Article Figures & Data
Figures
- Figure 1.
Literature search and selection. KDIGO, Kidney Disease Improving Global Outcomes.
- Figure 2.
Pooled incidence rate of AKI in studies that used KDIGO-equivalent serum creatinine-based AKI definition and staging system, or dialysis requirement. Some studies and patients are included in more than one category. KDIGO, Kidney Disease Improving Global Outcomes; 95% CI, 95% confidence interval.
- Figure 3.
Pooled incidence rate of AKI by world zones in studies that used a KDIGO-equivalent serum creatinine-based AKI definition. Some studies and patients are included in more than one category. KDIGO, Kidney Disease Improving Global Outcomes.
- Figure 4.
Pooled AKI-associated mortality rate in studies that used a KDIGO-equivalent serum creatinine-based AKI definition and staging system, or dialysis requirement. Some studies and patients are included in more than one category. KDIGO, Kidney Disease Improving Global Outcomes; 95% CI, 95% confidence interval.
- Figure 5.
Pooled unadjusted odds ratio for all-cause mortality in patients with AKI relative to patients without AKI in studies that used a KDIGO-equivalent serum creatinine-based AKI definition and staging system, or dialysis requirement. Some studies and patients are included in more than one category. KDIGO, Kidney Disease Improving Global Outcomes; 95% CI, 95% confidence interval.
Tables
All Studies Studies of Adults Studies of Children No. of studies 154 130 24 Sample size 22,220 (95–1,126,636) 26,240 (509–1,126,636) 593 (95–3396) Percentage of male participants 63 (28–100) 65 (28–100) 56 (49–79) Age of participants (yr) 51.6 (0.0–80.3)a 60.6 (25.5–80.3) 4.7 (0.0–11.4)a Studies by clinical setting Community acquired 7 (5) 6 (5) 1 (4) Critical care 41 (27) 32 (25) 9 (38) Cardiac surgery 42 (27) 35 (27) 7 (29) Trauma 4 (2) 4 (3) 0 (0) Heart failure 1 (1) 1 (1) 0 (0) Hematology/oncology 3 (2) 3 (2) 0 (0) Nephrotoxins 4 (2) 2 (1) 2 (8) Hospital acquired, unspecified 52 (34) 47 (36) 5 (21) Studies by continent Australia and New Zealand 9 (6) 9 (7) 0 (0) Asia 21 (14) 18 (14) 3 (13) Europe 51 (33) 45 (35) 6 (25) America 70 (45) 55 (42) 15 (62) Africa 0 (0) 0 (0) 0 (0) Multiple continents 3 (2) 3 (2) 0 (0) Studies by world zoneb Australia and New Zealand 9 (6) 9 (7) 0 (0) Eastern Asia 17 (11) 15 (12) 2 (8) Western Asia 2 (1) 1 (1) 1 (4) Southern Asia 2 (1) 2 (2) 0 (0) South East Asia 0 (0) 0 (0) 0 (0) Eastern Europe 2 (1) 1 (1) 1 (4) Western Europe 15 (10) 13 (10) 2 (8) Northern Europe 12 (8) 10 (8) 2 (8) Southern Europe 18 (11) 17 (13) 1 (4) Multi-zone Europe 4 (3) 4 (3) 0 (0) North America 64 (42) 50 (38) 14 (60) South America 6 (4) 5 (3) 1 (4) North Africa 0 (0) 0 (0) 0 (0) Western Africa 0 (0) 0 (0) 0 (0) Multiple zones 3 (2) 3 (2) 0 (0) Studies by latitude North 138 (89) 115 (88) 23 (96) South 15 (10) 14 (11) 1 (4) North and South 1 (1) 1 (1) 0 (0) Country income classificationc Low income 1 (1) 1 (1) 0 (0) Lower middle income 1 (1) 1 (1) 0 (0) Upper middle income 20 (13) 16 (12) 4 (17) High income 130 (84) 110 (85) 20 (83) Not available 2 (1) 2 (1) 0 (0) Country total health expenditure (% of GDP)d <5 8 (5) 7 (5) 1 (4) 5–10 68 (45) 58 (45) 10 (42) >10 76 (49) 63 (48) 13 (54) Not available 2 (1) 2 (2) 0 (0) Data are presented as the mean (range) or n (%). KDIGO, Kidney Disease Improving Global Outcomes; GDP, gross domestic product.
↵a A zero value indicates newborns.
↵b According to the United Nations geo-scheme classification (11).
↵c According to the World Bank's classification of income of countries (12).
↵d According to the World Health Organization (14).
Subgroup Studies (n) Patients (n) Patients with AKI (n) AKI Incidence Rate (%) 95% Confidence Interval Test for Heterogeneity I2 Index Q Test P Value All 154 3,585,911 573,424 23.2 21.0 to 25.7 99.9 <0.001 Age category Adults 130 3,571,691 569,861 21.6 19.3 to 24.1 99.9 <0.001 Children 24 14,220 3563 33.7 26.9 to 41.3 98.3 <0.001 Clinical setting Community acquired 7 548,398 4897 8.3 1.6 to 33.0 99.9 <0.001 Critical care 41 888,604 272,580 31.7 28.6 to 35.0 99.9 <0.001 Cardiac surgery 42 164,333 33,157 24.3 20.4 to 28.8 99.7 <0.001 Trauma 4 14,947 2557 19.9 13.6 to 28.2 98.7 <0.001 Heart failure 1 682 221 32.4 29.0 to 36.0 — — Hematology/oncology 3 2401 453 21.3 7.5 to 47.6 99.2 <0.001 Nephrotoxins 4 17,786 1681 12.2 6.2 to 22.7 98.7 <0.001 Hospital acquired, unspecified 52 1,948,760 257,878 20.9 17.2 to 25.2 99.9 <0.001 Continent Australia and New Zealand 9 523,715 182,405 25.6 22.3 to 29.3 99.9 <0.001 Asia 21 286,377 17,358 15.6 8.7 to 26.4 99.9 <0.001 Europe 51 918,068 72,390 23.1 18.0 to 29.2 99.9 <0.001 America 70 1,847,689 296,655 24.9 22.1 to 27.8 99.9 <0.001 Multiple continents 3 10,062 4616 49.4 22.9 to 76.3 99.9 <0.001 World zonea Australia and New Zealand 9 523,715 182,405 25.6 22.3 to 29.3 99.9 <0.001 Eastern Asia 17 258,161 14,794 14.7 7.0 to 28.2 99.9 <0.001 Western Asia 2 25,989 2006 16.7 3.3 to 54.3 99.3 <0.001 South Asia 2 2227 558 23.7 7.5 to 54.4 99.4 <0.001 Eastern Europe 2 2600 639 22.0 9.5 to 43.3 98.9 <0.001 Western Europe 15 161,198 14,725 20.1 12.1 to 31.5 99.9 <0.001 Northern Europe 12 607,956 8894 14.7 5.5 to 33.6 99.9 <0.001 Southern Europe 18 24,080 6546 31.5 23.1 to 41.3 99.5 <0.001 Multi-zone Europe 4 122,234 41586 32.5 28.3 to 37.0 99.6 <0.001 North America 64 1,843,814 295,554 24.5 21.7 to 27.5 99.9 <0.001 South America 6 3875 1101 29.6 19.1 to 42.7 98.3 <0.001 Multiple zones 3 10,062 4616 49.4 22.9 to 76.3 99.9 <0.001 Latitude North 138 3,057,543 389,454 22.6 20.2 to 25.2 99.9 <0.001 South 15 527,590 183,506 27.0 24.2 to 30.0 99.8 <0.001 North and South 1 778 464 59.6 56.2 to 63.0 — — Country income classificationb Low income 1 1047 399 38.1 35.2 to 41.1 — — Lower middle income 1 1180 159 13.5 11.6 to 15.5 — — Upper middle income 20 248,718 14,335 19.5 10.4 to 33.7 99.9 <0.001 High income 130 3,313,430 553,203 23.8 21.4 to 26.4 99.9 <0.001 Not available 2 21,536 5328 25.1 23.6 to 26.7 80.4 0.02 Country total health expenditure (% of GDP)c <5 8 222,178 7823 14.5 7.2 to 26.9 99.8 <0.001 5–10 68 1,406,796 258,636 22.3 19.6 to 25.3 99.9 <0.001 >10 76 1,935,401 301,637 25.2 22.3 to 28.3 99.9 <0.001 Not available 2 21,536 5328 25.1 23.6 to 26.7 80.4 <0.001 - Table 3.
Pooled AKI-associated mortality rate in studies that adopted a KDIGO-equivalent AKI definition
Subgroup Studies (n) Patients with AKI (n) Deaths (n) Pooled Mortality Rate 95% Confidence Interval Test for Heterogeneity I2 Index Q Test P Value All 110 429,535 107,433 23.0 21.3 to 24.8 99.3 <0.001 Age category Adults 99 427,804 107,167 23.9 22.1 to 25.7 99.4 <0.001 Children 11 1731 266 13.8 8.8 to 21.0 91.3 <0.001 Clinical setting Community acquired 5 4349 2015 32.8 20.8 to 47.5 98.1 <0.001 Critical care 31 198,645 53,783 33.1 29.8 to 36.6 99.5 <0.001 Cardiac surgery 23 21,811 1871 8.3 6.6 to 10.4 95.3 <0.001 Trauma 3 2387 593 32.2 13.0 to 60.1 99.1 <0.001 Heart failure 1 221 47 21.3 16.4 to 27.2 — — Hematology/oncology 2 278 76 25.7 16.1 to 38.3 73.9 <0.001 Nephrotoxins 1 81 12 14.8 8.6 to 24.3 — — Hospital acquired, unspecified 44 201,763 49,036 25.7 22.5 to 29.1 99.2 <0.001 Continent Australia and New Zealand 7 137,116 33,281 24.4 23.2 to 25.6 93.9 <0.001 Asia 13 14,718 4089 30.2 21.9 to 40.1 98.9 <0.001 Europe 40 65,200 21,157 23.5 20.6 to 26.7 98.8 <0.001 America 48 209,120 46,992 18.8 16.1 to 21.8 99.3 <0.001 Multiple continents 2 3381 1914 49.0 29.3 to 69.0 98.6 <0.001 World zonea Australia and New Zealand 7 137,116 33,281 24.4 23.2 to 25.6 93.9 <0.001 Eastern Asia 9 12,154 3688 36.9 25.7 to 49.7 99.2 <0.001 Western Asia 2 2006 333 23.6 10.1 to 46.0 93.1 <0.001 South Asia 2 558 68 13.8 4.6 to 34.3 95.2 <0.001 Eastern Europe 2 639 111 21.4 3.6 to 66.8 98.8 <0.001 Western Europe 10 8769 1951 21.3 17.4 to 25.8 93.3 <0.001 Northern Europe 10 8712 1451 17.2 9.9 to 28.2 98.9 <0.001 Southern Europe 14 5494 1650 26.3 19.2 to 34.9 97.6 <0.001 Multi-zone Europe 4 41,586 15,994 38.3 35.9 to 40.8 96.2 <0.001 North America 42 208,019 46,565 16.6 14.0 to 19.5 99.3 <0.001 South America 6 1101 427 38.9 19.0 to 63.3 97.9 <0.001 Multiple zones 2 3381 1914 49.0 29.3 to 69.0 98.6 <0.001 Latitude North 96 290,854 73,547 21.4 19.3 to 23.6 99.4 <0.001 South 13 138,217 33,708 30.7 28.4 to 33.1 97.5 <0.001 North and South 1 464 178 38.4 34.0 to 42.9 — — Country income classificationb Low income 1 399 32 8.0 5.7 to 11.1 — — Lower middle income 1 159 36 22.6 16.8 to 29.8 — — Upper middle income 14 12,697 3992 41.4 30.8 to 52.9 98.9 <0.001 High income 93 412,187 101,884 20.9 19.2 to 22.6 99.3 <0.001 Not available 1 4093 1489 36.4 34.9 to 37.9 — — Country total health expenditure (% of GDP)c <5 4 6554 1571 36.1 17.3 to 60.2 99.2 <0.001 5–10 53 208,689 57,064 26.6 24.1 to 29.3 99.3 <0.001 >10 52 210,199 47,309 18.4 15.9 to 21.2 99.2 <0.001 Not available 1 4093 1489 36.4 34.9 to 37.9 — — Duration of follow-up (mo) <3 95 413,487 102,169 22.1 20.4 to 23.9 99.3 <0.001 3–6 6 4831 2101 31.5 18.6 to 48.0 98.6 <0.001 >6 9 11,217 3163 27.7 22.2 to 33.9 97.3 <0.001 - Table 4.
Meta-regression analyses examining the association of AKI incidence rate according to the KDIGO-equivalent definition and its associated mortality rate with aggregate study- and country-level characteristics
Characteristic Rate Change (%) 95% Confidence Interval P Value AKI incidence rate Country percentage GDP spent on total health expenditure (per 1% ↑) 0.54 0.07 to 1.02 0.03 Country gross national income per capita (per $10,000 ↑) 0.18 −0.90 to 1.27 0.74 Year of study publication (per year ↑) −2.02 −2.83 to −1.22 <0.001 AKI-associated mortality rate Country percentage GDP spent on total health expenditure (per 1% ↑) −1.36 −1.97 to −0.75 <0.001 Country gross national income per capita (per $10,000 ↑) −3.43 −4.63 to −2.23 <0.001 Year of study publication (per year ↑) −1.46 −2.69 to −0.24 0.02 GDP, gross domestic product.
- Table 5.
Pooled odds ratio for mortality in patients with AKI relative to patients without AKI in studies that adopted a KDIGO-equivalent AKI definition
Subgroup Studies (n) Patients with AKI (n) Deaths (n) Patients without AKI (n) Deaths (n) Pooled Odds Ratio 95% Confidence Interval P Value Test for Heterogeneity I2 Index Q Test P Value Age category Adults 81 403,880 98,348 1,760,311 91,915 4.92 4.07 to 5.93 <0.001 99.6 <0.001 Children 11 1736 260 5263 158 5.57 3.49 to 8.89 <0.001 54.7 <0.001 Clinical setting Community acquired 4 3875 1,724 17,202 6978 2.56 1.31 to 5.01 0.01 95.9 <0.001 Critical care 24 182,393 46,880 269,613 28,923 3.93 3.12 to 4.96 <0.001 99.28 <0.001 Cardiac surgery 22 21,402 1852 64,776 1118 6.31 4.81 to 8.28 <0.001 87.3 <0.001 Trauma 3 2387 593 11,989 894 6.62 1.75 to 24.99 0.01 98.9 <0.001 Heart failure 1 221 47 461 52 2.13 1.38 to 3.27 0.001 — — Hematology/oncology 2 278 76 1604 27 15.50 8.40 to 28.60 <0.001 37.5 0.21 Nephrotoxins 1 81 12 2112 140 2.45 1.30 to 4.63 0.01 — — Hospital acquired, unspecified 35 194,979 47,424 1,397,817 53,941 5.15 3.86 to 6.87 <0.001 99.4 <0.001 Continent Australia and New Zealand 6 136,888 33,190 210,289 21,413 3.34 2.14 to 5.22 < 0.001 99.8 <0.001 Asia 10 13,702 3424 208,457 5374 8.10 4.78 to 13.71 <0.001 98.3 <0.001 Europe 33 44,525 13,743 150,667 10,776 5.21 4.39 to 6.18 <0.001 95.0 <0.001 America 41 207,120 46,337 1,194,232 53,832 4.57 3.30 to 6.33 <0.001 99.5 <0.001 Multiple continents 2 3381 1914 1929 678 2.12 1.42 to 3.16 <0.001 82.8 0.02 World zonea Australia and New Zealand 6 136,888 33,190 210,289 21,413 3.34 2.14 to 5.22 <0.001 99.8 <0.001 Eastern Asia 6 11,133 3023 182,810 5062 6.73 3.41 to 13.29 <0.001 98.9 <0.001 Western Asia 2 2011 333 23,978 303 9.18 2.95 to 28.62 <0.001 87.2 0.01 South Asia 2 558 68 1669 9 49.45 0.57 to 4275.16 0.09 89.5 0.002 Eastern Europe 2 639 111 1961 131 6.06 3.896 to 9.43 <0.001 36.2 0.21 Western Europe 9 4473 1114 16,732 955 6.25 3.93 to 9.94 <0.001 90.9 <0.001 Northern Europe 8 7764 1005 68,554 2008 5.70 3.95 to 8.24 <0.001 85.6 <0.001 Southern Europe 11 4639 1410 9371 1410 4.73 3.23 to 6.92 <0.001 90.2 <0.001 Multi-zone Europe 3 27,010 10,103 54,049 6272 4.34 2.84 to 6.64 <0.001 99.2 <0.001 North America 38 206,460 46,204 1,193,397 53,769 4.49 3.21 to 6.29 <0.001 99.5 <0.001 South America 3 660 133 835 63 5.64 2.18 to 14.62 <0.001 65.6 0.06 Multiple zones 2 3381 1914 1929 678 2.12 1.42 to 3.16 <0.001 82.8 0.02 Latitude North 82 267,604 65,107 1,554,136 70,512 5.15 4.29 to 6.19 <0.001 99.2 <0.001 South 9 137,548 33,323 211,124 21,476 3.71 2.50 to 5.51 <0.001 99.7 <0.001 North and South 1 464 178 314 85 1.68 1.23 to 2.29 0.001 — — Country income classificationb Low income 1 399 32 648 9 6.19 2.92 to 13.11 <0.001 — — Lower middle income 1 159 36 1021 0 597.37 36.43 to 9796.52 <0.001 — — Upper middle income 9 11,336 3064 181,135 5051 6.57 3.68 to 11.74 <0.001 98.2 <0.001 High income 80 389,629 93,987 1,570,079 85,383 4.73 3.89 to 5.75 <0.001 99.6 <0.001 Not available 1 4093 1489 12,691 1630 3.88 3.57 to 4.21 <0.001 — — Country total health expenditure (% of GDP)c <5 3 6201 1379 175,079 4133 13.85 8.76 to 21.89 <0.001 87.4 <0.001 5–10 42 191,213 49,672 401,894 32,656 4.69 3.83 to 5.74 <0.001 99.1 <0.001 >10 46 204,109 46,068 1,175,910 53,654 4.83 3.54 to 6.59 <0.001 99.4 <0.001 Not available 1 4093 1489 12,691 1630 3.88 3.57 to 4.21 <0.001 — — Duration of follow-up (mo) <3 79 390,221 93,750 1,725,376 82,092 5.58 4.60 to 6.76 <0.001 99.5 <0.001 3–6 3 4178 1695 16,947 6913 2.25 1.09 to 4.68 0.03 94.8 <0.001 >6 10 11,217 3163 23,251 3068 2.74 2.09 to 3.58 <0.001 93.9 <0.001
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