KDIGO clinical practice guidelines for acute kidney injury

Stress hyperglycemia ratio as a predictor of acute kidney injury and its outcomes in critically ill patients

This study investigated stress hyperglycemia ratio (SHR) for acute kidney injury (AKI) and clinical outcomes in intensive care unit (ICU). Key outcomes were AKI within 48 h after ICU admission, acute kidney disease (AKD), ICU mortality, 28-day mortality, 90-day mortality and 1-year mortality. The associations between SHR and outcomes was estimated via logistic regression, Cox proportional hazards regression, and restricted cubic spline (RCS) analyses. Subgroup analyses assessed the consistency of these associations. Totally 3,714 patients were included from the Medical Information Mart for Intensive Care IV. SHR was associated with an increased risk of AKI (ORadjusted 1.29 95%CI 1.05-1.59). Among AKI patients, SHR was associated with increased risks of AKD (ORadjusted 1.94 95%CI 1.57-2.39), ICU mortality (ORadjusted 2.31 95%CI 1.60-3.32), 28-day mortality (HRadjusted 1.39 95%CI 1.29-1.50), 90-day mortality (HRadjusted 1.37 95%CI 1.26-1.48), and 1-year mortality (HRadjusted 1.37 95%CI 1.27-1.47). RCS analysis revealed a linear relationship with AKI, a J-shaped relationship with AKD, and a U-shaped relationship with mortality. Subgroup analysis confirmed the consistency of relationship between SHR and AKI. SHR demonstrates significant associations with AKI incidence, and correlates with AKD progression/mortality in critically ill adult ICU patients, suggesting its potential as a risk stratification and prognostic tool for AKI management, though further prospective validation is required.

Crosstalk between macrophages and adjacent cells in AKI to CKD transition

Acute kidney injury (AKI), triggered by ischemia, sepsis, toxicity, or obstruction, is marked by a rapid impairment of renal function and could lead to the initiation and advancement of chronic kidney disease (CKD). The concept of AKI to CKD transition has gained much interest. Despite a series of studies highlighting the diverse roles of renal macrophages in the immune response following AKI, the intricate mechanisms of macrophage-driven cell-cell communication in AKI to CKD transition remains incompletely understood. In this review, we introduce the dynamic phenotype change of macrophages under the different stages of kidney injury. Importantly, we present novel perspectives on the extensive interaction of renal macrophages with adjacent cells, including tubular epithelial cells, vascular endothelial cells, fibroblasts, and other immune cells via soluble factors, extracellular vesicles, and direct contact, to facilitate the transition from AKI to CKD. Additionally, we summarize the potential therapeutic strategies based on the adverse macrophage-neighboring cell crosstalk.

Association between renal mean perfusion pressure and prognosis in patients with sepsis-associated acute kidney injury: insights from the MIMIC IV database

OBJECTIVE

To investigate the association between renal mean perfusion pressure (MPP) and prognosis in sepsis-associated acute kidney injury (SA-AKI).

METHODS

Data were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Group-based trajectory modeling (GBTM) was applied to identify dynamic MPP patterns, while restricted cubic spline (RCS) curves were utilized to confirm the non-linear relationship between MPP and mortality. Cox regression analysis assessed the risk of mortality across different MPP levels, adjusting for potential confounders. Subgroup analyses and sensitivity analyses were conducted to ensure the robustness of the findings.

RESULTS

A total of 2318 patients with SA-AKI were stratified into five MPP trajectories by GBTM. Patients in Traj-1 and Traj-2, characterized by consistently low MPP (<60 mmHg), demonstrated markedly higher 90-d mortality (62.86% and 26.98%). RCS curves revealed a non-linear inverse relationship between MPP and 90-d mortality, identifying 60 mmHg as the optimal threshold. Patients with MPP ≤ 60 mmHg exhibited significantly elevated 90-d mortality compared to those with MPP > 60 mmHg (29.81% vs. 20.88%). Cox regression analysis established Traj-1 and Traj-2 as independent risk factors for increased mortality relative to Traj-3 (60-70 mmHg), with hazard ratios (HRs) of 4.67 (95%-CI 3.28-6.67) and 1.45 (95%-CI 1.20-1.76). MPP > 60 mmHg was significantly associated with reduced 90-d mortality (HR 0.65, 95%-CI 0.55-0.77). Subgroup and PSM analyses supported these findings.

CONCLUSIONS

Dynamic MPP trajectory serves as a valuable prognostic biomarker for SA-AKI. Early monitoring of MPP trends offers critical insights into renal perfusion management, potentially improving outcomes in SA-AKI.

Utilization of lactate trajectory models for predicting acute kidney injury and mortality in patients with hyperlactatemia: insights across three independent cohorts

This study aims to investigate the association between lactate trajectories and the risk of acute kidney injury (AKI) and hospital mortality in patients with hyperlactatemia. We conducted a multicenter retrospective study using data from three independent cohorts. By the lactate levels during the first 48 h of ICU admission, patients were classified into distinct lactate trajectories using group-based trajectory modeling (GBTM) method. The primary outcomes were AKI incidence and hospital mortality. Logistic regression analysis assessed the association between lactate trajectories and clinical outcomes, with adjusting potential confounders. Patients were divided into three trajectories: mild hyperlactatemia with rapid recovery (Traj-1), severe hyperlactatemia with gradual recovery (Traj-2), and severe hyperlactatemia with persistence (Traj-3). Traj-3 was an independent risk factor of both hospital mortality (all p < 0.001) and AKI development (all p < 0.001). Notably, Traj-2 was also associated with increased risk of mortality and AKI development (all p < 0.05) using Traj-1 as reference, except for the result in the Tianjin Medical University General Hospital (TMUGH) cohort for mortality in adjusted model (p = 0.123). Our finding was still robust in subgroup and sensitivity analysis. In the combination cohort, both Traj-2 and Traj-3 were considered as independent risk factor for hospital mortality and AKI development (all p < 0.001). When compared with the Traj-3, Traj-2 was only significantly associated with the decreased risk of hospital mortality (OR 0.17, 95% CI 0.14-0.20, p < 0.001), but no with the likelihood of AKI development (OR 0.90, 95% CI 0.77-1.05, p = 0.172). Lactate trajectories provide valuable information for predicting AKI and mortality in critically ill patients.

Stress hyperglycemia ratio as an independent predictor of acute kidney injury in critically ill patients with acute myocardial infarction: a retrospective U.S. cohort study

BACKGROUND

Acute kidney injury (AKI) is a frequent and severe complication in critically ill patients with acute myocardial infarction (AMI), significantly worsening prognosis. Identifying early risk markers for AKI in AMI patients is critical for timely intervention. The stress hyperglycemia ratio (SHR), a marker of acute glycemic response to physiological stress, has been proposed as a predictor of AKI, but its role remains unclear.

OBJECTIVE

This study investigates the association between SHR and AKI development in critically ill patients with AMI, using data from the MIMIC-III and MIMIC-IV databases.

METHODS

A total of 4,663 critically ill AMI patients were analyzed. SHR was evaluated for its association with AKI incidence using logistic regression, restricted cubic splines, and mediation analysis. Subgroup and sensitivity analyses were performed to confirm robustness. Additionally, Cox regression and Kaplan-Meier survival analysis were used to explore SHR's association with in-hospital mortality in the overall cohort and AKI subgroup.

RESULTS

Higher SHR levels were independently associated with an increased risk of AKI, demonstrating a J-shaped relationship. Mediation analysis revealed that neutrophil count and albumin partially mediated this effect. Kaplan-Meier survival curves showed significant differences in in-hospital mortality among SHR quartiles (log-rank p < 0.001). However, Cox regression analysis indicated that SHR was not an independent predictor of in-hospital mortality in either the full cohort or the AKI subgroup.

CONCLUSIONS

SHR serves as an early and independent marker for AKI risk in critically ill AMI patients, offering potential utility in clinical risk stratification. However, its role in predicting in-hospital mortality appears limited. These findings underscore the importance of glycemic monitoring and management in AMI patients at risk of AKI.

Living Donor Liver Transplantation for Pediatric Wilson's Disease-related Acute Liver Failure-Hard Work With High Rewards

Background

Liver transplantation (LT) is indicated for children with Wilson's disease (WD) presenting with acute liver failure (ALF) or with chronic liver disease (CLD) that has progressed to decompensation. We present our experience of living donor liver transplantation (LDLT) for pediatric WD, discuss the challenges of managing WD-ALF and compare outcomes of children presenting with WD-ALF with WD-CLD.

Methods

We compared presentation and outcomes of the WD-ALF and WD-CLD cohorts. Fifty-three children (WD-ALF: 28 (53%), WD-CLD: 25 (47%)) underwent LDLT for WD.

Results

WD-ALF group had higher Kings New Wilson Index (KNWI) (15 vs 9, P = 0.001), higher pediatric end-stage liver disease/model for end-stage liver disease score (35 vs 20, P = 0.001), were more frequently encephalopathic (64% vs 4%, P = 0.001), and had ongoing hemolysis (86% vs 28%, <0.001). Preoperative mechanical ventilation, operative continuous renal replacement therapy (CRRT), therapeutic plasma exchange (TPE) was needed in 32%, 46.5%, and 89% of WD-ALF children, respectively. WD-ALF patients had longer postoperative ICU stay (4.5 days vs 3 days, P = 0.001), longer hospital stay (20.5 days vs 14 days, P = 0.001), more major complications (57% vs 20%, P = 0.006). WD-ALF cohort also had more postoperative neurological complications (42.9% vs 8%, P = 0.004) and invasive fungal infections (21.4% vs none, P = 0.024). There were two perioperative (90 day) mortalities in WD-ALF group and none in WD-CLD group. Patient survival of the entire cohort at median follow-up of 26 months was 94.3% and all survivors had good allograft function neurological sequelae. Patient survival was inferior for WD-ALF cohort though the difference was not statistically significant (88.5% vs 100%, log rank test, P = 0.089).

Conclusion

LDLT is a curative treatment for children with WD with excellent short-term and long-term outcomes. WD-ALF patients can have a complicated postoperative course but have good long-term survival.

Incidence and outcome of rhabdomyolysis after type A aortic dissection surgery: A retrospective analysis

BACKGROUND

Rhabdomyolysis (RML) as an etiological factor causing acute kidney injury (AKI) is sparsely reported in the literature.

AIM

To study the incidence of RML after surgical repair of an ascending aortic dissection (AAD) and to correlate with the outcome, especially regarding renal function. To pinpoint the perioperative risk factors associated with the development of RML and adverse renal outcomes after aortic dissection repair.

METHODS

Retrospective single-center cohort study conducted in a tertiary cardiac center. We included all patients who underwent AAD repair from 2011-2017. Post-operative RML workup is part of the institutional protocol; studied patients were divided into two groups: Group 1 with RML (creatine kinase above cut-off levels 2500 U/L) and Group 2 without RML. The potential determinants of RML and impact on patient outcome, especially postoperative renal function, were studied. Other outcome parameters studied were markers of cardiac injury, length of ventilation, length of stay in the intensive care unit), and length of hospitalization.

RESULTS

Out of 33 patients studied, 21 patients (64%) developed RML (Group RML), and 12 did not (Group non-RML). Demographic and intraoperative factors, notably body mass index, duration of surgery, and cardiopulmonary bypass, had no significant impact on the incidence of RML. Preoperative visceral/peripheral malperfusion, though not statistically significant, was higher in the RML group. A significantly higher incidence of renal complications, including de novo postoperative dialysis, was noticed in the RML group. Other morbidity parameters were also higher in the RML group. There was a significantly higher incidence of AKI in the RML group (90%) than in the non-RML group (25%). All four patients who required de novo dialysis belonged to the RML group. The peak troponin levels were significantly higher in the RML group.

CONCLUSION

In this study, we noticed a high incidence of RML after aortic dissection surgery, coupled with an adverse renal outcome and the need for post-operative dialysis. Prompt recognition and management of RML might improve the renal outcome. Further large-scale prospective trials are warranted to investigate the predisposing factors and influence of RML on major morbidity and mortality outcomes.

Effect of regional citrate anticoagulation vs. low molecular weight heparin anticoagulation in continuous renal replacement therapy for critically ill patients: A retrospective cohort study

INTRODUCTION

This study aimed to assess the efficacy and safety of regional citrate anticoagulation (RCA) and low molecular weight heparin anticoagulation (LMHA) in critically ill patients undergoing continuous renal replacement therapy (CRRT).

METHODS

The clinical data of patients who underwent CRRT at Inner Mongolia People's Hospital from January 2022 to March 2024 were collected. Patients were divided into the RCA group and the LMHA group. The primary outcomes were filter survival time and 28-day mortality. The secondary outcomes were adverse events of CRRT anticoagulation.

RESULTS

The filter lifespan of the RCA group was significantly extended (33.5 vs. 27.5 h, p ≤ 0.001), and the occurrence of filter coagulation events in the RCA group was markedly reduced (7.0% vs. 21.1%, p = 0.03). There were no statistically significant differences in bleeding and electrolyte disturbances between the two groups. The multivariate COX regression analysis demonstrated that the anticoagulation strategy was the singular factor influencing filter survival time (hazard ratio [HR] = 4.74, 95% CI 1.67-13.50, p = 0.004).

CONCLUSIONS

RCA demonstrated significantly prolonged filter lifespan and reduced instances of filter clotting compared to LMHA. RCA represents a safe and effective anticoagulation strategy for CRRT.

Generalization of regional citrate anticoagulation for continuous renal replacement therapy is not associated with an increased rate of severe complications

BACKGROUND

Contraindications to regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) have recently been challenged. We aimed to assess the safety of the generalization of RCA to all CRRT sessions.

METHODS

We reviewed all CRRT sessions performed in our ICU during two periods (P1:2018-2019 and P2:2020-2022). RCA was considered as contraindicated in situations at risk of citrate accumulation (lactate >4 mmol/L and/or prothrombin time < 40 %) during P1 but not P2. We reviewed CRRT modality, filter lifespan, and therapy-associated complications including citrate accumulation, electrolyte and acid/base disturbances, and blood transfusion requirements. CRRT efficacy was assessed by serum creatinine and urea kinetics across circuits' lifespan.

RESULTS

We studied 1877 circuits in 467 (P1:245, P2:222) patients. The proportion of patients with risk factors for citrate accumulation was similar between both periods (P1:35 %, P2:32 % p = 0.61). During P2, RCA was used in more circuits (93 vs 66 %, p < 0.001) and filter lifespan was longer (44 vs 32 h, p < 0.001). CRRT efficacy was similar between the two periods. Although risk factors for citrate accumulation were present at first circuit initiation in more RCA circuits during P2 (25 vs 11 %, p = 0.002), the rate of citrate accumulation remained similar (0.3 vs 0.4 %, p = 0.72). There was no increase in the rates of electrolyte disturbances or significant bleeding. There was, however, a higher rate of metabolic acidoses during P2 (13 vs. 9 %, p = 0.01).

CONCLUSION

In an experienced team, generalization of RCA to nearly all patients requiring CRRT extended median filter lifespan without increasing the rate of significant complications.

Cardiogenic shock in patients with active onco-hematological malignancies: A multicenter retrospective study

PURPOSE

Onco-hematological (OH) patients face significant cardiovascular risks due to malignancy and drug toxicity. Data are limited on the characteristics and outcomes of OH patients with cardiogenic shock (CS) in intensive care units (ICUs).

METHODS

This multicenter retrospective study included 214 OH patients with CS across 22 ICUs (2010-2021). The objectives were to (i) identify risk factors for 30-day mortality, (ii) describe early and long-term outcomes, and (iii) assess the prognostic impact of malignancy by comparing OH patients to a control group of CS patients.

RESULTS

The 30-day survival rate was 44.8 %. Multivariate analysis identified previous cardiomyopathy (OR = 1.61), acute kidney injury (OR = 1.62), lactate levels (OR = 1.08 per 1 mmol/L), pulmonary embolism (OR = 3.04), invasive mechanical ventilation (OR = 3.48), and epinephrine use (OR = 2.09) as factors associated with 30-day mortality. Among ICU survivors, 54 % were alive at 1 year with a median left ventricular ejection fraction of 52 %. OH malignancy was significantly associated with 30-day mortality (HR 2.54).

CONCLUSION

The prognosis for OH patients with CS in the ICU is poor, with epinephrine use associated with worse outcomes. Further research is needed to refine risk stratification and improve treatments for this population.

CircPICALM promotes neonatal acute kidney injury triggered by hypoxia/reoxygenation via sponging microRNA-204-5p

BACKGROUND

Circular RNAs (circRNAs) have been documented to regulate neonatal acute kidney injury (AKI). Based on previous RNA-sequence findings, circPICALM exhibited significantly disparate expression between AKI newborns and Controls. This study aimed to provide further insights into the regulatory mechanism of circPICALM in neonatal AKI.

METHODS

C57BL/6 mice born 7 days were divided into Control group and hypoxia groups (11%O2 and 8%O2 groups). Human tubule epithelial cells (HK-2) were stimulated with hypoxia/reoxygenation (H/R) to establish an AKI cell model. Through overexpression and knockdown techniques, the regulatory role of circPICALM in H/R-induced kidney injury was explored. Inflammatory cytokines, cell apoptosis, and oxidative stress were also detected to confirm the regulatory function of circPICALM in neonatal AKI.

RESULTS

RT-qPCR confirmed that circPICALM was highly expressed in the serum of AKI newborns, neonatal I/R mice and H/R-treated HK-2 cells. Functionally, circPICALM exacerbated H/R-induced HK-2 cell injury by aggravating apoptosis and mitochondrial oxidative stress, increasing the expression of inflammatory factors, including IL-6, IL-1β, and TNF-α. Conversely, inhibition of circPICALM alleviated H/R injury in the HK-2 cell line. The interaction between circPICALM and miR-204-5p was validated through RNA immunoprecipitation and luciferase assay. Finally, circPICALM functioned as a molecular sponge of miR-204-5p and promoted the upregulation of downstream IL-1β expression.

CONCLUSION

CircPICALM plays a critical role in H/R-induced neonatal AKI by sponging miR-204-5p and then activating the downstream IL-1β signaling axis. The inhibition of circPICALM and subsequent suppression of pro-inflammatory factors could serve as a promising biomarker and therapeutic target for early intervention in neonatal AKI.

Risk of Contrast-Induced Acute Kidney Injury in Computed Tomography: A 16 Institutional Retrospective Cohort Study

OBJECTIVES

Concern about contrast-induced acute kidney injury (CI-AKI) may delay the timely administration of contrast media for computed tomography (CT). The precise causative effect of iodinated contrast media on CI-AKI and its relevant risk factors remains an area of ongoing investigation. Therefore, this study aimed to determine the risk of CI-AKI following contrast-enhanced CT and its predisposing risk factors.

MATERIALS AND METHODS

This study employed a 1:1 propensity score matching analysis using electronic medical records gathered between January 2006 and December 2022 from 16 institutions in South Korea. Contrast-enhanced and nonenhanced CT scans in patients aged 18 years and above were matched for baseline estimated glomerular filtration rate (eGFR), demographic characteristics, and clinical variables to assess the risk of CI-AKI. Subgroup analyses were conducted to evaluate any significant risk factors for CI-AKI.

RESULTS

A total of 182,170 CT scans with contrast were matched to 182,170 CT scans without contrast. The risk of CI-AKI in the entire study cohort was not statistically significant (odds ratio [OR], 1.036; 95% confidence interval [CI], 0.968-1.109; P = 0.34). Subgroup analyses revealed a significantly higher risk of CI-AKI in patients with eGFR <30 mL/min/1.73m 2 (OR, 1.176; 95% CI, 1.080-1.281; P = 0.011) or eGFR 30-45 mL/min/1.73m 2 (OR, 1.139; 95% CI, 1.043-1.244; P = 0.019), patients diagnosed with chronic kidney disease (OR, 1.215; 95% CI, 1.084-1.361; P = 0.011), and those administered with iso-osmolar contrast media (OR, 1.392; 95% CI, 1.196-1.622; P = 0.011).

CONCLUSIONS

The risk of CI-AKI following CT was minimal in the general population. However, caution is warranted for patients with chronic kidney disease and eGFR lower than 45 mL/min/1.73m 2 , or those administered with iso-osmolar contrast media.

Predicting a strongly positive fluid balance in critically ill patients with acute kidney injury: A multicentre, international study

BACKGROUND

In critically ill patients with acute kidney injury (AKI), a fluid balance (FB) > 2 L at 72 h after AKI diagnosis is associated with adverse outcomes. Identification of patients at high-risk for such fluid accumulation may help prevent it.

METHODS

We used Australian electronic medical record (EMR)-based clinical data to develop the "AKI-FB risk score", validated it in a British cohort and used it to predict a positive FB >2 L at 72 h after AKI diagnosis.

RESULTS

We developed the AKI-FB score in 32,030 patients with a median age of 63 years and a median APACHE 2 score of 16. We validated it in 4465 patients, with significant differences in admission diagnoses and interventions. The key score variables were admission after trauma, sepsis or septic shock, and, on the day of AKI diagnosis, highest creatinine, daily cumulative FB, mechanical ventilation, noradrenaline use, noradrenaline equivalent dose >0.07 μg/kg/min, lactate ≥2 mmol/L, transfusion, and nutritional support. A score threshold of 32 had a sensitivity of 75 % and a specificity of 72 % for predicting a > 2 L positive FB with an AUC-ROC of 0.805; 95 % CI 0.799 to 0.810. External validation demonstrated an AUC of 0.761 (95 % CI 0.746 to 0.775).

CONCLUSION

We developed and validated the "AKI-FB risk score" to predict patients who developed a positive FB >2 L within 72 h of AKI diagnosis. This prediction score was robust and facilitated the identification of high-risk AKI patients who could be the tarted for preventive measures and be included in future clinical trials of FB management.

Treatment of Additional Vessels During Percutaneous Coronary Intervention for Unprotected Left Main Disease: Insights From a Large Prospective Registry

Percutaneous coronary intervention (PCI) is an established alternative to coronary artery bypass grafting for the treatment of select patients with unprotected left main (LM) coronary artery disease (CAD). This study evaluates the safety and clinical impact of treating additional coronary arteries during LM-PCI. Consecutive patients undergoing PCI with drug-eluting stents for unprotected LM-CAD between 2010 and 2021 at The Mount Sinai Hospital, New York, USA were eligible for inclusion. Patients were stratified based on whether they underwent treatment of the LM complex alone or had concomitant PCI to an additional vessel outside the LM complex. The primary outcome was major adverse cardiovascular events (MACE), a composite of death, myocardial infarction, or stroke, at 1 year following PCI. Among 869 consecutive patients (mean age 70.9, 33.0% female, 27.9 mean SYNTAX score) undergoing LM-PCI, 479 (55.1%) underwent treatment of the LM complex alone, and 390 (44.9%) had concomitant PCI of an additional non-LM vessel. Compared with LM complex PCI only, there were no significant differences in the rate of MACE at 1 year [HR 12.0% vs 13.3%; HR: 0.95; 95% CI (0.62-1.44), p = 0.797], even after adjustment for potential confounders [HR 12.0% vs 13.3%; HR: 0.87; 95% CI (0.56-1.36), p = 0.550]. In conclusion, in a large, real-world cohort of patients undergoing unprotected LM-PCI, treatment of an additional non-LM vessel did not increase the risk of MACE at 1 year compared to LM complex PCI alone.

Temporal trends in patient demographics and kidney outcomes in cardiac surgery: a regional Danish follow-up study

OBJECTIVES

Chronic kidney disease can develop as a long-term complication after cardiac surgery-a condition associated with increased risk of new cardiovascular events, readmissions and mortality. Diagnosis is often delayed, as the condition is asymptomatic in early stages and post-discharge kidney follow-up is not routinely performed. We aimed to evaluate the occurrence and timing of chronic kidney disease after cardiac surgery in patients with normal preoperative kidney function and describe associated temporal trends in risk factors and mortality.

METHODS

Patients undergoing cardiac surgery at Odense University Hospital, Denmark, between January 2000 and May 2022 were identified from the Western Denmark Heart Registry. Clinical data were extracted and merged with biochemical data from regional laboratory systems. Only the most recent operation was included in the analysis. Patients with pre-existing kidney disease and endovascular procedures were excluded.

RESULTS

A total of 13 299 patients were included. Median follow-up time was 88 months (42-141 months). Competing risk analysis revealed that 13.8% developed chronic kidney disease within 3 years after surgery and 18.8% within 5 years. Overall 90-day mortality was 3.6%, and 1-year mortality was 5.1%, with variations over time. During the observation period, patients became older and more comorbid, while preoperative kidney function improved. Postoperative acute kidney injury occurred in 25-30% of patients, with increasing severity over time.

CONCLUSIONS

Chronic kidney disease is a common and serious complication following cardiac surgery. Identification of patients in high risk of chronic kidney disease is important to develop post-discharge follow-up programs and improve patient outcomes.

Effects of an extended therapeutic strategy versus standard-of-care therapy on persistent acute kidney injury in high-risk patients after major surgery: study protocol for the randomised controlled single-centre PrevProgAKI trial

INTRODUCTION

Persistent acute kidney injury (AKI) is associated with an increased morbidity and mortality. In patients with an already established AKI, the new urinary biomarker C-C motif chemokine ligand 14 (CCL14) can predict a persistent AKI. However, it is still unknown whether the implementation of nephroprotective measures in patients with an already established moderate/severe AKI can positively influence the trajectory of AKI and patients' outcome.

METHODS AND ANALYSIS

The PrevProgAKI trial is a randomised, controlled, single-centre trial designed to evaluate the effectiveness of nephroprotective measures in patients with established moderate/severe AKI. We aim to enrol 480 patients with moderate or severe AKI (Kidney Disease: Imroving Global Outcomes, KDIGO, stage 2 or 3) within 72 hours of major surgery. Eligible patients will be randomised to receive either standard of care (control group) or an extended therapeutic strategy that consists of different supportive measures (intervention group). The randomisation will be stratified by urinary CCL14 results (CCL14<1.3 ng/mL or CCL14≥1.3 ng/mL). Treating physicians will be blinded to the test results. The primary endpoint is a composite of the development of persistent severe (stage 3) AKI, need for renal replacement therapy or death within 72 hours. The key secondary endpoint is the composite of death, initiation of renal replacement therapy within 90 or persistent renal dysfunction at day 90.

ETHICS AND DISSEMINATION

The PrevProgAKI trial has been approved by the Ethics Committee of the Chamber of Physicians Westfalen-Lippe and the University of Muenster (no. 2021-569 f-S). Results will be disseminated widely and published in peer-reviewed journals, presented at conferences and will guide patient care and further research.

TRIAL REGISTRATION NUMBER

NCT05275218 (clinicaltrials.gov), first posted 11 March 2022.

Superior Clinical Results with Intraosseous Vancomycin in Primary Total Knee Arthroplasty

INTRODUCTION

Periprosthetic joint infection (PJI) remains a feared complication after total knee arthroplasty (TKA). This study reports updated outcomes of the incidence of PJI, adverse reactions, and complications of our cohort with increased clinical follow-up of our previous study reported in 2021.

METHODS

A retrospective review of 1,923 knees that received either IV or IO vancomycin during primary TKA between May 2016 and May 2023 with a minimum 90-day follow-up (mean 913 ± 611 days). There were 564 cases in the IV group and 1,359 in the IO group. The IV group received a weight-based dose of vancomycin before incision, and the IO group received 500 mg of vancomycin in the proximal tibia after tourniquet inflation. All patients received a weight-based dose of IV cefazolin perioperatively. The 2018 International Consensus Meeting criteria were used to diagnose PJI. Acute kidney injury (AKI) was defined as a creatinine increase of 0.3 mg/dL.

RESULTS

The IO group demonstrated a significantly lower incidence of PJI compared to the IV group at 90-day (0.5 versus 1.6%, P = 0.018), 1-year (0.7 versus 1.8%, P = 0.048), and 2-year (0.9 versus 2.4%, P = 0.032) follow-up. Additionally, there was a lower incidence of non-operative wound complications requiring oral antibiotics in the IO group at 30-day (2.3 versus 4.3%, P = 0.023) and at 90-day (2.5 versus 5.4%, P = 0.003) follow-up. There was a lower incidence of AKI in the IO group (1.6 versus 3.2%, P = 0.078), but this did not reach statistical significance. There was no difference in the incidence of deep vein thrombosis, pulmonary embolism, or operative wound complications.

CONCLUSIONS

Intraosseous vancomycin demonstrated superior clinical outcomes over IV vancomycin with a reduced incidence of PJI at 90-day, 1- and 2-year follow-up after primary TKA. Additional benefits of IO vancomycin were a reduction in non-operative wound complications through 90-day follow-up and a non-statistically significant reduction in the incidence of AKI.

Aggressive Up-titration of Heart Failure Guideline-Directed Medical Therapies in Cardiogenic Shock Supported by a Percutaneous Ventricular Assist Device

BACKGROUND

Survival after cardiogenic shock (CS) remains dismal and largely unaltered in clinical trials, contrasting heart failure with reduced ejection fraction where new drugs have established guideline directed therapy, improving long term outcomes. Unfortunately, unfavorable effects on blood pressure and glomerular perfusion limits their use in CS. A percutaneous ventricular assist device (pVAD) supports cardiac output and blood pressure, offering an option to counteract these negative drug effects.

OBJECTIVES

This study aimed to evaluate if a protocol prolonging pVAD support to up-titrate heart failure drugs, is feasible and safe.

METHODS

All CS patients treated with pVAD after the introduction of the protocol in October 2021 were included as was a control group of patients between 2019 and October 2021. Data were retrospectively extracted from health records to calculate the use of heart failure drugs and study outcomes.

RESULTS

28 patients were in the intervention cohort, 33 in the historical cohort. Median ages were 61 and 68 years and acute myocardial infarction was predominant etiology. SCAI shock stages were D or E in 82% vs 69% (p=0.449). Lactate levels were 6.2 mmol/L (2.8-9.9 mmol/L) and 6.6 mmol/L (2-12 mmol/L); p=0.341. In the intervention group, at discharge, 94% was treated with spironolactone 25 mg, 94% with dapagliflozin/empaglifozin 10 mg, 100% with valsartan or sacubitril/valsartan and 94% with rate control, associated to significantly higher treatment intensity, compared to the historical cohort. 90-day survival was 71% in the intervention group vs 52% in the historical cohort (p=0.081), and complications rates were comparable.

CONCLUSION

Prolonging pVAD support to uptitrate medical therapy is feasible and safe.

Rhabdomyolysis in patients with COVID-19: A cause or consequence of acute kidney injury or mortality?

Rhabdomyolysis can occur due to many traumatic and nontraumatic causes. Rhabdomyolysis has been reported in new type of coronavirus disease (COVID-19) cases. The aim of our study was to examine the effects of rhabdomyolysis on mortality and renal outcomes in patients hospitalized in our hospital's COVID-19 wards. In our single-center and retrospective study, we included patients who were admitted with a diagnosis of COVID-19 by a thorax-computed tomography finding who were older than 18 years of age and with a measured creatinine kinase (CK) > 1000 U/L on any day of hospitalization. The same number of patients hospitalized in COVID-19 services with CK < 1000 U/L and with similar gender and age were determined as the control group. We analyzed the data of 2065 patients, and compared 154 patients in the rhabdomyolysis group (group 1) and 154 patients in the control group (group 2). Acute kidney injury (AKI) (44.2% vs 21.4%; P < .001), intensive care unit (ICU) admissions (53.2% vs 13.6%; P < .001), intubation (75.6% vs 23.8%; P < .001), mortality (36.4% vs 3.2%; P < .001) and the need for dialysis (3.9% vs 0.6%; P = .005) were seen more in the rhabdomyolysis group. When that group was divided into the early rhabdomyolysis group (group 1a), where the CK value reached its highest value in ≤3 days, and the late rhabdomyolysis group (group 1b), where it was ≥ 4 days, AKI (29.7% vs 65.1%; P < .001), ICU (35.2% vs 79.4%; P < .001), intubation (56.2% vs 88%; P = .001), mortality (18% vs 61.9%; P < .001), and dialysis (1.1% vs 7.9%; P = .031), the results were higher in the group 1b. The available data suggest that rhabdomyolysis seen in COVID-19 patients is not a direct predictor of mortality and poor renal outcomes, but is a secondary outcome to multiple-organ failure caused by worsening clinical status.

Adequate posology of antimicrobial therapy in the septic critically ill in continuous veno-venous hemofiltration: a single centre prospective observational study

BACKGROUND

Determining the optimal antibiotic (ATB) dosage in septic critically ill patients on continuous renal replacement therapy (CRRT) is still challenging. CRRT further disrupts antibiotic PK, already altered by sepsis-induced fluid shifts, volume of distribution (VD) changes and half-life modifications.

MATERIALS AND METHODS

Our multi-disciplinary team-comprising an intensivist, nephrologist and clinical pharmacologist-conducted a prospective observational cohort study to evaluate the extent of ATB removal by CRRT and to assess the pharmacokinetic/pharmacodynamic (PK/PD) parameters of the most commonly used antibiotics for treating severe infections.

RESULTS

A total of 135 ATB therapeutic drug monitoring (TDM) assessments were conducted, measuring total drug concentrations (C) in both plasma (P) and ultrafiltrate in 85 septic patients undergoing CRRT. A high sieving coefficient (∼75%) was recorded for all antibiotics, with CRRT-related drug loss described by the following equations: (i) [CUF-ATB](trough level) = 0.77 × [CP-ATB](trough level) + 0.93 ng/mL; (ii) [CUF-ATB](peak) = 0.77 × [CP-ATB](peak) + 3.1 ng/mL. The VD exhibited wide variability, with values exceeding those reported in the literature. Lower ATB molecular weight and steric hindrance were associated with a higher elimination rate constant (Kemin⁻¹). ATB TDM consistently correlated with AUC and AUC/MIC, ensuring effective bactericidal activity.

CONCLUSIONS

Despite its limitations, our study suggests to carry out a loading dose for the main antibiotics and consider the daily drug loss, as identified by the linear regression equation, along with daily TDM to guide further dosing adjustments.

How Would We Prevent Our Own Acute Kidney Injury After Cardiac Surgery?

Acute Kidney Injury (AKI) is a common complication after cardiac surgery affecting up to 40% leading to increased morbidity and mortality. To date, there is no specific treatment for AKI, thus, clinical research efforts are focused on preventive measures. The only pharmacological preventive intervention that has demonstrated a beneficial effect on AKI in a high-quality, double-blind, randomized controlled trial is a short perioperative infusion of a balanced mixture of amino acid solution. Amino acid infusion reduced the incidence of AKI by recruiting renal functional reserve and, therefore, increasing the glomerular filtration rate. The beneficial effect of amino acids was further confirmed for severe AKI and applied to patients with chronic kidney disease. Among non-pharmacological interventions, international guidelines on AKI suggest the implementation of a bundle of good clinical practice measures to reduce the incidence of perioperative AKI or to improve renal function whenever AKI occurs. The Kidney Disease Improving Global Outcomes (KDIGO) bundle includes the discontinuation of nephrotoxic agents, volume status and perfusion pressure assessment, renal functional hemodynamic monitoring, serum creatine, and urine output monitoring, and the avoidance of hyperglycemia and radiocontrast procedures. However, pooled data from a meta-analysis did not find a significant reduction in AKI. The aim of this review is to delineate the most appropriate evidence-based approach to prevent AKI in cardiac surgery patients.

Effect of Post-Acute Kidney Injury Use of Renin-Angiotensin Inhibitors on Long-term Mortality and Major Adverse Kidney Events: A 5-year Retrospective Observational Cohort Study

Rationale & Objective

Acute kidney injury (AKI) is common in hospitalized adults and a risk factor for chronic kidney disease and mortality. The effect of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) post-AKI on mortality and long-term kidney function remains unclear.

Study Design

Propensity-weighted retrospective observational cohort study.

Setting & Participants

A total of 3,289 patients with AKI admitted to a tertiary care hospital from November 2015-October 2016, with follow-up until September 2020.

Exposures

ACEi/ARB use within 180 days post-AKI.

Outcomes

All-cause mortality, and major adverse kidney events (MAKE) as defined by composite of renal replacement therapy post-AKI, sustained estimated glomerular filtration rate (eGFR) decline >30% from baseline, or eGFR ≤15 mL/min/1.73 m2.

Analytical Approach

We generated propensity weights for ACEi/ARB use post-AKI, using age, sex, comorbid conditions, prior medication, intensive care unit admission, severe sepsis, and index AKI Kidney Disease: Improving Global Outcomes severity. Cox proportional hazard models were used to test associations of post-AKI ACEi/ARB with mortality, MAKE, and joint models for eGFR slopes.

Results

A total of 2,309 (70.2%) participants died or experienced MAKE by end of follow-up. 161 (4.9%) and 406 (12.3%) patients initiated or resumed prior ACEi/ARB use within 180 days post-AKI, respectively. Although the overall cohort had no significant mortality association with post-AKI ACEi/ARB use, a significant association with lower mortality was observed in patients with KDIGO 3 AKI (HR, 0.40; 95% CI, 0.21-0.75; P interaction = 0.003). However, post-AKI ACEi/ARB use was associated with increased MAKE in patients without cardiovascular indications for ACEi/ARB use (HR, 1.52; 95% CI, 1.17-1.98; P interaction = 0.03). Although post-AKI use of ACEi/ARB was associated with acute eGFR decline (initial eGFR change -2.3 mL/min/1.73 m2/year; 95% CI, -3.1 to -1.5; P < 0.001), no association with longer-term eGFR decline was observed.

Limitations

Retrospective observational study on heterogeneous AKI cohort without data on ACEi/ARB cumulative exposure.

Conclusions

Early ACEi/ARB post-AKI was not associated with better long-term survival or kidney function but was associated with lower mortality in patients with KDIGO 3 AKI.

Syndecan-1 as a Biomarker for Fluid Overload After High-Risk Pediatric Cardiac Surgery: A Pilot Study

OBJECTIVE

Fluid overload (FO) after pediatric cardiac surgery with cardiopulmonary bypass (CPB) is common and has been associated with poor outcomes. We aimed to describe the relationship between plasma concentrations of syndecan-1 (SD1), a biomarker of endothelial glycocalyx injury, and FO in a cohort of children undergoing cardiac surgery.

DESIGN

Single-center prospective observational pilot study, 2022-2023.

SETTING

Twenty-six-bed pediatric cardiac ICU (CICU) at a quaternary pediatric referral center.

PATIENTS

Children younger than 18 years old undergoing Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery congenital heart surgery mortality category 3, 4, and 5 cardiac surgeries with CPB.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We enrolled 15 patients. Blood samples were collected preoperatively and 4 hours postoperatively, then processed for plasma. SD1 concentrations were measured using enzyme-linked immunosorbent assays and compared with fluid balance on postoperative days (PODs) 1, 2, 3, and peak. SD1 discriminated fluid balance of greater than or equal to 10% on POD-1, POD-2, and POD-3 with an area under the receiver operating characteristic curve (AUROC) of 0.74, 0.84, and 0.88, respectively. SD1 also discriminated peak fluid balance of greater than or equal to 10% occurring on any day over the first seven PODs with an AUROC of 0.94. Patients with greater than or equal to 10% fluid balance on POD-2 ( p = 0.037), POD-3 ( p = 0.020), or peak ( p = 0.021) had significantly elevated delta SD1 when compared with those reaching less than 10%. Fluid balance of greater than or equal to 10% on POD-2 was associated with adverse events including longer duration of mechanical ventilation and CICU stay.

CONCLUSIONS

Plasma SD1 was associated with FO in pediatric patients undergoing high-risk cardiac surgery with CPB. Further studies exploring the clinical utility of SD1 as a biomarker for FO in the postoperative management of children who undergo cardiac surgery with CPB should be pursued.

Acute kidney injury is associated with liver-related events in patients with metabolic dysfunction-associated fatty liver disease

BACKGROUND

Evidence regarding the role of acute kidney injury (AKI) in long-term development of metabolic dysfunction-associated fatty liver disease (MAFLD) is limited. We aimed to investigate the associations between AKI and liver-related events in patients with MAFLD.

METHODS

This study involved 50,499 Chinese adults with MAFLD from the China Renal Data System (CRDS) database. We identified AKI using patient-level serum creatinine data according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. The primary outcome was a composite of liver-related mortality and major adverse liver outcomes. The secondary outcome was an escalation of fibrosis-4 (FIB-4) risk scores. Cox proportional hazard models were performed to assess the association between AKI and the study outcomes.

RESULTS

The median age of the patients was 59.17 years, with 54.7% being male. There were 3,711 (7.3%) patients who experienced AKI during hospitalization. A total of 1,660 (3.3%) patients experienced composite liver outcome. Patients with AKI during hospitalization had higher risk of composite liver outcomes (adjusted hazard ratio (aHR) 1.83 [95% confidence interval 1.38;2.41] P < 0.001), especially among those with severe AKI (stage 2/3) (aHR 2.36 [1.57;3.54] P < 0.001). Regarding the secondary outcome, AKI was also associated with an increased risk of escalation of FIB-4 risk scores (aHR 1.28 [1.14;1.44] P < 0.001). These associations remained consistent across various subgroups and sensitivity analyses.

CONCLUSIONS

AKI was significantly associated with an increased risk of liver-related events among patients with MAFLD. These findings suggest that enhanced vigilance toward AKI may be justifiable in MAFLD patients.

External validation of a flowchart related to achieving the target area under the concentration-time curve for vancomycin: A retrospective multicenter study

During therapeutic drug monitoring (TDM) for vancomycin (VCM), the area under the concentration-time curve (AUC) is important for balancing efficacy versus toxicity. In a previous study, we developed a decision tree (DT) model to achieve the target AUC during TDM over the follow-up period (AUCfollow-up). This study aimed to validate the DT model for achieving the target AUCfollow-up. Patients who received VCM for at least 72 h and had an initial TDM within four doses between January 2023 and December 2023 were analyzed. The AUC of the initial TDM was calculated over 2-point (peak/trough) concentrations via Bayesian estimation. The target AUCfollow-up was defined as 400-600 μg h/mL. Among 188 patients (median age [interquartile range], 66 [56, 79] years; 50 % female), the target AUCfollow-up was achieved in 70 % (132/188). When the predicted AUC was 400-600 μg h/mL, 84 % (102/121) achieved the target AUCfollow-up. In a 12 h dosing interval subgroup, 86 % (88/102) achieved the target AUCfollow-up. Conversely, when the predicted AUC was <400 or >600 μg h/mL, the proportion who achieved the target AUCfollow-up dropped to 44 % (30/67). Only 30 % (3/10) of those with creatinine clearance rates of >130 mL/min/1.73 m2 achieved the target. The area under the receiver operating characteristics curve was 0.74, and the R2 value was 0.15. Our findings confirmed the external validity of the DT model and supported its use for optimizing VCM dosing. Overall, the DT model offers a reliable framework for achieving target AUC values during follow-up for TDM, aiding safe and effective treatment.

Hospital and Clinician Practice Variation in Cardiac Surgery and Postoperative Acute Kidney Injury

Importance

Approximately 30% of US patients develop acute kidney injury (AKI) after cardiac surgery, which is associated with increased morbidity, mortality, and health care costs. The variation in potentially modifiable hospital- and clinician-level operating room practices and their implications for AKI have not been rigorously evaluated.

Objective

To quantify variation in clinician- and hospital-level hemodynamic and resuscitative practices during cardiac surgery and identify their associations with AKI.

Design, Setting, and Participants

This cohort study analyzed integrated hospital, clinician, and patient data extracted from the Multicenter Perioperative Outcomes Group dataset and the Society of Thoracic Surgeons Adult Cardiac Surgical Database. Participants were adult patients (aged ≥18 years) who underwent cardiac surgical procedures between January 1, 2014, and February 1, 2022, at 8 geographically diverse US hospitals. Patients were followed up through March 2, 2022. Statistical analyses were performed from October 2024 to February 2025.

Exposures

Hospital- and clinician-level variations in operating room hemodynamic practices (inotrope infusion >60 minutes and vasopressor infusion >60 minutes) and resuscitative practices (homologous red blood cell [RBC] transfusion and total fluid volume administration).

Main Outcomes and Measures

The primary outcome was consensus guideline-defined AKI (any stage) within 7 days after cardiac surgery. Hospital- and clinician-level variations were quantified using intraclass correlation coefficients (ICCs). Associations of hospital- and clinician-level practices with AKI were analyzed using multilevel mixed-effects models, adjusting for patient-level characteristics.

Results

Among 23 389 patients (mean [SD] age, 63 [13] years; 16 122 males [68.9%]), 4779 (20.4%) developed AKI after cardiac surgery. AKI rates varied across hospitals (median [IQR], 21.7% [15.5%-27.2%]) and clinicians (18.1% [10.1%-23.7%]). Significant clinician- and hospital-level variation existed for inotrope infusion (ICC, 6.2% [95% CI, 4.2%-8.0%] vs 17.9% [95% CI, 3.3%-31.9%]), vasopressor infusion (ICC, 11.7% [95% CI, 8.3%-14.9%] vs 44.5% [95% CI, 11.7%-63.5%]), RBC transfusion (ICC, 1.7% [95% CI, 0.9%-2.6%] vs 4.5% [95% CI, 1.2%-9.4%]), and fluid volume administration (ICC, 2.1% [95% CI, 1.3%-2.7%] vs 23.8% [95% CI, 2.7%-39.9%]). In multilevel risk-adjusted models, the AKI rate was higher for patients at hospitals with higher inotrope infusion rates (adjusted odds ratio [AOR], 1.98; 95% CI, 1.18-3.33; P = .01) and lower among clinicians with higher RBC transfusion rates (AOR, 0.89; 95% CI, 0.79-0.99; P = .03). Other practice variations were not associated with AKI.

Conclusions and Relevance

This cohort study of adult patients found that hospital- and clinician-level variation in operating room practices was associated with AKI after cardiac surgery, suggesting possible targets for intervention.

Nephrotoxicity of CAR-T therapy in patients with relapsed and refractory multiple myeloma

OBJECTIVE

Chimeric antigen receptor T (CAR-T) cell therapy has achieved impressive efficacy in treating relapsed and refractory multiple myeloma (R/R MM). Nephrotoxicity after CAR-T cell therapy has rarely been reported.

METHODS

We investigated the occurrence and clinical outcomes of acute kidney injury (AKI) in 111 patients with R/R MM after CAR-T cell therapy.

RESULTS

Thirteen patients (12.1%) developed AKI within 1 month of CAR-T cell therapy, of which 11 had grade 1 AKI, 1 had grade 2, and 1 had grade 3. Eleven (84.6%) cases resolved within 1 month after CAR-T cell therapy. The baseline tumor burden was an independent risk factor for the development of AKI. The finding of a high baseline tumor burden or hyponatremia after CAR-T cell therapy and close monitoring of lactate dehydrogenase, uric acid, interleukin (IL)-5 and IL-10 levels were helpful in predicting the development of AKI. The incidence of cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome were similar between the AKI and non-AKI groups. There was also no significant difference in clinical efficacy between the two groups.

CONCLUSION

AKI is a mild severity and reversible complication. It has no impact on clinical outcomes in R/R MM patients receiving CAR-T cell therapy.

Kidney Injury Following Cardiac Surgery: A Review of Our Current Understanding

Around one-quarter of all patients undergoing cardiac procedures, particularly those on cardiopulmonary bypass, develop cardiac surgery-associated acute kidney injury (CSA-AKI). This complication increases the risk of several serious morbidities and of mortality, representing a significant burden for both patients and the healthcare system. Patients with diminished kidney function before surgery, such as those with chronic kidney disease, are at heightened risk of developing CSA-AKI and have poorer outcomes than patients without preexisting kidney injury who develop CSA-AKI. Several mechanisms are involved in the development of CSA-AKI; injury is primarily thought to result from an amplification loop of inflammation and cell death, with complement and immune system activation, cardiopulmonary bypass, and ischemia-reperfusion injury all contributing to pathogenesis. At present there are no effective, targeted pharmacological therapies for the prevention or treatment of CSA-AKI, although several preclinical trials have shown promise, and clinical trials are under way. Progress in the understanding of the complex pathophysiology of CSA-AKI is needed to improve the development of successful strategies for its prevention, management, and treatment. In this review, we outline our current understanding of CSA-AKI development and management strategies and discuss potential future therapeutic targets under investigation.

Renal Dysfunction and Liver Transplantation

Renal dysfunction is common in patients undergoing liver transplant (LT) evaluation, thereby making it imperative for hepatologists to know how to diagnose, manage, and optimize treatment of acute kidney injury (AKI) and chronic kidney disease. This article reviews pre-transplant, peri-transplant, and post-transplant AKI diagnosis and management, and the role of renal replacement therapy in LT candidates.

Oxygen Targets for Mechanically Ventilated Adults with Sepsis: Secondary Analysis of the PILOT Trial

BackgroundPatients with sepsis frequently require invasive mechanical ventilation. How oxygenation during mechanical ventilation affects clinical outcomes for patients with sepsis remains uncertain.Research QuestionTo evaluate the effects of different oxygen saturation targets on clinical outcomes for patients with sepsis receiving mechanical ventilation.Study Design and MethodsWe performed a secondary analysis of the Pragmatic Investigation of optimaL Oxygen Targets (PILOT) trial dataset among patients who met criteria for sepsis by the Sepsis-3 definition at the time of enrollment. We compared patients randomized to a lower oxygen saturation target (90%; range, 88-92%), an intermediate target (94%; range, 92-96%), and a higher target (98%; range, 96-100%) with regard to the outcomes of 28-day in-hospital mortality and ventilator-free days to study day 28.ResultsOf 2541 patients in the PILOT dataset, 805 patients with sepsis were included in the current analysis. In-hospital mortality by day 28 did not differ significantly between the lower target group (48%; 95% confidence interval [CI], 42% to 54%), the intermediate target group (50%; 95% CI, 43% to 56%), and the higher target group (51%; 95% CI, 45% to 56%) (P = 0.83). The number of ventilator-free days to day 28 did not significantly differ between the trial groups, with a mean of 9.9 (standard deviation [SD], 11.8) in the lower oxygen saturation target group, 9.5 (SD, 11.2) in the intermediate group, and 9.4 (SD, 11.4) in the higher group (P = 0.65).InterpretationAmong mechanically ventilated patients with sepsis in a large, randomized trial, the incidence of 28-day in-hospital mortality was not statistically significantly different between the use of a lower, intermediate, or higher oxygen target. However, the confidence intervals included treatment effects that would be clinically meaningfully and further randomized trials of oxygen targets in sepsis are required.Referenced trial namePragmatic Investigation of optimaL Oxygen Targets Trial (PILOT)ClinicalTrials.gov number NCT03537937URL: https://clinicaltrials.gov/study/NCT03537937.

Predictive factors for 30-day mortality after polymyxin B treatment of carbapenem-resistant Gram-negative bacilli infections

OBJECTIVES

This study aimed to investigate the associated factors predicting 30-day mortality of carbapenem-resistant Gram-negative bacilli (CR-GNB) infections, with focus on polymyxin B AUCss,24h/MIC.

METHODS

This prospective cohort study included patients with CR-GNB infections from January 2022 to January 2024. The primary outcome was 30-day mortality. Classification and regression tree (CART) analysis was used to calculate the AUCss,24h/MIC threshold for 30-day mortality. Multivariate analysis was conducted to assess risk factors affecting this outcome.

RESULTS

We enrolled 107 patients, among which 30-day mortality occurred in 31 (29.0%) cases. The CART-derived AUCss,24h/MIC breakpoint was 51.3, and patients in the below-breakpoint group had 3.4-fold higher 30-day mortality than those in the above-breakpoint group (58.1% vs 17.1%, P < 0.001). On multivariate analysis, polymyxin B AUCss,24h/MIC of ≥51.3 (aOR 0.08, P = 0.001) predicted a lower risk for 30-day mortality. In subgroup analysis, the survival benefit of AUCss,24h/MIC target attainment remained in patients with high risk of mortality or carbapenem-resistant Acinetobacter baumannii infections.

CONCLUSIONS

Polymyxin B AUCss,24h/MIC of ≥51.3 independently predicted lower 30-day mortality in treating CR-GNB infections. Further studies should verify the AUCss,24h/MIC target associated with survival outcomes in larger randomized controlled trials.

Risk Factors for Vancomycin-Induced Nephrotoxicity and Kidney Prognosis in Patients Aged 75 Years and Older: A Retrospective Study

INTRODUCTION

Whether risk factors for vancomycin-induced nephrotoxicity (VIN) development reported in recent years are also risk factors in the older population has not yet been fully investigated. This study aimed to investigate the risk factors for VIN development in the older population and to examine factors influencing kidney prognosis after VIN development.

METHODS

A total of 468 patients aged ≥ 75 years were included in this study. Factors related to VIN onset in older adults were examined through logistic regression analysis.

RESULTS

A total of 40 patients (8.5%) with VIN were identified. Univariate analysis revealed significant differences in body mass index (BMI), combined use of tazobactam/piperacillin (T/P), and intensive care unit admission between the VIN and non-VIN groups (P = 0.042, 0.005, and 0.040, respectively). Multivariate analysis identified the combined use of T/P as a factor related to VIN. In patients aged 85 years or older, the concomitant use of T/P and intensive care unit (ICU) admission were identified as factors related to VIN. Compared with the VIN recovery group, the nonrecovery group had a longer time to VIN onset and a higher proportion of patients on concomitant diuretics.

CONCLUSIONS

This study revealed that the combined use of T/P and ICU admission were risk factors for VIN in older individuals. Additionally, the time until VIN onset and the concomitant use of diuretics may affect the kidney prognosis of older patients who develop VIN. When administering vancomycin to older patients, it is necessary to eliminate or be cautious of these factors in relation to VIN development and kidney prognosis.

Comparison of intermittent and continuous renal replacement therapy for sepsis-associated AKI: a retrospective analysis of the Japanese ICU database

INTRODUCTION

While both intermittent renal replacement therapy (IRRT) and continuous renal replacement therapy (CRRT) are used to treat sepsis-associated acute kidney injury (S-AKI), their comparative effectiveness remains unclear. We compared the outcomes between these modalities in patients with S-AKI.

METHODS

Data from the Japanese Intensive Care Patient Database (JIPAD) was used for this multi-center retrospective cohort study. Adult patients with S-AKI who received either IRRT or CRRT between 2015 and 2021 were included. The primary outcome was in-hospital mortality. We compared IRRT and CRRT using one-to-three propensity score matching analysis. A subgroup analysis was performed in patients with septic shock.

RESULTS

Of the 756 patients analyzed, 79 received IRRT, and 677 received CRRT. After propensity score matching, baseline characteristics were well-balanced between groups. In-hospital mortality showed no significant difference between IRRT and CRRT (48.6% vs. 38.0%; risk difference - 10.6%; 95% CI - 23.0 to 2.9; P = 0.11). In patients with septic shock, in-hospital mortality was also not different between groups (52.6% vs. 40.4%; risk difference - 12.2%; 95% CI - 28.8 to 3.7; P = 0.10).

CONCLUSION

IRRT and CRRT may be similar in-hospital mortality in patients with S-AKI. Further studies are warranted to determine the most effective renal replacement modality for this patient population.

The potential role of leukocytes cell population data (CPD) for diagnosing sepsis in adult patients admitted to the intensive care unit

OBJECTIVES

The aim of the study was to evaluate the predictive value of cell population data (CPD) parameters in comparison with procalcitonin (PCT) and C-reactive protein (CRP) for an early diagnosis of sepsis in intensive care unit (ICU). The effect of renal function on CPD, PCT and CRP, in septic and non-septic patients was also investigated.

METHODS

This is a retrospective, observational and single-center study, performed with data collected from patients consecutively admitted to the ICU of the Edoardo Bassini Hospital in Milan. Patients were divided in septic and non-septic according to Sepsis-III criteria. The control group was formed by critically ill patients without sepsis. Patients with sepsis were further divided in patients with sepsis and patients with septic shock.

RESULTS

A significant difference between septic and non-septic patients was found for neutrophils complexity (NE-SSC), neutrophils fluorescence intensity (NE-SFL), width of dispersion of neutrophils fluorescence (NE-WY), monocytes complexity (MO-X), monocytes fluorescence intensity (MO-Y), PCT and CRP parameters. PCT, neutrophils sixe (NE-FSC), NE-WY, width of dispersion of neutrophils size (NE-WZ) and MO-X discriminated sepsis and septic-shock patients. CPD parameters were not influenced by renal function. CPD, PCT and CRP had a heterogeneous diagnostic performance efficiency in the prediction of sepsis. Overall, NE-SSC, NE-SFL, width of dispersion of neutrophils complexity (NE-WX), MO-X, MO-Y, PCT and CRP displayed the best diagnostic performance for sepsis.

CONCLUSIONS

This study suggested that some CPD parameters (i.e., NE-SFL and MO-X) might provide useful information for diagnosis and management of sepsis.

Artificial Placenta and Artificial Womb Technologies for Lung and Kidney Failure: A Holistic Perspective

Preterm birth remains the leading cause of mortality among neonates. Despite improvements in neonatal intensive care over the years, current treatments for lung and kidney failure are highly invasive, associated with lifelong disability, and limit family integration. Artificial womb and artificial placenta technologies offer a promising alternative by providing more tailored and less invasive neonatal care. Although these technologies share some similarities, artificial womb and artificial placenta technologies differ significantly in terms of treatment initiation, treatment environment, and the potential to support family-centered care. Moreover, even though acute kidney injury is common in neonatal extracorporeal membrane oxygenation (ECMO) patients, current artificial placenta and artificial womb devices lack renal support functionality. Most artificial womb and artificial placenta studies focus on the technical feasibility of these technologies based on in-vivo animal tests. However, translation toward envisioned use of these devices in preterm neonates remains mostly underexposed. A comprehensive stakeholder analysis, including parents and caregivers, is critical to the development of socially acceptable artificial placenta and artificial womb systems. This state-of-the-art review provides an overview of conventional neonatal lung and kidney treatments, delineates the differences between artificial womb and placenta technologies, and addresses the technological and ethical challenges in advancing these technologies toward potential clinical implementation.

Association between triglyceride-glucose index and risk of acute kidney injury in patients with aneurysmal subarachnoid hemorrhage

PURPOSE

This study aimed to investigate the association between the triglyceride-glucose (TyG) index and the risk of acute kidney injury (AKI) in patients with aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

This retrospective cohort study included aSAH patients in West China Hospital. The TyG index was calculated as ln[fasting triglycerides (mg/dL) × fasting glucose (mg/dL)/2]. The primary outcome was AKI within 7 days of admission, and secondary outcomes included hospital, 90-day, and 180-day mortality. Multivariate logistic regression and Cox proportional hazards models were used to adjust for potential confounders. The association between the TyG index and AKI was also assessed with restricted cubic spline analysis. A predictive logistic model for AKI risk was developed and its performance was assessed using the area under the receiver operating characteristic curve, calibration correction curves, and decision curve analysis. Based on the optimal model, an online Shiny R application was developed.

RESULTS

A total of 3271 patients with aneurysmal subarachnoid hemorrhage were included. AKI occurred in 156 patients (4.7%), with the incidence significantly increasing across TyG index quartiles (Q1: 2.7%, Q4: 8.6%; P for trend < 0.001). Each 1-unit increase in TyG index was associated with an 90% higher odds of AKI (OR 1.90, 95% CI 1.48-2.45). Mortality rates also increased with higher TyG quartiles: hospital mortality (HR 1.30, 95% CI 1.05-1.62), 90-day mortality (HR 1.20, 95% CI 1.03-1.39), and 180-day mortality (HR 1.18, 95% CI 1.02-1.37). Kaplan-Meier analysis revealed reduced survival in higher TyG quartiles (Log-rank P < 0.001). Subgroup analyses confirmed consistent associations across demographics characteristics and treatment modalities. Incorporating the TyG index into risk models improves their discriminatory power and calibration. A Shiny application based on this model is freely accessible at ( https://asahaki.shinyapps.io/asahaki/ ).

CONCLUSION

The TyG index is an independent predictor of AKI and mortality in aSAH patients. Its incorporation into clinical assessment facilitates early risk stratification and individualized management.

Pulsatile cardiopulmonary bypass using a centrifugal pump reduces acute kidney injury after cardiac surgery: a propensity score-matched analysis

OBJECTIVE

Acute kidney injury (AKI) affects approximately 30% of patients undergoing cardiac surgery with conventional non-pulsatile cardiopulmonary bypass (CPB). Pulsatile flow has long been proposed for mitigating this complication. While the 2019 EACTS guidelines recommend pulsatile perfusion for high-risk renal patients, most evidence is based on intra-aortic balloon pump (IABP) studies, with limited evidence for centrifugal pumps. We aimed to evaluate whether pulsatile CPB using a centrifugal pump reduces postoperative AKI in patients undergoing cardiac surgery.

METHODS

This retrospective study analyzed 824 patients who underwent cardiac surgery between December 2008 and December 2023. The patients were divided into pulsatile perfusion (PP) and non-pulsatile perfusion (NP) groups. Propensity score matching was adjusted for the baseline characteristics, resulting in 265 matched pairs. The primary endpoint was postoperative AKI, defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Subgroup analyses were performed based on estimated glomerular filtration rate (eGFR).

RESULTS

In the matched cohort, the PP group had a significantly lower incidence of AKI than the NP group (20.8 vs. 34.3%; odds ratio, 0.5; 95% confidence interval, 0.33-0.75; P < 0.001). A subgroup analysis showed that patients with a preoperative eGFR of 15-60 had a significantly lower incidence of AKI in the PP group (28.3 vs. 47.1%; P = 0.005). No significant differences were observed in secondary outcomes, including hemodialysis, cerebrovascular events, and in-hospital mortality.

CONCLUSIONS

Pulsatile CPB using a centrifugal pump significantly reduced the incidence of postoperative AKI in cardiac surgery patients, particularly in those with preoperative renal impairment.

Fine-Mapping the Association of Acute Kidney Injury With Mean Arterial and Central Venous Pressures During Coronary Artery Bypass Surgery

BACKGROUND

Prior studies identified thresholds for mean arterial pressure (MAP <65 mm Hg) and central venous pressure (CVP >12 mm Hg) beyond which risk for cardiac surgery-associated acute kidney injury (AKI) increases. Optimal hemodynamic targets-that is, where active protection from AKI is observed-are unclear; however, current guidelines suggest maintaining MAP >65 and CVP 8 to 12. The aim of this study was to identify hemodynamic ranges associated with both increased and decreased risk of AKI by evaluating narrow ranges of MAP, CVP, and joint exposure to MAP and CVP concurrently.

METHODS

In a retrospective cohort study of adults undergoing coronary artery bypass surgery, we fine-mapped the association between AKI and the total number of minutes spent in each of the following narrow hemodynamic ranges: 14 MAP ranges in increments of 5 mm Hg (45-115), 10 CVP ranges in increments of 2 mm Hg (0-20), and 70 joint MAP/CVP ranges. Separate multivariable regression models estimated adjusted odds ratios (aOR) for each range including adjustments for correlations and multiple comparisons across ranges. Joint MAP/CVP ranges were grouped into 5 hemodynamic zones based on contiguity of the ranges and similarity of ORs observed across ranges in a color-coded heatmap. The 5 MAP/CVP zones were included in a single regression model to assess risk for AKI associated with time spent in each hemodynamic zone, independent of time spent in other zones.

RESULTS

In 1199 participants, incidence of AKI was 28%. For every 5-minute spent in each hemodynamic range, risk of AKI was significantly increased in MAP range 45 to 50 (aOR 1.18; P = .002), 50 to 55 (aOR 1.13; P = .001), and 55 to 60 mm Hg (aOR 1.06; P = .001); and significantly decreased in MAP range 90 to 95 mm Hg (aOR 0.85; P <.001). Risk of AKI was significantly increased in CVP range 16 to 18 mm Hg (aOR 1.07; P = .002) and significantly decreased in CVP range 4 to 6 mm Hg (aOR 0.97; P = .025). In joint analyses, both MAP and CVP contributed to AKI risk estimates; risk decreased as CVP decreased within every MAP range and was significantly lower for joint ranges of CVP <8 and MAP >75. In analyses containing all 5 MAP/CVP hemodynamic zones, risk estimates suggested protection from AKI in zone 1 (high MAP/low CVP) and increased risk of AKI in zones 3 to 5 (low MAP/high CVP).

CONCLUSIONS

Fine-mapping identified narrow ranges of MAP, CVP, and joint MAP/CVP associated with both AKI risk and protection. This report is among the first to characterize the association between joint MAP/CVP and AKI. Contrary to current guidelines, there was no evidence for protection associated with MAP 65 to 75 or CVP 8 to 12 mm Hg.

Persistent Renal Hypoxia and Histologic Changes at 4 Weeks after Cardiopulmonary Bypass in Sheep

BACKGROUND

The sustained renal effects of exposure to cardiopulmonary bypass are unknown. This study aimed to test whether cardiopulmonary bypass (CPB) is associated with sustained renal tissue hypoxia and whether such hypoxia is associated with histologic injury.

METHODS

The study included 12 adult female sheep undergoing CPB with a 2-h aortic cross-clamp. Systemic and renal hemodynamics and oxygen delivery, kidney function, and renal tissue oxygenation were measured before and during CPB, in the 48 h after CPB, and weekly for 4 weeks. The sheep were euthanized at 4 weeks and obtained renal tissue to perform histopathologic assessments for comparison with an independent cohort of five healthy animals that were euthanized without undergoing surgical or experimental interventions. These histologic assessments were performed by an independent, treatment-blinded pathologist.

RESULTS

Compared with baseline, renal blood flow and renal medullary tissue oxygenation decreased significantly during CPB. In the first 48 h after CPB, there was a continuing significant decrease in medullary tissue oxygenation (from 39.2 ± 13.8 mmHg at baseline to 21.7 ± 16.2 mmHg at 48 h; Ptime = 0.006) with stage 1 acute kidney injury in 42% of the animals. Moreover, in the following 4 weeks, medullary (16.1 ± 12.9 mmHg at 4 weeks; Ptime = 0.005) and cortical (17.2 ± 6.5 mmHg at 4 weeks; Ptime = 0.005) tissue oxygenation remained significantly lower than baseline. Finally, compared with healthy sheep, at 4 weeks after CPB, sheep kidneys had significantly more peritubular inflammation (8 of 8 vs . 1 of 5; P = 0.007), interstitial fibrosis (6 of 8 vs . 0 of 5; P = 0.021), and tubular casts (8 of 8 vs . 1 of 5; P = 0.007).

CONCLUSIONS

Exposure to CPB triggers sustained medullary and cortical tissue hypoxia and is associated with histopathologic renal injury. These findings suggest that the renal effect of exposure to CPB may be more profound and longer lasting than currently appreciated.

Risk factors and predictive model for renal outcomes in autoimmune membranous nephropathy with and without acute kidney injury: a retrospective cohort study

Objective

This study aimed to delineate the risk factors affecting renal outcomes in autoimmune membranous nephropathy (aMN) with or without acute kidney injury (AKI) and develop a predictive model.

Methods

This retrospective cohort study included 441 patients with biopsy-confirmed aMN from the First Affiliated Hospital of Fujian Medical University (January 2010 to March 2023). Patients were grouped based on the presence of AKI and followed up until a renal endpoint event (progression to end-stage renal disease, initiation of dialysis, or either a >40% decline in estimated glomerular filtration rate from baseline or a doubling of serum creatinine levels from baseline, both sustained for ≥3 months) or study endpoint (March 2024). Clinicopathological and renal outcomes were collected and analyzed. Risk factors for renal endpoints were identified via Cox regression analyses, and a nomogram was constructed. Model performance was evaluated using the C-index, time-dependent receiver operating characteristic (Time-ROC) curves, calibration curves, and decision curve analysis (DCA). Kaplan-Meier survival curves compared renal survival between AKI subgroups.

Results

Among 441 patients, 109 (24.72%) experienced AKI. Renal endpoint events occurred in 40.4% of the AKI group and 4.5% of the non-AKI group. Multivariate Cox regression identified AKI (HR = 7.298, P < 0.001), triglycerides (HR = 1.140, P = 0.002), serum creatinine (HR = 1.008, P = 0.012), hematuria (HR = 2.246, P = 0.040), and kidney anti-M-type phospholipase A2 receptor staining 4+ (HR = 2.473, P = 0.003) as independent risk factors, while serum C3 (HR = 0.082, P < 0.001) was an independent protective factor. The nomogram had a C-index of 0.845 (P < 0.001), with Time-ROC AUCs of 0.92, 0.81, 0.83, and 0.87 for 3 to 6 years, respectively. Calibration plots revealed good consistency between the predicted and actual probabilities. DCA indicated that the nomogram had potential clinical utility. Kaplan-Meier analysis showed lower cumulative renal survival in patients with AKI (P < 0.001).

Conclusions

The risk factor model suggests that renal outcomes in patients with aMN can be predicted. Early assessment and management targeting these identified risk factors could help delay renal function decline in these patients.

Implementation of a goal directed perfusion strategy to reduce cardiac surgery associated kidney injury: A before and after study

PURPOSE

Cardiac surgery associated acute kidney injury (CSA-AKI) is a frequent and severe complication. Goal Directed Perfusion (GDP) during cardiopulmonary bypass (CPB) has been developed to reduce post-operative complications, in particular CSA-AKI. Hence, we aimed to assess the implementation of a GDP strategy during CPB on the incidence of CSA-AKI in a large, unselected cardiac surgery population.

METHODS

We conducted a retrospective, before and after study, including all patients admitted to our surgical intensive care unit (ICU) following a cardiac surgery with CPB in the year prior to GDP implementation (No-GDP group), and in the year following its implementation (GDP group). Primary endpoint was the incidence of acute kidney injury (AKI) according to KDIGO classification in each group. Secondary endpoints were ICU mortality and length of stay, and the main post-operative complications after cardiac surgery. Risk factors of AKI were evaluated using a multivariable logistic regression model.

RESULTS

Among 903 patients in our analysis, 314 (34 %) developed AKI. The incidence of AKI was lower after the implementation of GDP strategy (n = 111; 27.6 % vs n = 203; 40.5 %, p < 0.001). In the multivariable analysis, GDP was an independent factor of AKI reduction (OR 0.37, 95 %CI [0.27-0.52], p < 0.001). This benefit was significant regarding stage 1 AKI, but not stage 2 or 3 AKI. GDP was not associated with a change in post-operative ICU mortality, length of stay or any other post-operative complication.

CONCLUSION

GDP strategy implantation during CPB is associated with a reduction of postoperative AKI.

Effectiveness of rasburicase 4.5 mg in the treatment of tumor lysis syndrome-related hyperuricemia

PURPOSE

Optimal rasburicase dosing remains unknown. This study evaluated outcomes of single rasburicase 4.5 mg doses when treating moderate (12 to <15 mg/dL) versus high (≥15 mg/dL) uric acid (UA) levels.

METHODS

This retrospective observational cohort study included patients with an active malignancy and tumor lysis syndrome (TLS) who received rasburicase 4.5 mg. Patients were categorized by UA levels before administration of rasburicase. The primary outcome was UA normalization (<8 mg/dL) 24 hours post rasburicase administration. Secondary outcomes included repeat rasburicase dose(s) within 72 hours and renal replacement therapy (RRT) within 7 days. Nominal and continuous data were analyzed using chi squared or Fisher's exact and Wilcoxon rank-sum or Student's t test, respectively. Multivariate regression analysis explored risk factors for continued hyperuricemia.

RESULTS

After screening of 428 patients, 124 moderate and 95 high baseline UA values were included. Overall, baseline characteristics were similar between cohorts. The primary outcome was achieved more often in the moderate cohort (92.7% vs 67.4% [P < 0.001]). More high cohort patients received repeat rasburicase doses (8.1% vs 21.1% [P = 0.009]) with no difference in RRT frequency. Risk factors for continued hyperuricemia included baseline UA, potassium and body mass index.

CONCLUSION

A single dose of rasburicase 4.5 mg was less effective in achieving UA normalization in patients with a baseline UA of ≥15 mg/dL vs 12 to <15 mg/dL, without significant differences in patient-oriented outcomes such as RRT. Higher initial doses of rasburicase may be needed for patients with a baseline UA of ≥15 mg/dL. Additional studies are needed to determine optimal dosing for these patients.

Lesson learnt from implementing a CRRT reimbursement program in a resource-limited setting

Acute kidney injury (AKI) poses significant risks, including high mortality and progression to chronic kidney disease. Effective treatment modalities include peritoneal dialysis (PD), intermittent hemodialysis (IHD), sustained low-efficiency dialysis (SLED), and continuous renal replacement therapy (CRRT). While each modality has specific advantages, CRRT is particularly vital for critically ill patients with severe AKI and contraindications for IHD. Despite its clinical benefits, the high cost of CRRT presents challenges, especially in resource-limited settings like Thailand. This manuscript reviews the process of integrating CRRT into Thailand's Universal Coverage Scheme (UCS). Initial proposals in 2017 highlighted CRRT's importance, yet its high costs posed barriers to inclusion. A rigorous policy development process, emphasizing evidence-based and participatory decision-making, led to the proposal's acceptance in 2018. Key recommendations included optimizing reimbursement rates and increasing budget allocations. By 2022, CRRT reimbursement was incorporated into the UCS, significantly improving access to treatment for patients with AKI. Specific outcomes from our 2-year policy implementation, including patient outcomes such as mortality, renal recovery, length of hospital stay, and complications, as well as cost-saving outcomes reflecting the need for intensive care resources, are ongoing. These cost-benefit analyses, along with policy adjustments, are necessary to ensure continued equitable and effective treatment. This case underscores the importance of aligning reimbursement strategies with clinical needs and financial realities to enhance both healthcare outcomes and system sustainability.

Brief Report: Preadmission VACS Index as a Predictor of Hospital Acute Kidney Injury in People With HIV

BACKGROUND

The Veterans Aging Cohort Study (VACS) Index is a summary measure of routinely obtained clinical variables that predicts numerous health outcomes. Because there are currently no tools to predict acute kidney injury (AKI) in people with HIV (PWH), we investigated the association of preadmission VACS Index with hospital AKI in PWH.

METHODS

We conducted an observational study of PWH hospitalized in a New York City health system between 2010 and 2019. The VACS Index, calculated using outpatient laboratory values within 8-365 days of admission, was examined continuously and in quartiles. Multivariable Cox proportional hazards models, adjusting for sociodemographic factors, comorbidities, and ICU admission, determined the association of the VACS Index with AKI.

RESULTS

Among 1186 PWH, median age was 53 years, 43.5% were women, 86.2% were Hispanic or Black, 23.1% were coinfected with hepatitis C, and 65% were virally suppressed (<200 copies/mL). Overall AKI incidence was 20.9%. The proportion with AKI was higher by increasing VACS Index quartile: 10.7%, 18.6%, 28.1%, and 60.7% in quartiles 1-4, respectively. There was a graded, independent association of VACS Index quartile with AKI. Compared with those in the lowest quartile, the adjusted relative hazard of AKI was 1.55, 1.92, and 3.07 times higher in quartiles 2-4, respectively ( P for trend <0.001).

CONCLUSIONS

Preadmission VACS Index is associated with hospital AKI. Use of the VACS Index may allow for early identification of PWH at risk for AKI and initiation of preventative strategies. These findings should be externally validated in other health systems, including its predictive performance in specific hospital settings.

Prognosis and mortality risk in elderly patients with dengue virus infection: Excess fatality and the urgent need for revising current WHO criteria for elderly patients

BACKGROUND

The World Health Organization (WHO) reports a rising global incidence of dengue and severe outcomes among the elderly. This study investigates the differences in dengue characteristics between elderly and non-elderly patients and identifies mortality risk factors among elderly dengue patients.

METHODS

We conducted a retrospective study of adults (≥20 years) with dengue virus (DENV) infection at two medical centers from 2002 to 2018. Participants were divided into non-elderly (20-64 years) and elderly (≥65 years) groups.

RESULTS

A total of 1274 patients with laboratory-confirmed dengue were included in the study, of whom 373 (29.3 %) were classified as elderly. The majority of patients (67.5 %) were infected with DENV-2. In the overall cohort, age ≥65 years was identified as an independent predictor of mortality. Compared with non-elderly patients, elderly individuals exhibited significantly lower frequencies of classical dengue symptoms (e.g., fever, myalgia, bone pain, rash), but experienced higher rates of severe dengue, longer hospital stays, and more frequent complications, including acute kidney injury, severe hepatitis, bacteremia, pneumonia, and acute respiratory failure. The mortality rate was significantly higher among elderly patients (18 %) compared to non-elderly patients (2.7 %). Multivariate analysis among the elderly subgroup identified altered consciousness and pleural effusion at presentation, along with the development of acute kidney injury, severe hepatitis, and pneumonia during hospitalization, as independent predictors of mortality.

CONCLUSIONS

The current WHO criteria may be insufficient for the timely identification of dengue in the elderly population. Excess mortality in this group underscores the urgent need for updated guidelines. Neurological symptoms, pleural effusion at presentation, and organ impairment during hospitalization are key predictors of mortality in elderly dengue patients.

Association between stress hyperglycemia ratio and acute kidney injury development in patients with sepsis: a retrospective study

Background

Stress hyperglycemia ratio (SHR), which adjusts blood glucose levels using glycated hemoglobin to eliminate the influence of chronic hyperglycemia, has been demonstrated to have superior predictive value than absolute hyperglycemia. However, its predictive value for sepsis-associated acute kidney injury (SA-AKI) remains unclear. This study aimed to investigate the relationship between the SHR and the risk of developing SA-AKI.

Methods

Data were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Restricted cubic splines (RCS) were employed to depict the relationship between SHR and the likelihood of SA-AKI, determining an optimal cut-off value. Based on this threshold, patients were categorized into two groups. Logistic regression was utilized to evaluate SHR's predictive value for SA-AKI, with adjustments for confounding variables. Propensity score matching (PSM) was applied to balance baseline characteristics. Subgroup and sensitivity analyses were conducted.

Results

A total of 2,249 patients were included. The RCS curve indicated a non-linear positive association between SHR and the likelihood of SA-AKI (P for non-linearity < 0.001), with an optimal cut-off at 1.55. Accordingly, patients were divided into SHR ≤ 1.55 and SHR > 1.55 subgroups, comprising 1,131 and 1,118 individuals, respectively. A higher incidence of SA-AKI was observed in the SHR > 1.55 group (38.64% vs. 27.23%, P < 0.001). This association persisted after baseline adjustment through PSM. Logistic regression analysis confirmed that SHR > 1.55 was linked to increased odds of SA-AKI in both unadjusted (OR: 1.68, P < 0.001) and adjusted models (OR: 1.73, P < 0.001), with SHR ≤ 1.55 serving as the reference. In subgroup analysis, all subgroups consistently demonstrated a significant association between SHR > 1.55 and elevated odds of SA-AKI (all OR > 1). Sensitivity analysis validated that SHR > 1.55 remained significantly correlated with SA-AKI occurrence in the survival subgroup (OR: 1.46, P < 0.001) and the non-CKD subgroup (OR: 1.69, P < 0.001).

Conclusion

The findings indicate a non-linear positive relationship between SHR and the likelihood of SA-AKI in patients with sepsis, suggesting that SHR could be a potential predictor for SA-AKI.