AKI itself Epidemiology
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Transcript AKI itself Epidemiology
AKI ITSELF
EPIDEMIOLOGY
Michael Zappitelli, MD, MSc
Montreal Children's Hospital
McGill University Health Centre
Epidemiology: Distribution and patterns of
Health-events
Health-characteristics
Their causes, determinants or influences in welldefined populations
AKI
Who, What, When, Where, Why and How?
Past: Pediatric AKI studies
Mostly studies of RRT requirement: rare
Small
Retrospective
Poor outcome
Lack of
understanding of
severity spectrum
Pediatric acute RRT is not easy!
Studies on acute
RRT technique
Pediatric RRT
refinement
Experience
description
Past: Pediatric AKI studies
Pre-2004:
Descriptions of specific diagnoses
HUS
Malaria
Glomerulonephritis
Bee stings!!
Changes with Era's
HUS: >25% to ~15%
Heme-Onc: 8 to ~18%
Sepsis:No change (~1/5)
Williams et al, Arch Ped Adolesc Med, 2002
Changes with Era's
Williams et al, Arch Ped Adolesc Med, 2002
Moghal et al, Clin Nephrol 1998
UK, 1984-1991
52% of AKI referred cases either HUS or “primary renal disease”
Most patients requiring RRT: “primary renal disease”
DEFINITIONS
Pediatric AKI – around the world!
AKI or AKI recognition may be increasing
Vachvanichsanong et al, Pediatrics, 2006
THAILAND
Overview
Epidemiology Today
Studies using recent definitions
Incidence
Characteristics, patterns
Outcomes, mortality
Highlighting:
Different regions
Studies reporting RRT need
Incidence
Characteristics
Mortality
Diagnostic populations
AKI- using definitions
X X
Goodbye
Incidence: PICU full cohort studies
USA
N=3396
No severe
CKD
Creat
Turkey
N=189
No severe
CKD
Creat
Kayaz et al, Acta Pediatr, 2012
Schneider et al, Ped Crit Care, 2010
Incidence: PICU partial cohort studies
Canada
N=2106
≥12 hours
Creat
USA
N=150
Vent and/or Vaso,
Foley
Urine
Alkandari Creat
et al, +
Crit
Care, 2011
Plotz et al, Intens Care Med, 2008
North India
Netherlands
N=486
N=189
>24≥4
hours,
Vent
days
NO severe
Admx
Creat
Urine AKI
South+India
Creat
N=215
>48 hours
Creat + Urine
Mehta, et al, Ind Ped, 2012
Ackan-Arikan, Ped Crit Care, 2007
Krishnamoorthy, et al, Ind J Ped, 2012
Incidence: Cardiac
2 Canadian studies (646)
Morgan, j Ped, 2012
Zappitelli, KI, 2009
4 US studies (1594)
Manrique, Ped Anesth, 2009
Li, Crit Care Med, 2011
Aydin, Ann Thorac Surg, 2012
Blinder, J Thor Card Surg, 2012
1 Hungarian study (1510)
Toth, Card Anethes, 2012
1 Indian study (124)
Sethi, Clin Exp Nephrol, 2011
Incidence: Nephrotoxins
Vancomycin ≥2 days
N=167
Aminoglycosides ≥5 days
N=557
100
100
80
80
Increasing numbers (≥3)
60 of NTM used
pRIFLE
creat
Increases risk for
AKI in 40
non-ICU children
20
Moffett & Goldstein, CJASN,
2011
60
40
20
0
No AKI
R
I
F
Zappitelli et al, NDT, 2011
~pRIFLE
creat
0
No AKI
AKI
McKamy et al, J Peds, 2012
? independent of ICU/other drugs?
Smyth et al, Thorax, 2008
Case-control study, CF
24 AKI (UK CF Database)
IV Aminoglycoside independent RF
Incidence: Stem cell transplant
& other cancers
Most commonly expressed as SCr doubling
Generally determined 30-100 days post
Range from 5 to 40%!
Many nephrotoxins, critical illness, sepsis
Better understanding of AKI spectrum needed
RRT-requiring AKI
X X
Goodbye
Incidence of D-AKI
Cardiac surgery: 0 to 31%!
~1%
~6%
5-6%
~1-3%
1-2%
~4%
PD>> others
RRT-AKI Mortality high everywhere (almost!)
50-60%
25-50%
42-67%
52-77%
40-45%
40%
33-65%
64%
36%
11%
Characteristics, patterns
AKI due to other causes >>> primary renal disease
Developing countries:
More importance of primary renal disease, Malaria, HUS
However, now secondary causes emerging
“TOP HITS” around room:
“ATN”
“Hypovolemia”
Sepsis
Nephrotoxic medication – almost always significant when looked at!!
Heme-Onc
Cardiac surgery
Majority have multiple organ dysfunction
Characteristics, patterns
Characteristics, patterns
AKI OCCURS EARLY
Distribution of the day of admission that subjects reached pRIFLEmax
(n=123) and pRIFLE F stratum (n=31).
Confirmed in several other larger epidemiologic cohort studies
Outcome associations
In repeated studies last 5 years:
AKI independently associated with
PICU mortality
Length of stay
Duration of mechanical ventilation
Graded response: Stage 1 worse than 2 worse than 3
A few studies: associated with higher costs
Difficult to REALLY know if independent of illness severity
Importance of all these studies
Paradigm changed
PAST
Only severe AKI, requiring
RRT is of serious significance.
AKI is a marker of disease
severity.
CURRENT
People die WITH AKI, not
BECAUSE of AKI.
AKI is a spectrum of disease:
worse AKI = more significance
AKI is more likely and worse,
with increasing illness severity.
AKI itself may be an
independent contributor to
poor outcome.