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Background <p>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.</p> Methods <p>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) &gt; 65 mmHg, monitoring of serum creatinine and urine output, and avoidance of hyperglycemia, radiocontrast agents and nephrotoxins when possible, within 12&#xa0;h after AKI diagnosis for 48&#xa0;h or until ICU discharge. Exploratory analyses examined associations between adherence and renal outcomes.</p> Results <p>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; <i>p</i> = 0.046), a higher incidence of renal recovery at hospital discharge (SHR 6.02; 95% CI, 4.00–9.05; <i>p</i> &lt; 0.0001), and a lower incidence of RRT within 30 days (SHR 0.12; 95% CI, 0.02–0.91; <i>p</i> = 0.04). After multivariable adjustment, the association with renal recovery remained robust (adjusted SHR 6.29; 95% CI, 3.08–12.85; <i>p</i> &lt; 0.0001). A clear dose-response relationship was observed between the number of implemented KPS components and renal outcomes.</p> Conclusions <p>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.</p>

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

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  • 发表日期：

    2026年6月19日

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  • Mahan Sadjadi,
  • Matteo Marcello,
  • Andrea Köhler,
  • Fabian Perschinka,
  • Sebastian Schauflinger,
  • Michael Joannidis,
  • István Vadász,
  • Faeq Husain-Syed,
  • Margreet Klop-Riehl,
  • Peter Pickkers,
  • Gianluca Villa,
  • Tobias Nagel,
  • Eike Bormann,
  • Hendrik Booke,
  • Ludwig Maximilian Schöne,
  • Thilo von Groote,
  • Moritz J. Mertes,
  • John A. Kellum,
  • Christian Strauß,
  • Alexander Zarbock

摘要

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.