A systematic review and meta-analysis of acute kidney injury in the intensive care units of developed and developing countries

Abstract

Objectives: Although the majority of the global population lives in developing countries, most of the epidemiological data related to intensive care unit (ICU) acute kidney injury (AKI) comes from developed countries. This systematic review aims to ascertain the methodology of studies on ICU AKI patients in developing and developed countries, to determine whether epidemiological comparisons between these two settings are possible, and to present a summary estimate of AKI incidence.

Methods: A systematic review of published studies reporting AKI in intensive care units (2005-2015) identified in PubMed, LILACS, and IBECs databases was conducted. We compared developed and developing countries by evaluating study methodology, AKI reference serum creatinine definitions, population characteristics, AKI incidence and mortality. AKI incidence was calculated with a random-effects model.

Results: Ninety-two studies were included, one of which reported data from both country categories: 60 from developed countries (1,057,332 patients) and 33 from developing countries (34,539 patients). In 78% of the studies, AKI was defined by the RIFLE, AKIN or KDIGO criteria. Oliguria had 11 different definitions and reference creatinine 23 different values. For the meta-analysis, 38 studies from developed and 18 from developing countries were selected, with similar AKI incidence: 39.3% and 35.1%, respectively. The need for dialysis, length of ICU stay and mortality were higher in developing countries.

Conclusion: Although patient characteristics and AKI incidence were similar in developed and developing countries, main outcomes were worse in developing country studies. There are significant caveats when comparing AKI epidemiology in developed and developing countries, including lack of standardization of reference serum creatinine, oliguria and the timeframe for AKI assessment. Larger, prospective, multicenter studies from developing countries are urgently needed to capture AKI data from the overall population without ICU access.

Fig 1. Flowchart of study selection.

Fig 2. Flowchart of AKI definition criteria.

Footnote: 1 One study contained data from both (developed and developing) country groups, and the respective data were included in each country group for the analysis. 2 Two studies did not mention the criteria used for the definition of IRA.

Fig 3. Forest plot of AKI incidence.

Footnote: The studies shown are those that used the RIFLE, AKIN or KDIGO criteria for AKI definition. A) Developed country studies; B) Developing country studies.

Fig 4. Funnel plot of sample size of studies as a function of AKI incidence.

Footnote: The studies shown are those that used the RIFLE, AKIN or KDIGO criteria for AKI definition. A) Developed country studies; B) Developing country studies. Pooled AKI incidence is depicted as a vertical line.