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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 3  |  Page : 1413-1419

Prediction and outcomes of acute kidney injury in severe trauma patients


1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Internal Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission28-Dec-2021
Date of Decision16-Jan-2022
Date of Acceptance18-Jan-2022
Date of Web Publication29-Oct-2022

Correspondence Address:
Ibrahim M. S K. El Ghobashy
Al Shohda City, Menoufia Government
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_314_21

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  Abstract 


Objective
To define and determine acute kidney injury (AKI) based on the Kidney Disease Improving Global Outcome criteria in severe trauma patients, and to evaluate injury severity score (ISS) in the prediction of AKI and outcomes.
Background
Because of the great risk of AKI in severe trauma that may be life threatening especially if uncontrolled, early assessment of it reduces mortality of polytraumatized patients.
Patients and methods
This is a prospective study on 116 trauma patients, who were presented to the Emergency Department of Menoufia University Hospital from April 2019 to April 2020. ISS and the Acute Physiology and Chronic Health Evaluation scores were applied to all trauma patients.
Results
The overall incidence of AKI following trauma was 33.6%. There was no difference in patients' age, sex, and body weight between groups, whereas there was a significant difference in ISS, Glasgow coma scale, and presence of shock. In multivariate analysis, the independent risk factors associated with AKI after trauma included the ISS (odds ratio = 1.063, P < 0.05) and presence of shock (odds ratio = 0.958, P = 0.003). Renal replacement therapy was required for 11 (28.2%) patients in the AKI group. Hospital mortality rate was higher in the AKI group (23/39, 59%) than the non-AKI group (20/77, 26%; P = 0.001).
Conclusion
The development of AKI was associated with the severity of trauma, and AKI increased mortality rates.

Keywords: acute kidney injury, injury severity score, outcomes, trauma


How to cite this article:
Lolah MA, Zahran AM, El Ghobashy IM. Prediction and outcomes of acute kidney injury in severe trauma patients. Menoufia Med J 2022;35:1413-9

How to cite this URL:
Lolah MA, Zahran AM, El Ghobashy IM. Prediction and outcomes of acute kidney injury in severe trauma patients. Menoufia Med J [serial online] 2022 [cited 2024 Mar 28];35:1413-9. Available from: http://www.mmj.eg.net/text.asp?2022/35/3/1413/359497




  Introduction Top


Acute kidney injury (AKI) is a common complication of severe trauma that is independently associated with increased morbidity and mortality in patients admitted to the ICU[1].

The first studies reporting an association between AKI and acute trauma were published during the Second World War and since then there has been progressive technical and scientific development in patient care toward AKI prevention. However, establishing the risk factors for developing AKI after trauma remains crucial and may help reduce this complication, with prevention and earlier and more adequate treatment[2].

In trauma patients surviving the initial phase, a number of complications may challenge further recovery. AKI is common in critically ill patients and strongly associated with poor outcome in general. Severe trauma triggers initial AKI risk factors including hemorrhage, shock, rhabdomyolysis, traumatic inflammation, and leads to second hits due to emergency surgery or infections that may cause additional renal disorders resulting in renal function impairment. Identifying AKI risk factors after trauma is essential to establish a strategy aiming to prevent AKI and its related complications[3].

Many systems have been developed for diagnosing and staging AKI in patients. Acute Kidney Injury Network, Risk, Injury, and Failure, and Loss, and End-stage Kidney Disease, and Kidney Disease Improving Global Outcome (KDIGO) are panels with different criteria[4].

The aim of this study is to define and determine the incidence of AKI based on the KDIGO criteria in severe trauma patients admitted to the ICU, and to identify predictors of AKI and the outcomes after trauma.


  Patients and methods Top


This is a prospective study performed in Menoufia University hospitals on 116 patients, who were presented to the Emergency Department in a trauma event, Menoufia University Hospitals, during the period from April 2019 to October 2020. The study protocol was approved by the local ethics committee of the Menoufia University. Informed consent was taken from the patients or the relatives before the beginning of the study. The inclusion criteria was (a) all patients admitted to the ICU for the treatment of traumatic injury are eligible to apply for enrollment in the study, (b) age 18 years or older, (c) patients with injury severity score (ISS) greater than 15, and the exclusion criteria were (a) patients with chronic kidney disease: chronic kidney disease categories were estimated using Chronic Kidney Disease Epidemiology Collaboration equation, and chronic kidney disease categories 3, 4, and 5 'end-stage renal disease', (b) patients who underwent renal transplantation, and (c) age less than 18 years.

The study technique was as follows: after obtaining written consent each patient was subjected to the following: first, full history taking and second thorough clinical examination using the ABCDE protocol.

Primary survey (ABCDE) includes airway and cervical spine control, breathing, circulation and hemorrhage control, and disability and exposure.

Secondary survey is performed once the patient has been resuscitated and stabilized. It involves a more thorough head-to-toe examination, and the aim is to detect other significant but not immediately life-threatening injuries.

Investigation include radiological and laboratory.

Calculation of ISS: the ISS is the sum of the squares of the highest abbreviated injury score code in each of the three most severely injured ISS body regions. ISS was calculated by the abbreviated injury score, which is an anatomically based system of grading injuries on an ordinal scale ranging from 1 (minor injury) to 6 (lethal injury) and follow-up of the patients by labs and hemodynamic monitoring, and the outcomes are reviewed.

Statistical analysis

Data were collected, tabulated, and statistically analyzed by an IBM-compatible personal computer with SPSS statistical package, version 23 (SPSS Inc. Released 2015. IBM SPSS statistics for Windows, version 23.0; IBM Corp., Armonk, New York, USA).

Two types of statistical analysis were done: (a) descriptive statistics: qualitative data were expressed in number and percentage, while quantitative data were expressed as mean, SD, median, and range. (b) Analytical statistics, for example Student's t test is a test of significance used for comparison of quantitative variables between two groups of normally distributed data, while Mann–Whitney test (U) was used for comparison of quantitative variables between two groups of non-normally distributed data. χ2 test was used to study the association between qualitative variables.

Whenever any of the expected cells were less than five, Fisher's exact test was used. Overall survival analysis and disease-free survival were done using Kaplan–Meier statistics. P value: a P value of less than or equal to 0.05 was considered statistically significant.


  Results Top


The study was conducted on 116 patients; the mean age of patients presented to Eergency Department in a trauma event was 37.28 ± 14.30 where males were more than females (88 and 28, respectively) and some patients had comorbidities that affected their outcomes. The AKI incidence was 33.6% (N = 39). The mechanism of injury in the studied patients, most of them presented in blunt trauma (94.8%). In the primary triage of patients, the mean ± SD of respiratory rate, mean arterial pressure (MAP), pulse, Glasgow coma score (GCS) was 20.5 ± 5.11, 77.55 ± 22.91, 97.45 ± 27.26, and 9.85 ± 4.7, respectively, and that of ISS and the Acute Physiology and Chronic Health Evaluation (APACHE) was 29.91 ± 10.97 and 13.08 ± 7.64 respectively, and the follow-up of all studied patients was done in the ICU [Table 1].
Table 1: Sociodemographic characteristics, medical history, and trauma characteristics of the studied group (n=116)

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The duration of stay in the ICU ranged from 2 to 38 days, about 9.5% of patients needed dialysis. Most of the patients treated by mechanical ventilation (MV), mannitol, vasopressors, and 49.1% had undergone surgical operations [Table 2]. There is a highly significant difference between AKI and non-AKI patients in initial MAP as the P value less than 0.001 and significant difference between them regarding admission GCS, APACHE score, and ISS as P value less than 0.05 [Table 3]. There was a highly significant difference between AKI and non-AKI patients; sepsis patients needed dialysis; MV was using vasopressors and mortality as the P value less than 0.001 and significant difference between them regarding patients needing surgical operations; those treated by mannitol, and ICU length of stay with a P value less than 0.05. AKI patients remained for a longer period in the ICU [Table 4].
Table 2: Treatment and outcomes of the studied population (n=116)

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Table 3: Comparison between acute kidney injury and non-acute kidney injury cases regarding clinical and trauma characteristics

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Table 4: Comparison between acute kidney injury and non-acute kidney injury cases regarding treatment and outcomes

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In univariate logistic regression the number of comorbidities, ISS, GCS, MAP at the time of admission, volume expanding using hydroxyethyl starch, white blood cells, renal functions, MV, treatment with mannitol, vasoactive drugs, acid–base balance, creatine kinase (CK) level, acquired sepsis, and receipt of trauma surgery were all associated with AKI. In the multivariable regression analysis the ISS [odds ratio (OR)=1.063, P = 0.014], MAP at the time of admission (OR = 0.958, P = 0.003), serum potassium (OR = 4.120, P = 0.040), CK level (OR = 1.012, P < 0.001), serum urea (OR = 0.149, P = 0.001), and acquired sepsis (OR = 11.610, P = 0.011) remained independent risk factors for AKI [Table 5].
Table 5: Univariate and multivariate logistic regression for predictors of acute kidney injury development

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Cox regression analysis shows a highly significant correlation between patients who developed AKI, APACHE score, and mortality as P value less than 0.001 and a significant correlation between patients who need MV and mortality as P value less than 0.05.


  Discussion Top


The study included 116 patients presented to the Emergency Department in a trauma event. This study describes the incidence, risk factors, and outcomes of AKI, as defined by the KDIGO criteria, in a population of injured patients. Of the patients, 33.6% developed AKI following injury, with 9.5% requiring RRT. Independent risk factors for trauma-induced AKI were greater injury severity, shock, sepsis, and higher admission serum K, CK, and urea.

Furthermore, the development of AKI was an independent risk factor for death and was associated with an increase in mortality.

There is wide variability in the published incidence rates of AKI following trauma. Incidence rates as low as 0.54% and as high as 50% have been reported, Heegard et al.[5].

The mean age of these patients was 37.28 ± 14.30, where males were more than females (88 and 28, respectively). In the results reported by Eriksson et al.[1], the female/male ratio was 91/322.

It was observed that 94.8% of patients presented by blunt trauma. This is similar to Sharma et al.[6], who said that the most common mechanism of injury was blunt trauma.

The mean ± SD of respiratory rate, MAP, pulse, GCS was 20.5 ± 5.11, 77.55 ± 22.91, 97.45 ± 27.26, and 9.85 ± 4.7, respectively, and that of ISS and APACHE was 29.91 ± 10.97 and 13.08 ± 7.64, respectively, and the follow-up of all studied patients were done in the ICU. Similarly to the results reported by Uchino et al.[7], it was observed that there was nonsignificant difference between AKI and non-AKI patients regarding age, gender, weight, some of the chronic diseases. This is in agreement with the study conducted by Jheong et al.[8], who reported that there was no difference in the age of the patients, sex, and body weight between groups.

ISS and admission systolic blood pressure were identified as independent risk factors for the development of AKI, similar to the results reported by Perkins et al.[9].

In our study, there was a highly significant difference between AKI and non-AKI patients in initial MAP as the P value less than 0.001 and significant difference between them regarding admission GCS, APACHE score, and ISS as the P value less than 0.05. This meant that high ISS represents the risk factors for AKI. Eriksson et al.[1] reported that the risk factors for AKI were male sex, age, nondiabetic comorbidity, diabetes mellitus, ISS greater than 40, massive transfusion, and volume loading with hydroxyethyl starch within the first 24 h.

In multivariate analysis, the independent risk factors associated with AKI after trauma included the ISS (OR = 1.063, P = 0.014), presence of shock (MAP) (OR = 0.958, P = 0.003), serum K (OR = 4.120, P = 0.040) and urea (OR = 0.149, P = 0.001). Similarly the multivariate analysis of the study conducted by Jheong et al.[8] reported that the risk factors associated with AKI after trauma included the ISS (OR = 1.065, P < 0.01), presence of shock (OR = 3.949, P = 0.012), and severe rhabdomyolysis (OR = 4.475, P < 0.01).

There was highly significant difference between AKI and non-AKI patients in outcomes regarding patients who needed dialysis (11 of AKI ones and no patients in non-AKI) MV, and ICU length of stay as the P value less than 0.05. This is similar to the outcomes reported by Skinner et al.[10].

The mortality rate in AKI and non-AKI groups was 59 and 26%, respectively, which is in agreement with the studies conducted by Jheong et al.[8], where the hospital mortality rate was higher in the AKI group (5/21, 23%) than the non-AKI group (3/301, 1%; P < 0.01).

It was noted in this study that a highly significant correlation between patients who developed AKI, APACHE score, and mortality as the P value less than 0.001 and significant correlation between patients who needed MV and mortality as the P value less than 0.05, and this meant that outcomes worsened with increased score. This is in agreement with the studies conducted by Gabbe et al.[11] and Elbaih et al.[12], where they concluded that there is a significant relationship between outcome and the scores used.

The mortality rate in our study was high. We believe that this was due to the severity of the studied cases that necessitate ICU admission.

The main limitation of the study is that it was conducted in a single center and with a limited number of patients.


  Conclusion Top


The development of AKI was associated with the severity of trauma, and AKI increased the mortality rates. Because of the high mortality rates, prevention of AKI in severe trauma patients is important. The risk factors for posttraumatic AKI identified in the present study may help the provision of future strategies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Eriksson M, Brattstrom O, Martensson J, Larsson E, Oldner A. Acute kidney injury following severe trauma: Risk factors and long-term outcome. J Trauma Acute Care Surg 2015; 79:407–412.  Back to cited text no. 1
    
2.
Baker SP, O'Neill B, Haddon W, Long WB. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974; 14:187–196.  Back to cited text no. 2
    
3.
Harrois A, Soyer B, Gauss T, Hamada S, Raux M, Duranteau J, Traumabase Group. Prevalence and risk factors for acute kidney injury among trauma patients: a multicenter cohort study. Crit Care 2018; 22:344.  Back to cited text no. 3
    
4.
Akcan-Arikan A, Zappitelli M, Loftis LL, Washburn KK, Jefferson LS, Goldstein SL. Modified RIFLE criteria in critically ill children with acute kidney injury. Kidney Int 2007; 71:1028.  Back to cited text no. 4
    
5.
Heegard KD, Stewart IJ, Cap AP, Sosnov JA, Kwan HK, Glass KR, et al. Early acute kidney injury in military casualties. J Trauma Acute Care Surg 2015; 78:988–993.  Back to cited text no. 5
    
6.
Sharma A, Shaitan S, Vijay V, Parul Y. A study to validate thoracic trauma severity score in chest trauma patients. Int Surg J 2020; 7:5.  Back to cited text no. 6
    
7.
Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 2005; 294:813–818.  Back to cited text no. 7
    
8.
Jheong J, Hong S, Kim T. Acute kidney injury after trauma: risk factors and clinical outcomes. J Acute Care Surg 2020; 10:90–95.  Back to cited text no. 8
    
9.
Perkins ZB, Captur G, Bird R, Gleeson L, Singer B, O'Brien B. Trauma induced acute kidney injury. PLoS One 2019; 14:e0211001.  Back to cited text no. 9
    
10.
Skinner DL, Hardcastle TC, Rodseth RN, Muckart DJ. The incidence and outcomes of acute kidney injury amongst patients admitted to a level I trauma unit. Injury 2013; 45:259–264.  Back to cited text no. 10
    
11.
Gabbe BJ, Magtengaard K, Hannaford AP, Cameron PA. Is the Charlson Comorbidity Index useful for predicting trauma outcomes?. Acad Emerg Med 2005; 12:318–321.  Back to cited text no. 11
    
12.
Elbaih A, Islam Elshaboury I, Kalil N, El-Aouty H. Evaluation of thoracic trauma severity score in predicting the outcome of isolated blunt chest trauma patients. Int J Surg Med 2016; 2:100–106.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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