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

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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.

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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.

Author information

Authors and Affiliations

  1. Division of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada

    Sean M. Bagshaw

  2. Section of Critical Care Medicine, Mount Sinai Hospital, Toronto, ON, Canada

    Stephen Lapinsky

  3. Section of Critical Care Medicine, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada

    Sandra Dial

  4. Department of Critical Care, National Guard Hospital, Riyadh, Saudi Arabia

    Yaseen Arabi

  5. Section of Critical Care Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada

    Peter Dodek

  6. Critical Care Medicine, Royal Jubilee and Victoria General Hospitals, Vancouver Island Health Authority, Victoria, BC, Canada

    Gordon Wood

  7. Department of Emergency Medicine, United Health Network, University of Toronto, Toronto, ON, Canada

    Paul Ellis

  8. Section of Critical Care Medicine, Harper Hospital, Wayne State University, Detroit, MI, USA

    Jorge Guzman

  9. Section of Critical Care Medicine, St. Michael’s Hospital, Toronto, ON, Canada

    John Marshall

  10. Department of Medicine, Robert Wood Johnson Medical School, UMDNJ, Cooper Hospital, University Medical Center, Camden, NJ, USA

    Joseph E. Parrillo

  11. Section of Critical Care Medicine, Hôpital Maisonneuve Rosemont, Montreal, QC, Canada

    Yoanna Skrobik

  12. Section of Critical Care Medicine, Section of Infectious Diseases, Health Sciences Centre JJ 399, University of Manitoba, 700 William Ave, Winnipeg, MB, R3E-0Z3, Canada

    Anand Kumar

Authors
  1. Sean M. Bagshaw
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  2. Stephen Lapinsky
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  3. Sandra Dial
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  6. Gordon Wood
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  7. Paul Ellis
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  8. Jorge Guzman
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  9. John Marshall
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  10. Joseph E. Parrillo
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  11. Yoanna Skrobik
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  12. Anand Kumar
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Consortia

The Cooperative Antimicrobial Therapy of Septic Shock (CATSS) Database Research Group

Corresponding author

Correspondence to Anand Kumar.

Appendix

Appendix

Additional members of the CATSS Database Research Group

Dan Roberts, MD, Health Sciences Centre, Winnipeg MB, 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

Aseem Kumar, PhD, Biomolecular Sciences, Laurentian University, Sudbury ON 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

Dave Simon, MD, Rush-Presbyterian-St. Luke’s Medical Center, Chicago IL, USA

Nehad Al Shirawi, MD, King Fahad National Guard Hospital, Saudi Arabia

Abdullah Al Shimemeri, MD, King Fahad National Guard Hospital, Saudi Arabia

Associate members of the CATSS Database Research Group

John Ronald, MD, Nanaimo Regional Hospital, Nanaimo BC, Canada

Mustafa Suleman, MD, Concordia Hospital, Winnipeg, MB

Harleena Gulati, MD, University of Manitoba, Winnipeg MB, Canada

Erica Halmarson, MD, University of Manitoba, Winnipeg MB, Canada

Robert Suppes, MD, University of Manitoba, Winnipeg MB, Canada

Cheryl Peters, University of Manitoba, Winnipeg MB, Canada

Katherine Sullivan, University of Manitoba, Winnipeg MB, Canada

Rob Bohmeier, University of Manitoba, Winnipeg MB, Canada

Sheri Muggaberg, University of Manitoba, Winnipeg MB, Canada

Laura Kravetsky, University of Manitoba, Winnipeg MB, Canada

Muhammed Wali Ahsan, MD, Winnipeg MB, Canada

Amrinder Singh, MD, Winnipeg MB Canada

Lindsey Carter, BA, Winnipeg MB, Canada

Kym Wiebe, RN, St. Boniface Hospital, Winnipeg MB, Canada

Laura Kolesar, RN, St. Boniface Hospital, Winnipeg MB, Canada

Jody Richards, Camosun College, Victoria BC, Canada

Danny Jaswal, MD, University of British Columbia, Vancouver BC, Canada

Harris Chou, BSc, of British Columbia, Vancouver BC, Canada

Tom Kosick, MD, University of British Columbia, Vancouver BC, Canada

Winnie Fu, University of British Columbia, Vancouver BC, Canada

Charlena Chan, University of British Columbia, Vancouver BC, Canada

Jia Jia Ren, University of British Columbia, Vancouver BC, Canada

Mozdeh Bahrainian, MD, Madison WI

Zial Haque, MD, Montreal QC, Canada

Heidi Paulin, University of Toronto, Toronto ON, Canada

Farah Khan, MD, Toronto ON, Canada

Runjun Kumar, University of Toronto, Toronto ON, Canada

Johanne Harvey, RN, Hôpital Maisonneuve Rosemont, Montreal QC, Canada

Christina Kim, McGill University, Montreal QC, Canada

Jennifer Li, McGill University, Montreal QC, Canada

Latoya Campbell, McGill University, Montreal QC, Canada

Leo Taiberg, MD, Rush Medical College, Chicago IL, USA

Christa Schorr, RN, Cooper Hospital/University Medical Center, Camden NJ, USA

Ronny Tchokonte, MD, Wayne State University Medical School, Detroit MI, USA

Ziad Al Memish, MD, King Fahad National Guard Hospital, Saudi Arabia

Catherine Gonzales, RN, King Fahad National Guard Hospital, Saudi Arabia

Norrie Serrano, RN, King Fahad National Guard Hospital, Saudi Arabia

Sofia Delgra, RN, King Fahad National Guard Hospital, Saudi Arabia

Special Thanks to Christine Mendez, Sheena Ablang, Debbie Friesen and Lisa Halstead for data entry

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Bagshaw, S.M., Lapinsky, S., Dial, S. et al. Acute kidney injury in septic shock: clinical outcomes and impact of duration of hypotension prior to initiation of antimicrobial therapy. Intensive Care Med 35, 871–881 (2009). https://doi.org/10.1007/s00134-008-1367-2

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