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Original Investigation Pathogenesis and Treatment of Kidney Disease| Volume 68, ISSUE 4, P564-570, October 01, 2016

Acute Kidney Injury in Critically Injured Combat Veterans: A Retrospective Cohort Study

      Background

      Acute kidney injury (AKI) has been associated with mortality after traumatic injury. However, there is a paucity of data for military service members with injuries received in combat. We sought to identify risk factors for AKI after combat trauma and evaluate whether AKI is a predictor of mortality.

      Study Design

      Retrospective observational study.

      Settings & Participants

      US service members who were critically wounded in Iraq or Afghanistan from February 1, 2002, to February 1, 2011, and survived until evacuation to Landstuhl Regional Medical Center, Germany.

      Predictors

      Demographic variables, vital signs, injury severity score, presence of burn injury, and mechanism of injury as defined at the time of initial injury, as well as the presence of AKI ascertained within the first 7 days using KDIGO (Kidney Disease: Improving Global Outcomes) serum creatinine criteria.

      Outcomes

      Logistic regression models were used to identify risk factors for both AKI and death.

      Results

      Of 6,011 records, 3,807 were included for analysis after excluding patients with missing data. AKI occurred in 474 (12.5%) patients and 112 (2.9%) died. More patients with versus without AKI died (n = 62 [13.1%] vs n = 50 [1.5%]; P < 0.001). After adjustment, AKI was a predictor of mortality (OR, 5.14; 95% CI, 3.33-7.93; P < 0.001). Predictors of AKI were age, African American race, injury severity score, amputations, burns, and presenting vital signs.

      Limitations

      AKI diagnoses limited to creatinine-based definitions.

      Conclusions

      AKI predicted mortality in combat veterans injured in the wars in Iraq and Afghanistan.

      Index Words

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      References

        • Bagshaw S.
        • George C.
        • Gibney R.
        • Bellomo R.
        A multi-center evaluation of early acute kidney injury in critically ill trauma patients.
        Ren Fail. 2008; 30: 581-589
        • Bihorac A.
        • Delano M.
        • Schold J.
        • et al.
        Incidence, clinical predictors, genomics, and outcome of acute kidney injury among trauma patients.
        Ann Surg. 2010; 252: 158-165
        • Eriksson M.
        • Brattstrom O.
        • Martensson J.
        • Larsson E.
        • Oldner A.
        Acute kidney injury following severe trauma: risk factors and long-term outcome.
        J Trauma Acute Care Surg. 2015; 79: 407-412
        • Podoll A.
        • Kozar R.
        • Holcomb J.
        • Finkel K.
        Incidence and outcome of early acute kidney injury in critically-ill trauma patients.
        PloS One. 2013; 8: e77376
        • Shashaty M.
        • Meyer N.
        • Localio A.
        • et al.
        African American race, obesity, and blood product transfusion are risk factors for acute kidney injury in critically ill trauma patients.
        J Crit Care. 2012; 27: 496-504
        • Skinner D.
        • Hardcastle T.
        • Rodseth R.
        • Muckhart D.
        The incidence and outcomes of acute kidney injury amongst patients admitted to a level I trauma unit.
        Injury. 2014; 45: 259-264
        • Stewart I.
        • Tilley M.
        • Cotant C.
        • et al.
        Association of AKI with adverse outcomes in burned military casualties.
        Clin J Am Soc Nephrol. 2012; 7: 199-206
        • Heegard K.
        • Stewart I.
        • Cap A.
        • et al.
        Early acute kidney injury in military casualties.
        J Trauma Acute Care Surg. 2015; 78: 988-993
        • Bolanos J.
        • Yuan C.
        • Little D.
        • et al.
        Outcomes after post-traumatic AKI requiring RRT in United States military service members.
        Clin J Am Soc Nephrol. 2015; 10: 1732-1739
        • Bellomo R.
        • Ronco C.
        • Kellum J.
        • Mehta R.
        • Palevsky P.
        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; 8: R204-R212
        • Mehta R.
        • Kellum J.
        • Shah S.
        • et al.
        Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury.
        Crit Care. 2007; 11: R31
        • Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group
        KDIGO clinical practice guideline for acute kidney injury.
        Kidney Int Suppl. 2012; 2: 1-138
        • Stewart I.
        • Fang R.
        • Cannon J.
        • et al.
        Derivation of candidates for the combat casualty critical care (C4) database.
        Mil Med. 2014; 179: 370-374
        • Baker S.
        • O'Neill B.
        • Haddon W.
        • Long W.
        The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care.
        J Trauma. 1974; 14: 187-196
        • Gennarelli T.
        • Wodzin E.
        AIS 2005: a contemporary injury scale.
        Injury. 2006; 37: 1083-1091
        • Levey A.
        • Stevens L.
        • Schmid C.
        • et al.
        A new equation to estimate glomerular filtration rate.
        Ann Intern Med. 2009; 150: 604-612
        • Kotwal R.
        • Howard J.
        • Orman J.
        • et al.
        The effect of a golden hour policy on the morbidity and mortality of combat casualties.
        JAMA Surg. 2016; 151: 15-24
        • Stewart I.
        • Sosnov J.
        • Howard J.
        • et al.
        Retrospective analysis of long-term outcomes after combat injury: a hidden cost of war.
        Circulation. 2015; 132: 2126-2133
        • Dellinger R.
        • Levy M.
        • Rhodes A.
        • et al.
        Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.
        Intensive Care Med. 2013; 39: 165-228
        • James P.
        • Oparil S.
        • Carter B.
        • et al.
        2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).
        JAMA. 2014; 311: 507-520
        • Chung K.
        • Stewart I.
        • Gisler C.
        • et al.
        The Acute Kidney Injury Network (AKIN) criteria applied in burns.
        J Burn Care Res. 2012; 33: 483-490
        • Coca S.
        • Bauling P.
        • Schifftner T.
        • Howard C.
        • Teitelbaum I.
        • Parikh C.
        Contribution of acute kidney injury toward morbidity and mortality in burns: a contemporary analysis.
        Am J Kidney Dis. 2007; 49: 517-523
        • Steinvall I.
        • Bak Z.
        • Sjoberg F.
        Acute kidney injury is common, parallels organ dysfunction or failure, and carries appreciable mortality in patients with major burns: a prospective exploratory cohort study.
        Crit Care. 2008; 12: R124
        • Thurlow J.
        • Abbott K.
        • Linberg A.
        • Little D.
        • Fenderson J.
        • Olson S.
        SCr and SCysC concentrations before and after traumatic amputation in male soldiers: a case-control study.
        Am J Kidney Dis. 2014; 63: 167-170
        • Im E.
        • Stewart I.
        • Morrow B.
        • et al.
        Retrospective review of serum creatinine and creatinine-based measures of estimated glomerular filtration rate in an amputee population.
        Mil Med. 2012; 177: 952-956
        • Stewart I.
        • Faulk T.
        • Sosnov J.
        • et al.
        Rhabdomyolysis among critically ill combat casualties: Associations with acute kidney injury and mortality.
        J Trauma Acute Care Surg. 2016; 80: 492-498
        • Kellum J.
        • Sileanu F.
        • Murugan R.
        • Lucko N.
        • Shaw A.
        • Clermont G.
        Classifying AKI by urine output versus serum creatinine level.
        J Am Soc Nephrol. 2015; 26: 2231-2238
        • Siew E.
        • Peterson J.
        • Eden S.
        • Moons K.
        • Ikizler T.
        • Matheny M.
        Use of multiple imputation method to improve estimation of missing baseline serum creatinine in acute kidney injury research.
        Clin J Am Soc Nephrol. 2013; 8: 10-18