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Birkelo BC, Pannu N, Siew ED. Overview of Diagnostic Criteria and Epidemiology of Acute Kidney Injury and Acute Kidney Disease in the Critically Ill Patient. Clin J Am Soc Nephrol 2022; 17:717-735. [PMID: 35292532 PMCID: PMC9269585 DOI: 10.2215/cjn.14181021] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Since the description ischuria renalis by William Heberden (1), AKI has remained a prominent complication of critical illness. Beyond KRT, treatment has been limited by the capacity to phenotype this condition. Here, we chronicle the evolution of attempts to classify AKI, including the adoption of consensus definitions, the expansion of diagnosis and prognosis with novel biomarkers, and emerging tools such as artificial intelligence (AI).
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Affiliation(s)
- Bethany C. Birkelo
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neesh Pannu
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Edward D. Siew
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
- Health Services Research and Development, Veterans Affairs Tennessee Valley, Nashville, Tennessee
- Veterans Affairs Geriatrics Research Education and Clinical Center (GRECC), Tennessee Valley Health System (THVS), Veteran’s Health Administration, Nashville, Tennessee
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Uduman J, Yee J. Urine Sediment Exam Provides More Diagnostic Information in AKI than Novel Urinary Biomarkers: COMMENTARY. KIDNEY360 2022; 3:604-607. [PMID: 35727717 PMCID: PMC9136908 DOI: 10.34067/kid.0005562021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 06/15/2023]
Affiliation(s)
- Junior Uduman
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, Michigan
- Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Jerry Yee
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, Michigan
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Zhang H, Wang Z, Tang Y, Chen X, You D, Wu Y, Yu M, Chen W, Zhao Y, Chen X. Prediction of acute kidney injury after cardiac surgery: model development using a Chinese electronic health record dataset. J Transl Med 2022; 20:166. [PMID: 35397573 PMCID: PMC8994277 DOI: 10.1186/s12967-022-03351-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/15/2022] [Indexed: 01/23/2023] Open
Abstract
Abstract
Background
Acute kidney injury (AKI) is a major complication following cardiac surgery that substantially increases morbidity and mortality. Current diagnostic guidelines based on elevated serum creatinine and/or the presence of oliguria potentially delay its diagnosis. We presented a series of models for predicting AKI after cardiac surgery based on electronic health record data.
Methods
We enrolled 1457 adult patients who underwent cardiac surgery at Nanjing First Hospital from January 2017 to June 2019. 193 clinical features, including demographic characteristics, comorbidities and hospital evaluation, laboratory test, medication, and surgical information, were available for each patient. The number of important variables was determined using the sliding windows sequential forward feature selection technique (SWSFS). The following model development methods were introduced: extreme gradient boosting (XGBoost), random forest (RF), deep forest (DF), and logistic regression. Model performance was accessed using the area under the receiver operating characteristic curve (AUROC). We additionally applied SHapley Additive exPlanation (SHAP) values to explain the RF model. AKI was defined according to Kidney Disease Improving Global Outcomes guidelines.
Results
In the discovery set, SWSFS identified 16 important variables. The top 5 variables in the RF importance matrix plot were central venous pressure, intraoperative urine output, hemoglobin, serum potassium, and lactic dehydrogenase. In the validation set, the DF model exhibited the highest AUROC (0.881, 95% confidence interval [CI] 0.831–0.930), followed by RF (0.872, 95% CI 0.820–0.923) and XGBoost (0.857, 95% CI 0.802–0.912). A nomogram model was constructed based on intraoperative longitudinal features, achieving an AUROC of 0.824 (95% CI 0.763–0.885) in the validation set. The SHAP values successfully illustrated the positive or negative contribution of the 16 variables attributed to the output of the RF model and the individual variable’s effect on model prediction.
Conclusions
Our study identified 16 important predictors and provided a series of prediction models to enhance risk stratification of AKI after cardiac surgery. These novel predictors might aid in choosing proper preventive and therapeutic strategies in the perioperative management of AKI patients.
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Molecular Mechanisms and Biomarkers Associated with Chemotherapy-Induced AKI. Int J Mol Sci 2022; 23:ijms23052638. [PMID: 35269781 PMCID: PMC8910619 DOI: 10.3390/ijms23052638] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 12/10/2022] Open
Abstract
Acute kidney injury (AKI) is a life-threatening condition characterized by a rapid and transient decrease in kidney function. AKI is part of an array of conditions collectively defined as acute kidney diseases (AKD). In AKD, persistent kidney damage and dysfunction lead to chronic kidney disease (CKD) over time. A variety of insults can trigger AKI; however, chemotherapy-associated nephrotoxicity is increasingly recognized as a significant side effect of chemotherapy. New biomarkers are urgently needed to identify patients at high risk of developing chemotherapy-associated nephrotoxicity and subsequent AKI. However, a lack of understanding of cellular mechanisms that trigger chemotherapy-related nephrotoxicity has hindered the identification of effective biomarkers to date. In this review, we aim to (1) describe the known and potential mechanisms related to chemotherapy-induced AKI; (2) summarize the available biomarkers for early AKI detection, and (3) raise awareness of chemotherapy-induced AKI.
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Acute Kidney Injury: Biomarker-Guided Diagnosis and Management. Medicina (B Aires) 2022; 58:medicina58030340. [PMID: 35334515 PMCID: PMC8953384 DOI: 10.3390/medicina58030340] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 12/23/2022] Open
Abstract
Acute kidney injury (AKI) is a common clinical syndrome that is characterized by abnormal renal function and structure. The Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference in 2019 reviewed the stages of AKI and the definitions of AKI-related terminologies, and discussed the advances in the last decade. Along with serum creatinine level and urine output, more accurate novel biomarkers for predicting AKI are being applied for the early detection of renal dysfunction. A literature search was conducted in PubMed, Scopus, Medline, and ClinicalTrials.gov using the terms AKI and biomarker, combined with diagnosis, management, or prognosis. Because of the large volume of data (160 articles) published between 2005 and 2022, representative literature was chosen. A number of studies have demonstrated that new biomarkers are more sensitive in detecting AKI in certain populations than serum creatinine and urine output according to the recommendations from the Acute Disease Quality Initiative Consensus Conference. To be specific, there is a persistently unresolved need for earlier detection of patients with AKI before AKI progresses to a need for renal replacement therapy. Biomarker-guided management may help to identify a high-risk group of patients in progression to severe AKI, and decide the initiation time to renal replacement therapy and optimal follow-up period. However, limitations such as biased data to certain studied populations and absence of cutoff values need to be solved for worldwide clinical use of biomarkers in the future. Here, we provide a comprehensive review of biomarker-based AKI diagnosis and management and highlight recent developments.
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Soluble IL-33 receptor predicts survival in acute kidney injury. J Circ Biomark 2022; 11:28-35. [PMID: 35707675 PMCID: PMC9185730 DOI: 10.33393/jcb.2022.2386] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/16/2022] [Indexed: 12/29/2022] Open
Abstract
Introduction: The prediction of acute kidney injury (AKI)-related outcomes remains challenging. Herein we prospectively quantified soluble ST2 (sST2), the circulating isoform of the IL-33 receptor, in hospitalized patients with AKI.
Methods: In-hospital subjects with AKI of various etiology were identified through the in-hospital AKI alert system of the Brandenburg University hospital. sST2 was measured within a maximum of 48 hours from the time of diagnosis of AKI. The following endpoints were defined: in-hospital death, dialysis, recovery of kidney function until demission.
Results: In total, 151 individuals were included in the study. The in-hospital mortality was 16.6%, dialysis therapy became mandatory in 39.7%, no recovery of kidney function occurred in 27.8%. sST2 was significantly higher in nonsurvivors (p = 0.024) but did not differ in the two other endpoints. The level of sST2 increased significantly with the severity of AKI. Further differences were detected in subjects with heart insufficiency (lower sST2), and in patients that required ICU treatment, or ventilatory therapy, or vasopressors (all higher).
Conclusions: The current study suggests sST2 as biomarker of “acute distress”: it predicts post-AKI survival and substantially increases in subjects with a higher degree of cumulative morbidity under acute circumstances (e.g., ICU therapy, vasopressor administration).
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Kelly BJ, Chevarria J, O'Sullivan B, Shorten G. The potential for artificial intelligence to predict clinical outcomes in patients who have acquired acute kidney injury during the perioperative period. Perioper Med (Lond) 2021; 10:49. [PMID: 34906249 PMCID: PMC8672488 DOI: 10.1186/s13741-021-00219-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 07/29/2021] [Indexed: 11/10/2022] Open
Abstract
Acute kidney injury (AKI) is a common medical problem in hospitalised patients worldwide that may result in negative physiological, social and economic consequences. Amongst patients admitted to ICU with AKI, over 40% have had either elective or emergency surgery prior to admission. Predicting outcomes after AKI is difficult and the decision on whom to initiate RRT with a goal of renal recovery or predict a long-term survival benefit still poses a challenge for acute care physicians. With the increasing use of electronic healthcare records, artificial intelligence may allow postoperative AKI prognostication and aid clinical management. Patients will benefit if the data can be readily accessed andregulatory, ethical and human factors challenges can be overcome.
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Affiliation(s)
- Barry J Kelly
- Department of Anaesthesiology and Intensive Care Medicine, University College Cork School of Medicine, Cork, Ireland.
| | - Julio Chevarria
- Department of Nephrology, University College Cork School of Medicine, Cork, Ireland
| | - Barry O'Sullivan
- Insight Centre for Data Analytics, School of Computer Science & Information Technology, University College Cork, Cork, Ireland
| | - George Shorten
- Anaesthesiology and Intensive Care Medicine, School of Medicine, University College Cork, Cork, Ireland
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58
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The incidence, mortality and renal outcomes of acute kidney injury in patients with suspected infection at the emergency department. PLoS One 2021; 16:e0260942. [PMID: 34879093 PMCID: PMC8654152 DOI: 10.1371/journal.pone.0260942] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 11/19/2021] [Indexed: 12/29/2022] Open
Abstract
Background Acute kidney injury (AKI) is a major health problem associated with considerable mortality and morbidity. Studies on clinical outcomes and mortality of AKI in the emergency department are scarce. The aim of this study is to assess incidence, mortality and renal outcomes after AKI in patients with suspected infection at the emergency department. Methods We used data from the SPACE-cohort (SePsis in the ACutely ill patients in the Emergency department), which included consecutive patients that presented to the emergency department of the internal medicine with suspected infection. Hazard ratios (HR) were assessed using Cox regression to investigate the association between AKI, 30-days mortality and renal function decline up to 1 year after AKI. Survival in patients with and without AKI was assessed using Kaplan-Meier analyses. Results Of the 3105 patients in the SPACE-cohort, we included 1716 patients who fulfilled the inclusion criteria. Of these patients, 10.8% had an AKI episode. Mortality was 12.4% for the AKI group and 4.2% for the non-AKI patients. The adjusted HR for all-cause mortality at 30-days in AKI patients was 2.8 (95% CI 1.7–4.8). Moreover, the cumulative incidence of renal function decline was 69.8% for AKI patients and 39.3% for non-AKI patients. Patients with an episode of AKI had higher risk of developing renal function decline (adjusted HR 3.3, 95% CI 2.4–4.5) at one year after initial AKI-episode at the emergency department. Conclusion Acute kidney injury is common in patients with suspected infection in the emergency department and is significantly associated with 30-days mortality and renal function decline one year after AKI.
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59
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Fliser D. Urinary Dickkopf-3 and the evaluation of chronic kidney disease progression. Nephrol Dial Transplant 2021; 36:2161-2163. [PMID: 34383927 DOI: 10.1093/ndt/gfab246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Danilo Fliser
- Department of Internal Medicine IV, Saarland University Medical Center, Homburg, Germany
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60
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Thöni S, Mayer G. Urinary Dickkopf-3 and kidney injury in patients with chronic pulmonary disease. Kidney Int 2021; 100:983-985. [PMID: 34688388 DOI: 10.1016/j.kint.2021.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/04/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
Dickkopf-related protein 3 is a stress-induced, epithelial cell-derived glycoprotein that is promoted as a prognostic as well as a predictive urinary biomarker in acute and chronic kidney disease. Schunk et al. provided evidence that Dickkopf-related protein 3 identifies patients with chronic obstructive pulmonary disease and preserved kidney function at increased risk for a loss of estimated glomerular filtration rate and deterioration of pulmonary function. Experimental data highlighted Dickkopf-related protein 3-related pathophysiological similarities and interactions between chronic kidney disease and chronic obstructive pulmonary disease.
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Affiliation(s)
- Stefanie Thöni
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Tyrol, Austria
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Tyrol, Austria.
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61
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Noe KM, Ngo JP, Martin A, Zhu MZL, Cochrane AD, Smith JA, Thrift AG, Singh H, Evans RG. Intra-operative and early post-operative prediction of cardiac surgery-associated acute kidney injury: Urinary oxygen tension compared with plasma and urinary biomarkers. Clin Exp Pharmacol Physiol 2021; 49:228-241. [PMID: 34674291 DOI: 10.1111/1440-1681.13603] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/11/2021] [Accepted: 10/19/2021] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI) is a common and serious post-operative complication of cardiac surgery. The value of a predictive biomarker is determined not only by its predictive efficacy, but also by how early this prediction can be made. For a biomarker of cardiac surgery-associated AKI, this is ideally during the intra-operative period. Therefore, in 82 adult patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB), we prospectively compared the predictive efficacy of various blood and urinary biomarkers with that of continuous measurement of urinary oxygen tension (UPO2 ) at pre-determined intra- and post-operative time-points. None of the blood or urine biomarkers we studied showed predictive efficacy for post-operative AKI when measured intra-operatively. When treated as a binary variable (≤ or > median for the whole cohort), the earliest excess risk of AKI was predicted by an increase in urinary neutrophil gelatinase-associated lipocalin (NGAL) at 3 h after entry into the intensive care unit (odds ratio [95% confidence limits], 2.86 [1.14-7.21], p = 0.03). Corresponding time-points were 6 h for serum creatinine (3.59 [1.40-9.20], p = 0.008), and 24 h for plasma NGAL (4.54 [1.73-11.90], p = 0.002) and serum cystatin C (6.38 [2.35-17.27], p = 0.001). In contrast, indices of intra-operative urinary hypoxia predicted AKI after weaning from CPB, and in the case of a fall in UPO2 to ≤10 mmHg, during the rewarming phase of CPB (3.00 [1.19-7.56], p = 0.02). We conclude that continuous measurement of UPO2 predicts AKI earlier than plasma or urinary NGAL, serum cystatin C, or early post-operative changes in serum creatinine.
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Affiliation(s)
- Khin M Noe
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Jennifer P Ngo
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Cardiac Physiology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Andrew Martin
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Michael Z L Zhu
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Harshil Singh
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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62
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Thiel TA, Schweitzer J, Xia T, Bechler E, Valentin B, Steuwe A, Boege F, Westenfeld R, Wittsack HJ, Ljimani A. Evaluation of Radiographic Contrast-Induced Nephropathy by Functional Diffusion Weighted Imaging. J Clin Med 2021; 10:4573. [PMID: 34640591 PMCID: PMC8509538 DOI: 10.3390/jcm10194573] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 01/07/2023] Open
Abstract
Contrast-induced nephropathy (CIN) resembles an important complication of radiographic contrast medium (XCM) displayed by a rise in creatinine levels 48-72 h after XCM administration. The purpose of the current study was to evaluate microstructural renal changes due to CIN in high-risk patients by diffusion weighted (DWI) and diffusion tensor imaging (DTI). Fifteen patients (five CIN and ten non-CIN) scheduled for cardiological intervention were included in the study. All patients were investigated pre- and post-intervention on a clinical 3T scanner. After anatomical imaging, renal DWI was performed by a paracoronal echo-planar-imaging sequence. Renal clinical routine serum parameters and advanced urinary injury markers were determined to monitor renal function. We observed a drop in cortical and medullar apparent diffusion coefficient (ADC) and fractional anisotropy (FA) before and after XCM administration in the CIN group. In contrast, the non-CIN group differed only in medullary ADC. The decrease of ADC and FA was apparent even before serum parameters of the kidney changed. In conclusion, DWI/DTI may be a useful tool for monitoring high-risk CIN patients as part of multi-modality based clinical protocol. Further studies, including advanced analysis of the diffusion signal, may improve the identification of patients at risk for CIN.
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Affiliation(s)
- Thomas Andreas Thiel
- Department of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich Heine University Dusseldorf, D-40225 Düsseldorf, Germany; (T.A.T.); (E.B.); (B.V.); (A.S.); (H.-J.W.)
| | - Julian Schweitzer
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, D-40225 Düsseldorf, Germany; (J.S.); (R.W.)
| | - Taogetu Xia
- Institute of Clinical Chemistry and Laboratory Diagnostics, Medical Faculty, Heinrich Heine University Düsseldorf, D-40225 Düsseldorf, Germany; (T.X.); (F.B.)
| | - Eric Bechler
- Department of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich Heine University Dusseldorf, D-40225 Düsseldorf, Germany; (T.A.T.); (E.B.); (B.V.); (A.S.); (H.-J.W.)
| | - Birte Valentin
- Department of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich Heine University Dusseldorf, D-40225 Düsseldorf, Germany; (T.A.T.); (E.B.); (B.V.); (A.S.); (H.-J.W.)
| | - Andrea Steuwe
- Department of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich Heine University Dusseldorf, D-40225 Düsseldorf, Germany; (T.A.T.); (E.B.); (B.V.); (A.S.); (H.-J.W.)
| | - Friedrich Boege
- Institute of Clinical Chemistry and Laboratory Diagnostics, Medical Faculty, Heinrich Heine University Düsseldorf, D-40225 Düsseldorf, Germany; (T.X.); (F.B.)
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, D-40225 Düsseldorf, Germany; (J.S.); (R.W.)
| | - Hans-Jörg Wittsack
- Department of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich Heine University Dusseldorf, D-40225 Düsseldorf, Germany; (T.A.T.); (E.B.); (B.V.); (A.S.); (H.-J.W.)
| | - Alexandra Ljimani
- Department of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich Heine University Dusseldorf, D-40225 Düsseldorf, Germany; (T.A.T.); (E.B.); (B.V.); (A.S.); (H.-J.W.)
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63
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Wang C, Gao Y, Tian Y, Wang Y, Zhao W, Sessler DI, Jia Y, Ji B, Diao X, Xu X, Wang J, Li J, Wang S, Liu J. Prediction of acute kidney injury after cardiac surgery from preoperative N-terminal pro-B-type natriuretic peptide. Br J Anaesth 2021; 127:862-870. [PMID: 34561052 DOI: 10.1016/j.bja.2021.08.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/28/2021] [Accepted: 08/19/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is common after cardiac surgery and is difficult to predict. N-terminal pro-B-type natriuretic peptide (NT-proBNP) is highly predictive for perioperative cardiovascular complications and may also predict renal injury. We therefore tested the hypothesis that preoperative NT-proBNP concentration is associated with renal injury after major cardiac surgery. METHODS We included 35 337 patients who had cardiac surgery and measurements of preoperative NT-proBNP and postoperative creatinine. The primary outcome was Kidney Disease: Improving Global Outcomes Stages 1-3 AKI. We also separately considered severe AKI, including Stage 2, Stage 3, and new-onset dialysis. RESULTS Postoperative AKI occurred in 11 999 (34.0%) patients. Stage 2 AKI occurred in 1200 (3.4%) patients, Stage 3 AKI in 474 (1.3%) patients, and new-onset dialysis was required in 241 (0.7%) patients. The NT-proBNP concentrations (considered continuously or in quartiles) were significantly correlated with any-stage AKI and severe AKI (all adjusted P<0.01). Including NT-proBNP significantly improved AKI prediction (net reclassification improvement: 0.24 [0.22-0.27]; P<0.001) beyond basic models derived from other baseline factors in the overall population. Reclassification was especially improved for higher grades of renal injury: 0.30 (0.25-0.36) for Stage 2, 0.46 (0.37-0.55) for Stage 3, and 0.47 (0.35-0.60) for dialysis. CONCLUSIONS Increased preoperative NT-proBNP concentrations were associated with postoperative AKI in patients having cardiac surgery. Including NT-proBNP substantially improves AKI predictions based on other preoperative factors.
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Affiliation(s)
- Chunrong Wang
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuchen Gao
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Tian
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuefu Wang
- Department of Anaesthesiology and Surgical Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.
| | - Wei Zhao
- Information Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Daniel I Sessler
- Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Yuan Jia
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bingyang Ji
- Cardiopulmonary Bypass, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaolin Diao
- Information Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinyi Xu
- Information Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianhui Wang
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Li
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sudena Wang
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia Liu
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Ostermann M, Karsten E, Lumlertgul N. Biomarker-Based Management of AKI: Fact or Fantasy? Nephron Clin Pract 2021; 146:295-301. [PMID: 34515152 PMCID: PMC9216309 DOI: 10.1159/000518365] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/15/2021] [Indexed: 11/19/2022] Open
Abstract
New biomarkers for acute kidney injury (AKI) have improved our understanding of the etiology and pathogenesis of AKI. Depending on their origin, function, and kinetic profile, biomarkers have a role in screening, diagnosis, prognostication, and monitoring of AKI. This offers opportunities to improve the management of AKI, but concerns and limitations remain. In this review, we summarize the current role of new AKI biomarkers in the management of AKI and outline some of the ongoing limitations and challenges.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Emma Karsten
- Emergency Department, Guy's & St Thomas' Foundation Trust, London, United Kingdom
| | - Nuttha Lumlertgul
- Department of Critical Care, King's College London, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
- Division of Nephrology, Department of Internal Medicine and Excellence Center in Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Research Unit in Critical Care Nephrology, Chulalongkorn University, Bangkok, Thailand
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Diagnosis of Cardiac Surgery-Associated Acute Kidney Injury. J Clin Med 2021; 10:jcm10163664. [PMID: 34441960 PMCID: PMC8397056 DOI: 10.3390/jcm10163664] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 01/22/2023] Open
Abstract
Acute kidney injury after cardiac surgery is characterized by specific patterns of damage and recovery that are important to consider for management and outcome. The Kidney Disease: Improving Global Outcomes (KDIGO) classification covers only part of the conceptual framework and is thus insufficient for a comprehensive diagnosis. This review highlights the strengths and limitations of the recent criteria and provides an overview of biomarkers of cardiac surgery-associated acute kidney injury (CSA-AKI). The evolving understanding of CSA-AKI as a time-sensitive condition has increased the demand to enhance the diagnostic criteria and translate biomarkers into clinical practice.
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Singh S, Kanwar A, Sundaragiri PR, Cheungpasitporn W, Truesdell AG, Rab ST, Singh M, Vallabhajosyula S. Acute Kidney Injury in Cardiogenic Shock: An Updated Narrative Review. J Cardiovasc Dev Dis 2021; 8:88. [PMID: 34436230 PMCID: PMC8396972 DOI: 10.3390/jcdd8080088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 12/19/2022] Open
Abstract
Acute myocardial infarction with cardiogenic shock (AMI-CS) is associated with high mortality and morbidity despite advancements in cardiovascular care. AMI-CS is associated with multiorgan failure of non-cardiac organ systems. Acute kidney injury (AKI) is frequently seen in patients with AMI-CS and is associated with worse mortality and outcomes compared to those without. The pathogenesis of AMI-CS associated with AKI may involve more factors than previously understood. Early use of renal replacement therapies, management of comorbid conditions and judicious fluid administration may help improve outcomes. In this review, we seek to address the etiology, pathophysiology, management, and outcomes of AKI complicating AMI-CS.
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Affiliation(s)
- Sohrab Singh
- Department of Medicine, The Brooklyn Hospital, Brooklyn, NY 11201, USA;
| | - Ardaas Kanwar
- Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN 55455, USA;
| | - Pranathi R. Sundaragiri
- Section of Primary Care Internal Medicine, Wake Forest Baptist Health, High Point, NC 27262, USA;
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | | | - Syed Tanveer Rab
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA;
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
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Tian Y, Li X, Wang Y, Zhao W, Wang C, Gao Y, Wang S, Liu J. Association Between Preoperative Statin Exposure and Acute Kidney Injury in Adult Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:1014-1020. [PMID: 34389211 DOI: 10.1053/j.jvca.2021.07.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVES The existing literature has shown conflicting results regarding the association between preoperative statin exposure and the risk of postoperative cardiac surgery-associated acute kidney injury (CSA-AKI). DESIGN A single-center retrospective observational study. SETTING A single, large, tertiary care center. PARTICIPANTS Adult patients undergoing open cardiac surgery between January 1, 2012 and January 1, 2019. INTERVENTIONS AKI was defined using the Kidney Disease: Improving Global Outcomes criteria. A multivariate logistic regression analysis and propensity score-matched analysis were used to study the association. MEASUREMENTS AND MAIN RESULTS A total of 58,399 patient charts were retrospectively reviewed. The preoperative statin exposure cohort had a lower prevalence of all stages of CSA-AKI (30.7% v 36.3%, p < 0.001) and stage 3 CSA-AKI (0.9% v 2.1%, p < 0.001). After adjusting for confounding factors, preoperative statin exposure was a protective factor against all stages of postoperative CSA-AKI (odds ratio [OR], 0.885, 95% confidence interval [CI], 0.852-0.920, p < 0.001) and stage 3 CSA-AKI in adults (OR, 0.671, 95% CI, 0.567-0.795, p < 0.001). A propensity score-matched analysis showed that the preoperative statin exposure cohort had a lower risk of all stages of postoperative CSA-AKI (30.7% v 35.3%, p < 0.001) and stage 3 CSA-AKI (0.9% v 2.2%, p < 0.001) than the control cohort. CONCLUSIONS Preoperative statin exposure was associated with all stages of postoperative CSA-AKI and stage 3 CSA-AKI.
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Affiliation(s)
- Yu Tian
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China; Department of Anesthesiology, Beijing An Zhen Hospital, Capital Medical University, Beijing, China
| | - Xiuyuan Li
- Department of Histology and Embryology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Yuefu Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China; Department of Surgery Intensive Care Unit & Center of Anesthesia, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.
| | - Wei Zhao
- Information Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Chunrong Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yuchen Gao
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Sudena Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jia Liu
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Schunk SJ, Speer T, Petrakis I, Fliser D. Dickkopf 3-a novel biomarker of the 'kidney injury continuum'. Nephrol Dial Transplant 2021; 36:761-767. [PMID: 32025732 DOI: 10.1093/ndt/gfaa003] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Indexed: 12/12/2022] Open
Abstract
Chronic kidney disease (CKD) is a global public health problem accompanied by substantial comorbidities and reduced life expectancy. In this respect, progressive CKD leading to uraemia can be seen as a systemic disease with a critical impact on virtually all organ systems. Therefore, it is of particular importance to identify patients with ongoing CKD progression, which is challenging, because the individual course of CKD is difficult to predict. Patterns of progression in CKD patients include linear and non-linear trajectories of GFR loss, but kidney function can also remain stable for years. Moreover, a substantial GFR decline may occur in the absence of higher-grade albuminuria (non-proteinuric CKD), rendering the measurement of albuminuria less reliable for progression prediction in such individuals. In the present review, we focus on the recently identified glycoprotein Dickkopf-3 (DKK3) as a stress-induced, renal tubular epithelial cell-derived, pro-fibrotic molecule. In experimental CKD models, DKK3 promoted renal tubulointerstitial fibrosis through modulation of the canonical Wnt/β-catenin signalling pathway. In clinical studies, increased urinary DKK3 levels identified patients at high risk for short-term CKD progression, regardless of the cause of kidney disease, baseline kidney function and albuminuria. Moreover, increased urinary DKK3 levels are associated with a high risk for acute kidney injury and the subsequent loss of kidney function after cardiac surgery. These findings highlight DKK3 as a mediator of renal tubular cell damage in kidney injury and short-term progression of kidney disease, with potential therapeutic implications.
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Affiliation(s)
- Stefan J Schunk
- Department of Internal Medicine IV - Nephrology and Hypertension, Saarland University Medical Center, Homburg/Saar, Germany
| | - Thimoteus Speer
- Department of Internal Medicine IV - Nephrology and Hypertension, Saarland University Medical Center, Homburg/Saar, Germany
| | - Ioannis Petrakis
- Department of Internal Medicine IV - Nephrology and Hypertension, Saarland University Medical Center, Homburg/Saar, Germany
| | - Danilo Fliser
- Department of Internal Medicine IV - Nephrology and Hypertension, Saarland University Medical Center, Homburg/Saar, Germany
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Schunk SJ, Beisswenger C, Ritzmann F, Herr C, Wagner M, Triem S, Hütter G, Schmit D, Zewinger S, Sarakpi T, Honecker A, Mahadevan P, Boor P, Wagenpfeil S, Jörres R, Watz H, Welte T, Vogelmeier CF, Gröne HJ, Fliser D, Speer T, Bals R. Measurement of urinary Dickkopf-3 uncovered silent progressive kidney injury in patients with chronic obstructive pulmonary disease. Kidney Int 2021; 100:1081-1091. [PMID: 34237325 DOI: 10.1016/j.kint.2021.06.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/28/2021] [Accepted: 06/18/2021] [Indexed: 12/31/2022]
Abstract
Chronic kidney disease (CKD) represents a global public health problem with high disease related morbidity and mortality. Since CKD etiology is heterogeneous, early recognition of patients at risk for progressive kidney injury is important. Here, we evaluated the tubular epithelial derived glycoprotein dickkopf-3 (DKK3) as a urinary marker for the identification of progressive kidney injury in a non-CKD cohort of patients with chronic obstructive pulmonary disease (COPD) and in an experimental model. In COSYCONET, a prospective multicenter trial comprising 2,314 patients with stable COPD (follow-up 37.1 months), baseline urinary DKK3, proteinuria and estimated glomerular filtration rate (eGFR) were tested for their association with the risk of declining eGFR and the COPD marker, forced expiratory volume in one second. Baseline urinary DKK3 but not proteinuria or eGFR identified patients with a significantly higher risk for over a 10% (odds ratio: 1.54, 95% confidence interval: 1.13-2.08) and over a 20% (2.59: 1.28-5.25) decline of eGFR during follow-up. In particular, DKK3 was associated with a significantly higher risk for declining eGFR in patients with eGFR over 90 ml/min/1.73m2 and proteinuria under 30 mg/g. DKK3 was also associated with declining COPD marker (2.90: 1.70-4.68). The impact of DKK3 was further explored in wild-type and Dkk3-/- mice subjected to cigarette smoke-induced lung injury combined with a CKD model. In this model, genetic abrogation of DKK3 resulted in reduced pulmonary inflammation and preserved kidney function. Thus, our data highlight urinary DKK3 as a possible marker for early identification of patients with silent progressive CKD and for adverse outcomes in patients with COPD.
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Affiliation(s)
- Stefan J Schunk
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Hospital, Homburg/Saar, Germany
| | - Christoph Beisswenger
- Department of Internal Medicine V, Pulmonology, Allergology and Critical Care Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Felix Ritzmann
- Department of Internal Medicine V, Pulmonology, Allergology and Critical Care Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Christian Herr
- Department of Internal Medicine V, Pulmonology, Allergology and Critical Care Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Martina Wagner
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Hospital, Homburg/Saar, Germany
| | - Sarah Triem
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Hospital, Homburg/Saar, Germany; Translational Cardio-Renal Medicine, Saarland University, Homburg/Saar, Germany
| | - Gregor Hütter
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Hospital, Homburg/Saar, Germany; Translational Cardio-Renal Medicine, Saarland University, Homburg/Saar, Germany
| | - David Schmit
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Hospital, Homburg/Saar, Germany
| | - Stephen Zewinger
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Hospital, Homburg/Saar, Germany
| | - Tamim Sarakpi
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Hospital, Homburg/Saar, Germany
| | - Anja Honecker
- Department of Internal Medicine V, Pulmonology, Allergology and Critical Care Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Peer Mahadevan
- Department of Internal Medicine V, Pulmonology, Allergology and Critical Care Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Peter Boor
- Institute of Pathology, Department of Nephrology, RWTH University HospitalAachen, Aachen, Germany
| | - Stefan Wagenpfeil
- Institute of Medical Biometry, Epidemiology, and Medical Informatics, Saarland University, Homburg/Saar
| | - Rudolf Jörres
- Institute and Clinic for Occupational, Social and Environmental Medicine, Comprehensive Pneumology Centre Munich (CPC-M), University Hospital, LMU Munich, Munich, Germany
| | - Henrik Watz
- Institute and Clinic for Occupational, Social and Environmental Medicine, Comprehensive Pneumology Centre Munich (CPC-M), University Hospital, LMU Munich, Munich, Germany; Pulmonary Research Institute at LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Tobias Welte
- Department of Pneumology, Hannover Medical School, Hannover, Germany
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Centre Giessen and Marburg, Philipps-University Marburg, German Centre for Lung Research (DZL), Marburg, Germany
| | | | - Danilo Fliser
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Hospital, Homburg/Saar, Germany
| | - Thimoteus Speer
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Hospital, Homburg/Saar, Germany; Translational Cardio-Renal Medicine, Saarland University, Homburg/Saar, Germany.
| | - Robert Bals
- Department of Internal Medicine V, Pulmonology, Allergology and Critical Care Medicine, Saarland University Hospital, Homburg/Saar, Germany
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Acute kidney injury in the critically ill: an updated review on pathophysiology and management. Intensive Care Med 2021; 47:835-850. [PMID: 34213593 PMCID: PMC8249842 DOI: 10.1007/s00134-021-06454-7] [Citation(s) in RCA: 163] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/04/2021] [Indexed: 01/10/2023]
Abstract
Acute kidney injury (AKI) is now recognized as a heterogeneous syndrome that not only affects acute morbidity and mortality, but also a patient’s long-term prognosis. In this narrative review, an update on various aspects of AKI in critically ill patients will be provided. Focus will be on prediction and early detection of AKI (e.g., the role of biomarkers to identify high-risk patients and the use of machine learning to predict AKI), aspects of pathophysiology and progress in the recognition of different phenotypes of AKI, as well as an update on nephrotoxicity and organ cross-talk. In addition, prevention of AKI (focusing on fluid management, kidney perfusion pressure, and the choice of vasopressor) and supportive treatment of AKI is discussed. Finally, post-AKI risk of long-term sequelae including incident or progression of chronic kidney disease, cardiovascular events and mortality, will be addressed.
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71
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Fliser D, Wanner C. Precision medicine in diabetic nephropathy and chronic kidney disease. Nephrol Dial Transplant 2021; 36:10-13. [PMID: 34153982 DOI: 10.1093/ndt/gfaa380] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Indexed: 12/12/2022] Open
Abstract
Progressive chronic kidney disease (CKD) in individuals with type 2 diabetes mellitus is a global public health problem accompanied by substantial comorbidities and reduced life expectancy. In this respect, CKD leading to uremia can be seen as a systemic disease with a critical impact on virtually all organ systems. Thus it is of particular importance to identify patients with incipient CKD and ongoing CKD progression, but the individual course of CKD is challenging to predict. Patterns of progression in persons with CKD include linear and nonlinear trajectories of glomerular filtration rate (GFR) loss. Kidney function can also remain stable for years, especially in the elderly. In particular, one-fifth of individuals show a substantial GFR decline in the absence of high albuminuria (nonproteinuric CKD), rendering albuminuria less suitable for predicting the progression in such individuals.
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Affiliation(s)
- Danilo Fliser
- Department of Internal Medicine IV-Nephrology and Hypertension, Saarland University Medical Center, Homburg, Germany
| | - Christoph Wanner
- Department of Internal Medicine I, Division of Nephrology, Würzburg University Medical Center, Würzburg, Germany
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Association of Urinary Dickkopf-3 with Residual Renal Function Decline in Patients Undergoing Peritoneal Dialysis. ACTA ACUST UNITED AC 2021; 57:medicina57060631. [PMID: 34207077 PMCID: PMC8235738 DOI: 10.3390/medicina57060631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/12/2021] [Accepted: 06/15/2021] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Urinary levels of dickkopf-3 (DKK-3) are associated with poor renal survival in patients with non-dialytic chronic kidney disease. However, it remains unknown whether urinary DKK-3 levels can predict residual renal function (RRF) decline in patients undergoing peritoneal dialysis (PD). Therefore, we investigated the correlation between urinary levels of DKK-3 and the subsequent rate of RRF decline in PD patients. Materials and Methods: This study included 36 PD patients who underwent multiple peritoneal equivalent tests during 2011–2021. The relationship between baseline clinical characteristics and the subsequent annual rate of Kt/V decline was investigated. Results: The annual rate of renal Kt/V decline was 0.29 (range: 0.05–0.48), which correlated with renal Kt/V (r = 0.55, p = 0.0005) and 24 h urinary DKK-3 excretion (r = 0.61, p < 0.0001). Similarly, 24 h urinary DKK-3 excretion (β = 0.44, p = 0.0015) and renal Kt/V (β = 0.38, p = 0.0059) were independently associated with the annual rate of renal Kt/V decline in multivariate analyses. Conclusions: Urinary DKK-3 assessment may help identify PD patients at a high risk of RRF decline.
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Sanchez-Alamo B, García-Iñigo FJ, Shabaka A, Acedo JM, Cases-Corona C, Domínguez-Torres P, Diaz-Enamorado Y, Landaluce E, Navarro-González JF, Gorriz JL, Martínez-Castelao A, Fernández-Juárez G. Urinary Dickkopf-3 (uDKK3): a new biomarker for CKD progression and mortality? Nephrol Dial Transplant 2021; 36:2199-2207. [PMID: 34145894 DOI: 10.1093/ndt/gfab198] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Kidney fibrosis has been reported to be a prognostic factor in CKD progression. Previous studies have shown that the assessment of urinary Dickkopf-3 (uDKK3), a stress induced tubular epithelial-derived profibrotic glycoprotein, might be a potential tubulointerstitial fibrosis biomarker and might identify patients at short-term risk of eGFR loss. We aim to evaluate uDKK3 as a potential biomarker for progression of CKD in a cohort with various etiologies of CKD, and subsequently in an overt diabetic nephropathy cohort. METHODS We prospectively studied two independent cohorts comprising a total of 351 patients with stage 2-3 CKD. Combined primary outcome consisted of a 50% increase in serum creatinine, ESKD or death. Progreser cohort included patients with heterogeneous etiologies and Pronedi cohort 101 patients with overt diabetic nephropathy. Median time of follow-up was 36 (30-39) and 36 (16-48) months, respectively. RESULTS At baseline, median uDKK3 was 2200 (671 - 7617) pg/mg in the Progreser cohort and 3042 (661-9747) pg/mg in the Pronedi cohort. There were any statically significant differences in uDKK3 ratio between both cohorts, nor between CKD etiologies. Baseline uDKK3 was significantly higher in patients who reached primary outcome. In the Cox proportional-hazard model, the highest levels of uDKK3 were found to be an independent factor for renal progression in Progreser cohort (HR 1.91, CI95% 1.04 - 3.52) and in Pronedi cohort (HR 3.03, CI95% 1.03-8.92). uDKK3 gradually increased in the following months, especially in patients with higher proteinuria. Treatment with RAAS-blockers did not modify uDKK3 after 4 nor 12 months of treatment. CONCLUSIONS uDKK3 identifies patients at high risk of CKD progression regardless of the cause of kidney injury. uDKK3 might serve as a useful biomarker for kidney disease progression and therefore could be used by clinicians to optimize staging for renal progression and monitor the response to potential treatments.
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Affiliation(s)
| | | | - Amir Shabaka
- Department of Nephrology., Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Juan Manuel Acedo
- Department of Clinical Biochemistry. Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Clara Cases-Corona
- Department of Nephrology., Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | | | - Eugenia Landaluce
- Department of Nephrology., Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Juan F Navarro-González
- Research Department. Hospital, Universitario Nuestra Señora de Candelaria. Santa Cruz de Tenerife, Spain
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Urinary Dickkopf-3 and Contrast-Associated Kidney Damage. J Am Coll Cardiol 2021; 77:2667-2676. [PMID: 34045024 DOI: 10.1016/j.jacc.2021.03.330] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Administration of iodinated contrast medium (CM) during invasive cardiovascular procedures may be associated with impairment of kidney function. OBJECTIVES Urinary dickkopf-3 (DKK3), a stress-induced renal tubular epithelium-derived glycoprotein, has been identified as a biomarker predicting both acute kidney injury (AKI) and persistent kidney dysfunction. METHODS Urinary DKK3/creatinine ratio (uDKK3/uCr), urine and serum neutrophil gelatinase-associated lipocalin (uNGAL, sNGAL) and serum cystatin C (sCyC) were assessed in 458 patients with chronic kidney disease scheduled for invasive cardiovascular procedures requiring CM administration with universal adoption of nephroprotective interventions. Contrast-associated AKI (CA-AKI) was defined as serum creatinine increase ≥0.3 mg/dl at 48 h after CM administration. Persistent kidney dysfunction was defined as persistent estimated glomerular filtration rate reduction ≥25% at 1 month compared with baseline. RESULTS CA-AKI occurred in 64 or the 458 patients (14%), and baseline uDKK3/uCr ≥491 pg/mg was the best threshold for its prediction. Net reclassification improvement (NRI) was significantly increased by adding baseline uDKK3/uCr to the Mehran, Gurm, and National Cardiovascular Data Registry (NCDR) scores (all p < 0.05), and the same applied to integrated discrimination improvement (IDI) when adding uDKK3/uCr to the Gurm and NCDR scores (p < 0.001). Persistent kidney dysfunction occurred in 57 of the 458 patients (12%) and baseline uDKK3/uCr ≥322 pg/mg appeared as the best threshold for its prediction. Adding baseline uDKK3/uCr to the Mehran, Gurm, and NCDR scores significantly increased IDI and NRI (all p < 0.001). CONCLUSIONS Baseline uDKK3/uCr seems to be a reliable marker for improving the identification of patients with chronic kidney disease undergoing invasive coronary and peripheral procedures at risk for AKI and persistent kidney dysfunction.
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Gurm HS. Will Urinary Dickkopf-3 Disrupt the Field of Contrast-Induced Acute Kidney Injury? J Am Coll Cardiol 2021; 77:2677-2679. [PMID: 34045025 DOI: 10.1016/j.jacc.2021.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Hitinder S Gurm
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.
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Clendenen N, Ahlgren B, Robitaille MJ, Christensen E, Morabito J, Grae L, Lyman M, Weitzel N. Year in Review 2020: Noteworthy Literature in Cardiothoracic Anesthesiology. Semin Cardiothorac Vasc Anesth 2021; 25:94-106. [PMID: 33938302 PMCID: PMC10088871 DOI: 10.1177/10892532211013614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The year 2020 was marred by the emergence of a deadly pandemic that disrupted every aspect of life. Despite the disruption, notable research accomplishments in the practice of cardiothoracic anesthesiology occurred in 2020 with an emphasis on optimizing care, improving outcomes, and expanding what is possible for patients undergoing cardiac surgery. This year's edition of Noteworthy Literature Review will focus on specific themes in cardiac anesthesiology that include preoperative anemia, predictors of acute kidney injury following cardiac surgery, pain management modalities, anticoagulation strategies after transcatheter aortic valve replacement, mechanical circulatory support, and future directions in research.
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Affiliation(s)
| | - Bryan Ahlgren
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mark J Robitaille
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Joseph Morabito
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lyndsey Grae
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew Lyman
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nathaen Weitzel
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Pre-operative N-terminal pro-B-type natriuretic peptide for prediction of acute kidney injury after noncardiac surgery: A retrospective cohort study. Eur J Anaesthesiol 2021; 38:591-599. [PMID: 33720062 DOI: 10.1097/eja.0000000000001495] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is associated with poor outcomes after noncardiac surgery. Whether pre-operative N-terminal pro-B-type natriuretic peptide (NT-proBNP) predicts AKI after noncardiac surgery is unclear. OBJECTIVE To investigate the predictive role of pre-operative NT-proBNP on postoperative AKI. DESIGN Retrospective cohort study. SETTING Nanfang Hospital, Southern Medical University, China. PATIENTS Adult patients who had a serum creatinine and NT-proBNP measurement within 30 pre-operative days and at least one serum creatinine measurement within 7 days after noncardiac surgery between February 2008 and May 2018 were identified. MAIN OUTCOME MEASURES The primary outcome was postoperative AKI, defined by the kidney disease: improving global outcomes creatinine criteria. RESULTS In all, 6.1% (444 of 7248) of patients developed AKI within 1 week after surgery. Pre-operative NT-proBNP was an independent predictor of AKI after adjustment for clinical variables (OR comparing top to bottom quintiles 2.29, 95% CI, 1.47 to 3.65, P < 0.001 for trend; OR per 1-unit increment in natural log transformed NT-proBNP 1.27, 95% CI, 1.16 to 1.39). Compared with clinical variables alone, the addition of NT-proBNP improved model fit, modestly improved the discrimination (change in area under the curve from 0.764 to 0.773, P = 0.005) and reclassification (continuous net reclassification improvement 0.210, 95% CI, 0.111 to 0.308, improved integrated discrimination 0.0044, 95% CI, 0.0016 to 0.0072) of AKI and non-AKI cases, and achieved higher net benefit in decision curve analysis. CONCLUSIONS Pre-operative NT-proBNP concentrations provided predictive information for AKI in a cohort of patients undergoing noncardiac surgery, independent of and incremental to conventional risk factors. Prospective studies are required to confirm this finding and examine its clinical impact. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR1900024056. www.chictr.org.cn/showproj.aspx?proj=40385.
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Haines RW, Powell-Tuck J, Leonard H, Crichton S, Ostermann M. Long-term kidney function of patients discharged from hospital after an intensive care admission: observational cohort study. Sci Rep 2021; 11:9928. [PMID: 33976354 PMCID: PMC8113423 DOI: 10.1038/s41598-021-89454-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/26/2021] [Indexed: 12/20/2022] Open
Abstract
The long-term trajectory of kidney function recovery or decline for survivors of critical illness is incompletely understood. Characterising changes in kidney function after critical illness and associated episodes of acute kidney injury (AKI), could inform strategies to monitor and treat new or progressive chronic kidney disease. We assessed changes in estimated glomerular filtration rate (eGFR) and impact of AKI for 1301 critical care survivors with 5291 eGFR measurements (median 3 [IQR 2, 5] per patient) between hospital discharge (2004-2008) and end of 7 years of follow-up. Linear mixed effects models showed initial decline in eGFR over the first 6 months was greatest in patients without AKI (- 9.5%, 95% CI - 11.5% to - 7.4%) and with mild AKI (- 12.3%, CI - 15.1% to - 9.4%) and least in patients with moderate-severe AKI (- 4.3%, CI - 7.0% to - 1.4%). However, compared to patients without AKI, hospital discharge eGFR was lowest for the moderate-severe AKI group (median 61 [37, 96] vs 101 [78, 120] ml/min/1.73m2) and two thirds (66.5%, CI 59.8-72.6% vs 9.2%, CI 6.8-12.4%) had an eGFR of < 60 ml/min/1.73m2 through to 7 years after discharge. Kidney function trajectory after critical care discharge follows a distinctive pattern of initial drop then sustained decline. Regardless of AKI severity, this evidence suggests follow-up should incorporate monitoring of eGFR in the early months after hospital discharge.
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Affiliation(s)
- Ryan W Haines
- William Harvey Research Institute, Queen Mary University of London, London, EC1M 6BQ, UK.
| | - Jonah Powell-Tuck
- Department of Critical Care, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Hugh Leonard
- Department of Renal Medicine, Guy's and St Thomas' NHS Foundation Trust, London, SE1 9RT, UK
| | - Siobhan Crichton
- MRC Clinical Trials Unit at University College London, London, UK
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
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Huffstater T, Merryman WD, Gewin LS. Wnt/β-Catenin in Acute Kidney Injury and Progression to Chronic Kidney Disease. Semin Nephrol 2021; 40:126-137. [PMID: 32303276 DOI: 10.1016/j.semnephrol.2020.01.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute kidney injury (AKI) portends a poor clinical prognosis and increases the risk for the development of chronic kidney disease (CKD). Currently, there are no therapies to treat AKI or prevent its progression to CKD. Wnt/β-catenin is a critical regulator of kidney development that is up-regulated after injury. Most of the literature support a beneficial role for Wnt/β-catenin in AKI, but suggest that this pathway promotes the progression of tubulointerstitial fibrosis, the hallmark of CKD progression. We review the role of Wnt/β-catenin in renal injury with a focus on its potential as a therapeutic target in AKI and in AKI to CKD transition.
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Affiliation(s)
- Tessa Huffstater
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - W David Merryman
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - Leslie S Gewin
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Department of Medicine, Veterans Affairs Hospital, Tennessee Valley Healthcare System, Nashville, TN; Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN.
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80
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The emerging plasma biomarker Dickkopf-3 (DKK3) and its association with renal and cardiovascular disease in the general population. Sci Rep 2021; 11:8642. [PMID: 33883651 PMCID: PMC8060267 DOI: 10.1038/s41598-021-88107-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/05/2021] [Indexed: 12/29/2022] Open
Abstract
Dickkopf-3 (DKK3) is an emerging biomarker for cardiovascular disease (CVD) and chronic kidney disease (CKD). Herein, baseline DKK3 plasma levels were measured in 8420 subjects from the Prevention of Renal and Vascular ENd-stage Disease (PREVEND) cohort, a large general population cohort, using enzyme-linked immunosorbent assays. Associations with clinical variables and outcomes were analysed. Median DKK3 level was 32.8 ng/ml (28.0–39.0). In multivariable linear regression analysis, the strongest correlates for plasma DKK3 were age, body mass index and estimated glomerular filtration rate (eGFR). At baseline, 564 (6.7%) subjects had CVD (defined as a myocardial infarction and/or cerebrovascular accident) and 1361 (16.2%) subjects had CKD (defined as eGFR < 60 ml/min/1.73m2 and/or urinary albumin excretion (UAE) > 30 mg/24 h). Of subjects with known CVD and CKD follow-up status (respectively 7828 and 5548), 669 (8.5%) developed CVD and 951 (17.1%) developed CKD (median follow-up respectively 12.5 and 10.2 years). Crude logistic regression analysis revealed that DKK3 levels were associated with prevalent CVD (Odds ratio: 2.14 [1.76–2.61] per DKK3 doubling, P < 0.001) and CKD (Odds ratio: 1.84 [1.59–2.13] per DKK3 doubling, P < 0.001). In crude Cox proportional hazard regression analysis, higher DKK3 levels were associated with higher risk for new-onset CVD (Hazard ratio: 1.47 [1.13–1.91] per DKK3 doubling, P = 0.004) and CKD (Hazard ratio: 1.45, [1.25–1.69] per DKK3 doubling, P < 0.001). However, these associations remained no longer significant after correction for common clinical variables and risk factors, though independently predicted for new-onset CKD in a subgroup of subjects with the lowest UAE values. Together, DKK3 plasma levels are associated with cardiovascular risk factors, but are generally not independently associated with prevalent and new-onset CVD and CKD and only predicted for new-onset CKD in those subjects with the lowest UAE values.
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Radhakrishnan K, Kim YH, Jung YS, Kim DK, Na SY, Lim D, Kim DH, Kim J, Kim HS, Choy HE, Cho SJ, Lee IK, Ayvaz Ş, Nittka S, Fliser D, Schunk SJ, Speer T, Dooley S, Lee CH, Choi HS. Orphan nuclear receptor ERR-γ regulates hepatic FGF23 production in acute kidney injury. Proc Natl Acad Sci U S A 2021; 118. [DOI: https:/doi.org/10.1073/pnas.2022841118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023] Open
Abstract
Significance
Bone is the main source of fibroblast growth factor 23 (FGF23), which is important for phosphate and vitamin D homeostasis. In acute kidney injury (AKI), high blood levels of FGF23 are positively correlated with disease progression and increased risk of mortality. Reducing adverse plasma FGF23 levels in AKI patients is favorable. We showed here that hepatocytes are the major source of circulating FGF23, and orphan nuclear receptor ERR-γ is a novel transcriptional regulator of hepatic FGF23 production in AKI. Liver-specific depletion of ERR-γ or ERR-γ inverse agonist, GSK5182, significantly reduced plasma levels of FGF23 in AKI. This study reveals liver is the source of FGF23 and a therapeutic strategy to control pathologically adverse plasma FGF23 levels in AKI.
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Affiliation(s)
- Kamalakannan Radhakrishnan
- School of Biological Sciences and Technology, Chonnam National University, 61186 Gwangju, Republic of Korea
| | - Yong-Hoon Kim
- Laboratory Animal Resource Center, Korea Research Institute of Bioscience and Biotechnology, 34141 Daejeon, Republic of Korea
- Department of Functional Genomics, Korea Research Institute of Biosciences and Biotechnology School of Bioscience, University of Science and Technology, 34141 Daejeon, Republic of Korea
| | - Yoon Seok Jung
- School of Biological Sciences and Technology, Chonnam National University, 61186 Gwangju, Republic of Korea
| | - Don-Kyu Kim
- Department of Molecular Biotechnology, Chonnam National University, 61186 Gwangju, Republic of Korea
| | - Soon-Young Na
- School of Biological Sciences and Technology, Chonnam National University, 61186 Gwangju, Republic of Korea
| | - Daejin Lim
- Department of Microbiology, Chonnam National University Medical School, 61468 Gwangju, Republic of Korea
| | - Dong Hun Kim
- Department of Biomedical Science, Graduate School, Kyungpook National University, 41404 Daegu, Republic of Korea
| | - Jina Kim
- New Drug Development Center, Daegu Gyeongbuk Medical Innovation Foundation, 41061 Daegu, Republic of Korea
| | - Hyung-Seok Kim
- Department of Forensic Medicine, Chonnam National University Medical School, 61468 Gwangju, Republic of Korea
| | - Hyon E. Choy
- Department of Microbiology, Chonnam National University Medical School, 61468 Gwangju, Republic of Korea
| | - Sung Jin Cho
- New Drug Development Center, Daegu Gyeongbuk Medical Innovation Foundation, 41061 Daegu, Republic of Korea
- Leading-edge Research Center for Drug Discovery and Development for Diabetes and Metabolic Disease, Kyungpook National University Hospital, 41404 Daegu, Republic of Korea
| | - In-Kyu Lee
- Leading-edge Research Center for Drug Discovery and Development for Diabetes and Metabolic Disease, Kyungpook National University Hospital, 41404 Daegu, Republic of Korea
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 41944 Daegu, Republic of Korea
| | - Şamil Ayvaz
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Stefanie Nittka
- Institute for Clinical Chemistry, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Danilo Fliser
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University, D-66421 Homburg/Saar, Germany
| | - Stefan J. Schunk
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University, D-66421 Homburg/Saar, Germany
| | - Thimoteus Speer
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University, D-66421 Homburg/Saar, Germany
| | - Steven Dooley
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Chul-Ho Lee
- Laboratory Animal Resource Center, Korea Research Institute of Bioscience and Biotechnology, 34141 Daejeon, Republic of Korea
- Department of Functional Genomics, Korea Research Institute of Biosciences and Biotechnology School of Bioscience, University of Science and Technology, 34141 Daejeon, Republic of Korea
| | - Hueng-Sik Choi
- School of Biological Sciences and Technology, Chonnam National University, 61186 Gwangju, Republic of Korea
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82
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Orphan nuclear receptor ERR-γ regulates hepatic FGF23 production in acute kidney injury. Proc Natl Acad Sci U S A 2021; 118:2022841118. [PMID: 33853949 DOI: 10.1073/pnas.2022841118] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Fibroblast growth factor 23 (FGF23), a hormone generally derived from bone, is important in phosphate and vitamin D homeostasis. In acute kidney injury (AKI) patients, high-circulating FGF23 levels are associated with disease progression and mortality. However, the organ and cell type of FGF23 production in AKI and the molecular mechanism of its excessive production are still unidentified. For insight, we investigated folic acid (FA)-induced AKI in mice. Interestingly, simultaneous with FGF23, orphan nuclear receptor ERR-γ expression is increased in the liver of FA-treated mice, and ectopic overexpression of ERR-γ was sufficient to induce hepatic FGF23 production. In patients and in mice, AKI is accompanied by up-regulated systemic IL-6, which was previously identified as an upstream regulator of ERR-γ expression in the liver. Administration of IL-6 neutralizing antibody to FA-treated mice or of recombinant IL-6 to healthy mice confirms IL-6 as an upstream regulator of hepatic ERR-γ-mediated FGF23 production. A significant (P < 0.001) interconnection between high IL-6 and FGF23 levels as a predictor of AKI in patients that underwent cardiac surgery was also found, suggesting the clinical relevance of the finding. Finally, liver-specific depletion of ERR-γ or treatment with an inverse ERR-γ agonist decreased hepatic FGF23 expression and plasma FGF23 levels in mice with FA-induced AKI. Thus, inverse agonist of ERR-γ may represent a therapeutic strategy to reduce adverse plasma FGF23 levels in AKI.
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83
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Tomlinson A, Bullman L, Singh R, Forni LG. Perioperative acute kidney injury following major abdominal surgery. Br J Hosp Med (Lond) 2021; 82:1-9. [PMID: 33792381 DOI: 10.12968/hmed.2020.0661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Major abdominal surgery is associated with significant morbidity, not least the development of acute kidney injury. As a common perioperative complication, acute kidney injury is associated with increased length of stay, increased risk of perioperative infection and the potential development of chronic kidney disease. Moreover, the development of acute kidney injury is independently associated with an increased risk of death. Perioperative acute kidney injury is not a single entity, but describes a clinical syndrome with multiple causes including physical causes related to the surgical procedure, ischaemia-reperfusion injury and the use of potential nephrotoxins. Currently, acute kidney injury is defined by changes in serum creatinine level and urine output criteria, which although robust in heterogenous populations, may not perform as accurately in the perioperative period. This article discusses these issues including the potential role of novel biomarkers for early detection of perioperative acute kidney injury, as well as the use of predictive modelling. Treatment is mainly supportive but evidence suggests that more targeted therapy may lead to improved outcomes.
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Affiliation(s)
- Ashley Tomlinson
- Intensive Care Unit, Royal Surrey Hospital Foundation Trust, Guildford, UK
| | - Laetitia Bullman
- Intensive Care Unit, Royal Surrey Hospital Foundation Trust, Guildford, UK
| | - Rishabh Singh
- Department of Surgery, Royal Surrey Hospital Foundation Trust, Guildford, UK
| | - Lui G Forni
- Intensive Care Unit, Royal Surrey Hospital Foundation Trust, Guildford, UK.,Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, UK
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84
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McWilliam SJ, Wright RD, Welsh GI, Tuffin J, Budge KL, Swan L, Wilm T, Martinas IR, Littlewood J, Oni L. The complex interplay between kidney injury and inflammation. Clin Kidney J 2021; 14:780-788. [PMID: 33777361 PMCID: PMC7986351 DOI: 10.1093/ckj/sfaa164] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 06/10/2020] [Indexed: 12/11/2022] Open
Abstract
Acute kidney injury (AKI) has gained significant attention following patient safety alerts about the increased risk of harm to patients, including increased mortality and hospitalization. Common causes of AKI include hypovolaemia, nephrotoxic medications, ischaemia and acute glomerulonephritis, although in reality it may be undetermined or multifactorial. A period of inflammation either as a contributor to the kidney injury or resulting from the injury is almost universally seen. This article was compiled following a workshop exploring the interplay between injury and inflammation. AKI is characterized by some degree of renal cell death through either apoptosis or necrosis, together with a strong inflammatory response. Studies interrogating the resolution of renal inflammation identify a whole range of molecules that are upregulated and confirm that the kidneys are able to intrinsically regenerate after an episode of AKI, provided the threshold of damage is not too high. Kidneys are unable to generate new nephrons, and dysfunctional or repeated episodes will lead to further nephron loss that is ultimately associated with the development of renal fibrosis and chronic kidney disease (CKD). The AKI to CKD transition is a complex process mainly facilitated by maladaptive repair mechanisms. Early biomarkers mapping out this process would allow a personalized approach to identifying patients with AKI who are at high risk of developing fibrosis and subsequent CKD. This review article highlights this process and explains how laboratory models of renal inflammation and injury assist with understanding the underlying disease process and allow interrogation of medications aimed at targeting the mechanistic interplay.
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Affiliation(s)
- Stephen J McWilliam
- Department of Paediatric Pharmacology, Alder Hey Children’s Hospital, Liverpool, UK
- Department of Women and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Rachael D Wright
- Department of Women and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Gavin I Welsh
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jack Tuffin
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kelly L Budge
- Department of Women and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Laura Swan
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Thomas Wilm
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Ioana-Roxana Martinas
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - James Littlewood
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Nephrology, Royal Liverpool University Hospital, Liverpool, UK
| | - Louise Oni
- Department of Women and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Paediatric Nephrology, Alder Hey Children’s NHS Foundation Trust Hospital, Liverpool, UK
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85
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Shabaka A, Cases-Corona C, Fernandez-Juarez G. Therapeutic Insights in Chronic Kidney Disease Progression. Front Med (Lausanne) 2021; 8:645187. [PMID: 33708784 PMCID: PMC7940523 DOI: 10.3389/fmed.2021.645187] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/01/2021] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease (CKD) has been recognized as a leading public health problem worldwide. Through its effect on cardiovascular risk and end-stage kidney disease, CKD directly affects the global burden of morbidity and mortality. Classical optimal management of CKD includes blood pressure control, treatment of albuminuria with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, avoidance of potential nephrotoxins and obesity, drug dosing adjustments, and cardiovascular risk reduction. Diabetes might account for more than half of CKD burden, and obesity is the most important prompted factor for this disease. New antihyperglycemic drugs, such as sodium-glucose-cotransporter 2 inhibitors have shown to slow the decline of GFR, bringing additional benefit in weight reduction, cardiovascular, and other kidney outcomes. On the other hand, a new generation of non-steroidal mineralocorticoid receptor antagonist has recently been developed to obtain a selective receptor inhibition reducing side effects like hyperkalemia and thereby making the drugs suitable for administration to CKD patients. Moreover, two new potassium-lowering therapies have shown to improve tolerance, allowing for higher dosage of renin-angiotensin system inhibitors and therefore enhancing their nephroprotective effect. Regardless of its cause, CKD is characterized by reduced renal regeneration capacity, microvascular damage, oxidative stress and inflammation, resulting in fibrosis and progressive, and irreversible nephron loss. Therefore, a holistic approach should be taken targeting the diverse processes and biological contexts that are associated with CKD progression. To date, therapeutic interventions when tubulointerstitial fibrosis is already established have proved to be insufficient, thus research effort should focus on unraveling early disease mechanisms. An array of novel therapeutic approaches targeting epigenetic regulators are now undergoing phase II or phase III trials and might provide a simultaneous regulatory activity that coordinately regulate different aspects of CKD progression.
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Affiliation(s)
- Amir Shabaka
- Nephrology Department, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Clara Cases-Corona
- Nephrology Department, Hospital Universitario Fundación Alcorcón, Madrid, Spain
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86
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Obert LA, Elmore SA, Ennulat D, Frazier KS. A Review of Specific Biomarkers of Chronic Renal Injury and Their Potential Application in Nonclinical Safety Assessment Studies. Toxicol Pathol 2021; 49:996-1023. [PMID: 33576319 DOI: 10.1177/0192623320985045] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A host of novel renal biomarkers have been developed over the past few decades which have enhanced monitoring of renal disease and drug-induced kidney injury in both preclinical studies and in humans. Since chronic kidney disease (CKD) and acute kidney injury (AKI) share similar underlying mechanisms and the tubulointerstitial compartment has a functional role in the progression of CKD, urinary biomarkers of AKI may provide predictive information in chronic renal disease. Numerous studies have explored whether the recent AKI biomarkers could improve upon the standard clinical biomarkers, estimated glomerular filtration rate (eGFR), and urinary albumin to creatinine ratio, for predicting outcomes in CKD patients. This review is an introduction to alternative assays that can be utilized in chronic (>3 months duration) nonclinical safety studies to provide information on renal dysfunction and to demonstrate specific situations where these assays could be utilized in nonclinical drug development. Novel biomarkers such as symmetrical dimethyl arginine, dickkopf homolog 3, and cystatin C predict chronic renal injury in animals, act as surrogates for GFR, and may predict changes in GFR in patients over time, ultimately providing a bridge from preclinical to clinical renal monitoring.
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Affiliation(s)
- Leslie A Obert
- 549350GlaxoSmithKline (GSK), Nonclinical Safety, Collegeville, PA, USA
| | - Susan A Elmore
- Cellular and Molecular Pathology Branch, National Toxicology Program (NTP), 6857National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, USA
| | - Daniela Ennulat
- 549350GlaxoSmithKline (GSK), Nonclinical Safety, Collegeville, PA, USA
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Abstract
Interstitial fibrosis with tubule atrophy (IF/TA) is the response to virtually any sustained kidney injury and correlates inversely with kidney function and allograft survival. IF/TA is driven by various pathways that include hypoxia, renin-angiotensin-aldosterone system, transforming growth factor (TGF)-β signaling, cellular rejection, inflammation and others. In this review we will focus on key pathways in the progress of renal fibrosis, diagnosis and therapy of allograft fibrosis. This review discusses the role and origin of myofibroblasts as matrix producing cells and therapeutic targets in renal fibrosis with a particular focus on renal allografts. We summarize current trends to use multi-omic approaches to identify new biomarkers for IF/TA detection and to predict allograft survival. Furthermore, we review current imaging strategies that might help to identify and follow-up IF/TA complementary or as alternative to invasive biopsies. We further discuss current clinical trials and therapeutic strategies to treat kidney fibrosis.Supplemental Visual Abstract; http://links.lww.com/TP/C141.
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Abstract
PURPOSE OF REVIEW The current narrative review discusses practical applications of stress and damage biomarkers for the management of acute kidney injury (AKI) based on clinical trials and real-world evaluations. RECENT FINDINGS In 2013 with the discovery and validation study of biomarkers for AKI (Sapphire) advancement in care was provided allowing for the early identification of patients at high risk for developing AKI. It was the combination of new biomarkers and the Kidney Disease Improving Global Outcomes (KDIGO) guidelines for managing patients with AKI that provided an opportunity to improve patient care. In 2017, the PrevAKI study implemented KDIGO guideline management in high-risk patients identified by biomarkers followed in 2018 with the BigPAK study that used a similar approach, both of which demonstrated positive outcomes in patient care. Next, real-world evaluations followed supporting biomarker guided management of AKI in clinical practice. Also, proposals for better nephrotoxin management, a major modifiable exposure to prevent AKI, were provided with the foresight in identifying high-risk patients. SUMMARY Stress and damage biomarker-based approaches to patient care seem to be promising for identifying patients at high risk for developing AKI and thus offers an opportunity for early management to prevent and ameliorate AKI and drug-associated AKI.
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89
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Luft FC. Biomarkers and predicting acute kidney injury. Acta Physiol (Oxf) 2021; 231:e13479. [PMID: 32311830 DOI: 10.1111/apha.13479] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 12/20/2022]
Abstract
AIM How can we convert biomarkers into reliable, validated laboratory tests? Glomerular filtration rate (GFR) estimators exist for more than a century. The first utilitarian biomarkers were endogenously produced urea and creatinine. Clinicians then developed simple tests to determine whether or not renal tubular function was maintained. Are there faster and better tests that reflect decreased renal function and increased acute kidney injury (AKI) risk? METHODS We inspect earlier, and recently propagated biomarkers. Cystatin C reflects GFR and is not confounded by muscle mass. Direct GFR and plasma volume can now be measured acutely within 3 hours. Better yet would be tests that give information before GFR decreases and prior to urea, creatinine, and cystatin C increases. Prospective tests identifying those persons likely to develop AKI would be helpful. Even more utilitarian would be a test that also suggests a therapeutic avenue. RESULTS A number of highly provocative biomarkers have recently been proposed. Moreover the application of big data from huge electronic medical records promise new directions in identifying and dealing with AKI. CONCLUSIONS Pipedreams are in the pipeline; the novel findings require immediate testing, verification, and perhaps application. Future research promises to make such dreams come true.
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Affiliation(s)
- Friedrich C. Luft
- Experimental and Clinical Research Center Max‐Delbrück Center for Molecular Medicine
- Charité Medical Faculty Berlin Germany
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90
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Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative. Nat Rev Nephrol 2021; 17:605-618. [PMID: 33976395 PMCID: PMC8367817 DOI: 10.1038/s41581-021-00418-2] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2021] [Indexed: 02/03/2023]
Abstract
Postoperative acute kidney injury (PO-AKI) is a common complication of major surgery that is strongly associated with short-term surgical complications and long-term adverse outcomes, including increased risk of chronic kidney disease, cardiovascular events and death. Risk factors for PO-AKI include older age and comorbid diseases such as chronic kidney disease and diabetes mellitus. PO-AKI is best defined as AKI occurring within 7 days of an operative intervention using the Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI; however, additional prognostic information may be gained from detailed clinical assessment and other diagnostic investigations in the form of a focused kidney health assessment (KHA). Prevention of PO-AKI is largely based on identification of high baseline risk, monitoring and reduction of nephrotoxic insults, whereas treatment involves the application of a bundle of interventions to avoid secondary kidney injury and mitigate the severity of AKI. As PO-AKI is strongly associated with long-term adverse outcomes, some form of follow-up KHA is essential; however, the form and location of this will be dictated by the nature and severity of the AKI. In this Consensus Statement, we provide graded recommendations for AKI after non-cardiac surgery and highlight priorities for future research.
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Fang X, Hu J, Chen Y, Shen W, Ke B. Dickkopf-3: Current Knowledge in Kidney Diseases. Front Physiol 2020; 11:533344. [PMID: 33391006 PMCID: PMC7772396 DOI: 10.3389/fphys.2020.533344] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 11/26/2020] [Indexed: 12/16/2022] Open
Abstract
Dickkopf-related protein 3 (DKK3) is a secreted glycoprotein that has been implicated in the pathogenesis of a variety of diseases. Recent evidence suggests that urinary DKK3 may serve as a potential biomarker for monitoring kidney disease progression and assessing the effects of interventions. We review the biological role of DKK3 as an agonist in chronic kidney disease (CKD) and autosomal dominant polycystic kidney disease (ADPKD) and as an antagonist in idiopathic membranous nephropathy (IMN). In addition, we present the clinical applications of DKK3 in acute kidney disease and tubulointerstitial fibrosis, suggesting that urine DKK3 may be a potential biomarker for acute kidney disease and CKD. Further research into the mechanism of DKK3 and its use as a diagnostic tool, alone or in combination with other biomarkers, could prove clinically useful for better understanding the pathology of kidney diseases and improving early detection and treatment.
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Affiliation(s)
- Xiangdong Fang
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jing Hu
- The Third Hospital of Nanchang, Nanchang, China
| | - Yanxia Chen
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wen Shen
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ben Ke
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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92
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Hu P, Chen Y, Wu Y, Song L, Zhang L, Li Z, Fu L, Liu S, Ye Z, Shi W, Liang X. Development and validation of a model for predicting acute kidney injury after cardiac surgery in patients of advanced age. J Card Surg 2020; 36:806-814. [PMID: 33314365 PMCID: PMC7898501 DOI: 10.1111/jocs.15249] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/25/2020] [Accepted: 11/28/2020] [Indexed: 02/03/2023]
Abstract
Objective To develop a clinical model for predicting postoperative acute kidney injury (AKI) in patients of advanced age undergoing cardiac surgery. Methods A total of 848 patients (aged ≥ 60 years) undergoing cardiac surgery were consecutively enrolled. Among them, 597 were randomly selected for the development set and the remaining 251 for the validation set. AKI was the primary outcome. To develop a model for predicting AKI, visualized as a nomogram, we performed logistic regression with variables selected by Lasso regression analysis. The discrimination, calibration, and clinical usefulness of the new model were assessed and compared with those of Cleveland Clinic score and Simplified Renal Index (SRI) score in the validation set. Results The incidence of AKI was 61.8% in the development set. The new model included seven variables including preoperative serum creatinine, hypertension, preoperative uric acid, New York Heart Association classification ≥ 3, cardiopulmonary bypass time > 120 min, intraoperative red blood cell transfusion, and postoperative prolonged mechanical ventilation. In the validation set, the areas under the receiver operating characteristic curves for assessing discrimination of the new model, Cleveland Clinic score, and SRI score were 0.801, 0.670, and 0.627, respectively. Compared with the other two scores, the new model presented excellent calibration according to the calibration curves. Decision curve analysis presented the new model was more clinically useful than the other two scores. Conclusions We developed and validated a new model for predicting AKI after cardiac surgery in patients of advanced age, which may help clinicians assess patients' risk for AKI.
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Affiliation(s)
- Penghua Hu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yuanhan Chen
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yanhua Wu
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Li Song
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Li Zhang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhilian Li
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Lei Fu
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shuangxin Liu
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhiming Ye
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wei Shi
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xinling Liang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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93
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Seibert FS, Heringhaus A, Pagonas N, Rohn B, Bauer F, Trappe HJ, Landmesser U, Babel N, Westhoff TH. Dickkopf-3 in the prediction of contrast media induced acute kidney injury. J Nephrol 2020; 34:821-828. [PMID: 33275197 PMCID: PMC8192364 DOI: 10.1007/s40620-020-00910-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/10/2020] [Indexed: 12/31/2022]
Abstract
Background Dickkopf-3 (DKK3) has recently been discovered as a urinary biomarker for the prediction of acute kidney injury (AKI) after cardiac surgery. This finding needs to be confirmed for AKI in other clinical settings. The present study investigates whether DKK3 can predict contrast-induced AKI (CI-AKI). Methods We performed a prospective study in 490 patients undergoing coronary angiography. Primary endpoint was an increase in serum creatinine concentration ≥ 0.3 mg/dl within 72 h after the procedure. DKK3 was assessed < 24 h before coronary angiography. Predictive accuracy was assessed by receiver operating characteristic (ROC) curves. Results CI-AKI was observed in 30 (6.1%) patients, of whom 27 corresponded to stage I and 3 to stage II according to the Acute Kidney Injury Network (AKIN) criteria. Subjects who developed CI-AKI had a 3.8-fold higher urinary DKK3/creatinine ratio than those without CI-AKI (7.5 pg/mg [interquartile range [IQR] 1.2–1392.0] vs. 2.0 pg/mg [IQR 0.9–174.0]; p = 0.047). ROC analysis revealed an area under the curve (AUC) of 0.61. Among subjects without clinically overt chronic kidney disease (estimated glomerular filtration rate [eGFR] > 60 ml/min, urinary albumin creatinine ratio < 30 mg/g), the DKK3/creatinine ratio was 5.4-fold higher in those with subsequent CI-AKI (7.5 pg/mg [IQR 0.9–590.1] vs. 1.38 pg/mg [IQR 0.8–51.0]; p = 0.007; AUC 0.62). Coronary angiography was associated with a 43 times increase in the urinary DKK3/creatinine ratio. Conclusions Urinary DKK3 is an independent predictor of CI-AKI even in the absence of overt chronic kidney disease (CKD). The study thereby expands the findings on DKK3 in the prediction of postoperative loss of kidney function to other entities of AKI. Graphic abstract ![]()
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Affiliation(s)
- Felix S Seibert
- Department of Nephrology, University Hospital Marien Hospital Herne, Ruhr-University of Bochum, Hölkeskampring 40, 44625, Herne, Germany.
| | - Anja Heringhaus
- Department of Nephrology, University Hospital Marien Hospital Herne, Ruhr-University of Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Nikolaos Pagonas
- Department of Nephrology, University Hospital Marien Hospital Herne, Ruhr-University of Bochum, Hölkeskampring 40, 44625, Herne, Germany
- Department for Angiology, Centre for Internal Medicine I, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
| | - Benjamin Rohn
- Department of Nephrology, University Hospital Marien Hospital Herne, Ruhr-University of Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Frederic Bauer
- Department of Nephrology, University Hospital Marien Hospital Herne, Ruhr-University of Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Hans-Joachim Trappe
- Department of Cardiology, University Hospital Marien Hospital Herne, Ruhr-University of Bochum, Herne, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité - Campus Benjamin Franklin, Berlin, Germany
| | - Nina Babel
- Department of Nephrology, University Hospital Marien Hospital Herne, Ruhr-University of Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Timm H Westhoff
- Department of Nephrology, University Hospital Marien Hospital Herne, Ruhr-University of Bochum, Hölkeskampring 40, 44625, Herne, Germany
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94
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Wang L, Liu S, Niu J, Zhao Z, Xu M, Lu J, Li M, Wang T, Chen Y, Wang S, Dai M, Bi Y, Wang W, Ning G, Xu Y. Serum Dickkopf-3 Level Is Inversely Associated with Significant Coronary Stenosis in an Asymptomatic Chinese Cohort. Int Heart J 2020; 61:1107-1113. [PMID: 33191341 DOI: 10.1536/ihj.20-094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Dickkopp-3 (DKK3) has been identified to play a protection role against atherosclerosis. However, little is known about the relationship between serum DKK3 levels and subclinical coronary atherosclerosis. We aimed to investigate the association of serum DKK3 with coronary stenosis in an asymptomatic Chinese population. A total of 550 Chinese adults aged 40-60 years and without symptoms or histories of cardiovascular diseases were randomly selected to undergo coronary computed tomography angiography. We defined ≥ 50% luminal narrowing as significant coronary stenosis and measured serum DKK3 levels by an enzyme-linked immunosorbent assay (ELISA). Fifty-nine participants had significant coronary stenosis and 223 had < 50% coronary stenosis. Proportions of significant coronary stenosis were 13.7%, 11.4%, and 7.1% in DKK3 tertiles 1-3, respectively (Ptrend = 0.0427). In the univariable multinomial logistic regression model, a decreasing DKK3 tertile was associated with significant coronary stenosis with borderline significance (OR: 1.40; 95% confidence intervals (CI): 0.98-1.99, P = 0.0642). In the multivariable regression model, participants in the lowest DKK3 tertile were associated with a 1.42-fold increased risk of significant coronary stenosis than those in the highest DKK3 tertile (OR: 2.42; 95% CI: 1.10-5.33; P = 0.0279) after adjustment for conventional cardiovascular risk factors. In addition, associations between DKK3 and significant coronary stenosis were consistent among subgroups. However, no significant association was found between serum DKK3 levels and < 50% coronary stenosis. Therefore, we have added to the existing evidence that serum DKK3 is inversely associated with the risk of significant coronary stenosis in asymptomatic middle-aged Chinese.
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Affiliation(s)
- Long Wang
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Shanshan Liu
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Jingya Niu
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Zhiyun Zhao
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Min Xu
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Jieli Lu
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Mian Li
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Tiange Wang
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Yuhong Chen
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Shuangyuan Wang
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Meng Dai
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Yufang Bi
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Weiqing Wang
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Guang Ning
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Yu Xu
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
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95
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Nusshag C, Reuß CJ, Dietrich M, Hecker A, Jungk C, Michalski D, Fiedler MO, Bernhard M, Beynon C, Weigand MA, Brenner T. [Focus nephrology : Intensive medical care studies from 2019/2020]. Anaesthesist 2020; 70:250-256. [PMID: 33103208 DOI: 10.1007/s00101-020-00856-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- C Nusshag
- Klinik für Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C J Reuß
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - A Hecker
- Klinik für Allgemein‑, Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen, Deutschland
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - D Michalski
- Neurologische Intensivstation und Stroke Unit, Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
| | - M O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - T Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Deutschland
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96
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Ostermann M, Zarbock A, Goldstein S, Kashani K, Macedo E, Murugan R, Bell M, Forni L, Guzzi L, Joannidis M, Kane-Gill SL, Legrand M, Mehta R, Murray PT, Pickkers P, Plebani M, Prowle J, Ricci Z, Rimmelé T, Rosner M, Shaw AD, Kellum JA, Ronco C. Recommendations on Acute Kidney Injury Biomarkers From the Acute Disease Quality Initiative Consensus Conference: A Consensus Statement. JAMA Netw Open 2020; 3:e2019209. [PMID: 33021646 DOI: 10.1001/jamanetworkopen.2020.19209] [Citation(s) in RCA: 332] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE In the last decade, new biomarkers for acute kidney injury (AKI) have been identified and studied in clinical trials. Guidance is needed regarding how best to incorporate them into clinical practice. OBJECTIVE To develop recommendations on AKI biomarkers based on existing data and expert consensus for practicing clinicians and researchers. EVIDENCE REVIEW At the 23rd Acute Disease Quality Initiative meeting, a meeting of 23 international experts in critical care, nephrology, and related specialties, the panel focused on 4 broad areas, as follows: (1) AKI risk assessment; (2) AKI prediction and prevention; (3) AKI diagnosis, etiology, and management; and (4) AKI progression and kidney recovery. A literature search revealed more than 65 000 articles published between 1965 and May 2019. In a modified Delphi process, recommendations and consensus statements were developed based on existing data, with 90% agreement among panel members required for final adoption. Recommendations were graded using the Grading of Recommendations, Assessment, Development and Evaluations system. FINDINGS The panel developed 11 consensus statements for biomarker use and 14 research recommendations. The key suggestions were that a combination of damage and functional biomarkers, along with clinical information, be used to identify high-risk patient groups, improve the diagnostic accuracy of AKI, improve processes of care, and assist the management of AKI. CONCLUSIONS AND RELEVANCE Current evidence from clinical studies supports the use of new biomarkers in prevention and management of AKI. Substantial gaps in knowledge remain, and more research is necessary.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care and Nephrology, King's College London, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care Medicine, and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Stuart Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Nephrology Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Etienne Macedo
- Division of Nephrology, Department of Medicine, University of California, San Diego
| | - Raghavan Murugan
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Max Bell
- Department of Perioperative Medicine and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Lui Forni
- Intensive Care Unit, Royal Surrey Hospital NHS Foundation Trust, Surrey, United Kingdom
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Surrey, United Kingdom
| | - Louis Guzzi
- Department of Critical Care Medicine, AdventHealth Waterman, Orlando, Florida
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Mathieu Legrand
- Department of Anesthesia and Perioperative Care, University of California, San Francisco
| | - Ravindra Mehta
- Department of Medicine, UCSD Medical Center, University of California, San Diego
| | | | - Peter Pickkers
- Department of Intensive Care Medicine, Nijmegen Medical Center, Radboud University, Nijmegen, the Netherlands
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
- Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - John Prowle
- William Harvey Research Institute, Royal London Hospital, Queen Mary University of London, London, United Kingdom
| | - Zaccaria Ricci
- Pediatric Cardiac Intensive Care Unit, Bambino Gesu Children's Hospital, Istituto Di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Thomas Rimmelé
- Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France
| | - Mitchell Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padova, Italy
- Department of Nephrology, Dialysis, and Transplantation, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
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97
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WNT-β-catenin signalling - a versatile player in kidney injury and repair. Nat Rev Nephrol 2020; 17:172-184. [PMID: 32989282 DOI: 10.1038/s41581-020-00343-w] [Citation(s) in RCA: 212] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2020] [Indexed: 12/11/2022]
Abstract
The WNT-β-catenin system is an evolutionary conserved signalling pathway that is of particular importance for morphogenesis and cell organization during embryogenesis. The system is usually suppressed in adulthood; however, it can be re-activated in organ injury and regeneration. WNT-deficient mice display severe kidney defects at birth. Transient WNT-β-catenin activation stimulates tissue regeneration after acute kidney injury, whereas sustained (uncontrolled) WNT-β-catenin signalling promotes kidney fibrosis in chronic kidney disease (CKD), podocyte injury and proteinuria, persistent tissue damage during acute kidney injury and cystic kidney diseases. Additionally, WNT-β-catenin signalling is involved in CKD-associated vascular calcification and mineral bone disease. The WNT-β-catenin pathway is tightly regulated, for example, by proteins of the Dickkopf (DKK) family. In particular, DKK3 is released by 'stressed' tubular epithelial cells; DKK3 drives kidney fibrosis and is associated with short-term risk of CKD progression and acute kidney injury. Thus, targeting the WNT-β-catenin pathway might represent a promising therapeutic strategy in kidney injury and associated complications.
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98
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Piek A, Suthahar N, Voors AA, de Boer RA, Silljé HHW. A combined bioinformatics, experimental and clinical approach to identify novel cardiac-specific heart failure biomarkers: is Dickkopf-3 (DKK3) a possible candidate? Eur J Heart Fail 2020; 22:2065-2074. [PMID: 32809235 PMCID: PMC7756877 DOI: 10.1002/ejhf.1988] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/15/2020] [Accepted: 08/01/2020] [Indexed: 12/11/2022] Open
Abstract
Aims Cardiac specificity provides an advantage in correlating heart failure (HF) biomarker plasma levels with indices of cardiac function and remodelling, as shown for natriuretic peptides. Using bioinformatics, we explored the cardiac specificity of secreted proteins and investigated in more detail the relationship of Dickkopf‐3 (DKK3) gene expression and DKK3 plasma concentrations with cardiac function and remodelling in (pre)clinical studies. Methods and results The cardiac specificity of secreted proteins was determined using RNAseq data for a large panel of organs and tissues. This showed that natriuretic peptides (NPPA and NPPB) are highly cardiac‐specific (>99%), whereas other HF biomarkers, including galectin‐3 (Gal‐3, LGALS3) and growth differentiation factor‐15 (GDF‐15), lack cardiac specificity (<4%). DKK3 was cardiac‐enriched (44%), warranting further investigation. In three different HF mouse models, cardiac Dkk3 expression was altered, but DKK3 plasma concentrations were not. In humans, DKK3 plasma concentrations were higher in HF patients (n = 2090) in comparison with age‐ and sex‐matched controls without HF (n = 240) (46.4 ng/mL vs. 36.3 ng/mL; P < 0.001). Multivariate regression analysis revealed that DKK3 was strongly associated with HF risk factors and comorbidities, including age, kidney function and atrial fibrillation. After correction for existing prediction models, DKK3 did not independently predict HF outcome [all‐cause mortality/HF hospitalization, hazard ratio 1.13 (0.79–1.61) per DKK3 doubling; P = 0.503]. Conclusions Of actively secreted HF biomarkers, only natriuretic peptides showed high cardiac specificity. Despite a cardiac specificity of 44%, secreted DKK3 had limited additional diagnostic and prognostic value.
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Affiliation(s)
- Arnold Piek
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Navin Suthahar
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Herman H W Silljé
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
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99
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Gutsche JT, Grant MC, Kiefer JJ, Ghadimi K, Lane-Fall MB, Mazzeffi MA. The Year in Cardiothoracic Critical Care: Selected Highlights from 2019. J Cardiothorac Vasc Anesth 2020; 36:45-57. [PMID: 33051148 DOI: 10.1053/j.jvca.2020.09.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 11/11/2022]
Abstract
In 2019, cardiothoracic and vascular critical care remained an important focus and subspecialty. This article continues the annual series to review relevant contributions in postoperative critical care that may affect the cardiac anesthesiologist. Herein, the pertinent literature published in 2019 is explored and organized by organ system.
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Affiliation(s)
- J T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - M C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J J Kiefer
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - K Ghadimi
- Department of Anesthesiology and Critical Care, Duke University, Durham, NC
| | - M B Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - M A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
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100
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Abstract
Physical trauma can affect any individual and is globally accountable for more than one in every ten deaths. Although direct severe kidney trauma is relatively infrequent, extrarenal tissue trauma frequently results in the development of acute kidney injury (AKI). Various causes, including haemorrhagic shock, rhabdomyolysis, use of nephrotoxic drugs and infectious complications, can trigger and exacerbate trauma-related AKI (TRAKI), particularly in the presence of pre-existing or trauma-specific risk factors. Injured, hypoxic and ischaemic tissues expose the organism to damage-associated and pathogen-associated molecular patterns, and oxidative stress, all of which initiate a complex immunopathophysiological response that results in macrocirculatory and microcirculatory disturbances in the kidney, and functional impairment. The simultaneous activation of components of innate immunity, including leukocytes, coagulation factors and complement proteins, drives kidney inflammation, glomerular and tubular damage, and breakdown of the blood-urine barrier. This immune response is also an integral part of the intense post-trauma crosstalk between the kidneys, the nervous system and other organs, which aggravates multi-organ dysfunction. Necessary lifesaving procedures used in trauma management might have ambivalent effects as they stabilize injured tissue and organs while simultaneously exacerbating kidney injury. Consequently, only a small number of pathophysiological and immunomodulatory therapeutic targets for TRAKI prevention have been proposed and evaluated.
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