Disseminated intravascular coagulation is strongly associated with severe acute kidney injury in patients with septic shock

Abstract

Background: Disseminated intravascular coagulation (DIC) worsens the prognosis of septic shock and contributes to multiple organ failure. To date, no data linking DIC and acute kidney injury (AKI) occurrence, severity, and evolution in this setting are available. We aimed at analyzing the association between AKI occurrence, severity and evolution in patients with septic shock-induced DIC. In a prospective monocentric cohort study, consecutive patients, 18 years and older, admitted in the ICU of Strasbourg University Hospital in the setting of systemic hypotension requiring vasopressor related to an infection, without history of terminal chronic kidney disease were eligible. AKI was defined according to the KDIGO classification. DIC diagnosis was based on the International Society on Thrombosis and Haemostasis (ISTH) score. Evolution of AKI was evaluated through the composite endpoint of major adverse kidney events. Only patients with DIC that occurred before or at the time of AKI diagnosis were considered. Univariate and multivariate analysis were performed to determine factors associated with renal outcomes.

Results: 350 patients were included, of whom 129 experienced DIC. Patients with DIC were more seriously ill (median SAPS II 64 vs. 56, p < 0.001), and had higher 28-day mortality (43.3% vs. 26.2%, p < 0.001). AKI was more frequent in patients with DIC (86.8% vs. 74.2%, p < 0.005), particularly for the more severe stage of AKI [KDIGO 3 in 58.1% of patients with DIC vs. 30.8% of patients without DIC, p < 0.001, AKI requiring renal replacement therapy (RRT) in 47.3% of patients with DIC vs. 21.3% of patients without DIC, p < 0.001]. After adjustment for confounding factors, DIC occurrence remained associated with the risk of having the more severe stage of AKI with an odds ratio (OR) of 2.74 [IC 95% (1.53-4.91), p < 0.001], and with the risk of requiring RRT during the ICU stay [OR 2.82 (1.53-5.2), p < 0.001].

Conclusion: DIC appears to be strongly associated with the risk of developing the more severe form of AKI (stage 3 of the KDIGO classification, RRT requirement), even after adjustment for severity and other relevant factors.

Keywords: Acute kidney disease; Acute kidney injury; Disseminated intravascular coagulation; Sepsis; Septic shock.

Fig. 1

Flowchart of the study

Fig. 2

Cumulative incidence functions of competing events: acute kidney injury in the ICU (a), AKI KDIGO3 in the ICU (b), ICU death and ICU discharge. b AKI KDIGO unstratified and according to DIC status (DIC [KDIGO3 DIC +] c and no DIC [KDIGO3 DIC −] d). AKI, acute kidney injury; DIC, disseminated intravascular coagulation; KDIGO, Kidney Disease Improving Global Outcome (KDIGO 3: threefold increase from creatinine baseline or creatinine > 354 µmol/L; or Renal replacement Therapy or urine output < 0.3 mL/kg/h during 24 h or anuria during more than 12 h)

Fig. 3

Proportion of patients with acute kidney injury stage 3 of the KDIGO classification according to the value of the ISTH score. AKI, acute kidney injury; ISTH, International Society on Thrombosis and Haemostasis; KDIGO, Kidney Disease Improving Global Outcome

Fig. 4

Probability of survival without acute kidney injury stage 3 of the KDIGO classification. AKI, acute kidney injury; DIC, disseminated intravascular coagulation; KDIGO, Kidney Disease Improving Global Outcome. Kaplan–Meier curves of the probability of survival without AKI reaching the stage 3 of the KDIGO classification during the first 7 days, according to the presence of DIC or not. p < 0.001 between groups (log-rank test)