The online version of this article (doi:10.1186/cc13057) contains supplementary material, which is available to authorized users.
The authors have no financial or nonfinancial competing interests to declare.
JV coordinated the study, collected the samples, and acquired all necessary information for analysis and interpretation of the data and writing of the draft. GG was responsible for all laboratory analyses and revised the manuscript critically. EH helped including patients and revised the manuscript critically. AD helped including patients and revised the manuscript critically. RV helped designing the study and revised the manuscript critically. RV also participated in carrying out the statistical analysis. WVB conceived of the study and participated in its design and coordination and helped to draft the manuscript. WVB also performed statistical analysis. All authors read and approved the final manuscript.
The pathophysiology of acute kidney injury (AKI) in sepsis is ill defined. We investigated parameters associated with low glomerular filtration, and their predictive value to discriminate transient from intrinsic septic AKI.
In 107 sepsis patients, AKI was defined by the Risk, Injury, Failure, Loss of Kidney Function, End-stage renal disease (RIFLE) urinary output or serum creatinine criterion, or both. Transient AKI (TAKI) versus intrinsic AKI was defined as RIFLE R, I, or F on the first day evolving to no AKI or not, respectively, over the following 5 days. Fractional excretion of sodium (FENa), urea (FEUrea), and NGAL (FENGAL) at admission (d0t0), 4 (d0t4), and 24 hours (d1) was determined.
Including versus not including the urinary-output criterion of RIFLE increased AKI from 43% to 64.5%. Median uNGAL levels and FENGAL were lower in no AKI versus transient AKI when AKI was defined based on creatinine (P = 0.002 and P = 0.04, respectively), but not when based on urinary output (P = 0.9 and P = 0.49, respectively). FENa < 1% and FEUrea <35% was present in 77.3% and 63.2% of patients. Urinary NGAL was higher (P < 0.001) in those with high versus low fractional sodium excretion, but this was only in patients with transient or intrinsic AKI (P < 0.001 in subgroups), and not in patients without AKI. The negative predictive value for either intrinsic AKI or not restoring diuresis in patients with FENa > 0.36% and FEUrea > 31.5% was 92% and 94.5% respectively.
A low FENa and FEUrea is highly prevalent in the first hours of sepsis. In sepsis, oliguria is an earlier sign of impending AKI than increase in serum creatinine. A combination of a high FENa and a low FEUrea is associated with intrinsic AKI, whereas a combined high FENa and FEUrea is strongly predictive of transient AKI.
Kidney disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury Kidney Int.Suppl 2012, 2: 1-138.
Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P: 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 2004, 8: R204-R212. 10.1186/cc2872 PubMedCentralCrossRefPubMed
Fliser D, Laville M, Covic A, Fouque D, Vanholder R, Juillard L, Van BW: A European Renal Best Practice (ERBP) position statement on the Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guidelines on acute kidney injury: part 1: definitions, conservative management and contrast-induced nephropathy. Nephrol Dial Transplant 2012, 27: 4263-4272. PubMedCentralCrossRefPubMed
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 1992, 20: 864-874. 10.1097/00003246-199206000-00025
Cruz DN, Bolgan I, Perazella MA, Bonello M, de CM, Corradi V, Polanco N, Ocampo C, Nalesso F, Piccinni P, Ronco C: North East Italian Prospective Hospital Renal Outcome Survey on Acute Kidney Injury (NEiPHROS-AKI): targeting the problem with the RIFLE Criteria. Clin J Am Soc Nephrol 2007, 2: 418-425. 10.2215/CJN.03361006 CrossRefPubMed
Pepin MN, Bouchard J, Legault L, Ethier J: 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 2007, 50: 566-573. 10.1053/j.ajkd.2007.07.001 CrossRefPubMed
Darmon M, Vincent F, Dellamonica J, Schortgen F, Gonzalez F, Das V, Zeni F, Brochard L, Bernardin G, Cohen Y, Schlemmer B: Diagnostic performance of fractional excretion of urea in the evaluation of critically ill patients with acute kidney injury: a multicenter cohort study. Crit Care 2011, 15: R178. 10.1186/cc10327 PubMedCentralCrossRefPubMed
Bagshaw SM, Bennett M, Haase M, Haase-Fielitz A, Egi M, Morimatsu H, D'Amico G, Goldsmith D, Devarajan P, Bellomo R: Plasma and urine neutrophil gelatinase-associated lipocalin in septic versus non-septic acute kidney injury in critical illness. Intensive Care Med 2010, 36: 452-461. 10.1007/s00134-009-1724-9 CrossRefPubMed
Wheeler DS, Devarajan P, Ma Q, Harmon K, Monaco M, Cvijanovich N, Wong HR: Serum neutrophil gelatinase-associated lipocalin (NGAL) as a marker of acute kidney injury in critically ill children with septic shock. Crit Care Med 2008, 36: 1297-1303. 10.1097/CCM.0b013e318169245a PubMedCentralCrossRefPubMed
Hvidberg V, Jacobsen C, Strong RK, Cowland JB, Moestrup SK, Borregaard N: The endocytic receptor megalin binds the iron transporting neutrophil-gelatinase-associated lipocalin with high affinity and mediates its cellular uptake. FEBS Lett 2005, 579: 773-777. 10.1016/j.febslet.2004.12.031 CrossRefPubMed
Paragas N, Qiu A, Zhang Q, Samstein B, Deng SX, Schmidt-Ott KM, Viltard M, Yu W, Forster CS, Gong G, Liu Y, Kulkarni R, Mori K, Kalandadze A, Ratner AJ, Devarajan P, Landry DW, D'Agati V, Lin CS, Barasch J: The Ngal reporter mouse detects the response of the kidney to injury in real time. Nat Med 2011, 17: 216-222. 10.1038/nm.2290 PubMedCentralCrossRefPubMed
- Urinary output and fractional excretion of sodium and urea as indicators of transient versus intrinsic acute kidney injury during early sepsis
Wim Van Biesen
- BioMed Central
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