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Low Admission Plasma Creatinine Concentration and In-Hospital MortalityWisit Cheungpasitporn
Disclosure• None
Crit Care Med. 2013;41(8):1878-83.
• Observational cohort study in Dutch 154,308 ICU patients
• Hospital mortality, increasing for BMI< 18.5 kg/m2
• BMI 30–39.9 kg/m2 had the lowest risk of death with an adjusted OR of 0.86 (0.83–0.90)
Background
• BMI suffers from numerous practical limitations in the ICU (such as accurately weighing patients).
• Several studies reported on the association between low BMI and poor outcome of critical illness .
• BMI does not readily discriminate between lean, fat, and water body mass.
Cartin-Ceba R1, Afessa B, Gajic O. Crit Care Med 2007;35:2420-3.
Crit Care Med 2007;35:2420-3.
• A retrospective cohort study of 11,291 adult patients
• Mayo Clinic Hospital—Rochester ICUs
• Between 2003 and 2006
Crit Care Med 2007;35:2420-3.
Crit Care Med. 2016 Jan;44(1):73-82.
Objective• To evaluate the independent association
between low peak admission plasma creatinine concentrations and in-hospital mortality in patients requiring critical care in Australia and New Zealand.
Methods: Study design• Multicenter, binational, retrospective cohort study.
• The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation and adult patient database (APD)
• Data on over 1.5 million admission to 175 ICUs in Australia and New zealand
• 2000 – 2013
• Exclusion criteria:• Readmission episodes, missing in-hospital mortality, post-
kidney transplant, chronic RRT, missing peak plasma creatinine
Patients’ flow chart
Creatinine and Outcome• Peak plasma creatinine
• The highest value in the first 24 hours of ICU admission
• Creatinine (µmol/L) were categorized into < 30, 30-39, 40-49, 50-59, 60-69, 70-79, 80-89, 90-99, 100-119,120-139, 140-179 and ≥ 180
• Reference group: 70-79 µmol/L (0.79-0.89 mg/dL)
• Primary outcome• In-hospital mortality
Statistical analysis• Association with mortality and serum creatinine
• Logistic regression models• Adjusting for a priori-defined list of covariates
• Illness severity• Site of admission• Age• Gender• Year of admission
• 2-sided p value < 0.01 considered statistically significant
Result - Characteristics
1.23 (1.13)
Result
All patient (n=1,047,518)
Adjusted for year of ICU admission, age, gender, institution, ANZROD predicted mortality
No significant interaction between creatinine and year of ICU admission
0.79-0.89<0.34 ≥ 2.04
<0.340.34-0.440.45-0.550.57-0.670.68-0.780.79-0.890.90-1.011.02-1.121.13-1.351.36-1.571.58-2.02≥2.04
Patient with height and weight date (n=96,630)
Adjusted for year of ICU admission, age, gender, institution, weight, height, ANZROD predicted mortality
0.79-0.89<0.34 ≥ 2.04
<0.340.34-0.440.45-0.550.57-0.670.68-0.780.79-0.890.90-1.011.02-1.121.13-1.351.36-1.571.58-2.02≥2.04
Non-operative admission (n=465,771)
Adjusted for year of ICU admission, age, gender, institution, ANZROD predicted mortality
0.79-0.89<0.34 ≥ 2.04
Postoperative admission (n=572,320)
Adjusted for year of ICU admission, age, gender, institution, ANZROD predicted mortality
0.79-0.89<0.34 ≥ 2.04
Elective surgical admission (n=470,594)
Adjusted for year of ICU admission, age, gender, institution, ANZROD predicted mortality
0.79-0.89<0.34 ≥ 2.04
Trauma admission (n=56,450)
Adjusted for year of ICU admission, age, gender, institution, ANZROD predicted mortality
0.79-0.89<0.34 ≥ 2.04
Infection-related admission (n=148,164)
Adjusted for year of ICU admission, age, gender, institution, ANZROD predicted mortality
0.79-0.89<0.34 ≥ 2.04
<0.340.34-0.44
0.45-0.550.57-0.670.68-0.78
<0.340.34-0.440.45-0.550.57-0.670.68-0.78
<0.340.34-0.44
0.45-0.550.57-0.670.68-0.78
<0.340.34-0.440.45-0.550.57-0.670.68-0.78
<0.340.34-0.44
0.45-0.550.57-0.67
0.68-0.78
<0.340.34-0.440.45-0.550.57-0.670.68-0.78
Discussion
• This study demonstrated a significant association between low peak plasma Cr concentrations and increased in-hospital mortality.
• Peak plasma Cr <60 μmol/L (<0.68 mg/dL) in the first 24 hours after ICU admission imply a steadily increasing adjusted mortality risk, compared with a peak plasma Cr of 70–79 μmol/L (0.79-0.89 mg/dL).
Discussion
• In cases where Cr value < 30 μmol/L (<0.34 mg/dL), the adjusted odds of dying in-hospital is > two-fold higher than the reference category and exceeds the risk implied with elevated (≥ 180 μmol/L) values (≥ 2.04 mg/dL).
Thongprayoon C, Cheungpasitporn W, Kashani K. J Thorac Dis. 2016;3(2).
Sime FB et al. Curr Opin Pharmacol. 2015 Oct;24:1-6.
Limitations
• Retrospective cohort study• Information on fluid balance, feeding, functional
status, and physical therapy are lacking, all of which are likely to intimately influence these results.
Conclusion
• In a large heterogenous cohort of critically ill patients, low admission peak plasma creatinine concentrations are independently associated with increased risk-adjusted in-hospital mortality.
• Further research should now focus on the potential mechanisms underpinning this finding, such as a low skeletal muscle mass and/or fluid overload.
Thongprayoon C, Cheungpasitporn W, Kashani K. J Thorac Dis. 2016;3(2).
A Novel Index for Estimation of Muscle Mass Using Biomarkers of Kidney Function: Sarcopenia Index
Kashani K, Kukrálová L, Kashyap R, Frazee E. Am J Respir Crit Care Med 191: A2284, 2015
A Novel Index for Estimation of Muscle Mass Using Biomarkers of Kidney Function: Sarcopenia Index
• Critically ill patients • Mayo Clinic Hospital, Rochester ICU • October 2008-December 2010
*SI = (serum creatinine/serum cystatin C) X 100Am J Respir Crit Care Med 191: A2284, 2015
Low admission serum creatinine concentration predicts mortality in in hospitalized patients independent of body mass index
• Observational cohort study in 73,994 patients
• Mayo Clinic Hospital—Rochester ICUs
• Between 2011 and 2013
Thongprayoon C, Cheungpasitporn W, Kittanamongkolchai W, Harrison AM, Kashani K.Am J Med. 2016 Dec 18. pii: S0002-9343(16)31234-7. doi:
10.1016/j.amjmed.2016.11.020. [Epub ahead of print]PMID: 27998681
In-hospital MortalityOutcome Serum creatinine level at hospital admission (mg/dL)
≤0.4 0.5-0.6 0.7-0.8 0.9-1.0 1.1-1.2 1.3-1.4 ≥1.5
Hospital mortality
25 (2.8) 93 (1.0) 173 (0.8) 187 (1.0) 136 (1.3) 113 (2.4) 246 (3.6)
Mortality, OR (95%CI)
Model 1: unadjusted
3.69 (2.35-5.52)
1.23 (0.95-1.58)
1 (ref) 1.24 (1.01-1.53)
1.71 (1.37-2.15)
3.16 (2.48-4.01)
4.81 (3.96-5.86)
Model 2# 3.29 (2.08-5.00)
1.28 (0.99-1.66)
1 (ref) 1.13 (0.91-1.39)
1.29 (1.03-1.64)
1.96 (1.52-2.51)
2.56 (2.07-3.17)
Model 3: Model 2 and BMI
3.40 (2.10-5.28)
1.34 (1.02-1.7)
1 (ref) 1.14 (0.91-1.43)
1.34 (1.04-1.72)
2.10 (1.60-2.74)
2.65 (2.11-3.35)
#model 2: Adjusted for age, sex, race, principal diagnosis, Charlson comorbidity score, CAD, CHF, PVD, stroke, DM, COPD and cirrhosis.
Thongprayoon C, Cheungpasitporn W, Kittanamongkolchai W, Harrison AM, Kashani K.Am J Med. 2016 Dec 18. pii: S0002-9343(16)31234-7. doi:
10.1016/j.amjmed.2016.11.020. [Epub ahead of print]PMID: 27998681
Questions & Discussion