Elsevier

The Lancet

Volume 387, Issue 10032, 14–20 May 2016, Pages 2017-2025
The Lancet

Articles
Recognition and management of acute kidney injury in the International Society of Nephrology 0by25 Global Snapshot: a multinational cross-sectional study

https://doi.org/10.1016/S0140-6736(16)30240-9Get rights and content

Summary

Background

Epidemiological data for acute kidney injury are scarce, especially in low-income countries (LICs) and lower-middle-income countries (LMICs). We aimed to assess regional differences in acute kidney injury recognition, management, and outcomes.

Methods

In this multinational cross-sectional study, 322 physicians from 289 centres in 72 countries collected prospective data for paediatric and adult patients with confirmed acute kidney injury in hospital and non-hospital settings who met criteria for acute kidney injury. Signs and symptoms at presentation, comorbidities, risk factors for acute kidney injury, and process-of-care data were obtained at the start of acute kidney injury, and need for dialysis, renal recovery, and mortality recorded at 7 days, and at hospital discharge or death, whichever came earlier. We classified countries into high-income countries (HICs), upper-middle-income countries (UMICs), and combined LICs and LMICs (LLMICs) according to their 2014 gross national income per person.

Findings

Between Sept 29 and Dec 7, 2014, data were collected from 4018 patients. 2337 (58%) patients developed community-acquired acute kidney injury, with 889 (80%) of 1118 patients in LLMICs, 815 (51%) of 1594 in UMICs, and 663 (51%) of 1241 in HICs (for HICs vs UMICs p=0.33; p<0.0001 for all other comparisons). Hypotension (1615 [40%] patients) and dehydration (1536 [38%] patients) were the most common causes of acute kidney injury. Dehydration was the most frequent cause of acute kidney injury in LLMICs (526 [46%] of 1153 vs 518 [32%] of 1605 in UMICs vs 492 [39%] of 1260 in HICs) and hypotension in HICs (564 [45%] of 1260 vs 611 [38%%] of 1605 in UMICs vs 440 [38%] of 1153 LLMICs). Mortality at 7 days was 423 (11%) of 3855, and was higher in LLMICs (129 [12%] of 1076) than in HICs (125 [10%] of 1230) and UMICs (169 [11%] of 1549).

Interpretation

We identified common aetiological factors across all countries, which might be amenable to a standardised approach for early recognition and treatment of acute kidney injury. Study limitations include a small number of patients from outpatient settings and LICs, potentially under-representing the true burden of acute kidney injury in these areas. Additional strategies are needed to raise awareness of acute kidney injury in community health-care settings, especially in LICs.

Funding

International Society of Nephrology.

Introduction

In high-income countries (HICs), progress in acute kidney injury epidemiology (especially in the critically ill population) has translated into improved prevention, diagnosis, and treatment of acute kidney injury.1 However, in low-income countries (LICs) and lower-middle-income countries (LMICs), epidemiology of acute kidney injury is poorly described.2, 3, 4 In these countries, low availability of resources and inadequate health infrastructure are associated with poor recognition and treatment of acute kidney injury. In LICs and LMICs (LLMICs), the few available studies suggest that a substantial proportion of acute kidney injury cases and their adverse clinical effects could be prevented or attenuated.2

The International Society of Nephrology's 0by25 acute kidney injury initiative aims to prevent all avoidable deaths from acute kidney injury worldwide by 2025.5 As an initial step, we did a Global Snapshot during a 10-week period in 2014 to assess the range of acute kidney injury seen by physicians in different settings worldwide.6 We postulated that differences in risk factors, exposures, and resources available for non-dialytic and dialytic management and follow-up would be associated with dissimilar acute kidney injury outcomes in different settings and countries.

Section snippets

Study design and participants

The International Society of Nephrology Global Snapshot is a multinational, observational cross-sectional study. We recruited physicians by open invitation via the International Society of Nephrology and partnering nephrology and critical care societies, announcements at national and international meetings, a dedicated website for 0by25, and individual contacts between June 1 and Dec 1, 2014. We recruited 322 providers from 72 countries. Physician participation was voluntary, without financial

Results

322 providers from 289 centres across 72 countries participated in the Global Snapshot (appendix). 27 981 patients were screened for eligibility and data were entered for 3664 adult and 354 paediatric patients with acute kidney injury (figure). 145 (45%) providers were from HICs, 91 (28%) from UMICs, and 85 (26%) from LLMICs (table 1). Data from LICs are presented separately (appendix pp 9–14). 124 (43%) of 289 participant centres were university hospitals and 249 (77%) of the 322 providers

Discussion

Our study is the first worldwide, prospective cross-sectional study designed to assess similarities and differences in recognition and management of acute kidney injury in different health-care settings (community, hospital, ICU, and non-ICU) across six continents. We developed this study to provide baseline evidence for the International Society of Nephrology's 0by25 initiative targeting preventable deaths from acute kidney injury.2 In view of the paucity of information about the natural

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