Akute Nierenschädigung – Evaluation klassischer Parameter und Indices zur Unterscheidung einer prä- und intrarenalen Genese im klinischen Alltag sowie Untersuchung verschiedener Faktoren auf renales Outcome und Mortalität
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Philipps-Universität Marburg
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Background: Acute kidney injury (AKI) is a common diagnosis in hospitalized patients, significantly affecting morbidity and mortality of affected individuals. AKI can be categorized into stages I-III, based on the severity of functional impairment via AKIN criteria. In addition, it can be further classified as pre-, intra- or postrenal AKI. Prerenal AKI or acute tubular necrosis (ATN) are the most common causes. Although differentiation between both entities is important for initiation of adequat thereapy and subsequent patient outcome, prompt nephrological consultations are infrequent - due to both lack of local experts and underestimation of ist clinical relevance. So far, the impact of pre-existing chronic kidney disease (CKD), infections, and AKI etiology on renal outcome and mortality remains unclear. The objective of the present study was to assess simple laboratory parameters and indices to differentiate between pre- and intrarenal AKI and to identify pragmatic, easily acessible valid tests for non-nephrologists. Additionally, the effect of pre-existing CKD, AKI etiology, and infections on renal function and overall mortality should be evaluated in hospitalized patients with AKI.
Methods: A retrospective analysis was conducted over 12 months, identifying all AKI
patients ≥18 years that were treated on the nephrology ward at the University hospital Marburg. Patients with kidney transplants or another pre-existing renal replacment therapy were excluded. Demographic and clinical data was collected, and various parameters and indices (urine specific gravity [USG], urine sodium [UNa], urine osmolality [UOsm], urine/plasma creatinine ratio [UCr/PCr], fractional sodium excretion [FENa], fractional urea excretion [FEUrea], and renal failure index [RFI]) were retrospectively analyzed for their reliability in differentiating pre- and intrarenal AKI. Intrahospital and post-discharge outcomes were investigated, with the primary endpoint being a combination of terminal kidney failure and death. Secondary endpoints included length of stay, requirement of in-hospital dialysis and mortality.
Results: Among 1,402 screened patients, 431 with a mean age of 71.7 ± 15.4 years were included, of whom 2/3 were male and approximately ¾ had severe AKI (AKIN II-III). Pre-existing CKD was present in 49.5% of all patients, mostly in advanced stages (KDIGO G3b-G5). The average length of hospital stay was 15.1 days, with a mean follow-up of 304 days. During hospitalization, 40.1% of patients were temporarily treated in the nephrology intensive care unit, and ¼ developed AKI with positive infectious status. UNa, UOsm, USG, and RFI have shown to be highly specific (>85%) for a prerenal origin with low sensitivity, while UNa and RFI were specific for ATN. Interstingly, those parameters and indices were not sifgnificantly affected in the presence of loop diuretics, ACE inhibitors or AT1 blockers, pre-existing CKD, and comorbidities. Surprisingly, FENa and FEUrea were of limited value in differentiating pre- and intrarenal AKI. In the short term, AKI patients with pre-existing CKD were more frequently discharged requiring dialysis, but had shorter hospital stays and lower in-hospital mortality. Admission tot he intensive care unit was a risk factor for mortality. Neither AKI etiology nor pre-existing CKD significantyl affected the primary combined endpoint. Of note, only severity of AKI had a negativ impact on outcome. Patients presenting with urosepsis had the shortest hospital stay and required less frequently renal replacement therapy, whereas other sepsis patients with AKI showed the highest in-hospital mortality and prolonged hospital stays.
Conclusion: Overall, this study demonstrated that (1) UNa, USG, and RFI are practical
and reliable parameters/indices for differentiating pre- and intrarenal etiologies in clinical practice; (2) loop diuretics, ACE inhibitors, AT1 blockers, and pre-existing CKD do not affect the reliability of these parameters/indices; (3) AKI etiology - if treated accordingly - does not have an impact on renal outcome and mortality; (4) long-term outcome depends on severity of AKI, but seems to be uneffected by pre-existing CKD; and (5) patients presenting with urosepsis recover more rapidly despite similar AKI severity.
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Created: 2024Issued: 2024-12-09Updated: 2024-12-09
Faculty
Medizin
Publisher
Philipps-Universität Marburg
Language
ger
Data types
DoctoralThesis
Keywords
NephrologyAkute NierenschädigungAKIrenal diagnostic parameters and indicesrenales Outcome nach akuter NierenschädigungAKIetiology of acute kidney injuryrenale diagnostische Parameter und Indicesrenal outcome following acute kidney injuryGenese der akuten Nierenschädigungacute kidney injury
DFG-subjects
Nephrologie
DDC-Numbers
610
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Siebler, Nadja Heike: Akute Nierenschädigung – Evaluation klassischer Parameter und Indices zur Unterscheidung einer prä- und intrarenalen Genese im klinischen Alltag sowie Untersuchung verschiedener Faktoren auf renales Outcome und Mortalität. : Philipps-Universität Marburg 2024-12-09. DOI: https://doi.org/10.17192/z2024.0366.
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This item has been published with the following license: In Copyright