Early-phase cumulative hypotension duration and severe-stage progression in oliguric acute kidney injury with and without sepsis: an observational study

BACKGROUND: Managing blood pressure in patients with acute kidney injury (AKI) could effectively prevent severe-stage progression. However, the effect of hypotension duration in the early phase of AKI remains poorly understood. This study investigated the association between early-phase cumulative duration of hypotension below threshold mean arterial pressure (MAP) and severe-stage progression of oliguric AKI in critically ill patients, and assessed the difference in association with presence of sepsis. METHODS: This was a single-center, observational study conducted in the ICU of a university hospital in Japan. We examined data from adults with oliguric AKI who were admitted to the ICU during 2010–2014 and stayed in the ICU for ≥24 h after diagnosis of stage-1 oliguric AKI defined in the Kidney Disease Improving Global Outcomes (KDIGO) guidelines. The primary outcome was the progression from stage-1 oliguric AKI to stage-3 oliguric AKI (progression to oligoanuria and use of renal replacement therapy) according to the KDIGO criteria. During the first 6 h after oliguric AKI, we analyzed the association between cumulative time the patient had below threshold MAP (65, 70, and 75 mm Hg) and progression to stage-3. RESULTS: Among 538 patients with oliguric AKI, progression to stage-3 increased as the time spent below any threshold MAP was elongated. In the multivariable analysis of all patients, longer hypotension time (3–6 h) showed significant association with stage-3 progression for the time spent below MAP of 65 mm Hg (adjusted odds ratio (OR) 3.73, 95% confidence interval (CI) 1.53–9.09, p = 0.004), but the association was attenuated for the threshold MAP of 70 mm Hg (adjusted OR 2.35, 95% CI 0.96–5.78, p = 0.063) and 75 mm Hg (adjusted OR 1.92, 95% CI 0.72–5.15, p = 0.200). Longer hypotension time with the thresholds of 65 and 70 mm Hg was significantly associated with the risk of stage-3 progression in patients without sepsis, whereas the association was weak and not significant in patients with sepsis. CONCLUSIONS: Even in a short time frame (6 h) after oliguric AKI diagnosis, early-phase cumulative hypotension duration was associated with progression to stage-3 oliguric AKI, especially in patients without sepsis.