Intensive Care Medicine

, Volume 37, Issue 1, pp 68–76

Diagnostic accuracy of Doppler renal resistive index for reversibility of acute kidney injury in critically ill patients

  • Michael Darmon
  • Frédérique Schortgen
  • Frederic Vargas
  • Aissam Liazydi
  • Benoît Schlemmer
  • Christian Brun-Buisson
  • Laurent Brochard
Original

Abstract

Objectives

Diagnosing persistent acute kidney injury (AKI) as opposed to transient AKI in critically ill patients may help physicians in making treatment decisions. This diagnosis relies chiefly on urinary indices, which may be of limited value or difficult to obtain. We assessed the performance of the Doppler renal resistive index (RI) in diagnosing persistent AKI.

Design

Prospective observational study.

Setting

Twenty-four-bed medical intensive care unit in a university hospital.

Patients

Consecutive patients requiring mechanical ventilation, without severe chronic renal dysfunction or receiving diuretic therapy.

Definitions

Persistent AKI was defined as AKI lasting longer than 3 days. AKI resolving within 3 days in a patient with a cause of renal hypoperfusion was considered to be transient AKI. Results are reported as median values with interquartile range (IQR).

Measurements and main results

Of the 51 patients enrolled in the study, 16 had no AKI, 13 had transient AKI, and 22 had persistent AKI. The RI was 0.71 (0.66–0.77) in the no-AKI group, 0.71 (0.62–0.77) in the transient AKI group, and 0.82 (0.80–0.89) in the persistent AKI group (P < 0.0001). The RI was better than urinary indices for diagnosing persistent AKI. The area under the RI ROC curve was 0.91 [95% confidence interval (95% CI) 0.83–0.99; P < 0.0001]. An RI > 0.795 had a 92% sensitivity and 85% specificity for persistent AKI. Logistic regression analysis revealed that an RI > 0.795 [odds ratio (OR) 28.2; 95% CI 4.0–198] and a higher logistic organ dysfunction score (OR 1.85/point; 95% CI 1.20–2.85) predicted persistent AKI.

Conclusion

These preliminary results suggest that Doppler renal RI may be a promising tool for predicting the reversibility of AKI in critically ill patients.

Keywords

Kidney failure Acute Intensive care units Doppler Mechanical ventilation Sensitivity Specificity 

Abbreviations

AKI

Acute kidney injury

ICU

Intensive care unit

MV

Mechanical ventilation

RI

Doppler-based renal resistive index

Supplementary material

134_2010_2050_MOESM1_ESM.docx (213 kb)
Supplementary material 1 (DOCX 212 kb)

References

  1. 1.
    Brivet FG, Kleinknecht DJ, Loirat P, Landais PJ (1996) Acute renal failure in intensive care units—causes, outcome, and prognostic factors of hospital mortality; a prospective, multicenter study. French Study Group on acute renal failure. Crit Care Med 24:192–198CrossRefPubMedGoogle Scholar
  2. 2.
    Metnitz PG, Krenn CG, Steltzer H, Lang T, Ploder J, Lenz K, Le Gall JR, Druml W (2002) Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med 30:2051–2058CrossRefPubMedGoogle Scholar
  3. 3.
    Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Ronco C (2005) Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 294:813–818CrossRefPubMedGoogle Scholar
  4. 4.
    Lameire N, Van Biesen W, Vanholder R (2005) Acute renal failure. Lancet 365:417–430PubMedGoogle Scholar
  5. 5.
    Schrier RW, Wang W (2004) Acute renal failure and sepsis. N Engl J Med 351:159–169CrossRefPubMedGoogle Scholar
  6. 6.
    Esson ML, Schrier RW (2002) Diagnosis and treatment of acute tubular necrosis. Ann Intern Med 137:744–752PubMedGoogle Scholar
  7. 7.
    Gettings LG, Reynolds HN, Scalea T (1999) Outcome in post-traumatic acute renal failure when continuous renal replacement therapy is applied early vs. late. Intensive Care Med 25:805–813CrossRefPubMedGoogle Scholar
  8. 8.
    Seabra VF, Balk EM, Liangos O, Sosa MA, Cendoroglo M, Jaber BL (2008) Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis. Am J Kidney Dis 52:272–284CrossRefPubMedGoogle Scholar
  9. 9.
    Carvounis CP, Nisar S, Guro-Razuman S (2002) Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure. Kidney Int 62:2223–2229CrossRefPubMedGoogle Scholar
  10. 10.
    Miller TR, Anderson RJ, Linas SL, Henrich WL, Berns AS, Gabow PA, Schrier RW (1978) Urinary diagnostic indices in acute renal failure: a prospective study. Ann Intern Med 89:47–50PubMedGoogle Scholar
  11. 11.
    Perlmutter M, Grossman SL, Rothenberg S, Dobkin G (1959) Urine serum urea nitrogen ratio; simple test of renal function in acute azotemia and oliguria. J Am Med Assoc 170:1533–1537PubMedGoogle Scholar
  12. 12.
    Singri N, Ahya SN, Levin ML (2003) Acute renal failure. JAMA 289:747–751CrossRefPubMedGoogle Scholar
  13. 13.
    Bagshaw SM, Langenberg C, Wan L, May CN, Bellomo R (2007) A systematic review of urinary findings in experimental septic acute renal failure. Crit Care Med 35:1592–1598CrossRefPubMedGoogle Scholar
  14. 14.
    Nickolas TL, O’Rourke MJ, Yang J, Sise ME, Canetta PA, Barasch N, Buchen C, Khan F, Mori K, Giglio J, Devarajan P, Barasch J (2008) Sensitivity and specificity of a single emergency department measurement of urinary neutrophil gelatinase-associated lipocalin for diagnosing acute kidney injury. Ann Intern Med 148:810–819PubMedGoogle Scholar
  15. 15.
    Yoon DY, Kim SH, Kim HD, Na DG, Goo JM, Choi HJ, Yeon KM, Han MC (1995) Doppler sonography in experimentally induced acute renal failure in rabbits. Resistive index versus serum creatinine levels. Invest Radiol 30:168–172CrossRefPubMedGoogle Scholar
  16. 16.
    Izumi M, Sugiura T, Nakamura H, Nagatoya K, Imai E, Hori M (2000) Differential diagnosis of prerenal azotemia from acute tubular necrosis and prediction of recovery by Doppler ultrasound. Am J Kidney Dis 35:713–719CrossRefPubMedGoogle Scholar
  17. 17.
    Platt JF, Rubin JM, Ellis JH (1991) Acute renal failure: possible role of duplex Doppler US in distinction between acute prerenal failure and acute tubular necrosis. Radiology 179:419–423PubMedGoogle Scholar
  18. 18.
    Stevens PE, Gwyther SJ, Hanson ME, Boultbee JE, Kox WJ, Phillips ME (1990) Noninvasive monitoring of renal blood flow characteristics during acute renal failure in man. Intensive Care Med 16:153–158CrossRefPubMedGoogle Scholar
  19. 19.
    Lerolle N, Guerot E, Faisy C, Bornstain C, Diehl JL, Fagon JY (2006) Renal failure in septic shock: predictive value of Doppler-based renal arterial resistive index. Intensive Care Med 32:1553–1559CrossRefPubMedGoogle Scholar
  20. 20.
    Lauschke A, Teichgraber UK, Frei U, Eckardt KU (2006) ‘Low-dose’ dopamine worsens renal perfusion in patients with acute renal failure. Kidney Int 69:1669–1674CrossRefPubMedGoogle Scholar
  21. 21.
    Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, Levin A (2007) Acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury. Crit Care 11:R31CrossRefPubMedGoogle Scholar
  22. 22.
    Schortgen F, Lacherade JC, Bruneel F, Cattaneo I, Hemery F, Lemaire F, Brochard L (2001) Effects of hydroxyethylstarch and gelatin on renal function in severe sepsis: a multicentre randomised study. Lancet 357:911–916CrossRefPubMedGoogle Scholar
  23. 23.
    Le Gall JR, Klar J, Lemeshow S, Saulnier F, Alberti C, Artigas A, Teres D (1996) The logistic organ dysfunction system. A new way to assess organ dysfunction in the intensive care unit. ICU Scoring Group. JAMA 276:802–810CrossRefPubMedGoogle Scholar
  24. 24.
    Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829CrossRefPubMedGoogle Scholar
  25. 25.
    Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G (2003) 2001 American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 31:1250–1256CrossRefPubMedGoogle Scholar
  26. 26.
    Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P (2004) Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 8:R204–R212CrossRefPubMedGoogle Scholar
  27. 27.
    Bellomo R, Kellum J, Ronco C (2001) Acute renal failure: time for consensus. Intensive Care Med 27:1685–1688CrossRefPubMedGoogle Scholar
  28. 28.
    Vittinghoff E, McCulloch CE (2007) Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol 165:710–718CrossRefPubMedGoogle Scholar
  29. 29.
    Wan L, Yang N, Hiew CY, Schelleman A, Johnson L, May C, Bellomo R (2008) An assessment of the accuracy of renal blood flow estimation by Doppler ultrasound. Intensive Care Med 34:1503–1510CrossRefPubMedGoogle Scholar
  30. 30.
    Mostbeck GH, Kain R, Mallek R, Derfler K, Walter R, Havelec L, Tscholakoff D (1991) Duplex Doppler sonography in renal parenchymal disease. Histopathologic correlation. J Ultrasound Med 10:189–194PubMedGoogle Scholar
  31. 31.
    Sugiura T, Nakamori A, Wada A, Fukuhara Y (2004) Evaluation of tubulointerstitial injury by Doppler ultrasonography in glomerular diseases. Clin Nephrol 61:119–126PubMedGoogle Scholar
  32. 32.
    Splendiani G, Parolini C, Fortunato L, Sturniolo A, Costanzi S (2002) Resistive index in chronic nephropathies: predictive value of renal outcome. Clin Nephrol 57:45–50PubMedGoogle Scholar
  33. 33.
    Derchi LE, Leoncini G, Parodi D, Viazzi F, Martinoli C, Ratto E, Vettoretti S, Vaccaro V, Falqui V, Tomolillo C, Deferrari G, Pontremoli R (2005) Mild renal dysfunction and renal vascular resistance in primary hypertension. Am J Hypertens 18:966–971CrossRefPubMedGoogle Scholar
  34. 34.
    Radermacher J, Mengel M, Ellis S, Stuht S, Hiss M, Schwarz A, Eisenberger U, Burg M, Luft FC, Gwinner W, Haller H (2003) The renal arterial resistance index and renal allograft survival. N Engl J Med 349:115–124CrossRefPubMedGoogle Scholar
  35. 35.
    Deruddre S, Cheisson G, Mazoit JX, Vicaut E, Benhamou D, Duranteau J (2007) Renal arterial resistance in septic shock: effects of increasing mean arterial pressure with norepinephrine on the renal resistive index assessed with Doppler ultrasonography. Intensive Care Med 33:1557–1562CrossRefPubMedGoogle Scholar
  36. 36.
    Darmon M, Schortgen F, Leon R, Moutereau S, Mayaux J, Di Marco F, Devaquet J, Brun-Buisson C, Brochard L (2009) Impact of mild hypoxemia on renal function and renal resistive index during mechanical ventilation. Intensive Care Med 35:1031–1038CrossRefPubMedGoogle Scholar
  37. 37.
    Tublin ME, Bude RO, Platt JF (2003) Review. The resistive index in renal Doppler sonography: where do we stand? AJR Am J Roentgenol 180:885–892PubMedGoogle Scholar
  38. 38.
    Pepin MN, Bouchard J, Legault L, Ethier J (2007) Diagnostic performance of fractional excretion of urea and fractional excretion of sodium in the evaluations of patients with acute kidney injury with or without diuretic treatment. Am J Kidney Dis 50:566–573CrossRefPubMedGoogle Scholar
  39. 39.
    Joannidis M, Metnitz B, Bauer P, Schusterschitz N, Moreno R, Druml W, Metnitz PG (2009) Acute kidney injury in critically ill patients classified by AKIN versus RIFLE using the SAPS 3 database. Intensive Care Med 35:1692–1702CrossRefPubMedGoogle Scholar

Copyright information

© Copyright jointly held by Springer and ESICM 2010

Authors and Affiliations

  • Michael Darmon
    • 2
    • 3
    • 4
    • 6
    • 7
  • Frédérique Schortgen
    • 1
    • 3
  • Frederic Vargas
    • 1
    • 3
  • Aissam Liazydi
    • 2
    • 3
  • Benoît Schlemmer
    • 4
    • 5
  • Christian Brun-Buisson
    • 1
    • 2
    • 3
  • Laurent Brochard
    • 1
    • 2
    • 3
  1. 1.Medical Intensive Care Unit, Centre hospitalier Albert Chenevier-Henri Mondor Assistance Publique des Hôpitaux de Paris (AP-HP)CréteilFrance
  2. 2.Université Paris-Est CréteilCréteilFrance
  3. 3.INSERM Unit 955CréteilFrance
  4. 4.Medical Intensive Care Unit, Saint-Louis University HospitalAssistance Publique des Hôpitaux de ParisParisFrance
  5. 5.Paris-7 Paris-Diderot UniversityParisFrance
  6. 6.Medical ICUSaint-Etienne University Hospital and Saint-Etienne Medical SchoolSaint-EtienneFrance
  7. 7.Thrombosis Research Group, EA 3065Saint-Etienne University Hospital and Saint-Etienne Medical SchoolSaint-EtienneFrance

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