Chest
Volume 138, Issue 4, October 2010, Pages 825-832
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Original Research
Lung Infection
Incidence and Prognostic Implications of Acute Kidney Injury on Admission in Patients With Community-Acquired Pneumonia

https://doi.org/10.1378/chest.09-3071Get rights and content

Background

A consensus definition of acute kidney injury (AKI)—the risk, injury, failure, loss, and end-stage kidney disease (RIFLE) classification—predicts mortality in general hospital and ICU populations. We aimed to assess its value on admission in patients with community-acquired pneumonia (CAP).

Methods

A prospective observational study with CAP was carried out. We classified each patient according to his or her maximum RIFLE class using admission creatinine (risk, ≥ 1.5 × baseline creatinine; injury, ≥ 2 × baseline; failure, ≥ 3 × baseline; no-AKI, < 1.5 × baseline). Outcomes were 30-day mortality, requirement for mechanical ventilation and inotropic support (MV/IS), and requirement for renal replacement therapy (RRT).

Results

A total of 1,241 patients were included (no-AKI, 1,018; risk, 130; injury, 63; failure, 30). On multivariate analysis, factors predicting development of AKI include severity of pneumonia (adjusted odds ratio [AOR], 1.74; 95% CI, 1.46-2.08; P < .0001), elevated C-reactive protein (AOR, 1.04; 95% CI, 1.03-1.06; P < .0001), and prior use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin-II-receptor blockers (AIIBs) (AOR, 1.77; 95% CI, 1.19-2.58; P = .005). Adjusting for severity of pneumonia, RIFLE criteria independently predicted 30-day mortality (AOR, 1.48; 95% CI, 1.15-1.91; P = .002), requirement for MV/IS (AOR, 2.22; 95% CI, 1.74-2.83; P < .0001), and RRT (AOR, 3.20; 95% CI, 2.01-5.11; P < .0001). Prior use of ACEIs or AIIBs was not associated with adverse outcome in either the entire cohort or patients without AKI.

Conclusion

The RIFLE classification is a simple tool to assess and classify AKI on admission and independently predicts 30-day mortality and the need for MV/IS and RRT in patients with CAP.

Section snippets

Materials and Methods

A prospective observational study of consecutively unselected patients with CAP admitted to NHS Lothian University Hospitals Division (Edinburgh, Scotland) between January 2005 and January 2008 was carried out. The study was approved by the Lothian Research Ethics Committee. Patients were included in the study if they presented with a new infiltrate on chest radiograph and had three or more of the following symptoms or signs: cough, sputum production, breathlessness, pleuritic chest pain,

Results

The study population included 1,241 patients with CAP who met the study inclusion criteria. Overall, 8.9% required mechanical ventilation and inotropic support, 2.4% required renal replacement therapy, and 30-day mortality was 8.7%. Based on admission creatinine levels, 1,018 (82%) patients had no AKI. Of the 18% with AKI, 130 were assigned to the risk RIFLE classification, 63 to injury, and 30 to failure. Patients were evenly matched with regard to age, sex, and comorbidities, with the

Discussion

This study found that 18% of patients with CAP admitted to the hospital have evidence of AKI, and after adjusting for pneumonia severity, evidence of AKI on admission for CAP is independently associated with increased 30-day mortality and increased risk of requiring mechanical ventilation, inotropic support, and renal replacement therapy. We believe that this study is the first to describe the increase in morbidity and mortality associated with AKI on admission for CAP.

The assessment of AKI on

Acknowledgments

Author contributions: Dr Akram: contributed to the data collection and analysis, preparation and drafting of the manuscript, and final approval of the submitted manuscript.

Dr Singanayagam: contributed to the data collection, review of the manuscript, and final approval of the submitted manuscript.

Dr Choudhury: contributed to the data collection, review of the manuscript, and final approval of the submitted manuscript.

Dr Mandal: contributed to the data collection, review of the manuscript, and

References (29)

  • A Kuitunen et al.

    Acute renal failure after cardiac surgery: evaluation of the RIFLE classification

    Ann Thorac Surg

    (2006)
  • R Murugan et al.

    Acute kidney injury in non-severe pneumonia is associated with an increased immune response and lower survival

    Kidney Int

    (2010)
  • Z Ricci et al.

    The RIFLE criteria and mortality in acute kidney injury: A systematic review

    Kidney Int

    (2008)
  • British Thoracic Society Standards of Care Committee

    BTS guidelines for the management of community acquired pneumonia in adults

    Thorax

    (2001)
  • The British Thoracic Society and the Public Health Laboratory Service

    Community-acquired pneumonia in adults in British hospitals in 1982-1983: a survey of aetiology, mortality, prognostic factors and outcome

    Q J Med

    (1987)
  • WS Lim et al.

    Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines

    Thorax

    (2001)
  • A Liapikou et al.

    Severe community-acquired pneumonia: validation of the Infectious Diseases Society of America/American Thoracic Society guidelines to predict an intensive care unit admission

    Clin Infect Dis

    (2009)
  • LA Mandell et al.

    Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults

    Clin Infect Dis

    (2007)
  • WS Lim et al.

    Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study

    Thorax

    (2003)
  • MJ Fine et al.

    A prediction rule to identify low-risk patients with community-acquired pneumonia

    N Engl J Med

    (1997)
  • EF Daher et al.

    Acute kidney injury in an infectious disease intensive care unit - an assessment of prognostic factors

    Swiss Med Wkly

    (2008)
  • JA Kellum et al.

    Developing a consensus classification system for acute renal failure

    Curr Opin Crit Care

    (2002)
  • R Bellomo et al.

    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)
  • S Uchino et al.

    An assessment of the RIFLE criteria for acute renal failure in hospitalized patients

    Crit Care Med

    (2006)
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    This work was presented at the British Thoracic Society Winter Meeting, London, 2009. [Akram AR, Singanayagam A, Choudhury G, Mandal P, Chalmers JD, Hill AT. Acute kidney injury on admission independently predicts need for dialysis and 30-day mortality in patients with pneumonia. Thorax 2009;64(suppl 4):A62-A64.]

    Funding/Support: Dr Chalmers is supported by a Clinical Research Training Fellowship from the Medical Research Council.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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