Incidence, Outcomes, and Predictors of Subphenotypes of Acute Kidney Injury among Acute Respiratory Distress Syndrome Patients: A Prospective Observational Study

Abstract

A bstract Background Acute kidney injury (AKI) is a heterogeneous syndrome with subphenotypes. Acute kidney injury is one of the most common complications in acute respiratory distress syndrome (ARDS) patients, which influences mortality. Material and methods It was a single-center observational study on 266 ARDS patients on invasive mechanical ventilation (IMV) to determine the subphenotypes of AKI associated with ARDS. Subphenotyping was done based on the serum creatinine (SCr) trajectories from day 1 to day 5 of IMV into resolving (subphenotype 1) or non-resolving (subphenotype 2) AKI. Results Out of 266 ARDS patients, 222 patients were included for data analysis. 141 patients (63.51%) had AKI. The incidence of subphenotype 2 AKI among the ARDS cohort was 78/222 (35.13%). Subphenotype 2 AKI was significantly more among the non-survivors (87.7% vs 36.2 %, p < 0.001). Subphenotype 2 AKI was an independent predictor of mortality among ARDS patients ( p < 0.001, adjusted odds ratio 8.978, 95% CI [2.790–28.89]. AKI subphenotype 1 had higher median day 1 SCr than subphenotype 2 but lower levels by day 3 and day 5 of IMV. The median time of survival was 8 days in AKI subphenotype 2 vs 45 days in AKI with subphenotype 1 [Log-Rank (Mantel-Cox) p < 0.001]. The novel DRONE score (Driving pressure, Oxygenation, and Nutritional Evaluation) ≥ 4 predicted subphenotype 2 AKI. Conclusion The incidence of subphenotype 2 (non-resolving) AKI among ARDS patients on IMV was about 35% (vs 20% subphenotype 1 AKI), and it was an independent predictor of mortality. The DRONE score ≥4 can predict the AKI subphenotype 2. Highlights The serum creatinine trajectory-based subphenotype of AKI (resolving vs non-resolving) determines survival in ARDS patients. Non-resolving AKI subphenotype 2 is an independent predictor of mortality in ARDS. The novel DRONE score (driving pressure, oxygenation, and nutritional evaluation) ≥ 4 within 48 hours of IMV predicted the AKI subphenotype 2 among ventilated ARDS patients. How to cite this article Todur P, Nileshwar A, Chaudhuri S, Srinivas T. Incidence, Outcomes, and Predictors of Subphenotypes of Acute Kidney Injury among Acute Respiratory Distress Syndrome Patients: A Prospective Observational Study. Indian J Crit Care Med 2023;27(10):724–731.

Hemodynamics: Strangers to Lung-kidney Crosstalk in ARDS?

“…Todur et al are applauded for their prospective observational study outlining lung-kidney crosstalk as an important determinant of acute kidney injury (AKI) prognosis in a cohort of acute respiratory distress syndrome (ARDS) patients on invasive mechanical ventilation (IMV). 1 The authors’ demonstration of the role of driving pressure, oxygenation, and nutritional evaluation (DRONE) score in predicting non-resolving (subphenotype 2) AKI is noteworthy, but there do exist other facets of the research subject necessitating deliberation. 1 …”

“… 1 The authors’ demonstration of the role of driving pressure, oxygenation, and nutritional evaluation (DRONE) score in predicting non-resolving (subphenotype 2) AKI is noteworthy, but there do exist other facets of the research subject necessitating deliberation. 1 …”

“…Hence, hemodynamics per se is far from being strangers to the lung-kidney crosstalk featured in the Todur et al research. 1 Appropriate to the context, one misses an account of the systemic blood pressure targets and/or vasopressor-inotropic management in the index study. After the assessment of the cumulative data from 31 diverse studies involving a total of 5,04,535 critically ill patients, Cartin-Ceba et al associate vasopressor-inotrope use with an accentuated risk of AKI, on separate random-effects meta-analysis (odds ratio: 4.52; 95% confidence interval: 2.03, 10.05; I 2 = 92%).…”

“…With recent primary and post-hoc analytical literature (VANISH, VANCS, and ATHOS-3 randomized controlled trials) focusing on differences between the potential renal impact of norepinephrine with vasopressin in septic shock, the importance of reporting the vasopressor practices in observational studies akin to Todur et al can indeed not be undermined. 1 , 4 Of further note, the authors utilized the respective highest and the lowest 48 hours values of driving pressure and PaO 2 /FiO 2 on IMV, to compute the corresponding DRONE score while following up the serum creatinine trajectories of their patients till day 5 for AKI-subphenotype characterization, where the vasopressor-inotrope support would have also classified as a peculiarly dynamic parameter of prognostic importance. 1 To that end, it is only for the acknowledgement of the upcoming role of vasopressor quantification employing scoring systems norepinephrine equivalents (NEE), vasoactive-inotropic score (VIS), and cumulative vasopressor index), that the novel models like the MAVIC (mechanical ventilation, acute physiology and chronic health evaluation-III, vasopressors, inotropes, Charlson comorbidity index) are captivating enhanced attention for risk stratification in critical care.…”

Author Response

“…The DRONE score has the modified nutritional risk in critically ill (mNUTRIC score) as one of its components. 3 The mNUTRIC score in itself includes factors like age, acute physiology, and chronic health evaluation (APACHE II score), and sequential organ failure assessment (SOFA) score as its elements. Thus, since the APACHE II score and the SOFA score were evaluated for the calculation of the DRONE score, the hemodynamics and vasopressor requirements had to be taken into consideration.…”