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Introduction <p>Intra-abdominal hypertension (IAH) is a common complication in critically ill patients and is associated with increased mortality. While acute kidney injury (AKI) and respiratory impairment are also linked to IAH, their roles as mediators of mortality remain unclear. This study aimed to evaluate the associations between IAH and mortality, with a focus on AKI and pulmonary parameters as potential mediators.</p> Methods <p>This retrospective cohort study utilized the MIMIC-IV database and included adult patients admitted to the intensive care unit (ICU) with intra-abdominal pressure measurements. Patients with previous advanced kidney disease or early kidney replacement therapy (KRT) were excluded. Time-varying exposure to IAH, AKI status, and respiratory parameters were analyzed via marginal structural models (MSMs) and a mediational g-formula to assess the effects of mediation on mortality.</p> Results <p>Among the 555 patients, IAH was associated with mortality HR 2.20 (95% CI 1.54–2.56) and stage 3 AKI emerged as a significant mediator of IAH-associated mortality, accounting for almost half (41.5%, <i>p</i> &lt; 0.001) of the excess mortality. KRT was associated with a protective effect, reducing the hazard ratio for mortality by 16.6%. Although the need for mechanical ventilation per se mediated a statistically significant but small effect of IAH on mortality (4.2%), no respiratory parameters, including driving pressure, demonstrated a significant mediating role.</p> Conclusion <p>Severe acute kidney injury (stage 3) is a key mediator of IAH-related mortality in critically ill patients, whereas KRT was associated with a protective effect. The absence of an important mediating role for respiratory parameters suggests that the relationship between IAH and mortality is driven primarily by renal mechanisms. However, pulmonary impairment may not have been fully captured by the variables studied, particularly in a retrospective study. Unmeasured aspects of pulmonary dysfunction could still contribute to mortality.</p>

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Acute kidney injury is a major mediator of intra-abdominal pressure-related mortality in critically ill patients: a longitudinal analysis

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年1月30日

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  • Wlademir Roriz Neto,
  • Alexandre Braga Libório

摘要

Introduction

Intra-abdominal hypertension (IAH) is a common complication in critically ill patients and is associated with increased mortality. While acute kidney injury (AKI) and respiratory impairment are also linked to IAH, their roles as mediators of mortality remain unclear. This study aimed to evaluate the associations between IAH and mortality, with a focus on AKI and pulmonary parameters as potential mediators.

Methods

This retrospective cohort study utilized the MIMIC-IV database and included adult patients admitted to the intensive care unit (ICU) with intra-abdominal pressure measurements. Patients with previous advanced kidney disease or early kidney replacement therapy (KRT) were excluded. Time-varying exposure to IAH, AKI status, and respiratory parameters were analyzed via marginal structural models (MSMs) and a mediational g-formula to assess the effects of mediation on mortality.

Results

Among the 555 patients, IAH was associated with mortality HR 2.20 (95% CI 1.54–2.56) and stage 3 AKI emerged as a significant mediator of IAH-associated mortality, accounting for almost half (41.5%, p < 0.001) of the excess mortality. KRT was associated with a protective effect, reducing the hazard ratio for mortality by 16.6%. Although the need for mechanical ventilation per se mediated a statistically significant but small effect of IAH on mortality (4.2%), no respiratory parameters, including driving pressure, demonstrated a significant mediating role.

Conclusion

Severe acute kidney injury (stage 3) is a key mediator of IAH-related mortality in critically ill patients, whereas KRT was associated with a protective effect. The absence of an important mediating role for respiratory parameters suggests that the relationship between IAH and mortality is driven primarily by renal mechanisms. However, pulmonary impairment may not have been fully captured by the variables studied, particularly in a retrospective study. Unmeasured aspects of pulmonary dysfunction could still contribute to mortality.