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Intensive Care Medicine

, Volume 35, Issue 5, pp 871–881 | Cite as

Acute kidney injury in septic shock: clinical outcomes and impact of duration of hypotension prior to initiation of antimicrobial therapy

  • Sean M. Bagshaw
  • Stephen Lapinsky
  • Sandra Dial
  • Yaseen Arabi
  • Peter Dodek
  • Gordon Wood
  • Paul Ellis
  • Jorge Guzman
  • John Marshall
  • Joseph E. Parrillo
  • Yoanna Skrobik
  • Anand Kumar
  • The Cooperative Antimicrobial Therapy of Septic Shock (CATSS) Database Research Group
Original

Abstract

Objective

To describe the incidence and outcomes associated with early acute kidney injury (AKI) in septic shock and explore the association between duration from hypotension onset to effective antimicrobial therapy and AKI.

Design

Retrospective cohort study.

Subjects

A total of 4,532 adult patients with septic shock from 1989 to 2005.

Setting

Intensive care units of 22 academic and community hospitals in Canada, the United States and Saudi Arabia.

Measurements and main results

In total, 64.4% of patients with septic shock developed early AKI (i.e., within 24 h after onset of hypotension). By RIFLE criteria, 16.3% had risk, 29.4% had injury and 18.7% had failure. AKI patients were older, more likely female, with more co-morbid disease and greater severity of illness. Of 3,373 patients (74.4%) with hypotension prior to receiving effective antimicrobial therapy, the median (IQR) time from hypotension onset to antimicrobial therapy was 5.5 h (2.0–13.3). Patients with AKI were more likely to have longer delays to receiving antimicrobial therapy compared to those with no AKI [6.0 (2.3–15.3) h for AKI vs. 4.3 (1.5–10.8) h for no AKI, P < 0.0001). A longer duration to antimicrobial therapy was also associated an increase in odds of AKI [odds ratio (OR) 1.14, 95% CI 1.10–1.20, P < 0.001, per hour (log-transformed) delay]. AKI was associated with significantly higher odds of death in both ICU (OR 1.73, 95% CI 1.60–1.9, P < 0.0001) and hospital (OR 1.62, 95% CI, 1.5–1.7, P < 0.0001). By Cox proportional hazards analysis, including propensity score-adjustment, each RIFLE category was independently associated with a greater hazard ratio for death (risk 1.31; injury 1.45; failure 1.56).

Conclusion

Early AKI is common in septic shock. Delays to appropriate antimicrobial therapy may contribute to significant increases in the incidence of AKI. Survival was considerably lower for septic shock associated with early AKI, with increasing severity of AKI, and with increasing delays to appropriate antimicrobial therapy.

Keywords

Acute kidney injury Acute renal failure Critically ill Sepsis Septic shock Mortality Incidence Multi-center 

Notes

Acknowledgment

Dr. Bagshaw is supported by a Clinical Investigator Award from the Alberta Heritage Foundation for Medical Research. Dr. Kumar received initial competitive grant support for the development of the septic shock database from Health Sciences Centre Department of Research and Health Sciences Centre Foundation. Subsequent database development was also supported through unrestricted grants from Astellas Pharma Inc., Eli-Lilly and Co., Pfizer Inc., Bayer Inc., Merck and Co., Wyeth Pharmaceuticals, Bristol-Myers Squibb Co., and Astra-Zeneca Inc.

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Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Sean M. Bagshaw
    • 1
  • Stephen Lapinsky
    • 2
  • Sandra Dial
    • 3
  • Yaseen Arabi
    • 4
  • Peter Dodek
    • 5
  • Gordon Wood
    • 6
  • Paul Ellis
    • 7
  • Jorge Guzman
    • 8
  • John Marshall
    • 9
  • Joseph E. Parrillo
    • 10
  • Yoanna Skrobik
    • 11
  • Anand Kumar
    • 12
  • The Cooperative Antimicrobial Therapy of Septic Shock (CATSS) Database Research Group
  1. 1.Division of Critical Care MedicineUniversity of AlbertaEdmontonCanada
  2. 2.Section of Critical Care MedicineMount Sinai HospitalTorontoCanada
  3. 3.Section of Critical Care MedicineSir Mortimer B. Davis Jewish General HospitalMontrealCanada
  4. 4.Department of Critical CareNational Guard HospitalRiyadhSaudi Arabia
  5. 5.Section of Critical Care MedicineSt. Paul’s Hospital, University of British ColumbiaVancouverCanada
  6. 6.Critical Care MedicineRoyal Jubilee and Victoria General Hospitals, Vancouver Island Health AuthorityVictoriaCanada
  7. 7.Department of Emergency Medicine, United Health NetworkUniversity of TorontoTorontoCanada
  8. 8.Section of Critical Care MedicineHarper Hospital, Wayne State UniversityDetroitUSA
  9. 9.Section of Critical Care MedicineSt. Michael’s HospitalTorontoCanada
  10. 10.Department of Medicine, Robert Wood Johnson Medical School, UMDNJCooper Hospital, University Medical CenterCamdenUSA
  11. 11.Section of Critical Care MedicineHôpital Maisonneuve RosemontMontrealCanada
  12. 12.Section of Critical Care Medicine, Section of Infectious Diseases, Health Sciences Centre JJ 399University of ManitobaWinnipegCanada

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