Risk factors for and outcomes of acute kidney injury in ward-based hospital trauma admissions: A retrospective cohort analysis

Omar Kiwan; Elizabeth Finnimore; Benjamin D. James; Paul W. Robinson; Mohammed Al-Kalbani; Becky Bonfield; Darren Green

doi:10.1371/journal.pone.0326780

Peer Review History

Original SubmissionJanuary 16, 2025
Decision Letter - Tarek Samy Abdelaziz, Editor PONE-D-24-58849Risk factors for and outcomes of acute kidney injury in ward-based hospital trauma admissions: a retrospective cohort analysisPLOS ONE Dear Dr. Green, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jun 05 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible. We will update your Data Availability statement on your behalf to reflect the information you provide. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? 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Reviewer #1: Yes ******** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Hello! i just reviewed the article entitled "Risk factors for and outcomes of acute kidney injury in ward-based hospital trauma admissions: a retrospective cohort analysis" by Omar Kiwan et al. The authors aimed to identify factors associated with AKI development in trauma patients, stratified by age in >65 and <65 years. The article is overall well-written, with a good flow, but before considering publishing the article, i have some suggestions: 1. You showed that pelvic trauma was more often associated with AKI in younger patients. Perhaps the pelvic trauma lead to obstructive AKI. Due to the fact that you do not have the AKI cause mentioned in the article (you present this in the limitations of the study), perhaps you can identify the number of patients with urinary catheters during the admission. Anyway, you should write a paragraph in the discussion section regarding this aspect. 2. Indeed, you mention that you identified AKI using the ICD score. Many studies showed that AKI is underdiagnosed using this score system, as many doctors are unaware of AKI. You should mention this in the discussion part also (e.g. of citation: "Holmes, Jennifer; Rainer, Timothy; Geen, John; Roberts, Gethin; May, Kate; Wilson, Nick; Williams, John D.; Phillips, Aled O.; on behalf of the Welsh AKI Steering Group. Acute Kidney Injury in the Era of the AKI E-Alert. Clinical Journal of the American Society of Nephrology 11(12):p 2123-2131, December 2016. \| DOI: 10.2215/CJN.05170516"). 3. Do you have any data regarding the type of antalgic medication use? NSAID are know to increase the risk of AKI, especially in older or preexistent CKD patients. Being trauma patients, I consider that many of them required antalgic medication. If you can extract the number of days of NSAID and include this in the analysis of AKI occurrence, would increase the value of the results. 4. I consider you could remove this statement: "These are staples of care in heart failure, but only 50% of people who have experienced AKI will have RAASi reinstated by 6 months after AKI [20]. Readmission rates and long term survival are worse in heart failure patients who do not have these drugs reinitiated after AKI than those that do [21]." On the other hand you could talk about NSAID impact on heart failure patients and increased risk of AKI. Because you do not have follow-up after discharge, you should not present RAASi impact, unless you have data regarding RAASi use during hospitalization. 5. The discussion section seems short. You can increase it by 20-25% with no problem and you should introduce a paragraph or two regarding medical management of patients with trauma to reduce AKI incidence. 6. You can introduce in table 1 the LoS as a continuous variable. 7. Overall, a good article. Good luck! ******* 6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy . Reviewer #1: Yes: MD, PhD, Lazar Chisavu, University of Medicine and Pharmacy "Victor Babes" from Timisoara, Romania, Nephrology Department ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0326780.r001
Revision 1
29 Apr 2025 Author Response RESPONSE TO REVIEW PONE-D-24-58849 - Risk factors for and outcomes of acute kidney injury in ward-based hospital trauma admissions: a retrospective cohort analysis Dear colleagues, We would like to thank the editorial team and the external reviewer for their time and effort in considering this manuscript and for providing comments that enhance the quality of the paper. Please find below a point by point response to each comment. We have incorporated the feedback as much as possible in all cases, as all comments were fair and appreciated. Best wishes Darren Green Editorial comments: 1.Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. We have adjusted the manuscript formatting to meet the requirements as set out. 2. In the Competing Interests section please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” The cover letter has been changed to include the above statement as requested. 3. We note that you have indicated that there are restrictions to data sharing for this study. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. The study dataset can now be accessed without restrictions. We have uploaded the study dataset to the Harvard Dataverse: https://doi.org/10.7910/DVN/9MLEGR Reviewers' comments: 1. You showed that pelvic trauma was more often associated with AKI in younger patients. Perhaps the pelvic trauma lead to obstructive AKI. Due to the fact that you do not have the AKI cause mentioned in the article (you present this in the limitations of the study), perhaps you can identify the number of patients with urinary catheters during the admission. Anyway, you should write a paragraph in the discussion section regarding this aspect. The following paragraph has been added to the limitations section of the discussion, to address the point raised above. Our study did not assign a cause to each AKI. The association of pelvic trauma with higher risk of AKI raises the possibility of obstruction as a cause of AKI in the absence of specific AKI causality data. In our dataset there were no ICD10 coded episodes of urinary obstruction (N13.8, N13.9). OPCS4 coding for each admission identified 68 people who had non-elective urinary catheterisation during their admission. Overall, 3% of patients were catheterised. The figure for pelvic trauma was 9%. Other primary trauma sites with higher catheterisation rates were spinal and lower limb trauma, both 5% of cases. Older people were more likely to be catheterised (6% of patients aged ≥80 years versus 2% of those aged <40 years). Whilst it can be hypothesised that there is a relationship between pelvic trauma and obstruction as the cause of AKI, other factors such as prolonged immobilisation may also be the reason for catheterisation. 2. Indeed, you mention that you identified AKI using the ICD score. Many studies showed that AKI is underdiagnosed using this score system, as many doctors are unaware of AKI. You should mention this in the discussion part also (e.g. of citation: "Holmes, Jennifer; Rainer, Timothy; Geen, John; Roberts, Gethin; May, Kate; Wilson, Nick; Williams, John D.; Phillips, Aled O.; on behalf of the Welsh AKI Steering Group. Acute Kidney Injury in the Era of the AKI E-Alert. Clinical Journal of the American Society of Nephrology 11(12):p 2123-2131, December 2016. \| DOI: 10.2215/CJN.05170516"). The citation you mention has been added to the study references. The discussion has been amended to provide more detail on this: This study is not without limitations. Using ICD10 coding data means that our study is likely to have underestimated AKI rates. Epidemiological evidence shows that estimations of AKI incidence are much lower when using clinical identification or hospital coding data compared to laboratory data [21]. In addition, using AKI coding does not allow comparison of outcomes between AKI stages. AKI onset is not time stamped: the study does not differentiate between community and hospital-acquired AKI. 3. Do you have any data regarding the type of antalgic medication use? NSAID are know to increase the risk of AKI, especially in older or preexistent CKD patients. Being trauma patients, I consider that many of them required antalgic medication. If you can extract the number of days of NSAID and include this in the analysis of AKI occurrence, would increase the value of the results. Unfortunately our data capture does not include the ability to find robust / detailed records of analgesic prescriptions. We have added the following text to the discussion on this topic, which raises important considerations for AKI care / prevention in trauma. Analgesia is an important part of caring for people hospitalised for trauma. NSAIDs are a core component of effective pain relief but are themselves associated with worsening renal function. Our data capture did not include NSAID prescribing patterns but this is a topic deserving of consideration in future work on trauma-related AKI. Our hospital analgesic policy highlights the need to avoid NSAIDs in CKD and AKI, but whether the same is true for people at risk of AKI is worthy of exploration. 4. I consider you could remove this statement: "These are staples of care in heart failure, but only 50% of people who have experienced AKI will have RAASi reinstated by 6 months after AKI [20]. Readmission rates and long term survival are worse in heart failure patients who do not have these drugs reinitiated after AKI than those that do [21]." On the other hand you could talk about NSAID impact on heart failure patients and increased risk of AKI. Because you do not have follow-up after discharge, you should not present RAASi impact, unless you have data regarding RAASi use during hospitalization. We have removed this section as advised and included comment on NSAIDs as detailed in the response to point 3 above. 5. The discussion section seems short. You can increase it by 20-25% with no problem and you should introduce a paragraph or two regarding medical management of patients with trauma to reduce AKI incidence. We have included the following paragraph on management of AKI in trauma patients, alongside the additional text / paragraphs as per responses to comments 1,2 and 3 above. Overall, we recommend approaching AKI risk and management in trauma patients following standard approaches as per available guidelines and recommendations. Regular measurement of serum creatinine paired with monitoring of hydration and urine output will provide indicators of AKI at the earliest stage. Some trauma-associated AKI will be unavoidable given that the primary insult which will cause the AKI has occurred before admission. However, the severity and duration of AKI can be reduced with early recognition and intervention [15]. Urgent imaging is indicated in major trauma cases, most often using computerised tomography. This will involve contrast agents which are associated with AKI. However, there is emerging recognition that this association is overstated, and does not implicitly indicate causation [20]. This is because people requiring contrast CT are at risk of AKI due to the reason a CT is required. Recommendations are increasingly moving towards highlighting that avoiding the use of contrast due to concerns of AKI risk may actually cause harm by missing diagnoses on imaging. Trauma admissions are an example of this, and it is important to state in local AKI guidelines that contrast should be used where indicated. 6. You can introduce in table 1 the LoS as a continuous variable. LoS has been added to the table shown as median (range) for each group, page 10. 7. Overall, a good article. Good luck! Thank you for your kind words! Attachments Attachment Submitted filename: Response to reviewers.docx* https://doi.org/10.1371/journal.pone.0326780.r002
Decision Letter - Tarek Samy Abdelaziz, Editor Risk factors for and outcomes of acute kidney injury in ward-based hospital trauma admissions: a retrospective cohort analysis PONE-D-24-58849R1 Dear Dr. Green, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Tarek Samy Abdelaziz, MD,FRCP Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The authors performed the required changes. I consider the article improved. From my point of view, it is ready for publication. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy . Reviewer #1: Yes: Lazar Chisavu ******** https://doi.org/10.1371/journal.pone.0326780.r003
Formally Accepted
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