Computed Tomography–Defined Abdominal Adiposity Is Associated With Acute Kidney Injury in Critically Ill Trauma Patients*

Objectives:Higher body mass index is associated with increased risk of acute kidney injury after major trauma. Since body mass index is nonspecific, reflecting lean, fluid, and adipose mass, we evaluated the use of CT to determine if abdominal adiposity underlies the body mass index-acute kidney injury association. Design:Prospective cohort study. Setting:Level I Trauma Center of a university hospital. Patients:Patients older than 13 years with an Injury Severity Score greater than or equal to 16 admitted to the trauma ICU were followed for development of acute kidney injury over 5 days. Those with isolated severe head injury or on chronic dialysis were excluded. Interventions:None. Measurements and Main Results:Clinical, anthropometric, and demographic variables were collected prospectively. CT images at the level of the L4–5 intervertebral disc space were extracted from the medical record and used by two operators to quantitate visceral adipose tissue and subcutaneous adipose tissue areas. Acute kidney injury was defined by Acute Kidney Injury Network creatinine and dialysis criteria. Of 400 subjects, 327 (81.8%) had CT scans suitable for analysis: 264 of 285 (92.6%) blunt trauma subjects and 63 of 115 (54.8%) penetrating trauma subjects. Visceral adipose tissue and subcutaneous adipose tissue areas were highly correlated between operators (intraclass correlation > 0.99, p < 0.001 for each) and within operator (intraclass correlation > 0.99, p < 0.001 for each). In multivariable analysis, the standardized risk of acute kidney injury was 15.1% (95% CI, 10.6–19.6%), 18.1% (14–22.2%), and 23.1% (18.3–27.9%) at the 25th, 50th, and 75th percentiles of visceral adipose tissue area, respectively (p = 0.001), with similar findings when using subcutaneous adipose tissue area as the adiposity measure. Conclusions:Quantitation of abdominal adiposity using CT scans obtained for clinical reasons is feasible and highly reliable in critically ill trauma patients. Abdominal adiposity is independently associated with acute kidney injury in this population, confirming that excess adipose tissue contributes to the body mass index-acute kidney injury association. Further studies of the potential mechanisms linking adiposity with acute kidney injury are warranted.

[1]  V. Montori,et al.  Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies , 2006, The Lancet.

[2]  D. Holbert,et al.  Body mass index and outcomes in critically injured blunt trauma patients: weighing the impact. , 2007, Journal of the American College of Surgeons.

[3]  E L Korn,et al.  Predictive Margins with Survey Data , 1999, Biometrics.

[4]  G. Hunter,et al.  Body fat distribution in white and black women: different patterns of intraabdominal and subcutaneous abdominal adipose tissue utilization with weight loss. , 2001, The American journal of clinical nutrition.

[5]  M. Rahm,et al.  The use of routine thoracoabdominal CT scans in the polytrauma patient to estimate obesity , 2012, Obesity.

[6]  R. S. Smith,et al.  The effect of obesity on outcomes among injured patients. , 2005, The Journal of trauma.

[7]  J. Bonventre,et al.  Ischemic acute renal failure: an inflammatory disease? , 2004, Kidney international.

[8]  P. Kimmel,et al.  Elevated plasma concentrations of IL-6 and elevated APACHE II score predict acute kidney injury in patients with severe sepsis. , 2006, Clinical journal of the American Society of Nephrology : CJASN.

[9]  A. Anzueto,et al.  Influence of body mass index on outcome of the mechanically ventilated patients , 2010, Thorax.

[10]  B. Riou,et al.  Impact of whole-body computed tomography on mortality and surgical management of severe blunt trauma , 2012, Critical Care.

[11]  D. Christiani,et al.  Body mass index and acute kidney injury in the acute respiratory distress syndrome , 2011, Critical care medicine.

[12]  M. Ibrahim.  Subcutaneous and visceral adipose tissue: structural and functional differences , 2010, Obesity reviews : an official journal of the International Association for the Study of Obesity.

[13]  I. Civil,et al.  The Abbreviated Injury Scale, 1985 revision: a condensed chart for clinical use. , 1988, The Journal of trauma.

[14]  J. McArdle,et al.  Obesity in the intensive care unit. , 2009, Clinics in chest medicine.

[15]  M. Rotondo,et al.  'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. , 1992, The Journal of trauma.

[16]  P. Metnitz,et al.  Impact of body mass on incidence and prognosis of acute kidney injury requiring renal replacement therapy , 2010, Intensive Care Medicine.

[17]  R. Bellomo,et al.  Incidence, Risk Factors and Outcome Associations of Intra-Abdominal Hypertension in Critically Ill Patients , 2012, Anaesthesia and intensive care.

[18]  L. Oud.  Reporting the methodology of height and weight acquisition in studies of body mass index-based prognosis in critically ill patients. , 2013, Journal of critical care.

[19]  M. Wachtel,et al.  Morbid Obesity Causes Chronic Increase of Intraabdominal Pressure , 2007, Digestive Diseases and Sciences.

[20]  R. Perkins,et al.  Acute kidney injury in the critically ill, morbidly obese patient: diagnostic and therapeutic challenges in a unique patient population. , 2010, Critical care clinics.

[21]  Christian Trautwein,et al.  Serum resistin levels in critically ill patients are associated with inflammation, organ dysfunction and metabolism and may predict survival of non-septic patients , 2009, Critical care.

[22]  Daniel Levy,et al.  Predictors of new-onset kidney disease in a community-based population. , 2004, JAMA.

[23]  B. F. Chatterjee,et al.  Abbreviated Injury Scale , 1983 .

[24]  P. Parsons,et al.  Predictive and pathogenetic value of plasma biomarkers for acute kidney injury in patients with acute lung injury * , 2007, Critical care medicine.

[25]  John A Kellum,et al.  Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury , 2007, Critical care.

[26]  M. Levi,et al.  The inflammation–coagulation axis as an important intermediate pathway in acute lung injury , 2008, Critical care.

[27]  P. Parsons,et al.  The association between BMI and plasma cytokine levels in patients with acute lung injury. , 2010, Chest.

[28]  M. Reilly,et al.  Gene Profiling of Human Adipose Tissue During Evoked Inflammation In Vivo , 2009, Diabetes.

[29]  S. Greenland,et al.  Simulation study of confounder-selection strategies. , 1993, American journal of epidemiology.

[30]  Dewey Odhner,et al.  3DVIEWNIX: an open, transportable software system for the visualization and analysis of multidimensional, multimodality, multiparametric images , 1993, Medical Imaging.

[31]  Lesly A. Dossett,et al.  Visceral adiposity is not associated with inflammatory markers in trauma patients. , 2010, The Journal of trauma.

[32]  J S Yudkin,et al.  Journal of Clinical Endocrinology and Metabolism Printed in U.S.A. Copyright © 1997 by The Endocrine Society Subcutaneous Adipose Tissue Releases Interleukin-6, But Not Tumor Necrosis Factor-�, in Vivo* , 2022 .

[33]  A. Localio,et al.  African American race, obesity, and blood product transfusion are risk factors for acute kidney injury in critically ill trauma patients. , 2012, Journal of critical care.

[34]  Burkhardt Seifert,et al.  Obese trauma patients are at increased risk of early hypovolemic shock: a retrospective cohort analysis of 1,084 severely injured patients , 2012, Critical Care.

[35]  Peili Chen,et al.  TNF induces caspase-dependent inflammation in renal endothelial cells through a Rho- and myosin light chain kinase-dependent mechanism. , 2009, American journal of physiology. Renal physiology.

[36]  J. Murabito,et al.  Visceral and Subcutaneous Adipose Tissue Volumes Are Cross-Sectionally Related to Markers of Inflammation and Oxidative Stress: The Framingham Heart Study , 2007, Circulation.

[37]  Lesly A. Dossett,et al.  Obesity and pulmonary complications in critically injured adults. , 2008, Chest.

[38]  R. Ross,et al.  Visceral Fat Is an Independent Predictor of All‐cause Mortality in Men , 2006, Obesity.

[39]  C. Cocanour,et al.  Supranormal trauma resuscitation causes more cases of abdominal compartment syndrome. , 2003, Archives of surgery.

[40]  J. Weissfeld,et al.  Sagittal diameter in comparison with single slice CT as a predictor of total visceral adipose tissue volume , 1998, International Journal of Obesity.

[41]  John D. Storey,et al.  A genomic storm in critically injured humans , 2011, The Journal of experimental medicine.

[42]  W. Frontera,et al.  Longitudinal changes in body composition in older men and women: role of body weight change and physical activity. , 2002, The American journal of clinical nutrition.

[43]  R. Bellomo,et al.  A Multi-Center Evaluation of Early Acute Kidney Injury in Critically Ill Trauma Patients , 2008, Renal failure.

[44]  J. Starkopf,et al.  Risk factors for intra‐abdominal hypertension in mechanically ventilated patients , 2011, Acta anaesthesiologica Scandinavica.

[45]  A. Ariza,et al.  Renal injury in the extremely obese patients with normal renal function. , 2008, Kidney international.

[46]  L. Moldawer,et al.  Traditional resuscitative practices fail to resolve metabolic acidosis in morbidly obese patients after severe blunt trauma. , 2010, The Journal of trauma.

[47]  Maria Crespo,et al.  Obesity and primary graft dysfunction after lung transplantation: the Lung Transplant Outcomes Group Obesity Study. , 2011, American journal of respiratory and critical care medicine.