KDIGO clinical practice guidelines for acute kidney injury

Comparison of regional citrate anticoagulation and nafamostat mesylate anticoagulation during plasma exchange for children at high bleeding risk: a retrospective study

BACKGROUND

There is currently no established optimal anticoagulation protocol for plasma exchange (PE) in pediatric patients at a high risk of bleeding. Therefore, we aimed to evaluate the efficacy and safety of regional citrate anticoagulation (RCA) and nafamostat mesylate (NM) for PE anticoagulation in this patient group.

METHODS

This retrospective study analyzed data from 66 children with high bleeding risk who underwent PE in the Pediatric Intensive Care Unit of Hunan Children's Hospital between June 2018 and January 2023. Patients were divided into two groups: RCA-PE (n = 45) and NM-PE (n = 21), and filter performance and adverse reaction rates were compared. Statistical analysis utilized SPSS 25.0, comprising two-sample t-tests, chi-square or Fisher's exact tests, and Mann-Whitney U tests, as appropriate. Data visualization was performed using ggplot2 in R-studio. P < 0.05 was considered statistically significant.

RESULTS

No statistically significant differences were found between the two groups in initial transmembrane pressure (TMP) [17.0 (14.0, 21.5) mmHg vs. 16.0 (14.0, 19.5) mmHg, P = 0.614], maximum TMP [46.0 (42.0, 49.5) mmHg vs. 43.0 (41.5, 49.5) mmHg, P = 0.689], and final TMP [40.0 (35.5, 45.0) mmHg vs. 38.0 (35.0, 42.0) mmHg, P = 0.298]. Filter grade distribution and bleeding events also showed no statistically significant difference between the groups. However, the NM-PE group had significantly lower overall adverse reaction and metabolic alkalosis rates (both P < 0.05) compared to the RCA-PE group.

CONCLUSIONS

NM demonstrates similar efficacy but superior safety compared with RCA, making it a more suitable anticoagulation strategy for children with high bleeding risk. Study limitations include single-center design, selection bias, and uncertain NM dosage.

A randomized controlled trial of catheters with different tips and lengths for patients requiring continuous renal replacement therapy in intensive care unit

BACKGROUND

The tip design and length of catheter impact catheter function. Two types of catheters with different tips, side-hole catheters and step-tip catheters, are commonly used during continuous renal replacement therapy (CRRT). However, there is insufficient evidence comparing their efficacy and safety in CRRT. In addition, whether the insertion of a longer catheter could enhance catheter function remains poorly studied and controversial.

METHODS

In this open-label, three-arm, randomized trial, critically ill patients receiving CRRT were randomized to three groups. Group A received 20 cm side-hole catheters (GDHK-1120), group B received 20 cm step-tip catheters (GDHK-1320) and group C received 25 cm step-tip catheters (GDHK-1325). The primary outcomes were the incidence of catheter dysfunction and catheter survival time.

RESULTS

A total of 351 patients were enrolled, with 116 in group A, 117 in group B, and 118 in group C. The incidence of catheter dysfunction in group A (35.7%, 51/143) was significantly higher than that in group B (17.7%, 22/124) (P = 0.001). However, there was no difference between group B and group C (15.6%, 23/147) (P = 0.744). The catheter survival time was comparable between group A (5.5 days, IQR 2.5-9.3) and group B (5.0 days, IQR 3.0-10.0) (P = 0.626). In contrast, group C (6.4 days, IQR 3.9-12.0) demonstrated a significantly longer catheter survival time compared to group B (P = 0.019). Cox regression analysis identified BMI (HR 1.052, 95% CI 1.003-1.103, P = 0.036) as an independent risk factor for catheter dysfunction. Results were not consistent across BMI tertiles, with similar results observed only in patients with a lower BMI (BMI < 24.2) (chi-square 13.65, P = 0.001). There was also a trend that patients in group C have a longer filter lifespan (36.5 h, IQR 16.9-68.1, P = 0.001) and a lower incidence of catheter-related thrombosis (10.40 per 1000 catheter-days, 95% CI 5.93, 17.83, P = 0.019). Other secondary outcomes were not significantly different among groups.

CONCLUSIONS

Step-tip catheters may be preferable for CRRT, particularly for patients in the lower BMI tercile. Longer femoral vein catheterization demonstrated enhanced benefits in CRRT, especially among obese patients. Further high-quality, multicenter RCTs are essential to strengthen the evidence guiding catheter selection during CRRT.

TRIAL REGISTRATION

ChiCTR2300075107. Registered 25 August 2023.

Disease Course and Long-Term Outcomes in Adult IgA Vasculitis Nephritis: A Prospective Observational Study

Background/Objectives: A limited number of previous studies have reported high rates of end-stage renal disease (ESRD) in adults with IgA vasculitis nephritis (IgAVN). Despite the high prevalence of the disease and the high rates of ESRD reported in the literature, no specific guidelines for adult patients have been established and there is no consensus on the management of the disease. This study aimed to prospectively investigate adults with IgAVN from a broad perspective. Methods: This investigation was designed as a prospective observational study and was conducted between 01.02.2022 and 01.10.2024. A total of 49 newly diagnosed adult (>18 years) patients with IgAVN were regularly followed up. At the end of the study, the renal remission rates, factors influencing remission, treatment data, treatment-related adverse events, and disease outcomes were determined. Results: The median follow-up time was 22 (IQR: 11-24) months. A total of 42 patients (87%) received immunosuppressive treatment in addition to the initial glucocorticoid treatment. Azathioprine (AZA) was the preferred (41%) first steroid-sparing agent. ESRD occurred in only one patient (2%), while a total of ten patients (20%) had an unfavorable outcome. The rate of nephrotic-range proteinuria (NRP) was significantly higher in the patients who did not achieve renal remission at the end of the 12-month follow-up period (9,7% vs. 60%; p = 0.02) and NRP was an independent risk factor for unfavorable outcomes [OR: 17.18; 95% CI: 1.31-224.95; p = 0.03]. A total of 16% of the patients developed an infection that required hospitalization during follow-up; these patients had a higher rate of IgAVN-associated acute kidney injury (62.5% vs. 22%; p = 0.02) and were significantly older (mean: 46 ± 15.3 vs. 65 ± 13.3; p = 0.002). One patient died of sepsis at 4 months and another died of a myocardial infarction at 32 months. Conclusions: These results suggest that adults with IgVAN do not have a high rate of ESRD if they receive effective immunosuppressive therapy. However, immunosuppressive therapy is associated with an increased risk of infection, particularly in the elderly. The presence of NRP is associated with lower long-term remission rates and has a predictive value for unfavorable outcomes.

Year in Review 2024: Noteworthy Literature in Cardiac Anesthesiology

The research findings relevant for Cardiac Anesthesiology studies published in 2024 involved key innovations in devices and gene therapy in addition to the expansion of transcatheter techniques for valve repair or replacement. We reviewed 447 relevant articles and selected 21 as the most noteworthy studies published in 2024. Themes that emerged from our review include the etiology and prevention of delirium or outcomes after mechanical circulatory support. Robust clinical outcome data now supports the use of microaxial flow devices for mechanical circulatory support for cardiogenic shock due to acute myocardial infarction. Pharmacology development presents colchicine as anti-inflammatory medication to prevent atrial fibrillation or intravenous amino acids for kidney protection after cardiopulmonary bypass. Technological advances include implantable wireless pacing-defibrillator devices, pulmonary artery pressure monitoring in heart failure patients, extracorporeal blood purification for preventing acute kidney injury and hypothermic oxygenated perfusion of the donor heart in heart transplantation. Transcatheter interventions on mitral or aortic valve were gaining advances over surgical procedures. Novel paradigms included treatments with gene therapy for cardiac amyloidosis or refractory angina and the emerging risk of microplastic exposure in cardiovascular events.

Study protocol: diagnosis of atrial fibrillation in postoperative thoracic surgery using a smartwatch, an open-label randomised controlled study (THOFAWATCH trial)

INTRODUCTION

Postoperative atrial fibrillation (POAF) affects approximately 20% of patients undergoing thoracic surgery and is associated with severe complications such as stroke, myocardial infarction, heart failure, and increased mortality. Early diagnosis is critical to mitigate these risks, but conventional monitoring is limited in detecting asymptomatic episodes. Smartwatches equipped with single-lead ECG and atrial fibrillation (AF) detection algorithms offer a novel approach for early POAF detection. This study aims to evaluate the effectiveness of smartwatch-based monitoring compared with standard care in identifying POAF following thoracic surgery.

METHODS AND ANALYSIS

The THOFAWATCH trial is a randomised, bicentric open-label study enrolling 302 adult patients undergoing major thoracic surgery (pneumonectomy or lobectomy) with one-lung ventilation. Eligible patients will be randomised into two groups: (1) the 'Smartwatch Monitoring' group, where participants will undergo rhythm monitoring using a smartwatch and (2) the 'Conventional Monitoring' group, receiving standard care without smartwatch monitoring. In the intervention group, any smartwatch-detected POAF episodes will be confirmed by 12-lead ECG. The primary outcome is the incidence of POAF within 7-day postsurgery. Secondary outcomes include the rate of asymptomatic POAF, cardiovascular prognosis evaluated at 2 and 6 months (composite major adverse cardiovascular events outcome), feasibility of smartwatch usage (device usage time and success rate of single-lead ECGs) and recurrence or management of AF at follow-up. Inclusion criteria include adults (>18 years) undergoing scheduled thoracic surgery and able to use the smartwatch device. Exclusion criteria encompass patients with prior AF, those requiring telemetry, or undergoing reoperations. Statistical analysis will assess the primary outcome using χ2 or Fisher's exact test (α=5%), while secondary outcomes will include descriptive and inferential statistics, with analysis conducted using SAS V.9.4.

ETHICS AND DISSEMINATION

Ethical approval for this bicentric study has been granted by the institutional review board (IRB) of the University Hospital of Amiens (Comité de Protection des Personnes sud-ouest et outre-mer 1, 21050 Toulouse, France, registration number ID RDB: 2022-A02028-27 in November 2024). The trial is registered under ClinicalTrials.gov (ID: (NCT06724718)). Results will be disseminated through peer-reviewed publications and scientific conferences to inform clinical practice regarding POAF detection and management following thoracic surgery.

TRIAL REGISTRATION NUMBER

NCT06724718; clinical trial.

Development and validation of a prediction model for the risk of citrate accumulation in critically ill patients with citrate anticoagulation for continuous renal replacement therapy: a retrospective cohort study based on MIMIC-IV database

BACKGROUND

Acute kidney injury (AKI) is a common clinical syndrome, especially in the intensive care unit (ICU), with an incidence of more than 50% and in-hospital mortality of 30%. Continuous renal replacement therapy (CRRT) is an important supportive treatment for patients with AKI (Patel in Trauma Surg Acute Care Open e001381, 2024). Citrate is the preferred anticoagulant for critically ill patients requiring CRRT. Unfortunately, such patients may be confronted with citrate accumulation during citrate anticoagulation.

METHODS

The MIMIC-IV2.2 database was used to extract data of patients undergoing CRRT who opted for citrate anticoagulation during ICU admission, including 883 critically ill patients. These 883 patients were randomized into training (n = 618) and Internal validation (n = 265) groups at a ratio of 7:3. Least Absolute Shrinkage and Selection Operator(LASSO)-logistic regression was utilized to screen the variables and construct the prediction model, followed by the plotting of the nomogram. Then, Utilizing the retrospective data from the ICU at Jiangbei Hospital in Nanjing, China, from 2014 to 2024 (n = 200) for external model validation, the model was evaluated with discriminant analysis, calibration curves, decision curve analysis, and rationality analysis.

RESULTS

A total of 883 critically ill patients undergoing CRRT were included, consisting of 542 males and 341 females, with a mean age of 65 ± 14 years. Additionally, there were 618 patients in the training set and 265 in the validation set. A total of 47 independent variables were obtained, among which 15 independent variables were screened with LASSO regression and included in the multivariate logistic analysis. The five risk factors ultimately included in the prediction model were height, hepatic insufficiency, mechanical ventilation, prefilter replacement rate, and albumin. The area under the receiver operating characteristic curve (ROC) of the model was 0.758 (0.701-0.816), 0.747 (0.678-0.817), and 0.714 (0.632-0.810) for the training set, internal validation set, and external validation set, respectively. The calibration curves in the training set and internal/external validation sets showed a high degree of consistency between predicted values and observed values (according to the Hosmer-Lemeshow test, the P-values were 0.7673, 0.2401, and 0.4512 for the training set, internal validation set, and external validation set, respectively). In addition, the Decision-Curve(DCA) revealed that the model had good clinical applicability. Nomo-score comparisons exhibited the rationality of the model.

CONCLUSION

The model developed based on LASSO-logistic regression can reliably predict the risk of citrate accumulation in critically ill patients with citrate anticoagulation for CRRT, providing valuable guidance for the application of early measures to prevent the occurrence of citrate accumulation and to improve the prognosis of patients.

HA380 Hemoperfusion Combined with Continuous Veno-Venous Hemodiafiltration for the Treatment of Septic Shock

OBJECTIVE

To explore the synergistic effect of HA380 hemoperfusion adsorbent combined with continuous veno-venous hemodiafiltration (CVVHDF) in the treatment of septic shock.

PATIENTS AND METHODS

This retrospective study included 56 adult septic shock patients who underwent blood purification treatment in the Surgical Intensive Care Unit (SICU) of Third Affiliated Hospital of Sun Yat-sen University from 1 September 2022 to 1 April 2024. Twenty patients received a combination therapy of HA380 hemoperfusion and CVVHDF, while 36 patients received only CVVHDF treatment. Inflammatory markers such as white blood cells (WBC), procalcitonin (PCT), and interleukin-6 (IL-6) were evaluated. Changes in acute physiology and chronic health status evaluation system (APACHE II) scores, sequential organ failure (SOFA) scores, and outcomes at 7 and 28 days after treatment were recorded.

RESULT

After 24 h of treatment, the levels of PCT and IL-6 in the combined group decreased significantly (p < 0.05). The 7-day and 28-day mortality rates of the combined group were 25% and 30%, respectively, while the mortality rates of the CVVHDF group were 27.8% and 50%, respectively.

CONCLUSION

HA380 hemoperfusion combined with CVVHDF was safe and effective in treating patients with septic shock.

Lack of Association Between Intraoperative Hypotension and Postoperative Acute Kidney Injury in Patients Undergoing Pancreaticoduodenectomy: A Retrospective Cohort Study

Background: Acute kidney injury (AKI) is a common postoperative event. Previous research suggests that intraoperative hypotension (IOH) is associated with postoperative AKI. This connection, however, has not been studied in patients undergoing pancreaticoduodenectomy. Methods: Based on a retrospective cohort study, we analyzed 844 adult patients who had pancreaticoduodenectomy between December 2016 and June 2020 in Henan Provincial People's Hospital. We graphically modeled the associations between the lowest intraoperative systolic and diastolic pressure and AKI using a restricted cubic spline with all covariates adjusted. The association between time under the above-specified systolic blood pressure (SPB) and diastolic blood pressure (DBP) thresholds and AKI, respectively, was investigated using logistic regression models. We further tested the robustness of our findings with a sensitivity analysis. Results: AKI occurred in 98 (11.6%) of the 844 patients in this cohort. Blood pressure components below the thresholds of 100 mmHg for systolic and 60 mmHg for diastolic were visual change points associated with increasing odds of AKI. The median (IQR) time under SBP < 100 mmHg was 15.0 (0, 40) min and 65.0 (18.8, 105.4) min for DBP < 60 mmHg. Time spent under the threshold of SBP less than 100 mmHg and DBP less than 60 mmHg was not significantly associated with AKI. Conclusions: We found no relationship between IOH and postoperative AKI after pancreaticoduodenectomy. More research is needed to investigate the complex aspects influencing intraoperative blood management in order to lessen the occurrence of AKI.

Risk factors and clinical outcome of postoperative hyperglycemia after cardiac surgery with cardiopulmonary bypass

Background

There is a high incidence of postoperative hyperglycemia (PHG) in cardiac surgery with cardiopulmonary bypass (CPB), as well as increased morbidity and mortality. The purpose of this study was to evaluate the incidence of PHG after cardiac surgery with CPB, the independent risk factors, and its association with clinical outcomes.

Methods

This was a retrospective, observational study of patients who underwent cardiac surgery with CPB between January 2023 and March 2024 in West China Hospital of Sichuan University. A total of 1,008 consecutive postoperative cardiac surgery patients admitted to the cardiac surgery intensive care unit (ICU) were divided into a non-PHG group and a PHG group. Patients' blood glucose levels were evaluated immediately after cardiac surgery and every 3-4 h daily for 10days, until discharge from the ICU. For patients with PHG, intravenous insulin infusion was performed according to the institution's protocol, and perioperative risk factors for hyperglycemia and clinical outcomes were assessed.

Results

PHG, defined as random blood glucose ≥10.0 mmol/L (180 mg/dl) on two occasions within 24 h, occurred in 65.28% of cardiac surgery patients. Multivariable logistic regression analysis identified that age [odds ratio (OR) 1.054, 95% confidence interval (CI) 1.040-1.069; p < 0.001], female sex (OR 1.380, 95% CI 1.023-1.864; p = 0.035), diabetes (OR 13.101, 95% CI 4.057-42.310; p < 0.001), pulmonary infection (OR 1.918, 95% CI 1.129-3.258; p = 0.016), aortic cross-clamp time (OR 1.007, 95% CI 1.003-1.010; p < 0.001), and intraoperative highest glucose (OR 1.515, 95% CI 1.370-1.675; p < 0.001) emerged as independent risk factors for PHG. Moreover, PHG had higher rates of acute kidney injury (12.61% vs. 4.00%; p < 0.001), delirium (9.57% vs. 3.43%; p < 0.001), pulmonary infection (12.01% vs. 5.14%; p < 0.001), longer duration of mechanical ventilation (19 vs. 14 h; p < 0.001), length of ICU stay (74 vs. 58 h; p < 0.001), length of hospitalization (13 vs. 11 days; p < 0.001), and higher rate of self-discharge or death (3.95% vs. 0.57%; p = 0.002) compared with patients with non-PHG.

Conclusions

PHG occurs frequently in patients after cardiac surgery. Age, female, diabetes, pulmonary infection, aortic cross-clamp time, and intraoperative highest glucose were independent risk factors for PHG. PHG is associated with worse clinical outcomes, including a higher rate of acute kidney injury, delirium, and pulmonary infection, greater duration of mechanical ventilation, length of ICU stay, length of hospitalization, and higher rate of automatic discharge or death.

Prognostic Value of Noninvasive Central Blood Pressure and Arterial Stiffness in Hemodynamic Shock

OBJECTIVES

Elevated central blood pressure (BP) and arterial stiffness are risk factors for cardiovascular mortality. However, their prognostic value in patients with hemodynamic shock has not been studied broadly. Evolved BP monitoring devices enable the noninvasive assessment of central BP and arterial stiffness. The objective of this study was to evaluate the prognostic value of central BP and arterial stiffness measurements, delivered by 2 noninvasive devices, in patients with septic or cardiogenic shock admitted to the intensive care unit.

DESIGN

This is a monocenter, prospective, cohort study.

SETTING

This study was conducted in a tertiary university hospital.

PARTICIPANTS

We enrolled 57 patients who were admitted to the intensive care unit with septic or cardiogenic shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Central BP and arterial stiffness indices like pulse wave velocity (PWV) and Aix were recorded with a Mobil-o-Graph 24h PWA and SphygmoCor XCEL. Age, catecholamine dosage, resuscitation incidence before inclusion, C-reactive protein, leukocytes, and creatinine were recorded as possible confounders. With regard to the confounders, central systolic BP measured in the first 24 hours, was predictive of 6-month mortality (odds ratio, 0.9; p < 0.05). Aix, recorded by Mobil-o-Graph 24h PWA, was associated with death in the first 14 days (odds ratio, 1.11; p = 0.03). An increased PWV was not associated with adverse outcomes.

CONCLUSIONS

Low central BP and increased Aix were linked to a higher mortality in shock patients. PWV had no prognostic value.

Impact of early versus conventional kidney replacement therapy initiation in tumor lysis syndrome: a target trial emulation

BACKGROUND

In the context of tumor lysis syndrome (TLS), the optimal timing and criteria for initiating kidney replacement therapy (KRT) remain unclear. This study aims to assess the effect of initiating KRT at various phosphatemia thresholds on Major Adverse Kidney Events at day 30 (MAKE30).

METHODS AND RESULTS

We retrospectively emulated a pragmatic clinical trial comparing the effect of KRT initiation at various phosphatemia thresholds versus a conventional approach during TLS on MAKE30. All consecutive patients admitted to the ICU at Saint-Louis University hospital in Paris and Angers University hospital between January 2007 and June 2020, presenting with laboratory TLS were included. The design criteria of a clinical trial were mimicked by using the cloning, censoring and weighting method. The primary outcome was the MAKE30 composite outcome, considering only KRT requirement between day 7 and day 30 for the dialysis criteria. We evaluated multiple phosphatemia thresholds to guide KRT initiation, ranging from 6.20 mg.dL-1 to 9.30 mg.dL-1. Among the initial population of 220 patients, 192 were included in the emulated trial (median age 60 years old, with non-Hodgkin Lymphoma and Acute Leukemia being the most frequent hematological malignancies). TLS-related AKI occurred in 140 patients, and 75 patients met the criteria for MAKE30. Regardless of the phosphate threshold considered, KRT initiation based on phosphate level was not associated with a significant difference in the MAKE30 rate. KRT requirement during the first 7 days (Odd Ratio [OR] 4.01 [1.65-4.86], p = 0.003) and non-renal SOFA (OR 1.39 per 1 point increment [1.25-1.57], p < 0.001) were identified as factors associated with MAKE30 (multivariable analysis).

CONCLUSION

Our results do not support the strategy of KRT initiation based on a sole critical phosphatemia level in TLS patients.

Predictors of kidney disease progression after renal artery stenting

BACKGROUND

Atherosclerotic renovascular disease (ARVD) is the most common cause of renal artery stenosis (RAS). ARVD is associated with an increased risk of progression of kidney disease and high mortality. In this regard, the aim was to evaluate the effects of the factors on kidney functions in short- and long-term follow-ups.

METHOD

Patients with RAS treated with renal artery stenting since January 2015 were evaluated retrospectively in a single center. The primary endpoint was a decline in the estimated glomerular filtration rate (eGFR) of ≥ 20 ml/min and/or evolution to end stage kidney disease. Predictors of the primary endpoint were determined using the Cox regression model.

RESULTS

Of the 95 patients included, 57 (56.4%) were male, and the mean age was 68.7 ± 10.4. Median serum creatinine (mg/dl) and eGFR (ml/min/1.73 m2) at presentation were 1.57 (IQR, 1.11-2.12) and 40 (27-58). The median follow-up was 31 months. Indications for renal artery revascularization included high blood pressure (34 patients, 35.8%), kidney failure (29 patients, 30.5%), or a mixture of these (32 patients, 33.7%). RAS was unilateral in 67 (70%) patients. In the multivariate Cox regression analysis, serum creatinine (HR 2.03, 95% CI 1.3-3.2, p = 0.002), peak systolic velocity (HR 1.005 per 10 ms, 95% CI 1.001-1.010, p = 0.007), and acute kidney injury after revascularization (HR 10.18, 95% CI 2.3-45.4, p < 0.001) were independent predictors of progression of chronic kidney disease.

CONCLUSION

Serum creatinine level, peak systolic velocity of the renal artery before revascularization, and acute kidney injury after angiographic intervention are independent predictors of the progression of chronic kidney disease in patients who underwent renal artery stenting.

Age-Dependent Risk of Long-Term All-Cause Mortality in Patients Post-Myocardial Infarction and Acute Kidney Injury

OBJECTIVES

We aimed to investigate the association between acute kidney injury (AKI) and the risk for long-term (up to 10 years) all-cause mortality among elderly compared with younger patients following an acute myocardial infarction (AMI).

METHODS

This study was a retrospective analysis of the Soroka Acute Myocardial Infarction registry and covered the years 2002 to 2017. It included patients diagnosed with an AMI who had a baseline estimated glomerular filtration rate (eGFR) greater than 60 mL/min/1.73 m2 and serum creatinine measurements available during hospitalization. The patients were stratified by age: elderly (aged 65 years or older at admission) and younger. In each stratum, two groups were defined based on the presence of an AKI. The survival approach (Kaplan-Meier survival curves, log-rank test and Cox regressions) was utilized to estimate and compare the probability of long-term (up to 10 years) all-cause mortality in each group.

RESULTS

Among the 10,511 eligible patients, which consisted of 6132 younger patients (58.3%) and 4379 elderly (41.7%), an AKI occurred in 15.2% of cases, where the elderly patients experienced a higher incidence than the younger patients (20.9% vs. 11.2%, p < 0.001). The presence of an AKI significantly increased the risk of death in both age groups, with the association being stronger among the younger patients (AdjHR = 1.634, 95% CI: 1.363-1.959, p < 0.001) than among the elderly (AdjHR = 1.278, 95% CI: 1.154-1.415, p < 0.001, p-for-interaction = 0.020).

CONCLUSIONS

An AKI following an AMI was associated with a high risk for long-term all-cause mortality in both age groups, with a stronger association among younger patients.

Impact of Dexmedetomidine Dosing and Timing on Acute Kidney Injury and Renal Outcomes After Cardiac Surgery: A Meta-Analytic Approach

BACKGROUND

Acute kidney injury (AKI) is a common and serious complication following cardiac surgery. Dexmedetomidine, a highly selective α2-adrenergic agonist, has shown potential renoprotective effects, but previous studies have yielded conflicting results.

OBJECTIVE

This meta-analysis aimed to evaluate the efficacy and safety of dexmedetomidine in preventing AKI and reducing postoperative serum creatinine levels in adult patients undergoing cardiac surgery.

METHODS

We comprehensively searched 5 databases for randomized controlled trials comparing dexmedetomidine with control groups in adult cardiac surgery patients. The main outcomes were the incidence of AKI and change in postoperative serum creatinine levels. Meta-analyses were conducted using RevMan 5.4 models, and subgroup analyses were performed based on dexmedetomidine dosing and timing of administration. Continuous outcomes were combined and analyzed using either mean difference (M.D.), while dichotomous outcomes were analyzed using risk ratio (RR) with 95% confidence intervals (CI).

RESULTS

Our study included a total of 14 trials involving 2744 patients. Dexmedetomidine administration significantly reduced the incidence of AKI compared to control groups (RR = 0.54, 95% CI: 0.41-0.70, P < 0.00001). Postoperative serum creatinine levels were also lower with dexmedetomidine (MD = -0.14 mg/dL, 95% CI: -0.28 to -0.001, P =0.04). Subgroup analyses revealed that higher initial doses (>0.5 μg/kg) and administration during intraoperative and postoperative periods were associated with more pronounced renoprotective effects. Dexmedetomidine did not significantly affect mortality but reduced the duration of the length of hospital stay and mechanical ventilation.

CONCLUSIONS AND RELEVANCE

This meta-analysis demonstrates that dexmedetomidine administration, particularly at higher doses and during both intraoperative and postoperative periods, reduces the risk of AKI in adults undergoing cardiac surgery. These findings support the use of dexmedetomidine as a preventive strategy to enhance renal outcomes in this population.

Relationship between septic acute kidney injury and adiponectin: A retrospective study in patients undergoing continuous plasma exchange with dialysis

INTRODUCTION

Adiponectin (APN) is a multimeric protein with anti-inflammatory properties that is specifically secreted by adipocytes. Continuous plasma exchange with dialysis (cPED) is a blood purification therapy in which plasma exchange is performed using a selective membrane plasma separator while the dialysate flows outside the hollow fibers.

METHODS

Patients with sepsis were divided into two groups based on the presence or absence of acute kidney injury (AKI) complications: AKI and non-AKI group.

RESULTS

Plasma APN levels significantly increased after cPED in both groups. The creatinine levels in the AKI group before cPED were significantly higher than those in the non- AKI group. The plasma APN levels in the AKI group before cPED were significantly higher than those in the non-AKI group.

CONCLUSION

cPED increased APN levels in both patients with and without AKI. Therefore, cPED therapy may be a promising intervention for increasing APN levels in patients with sepsis.

Incidence, risk factors, and outcomes of transplant-associated thrombotic microangiopathy in pediatric patients after allogeneic hematopoietic cell transplantation: a single-institution prospective study

Transplant-associated thrombotic microangiopathy (TA-TMA) is an increasingly recognized complication in hematopoietic cell transplantation (HCT). Given the rarity of prospective pediatric studies on TA-TMA, this study aimed to evaluate the incidence, survival outcomes, and risk factors for predicting early the development of TA-TMA in a pediatric population following allogeneic HCT. We conducted a prospective analysis of 173 pediatric patients to evaluate the incidence, survival outcome, and risk factors of TA-TMA. The cumulative incidence of TA-TMA at one-year post-HCT was 4.7% (95% CI, 2.2-8.6%). Patients with TA-TMA showed significantly poorer 1-year overall survival (OS) rate, 50.0% ± 17.7% compared to 85.4% ± 2.8% in those without TA-TMA (p = 0.008). Additionally, the non-relapse mortality (NRM) rate was higher in the TA-TMA group at 12.5% (95% CI, 3.7-55.8%) versus 7.0% (95% CI, 2.8-10.1%) (p = 0.598). A urine protein/creatinine ratio ≥ 1 mg/mg on day 30 post-HCT was significantly associated with TA-TMA occurrence (adjusted HR, 9.5; [95% CI], 1.28-70.39; p = 0.028). This study showed the significantly unfavorable clinical outcomes associated with TA-TMA in pediatric patients and emphasized the importance of early identification of patients at risk. Further research is needed to explore additional strategies for early detection and intervention to improve outcomes.

Kidney Fibrosis In Vitro and In Vivo Models: Path Toward Physiologically Relevant Humanized Models

Chronic kidney disease (CKD) affects over 10% of the global population and is a leading cause of mortality. Kidney fibrosis, a key endpoint of CKD, disrupts nephron tubule anatomy and filtration function, and disease pathomechanisms are not fully understood. Kidney fibrosis is currently investigated with in vivo models, that gradually support the identification of possible mechanisms of fibrosis, but with limited translational research, as they do not fully recapitulate human kidney physiology, metabolism, and molecular pathways. In vitro 2D cell culture models are currently used, as a starting point in disease modeling and pharmacology, however, they lack the 3D kidney architecture complexity and functions. The failure of several therapies and drugs in clinical trials highlights the urgent need for advanced 3D in vitro models. This review discusses the urinary system's anatomy, associated diseases, and diagnostic methods, including biomarker analysis and tissue biopsy. It evaluates 2D and in vivo models, highlighting their limitations. The review explores the state-of-the-art 3D-humanized in vitro models, such as 3D cell aggregates, on-chip models, biofabrication techniques, and hybrid models, which aim to mimic kidney morphogenesis and functions. These advanced models hold promise for translating new therapies and drugs for kidney fibrosis into clinics.

The Association Between Body Mass Index and 28-day Mortality in Patients With Sepsis: A Retrospective Cohort Study

BackgroundSepsis is a severe clinical syndrome with high morbidity and mortality in intensive care units (ICUs). Body Mass Index (BMI) shows a rising trend of obese patients being admitted to ICUs. The relationship between BMI and the clinical outcome of sepsis remains highly debated.MethodsThe data used in this study were sourced from the Intensive Care Information Center IV (MIMIC-IV) database. Baseline information extracted within 24 hours of ICU admission was categorized according to World Health Organization (WHO)'s BMI classifications. A multivariate Cox regression model and curve fitting assessed the independent correlation between BMI and the primary outcome.ResultsA total of 7836 patients were included in the study and categorized into five groups based on BMI. The overall 28-day mortality rate was 21.94% (1719/7836). Class I obesity (17.14%) and class II/III obesity (13.49%) individuals tended to be younger and male. Compared to patients with normal BMI (32.55%), those with low BMI (5.79%) had a 47% increased risk of 28-day mortality (HR 1.47, 95% CI 1.16-1.85, P = 0.0013), while class II/III obesity patients had a 17% lower 28-day mortality rate (HR 0.83, 95% CI 0.71-0.97, P = 0.0218). Curve fitting revealed a nonlinear relationship between BMI and 28-day mortality. The Kaplan-Meier survival analysis highlighted variations in survival rates across the five groups (P = 0.0123), with underweight patients exhibiting poorer survival outcomes.ConclusionIn sepsis patients, a low BMI is related to higher 28-day mortality compared to those with a normal BMI. Conversely, patients with a BMI≥35 kg/m2 have significantly reduced mortality risks.

Treatment Effect Heterogeneity in Acute Kidney Injury Incidence Following Intravenous Antihypertensive Administration for Severe Blood Pressure Elevation During Hospitalization

RATIONALE & OBJECTIVE

Severe hypertension (HTN) that develops after hospital admission is prevalent in 10% of patients admitted for reasons other than HTN. Severe HTN is commonly treated with intravenous (IV) antihypertensives and is associated with a greater risk of acute kidney injury (AKI). We explored whether there is heterogeneity in IV antihypertensives' effect on AKI incidence among patients who develop severe HTN during hospitalization.

STUDY DESIGN

Heterogeneity of treatment effect analysis.

SETTINGS & PARTICIPANTS

Patients who developed severe HTN, defined as systolic blood pressure (BP)>180 or diastolic BP>110mm Hg, during hospitalization and did not have kidney failure.

EXPOSURE

Treatment with IV antihypertensives within 3 hours of BP elevation.

OUTCOME

Time to developing AKI.

ANALYTICAL APPROACH

An accelerated failure time Bayesian additive regression trees (BART) model to capture the association between the time to develop AKI and predictors. Individual treatment effects were estimated for each participant using a counterfactual outcome framework, and these estimates were used to identify patient characteristics associated with treatment effect heterogeneity in response to IV antihypertensives.

RESULTS

We included 11,951 patients who developed severe HTN, 741 were treated with IV antihypertensives, and 11,210 were not, of whom 18% and 13% developed AKI, respectively. Most patients would have been harmed from IV antihypertensive treatment except for a small subset of 317 patients who were White, had a systolic BP on admission≥156mm Hg, an estimated glomerular filtration rate of≥70.7mL/min/1.73m2, and a serum bicarbonate of<21.7mmol/L.

LIMITATIONS

Data-driven, hypothesis-generating approach. Findings were not validated with external data sources.

CONCLUSIONS

These exploratory findings suggest that most patients who develop severe HTN will not benefit from IV antihypertensive treatment. Future studies should assess for heterogeneity when identifying treatment options, if any are needed, for severe HTN.

PLAIN-LANGUAGE SUMMARY

Patients who develop severe blood pressure elevation during hospitalization are commonly treated with intravenous antihypertensives; however, this could lead to acute kidney injury (AKI). We wanted to assess whether this is consistent across all patients, using a new statistical approach that predicts what would happen if patients who were treated had not been treated and those who were not treated had been. We found that most patients will develop AKI, and only a small subset of patients might not. This exploratory study can help inform future studies on the treatment of hypertension that develops during hospitalization.

Urological Outcomes and Adverse Events Following Total Pelvic Exenteration for Locally Advanced and Recurrent Rectal Cancer: A Single-center Retrospective Study

OBJECTIVE

To assess urological complications in patients undergoing total pelvic exenteration (TPE) for locally advanced (LARC) and recurrent rectal cancer (RRC) as publications in this area are limited. Secondary objectives were to assess whether LARC vs RRC or radiation status affected urological outcomes.

METHODS

Single-center, retrospective study of TPE patients between January 2017 and December 2022. Electronic records were evaluated to extract data. Postoperative outcomes were analyzed using two-tailed t-tests, Mann-Whitney U tests and chi-squared tests. Urological complications were analyzed using simple logistic regression.

RESULTS

A total of 128 patients underwent TPE (97 LARC, 31 RRC). 90 (70.3%) received neoadjuvant radiotherapy. The overall urological complication rate was 51.6%. Transient acute kidney injury and urinary tract infection were the two most common complications occurring in 38 (29.7%) and 33 (25.8%) respectively. 23 (18.0%) had at least one major complication of Clavien-Dindo III/IV related to the urinary system. Ureteroenteric stricture rate was 7.0% and 14.1% needed a reoperation for urological complications. There was no association between the overall incidence of urological complications and radiation status (OR 0.81 [0.37-1.73], P=.586) or between patients with LARC and RRC (OR 1.68 [0.75-3.93], P=.216).

CONCLUSION

Urological complications are common post-TPE. The urological complication rate is similar in LARC and RRC and radiation status did not affect outcomes in this cohort.

Clinical presentation, treatment, and antimicrobial susceptibility of 155 sequential Staphylococcus lugdunensis infections

Staphylococcus lugdunensis is known to be virulent, but there are few large-scale epidemiologic studies of this species to define types of infection, susceptibility patterns, and severity. S. lugdunensis isolates from any culture at four U.S. tertiary care hospitals between 1 April 2021 and 1 April 2022 were identified. For the first isolate from each subject, clinical, demographic, and outcome data were recorded. Of 291 isolates, 223 were obtained from a clinically significant infection. Of these 223 isolates, 86 (38.6%) were from monomicrobial cultures; additionally, S. lugdunensis was considered a true pathogen in 69/137 polymicrobial infections. Among 155 subjects with S. lugdunensis infections, 49.7% were female, 46.5% were black, and 41.9% were white; 51.6% of infections were community associated. The most common infection sites were skin and soft tissue (SSTI) (n = 98, 63.2%), urinary tract (n = 16, 10.3%), and sinusitis (n = 14, 9%). Of nine monomicrobial bloodstream infections (BSIs), two were fatal, three involved foreign bodies, and two had infective endocarditis. Greater than half of SSTIs required an invasive procedure for cure. Among 138/291 isolates from colonization or infection, tetracycline, trimethoprim-sulfamethoxazole, oxacillin, and vancomycin susceptibility rates were 94.8% (128/135), 95.9% (94/98), 84.1% (116/138), and 100% (138/138), respectively. There were similarities in types of infection comparing S. lugdunensis in this study and prior reports on Staphylococcus aureus. SSTI was the predominant S. lugdunensis infection type; more than 50% of SSTIs required procedural intervention. Of nine BSIs, three involved a foreign body, and there were two cases of infective endocarditis. Oxacillin resistance was identified in 16% of isolates.

IMPORTANCE

In recent years, Staphylococcus lugdunensis has been identified with increasing frequency as a human pathogen causing a wide variety of clinical syndromes, from soft tissue infections to fatal cases of bloodstream infection. Despite this, there are few large-scale epidemiologic studies examining this highly virulent organism. Our study adds to the growing literature on this emerging pathogen by analyzing a large case series of sequential S. lugdunensis infections at four U.S. hospitals to define its contemporary epidemiology, including the types of infections it causes, their outcomes, treatment approaches, and antimicrobial susceptibilities. These data provide valuable insights for clinicians in diagnosing and treating patients with these often debilitating infections. The findings also improve upon our understanding of the incidence of each infection syndrome and variability in antimicrobial susceptibilities of isolates to guide the design of future studies on the genomic epidemiology of this important pathogen.

Time on the waiting list is an independent risk factor for day-90 mortality after lung transplantation

BACKGROUND

The waitlist deaths of transplantation candidates based on their time on the waiting list (TWL) have already been studied, but the short-term mortality and early complications of lung transplant (LT) recipients based on their TWL have not been specifically studied. The first aim of this study was to assess the relationship between increased TWL and short-term mortality in LT recipients.

METHODS

In this observational, monocentric, retrospective study, all patients who underwent LT between January 2016 and August 2022 at Bichat Claude Bernard Hospital, Paris were analyzed. Univariate analysis (chi2 test, Mann-Whitney test, Fisher's exact test) and multivariate analysis (logistic regression) were performed. Ninety-days and one-year survival were studied (Kaplan-Meier curves, log-rank test). p < 0.05 indicated statistical significance.

RESULTS

242 LT patients were analyzed. The median TWL was 100 (43-229) days. Postoperative complications, including septic shock (36 versus 18%, p = 0.002), grade 3 primary graft dysfunction (31 versus 20%, p < 0.001), and KDIGO3 acute kidney injury (8 versus 25%, p < 0.001), were more common in the prolonged TWL (pTWL) group (>100 days) than in the short TWL group (≤100 days). The duration of hospitalization in the ICU was longer (18 [11-34] versus 13 [9-23] days, p = 0.02) in the pTWL group. According to our multivariate analysis, TWL was an independent risk factor for 90-days mortality (OR 1.02, 95% CI [1.00-1.04]; p = 0.032).

CONCLUSION

TWL was an independent risk factor for 90-days mortality after LT. Receiving LT after more than 100 days on the waitlist exposes to increased postoperative complications.

Comanagement of surgical patients between neurosurgeons and internal-medicine clinicians: observational cohort study

The rising prevalence of chronic diseases have contributed to a population with high complexity of care. There has been an increasing need for a new organizational model based on the interaction in the same department between the specialist skills of surgical and medical disciplines. This study aims to describe the implementation of a hospitalist co-management program in a Neurosurgery Department (ND) and its impact on the incidence of medical complications, 30 days readmission rate for medical causes, number of transfers to Intensive Care Units (ICU)/Neurosurgical Intensive Care Unit (NICU) or to medical wards (MW), length-of stay (LOS), mortality and satisfaction of health workers. We conducted an observational study comparing changes before and after the Internal medicine-Neurosurgical Comanagement (INC) intervention. We conducted a retrospective evaluation of patients enrolled before the INC intervention and a prospective evaluation of those enrolled after the INC intervention was implemented. We defined the pre-INC intervention group as 380 patients admitted to the ND for neurosurgical disease between January 2022 and April 2022 and the post-INC intervention group as 367 patients admitted to the ND between January 2023 and April 2023. INC intervention was associated with a significant decrease in medical complications during the hospital stay (OR 0.52; 95% CI; 0.39-0.70, p < 0.001), 30 days in-hospital readmission for medical reasons (OR 0.95; 95% CI 0.93-0.97, p < 0.001) and numbers of transfers to ICU/NICU (OR 0.31; 95% CI; 0.17-0.55, p < 0.001) or MW (OR 0.51; 95% CI 0.33-0.77, p = 0.002). During the INC intervention period, we observed a high satisfaction rate in health workers, evaluated by standardized questionnaire. In our study, LOS, in-hospital mortality and 30-day mortality were not significantly associated with INC. Hospitalist co-management in Neurosurgical Departments was associated with a reduced incidence of medical complications, 30-days in-hospital readmission and numbers of transfers to ICU/NICU or MW with a high satisfaction rate among healthcare workers, but without a significant decrease in LOS and mortality rate.

Soluble average Klotho level as a prognostic marker for acute kidney injury outcomes: a 90-day follow-up study

BACKGROUND

Klotho is highly expressed in the kidney and confers pleiotropic kidney protective effects. This study aimed to assess the soluble average Klotho level and its relationship to renal function and outcomes in participants with acute kidney injury (AKI).

METHODS

We recruited 102 participants with AKI and 30 healthy controls (HCs). For patients with AKI, serum soluble (sKlotho) levels upon admission to and discharge from hospital were measured to assess the relationship between sKlotho level and kidney function. Individuals with AKI were followed up for 90 days to determine the association between their average sKlotho level and short-term AKI outcomes.

RESULTS

The baseline sKlotho level in individuals with AKI at admission was significantly lower than that in HCs. For individuals with AKI, the sKlotho level was significantly lower in stage 3 than in stage 1 or 2. The sKlotho level was restored along with renal function improvement at discharge. During follow-up, a lower average, but not baseline, sKlotho level, or average sKlotho/creatinine ration predicted more AKI clinical outcomes.

CONCLUSION

The sKlotho level decreased significantly with kidney injury and represented severity. The average sKlotho level inversely correlated with detrimental kidney outcomes and may have potential diagnostic and predictive roles in AKI.

Hemodialysis Prescription and In-Hospital Cardiac Arrest in Patients With Acute Kidney Injury: A Single-Center Study

INTRODUCTION

Cardiac arrest is a common cause of death among patients undergoing maintenance hemodialysis; however, the prevalence and risk factors for cardiac arrest in the setting of acute kidney injury (AKI) are not studied in detail.

METHODS

Patients who received hemodialysis for AKI between 2014 and 2024 were classified as those who experienced cardiac arrest during hemodialysis (group A) and patients who had cardiac arrest during hospitalization outside the hemodialysis session (group B). Logistic regression analysis was performed to determine the odds of cardiac arrest during the hemodialysis session versus outside the session.

FINDINGS

Among the 1702 patients who received hemodialysis for AKI, 33 (0.02%) experienced cardiac arrest at the time of hemodialysis (group A), and 100 (0.06%) had cardiac arrest outside the session (group B). Previous history of atrial fibrillation was more common in group A (39% vs. 19%, p = 0.017). Groups were comparable in terms of oxygen or vasopressor requirement and baseline mean serum creatinine. Metabolic acidosis was more severe, and serum blood urea nitrogen and calcium levels were higher in group B (p < 0.05). Ultrafiltration rates were higher in group A than in group B (mean 10.6 mL/h/kg vs. 6.2 mL/h/kg, p < 0.001). There were more deaths in group A within the first 24 h following cardiac arrest (79% vs. 48%, p < 0.05); however, spontaneous recirculation and overall in-hospital mortality were comparable. In the multivariate regression model, atrial fibrillation (OR = 4.91, 95% CI 1.35-17.8, p = 0.016), lower pre-dialysis serum calcium levels (OR = 2.66, 95% CI 1.25-5.65, p = 0.011), and higher ultrafiltration volume (OR = 10.9, 95% CI 3.90-30.5, p < 0.001) were independently associated with an increased risk of cardiac arrest during hemodialysis sessions.

DISCUSSION

History of atrial fibrillation, lower pre-dialysis serum calcium levels, and higher ultrafiltration volumes are associated with an increased risk of cardiac arrest during hemodialysis than cardiac arrest outside the hemodialysis session in the AKI setting.

Association between enteral carboxymethyllysine intake and daily glycemic variability in critically ill adults: A retrospective cohort study

BACKGROUND

Advanced glycation end-products (AGEs) can enter patients' circulation through exogenous sources, such as enteral nutrition formulae. Circulating AGEs, specifically carboxymethyllysine, can promote insulin resistance and activation of pro-inflammatory pathways leading to oxidative stress, cell death, and organ failure. Suboptimal kidney function increases the risk of elevated circulating AGEs because levels are controlled through urinary excretion. Our aim was to determine associations between carboxymethyllysine intake and glycemic control as well as clinical outcomes in critically ill patients and explore these in the subset of patients with an acute kidney injury (AKI).

METHODS

This was a retrospective cohort study. Data were extracted from electronic medical records. Patients were eligible if they were ≥18 years and received enteral nutrition, with known carboxymethyllysine content, for ≥3 days. AKI was defined using the Kidney Disease: Improving Global Outcomes guidelines. Linear and logistic regression models were used to determine adjusted associations.

RESULTS

Between 2015 and 2021, 2636 patients met the eligibility criteria, with 848 (32%) patients having an AKI. Most were male (n = 1752, 67%) with a median (interquartile range) Acute Physiology And Chronic Health Evaluation III score of 59 (45-77). For every 10-μmol increase in carboxymethyllysine provision, mean blood glucose increased by 0.05 mmol (95% CI, 0.03-0.07), and the odds of dying increased by 16% (odds ratio = 1.16; 95% CI, 1.06-1.27). A subgroup analysis indicated these associations persisted in patients with AKI but not in those without.

CONCLUSION

Carboxymethyllysine intake was associated with increased mean blood glucose and odds of dying in our study cohort.

Impact on mortality at 90 days of acute kidney injuries in endovascularly treated stroke: A systematic review, meta-analysis, and meta-regression

AimTo investigate the prognostic implication (mortality at 3 months) of acute kidney injury (AKI) in acute ischemic stroke treated with mechanical thrombectomy (MT).Material and MethodsA literature search was performed using PubMed/OVID/Cochran's CENTRAL database (time frame: inception to January 2023). Study characteristics, patient status, clinical outcomes, AKI incidence, and sample size were recorded. The exclusion criteria were non-English literature, no human subjects, and <10 patients as the sample size. Studies were assessed using the MINORS/GRADE system. Meta-analysis and meta-regression with a random-effects model were performed.Results3314 studies were retrieved. After applying the exclusion criteria, the final population included of 18/3314 studies (0.5%). Among them, only 6/18 (33.3%) studies reported results in two separate groups (AKI vs non-AKI), allowing for inference statistics for a total population of 3229 (538.6 ± 403.7). The I^2 was 34.6 and Q's Cochrane was 7.80. The pooled odds ratio (OR) for mortality at 3 months in patients with AKI was 5.8 (95% confidence interval [95% CI] 95% CI 3.62 to 9.52). Leave-one-out meta-analysis showed no significant sources of heterogeneity. In the meta-regression, diabetes prevalence was associated with a higher mortality rate (OR 1.14, 95% CI 1.03 to 1.28), and lower age and a small amount of contrast media were negatively correlated (0.91 [95% CI 0.83 to 0.99] and OR 0.97 [95% CI 0.94 to 1.00], respectively).ConclusionAKI was significantly associated with the mortality rate in MT-treated stroke patients (OR 5.8 [95% CI 3.62 to 9.36]).

Rates of Acute Kidney Injury Utilizing Area Under the Concentration-Time Curve Versus Trough-Based Vancomycin Dosing Strategies in Patients With Obesity

Background

Vancomycin is commonly utilized for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections. Dosing recommendations for vancomycin have shifted in recent years to favor area under the concentration-time curve (AUC) instead of trough-based dosing strategies to decrease vancomycin exposure and rates of acute kidney injury (AKI). However, little data exist on the safety and efficacy of AUC-based dosing in patients with obesity.

Methods

This was a single-center retrospective cohort study conducted between 1 January 2014 and 31 December 2022. Adult patients aged ≥18 years were included if they were obese and received vancomycin for treatment of a severe MRSA infection for at least 72 hours. The primary outcome was incidence of AKI based on Kidney Disease: Improving Global Outcomes (KDIGO) criteria.

Results

After initial screening, 398 patients were included, with 230 in the trough group and 168 in the AUC group. Rates of AKI were lower in the AUC group compared to the trough group (11.3% vs 25.2%, P < .001). After adjusting for potential confounders, logistic regression maintained a reduction in AKI with AUC-based dosing for cumulative doses less than the median of 10 250 mg (odds ratio, 0.47 [95% confidence interval, .25-.88]) but not for doses above. Rates of initial target attainment were also higher with AUC-based dosing (50.0% vs 23.9%, P < .001).

Conclusions

Patients with obesity receiving vancomycin for treatment of severe MRSA infections experienced lower rates of AKI when utilizing an AUC- versus trough-based dosing strategy.

Systemic anticoagulation in progressive chronic kidney disease and atrial fibrillation

ObjectivePatients with chronic kidney disease are at high risk of developing atrial fibrillation. However, it remains unclear whether systemic anticoagulants should be utilized, particularly in the later stages of chronic kidney disease.MethodsThis retrospective observational cohort study included patients with chronic kidney disease of various etiologies. This study aimed to record the prevalence of atrial fibrillation, use of systemic anticoagulation, and incidence of thromboembolic events and bleeding events among these patients.ResultsA total of 146 patients with chronic kidney disease were included in this study, with 43.8% of them experiencing atrial fibrillation. There was no significant difference in the prevalence of atrial fibrillation across various stages of chronic kidney disease. Thromboembolic events were not common in patients with atrial fibrillation but were prevalent in those with late-stage chronic kidney disease. Furthermore, patients with atrial fibrillation experienced a higher frequency of bleeding events, with the highest incidence observed in chronic kidney disease stage IV.ConclusionsAs systemic anticoagulation did not lower the frequency of thromboembolic events in patients with chronic kidney disease and atrial fibrillation in our study and considering that these patients experienced a higher frequency of bleeding complications, the use of systemic anticoagulants should be approached with caution, particularly in the later stages of chronic kidney disease.

Wide pulse pressure as a novel predictor of contrast-induced acute kidney injury in diabetic patients undergoing primary percutaneous coronary intervention

BACKGROUND

Primary percutaneous coronary intervention (p-PCI) is pivotal in managing ST-segment elevation myocardial infarction (STEMI); however, it introduces potential risks, such as contrast-induced acute kidney injury (CI-AKI). This study aimed to investigate the relationship between pulse pressure (PP) and CI-AKI incidence in diabetic patients.

METHODS

In this retrospective study conducted between 2021 and 2022, 590 diabetic STEMI patients undergoing p-PCI were categorized based on the presence of wide PP. Individuals with PP ≥ 65 mmHg were classified as the 'wide PP (+) group', while those with PP < 65 mmHg were classified as the 'wide PP (-) group'. To determine independent predictors of CI-AKI, multivariable logistic regression models were applied. After establishing the base model, blood pressure indices, including PP, SBP, DBP, mean arterial pressure, and pulsatility were added to the model using the stepwise selection method.

RESULTS

Among the patients, 18.3% ( n  = 108) were in the wide PP (+) group, while 81.7% ( n  = 482) were in the wide PP (-) group. The incidence of hypertension, SBP, PP, and the risk of CI-AKI were higher in the wide PP (+) group. Multivariable analysis recognized PP, wide PP, and pulsatility as independent CI-AKI predictors [odds ratio (OR): 1.024, 95% confidence interval (CI): 1.003-1.045, P  = 0.025; OR: 1.684, 95% CI: 1.025-2.769, P  = 0.040; OR: 13.816, 95% CI: 2.069-92.245, P  = 0.007, respectively].

CONCLUSION

Increased PP emerges as an independent predictor for CI-AKI in diabetic patients undergoing p-PCI.

Predictors of Mortality in Venoarterial Extracorporeal Membrane Oxygenation Regardless of Early Left Ventricular Unloading: A National Experience

OBJECTIVE

The use of an intra-aortic balloon pump (IABP) has been suggested to unload the left ventricle while on venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock (CS), leading to possibly improved in-hospital mortality. However, the predictors of mortality on dual mechanical circulatory support have not yet been evaluated, especially in real-world clinical settings. Therefore, a case-control study was conducted to determine the rate of all-cause mortality associated with VA-ECMO use regardless of left ventricular (LV) unloading, and with early LV unloading in the setting of CS, and to identify the predictors of mortality associated with VA-ECMO, with concurrent early LV unloading.

DESIGN

Retrospective observational case-control study.

SETTING

National tertiary cardiology center.

PARTICIPANTS

All patients with CS requiring VA-ECMO cannulation during the index admission between January 06, 2016, and January 0, 2022.

INTERVENTION

VA-ECMO with or without IABP MEASUREMENTS AND MAIN RESULTS: Patient- and disease-related characteristics associated with in-hospital 30-day mortality following VA-ECMO with and without IABP support were assessed using multivariate logistic regression. Results are presented as odds ratio (OR), and a p-value < 0.05 indicates statistical significance. A total of 110 patients were included. Most were male (90%) with a mean age of 53 ± 11 years. Around 67% were Asian. The majority of patients were admitted with ST-elevation myocardial infarction (87%), with 26% presenting with left main disease. In-hospital 30-day mortality occurred in 42.7% of those who received VA-ECMO support regardless of IABP use, while it was 46.9% among those receiving early LV unloading with IABP. Significant positive predictors of mortality with VA-ECMO regardless of IABP in CS were cardiopulmonary resuscitation (CPR) >20 minutes (adjusted OR 14.74, 95% confidence interval 2.02-107.41, p-value = 0.008), older age (ie, >55 years) and left main disease of more than 50% stenosis were associated with a fourfold increase in the odds of mortality while on VA-ECMO. Conversely, CPR >20 minutes (adjusted OR 12.45, 95% confidence interval 1.79-86.36, p-value = 0.011) was the only significant positive predictor of mortality with VA-ECMO and IABP.

CONCLUSION

The mortality rate in CS requiring VA-ECMO, regardless of IABP use, remains high. However, only one predictor (ie, prolonged CPR) was found to increase the likelihood of 30-day mortality with early LV unloading, suggesting that concomitant IABP use might minimize the effect of mortality predictors.

The impact of perioperative positive fluid balance on postoperative acute kidney injury in patients undergoing open hepatectomy: A retrospective single center cohort study

BACKGROUND

Low central venous pressure (CVP) or fluid restriction strategies are frequently employed during liver parenchymal resection to minimize intraoperative blood loss. However, both hypovolemia and excessive fluid administration can impair organ perfusion, increasing the risk of renal dysfunction and acute kidney injury (AKI). This study explores the relationship between perioperative fluid management strategies and renal outcomes in patients undergoing hepatectomy.

METHOD

A retrospective single-center cohort study was conducted involving 691 patients who underwent an open hepatectomy. Patients were categorized by positive fluid balance: <1 Liter, 1-2 Liters, and >2 Liters. Propensity score was used for matching among the groups. The incidence of acute kidney injury (AKI) was compared. Multivariable logistic regression analyzed the correlation between fluid balance and AKI risk.

RESULT

The overall incidence of AKI was 11.58%, with the highest occurrence in the group with a fluid balance greater than 2 Liters. This group demonstrated a significantly higher relative risk of developing AKI compared to those with positive fluid balances of <1 Liter and 1-2 Liters (adjusted RR 1.85, p = 0.042, 95% CI 1.02-3.38). An increase in fluid balance was associated with a higher incidence rate ratio for AKI (p = 0.016). Additionally, an operating time >5 hours, blood loss >1000 ml, and Child-Turcotte-Pugh class B and C were significantly associated with an increased risk of post-hepatectomy AKI.

CONCLUSION

Maintaining a fluid balance of 1-2 liters during hepatectomy is crucial to reducing the risk of postoperative AKI, while balances above 2 liters significantly increase it. Prolonged operating times, high blood loss, and advanced liver disease also elevate AKI risk, emphasizing the need for careful fluid management.

Protective value of ischemia-free liver transplantation on post-transplant acute kidney injury

Background & Aims

Ischemia-free liver transplantation (IFLT) completely avoids ischemia-reperfusion injury (IRI), thus potentially reducing acute kidney injury (AKI) after liver transplantation (LT). Therefore, this study investigated whether IFLT has a protective effect against AKI after LT.

Methods

In total, 862 patients who had undergone LT between 2017 to 2022 were divided into an ischemia-free liver transplantation group (IFLT group) and conventional liver transplantation group (CLT group) based on the surgical methods used. Propensity score matching (PSM) was used for post hoc randomization in the 1:1 matching between the groups. Post-transplant kidney function, graft function, and patient survival were compared between the groups. Multivariate logistic regression analysis was used to identify the risk factors of AKI after LT.

Results

Overall, 745 out of 862 patients were finally enrolled, of whom 98 underwent IFLT. PSM created 94 pairs of patients. IFLT resulted in a significant reduction in Stage-3 AKI (3.2% vs. 16.0%, p = 0.003), severe AKI (SAKI) (13.8% vs. 25.5%, p = 0.044), and renal replacement therapy (RRT) ratio (3.2% vs. 12.8%, p = 0.015) compared with the CLT group. The early allograft dysfunction (EAD) incidence of the IFLT group significantly decreased (8.5% vs. 44.7%, p <0.001). Livers from the extended criteria donation (ECD) were received in 49 patients who underwent IFLT and 46 patients who underwent CLT. Compared with the ECD-CLT group, the Stage-3 AKI and SAKI incidence in the ECD-IFLT group were both decreased (p <0.05). Multivariate logistic regression analysis further confirmed that both using IFLT and avoiding ECD were protective factors for post-transplant Stage-3 AKI.

Conclusions

IFLT significantly reduces the incidence of post-transplant SCKI, Stage-3 AKI, and RRT. Importantly, this protective effect is also present in patients receiving ECD livers.

Impact and implications

Ischemia-free liver transplantation significantly reduces the incidence of severe acute kidney injury, Stage-3 acute kidney injury and renal replacement therapy after liver transplantation. Importantly, this protective effect is also present in patients receiving extended criteria donation livers.

Clinical trial number

ChiCTR2400081755.

Nephrotoxicity biomarkers following propanil (3,4-dichloropropionanilide) self-poisoning

BACKGROUND

Propanil toxicity is characterised by severe prolonged methaemoglobinaemia, cyanosis, acidosis, and progressive end-organ dysfunction. In vitro studies report propanil-induced kidney toxicity, which has not been studied clinically. This study determined the incidence of acute kidney injury and of methaemoglobinaemia after propanil self-poisoning and reported the diagnostic performance of novel and traditional biomarkers of acute kidney injury.

METHODS

Sixty-seven previously healthy patients were recruited following acute propanil self-poisoning, between October 2010 and October 2014. Concentrations of serum biomarkers and urine biomarkers normalised for urine creatinine excretion were measured. Plasma and urine concentrations of propanil, its main metabolite 3,4-dichloroaniline, the antidote methylthioninium chloride (methylene blue), and methaemoglobin levels were measured.

RESULTS

Kidney biomarkers were measured in 52 of the 67 patients, with 40% developing acute kidney injury (stage 1 [32%] and stage 2 [8%]). Blood methaemoglobin levels were recorded in 23 patients. Normalised urine biomarker concentrations of kidney injury molecule-1, trefoil factor 3, neutrophil gelatinase-associated lipocalin and beta2 microglobulin increased in patients who developed acute kidney injury, but only trefoil factor 3 and cystatin C showed a significantly predicted acute kidney injury at 16-24 h and 8-16 h post-ingestion, respectively. In contrast, serum creatinine concentrations had a very good diagnostic performance throughout the 24 h post-ingestion period, with area under the receiver operating characteristic curve values of 0.79-0.96. Blood methaemoglobin levels were higher in patients with acute kidney injury and correlated with plasma propanil and 3,4-dichloroaniline concentrations. Concentrations of serum creatinine, urine beta2 microglobulin, and trefoil factor 3 significantly correlated with plasma and urine concentrations of propanil, 3,4-dichloroaniline, and methylthioninium chloride.

DISCUSSION

Severe methaemoglobinaemia can impair oxygen delivery and may cause acute ischaemic kidney injury. The poor diagnostic performance of novel biomarkers may be attributed to non-renal factors influencing creatinine concentration or an unusual site or mechanism of nephrotoxicity after propanil poisoning.

CONCLUSIONS

Patients with propanil self-poisoning exhibited reversible kidney injury diagnosable using serum creatinine concentrations within 4 h. Although other biomarkers were increased, they were not effective for early diagnosis.

Outcomes of Elderly Patients Admitted to the Intensive Care Unit for Newly Diagnosed Acute Myeloid Leukemia

Acute myeloid leukemias (AMLs) are the hematological malignancies with the highest need for intensive care unit (ICU) admission due to their association with various life-threatening situations. Limited data exist regarding the outcomes of elderly individuals with AML admitted to the ICU. However, current therapeutic protocols offer the potential for extended survival in this population. This retrospective, monocentric study focused on the outcomes of individuals aged ≥ 60 years admitted to the ICU for newly diagnosed AML. It included 139 patients admitted to the ICU at the Paoli-Calmettes Institute between April 2010 and October 2020, during the initial phase of AML management. Patients were categorized into three groups based on the presence of biological criteria indicating "high risk" for complications (thrombocytopenia < 50 000/mm3 and leukocytosis > 50 000/mm3) and organ failure. Multiple logistic regression models were employed to identify predictive factors for in-hospital and day 90 mortality, while Cox regression was used for 1-year mortality. The rates of in-hospital, day 90, and 1-year mortality were 37%, 42%, and 60%, respectively. Variables associated with in-hospital mortality included the Charlson Comorbidity Index, the need for invasive mechanical ventilation (MV), and multi-organ failure. ELN17 risk was significantly associated with 1-year mortality rates. This study demonstrates the benefits of ICU management for individuals aged ≥ 60 years during the initial phase of AML. It illustrates the effects of age, comorbidities, and the severity of organ failures on short-term mortality and highlights the impact of classical prognostic markers on long-term mortality.

Multimodal convolutional neural networks for the prediction of acute kidney injury in the intensive care

Increased monitoring of health-related data for ICU patients holds great potential for the early prediction of medical outcomes. Research on whether the use of clinical notes and concepts from knowledge bases can improve the performance of prediction models is limited. We investigated the effects of combining clinical variables, clinical notes, and clinical concepts. We focus on the early prediction of Acute Kidney Injury (AKI) in the intensive care unit (ICU). AKI is a sudden reduction in kidney function measured by increased serum creatinine (SCr) or decreased urine output. AKI may occur in up to 30% of ICU stays. We developed three models based on convolutional neural networks using data from the Medical Information Mart for Intensive Care (MIMIC) database. The models used clinical variables, free-text notes, and concepts from the Elsevier H-Graph. Our models achieved good predictive performance (AUROC 0.73-0.90). These models were assessed both when using Scr and urine output as predictors and when omitting them. When Scr and urine output were used as predictors, models that included clinical notes and concepts together with clinical variables performed on par with models that only used clinical variables. When excluding SCr and urine output, predictive performance improved by combining multiple modalities. The models that used only clinical variables were externally validated on the eICU dataset and transported fairly to the new population (AUROC 0.68-0.77). Our in-depth comparison of modalities and text representations may further guide researchers and practitioners in applying multimodal models for predicting AKI and inspire them to investigate multimodality and contextualized embeddings for other tasks. Our models can support clinicians to promptly recognize and treat deteriorating AKI patients and may improve patient outcomes in the ICU.

C-C motif chemokine ligand 14 characterization for prediction of persistent severe AKI in post-cardiac surgery children

BACKGROUND

We evaluate the association of early postoperative urinary c-c motif chemokine ligand 14 (CCL14) and persistent severe acute kidney injury (AKI) in pediatric post-cardiac surgery patients.

METHODS

This is a retrospective single-center cohort study of patients < 18 years of age undergoing cardiac surgery who provided a biorepository urine sample within the first 24 postoperative hours. Persistent severe AKI was defined as any AKI stage lasting for ≥ 72 h with at least one time point of AKI stage 2 or 3 during that time frame. Patients with persistent severe AKI were matched 2:1 with non-AKI patients on age and sex. Urine samples were measured for CCL14 concentration. Logistic regression was used to evaluate associations between CCL14 and persistent severe AKI.

RESULTS

Persistent severe AKI occurred in 14 (5.4%) patients and was more common in patients with higher surgical complexity and longer cardiopulmonary bypass and cross-clamp duration. Patients with persistent severe AKI had longer median cardiac intensive care unit (CICU) (5 [3, 10] vs. 2 [1.5, 5.5], p-value = 0.039) and hospital length of stays (13.5 [7.8, 16.8] vs. 6 [4,8], p-value = 0.009). There was no difference in CCL14 levels between patients with and without persistent severe AKI (46.7 pg/ml [31.0, 82.9] vs. 44.2 pg/ml [25.1, 74.9], p-value = 0.49) in univariable and logistic regression.

CONCLUSIONS

In this heterogenous cohort of children undergoing cardiac surgery, CCL14 was not associated with persistent severe AKI. Future studies are needed to evaluate the use of CCL14 for predicting persistent severe AKI in children.

Improving Blood Pressure in High-Risk Patients With CKD Using an Interdisciplinary Remote Hypertension Program

Introduction

Interventions are needed to reduce racial and ethnic disparities in achieving blood pressure (BP) control among patients with chronic kidney disease (CKD). We determined the feasibility and effectiveness of an interdisciplinary remote patient monitoring (RPM) hypertension program in predominantly Black and Hispanic patients with CKD.

Methods

We evaluated an RPM hypertension program for patients with CKD in a New York City health system between July 2021 and October 2022. BP data were transmitted in real-time using a cellular-enabled BP device. Education on lifestyle and adherence was provided, and medications were adjusted by a nurse practitioner (NP) via telemedicine. Feasibility was quantitatively assessed as enrollment, participation, and retention at 3 months. Effect on BP was estimated as mean change in BP at 3 months and proportion with BP < 130/80 mmHg at 6 months.

Results

Among 111 patients invited, 102 (91.9%) enrolled and 87 (78.4%) were retained in the program for 3 months. Median age was 61 years, 50% were female, 55.9% were Black, 35.3% were Hispanic, and median estimated glomerular filtration rate was 47.5 ml/min per 1.73 m2. The median days per month that BP was measured ranged from 16 to 23. Mean change in systolic and diastolic BP from enrollment to 3 months was -15.0 ± 20.8 (P < 0.0001) and -6.7 ± 17.7 (P = 0.0007), respectively. By 6 months, 49.4% achieved BP < 130/80 mm Hg.

Conclusion

This RPM hypertension program in patients with CKD was feasible and effective in improving BP, which is promising for increasing equity in hypertension control. Future studies evaluating long-term maintenance of BP control using this approach compared with usual care are needed.

Acute kidney injury after lung transplantation, incidence, risk factors, and effects: A Swedish nationwide study

BACKGROUND

Acute kidney injury (AKI) is a serious complication after lung transplantation, but the reported incidence varies in the literature. No data on AKI have been published from the Swedish lung transplantation program.

METHODS

The aim of our study was to investigate the incidence, perioperative risk factors, and effects of early postoperative acute kidney injury (Kidney Disease Improving Global Outcomes [KDIGO] criteria) after lung transplantation. A retrospective, nationwide study of 568 lung-transplanted patients in Sweden between 2011 and 2020 was performed.

RESULTS

The incidence of AKI (any grade) was 42%. Renal replacement therapy was used in 5% of the patients. Preoperative factors independently associated with increased incidence of AKI were higher body mass index (odds ratio [OR]: 1.07, 95% CI: 1.02, 1.12) longer time on transplantation waiting list (OR: 1.05 [1.01, 1.09]), re-transplantation (OR: 2.24 [1.05, 4.80]) and moderate to severe tricuspid regurgitation (OR: 2.61 [1.36, 5.03]). Intraoperative factors independently associated with increased incidence of AKI were use of cardiopulmonary bypass (OR: 2.70 [1.57, 4.63]), increasing number of transfused red blood cell units, and use of immunosuppressive therapy other than routine (OR: 2,56 [1.47, 4.46]). A higher diuresis (OR: 0.70, 95% CI: 0.58-0.85) was associated with less incidence of acute kidney injury. Development of AKI was associated with increased time to extubation (median 30 h, IQR [9, 118] vs. 6 [3, 16]), length of stay in the intensive care unit (9 days [4, 25] vs. 3 [2, 5]) and increased rate of primary graft dysfunction (OR 2.33 [1.66, 3.29]) and 30-day mortality (OR: 10.8 [3.0, 69]).

CONCLUSIONS

Acute kidney injury is common after lung transplantation and affects clinical outcomes negatively. Preoperative factors may be used for risk assessment. The use of cardiopulmonary bypass is a potentially modifiable intraoperative risk factor.

EDITORIAL COMMENT

Acute kidney injury is a common complication after lung transplantation that severely influences patient outcomes. This large study of more than 500 patients treated over a decade identified potentially modifiable factors associated with the development of acute kidney injury.

Recent Developments and Future Perspectives in Magnetic Resonance Imaging and Computed Tomography Contrast Media

ABSTRACT

This review provides a comprehensive analysis of recent advancements in computed tomography (CT) and magnetic resonance imaging (MRI) contrast media, offering a critical evaluation of current trends and exploring future directions in the field. New clinical developments within the last 5-8 years are considered as well as clinical efficacy and safety aspects.For CT, the general safety of low- and iso-osmolar iodinated contrast agents and their effect on renal and thyroid function are reviewed. Special attention is given to contrast-enhanced mammography and a short outlook to photon-counting CT is provided.For MRI, a brief update on general safety, nephrogenic systemic fibrosis and the presence of gadolinium in the brain is given. The 2 new high-relaxivity gadolinium-based contrast agents, gadopiclenol and gadoquatrane (in late-stage clinical development), are highlighted.The review also describes targeted gadolinium-based contrast agents, superparamagnetic iron oxide particles, and developments of manganese-based contrast agents. It also introduces the emerging field of glymphatic imaging.

Renal Involvement in Sepsis: Acute Kidney Injury

Acute kidney injury (AKI) is a common complication of sepsis due to a myriad of contributing factors and leads to significant morbidity and mortality in critically ill patients. Prompt identification and management are vital to reverse and/or prevent the worsening of AKI. When renal function is severely compromised, there may be a need for dialytic therapy to meet the metabolic needs of patients. This article will review the definition of AKI, epidemiology, risk factors, and pathophysiology of AKI in sepsis, along with both non-dialytic and dialytic treatment strategies. We will also review landmark trials in fluid resuscitation in sepsis.

Predicting acute kidney injury in trauma using an extreme gradient boosting model

Background

Acute kidney injury (AKI) is a significant complication in patients with trauma. The early identification of AKI in these patients poses challenges. This study aimed to predict AKI in trauma patients 24 or 48 hours in advance using an extreme gradient boosting (XGBoost) model.

Methods

We analyzed 17 859 trauma patients admitted to a regional trauma center between January 2015 and July 2023. Demographic, clinical, and laboratory parameters were collected. The model was developed using data until July 2021 and validated using data from August 2021. We developed models to predict AKI stages 1-3 and AKI stages 2 and 3 occurring 48 and 24 hours later and measured predictive performance in the validation group. The models' performance was evaluated using the area under the receiver operating characteristic curve (AUROC), and feature importance was assessed through SHapley Additive exPlanations values.

Results

The study population exhibited an incidence of AKI of 6.6% in the development group and 5.4% in the validation group. The models demonstrated predictive performance with AUROCs of 0.864 and 0.886 for 48-hour predictions of AKI stages 1-3 and stages 2 and 3, and 0.904 and 0.903 for 24-hour predictions of AKI stages 1-3 and stages 2 and 3, respectively. Key features influencing model predictions included baseline and in-hospital serum creatinine values, injury severity score, age, lactate dehydrogenase, D-dimer, platelets, albumin, and C-reactive protein levels.

Conclusions

The XGBoost models effectively predicted AKI in trauma patients up to 48 hours in advance using clinical data.

Effects of Novel Antidiabetic Agents on Contrast-Associated Acute Kidney Injury in Diabetic Patients Undergoing Percutaneous Coronary Intervention

Contrast-associated acute kidney injury (CA-AKI) remains a serious complication after percutaneous coronary revascularization (PCI), with limited effective preventive strategies especially for diabetic patients. This study aimed to assess the effects of novel antidiabetic agents (NAD), i.e., glucagon-like peptide-1 receptor agonists (GLP-1RAs), sodium-glucose transporter-2 inhibitors (SGLT2i), and dipeptidyl peptidase-4 inhibitors (DPP4i), on the occurrence of this outcome in diabetic patients undergoing PCI. We enrolled 293 consecutive diabetic patients receiving NAD at the time of PCI (NAD group) and paired them with 293 diabetic individuals undergoing revascularization who were not on NAD (no-NAD group), matched according to age and sex. CA-AKI was defined as an increase in serum creatinine (SCr) ≥0.3 mg/dl or >50% from baseline within 48 to 72 hours after contrast exposure. A propensity score-adjusted logistic regression analysis was performed to account for potential selection bias. NAD treatment was associated with a significantly reduced incidence of CA-AKI than standard glucose-lowering therapies (4.1 vs. 8.5%, p = 0.023). Furthermore, patients using SGLT2i and GLP-1RAs exhibited a lower incidence of CA-AKI compared to those taking DPP4i. Both multivariate and propensity-score-adjusted regression analyses identified NAD therapy as an independent predictor of CA-AKI (OR 0.45, 95% CI 0.22-0.98, p = 0.040 and OR 0.48, 95% CI 0.23-0.98, p = 0.045). In conclusion, this study is the first to explore the potential benefit of all three NAD classes on CA-AKI incidence. The use of these agents is associated with a lower incidence of renal damage in diabetic patients undergoing PCI, with the greatest benefit observed with SGLT2i and GLP-1RAs use.

Individualized blood pressure regulation and acute kidney injury in older patients having major abdominal surgery: a pilot randomized trial

BACKGROUND

Acute kidney injury (AKI) is a common postoperative complication, and hypotension may contribute. We therefore tested the primary hypothesis that individualized intraoperative blood pressure regulation reduces postoperative AKI in older surgical patients.

METHODS

We enrolled patients ≥60 years old scheduled for elective major abdominal surgery with invasive arterial pressure monitoring. All had goal-directed fluid management based on stroke volume variation cardiac output, and administration of a starch. Participants were randomly assigned to: (1) individualized blood pressure management targeting a systolic blood pressure (SBP) within -20% and +10% if baseline SBP was ≥130 mmHg or diastolic blood pressure was ≥80 mmHg, or otherwise, to target SBP within ±10% of the baseline value; (2) maintenance of SBP ≥90 mmHg and MAP ≥65 mmHg. Metaraminol was used to achieve the blood pressure target. AKI incidence was assessed by Kidney Disease Improving Global Outcomes criteria during the initial 7 postoperative days.

RESULTS

192 patients were assigned to individualized ( n = 96) or routine ( n = 96) pressure management. 179 patients were included in the intention-to-treat analysis. Age averaged 68 ± 5 (SD) years and 64% were male. Randomization to the individualized management reduced the area under MAP <65 mmHg (median difference: -37 [-47 to -25] mmHg-minute, P < 0.001]. The incidence of the AKI was 11% in patients assigned to individualized management vs. 16 % in those assigned to routine management: relative risk 0.72 (95% confidence interval, 0.34-1.54), P = 0.396. Patients assigned to individualized pressure management had more urine output, a shorter postoperative mechanical ventilation duration, and faster recovery of bowel function.

CONCLUSION

Individualized blood pressure management markedly reduced hypotension. As expected in a pilot trial, the 28% reduction in AKI was not statistically significant. However, the reduction was clinically meaningful and suggests that a full trial is warranted.

Peri-operative and Midterm Results of Supracoeliac versus Infracoeliac Sealing for Fenestrated Endovascular Aortic Repair of Juxtarenal Aortic Aneurysms

OBJECTIVE

The aim of this study was to investigate peri-operative and midterm outcomes, including sac dynamics, of fenestrated endovascular aortic repair (F-EVAR) for juxtarenal abdominal aortic aneurysms (JAAAs), comparing supracoeliac with infracoeliac sealing. Supracoeliac sealing may offer an advantage due to a longer proximal sealing zone, but is associated with a more complex procedure and increased risk of complications. Furthermore, it is unknown whether supracoeliac sealing actually leads to increased durability.

METHODS

Patients undergoing elective F-EVAR for JAAAs from 2008 - 2021 at two hospitals in the Netherlands were included. The definition of supracoeliac sealing was sealing in zone 5 or 6, with incorporation of the coeliac axis. Infracoeliac sealing was defined below zone 6. The primary endpoints included peri-operative outcomes. Secondary endpoints included one year aneurysm sac dynamics, freedom from secondary intervention, five year mortality rate, and sac dynamics over time.

RESULTS

Among 167 patients, 78 (46.7%) had a proximal sealing at an infracoeliac level and 89 (53.3%) at a supracoeliac level. The median proximal sealing length was 37 (interquartile range [IQR] 28, 52) mm for the supracoeliac group and 26 (IQR 19, 34) mm for the infracoeliac group. Patients with supracoeliac sealing had more often had prior endovascular aortic aneurysm repair (31% vs. 12%; p = .004). Type IIIc endoleaks only occurred in patients with supracoeliac sealing (7% vs. 0%; p = .032). Other peri-operative complications and mortality rates were similar between the groups. Furthermore, no significant differences were found in one year aneurysm sac dynamics, freedom from secondary interventions, five year mortality rate, and sac dynamics over time.

CONCLUSION

Proximal supracoeliac and infracoeliac sealing showed similar midterm outcomes, including sac dynamics, despite the higher procedural complexity of supracoeliac sealing. Supracoeliac sealing had a higher rate of 30 day type IIIc endoleak, but no difference in five year secondary intervention rate. Theoretically, supracoeliac sealing may be advantageous as sealing zones dilate over time, although future studies with longer than five year follow up are needed to determine its impact on long term aneurysm sac exclusion.

An updated approach to the evaluation of the urinary sediment

Examination of the urinary sediment (U-sed) is an important non-invasive, rapid, and inexpensive tool for the diagnosis and surveillance over time of renal diseases. In this Educational Review, we describe first how to collect, prepare, and examine urine samples in order to obtain reliable results. Then, we describe the U-sed findings in isolated microscopic hematuria, glomerular diseases, acute interstitial nephritis, acute kidney injury, reactivation of the BK virus in kidney transplant recipients, and crystalluric genetic diseases.

Systematic review and meta-analysis of vancomycin therapeutic level for treatment of vancomycin-sensitive enterococcal infections

AIMS

Evidence on the optimal targets of vancomycin for treating other Gram-positive infections apart from methicillin-resistant Staphylococcus aureus (MRSA) is lacking. This review aims to identify the recommended vancomycin therapeutic level for favourable clinical outcomes among patients infected with vancomycin-sensitive enterococcal infections.

METHODS

Analytical studies describing the vancomycin levels of vancomycin-sensitive enterococcal infections among adult population were searched. The primary outcome was 30-day all-cause mortality, and the secondary outcomes were clinical failure and nephrotoxicity. Study characteristics were extracted and pooled using random-effects meta-analysis. The study quality was assessed using the Joanna Briggs Institute critical appraisal tool.

RESULTS

A total of nine retrospective cohorts studies involving 1013 patients with vancomycin-sensitive enterococci were included. The meta-analysis found that high area under the curve to minimum inhibitory concentration ratio (AUC/MIC) of vancomycin ≥ 389 mg*h/L significantly lowered the 30-day mortality (odds ratio [OR], 0.44, 95% confidence interval [CI], 0.26-0.75). Analysis of the target AUC/MIC showed that high vancomycin AUC/MIC (≥ 389-400 mg*h/L) significantly reduced clinical failure rate (OR 0.59, 95% CI 0.37-0.94). The mortality and treatment failure rates did not differ significantly between those with high or low trough levels. Higher vancomycin AUC/MIC and trough levels were significantly associated with increased nephrotoxicity (OR 3.11, 95% CI 1.65-5.89; OR 2.95, 95% CI 1.60-5.44, respectively).

CONCLUSIONS

The use of a higher vancomycin AUC/MIC concentration can be effective to reduce 30-day mortality and clinical failure but this needs to take into consideration the risk of nephrotoxicity. Well-conducted prospective studies are warranted due to the scarcity of evidence.

Evaluating the effects of intravenous magnesium sulfate for prevention of colistin induced acute kidney injury: an open-label, placebo-controlled, block randomized clinical trial

Colistin, has reinstated as a last-resort antibiotic despite its known nephrotoxicity. The aim of this study was to determine the potential nephroprotective effects of Magnesium (Mg) Sulfate during colistin therapy. This study was an open-label, placebo-controlled, block-randomized clinical trial conducted from January 2023 to February 2024 involving 87 patients eligible for colistin therapy. Patients were randomly assigned to receive either Mg sulfate (16 mEq in 100 mL of normal saline) or 100 mL of normal saline as placebo before each dose of colistin. The primary outcome of the study was the incidence of Acute Kidney Injury (AKI) during the first week of colistin therapy, while the secondary outcomes included colistin dose adjustments, length of stay in the ICU and hospital, and overall mortality. This study was registered in The Iranian Registry of Clinical Trials (IRCT20130917014693N15; 2023-01-12). A total of 87 patients (46 in Mg and 41 in control group) completed the study. Fourteen patients (30.43%) in the Mg group and twenty-one patients (51.21%) in the control group developed AKI during the first week of colistin therapy (p = 0.048). Although AKI incidence was not statistically different between the groups in unadjusted Cox regression model (HR =0.51, 95% CI =0.26-1.01, P =0.057), it became significant after adjusting for confounding factors (HR =0.40,95% CI =0.18-0.86, P =0.021). The length of hospital stay was 48.62 ± 18.82 and 44.82 ± 20.23 days for Mg and control groups respectively (p=0.373). In the Mg group, 25 out of 46 patients (54.34 %) and in the control group, 24 out of 41 patients (58.53%) eventually expired (p=0.694). This study indicates that Mg sulfate significantly reduces AKI rates and prevents hypomagnesemia, optimizing dosing and enhancing patient safety during colistin therapy.

CKD Progression after Acute Kidney Injury: A Secondary Analysis of the Standard versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury Trial

Key Points

Development or progression of CKD occurred in almost 40% of patients after an episode of severe AKI. Receipt of KRT, regardless of allocation to an accelerated or standard initiation strategy, was associated with development or progression of CKD. This study helps identify a subset of patients at risk of CKD after severe AKI who would benefit from dedicated kidney follow-up after discharge.

Background

CKD is a common complication after AKI. We aimed to evaluate whether a KRT initiation strategy had an effect on CKD progression. Secondarily, we aimed to identify factors that influenced the development or progression of CKD after severe AKI.

Methods

This secondary analysis of the Standard versus Accelerated Initiation of Renal Replacement Therapy in AKI trial included patients with outpatient serum creatinine values available in the year before hospitalization and who were alive at 90 days after randomization. Our main analysis focused on patients who had definitive assessment of kidney function at 90 days after randomization. Predictor markers included patient demographics, comorbidities, markers of acute illness, laboratory values, receipt of KRT, and KRT treatment strategy (accelerated versus standard). The primary outcome was CKD progression, a composite of de novo CKD, defined as new eGFR <60 ml/min per 1.73 m2 if baseline eGFR was ≥60 ml/min; a decline in eGFR ≥25% if baseline eGFR was <60 ml/min; or KRT dependence at day 90. The association of KRT treatment strategy with CKD progression was assessed in an unadjusted mixed-effect logistic regression model.

Results

Of the 401 surviving patients with a baseline serum creatinine, 39% experienced CKD progression. KRT initiation strategy had no effect on CKD progression (accelerated arm [41%], versus the standard arm [38%], odds ratio, 1.13 [95% confidence interval, 0.75 to 1.72]). Receipt of KRT and aortic surgery were the most potent risks of CKD progression.

Conclusions

These findings suggest that CKD progression is common after severe AKI. Risk factors of CKD progression included receipt of KRT and aortic surgery, suggesting that these patients should be prioritized for dedicated kidney follow-up after hospital discharge.

Clinical Trial registry name and registration number:

NCT01557361 .