Acute Kidney Injury
Conditions
Keywords
biomarker
Brief summary
There is no specific therapy for acute kidney injury. It is presumed that supportive measures improve the care and outcome of patients with acute kidney injury. The investigators hypothesize that the implementation of a bundle of supportive measures adapted to patients undergoing major surgery reduces the occurrence of AKI. This randomized prospective multicenter trial is needed to investigator whether the implementation of the bundle of measures is effective to prevent AKI in high risk patients undergoing major surgery.
Detailed description
In earlier studies, interventions to treat acute kidney injury (AKI) were started after a functional damage of the kidneys was already established. However, none of the interventions had an effect in treating AKI. The Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines recommend implementing different measures in patients at high risk for AKI, but the evidence that the implementation of the bundle (consisting of optimization of hemodynamics and perfusion pressure, avoidance of nephrotoxins and hyperglycemia) can prevent AKI is very weak. Biomarkers can be used to identify patients at high risk for AKI after surgery (prior to the development of AKI). The cell-cycle arrest biomarkers, Tissue Inhibitor of Metalloproteinases-2 (TIMP-2) and Insulin-like growth factor-binding protein 7 (IGFBP7), have been demonstrated to have the best predictive performance for the development of AKI after surgery as compared to other biomarkers. In addition, these biomarkers are not influenced by different co-morbidities or other clinical situations. In the BigpAK1 trial, which was a single-center trial, the authors investigated whether a biomarker-guided implementation of the KDIGO guidelines can reduce the occurrence of AKI in patients undergoing major non-cardiac surgery. The results demonstrate that the implementation of the KDIGO bundle in high risk patients for AKI (\[TIMP-2\]\*\[IGFBP7\] between 0.3 and 2) significantly reduced the occurrence of AKI compared to the standard of care group. However, this was a single center trial which needs to be confirmed in a large trial. Therefore, based on these data, a definitive, prospective, randomized controlled, multicenter study including 1302 surgical patients at high risk for AKI identified by \[TIMP-2\]\*\[IGFBP7\] will be performed. The goal of this trial is to investigate the effect of the implementation of the KDIGO bundle in patients at high risk for AKI after major surgery compared to standard of care in the same patient population. This biomarker-guided approach (individualized therapy) enables to treat patients at high risk for AKI prior to a functional damage of the kidneys.
Interventions
OTHERComprehensive Implementation of the Bundle recommended by the Kidney Disease: Improving Global Outcomes Group (KDIGO bundle)
Implementation of the KDIGO bundle for at least 12 hours 1. discontinuation of all nephrotoxic drugs when possible 2. optimization of volume status and hemodynamic parameters (consideration of a functional hemodynamic monitoring) 3. close monitoring of serum creatinine, fluid balance and urinary output 4. avoidance of hyperglycemia 5. considerations of alternatives to radiocontrast agents 6. discontinuation of angiotensin converting enzyme inhibitors and angiotensin receptor blockers in the perioperative period 7. avoidance of HES, gelatin, and chlorid-rich solutions
Sponsors
BioMérieux
University Hospital Muenster
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE
Masking
DOUBLE (Subject, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patients after major surgery who need to be admitted to the ICU * Age \> 18 years * \[TIMP-2\]\*\[IGFBP7\] ≥ 0.3 4-18 hours after surgery * Inserted jugular central venous line and a urinary catheter * Written informed consent. * At least one additional risk factor for AKI 1. Age \> 75 years 2. Critical illness such as ongoing requirement of vasopressor support and/or mechanical ventilation postoperatively 3. Pre-existing chronic kidney disease (eGFR\<60ml/min) 4. Intraoperative use of radio contrast agents.
Exclusion criteria
* Pregnancy or breastfeeding * Pre- existing high stages of chronic kidney disease (stage 4 or 5 i.e. eGFR \< 15 ml/ min) * Kidney transplant within the last 12 month * Known (Glomerulo-) Nephritis, interstitial nephritis or vasculitis * Anuria at inclusion time * Preexisting AKI * Renal replacement therapy (RRT) within the last 90 days * Indication for renal replacement at the time of inclusion * Participation in another intervention trial that investigates a drug/intervention that affects kidney function * Persons held in an institution by legal or official order * Persons with any kind of dependency on the investigator or employed by the responsible institution or investigator
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Occurence of moderate or severe AKI | 72 hours after start of intervention |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Severity of AKI | 3 days after start of intervention | Severity of AKI as defined by the KDIGO guidelines based on creatinine or urine output parameter: Stage 1 Creatinine: 1.5-1.9 times baseline OR \> 0.3 mg/dl (\> 26.5 mmol/l) increase and/or urine output \< 0.5 ml/kg/h for 6-12 hours Stage 2 Creatinine: 2.0-2.9 times baseline and/or urine output \< 0.5 ml/kg/h for \>= 12 hours Stage 3 Creatinine: 3.0 times baseline OR Increase in serum creatinine to \>= 4.0 mg/dl (\>= 353.6 mmol/l) OR Initiation of renal replacement therapy OR, In patients \< 18 years, decrease in eGFR to \< 35 ml/min per 1.73 m2 and/or urine output \< 0.3 ml/kg/h for \>= 24 hour |
| Changes in biomarker values | 12 hours after start of intervention | Difference between the 12 h after initial measuring and the initial measuring \[TIMP-2\]\*\[IGFBP7\] value |
| Free-days of mechanical ventilation | up to 3 days after start of intervention | — |
| Free-days of vasopressors | up to 3 days after start of intervention | — |
| Need of renal replacement therapy | up to 30 days after start of intervention | — |
| Adherence to the implementation of the KDIGO-bundle | 72 hours after start of intervention | Number of patients in whom * Nephrotoxic agents were discontinued * Optimal volume status and perfusion pressure were ensured * The use of hemodynamic monitoring was considered * Serum creatinine and urine output were considered * Hyperglycemia was avoided * Alternatives to radiocontrast were considered |
| Renal recovery | up to 90 days after start of intervention | renal recovery is defined as complete recovery: serum creatinine levels \< 0.5 mg/dl higher than baseline serum creatinine (creatinine level before surgery), partial recovery: serum creatinine \> 0.5 mg/dl higher than baseline but not dialysis-dependence; non-recovery: patients who remained dialysis dependent |
| Mortality | 30 days after start of intervention | — |
| ICU and hospital stay | up to 90 days after start of intervention (until discharge) | — |
| Major adverse kidney events (MAKE) | up to 90 days after start of intervention | \- major adverse kidney events consisting of mortality, dialysis dependency persistent renal dysfunction (defined as serum creatinine ≥ 2x to baseline value at hospital discharge) |
| Duration of renal replacement therapy | up to 30 days after start of intervention | — |
Countries
France, Germany, Italy, Netherlands, Spain, Switzerland, United Kingdom
Outcome results
None listed