Kidney Protection Strategy Adherence in Critically Ill Adults with AKI

Key Takeaways

• Complete bundle adherence was reported in 31% of patients.
• Sustained MAP optimization had the lowest component-level implementation rate at 33%.
• Adherence was associated with a lower incidence of AKD beyond day 7, a higher incidence of renal recovery at hospital discharge, and a lower incidence of RRT within 30 days; the renal recovery association remained after adjustment.

Complete implementation of a kidney protection strategy was uncommon in critically ill adults with moderate-to-severe AKI, occurring in 31% of the cohort. In a prospective study across five European centers, adherence was also associated in exploratory analyses with differences in renal outcomes. The cohort included 258 adults with KDIGO stage 2 or 3 AKI who required vasopressors, mechanical ventilation, or both.

This multicenter prospective cohort study enrolled critically ill adults with moderate-to-severe AKI, defined as KDIGO stage 2 or 3, across five centers in Europe. Patients required vasopressors and/or mechanical ventilation, reflecting a high-acuity ICU population. The cohort had a median age of 69 years, was 65% male, and had a median SOFA score of 10.

The kidney protection strategy included hemodynamic monitoring, sustained optimization of mean arterial pressure above 65 mmHg, serum creatinine monitoring, urine output monitoring, and avoidance of hyperglycemia, radiocontrast agents, and nephrotoxins when possible. Adherence was assessed within 12 hours after AKI diagnosis and tracked for 48 hours or until ICU discharge.

Complete implementation occurred in 80 patients, with a 95% CI of 25.5 to 37.2 for the cohort estimate. Adherence differed across bundle elements, with some process measures and avoidance targets delivered more consistently than others. Sustained mean arterial pressure optimization was the least frequently implemented component at 33%.

Exploratory analyses treated death as a competing risk in the renal outcomes analysis. Adherence was associated with a lower incidence of AKD beyond day 7, with an SHR of 0.64, a 95% CI of 0.41 to 0.99, and p=0.046. It was also associated with a higher incidence of renal recovery at hospital discharge, with an SHR of 6.02, a 95% CI of 4.00 to 9.05, and p<0.0001. There was also a lower incidence of RRT within 30 days, with an SHR of 0.12, a 95% CI of 0.02 to 0.91, and p=0.04.

The renal recovery association remained after multivariable adjustment, with an adjusted SHR of 6.29, a 95% CI of 3.08 to 12.85, and p<0.0001. Investigators also reported a dose-response relationship between the number of implemented components and renal outcomes across the studied endpoints.