Stratified Clinical Outcomes Of Patients With KDIGO-AKI_scrin Critical Care

BACKGROUND:Acute renal injury(AKI)is a syndrome characterized by rapid deterioration of renal function,often secondary to other acute diseases;it is particularly common in intensive care unit patients,and is closely related to the prognosis of patients.By the KDIGO AKI guidline in 2012,the changes of urine volume,the absolute increase value and relative increase rate of serum creatinine were classified into a certain stage In recent years,many scholars proposed to carry out subgroup analysis to better evaluate and manage AKI patients.At the same time,acute renal injury and chronic kidney disease are global public health problems,AKI is more common in patients with renal impairment,and AKI may be an important risk factor to promote the progress of potential CKD.Whether there are differences in clinical characteristics and outcomes between patients with pure AKI and Acute on CKD is also an urgent problem to be solved.Previous studies had shown that KDIGO-AKI can be divided into four stages:1a,1b,2 and 3.There were statistical differences in ICU length of stay and hospital mortality between stages.According to PAKI and AoCKD,there were significant differences in clinical prognosis.At present,there is no further detailed study on the classification of ICU-AKI patients in China.Therefore,through the reanalysis of CCCCTG database,we studied the influences of different classification and stages on the clinical prognosis of Chinese critical patients.OBJECTIVES:To explore the differences of clinical characteristics and outcomes of AKI patients diagnosed according to the serum creatinine standard established by KDIGO definition and classification system of Chinese adult ICU patients in different stages(1a,1b,2,3)and types(PAKI,AoCKD),and analyze the risk factors affecting the clinical prognosis of ICU patients.METHODS:In order to understand the clinical characteristics and prognosis of critically ill patients in ICU of China,China Critical Care Clinical Trial Group(CCCCTG)prospectively collected 3063 ICU critically ill patients' data from July 1 to August 31,2009.The data come from 22 tertiary ICUs in 19 provinces and autonomous regions of the Mainland of China.The database was analyzed retrospectively in this study,from which the ID number,gender,age,body weight,daily monitoring SCr value in ICU of the subjects were extracted.acute physiology and chronic health(APACHE II)score,Sequential Organ Failure Assessment(SOFA)score,the chalsen's syndrome index(CCI)and the glomerular filtration rate(EGFR)which was estimated by MDRD were calculated.The basic diseases include CKD,COPD,HTN,DM,CAD,MT,CTD,SOT,the reason of entering ICU,intervention in ICU-MVT,VDT,RRT,28 day mortality in ICU,ICU LOS and other data were assessed.According to KDIGOscr criteria,all patients were further classified into 4 stages(1a,1b,2,3)and 2 types(PAKI,AoCKD).Given the objective of the current study,those patients receiving RRT were classified according to KDIGOsCr criteria rather than assigned to AKI stage 3 based on KDIGO criteria.All cause mortality in ICU within 28 days was the primary outcome,ICU LOS and RRT ratio in ICU were second outcomes.By comparing the baseline data and prognostic outcomes between 4 stages and 2 types,the risk factors of ICU mortality within 28 days were analyzed by Kaplan-Meier survival analysis and Cox proportional risk modelRESULTS:We selected 345 cases from 3063 patients for statistics.The morbidity of ICU-AKI was 33.1 1%,and ICU mortality was 13.91%.When Scrrer= 53umol/L was used as the exclusion standard,there were no significant differences in ICU mortality,RRT ratio and ICU LOS among the 4 stages within 28 days(P=0.357,0.639,0.242);Stage 1b presented much longer ICU LOS than stage 1a(P=0.000),but there were no significant differences in ICU mortality(P=0.135)and RRT ratio(P=1.000).When Scrref=61.88umol/L was used as the exclusion standard,it was the same as the above results,and still only longer ICU LOS was seen(P=0.032).According to Kaplan Meier survival analysis,there was no significant difference in the cumulative survival rate of ICU within 28 days between the four stages of the two basic creatinine exclusion criteria(Log rank test:X2=4.056,P=0.255;Log rank test:X2=3.090,P=0.378).Compared with PAKI,the ICU mortality and RRT ratio of patients with AoCKD were 39.13%vs 12.11%(P=0.001)and 26.09%vs 4.04%(P=0.001)respectively,and there was no statistical difference in ICU LOS(P=0.728).Kaplan Meier survival curve analysis showed that the cumulative survival rate of ICU in AoCKD patients within 28 days was significantly lower than that in PAKI patients(Log rank test:X2=5.939,P=0.015).Further multivariate analysis of COX proportional risk regression showed that admission to ICU due to respiratory failure[HR=4.462(95%CI1.144-1 7.401),P=0.031]intervention within VDT[HR=4.023(95%CI1.584-10.216),P=0.003],and AoCKD[HR=5.377(95%CIl.303-22.186),P=0.020]were independent risk factors affecting the ICU mortality within 28 daysCONCLUSION:Further categorizing AKI into four stages based on serum creatinine criteria,there was only statistical difference in ICU LOS between groups,and there was no significant difference in the cumulative survival rate of ICU within 28 days for critically ill patients in China.KDIGO AKIscr was subdivided into PAKI and AoCKD groups,there were statistical differences in mortality and RRT ratio between groups.The cumulative survival rate of the patients with AoCKD within 28 days was significantly lower than that of the patients with PAKI.AoCKD was an independent risk factor affecting the mortality rate of the patients within 28 daysTherefore,it is necessary to refine the type of KDIGO AKIscr,and further refine the stage can also obtain certain clinical and scientific benefits.