Prevalence and risk factors for acute kidney injury among trauma patients: a multicenter cohort study

Abstract

Background: Organ failure, including acute kidney injury (AKI), is the third leading cause of death after bleeding and brain injury in trauma patients. We sought to assess the prevalence, the risk factors and the impact of AKI on outcome after trauma.

Methods: We performed a retrospective analysis of prospectively collected data from a multicenter trauma registry. AKI was defined according to the risk, injury, failure, loss of kidney function and end-stage kidney disease (RIFLE) classification from serum creatinine only. Prehospital and early hospital risk factors for AKI were identified using logistic regression analysis. The predictive models were internally validated using bootstrapping resampling technique.

Results: We included 3111 patients in the analysis. The incidence of AKI was 13% including 7% stage R, 3.7% stage I and 2.3% stage F. AKI incidence rose to 42.5% in patients presenting with hemorrhagic shock; 96% of AKI occurred within the 5 first days after trauma. In multivariate analysis, prehospital variables including minimum prehospital mean arterial pressure, maximum prehospital heart rate, secondary transfer to the trauma center and data early collected after hospital admission including injury severity score, renal trauma, blood lactate and hemorrhagic shock were independent risk factors in the models predicting AKI. The model had good discrimination with area under the receiver operating characteristic curve of 0.85 (0.82-0.88) to predict AKI stage I or F and 0.80 (0.77-0.83) to predict AKI of all stages. Rhabdomyolysis severity, assessed by the creatine kinase peak, was an additional independent risk factor for AKI when it was forced into the model (OR 1.041 (1.015-1.069) per step of 1000 U/mL, p < 0.001). AKI was independently associated with a twofold increase in ICU mortality.

Conclusions: AKI has an early onset and is independently associated with mortality in trauma patients. Its prevalence varies by a factor 3 according to the severity of injuries and hemorrhage. Prehospital and early hospital risk factors can provide good performance for early prediction of AKI after trauma. Hence, studies aiming to prevent AKI should target patients at high risk of AKI and investigate therapies early in the course of trauma care.

Keywords: Acute kidney injury; Hemorrhagic shock; Organ failure; Renal failure; Rhabdomyolysis; Trauma.

Fig. 1

a Receiver operating characteristics (ROC) curves for prediction of acute kidney injury (AKI) (stage I or F) with Injury Severity Score (ISS) (AUC = 0.79 (0.75–0.83)), blood lactate (AUC = 0.77 (0.73–0.81)), Creatine kinase (CK) peak (AUC = 0.73 (0.69–0.78)), minimum prehospital mean arterial pressure (MAP) (AUC = 0.70 (0.65–0.75)) and maximum prehospital heart rate (HR) (AUC = 0.66 (0.61–0.71)). The multivariate model includes the following variables: presence of hemorrhagic shock, blood lactate, minimum prehospital MAP, maximum prehospital heart rate, ISS and secondary transfer to a trauma center (Table 4). The AUC-ROC of the multivariate model is 0.85 (0.82–0.88). b ROC curves for prediction of AKI (stage R, I or F) with ISS (AUC = 0.76 (0.73–0.78)), blood lactate (AUC = 0.70 (0.67–0.73)), CK peak (AUC = 0.68 (0.65–0.71)), minimum prehospital MAP (AUC = 0.68 (0.65–0.71)). The multivariate model includes the following variables: presence of hemorrhagic shock, blood lactate, minimum prehospital MAP, ISS, secondary transfer to a trauma center and presence of severe renal trauma (Additional file 3). The AUC-ROC of the multivariate model is 0.80 (0.78–0.83)