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Relative Hypotension and Adverse Kidney-related Outcomes Among Critically Ill Patients with Shock- A Multicenter Prospective Cohort Study.

RATIONALE
There are no prospective observational studies exploring the relationship between relative hypotension and adverse kidney-related outcomes among critically ill patients with shock.


OBJECTIVES
To investigate the magnitude of relative hypotension during vasopressor-support among critically ill patients with shock, and to determine if such relative hypotension is associated with new significant acute kidney injury (AKI) or major adverse kidney event (MAKE) within 14 days of vasopressor-initiation.


METHODS
At seven multidisciplinary ICUs, 302 patients, aged ≥40 years, requiring ≥4 hours of vasopressor-support for non-hemorrhagic shock, were prospectively enrolled. We assessed time-weighted-average mean perfusion pressure (MPP)-deficit (i.e., percentage difference between patients' pre-illness basal-MPP and achieved-MPP) during vasopressor-support and percentage timepoints with MPP-deficit >20% as key exposure variables. New significant AKI was defined as two-or-more AKI-stage increase (KDIGO creatinine-based criteria).


MEASUREMENTS AND MAIN RESULTS
The median MPP-deficit was 19% [interquartile range: 13-25], and 54% [19-82] of timepoints were spent with MPP-deficit >20%. 73 (24%) patients developed new significant AKI; 86 (29%) patients developed MAKE. For every percentage increase in time-weighted-average MPP-deficit, multivariable-adjusted odds of developing new significant AKI and MAKE increased by 5.6% (95% confidence interval: 2.2-9.1; P=0.001) and 5.9% (2.2-9.8; P=0.002) respectively. Likewise, for every one-unit increase in the percentage timepoints with >20% MPP-deficit, multivariable-adjusted odds of developing new significant AKI and MAKE increased by 1.2% (0.3-2.2; P=0.008) and 1.4% (0.4-2.4; P=0.004) respectively.


CONCLUSIONS
Vasopressor-treated patients with shock are often exposed to a significant degree and duration of relative hypotension, which are associated with new-onset adverse kidney-related outcomes.