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Review
. 2024 Jul 9;14(1):110.
doi: 10.1186/s13613-024-01342-x.

Urine output is an early and strong predictor of acute kidney injury and associated mortality: a systematic literature review of 50 clinical studies

Manu L N G Malbrain  1   2   3 , Krista Tantakoun  4 , Anthony T Zara  4 , Nicole C Ferko  4 , Timothy Kelly  5 , Wojciech Dabrowski  6
Affiliations
Review

Urine output is an early and strong predictor of acute kidney injury and associated mortality: a systematic literature review of 50 clinical studies

Manu L N G Malbrain et al. Ann Intensive Care. .

Abstract

Background: Although the present diagnosis of acute kidney injury (AKI) involves measurement of acute increases in serum creatinine (SC) and reduced urine output (UO), measurement of UO is underutilized for diagnosis of AKI in clinical practice. The purpose of this investigation was to conduct a systematic literature review of published studies that evaluate both UO and SC in the detection of AKI to better understand incidence, healthcare resource use, and mortality in relation to these diagnostic measures and how these outcomes may vary by population subtype.

Methods: The systematic literature review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Data were extracted from comparative studies focused on the diagnostic accuracy of UO and SC, relevant clinical outcomes, and resource usage. Quality and validity were assessed using the National Institute for Health and Care Excellence (NICE) single technology appraisal quality checklist for randomized controlled trials and the Newcastle-Ottawa Quality Assessment Scale for observational studies.

Results: A total of 1729 publications were screened, with 50 studies eligible for inclusion. A majority of studies (76%) used the Kidney Disease: Improving Global Outcomes (KDIGO) criteria to classify AKI and focused on the comparison of UO alone versus SC alone, while few studies analyzed a diagnosis of AKI based on the presence of both UO and SC, or the presence of at least one of UO or SC indicators. Of the included studies, 33% analyzed patients treated for cardiovascular diseases and 30% analyzed patients treated in a general intensive care unit. The use of UO criteria was more often associated with increased incidence of AKI (36%), than was the application of SC criteria (21%), which was consistent across the subgroup analyses performed. Furthermore, the use of UO criteria was associated with an earlier diagnosis of AKI (2.4-46.0 h). Both diagnostic modalities accurately predicted risk of AKI-related mortality.

Conclusions: Evidence suggests that the inclusion of UO criteria provides substantial diagnostic and prognostic value to the detection of AKI.

Keywords: AKIN; Acute kidney injury; Detection; Epidemiology; KDIGO; Prognosis; RIFLE; Serum creatinine; Systematic literature review; Urine output.

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Conflict of interest statement

MLNGM is Professor of Critical Care Research at the First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Poland. He is co-founder, past-President, and current Treasurer of WSACS (The Abdominal Compartment Society, http://www.wsacs.org). He is member of the medical advisory Board of Pulsion Medical Systems (part of Getinge group), Serenno Medical, Potrero Medical, Sentinel Medical and Baxter. He consults for B.Braun, Becton, Dickinson and Company, ConvaTec, Spiegelberg, and Holtech Medical, and received speaker's fees from PeerVoice. He holds stock options for Serenno, Sentinel and Potrero. He is co-founder and President of the International Fluid Academy (IFA). The IFA (http://www.fluidacademy.org) is integrated within the not-for-profit charitable organization iMERiT, International Medical Education and Research Initiative, under Belgian law. KT, ATZ, and NCF are employees of EVERSANA™ which was engaged by Becton, Dickinson and Company for the purposes of this research. TK is an employee of Becton, Dickinson and Company. WD is Head of First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Poland.

Figures

Fig. 1
Fig. 1
PRISMA flow diagram. CDSR Cochrane Database of Systematic Reviews, MA meta-analysis, NMA network meta-analysis, SLR systematic literature review
Fig. 2
Fig. 2
Incidence of AKI—All patient populations. *Some studies contributed multiple data points for a given diagnostic method. Boxplots compare AKI incidence based on diagnostic criteria used. The error bars are the range excluding outliers. The bottom and top of the box are the 25th and 75th percentiles, and the line inside the box is the 50th percentile (median). AKI acute kidney injury, AKISC AKI-positive according to SC criteria alone, AKIUO AKI-positive according to UO criteria alone, AKIUOandSC AKI-positive according to both UO and SC criteria—both tests collected, AKIUOorSC AKI-positive according to UO criteria SC criteria, or both—both tests collected, IQR interquartile range
Fig. 3
Fig. 3
Incidence of AKI by staging – All patient populations. *Some studies contributed multiple data points for a given diagnostic method. Boxplots comparing AKI incidence based on diagnostic criteria used. The error bars are the range excluding outliers, the bottom and top of the box are the 25th and 75th percentiles, the line inside the box is the 50th percentile (median). AKI acute kidney injury, AKISC AKI-positive according to SC criteria alone, AKIUO AKI-positive according to UO criteria alone, AKIUOandSC AKI-positive according to both UO and SC criteria—both tests collected, AKIUOorSC AKI-positive according to UO criteria SC criteria, or both—both tests collected, IQR interquartile range
Fig. 4
Fig. 4
Time to AKI diagnosis – All patient populations. * Data presented as mean (± SD) where no median (IQR) was reported. Error bars correspond to the IQR or SD. AKIN Acute Kidney Injury Network, AKISC AKI-positive according to SC criteria alone, AKIUO AKI-positive according to UO criteria alone, AKIUOandSC AKI-positive according to both UO and SC criteria—both tests collected, AKIUOorSC AKI-positive according to UO criteria, SC criteria, or both—both tests collected, IQR interquartile range, KDIGO Kidney Disease: Improving Global Outcomes, RIFLE Risk, Injury, Failure, Loss, and End-stage kidney disease, SD standard deviation, VARC-2 Valve Academic Research Consortium-2
Fig. 5
Fig. 5
Adjusted mortality risk in AKI patients versus no AKI patients. *Data presented as HR (95% CI) where no OR (95% CI) was reported. Error bars correspond to the 95% CI and may extend past visible axis. **UO < 0.3 mL/kg/h for 6 h. The OR/HR of mortality is graphically represented per study and method as a point, with error bars as the 95%CI. The values for the OR/HR with the associated 95%CI are listed to the right of the figure. AKI acute kidney injury, CI confidence interval, HR hazard ratio, OR odds ratio, SC serum creatinine, UO urine output
Fig. 6
Fig. 6
ICU length of stay among patients with AKI. The median ICU length of stay is graphically represented per study and method as a point, with error bars as the IQR. Median values with the associated IQR are listed to the right of the figure. Note that unadjusted results are presented. AKI acute kidney injury, ICU intensive care unit, IQR interquartile range, SC serum creatinine, UO urine output
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