aki itself epidemiology michael zappitelli, md, msc montreal children's hospital mcgill...
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AKI ITSELF
EPIDEMIOLOGY
Michael Zappitelli, MD, MScMontreal Children's HospitalMcGill University Health Centre
Epidemiology: Distribution and patterns of
Health-events Health-characteristics Their causes, determinants or influences
in well-defined populations
AKI
Who, What, When, Where, Why and How?
Past: Pediatric AKI studies
Mostly studies of RRT requirement: rare
Pediatric acute RRT is not easy!
SmallRetrospectiv
eLack of
understanding of severity spectrum
Poor outcome
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!!
Williams et al, Arch Ped Adolesc Med, 2002
Changes with Era's
HUS: >25% to ~15%
Heme-Onc: 8 to ~18%
Sepsis:No change (~1/5)
Changes with Era's
Williams et al, Arch Ped Adolesc Med, 2002
Moghal et al, Clin Nephrol 1998UK, 1984-1991
52% of AKI referred cases either HUS or “primary renal disease” Most patients requiring RRT: “primary renal disease”
DEFINITIONSPediatric AKI – around the world!
AKI or AKI recognition may be increasing
Vachvanichsanong et al, Pediatrics, 2006THAILAND
Overview
Epidemiology Today
Studies using recent definitionsIncidenceCharacteristics, patternsOutcomes, mortality
Studies reporting RRT needIncidenceCharacteristicsMortality
Highlighting:
Different regions
Diagnostic populations
AKI- using definitions
X
Goodbye
X
Incidence: PICU full cohort studies
Schneider et al, Ped Crit Care, 2010
USAN=3396
No severe CKD
Creat
Kayaz et al, Acta Pediatr, 2012
TurkeyN=189
No severe CKD
Creat
Incidence: PICU partial cohort studies
Ackan-Arikan, Ped Crit Care, 2007
Plotz et al, Intens Care Med, 2008
Krishnamoorthy, et al, Ind J Ped, 2012
USAN=150
Vent and/or Vaso, Foley
Creat + Urine
NetherlandsN=189
Vent ≥4 daysCreat + Urine
South India
N=215>48 hours
Creat + Urine
North IndiaN=486
>24 hours, NO severe Admx
AKICreat
Mehta, et al, Ind Ped, 2012
CanadaN=2106
≥12 hoursCreat
Alkandari et al, Crit Care, 2011
Incidence: Cardiac
4 US studies (1594)Manrique, Ped Anesth, 2009Li, Crit Care Med, 2011Aydin, Ann Thorac Surg, 2012Blinder, J Thor Card Surg, 2012
1 Indian study (124)Sethi, Clin Exp Nephrol,
2011
2 Canadian studies (646)
Morgan, j Ped, 2012Zappitelli, KI, 2009 1 Hungarian study
(1510)Toth, Card Anethes, 2012
Incidence: Nephrotoxins
Smyth et al, Thorax, 2008Case-control study, CF
24 AKI (UK CF Database)IV Aminoglycoside independent RF
Aminoglycosides ≥5 daysN=557
No AKI R I F0
20
40
60
80
100
pRIFLE creat
Zappitelli et al, NDT, 2011
No AKI AKI0
20
40
60
80
100
~pRIFLEcreat
McKamy et al, J Peds, 2012
? independent of ICU/other drugs?
Vancomycin ≥2 daysN=167
Increasing numbers (≥3) of NTM used
Increases risk for AKI in non-ICU children
Moffett & Goldstein, CJASN, 2011
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
Goodbye
X
~1%
~1-3%
~4%
~6%5-6%
1-2%
PD>> others
Cardiac surgery: 0 to 31%!
Incidence of D-AKI
50-60%
40-45%
36%
25-50%42-67%
52-77%
33-65%40%
50-60%
64%
11%
RRT-AKI Mortality high everywhere (almost!)
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
Confirmed in several other larger epidemiologic cohort studies
Distribution of the day of admission that subjects reached pRIFLEmax (n=123) and pRIFLE F stratum (n=31).
Characteristics, patternsAKI OCCURS EARLY
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 studiesParadigm changed
Only severe AKI, requiring RRT is of serious significance.
AKI is a marker of disease severity.
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.
PAST CURRENT
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