Implementation of the kidney protection strategy in critically ill patients with acute kidney injury – a multi-center prospective cohort study

BACKGROUND: The international Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend the implementation of a kidney protection strategy (KPS) in patients at high risk of and with Acute Kidney Injury (AKI). However, real-world implementation of this strategy in critically ill patients with AKI is unclear. We quantified timely and sustained adherence to KPS in critically ill adults with moderate-to-severe (KDIGO stage 2 or 3) AKI and explored associations with clinical outcomes. METHODS: This was a multicenter, prospective cohort study enrolling adult patients with moderate or severe AKI requiring vasopressors and/or mechanical ventilation across five centers in Europe. The primary endpoint was adherence to the KPS, which included hemodynamic monitoring, sustained optimization of mean arterial pressure (MAP) > 65 mmHg, monitoring of serum creatinine and urine output, and avoidance of hyperglycemia, radiocontrast agents and nephrotoxins when possible, within 12 h after AKI diagnosis for 48 h or until ICU discharge. Exploratory analyses examined associations between adherence and renal outcomes. RESULTS: A total of 258 patients were enrolled (median age 69 years [IQR 62-75]; 65% male; median SOFA 10 [IQR 8-13]). The complete KPS was implemented in 80 patients (31%; 95% CI, 25.5-37.2%). Adherence to individual components of the KPS varied widely with optimization of MAP showing the lowest implementation rate (33%). In exploratory analyses accounting for death as a competing risk, KPS adherence was associated with a lower incidence of AKD beyond day 7 (subdistribution hazard ratio [SHR] 0.64; 95% CI, 0.41-0.99; p = 0.046), a higher incidence of renal recovery at hospital discharge (SHR 6.02; 95% CI, 4.00-9.05; p < 0.0001), and a lower incidence of RRT within 30 days (SHR 0.12; 95% CI, 0.02-0.91; p = 0.04). After multivariable adjustment, the association with renal recovery remained robust (adjusted SHR 6.29; 95% CI, 3.08-12.85; p < 0.0001). A clear dose-response relationship was observed between the number of implemented KPS components and renal outcomes. CONCLUSIONS: In critically ill patients with moderate-to-severe AKI, the complete KDIGO-recommended kidney protection strategy was implemented in approximately one-third of patients, and full KPS adherence was associated with a higher rate of renal recovery at hospital discharge.