what did we aim to learn from the finnaki -study · • the aims of the study – incidence of aki...
TRANSCRIPT
![Page 1: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/1.jpg)
What did we aim to learn fromthe FINNAKI -study
Maija Kaukonen, MD, PhD, EDICSpecialist in anesthesiology and intensive care
Specialist in clinical phramacologyIntensive Care Units, Division of Anaesthesia
and Intensive Care Medicine,Helsinki University Central Hospital, Helsinki, Finland
![Page 2: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/2.jpg)
Acute Kidney Injury -AKI
• Definition and classification of AKI:RIFLE 2004, AKIN 2007, KDIGO2012
• These criteria are based inmeasurements of serum creatinine orurine output
![Page 3: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/3.jpg)
RIFLE & AKIN & KDIGO
KDIGO 2012
20072004
0.3 mg/dl =26 umol/L
0.5 mg/dl =44 umol/L
4 mg/dl =354 umol/L
![Page 4: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/4.jpg)
AKIN vs. RIFLE
Joannidis et al. ICM 2009
![Page 5: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/5.jpg)
AKIN vs. RIFLE
Joannidis et al. ICM 2009
• RIFLE: 9% of patients unrecognised thatwere recognised by AKIN– 90% of thse were AKIN Stage 1 patients
• AKIN: 26.9% of patients unrecognised thatwere recognised by RIFLE– 30% of these were RIFLE I– 18% of these were RIFLE F
![Page 6: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/6.jpg)
AKI progression
![Page 7: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/7.jpg)
Creatinine as marker for AKI
• Limitations of creatinine• Slow and lateincrease in AKI• Largeinterindividualvariation (age, musclemass etc.)• Is affectedbyfluidbalance
(dehydration&volumeoverload)• Is notspecific for tubularinjury• Increasesonlyaftersignificantloss of GFR• Is a poorprognosticmarker
![Page 8: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/8.jpg)
AKI biomarkers
Bagshaw SM. Bellomo R. Et al. Canadian Journal of Anaesthesia; 2Bagshaw SM. Bellomo R. Et al. Canadian Journal of Anaesthesia; 2010010..
![Page 9: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/9.jpg)
AKI biomarkers
Devarajan, P. Nephrology 2010Devarajan, P. Nephrology 2010
![Page 10: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/10.jpg)
Subclinical AKI
Haase, Devarajan et al.Haase, Devarajan et al. J Am Coll Cardiol. 2011 Apr 26;57(17):1752J Am Coll Cardiol. 2011 Apr 26;57(17):1752--61.61.
![Page 11: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/11.jpg)
Population-based incidence of hospital treated AKI:
Ali, 2007: 2147 / million / year(RIFLE, retrospective, one region, Scotland, population of 523,390)
Population-based incidence of ICU treated AKI:
Cartin-Ceba, 2011: 2900 / million / year(RIFLE, retrospective, one county area USA, population of 124,277)
Population-basedincidence of AKI
![Page 12: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/12.jpg)
AKI incidence –ICU patients
AKI %
Cruz 2007 (2164) 10.8
Thakar 2009 (323 359) 22.0
Joannidis 2009 (16 784) 28.5
Ostermann 2007 (41 972) 35.8
Bagshaw 2008 (120 123) 37.1
Hoste 2006 (5383) 67.2
![Page 13: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/13.jpg)
AKI long-term prognosis
Wald, R., R. R. Quinn, et al. JAMA 2009Wald, R., R. R. Quinn, et al. JAMA 2009..
![Page 14: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/14.jpg)
AKI mortalityAKI mortality
AKIHospital
Mortality%
Stage 3 /RIFLE FHospitalMortality
%
AKILong-termmortality
Hoste 2006 (5383) 13.3 26.3 -
Ostermann 2007 (41 972) 56.8 -
Bagshaw 2008 (120 123) 24.5 32.6 -
Joannidis 2009 (16 784) 36.4 41.2 -
![Page 15: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/15.jpg)
AKI –genetics
• AngiotensinConvertingenzyme I/D geneticpolymorphism– 180 ICU patients, association with AKI (RIFLE –criteria)
• Hypoxia-inducedfactor 1– 241 patientswith AKI– Association withdiseaseseverity and outcome
• TNF alpha and IL 10 genepromotorpolymorphisms– 61 patientswithacuterenalfailurerequiringhemodialysis– Association withincreasedmortality
du Cheyron D, Fradin S, Ramakers M, et al. Angiotensinconvertingenzyme I/D geneticpolymorphism: Itsimpact on renalfunction in criticallyillpatients. CritCareMed2008;36:3178-83Kolyada AY, Tighiouart H et al. A geneticvariant of hypoxia-induced factor-1a is associatedwithadverseoutcomes in acutekidneyinjury. KidneyInt 2009; 75:1322-1329.Jaber BL, RaoMadhumathi, Guo D et al. Cytokinegenepromoterpolymorphisms and mortality in acuterenalfailure. Cytokine 2004; 25:212-219
![Page 16: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/16.jpg)
FINNAKI
• AKI study• RRT –substudy• Finnsepsis II• Genetic substudy• Cardiac surgery substudy
![Page 17: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/17.jpg)
FINNAKI
RRT –substudy
FINNSEPSIS II
Genetic study
Cardiac surgerysubstudy
RRT outsideICU
Study population
![Page 18: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/18.jpg)
ICU admission
AKI study
Excludedpatients
Cardiac surgerysubstudy
Geneticsubstudy RRT -substudy
RRT –treated AKIpatientsoutside ICU
FINNSEPSIS II
Patientflow
![Page 19: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/19.jpg)
• The aims of the study– Incidence of AKI in ICU and in Finnish population– Risk factors for AKI– Outcome of AKI
Renal recoveryMortality (90 –day, 6 month, 12 month, 5 –year)Quality of life after AKICost-utility of the treatment of AKI
– The mechanism of AKI; apoptosis/endothelial damage andinflammatory markers (eg. P-DNA, MMP-2, MMP-8, MMP-9,IL-6, TIMP-1, TIMP-2, PINP, PIIINP ja ICTP, caspases)
– New biomarkers of AKIPredictive value for AKI, RRT –treatment and mortality(e.g. P-/U-NGAL, U-NAG, U-KIM-1, U-IL-18)
FINNAKI
![Page 20: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/20.jpg)
RRT –substudy
• Incidence of RRT treatment in FinnishICUs– Riskfactors for RRT treatment in ICU– Description of RRT– Outcomeof AKI
• Incidence of RRT –treated AKI outside ICUs– All AKI –patientsincludedifnephrologicalconsultation is
asked for the need of renalreplacementtherapy– Description of RRT– Outcome of AKI
![Page 21: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/21.jpg)
• Incidence of septic AKI in ICU and inFinnishpopulation
• Riskfactors for septic AKI• Outcomeof septic AKI
RenalrecoveryMortality (90 –day, 6 month, 12 month, 5 –year)Quality of life afterseptic AKICost-utility of the treatment of septic AKI
• Biomarkers of septic AKI
FINNSEPSIS II -substudy
![Page 22: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/22.jpg)
• Incidence and interrelation of cardiac injuryand AKI measured with new cardiac biomarkers
• Correlation of acute kidney injury biomarkersand cardiac injury biomarkers with risk scoring(Euroscore, Syntax), morbidity and mortality
Cardiac surgery substudy
![Page 23: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/23.jpg)
FINNAKIFINNAKI
Under 18 yearsElective admission < 24hOn chronic RRTOrgan donorInitiation of chronic RRTDeclined / No consentNonresidentPreviously in study with RRTOver 5 days in study in another ICUIntermediate care
Emergency admissionElective admission >24 h
InclusionInclusion ExclusionExclusion
![Page 24: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/24.jpg)
• Demographics• Screening of riskfactors for AKI for 5• Screening of severesepsis/ septicshock for 5 days• DetailledRRT data• Hemodynamic data as 5 min median values for the whole
ICU stay (electronicalcollection)• Laboratoryvalues and vasoactivetreatment for the whole
ICU stay (electronicalcollection)• Laboratorysampling: Bloodand urine sampling0 h, 12 h,
24 h, 36 h, 48 h, day 3, day 5
Collection of data
![Page 25: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/25.jpg)
• Studyprotocolpreparation in 2010• Pilotstudy 3.-4.5.2011• Patientrecruitment 1.9.2011-1.2.2012
– Extension for severesepsispatients and RRT –patients to 30.04.2012
• Cardiacsurgerysubstudyrecuritmentup to21.06.2012
FINNAKI –execution
![Page 26: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/26.jpg)
• 5853 ICUadmissionsduringpatientrecruitmentperiod• 2901 ICU patientsincluded inFINNAKI• 2825 patients in geneticsubstudy• 918 patients in FINNSEPSIS II• 367 patients in RRT substudy
• 296 patients in ICUs• 71 patientstreated outside ICUswith RRT for AKI
• Cardiacsurgerysubstudyrecruitment isongoing (400 patientsrecruited28.05.)
FINNAKI
![Page 27: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/27.jpg)
FINNAKI –near future
• Population –basedincidence of AKI• RRT -substudy• FINNSEPSIS II
![Page 28: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/28.jpg)
FINNAKI - biomarkers
• Earlierdiagnosis of AKI in future– Validationof new biomarkers in unselected ICU
patientcohort– NGAL, IL-18, KIM1
• Biomarkerpanelfor diagnosing AKI inunselected ICU patients?
• Progress and resolutionof AKI in light ofnew biomarkers?
• Biomarker –guided new RCTs?
![Page 29: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/29.jpg)
FINNAKI –long termevaluation
• Long-termmortality: 1 and 5 years• Quality of life after AKI• Cost-effectivenessanalysis of AKI
![Page 30: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/30.jpg)
Central Finland Central Hospital: Raili Laru-Sompa, Anni Pulkkinen, Minna Saarelainen, Mikko Reilama, SinikkaTolmunen, Ulla Rantalainen, Marja Miettinen
East Savo Central Hospital: Markku Suvela, Katrine Pesola, Pekka Saastamoinen, Sirpa KauppinenHelsinki University Central Hospital: Ville Pettilä, Kirsi-Maija Kaukonen, Anna-Maija Korhonen, Sara Nisula, Suvi Vaara,
Raili Suojaranta-Ylinen, Leena Mildh, Mikko Haapio, Laura Nurminen, Sari Sutinen, Leena Pettilä, Helinä Laitinen,Heidi Syrjä, Kirsi Henttonen, Elina Lappi, Hillevi Boman
Jorvi Central Hospital: Tero Varpula, Päivi Porkka, Mirka Sivula Mira Rahkonen, Anne Tsurkka, Taina Nieminen, NiinaPrittinen.
Kanta-Häme Central hospital: Ari Alaspää, Hanna Juntunen, Teija SanisaloKuopio University Hospital: Ilkka Parviainen, Ari Uusaro, Esko Ruokonen, Stepani Bendel, Niina Rissanen, Maarit Lång,
Sari Rahikainen, Saija Rissanen, Merja Ahonen, Elina Halonen, Eija VaskelainenLapland Central Hospital: Meri Poukkanen, Esa Lintula, Sirpa SuominenLänsi Pohja Central Hospital: Jorma Heikkinen, Timo Lavander, Kirsi Heinonen, Anne-Mari Juopperi,Middle Ostrobothnia Central Hospital: Tadeusz Kaminski, Fiia Gäddnäs, Tuija Kuusela, Jane RoikoNorth Karelia Central Hospital: Sari Karlsson, Matti Reinikainen, Tero Surakka, Helena Jyrkönen, Tanja Eiserbeck,
Jaana KallinenSatakunta Hospital district: Vesa Lund, Päivi Tuominen, Pauliina Perkola, Riikka Tuominen, Marika Hietaranta, Satu
JohanssonSouth Karelia Central Hospital: Seppo Hovilehto, Anne Kirsi, Pekka Tiainen, Tuija Myllärinen, Pirjo Leino, Anne
ToropainenTampere University Hospital: Jyrki tenhunen, Anne Kuitunen, Ilona Leppänen, Markus Levoranta, Sanna Hoppu, Jukka
Sauranen, Atte Kukkurainen, Samuli Kortelainen, Simo VarilaTurku University Hospital: Outi Inkinen, Niina Koivuviita, Jutta Kotamäki, Anu LaineOulu University Hospital: Tero Ala-Kokko, Jouko Laurila, Sinikka SälkiöVaasa Central Hospital: Simo-Pekka Koivisto, Raku Hautamäki, Maria Skinnar
Study GroupStudy Group
![Page 31: What did we aim to learn from the FINNAKI -study · • The aims of the study – Incidence of AKI in ICU and in Finnish population – Risk factors for AKI – Outcome of AKI Renal](https://reader033.vdocuments.mx/reader033/viewer/2022050218/5f63acd048df9737e94754d1/html5/thumbnails/31.jpg)