka, Taina Nieminen, Niina Prittinen. Kanta-Häme Central hospital: Ari Alaspää, Hanna Juntunen, Teija Sanisalo Kuopio University Hospital: Ilkka Parviainen, Ari Uusaro, Esko Ruokonen, Stepani Bendel, Niina Rissanen, Maarit Lång, Sari Rahikainen, Saija Rissanen, Merja Ahonen, Elina Halonen, Eija Vaskelainen Lapland Central Hospital: Meri Poukkanen, Esa Lintula, Sirpa Suominen Länsi Pohja Central Hospital: Jorma Heikkinen, Timo Lavander, Kirsi Heinonen, Anne-Mari Juopperi, Middle Ostrobothnia Central Hospital: Tadeusz Kaminski, Fiia Gäddnäs, Tuija Kuusela, Jane Roiko North Karelia Central Hospital: Sari Karlsson, Matti Reinikainen, Tero Surakka, Helena Jyrkönen, Tanja Eiserbeck, Jaana Kallinen Satakunta Hospital district: Vesa Lund, Päivi Tuominen, Pauliina Perkola, Riikka Tuominen, Marika Hietaranta, Satu Johansson South Karelia Central Hospital: Seppo Hovilehto, Anne Kirsi, Pekka Tiainen, Tuija Myllärinen, Pirjo Leino, Anne Toropainen Tampere University Hospital: Anne Kuitunen, Jyrki Tenhunen, Ilona Leppänen, Markus Levoranta, Sanna Hoppu, Jukka Sauranen, Atte Kukkurainen, Samuli Kortelainen, Simo Varila Turku University Hospital: Outi Inkinen, Niina Koivuviita, Jutta Kotamäki, Anu Laine Oulu University Hospital: Tero Ala-Kokko, Jouko Laurila, Sinikka Sälkiö Vaasa Central Hospital: Simo-Pekka Koivisto, Raku Hautamäki, Maria Skinnar
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