aki itself epidemiology michael zappitelli, md, msc montreal children's hospital mcgill...

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

THANK YOU