mercredi 5 février 2020 

14h10 - 15h10


 
Espace Poster 10

Insuffisance rénale : complications et pronostic

MODÉRATEUR(S) :  Stéphane GAUDRY (Bobigny), Alexandre HERTIG (Chantilly)  
  

Predicting outcome in ICU trauma patients with AKI

Orateur(s) :   Mariem DLELA (Sfax, TUNISIE) 

Auteur(s) :  kamilia CHTARA (Sfax, TUNISIE)   Farah ZOUARI (Sfax, TUNISIE)   Mabrouk BAHLOUL (Sfax, TUNISIE)   Mounir BOUAZIZ (Sfax, TUNISIE)  

14h10 - 14h17
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Predicting outcome in ICU trauma patients with AKI

Introduction / Rationale :
Acute kidney injury in trauma patients is a problem that has been little studied in the ICU. Its occurrence has been shown to be associated with high morbidity and mortality. We aim to determine the outcome of ICU trauma patients with AKI, including the incidence of death in the ICU, of non-reversible renal impairment and ICU complications.

Méthodes / Patients and Methods :
This is a prospective study, conducted in the department of emergencies and ICU, including trauma patients with a minimum ICU stay of 7 days. Renal failure was defined based on the new KDIGO classification. Predictors of mortality and poor outcome were identified using univariate and then multivariate analysis.

Résultats / Results :
One hundred and fifty patients were admitted during the study period for the management of post-traumatic injuries, among which 98 patients were included. The incidence of AKI in the studied population was 47% (46 cases) with 26 (56%) diagnosed with stage one, ten (22%) with stage two and ten (22%) with stage three. The overall mortality of patients with post-traumatic AKI was 34.8% (16 patients) with a mean lengh of ICU stay (LOS) at 22 ± 18 days and of days on ventilator at 17 ± 15. Eight patients (17.4%) needed renal replacement therapy and thirty-four had non-reversible renal impairement (74%). During ICU stay eight patients (17%) were diagnosed with pulmonary embolism. On univariate analysis, the following variables were associated to mortality in patients with post-tramatic AKI including; age, hemodynamic instability on the day of diagnosis and bilirubin levels on the day of AKI diagnosis.
Besides, according to our analysis, the use of renal replacement therapy and the non-reversibility of renal impairment during ICU stay were also associated to ICU mortality.
Among these factors, the non-reversibility of renal impairment in the ICU was a predictor of mortality on multivariate analysis (p = 0.009, OR = 29, CI: 4-142). In this cohort, the following variables were predictive of non-reversible renal impairment during ICU stay; including age (with a best cut-off of 55 years old), medical history of hypertension, higher ISS and diuretics’ administration. On multivariate analysis, the age (p = 0.004, OR = 0.9, CI: 0.80-0.97) and use of diuretics (p = 0.003, OR = 33, CI: 3.1-359) were associated to non-reversible AKI in the ICU.

Discussion / Discussion :


Conclusion / Conclusion :
Our study confirms that post-traumatic AKI in the ICU is associated to high morbidity and mortality. The identification of outcome predictors could be valuable to guide the management AKI.
 

Predictors of post-traumatic AKI in the ICU

Orateur(s) :   Mariem DLELA (Sfax, TUNISIE) 

Auteur(s) :  Farah ZOUARI (Sfax, TUNISIE)   Olfa TURKI (Sfax, TUNISIE)   Mabrouk BAHLOUL (Sfax, TUNISIE)   Mounir BOUAZIZ (Sfax, TUNISIE)  

14h17 - 14h24
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Predictors of post-traumatic AKI in the ICU

Introduction / Rationale :
The occurrence of acute kidney injury (AKI) in trauma patients is a problem that has been little studied to date. Its presence has been shown to be associated with an increased risk of morbidity and mortality in affected individuals.
To determine the incidence of post-traumatic AKI and identify its predictive risk factors that could be eventually prevented.

Méthodes / Patients and Methods :
This is a ten-month long prospective cohort-study, conducted in the department of emergencies and intensive care unit (ICU) of a university hospital, including trauma patients with a minimum ICU stay of 7 days. Renal failure was defined based on the new KDIGO classification. Predictors of AKI were identified using univariate and then multivariate analysis.

Résultats / Results :
One hundred thirty patients were admitted during the study period for the management of post-traumatic injuries, among which 86 patients were included. The incidence of AKI in the studied population was 53% (46 cases) with 26 (56%) diagnosed with stage one, ten (22%) with stage two and ten (22%) with stage three.
On univariate analysis, older age and medical history of diabetes or hypertension were predictors of AKI. Injury assessment found traumatic brain injury (AIS>3), Glasgow (GCS) on admission, and the diagnosis of fat embolism to be associated to post-traumatic AKI. Moreover, hemodynamic instability on admission and during ICU stay, shock-index on admission, the amount of fluid administered the use of vasoactive drugs, sepsis, hyperbilirubinemia, P/F ratio and acute respiratory distress syndrome (ARDS) were also associated to post-traumatic AKI.
Among these factors, ARDS (p = 0.001, OR = 9 , CI: 6-100), fat embolism (p = 0.028, OR = 2, CI: 1.6-2.5), Shock index (p = 0.02, OR = 15.2, CI: 2.2-105), and bilirubin levels (p = 0.006, OR = 1.035, CI: 1.01-1.06) were identified as independent predictors of post-traumatic AKI on multi-variate analysis.
Besides, according to our analysis, the following variables were predictive of stage3 AKI, including bilirubin levels on the day of AKI diagnosis (p = 0.026, OR = 1.032, CI: 1.004-1.061), transfusions (p = 0.02, OR = 1.5, CI: 1.1-1.9), fat embolism (p = 0.015, OR = 11.3, CI: 1.6-75), and diuretics’ administration (p = 0.004, OR = 10.4, CI: 1.8-57).

Discussion / Discussion :


Conclusion / Conclusion :
Post-traumatic AKI could be associated with significant morbi-mortality in the ICU. The identification of predictors from the initial onset of trauma could be valuable to guide its management.
 

Prevalence and risk factors of hypotension associated with preload-dependence during continuous renal replacement therapy in critically ill patients

Orateur(s) :   Guillaume CHAZOT (Lyon) 

Auteur(s) :  Laurent BITKER (Lyon)   Mehdi MEZIDI (Lyon)   Hodane YONIS (Lyon)   Louis CHAUVELOT (Lyon)   Paul CHABERT (Lyon)   Laure FOLLIET (Lyon)   Jean-Christophe RICHARD (Lyon)  

14h24 - 14h31
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Prevalence and risk factors of hypotension associated with preload-dependence during continuous renal replacement therapy in critically ill patients

Introduction / Rationale :
Hypotension is a frequent complication of continuous renal replacement therapy (CRRT) in intensive care patients. Postural tests (i.e. passive leg raising in the supine position or Trendelenburg in the prone position) combined with continuous measurement of cardiac output are highly reliable to identify preload dependence, and may provide new insights into the mechanisms involved in CRRT-related hypotension. We aimed to assess the prevalence and risk factors of preload-dependence associated hypotension during CRRT.

Méthodes / Patients and Methods :
We conducted a single-center prospective observational study in ICU patients with acute kidney injury KDIGO 3, started on CRRT in the last 24 hours, and monitored with a PiCCO® device. The primary endpoint was the rate of hypotension associated with preload dependence during the first 7 days of CRRT. Hypotension was defined as the occurrence of a mean arterial pressure below 65 mm Hg requiring any of the following therapeutic intervention (initiation or increase in vasopressor dose, discontinuation of fluid removal by CRRT, or fluid bolus). Preload dependence was assessed every 4 hours, and during each hypotensive episodes, and was deemed present if the continuous cardiac index increased by at least 10 % during a passive leg raising test. Data are expressed in median [1rst quartile-3rd quartile], unless stated otherwise.

Résultats / Results :
23 patients (61% male, age 70 [61-75] year, SAPS-2 71 [64-79]) were included 8 [2-16] hours after CRRT initiation, and studied continuously for 95 [61-146] hours. At inclusion, 19 patients (83%) underwent mechanical ventilation, 19 (83%) met the Sepsis-3 criteria, 22 (96%) were under norepinephrine with a median dose of 0.7 [0.3-2.7] µg.kg.min-1, and preload dependence was identified in 12 patients (52%, [95% confidence interval: 33-71%]). A median of 4 [3-7] hypotensive episodes occurred per patient over the observation period, for a pooled total of 130 hypotension episodes. 76 episodes (58% [CI95%: 50-67%]) were associated with preload-dependence, 52 (40%, [CI95%: 32-49%]) without preload-dependence, and 2 were unclassified. Multivariate analysis (using variables collected prior to hypotension) identified the following variables as risk factors for the occurrence of hypotension associated with preload-dependence: preload-dependence before hypotension (odds ratio = 4.01, p<0.001), fluid removal rate by CRRT (OR=0.71 per 1 increase in SD, p<0.001), and lactate levels (OR=1.32 per 1 increase in SD, p<0.001).

Discussion / Discussion :


Conclusion / Conclusion :
In this single center study, preload dependence-associated hypotension was slightly more frequent than hypotension without preload dependence in ICU patients undergoing CRRT. Testing for preload dependence to adjust fluid removal could help prevent hypotension incidence during CRRT.
 

Comparison of the RIFLE, AKIN, CK and KDIGO criteria to predict acute renal failure and mortality in critically ill patients

Orateur(s) :   Karama BOUCHAALA (Sfax, TUNISIE) 

Auteur(s) :  Rania AMMAR ZAYANI (Sfax, TUNISIE)   Emna ENNOURI (Sfax, TUNISIE)   Sabrine BRADAI (Sfax, TUNISIE)   Chokri Ben Hamida (Sfax, TUNISIE)   Mounir BOUAZIZ (Sfax, TUNISIE)  

14h31 - 14h38
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Comparison of the RIFLE, AKIN, CK and KDIGO criteria to predict acute renal failure and mortality in critically ill patients

Introduction / Rationale :
Acute kidney injury is a common complication in critically ill patients. Since 2004, various criteria have been proposed to define and grade acute kidney injury (AKI).
Objective: To assess the power of the different methods of AKI classification to predict incidence of ARF and mortality.

Méthodes / Patients and Methods :
A prospective study conducted in a Tunisian intensive care unit (ICU) over a period of 6 months (January to June 2018). We included patients ≥18 years old. The acute renal failure (ARF) was defined according to the RIFLE, AKIN, CK and KDIGO criteria. We Excludes patients < 18 years, patients with end-stage chronic renal disease (CKD) already undergoing iterative hemodialysis, patients with CKD without information on baseline creatinine levels and patients with hospital stay less than 48 hours.

Résultats / Results :
During the study period, 428 patients were admitted in our ICU. We included 171 patients. The mean age (SD) was 49.26 ± 19.86 years. Sex ratio at 2. The mean (SD) APACHII was 15.1± 7.5. The mean (SD) SOFA was 6.7±2.9. The mean (SD) length of stay was 14.2 ±12.1 days. The mortality rate was 30%. Among the patients included, 81 patients (47%) had creatinine levels that corresponded to at least one of the 4 definitions RIFLE, AKIN, KDIGO or CK. In Univariate Study, ARF predictive factors were age(p<0.00001), hypertension(p=0.002),diabetes mellitus(p=0.002),heart failure (p=0.002),shock (p=0.001), polytrauma (p=0.001),hypoxemia(p=0.001), APACHE II score(p=0.000)and SOFA score(p=0.001). In multi-varied study, the risk factors independently associated to the occurrence of ARF were: age (OR1.030,CI[1.006-1.054];(p=0.014)),APACHEII score (OR1.079,CI[1.005- 1.158];(p=0.036))and shock at admission (OR 15.561,CI[1.751-138.266];p=0.014)).The Comparison between the different classifications showed that the incidence of ARF varied according to the classification adopted. The incidence according to AKIN and KDIGO were identical (46.8%) and very closer to the general incidence which was described above (47%). The incidence according to RIFLE criteria was 32.2% and 45% according to CK criteria. The ROC curve showed that the KDIGO and AKIN curves were confused and had the best predictive power of ARF occurrence with AUC= 0.994 than CK (AUC=0.975) and RIFLE (AUC=0.840). The mortality predictive powers of each of the classifications studied by analyzing the ROC curve showed that the AKIN and KDIGO curves were confused and had the best predictive power with AUC=0.763 than CK (ASC=0.753) and RIFLE (ASC=0.696).

Discussion / Discussion :


Conclusion / Conclusion :
The AKIN and KDIGO criteria were good tools to estimate the incidence of ARF and to predict mortality in critically ill patients.
 

Renal replacement therapy in a Medical Intensive Care Unit: Prognosis and challenges.

Orateur(s) :   Wafa ZARROUGUI (Sousse, TUNISIE) 

Auteur(s) :  Ghalia BOUBAKER (Sousse, TUNISIE)   Asma EL HADHRI (Sousse)   Khaoula MEDDEB (Sousse)   Emna ENNOURI (Sousse, TUNISIE)   Amal TRIKI (Sousse)   Imen BEN SAIDA (Sousse, TUNISIE)   Imed CHOUCHENE (Sousse)   Mohamed BOUSSARSAR (Sousse, TUNISIE)  

14h38 - 14h45
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Renal replacement therapy in a Medical Intensive Care Unit: Prognosis and challenges.

Introduction / Rationale :
Severe acute kidney injury (AKI) is a well-recognized complication of ICU patients with an important impact on mortality. Renal replacement therapy (RRT) represents a considerable escalation in the complexity and cost of care for those patients. The aim of the present study is to describe characteristics and outcomes of hemodialyzed patients in a medical ICU.

Méthodes / Patients and Methods :
This is a retrospective study including patients who received RRT from January 2013 to September 2019 in the ICU of Farhat Hached Sousse –Tunisia. Were collected all patients characteristics including underlying condition, diagnostic and severity at admission, ARF characteristics, RRT characteristics and outcomes.

Résultats / Results :
40 patients received intermittent haemodialysis. They were 61.3±20 years mean aged; 20(52%), male. Mean SAPSII, 47.9±15.5; mechanical ventilation, 27(71%); vasopressors, 28(74%). Mean ICU length-of-stay (LOS), 7.53±6.9 days. The most frequent etiology of ARF requiring RRT was tubular necrosis, 26(68%) with oligoanuria, 33(86,8%). The average timing to initiation of RRT after the onset of ARF was 29±30 hours. Only one haemodialysis session was necessary in 27(71%). The most frequent indications of haemodialysis were severe acidosis 14(36%) and pulmonary edema 10(26%). Median duration of sessions was 3.9[4-4] hours. Mean LOS after ARF onset was at 4.8±5.1 days. Median LOS after first haemodialysis session and last session were respectively 2.7[1.27-4.95] days and 21.5[12.5-60.75] hours. Mortality rate was at 26(68.5%).

Discussion / Discussion :


Conclusion / Conclusion :
The present study demonstrated the high severity and poor outcome of patients who received RRT leading to question the indication, delays, dose and efficiency of RRT.
 

SEPSIS INDUCED ACUTE KIDNEY INJURY: incidence, risk factors and prognostic impact in critically ill patients

Orateur(s) :   Karama BOUCHAALA (Sfax, TUNISIE) 

Auteur(s) :  Rania AMMAR ZAYANI (Sfax, TUNISIE)   Chokri Ben Hamida (Sfax, TUNISIE)   Mabrouk BAHLOUL (Sfax, TUNISIE)   Mounir BOUAZIZ (Sfax, TUNISIE)  

14h45 - 14h52
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
SEPSIS INDUCED ACUTE KIDNEY INJURY: incidence, risk factors and prognostic impact in critically ill patients

Introduction / Rationale :
Acute kidney injury (AKI) is a frequent complication in critically ill patients and is associated with increased morbidity and mortality. Sepsis is one of the most Common cause of AKI.

Méthodes / Patients and Methods :
A prospective study was conducted over 6 months (January 01–June 30, 2018).We included patients with septic shock at admission or at any time during hospitalization. Septic shock was defined according to the Third International Consensus definitions for Sepsis and Septic Shock.The AKI staging was based on KDIGO criteria.Patients were divided into two groups, a group with AKI (AKI+) and a group without AKI (AKI-). Then we compared the baseline characteristics, laboratory and physiologic data. Patients with AKI (AKI+) were subdivided according to their prognosis.

Résultats / Results :
Were enrolled 75 patients.The mean (SD) age was 56.43(±18) years. Sex ratio was 1.91. Fifty-two (70%) patients developed AKI. SAPSII and SOFA score in admission were higher in patients with kidney injury [59 Vs 44 points (p= 0.002), 6.5 Vs 4 points ;(p=0.003)] respectively. The serum lactate level was significantly higher in (AKI +) group patients during the first day of septic shock [6.12± 1.38 mmol/l (AKI+)Vs 4.11± 0.79 mmol/l(AKI-);(p=0.002) ] and its clearance was lower [(32±10.99% (AKI +)Vs 61±13%(AKI-);(p=0.001)]. A significant difference was observed in C reactive protein level [224±114 mg/l (AKI +) Vs 124±77 mg/l (AKI-) ; (p=0.004)]. Among (AKI+) patients, KADIGO III was observed in 59.6% of cases. Nineteen (36.5%) patients received hemodialysis. A normal kidney function was recovered in 40.4% of cases. AKI+ patients had a higher occurrence in Disseminated intravascular coagulation (32 Vs 3 patients, p=0.002), acute respiratory distress syndrome (18 Vs 2 patients; p=0.023) and cardiac dysfunction (20 Vs 1 patient, p=0.001). Mortality was higher in AKI group (67% Vs 9%; p=0.001).

Discussion / Discussion :


Conclusion / Conclusion :
The development of septic AKI was associated with poor outcomes and prognosis. A better understanding of sepsis induced AKI pathway will enable us to develop targeted therapeutic protocols. Newer tools, permitting AKI early detection, may make these therapies more fruitful.
 

Is augmented renal clearance a predictor of morbidity and mortality in severely burned patients ?

Orateur(s) :   Amel MOKLINE (Tunis, TUNISIE) 

Auteur(s) :  Somai MEHDI (Tunis)   Laajili ACHREF (Tunis)   Kawther FALEH (Tunis)   Hager ZOUARI (Tunis)   Hana FREDJ (Tunis)   Manel BEN SAAD (Tunis)   Amenallah MESSAADI (Tunis)  

14h52 - 14h59
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Is augmented renal clearance a predictor of morbidity and mortality in severely burned patients ?

Introduction / Rationale :
Augmented renal clearance (ARC) is common in critically ill patients. This may affect PK/PD characteristics of antibiotics. Our study aims to evaluate the prognostic impact of ARC in severely burned patients with septic shock.

Méthodes / Patients and Methods :
Retrospective, descriptive and comparative study, conducted in intensive burn care department in Tunis over 1 year (October 2017-September 2018). Were included adult patients with an acute burn surface area (ABSA) >20% and an ICU stay >3 days. ARC is defined as a creatinine clearance >130ml/min during a period ≥ 3 jours.

Résultats / Results :
70 patients were included. Two groups were individualized: G1 [ARC+, n = 43] and G2 [ARC-, n = 27]. The average age was 39.5±14.4 years for G1 vs. 46.3±21.1 years for G2 (p=0.15). The ideal average weight (8 Kg for both groups) and admission weight (78 Kg vs 77 kg) were comparable for both groups, as well as for the delta weight (9.6 vs 8.3 ; p=0.77). Burns were less extensive for G1 (ARC+) compared to G2 (ARC-), respectively 40.1±15.7% vs. 46.2±19% (p=0.15). The use of mechanical ventilation and catecholamines was comparable in both groups (81% for G1 vs. 85% for G2; p=0.75). Although the frequency of septic shock occurrence was comparable in both groups (75% for G1 vs. 71% for G2; p=0.71), septic shock mortality was statistically higher in patients with ARC+ (100% for G1 vs. 78% for G2; p=0.014).

Discussion / Discussion :


Conclusion / Conclusion :
ARC in severely burned patients is accompanied by a high mortality in septic burn patients (100%), related probably to sub-therapeutic exopsure of antibiotics in these patients. So, therapeutic drug monitoring of antibiotics must be necessary to guide dose optimization, reduction of therapeutic failures and emergence of resistant bacteria.
 

Post-traumatic acute renal failure in critically ill patients: risk factors

Orateur(s) :   Karama BOUCHAALA (Sfax, TUNISIE) 

Auteur(s) :  Rania AMMAR ZAYANI (Sfax, TUNISIE)   Yousfi MOUNIR (Sfax)   kamilia CHTARA (Sfax, TUNISIE)   Mabrouk BAHLOUL (Sfax, TUNISIE)   Chokri Ben Hamida (Sfax, TUNISIE)   Mounir BOUAZIZ (Sfax, TUNISIE)  

14h59 - 15h06
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Post-traumatic acute renal failure in critically ill patients: risk factors

Introduction / Rationale :
Bachground: Acute renal failure (ARF) in polytrauma was a life-threatening complication.
Objective: To determine the factors that predicts the occurrence of ARF.

Méthodes / Patients and Methods :
A cohort study including patients with trauma in an intensive care unit for 3 months studying the occurrence of ARF. The ARF was defined according to KDIGO criteria.

Résultats / Results :
we include 37 patients. The incidence of ARF was 24.32% (9 patients). Patient in the group ARF(ARF+), the mean age was 38.66±19.43 years, the mean IGS2 was 41.88±15.25 points, the mean SOFA score was 12.33±10,68 points and the average mean arterial pressure (MAP) was 77.3 ±28.02 mmHg with catecholamine’s used in 77.77%. Patients in the group non ARF (ARF-), the mean age was 36.07±15,5 years, the mean IGS2 was 25.57±10,52 points and the mean SOFA was 6.6±7.81 points and the mean MAP was 99.57 ±24.21 mmHg with catecholamine’s used in 0.39%. The mean time of occurrence of ARF was the 2.11±2.26 days. According to KDIGO criteria: stage1 (5 patients), stage 2 (2 patients) and stage 3 (2 patients). Oligoanuria was observed in 2 patients. One patient required hemodialysis. The return to normal renal function was observed in 7 patients. A mortality rate was 33.33% in (ARF+), while it was 7.14% in (ARF-). The IGS2 score was statistically significant between the two groups (p=00.1). The analysis of the ROC curve showed that IGSII > 31.1 points was statistically associated with the occurrence of ARF (p=0.002), sensitivity 77.8%, specificity 75% and AUC 0.839.

Discussion / Discussion :


Conclusion / Conclusion :
Predictive factors to the occurrence of Post-traumatic acute renal failure in critically ill patients are related to the nature and clinical consequences of the trauma.