title: Recognition and management of acute kidney injury in the International Society of Nephrology 0by25 Global Snapshot: a multinational cross-sectional study.
abstract: BACKGROUND
  Epidemiological data for acute kidney injury are scarce, especially in low-income countries (LICs) and lower-middle-income countries (LMICs). We aimed to assess regional differences in acute kidney injury recognition, management, and outcomes.
  
  
  METHODS
  In this multinational cross-sectional study, 322 physicians from 289 centres in 72 countries collected prospective data for paediatric and adult patients with confirmed acute kidney injury in hospital and non-hospital settings who met criteria for acute kidney injury. Signs and symptoms at presentation, comorbidities, risk factors for acute kidney injury, and process-of-care data were obtained at the start of acute kidney injury, and need for dialysis, renal recovery, and mortality recorded at 7 days, and at hospital discharge or death, whichever came earlier. We classified countries into high-income countries (HICs), upper-middle-income countries (UMICs), and combined LICs and LMICs (LLMICs) according to their 2014 gross national income per person.
  
  
  RESULTS
  Between Sept 29 and Dec 7, 2014, data were collected from 4018 patients. 2337 (58%) patients developed community-acquired acute kidney injury, with 889 (80%) of 1118 patients in LLMICs, 815 (51%) of 1594 in UMICs, and 663 (51%) of 1241 in HICs (for HICs vs UMICs p=0.33; p<0.0001 for all other comparisons). Hypotension (1615 [40%] patients) and dehydration (1536 [38%] patients) were the most common causes of acute kidney injury. Dehydration was the most frequent cause of acute kidney injury in LLMICs (526 [46%] of 1153 vs 518 [32%] of 1605 in UMICs vs 492 [39%] of 1260 in HICs) and hypotension in HICs (564 [45%] of 1260 vs 611 [38%%] of 1605 in UMICs vs 440 [38%] of 1153 LLMICs). Mortality at 7 days was 423 (11%) of 3855, and was higher in LLMICs (129 [12%] of 1076) than in HICs (125 [10%] of 1230) and UMICs (169 [11%] of 1549).
  
  
  CONCLUSIONS
  We identified common aetiological factors across all countries, which might be amenable to a standardised approach for early recognition and treatment of acute kidney injury. Study limitations include a small number of patients from outpatient settings and LICs, potentially under-representing the true burden of acute kidney injury in these areas. Additional strategies are needed to raise awareness of acute kidney injury in community health-care settings, especially in LICs.
  
  
  BACKGROUND
  International Society of Nephrology.
authors.affiliation: Department of Medicine, University of California San Diego, San Diego, CA, USA. Electronic address: rmehta@ucsd.edu.
authors.forename: Ravindra L
authors.initials: RL
authors.lastname: Mehta
authors.affiliation: LIM 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil.
authors.forename: Emmanuel A
authors.initials: EA
authors.lastname: Burdmann
authors.affiliation: Division of Nephrology, Department of Medicine, Albany Medical College, Albany, NY, USA.
authors.forename: Jorge
authors.initials: J
authors.lastname: Cerdá
authors.affiliation: Renal Medicine, University of Leicester, Leicester, UK.
authors.forename: John
authors.initials: J
authors.lastname: Feehally
authors.affiliation: Yale University, New Haven, CT, USA.
authors.forename: Fredric
authors.initials: F
authors.lastname: Finkelstein
authors.affiliation: Hospital Civil de Guadalajara, University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico.
authors.forename: Guillermo
authors.initials: G
authors.lastname: García-García
authors.affiliation: Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada.
authors.forename: Melanie
authors.initials: M
authors.lastname: Godin
authors.affiliation: The George Institute for Global Health India, University of Oxford, Oxford, UK.
authors.forename: Vivekanand
authors.initials: V
authors.lastname: Jha
authors.affiliation: Nephrology Section, Department of Internal Medicine, University Hospital, Ghent, Belgium.
authors.forename: Norbert H
authors.initials: NH
authors.lastname: Lameire
authors.affiliation: Mount Sinai School of Medicine, Renal Research Institute, New York, NY, USA.
authors.forename: Nathan W
authors.initials: NW
authors.lastname: Levin
authors.affiliation: Department of Nephrology, Leeds Teaching Hospitals, Leeds, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Lewington
authors.affiliation: Department of Critical Care Medicine, Servicio Médico Integral, Montevideo, Uruguay.
authors.forename: Raúl
authors.initials: R
authors.lastname: Lombardi
authors.affiliation: LIM 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil.
authors.forename: Etienne
authors.initials: E
authors.lastname: Macedo
authors.affiliation: Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Rocco
authors.affiliation: Department of Medicine, University of California San Diego, San Diego, CA, USA.
authors.forename: Eliah
authors.initials: E
authors.lastname: Aronoff-Spencer
authors.affiliation: University of Calgary, Calgary, AB, Canada.
authors.forename: Marcello
authors.initials: M
authors.lastname: Tonelli
authors.affiliation: Department of Medicine, University of California San Diego, San Diego, CA, USA.
authors.forename: Jing
authors.initials: J
authors.lastname: Zhang
authors.affiliation: IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy; Department of Medicine, Unit of Nephrology, Dialysis and Transplantation, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Remuzzi
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D005260:Female; D014943:Global Health; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016896:Treatment Outcome