Septic Shock, AKI and ESRD: Lessons from the CATSS Database

Transcription

1 Septic Shock, AKI and ESRD: Lessons from the CATSS Database Anand Kumar, MD Section of Critical Care Medicine Section of Infectious Diseases University of Manitoba, Winnipeg Manitoba

2 CATSS Database Research Group Paul Ellis, MD, University Health Network, Toronto ON, Canada Yaseen Arabi, MD, King Fahad National Guard Hospital, Saudi Arabia Daniel Roberts, MD, University of Manitoba, Winnipeg MB, Canada Aseem Kumar, PhD, Laurentian University, Sudbury ON, Canada Joseph E. Parrillo, MD, Cooper Hospital/University Medical Center, Camden NJ, USA Peter Dodek, MD, St. Paul s Hospital, Vancouver BC, Canada Gordon Wood, MD, Royal Jubilee Hospital, Victoria BC, Canada Kenneth E. Wood, MD, University of Wisconsin Hospital and Clinics, Madison WI, USA Kevin Laupland, MD, Foothills Hospital, Calgary AB, Canada Andreas Kramer, MD, Brandon General Hospital, Brandon MB, Canada Bruce Light, MD, Winnipeg Regional Health Authority, Winnipeg MB, Canada Satendra Sharma, MD Winnipeg Regional Health Authority, Winnipeg MB, Canada Steve Lapinsky, MD, Mount Sinai Hospital, Toronto ON, Canada John Marshall, MD, St. Michael s Hospital, Toronto ON, Canada Sandra Dial, MD, Jewish General Hospital, Montreal QC, Canada Ionna Skrobik, MD, Hôpital Maisonneuve Rosemont, Montreal QC, Canada Gourang Patel, PharmD, Rush-Presbyterian-St. Luke s Medical Center, Chicago IL, USA Dave Gurka, MD, Rush-Presbyterian-St. Luke s Medical Center, Chicago IL, USA Sergio Zanotti, MD, Cooper Hospital/University Medical Center, Camden NJ, USA Phillip Dellinger, MD, Cooper Hospital/University Medical Center, Camden NJ, USA Dan Feinstein, MD, St. Agnes Hospital, Baltimore MD, USA Jorge Guzman, MD, Harper Hospital, Detroit MI, USA Dave Simon, MD, Rush-Presbyterian-St. Luke s Medical Center, Chicago IL, USA Nehad Al Shirawi, MD, King Fahad National Guard Hospital, Saudi Arabia John Ronald, MD, Nanaimo Regional Hospital, Nanaimo BC, Canada Sean Keenan, MD, Royal Columbian Hospital, Vancouver BC, Canada Greg Martinek, MD, Richmond Hospital, Vancouver BC, Canada Dennis Maki, MD, University of Wisconsin Hospital and Clinics, Madison WI, USA 2

3 CATSS Database Research Group (Associate Contributors) Harleena Gulati, MD, Winnipeg MB Erica Halmarstrom, MD, Winnipeg MB Robert Suppes, MD, Winnipeg MB Cheryl Peters RN, Winnipeg MB Katherine Sullivan, Winnipeg MB Rob Bohmeier, Winnipeg MB Sheri Muggaberg, Winnipeg MB Laura Kravetsky, Winnipeg MB Muhammed Ahsan, MD, Winnipeg MB Lindsey Carter, Winnipeg MB Kym Wiebe, RN, Winnipeg MB Laura Kolesar, RN, Winnipeg MB Jody Richards, Victoria BC Danny Jaswal, MD, Vancouver BC Mozdeh Bahrainian, MD, Madison WI Amrinder Singh, MD, Winnipeg MB Oliver Gutierrez, MD, Winnipeg MB Aparna Jindal, MD, Winnipeg MB Tom Kosick, MD, Vancouver BC Winnie Fu, Vancouver BC Charlena Chan, Vancouver BC Harrris Chou, Vancouver BC Jia Jia Ren, Vancouver BC Heidi Paulin, Toronto ON Farah Khan, MD, Toronto ON Runjun Kumar, Toronto ON Johanne Harvey, RN, Montreal QC Christina Kim, Montreal QC Jennifer Li, Montreal QC Latoya Campbell, Montreal QC Leo Taiberg, MD, Chicago IL Christa Schorr, RN, Camden NJ Ronny Tchokonte, MD, Detroit MI Ziad Al Memish, MD, Saudi Arabia Catherine Gonzales, RN, Saudi Arabia Norrie Serrano, RN, Saudi Arabia Sofia Delgra, RN, Saudi Arabia 3

4 Mortality (%) Crude ICU and Hospital Mortality Septic AKI ~ aor 1.54 ( ) None Sepsis Non-septic AKI Septic AKI ICU Hospital Bagshaw et al Crit Care 2008

5 Contributing Factors for AKI n=1726 Septic shock (%, n) 47.5 (820) Major surgery 34.3 (592) Cardiogenic shock 26.9 (465) Hypovolemia 25.6 (442) Drug-Induced 19.0 (328) Hepato-renal syndrome 5.7 (99) Obstructive uropathy 2.6 (45) Other 12.2 (211) Uchino et al JAMA 2005

6 15/100 ICU Admission Rates 6/ X 0.2/ /100 Hutchison et al, Crit Care 2007 Strijack et al, JASN 2009

7 Definition of AKI New definition! Developed and validated in large international cohorts. Recognition of importance of decrease in urine output

8 Question 1 How does antimicrobial delay and degree of AKI affect incidence of AKI in septic shock

9 Received Antimicrobial Therapy (%) Incidence AKI (%) cumulative AKI stratified by duration of hypotension before antimicrobials in septic shock Antimicrobial therapy AKI < >36 Time from Hypotension Onset (hrs) Bagshaw et al, Intensive Care Med, 2009:35: Bagshaw et al, Intensive Care Med, 2009:35:

10 APACHE II Score >25 (%) Severity of illness (APACHE II score 25) stratified by RIFLE category in septic shock None Risk Injury Failure RIFLE Category Bagshaw et al, Intensive Care Med, 2009:35: Bagshaw et al, Intensive Care Med, 2009:35:

11 Survival Probability Crude survival for septic shock patients stratified by severity of AKI Bagshaw et al, Intensive Care Med, 2009:35: Log-rank, p< Time (Days) No AKI RIFLE: Risk RIFLE: Injury RIFLE: Failure 14

12 Impact of AKI and time to antimicrobial therapy on outcome of septic shock Bagshaw et al, Intensive Care Med, 2009:35:

13 Question 2 How does antimicrobial delay affect AKI reversibility?

14 Definitions 1) reversible AKI = AKI of any RIFLE severity prevalent at shock diagnosis or incident at 6 hours post-diagnosis that reverses by 24 hours 2) persistent AKI=AKI prevalent at shock diagnosis and persisting during the entire 24 hours post-shock diagnosis, 3) new AKI = AKI incident between 6 and 24 hours post-shock diagnosis 4) improved AKI=AKI prevalent at shock diagnosis or incident at 6 hours post followed by improvement of AKI severity across at least one RIFLE category over the first 24 hours

15 Impact of Antimicrobial Delay on AKI Reversibility Sood et al, J Crit Care 2014:29;

16 Unadjusted HR for in-hospital mortality based on 24 hr renal function in septic shock Improved survival is noted with any degree of AKI improvement with the greatest benefit in those with reversible AKI Sood et al, J Crit Care 2014:29;

17 Crude and adjusted hazard ratio for in-hospital mortality based on 24 hr renal function status Sood et al, J Crit Care 2014:29; Mortality is lower in patients with reversible AKI compared to No AKI (referent)

18 Impact of change in creatinine over 6 and 24 hrs on mortality Sood et al, J Crit Care 2014:29;

19 Characteristics of reversible AKI in septic shock Sood et al, J Crit Care 2014:29;

20 Question 3 Is septic shock-associated AKI related to pathogen or anatomic infection site?

21 Incidence of AKI in septic shock based on pathogen Sood et al, Intensive Care Medicine 2014:40;

22 Incidence of AKI in septic shock is associated with anatomic site Sood et al, Intensive Care Medicine 2014:40;

23 Incidence of AKI in septic shock is associated with anatomic site but not pathogen Sood et al, Intensive Care Medicine 2014:40;

24 aor survival in septic shock based on anatomic site of infection Leligdowicz et al, AJRCCM 2014; 189:

25 Question 4 What are the characteristics of septic shock in patients with ESRD?

26 Differences in populations: ESRD vs. General ICU population ESRD Non-ESRD APACHEII HR RR temp bicarb lactic acid Clark et al Int Care Med 42, 2016

27 Differences in populations: ESRD vs. General ICU population Clark et al Intensive Care Med (2016) 42:

28 Microbiology of infections Clark et al Intensive Care Med (2016) 42: N=800 dialysis N = 9,614 non-dialysis

29 Anatomic location of infections Clark et al Intensive Care Med (2016) 42: N=800 dialysis N = 9,614 non-dialysis

30 Can we do anything to improve outcomes? ESRD Non-ESRD Inappropriate AbRx 20% 18.5% No appropriate AbRx 5.6% 6.4% Time to AbRx (hours posthypotension) 6.0 ( ) 5.0 ( ) Associated with mortality aor 1.07 ( ) per hour delayed Clark et al Intensive Care Med (2016) 42:

31 Antimicrobial Resistance 14.1% 9.3% Clark et al Intensive Care Med (2016) 42:

32 Survival and Time to Antimicrobial in Septic Shock in ESRD Clark et al Intensive Care Med (2016) 42:

33 Adjusted Survival ICU ESRD vs non- ESRD with septic shock Clark et al Intensive Care Med (2016) 42:

34 Summary of CATSS database studies of AKI/ESRD in Septic Shock Time to appropriate antimicrobial is closely associated with the occurrence of AKI Both time to appropriate antimicrobial and severity of AKI impact on ICU survival Early reversibility of AKI is central in survival and is also related to time to antimicrobial Anatomic infection site but not pathogen is closely related to the occurrence of AKI (pneumonia has the lowest adjusted risk) Patients with ESRD exhibit a different profile of anatomic site of infections and microbial pathogens (with more frequent resistant pathogens) than non-esrd septic shock patients