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Evidence suggests AKI may induce neuroinflammation and impair clearance of neurotoxic metabolites, but the clinical relationship between AKI and delirium remains incompletely characterized. We hypothesized that AKI increases the risk of delirium in a biological gradient.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      We conducted a retrospective cohort study using two independent databases: MIMIC-IV (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200915,219 patients) and a local institutional database (Reality) from University Hospital M\u00fcnster (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20093,461 patients). Adult ICU patients with length of stay\u2009&gt;\u200912\u00a0h and validated delirium monitoring using the Confusion Assessment Method for the ICU (CAM-ICU) were included, with a positive assessment defining delirium presence. Patients with neurological\/neurosurgical primary diagnoses or pre-existing cognitive impairment, as well as patient with delirium onset before AKI were excluded. AKI was classified according to KDIGO criteria. We employed landmark analysis at 24\u00a0h post-ICU admission where AKI-status was recorded as the exposure variable. Subsequent delirium was recorded as follow-up during the ICU stay. Propensity score matching, and a Fine-Gray Model were added to assess the time-based association between AKI and subsequent delirium, independently of illness severity.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      At the 24-hour landmark, AKI was present in 58.6% (MIMIC-IV) and 55.6% (Reality) of patients. Rates of subsequent delirium were significantly higher in patients with AKI compared to those without: 25.6% versus 15.7% in MIMIC-IV (OR 1.84, CI 1.68\u20132.04,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001) and 12.1% versus 6.7% in Reality (OR 1.95, CI 1.44\u20132.64,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). After adjustment for confounders, AKI remained associated with delirium (adjusted-odds ratio [OR] 1.16, 95% CI 1.10\u20131.23 in MIMIC-IV; OR 1.20, 95% CI 1.01\u20131.41 in Reality). A biological gradient was observed, with delirium rates increasing progressively across AKI stages. In MIMIC-IV, adjusted-OR increased from 1.42 for Stage 1 to 4.11 for Stage 3 AKI (trend OR 1.55 per stage,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). The Reality cohort showed similar patterns (Stage 1 OR 1.01 and Stage 3 OR 1.92, trend OR 1.25 per stage,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.01). Propensity score matching confirmed these findings.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Acute kidney injury was associated with a higher risk of subsequent delirium in critically ill patients, with a graded association across AKI severity stages. Prospective studies are needed to determine whether interventions targeting AKI prevention or treatment can also reduce delirium burden.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s13054-026-05922-0","type":"journal-article","created":{"date-parts":[[2026,3,5]],"date-time":"2026-03-05T18:33:30Z","timestamp":1772735610000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Association between acute kidney injury and delirium in critically ill patients: a retrospective cohort study using two independent databases"],"prefix":"10.1186","volume":"30","author":[{"given":"Christian","family":"Porschen","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christian","family":"Strau\u00df","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sean M.","family":"Bagshaw","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John A.","family":"Kellum","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sven G.","family":"Meuth","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul","family":"Brauckmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ngoc-Anh Thi","family":"Nguyen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Fujarski","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Keyvan","family":"Mahjoory","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carla Barbara","family":"Schwienhorst","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander","family":"Zarbock","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,3,5]]},"reference":[{"issue":"8","key":"5922_CR1","doi-asserted-by":"publisher","first-page":"1411","DOI":"10.1007\/s00134-015-3934-7","volume":"41","author":"EAJ Hoste","year":"2015","unstructured":"Hoste EAJ, Bagshaw SM, Bellomo R, et al. 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Due to the retrospective nature of our study and the use of deidentified research data, the need for informed consent was waived in accordance with our local ethics board and regulatory framework. MIMIC-IV is licensed under the PhysioNet Credentialed Health Data Use Agreement 1.5.0 and prior approval was acquired for our study. Only appropriately trained researchers had access to the data.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"AZ has received consulting fees from Astute-Biomerieux, Baxter, Bayer, Novartis, Guard Therapeutics, AM Pharma, Paion, Viatris, Dropshot, Fresenius, research funding from Astute-Biomerieux, Fresenius, Baxter, and speaker fees from Astute-Biomerieux, Fresenius, Baxter, Alexion, and Paion. Although Prof. Zarbock is currently chair of the IZKF, there are no conflicts of interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"158"}}