Multiple-center evaluation of mortality associated with acute kidney injury in critically ill patients: a competing risks analysis
Christophe Clec'h , Frederic Gonzalez, Alexandre Lautrette, Moliere Nguile-Makao, Maite Garrouste-Orgeas, Samir Jamali, Dany Goldgran-Toledano, Adrien Descorps-Declere, Frank Chemouni, Rebecca Hamidfar-Roy, Elie Azoulay and Jean-Francois Timsit
Critical Care 2011, 15:R128doi:10.1186/cc10241
Introduction: To assess the association between acute kidney injury (AKI) and mortality in critically ill patients using an original competing risks approach.Methods : Unselected patients admitted between 1997 and 2009 to 13 French medical or surgical intensive care units were included in this observational, cohort study. AKI was defined according to the RIFLE criteria. The following data were recorded: baseline characteristics, daily serum creatinine, daily Sequential Organ Failure Assessment (SOFA) score, vital status at hospital discharge, and lengths of stays. Patients were classified according to the maximum RIFLE class reached during the ICU stay. The association of AKI with hospital mortality considering "discharge alive" as a competing event was assessed through the Fine and Gray model.
Results : Of the 8639 study patients, 32.9% had AKI, of whom 19.1% received renal replacement therapy. Patients with AKI had higher crude mortality rates and longer lengths of stays than patients without AKI. In the Fine and Gray model, independent risk factors for hospital mortality were: RIFLE classes Risk (sub-hazard ratio -SHR-: 1.58; 95% confidence interval -CI-: 1.32-1.88; p < 0.0001), Injury (SHR: 3.99; 95% CI: 3.43-4.65; p < 0.0001) and Failure (SHR: 4.12; 95% CI: 3.55-4.79; p < 0.0001), non-renal SOFA score (SHR: 1.19 per point; 95% CI: 1.18-1.21; p < 0.0001), class 3 of Mc Cabe (SHR: 2.71; 95% CI: 2.34-3.15; p < 0.0001), and respiratory failure (SHR: 3.08; 95% CI: 1.36-7.01; p < 0.01).
Conclusions : By using a competing risks approach, this study confirms that AKI affecting critically ill patients is associated with increased hospital mortality.
Réalpes a organisé une réunion intitulée: Insuffisance Rénale Aiguë le Jeudi 16 juin 2011
Les Conférences audio-visuelles sont en ligne !
Zahar, J. R., Timsit, J. F., Garrouste-Orgeas, M., Francais, A., Vesin, A., Descorps-Declere, A., Dubois, Y., Souweine, B., Haouache, H., Goldgran-Toledano, D., Allaouchiche, B., Azoulay, E. and Adrie, C. (2011),
"Outcomes in severe sepsis and patients with septic shock: Pathogen species and infection sites are not associated with mortality",
Crit Care Med.
OBJECTIVES:: We evaluated the respective influence of the causative pathogen and infection site on hospital mortality from severe sepsis related to community-, hospital-, and intensive care unit-acquired infections.
DESIGNS, SETTING, AND PATIENTS:: We used a prospective 10-yr database from 12 intensive care units that included 4006 first episodes of acquisition-site-specific severe sepsis in 3588 patients. We built a subdistribution hazards model with corrections for competing risks and adjustment for potential confounders including early appropriate antimicrobial therapy.
INTEVENTIONS:: None.
MEASUREMENTS AND MAIN RESULTS:: We included 1562 community-acquired, 1432 hospital-acquired, and 1012 intensive care unit-acquired episodes of severe sepsis. After adjustment, we found no independent associations of the causative organism, multidrug resistance of the causative organism, infection site, or presence of bacteremia with mortality. Early appropriate antimicrobial therapy was consistently associated with better survival in the community-acquired (0.64 [0.51-0.8], p = .0001), hospital-acquired (0.72 [0.58-0.88], p = .0011), and intensive care unit-acquired (0.79 [0.64-0.97], p = .0272) groups.
CONCLUSION:: The infectious process may not exert as strong a prognostic effect when severity, organ dysfunction and, above all, appropriateness of early antimicrobials are taken into account. Our findings emphasize the importance of developing valid recommendations for early antimicrobial therapy.
Kaminski, C., Timsit, J. F., Dubois, Y., Zahar, J. R., Garrouste-Orgeas, M., Vesin, A., Azoulay, E., Feger, C., Dumenil, A. S., Adrie, C., Cohen, Y., Allaouchiche, B. and Study Group, O. (2011),
Impact of ureido/carboxypenicillin resistance on the prognosis of ventilator-associated pneumonia due to Pseudomonas aeruginosa
Crit Care, 15, 2: R112.
INTRODUCTION: Although P. aeruginosa is a leading pathogen responsible for ventilator-associated pneumonia (VAP), the excess in mortality associated with multiresistance in patients with P. aeruginosa VAP (PA-VAP), taking into account confounders such as treatment adequacy and prior length of stay in the ICU, has not yet been adequately estimated.
METHODS: Two hundred and twenty-three episodes of PA-VAP recorded into the Outcomerea database were evaluated. Patients with ureido/carboxy-resistant P. aeruginosa (PRPA) were compared with those with ureido/carboxy-sensitive P. aeruginosa (PSPA) after matching on duration of ICU stay at VAP onset and adjustment for confounders.
RESULTS: Factors associated with onset of PRPA-VAP were as follows: admission to the ICU with septic shock, broad-spectrum antimicrobials at admission, prior use of ureido/carboxypenicillin, and colonization with PRPA before infection. Adequate antimicrobial therapy was more often delayed in the PRPA group. The crude ICU mortality rate and the hospital mortality rate were not different between the PRPA and the PSPA groups. In multivariate analysis, after controlling for time in the ICU before VAP diagnosis, neither ICU death [odds ratio (OR) = 0.73; 95% confidence interval (CI): 0.32-1.69 ; P = 0.46] nor hospital death [OR = 0.87; 95% CI : 0.38-1.99 ; P = 0.74] were increased in the presence of PRPA infection. This result remained unchanged in the subgroup of 87 patients who received adequate antimicrobial treatment on the day of VAP diagnosis.
CONCLUSIONS: After adjustment, and despite the more frequent delay in the initiation of an adequate antimicrobial therapy in these patients, resistance to ureido/carboxypenicillin was not associated with ICU or hospital death in patients with PA-VAP.
Intensive Care Med. 2010 Mar 16.
Attributable mortality of ventilator-associated pneumonia: respective impact of main characteristics at ICU admission and VAP onset using conditional logistic regression and multi-state models.
Nguile-Makao M, Zahar JR, Français A, Tabah A, Garrouste-Orgeas M, Allaouchiche B, Goldgran-Toledano D, Azoulay E, Adrie C, Jamali S, Clec'h C, Souweine B, Timsit JF.
INSERM U823, University Grenoble 1, Albert Bonniot Institute, Grenoble, France.
PURPOSE: Methods for estimating the excess mortality attributable to ventilator-associated pneumonia (VAP) should handle VAP as a time-dependent covariate, since the probability of experiencing VAP increases with the time on mechanical ventilation. VAP-attributable mortality (VAP-AM) varies with definitions, case-mix, causative microorganisms, and treatment adequacy. Our objectives here were to compare VAP-AM estimates obtained using a traditional cohort analysis, a multistate progressive disability model, and a matched-cohort analysis; and to compare VAP-AM estimates according to VAP characteristics.
METHODS: We used data from 2,873 mechanically ventilated patients in the Outcomerea((R)) database. Among these patients from 12 intensive care units, 434 (15.1%) experienced VAP; of the remaining patients, 1,969 (68.5%) were discharged alive and 470 (16.4%) died. With the multistate model, VAP-AM was 8.1% (95% confidence interval [95%CI], 3.1-13.1%) for 120 days' complete observation, compared to 10.4% (5.6-24.5%) using a matched-cohort approach (2,769 patients) with matching on mechanical ventilation duration followed by conditional logistic regression. VAP-AM was higher in surgical patients and patients with intermediate (but not high) Simplified Acute Physiologic Score II values at ICU admission. VAP-AM was significantly influenced by time to VAP but not by resistance of causative microorganisms. Higher Logistic Organ Dysfunction score at VAP onset dramatically increased VAP-AM (to 31.9% in patients with scores above 7).
CONCLUSION: A multistate model that appropriately handled VAP as a time-dependent event produced lower VAP-AM values than conditional logistic regression. VAP-AM varied widely with case-mix. Disease severity at VAP onset markedly influenced VAP-AM; this may contribute to the variability of previous estimates.