The Association between Renin-Angiotensin System Blockade, Premorbid Blood Pressure Control, and Acute Kidney Injury in Critically Ill Patients

Transcription

1 ICU AKI RAS A The Association between Renin-Angiotensin System Blockade, Premorbid Blood Pressure Control, and Acute Kidney Injury in Critically Ill Patients Acute Kidney Injury: AKI KDIGO ICU A 30 60% 4 1,2 AKI A A AKI A A 1 3,4 A A A Ca RAS S 5 A A RAS AKI A S 6,7 RAS AKI RAS AKI A R 8,9 8 AKI A R AKI A R ICU AKI RAS A 8 ICU A RAS A AKI A ICU A AKI A JAKID A 13ICU JAKID A 13ICU 8 A AKI 8 A JAKID RAS A A AKI A A

2 8 JAKID 4 8 ICU A A A A BMI A A A 4 8 AKI SOFA A APACHEII S CKD A AKI AKI (stage2&3/stage1& AKI) ICU A RRT AKI AKI RAS ( )A A 95% A A

3 BMI 4 8 AKI APACHEII S. CKD A A AKI

4 Figure 1.

5 Table 1. Demographics RAS n= Age Gender Body Mass Index Blood pressure before disease Antihypertensive drug RAS Antihypertensive drug except RAS Drug for diabetes mellitus Diuretic drug Chronic kidney disease Admission category Ward Selected surgery Emergency surgery Emergency room Transferred Most injured organ Cardiovascular Respiratory Gastrointestinal Central nerve Metabolic Blood Urogenital Musculoskeletal & dermatoses AKI risk within 48 hours Hypovolemia / bleeding Infection Cardiac event Antihypertensive drug except RAS n= No antihypertensive drug n=

6 Exacerbation of liver disease Contrasted computer tomography Angiography General anesthesia Nephrotoxic drug Postrenal Others No risk factor Cardiac surgery Sepsis APACHE II SOFA Vasopressor on day 1 Mechanical ventilation on day 1 Table 2. Outcome Acute kidney injury Severity of Acute kidney injury (stage2&3/stage1&non-aki) Renal replacement therapy ICU mortality Hospital mortality RAS Antihypertensive drug except RAS No antihypertensive drug

7 Table 3. Multivariable logistic regression model for acute kidney injury (AKI) 1) Odds ratio (95% CI) p value No hypertension group reference - Well-blood pressure control group with RAS Poor-blood pressure control group with RAS Well-blood pressure control group with antihypertension drug except RAS Poor-blood pressure control group with antihypertension drug except RAS No antihypertensive drug 1) Adjusting for age, gender, body mass index, drug for diabetes mellitus, diuretic drug, admission category, AKI risk within 48 hours, APACHE II, Vasopressor on day1. Table 4. Multivariable logistic regression model for acute kidney injury (AKI) among patients with Chronic kidney disease, after cardiac surgery and with sepsis 1) Chronic kidney disease Post cardiac surgery Sepsis Odds ratio p value Odds ratio p value Odds ratio p value (95% CI) (95% CI) (95% CI) No hypertension group reference - reference - reference - Well-blood pressure control group with RAS Poor-blood pressure control group with RAS Well-blood pressure control group with antihypertension drug except RAS Poor-blood pressure control group with antihypertension drug except RAS No antihypertensive drug 1) Adjusting for age, gender, body mass index, drug for diabetes mellitus, diuretic drug, admission category, AKI risk within 48 hours, APACHE II, Vasopressor on day1.

8 Table 5-1. Multivariable logistic regression model for severity of AKI 1) Odds ratio (95% CI) p value No hypertension reference - Well-blood pressure control group with RAS Poor-blood pressure control group with RAS Well-blood pressure control group with antihypertension drug except RAS Poor-blood pressure control group with antihypertension drug except RAS No antihypertensive drug 1) Adjusting for age, gender, body mass index, drug for diabetes mellitus, diuretic drug, admission category, AKI risk within 48 hours, APACHE II, Vasopressor on day1. Table 5-2. Multivariable logistic regression model for renal replacement therapy for AKI 1) Odds ratio (95% CI) p value No hypertension reference - Well-blood pressure control group with RAS Poor-blood pressure control group with RAS Well-blood pressure control group with antihypertension drug except RAS Poor-blood pressure control group with antihypertension drug except RAS No antihypertensive drug 1) Adjusting for age, gender, body mass index, drug for diabetes mellitus, diuretic drug, admission category, AKI risk within 48 hours, APACHE II, Vasopressor on day1. Reference 1. Nisula S, Kaukonen KM, Vaara ST, Korhonen AM, Poukkanen M, Karlsson S et al. FINNAKI Study Group. Incidence, risk factors and 90-day mortality of patients with acute kidney injury in Finnish intensive care units: the FINNAKI study. Intensive Care Med. 2013;39: Hoste EA, Bagshaw SM, Bellomo R, Cely CM, Colman R, Cruz DN et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med. 2015;41:

9 3. Nie S, Feng Z, Tang L, Wang X, He Y, Fang J et al. Risk Factor Analysis for AKI Including Laboratory Indicators: a Nationwide Multicenter Study of Hospitalized Patients. Kidney Blood Press Res. 2017;42: Kane-Gill SL, Sileanu FE, Murugan R, Trietley GS, Handler SM, Kellum JA. Risk factors for acute kidney injury in older adults with critical illness: a retrospective cohort study. Am J Kidney Dis. 2015;65: , 6. Yacoub R, Patel N, Lohr JW, Rajagopalan S, Nader N, Arora P. Acute kidney injury and death associated with renin angiotensin system blockade in cardiothoracic surgery: a meta-analysis of observational studies. Am J Kidney Dis. 2013;62: Shah M, Jain AK, Brunelli SM, Coca SG, Devereaux PJ, James M. Acute kidney injury in patients with sepsis and septic shock: risk factors and clinical outcomes. Yonsei Med J. 2013;54: Shi P, Li Z, Young N, Ji F, Wang Y, Moore P et al. The effects of preoperative renin-angiotensin system s on outcomes in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth. 2013;27: Tagawa M, Ogata A, Hamano T. Pre- and/or Intra-Operative Prescription of Diuretics, but Not Renin-Angiotensin-System Inhibitors, Is Significantly Associated with Acute Kidney Injury after Non-Cardiac Surgery: A Retrospective Cohort Study. PLoS One. 2015;10:e