Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1)

Acute Kidney Injury in Neonatal Hypoxic-Ischemic Encephalopathy Patients Treated with Therapeutic Hypothermia: Incidence and Risk Factors

Studies in infants with hypoxic-ischemic encephalopathy (HIE) due to perinatal asphyxia have generally focused on neurological outcomes. Although acute kidney injury (AKI) rate decreased in advent of therapeutic hypothermia (TH), it is still a common and important entity. In this retrospective study, we aimed to investigate the risk factors for AKI in HIE patients treated with hypothermia. Infants treated with TH due to HIE were reviewed retrospectively and infants who developed AKI and not were compared. Ninety-six patients were enrolled in the study. AKI developed in 27 (28%) patients and 4 (14.8%) of them were stage III AKI. In the AKI group, gestational age of the patients was significantly higher (p = 0.035), the 1st minute Apgar score was significantly lower (p = 0.042), and convulsions (p = 0.002), amplitude-integrated electroencephalography disorders (p = 0.025), sepsis (p = 0.017), need for inotropic therapy (p = 0.001), need of invasive mechanical ventilation (p = 0.03), and systolic dysfunction in echocardiography (p = 0.022) were significantly higher. In logistic regression tests, Apgar score at the 1st minute was found to be independent risk factor for developing AKI. AKI has the potential to worsen the neurological damage and correlates with morbidities of perinatal asphyxia. It is important to determine the incidence and risk factors for developing AKI in this delicate group of patients to prevent further renal damage.

Development of a predictive model for nephrotoxicity during tacrolimus treatment using machine learning methods

AIM

When administering tacrolimus, therapeutic drug monitoring is recommended because nephrotoxicity, an adverse event, occurs at supra-therapeutic whole-blood concentrations of tacrolimus. However, some patients exhibit nephrotoxicity even at the recommended concentrations, therefore establishing a therapeutic range of tacrolimus concentration for the individual patient is necessary to avoid nephrotoxicity. This study aimed to develop a model for individualized prediction of nephrotoxicity in patients administered tacrolimus.

METHODS

We collected data, such as laboratory test data at tacrolimus initiation, concomitant drugs and tacrolimus whole-blood concentration, from medical records of patients who received oral tacrolimus. Nephrotoxicity was defined as an increase in serum creatinine levels within 60 days of tacrolimus initiation. We built 13 prediction models based on different machine learning algorithms: logistic regression, support vector machine, gradient-boosting trees, random forest and neural networks. The best performing model was compared with the conventional model, which classifies patients according to the tacrolimus concentration alone.

RESULTS

Data from 163 and 41 patients were used to construct models and evaluate the best performing one, respectively. Most of the patients were diagnosed with inflammatory or autoimmune diseases. The best performing model was built using a support vector machine; it showed a high F2 score of 0.750 and outperformed the conventional model (0.500).

CONCLUSIONS

A machine learning model to predict nephrotoxicity in patients during tacrolimus treatment was developed using tacrolimus whole-blood concentration and other patient data. This model could potentially assist in identifying high-risk patients who require individualized target therapeutic concentrations of tacrolimus prior to treatment initiation to prevent nephrotoxicity.

The prevalence of acute kidney injury in patients with community-acquired pneumonia who required mechanical ventilation

BACKGROUND

Community-acquired pneumonia (CAP) is a common reason for intensive care unit (ICU) admission and sepsis. Acute kidney injury (AKI) is a frequent complication of community-acquired pneumonia and is associated with increased short- and long-term morbidity and mortality and healthcare costs.

OBJECTIVE

Describe the prevalence of AKI in patients with CAP requiring mechanical ventilation and evaluate its association with inhospital mortality.

DESIGN

Retrospective cohort.

SETTING

Intensive care unit.

PATIENTS AND METHODS

We included patients with CAP on mechanical ventilation. Patients were categorized according to the development of AKI in the first 24 hours of ICU admission using the Kidney Disease Improving Global Outcomes (KDIGO) classification from no AKI, stage 1 AKI, stage 2 AKI, and stage 3 AKI.

MAIN OUTCOME MEASURES

The primary outcome was hospital mortality. Secondary outcomes were ICU mortality, hospital and ICU length of stay, ventilation duration, tracheostomy, and renal replacement therapy requirement.

RESULTS

Of 1536 patients included in the study, 829 patients (54%) had no AKI while 707 (46%) developed AKI. In-hospital mortality was 288/829 (34.8%) for patients with no AKI, 43/111 (38.7%) for stage 1 AKI, 86/216 (40%) for stage 2 AKI, and 196/380 (51.7%) for stage 3 AKI (P<.0001). Multivariate analysis revealed that stages 1, 2, or 3 AKI compared to no AKI were not independently associated with in-hospital mortality. Older age, vasopressor use; decreased Glasgow coma scale, PaO2/Fio2 ratio and platelet count, increased bilirubin, lactic acid and INR were associated with increased mortality while female sex was associated with reduced mortality.

CONCLUSION

Among mechanically ventilated patients with CAP, AKI was common and was associated with higher crude mortality. The higher mortality could not be attributed alone to AKI, but rather appeared to be related to multi-organ dysfunction.

LIMITATIONS

Single-center retrospective study with no data on baseline serum creatinine and the use of estimated baseline creatinine distributions based on the MDRD (Modification of Diet in Renal Disease)equation which may lead to an overestimation of AKI. Second, we did not have data on the microbiology of pneumonia, appropriateness of antibiotic therapy or the administration of other medications that have been demonstrated to be associated with AKI.

Urinary Chloride Excretion Postcardiopulmonary Bypass in Pediatric Patients-A Pilot Study

The aim of this study was to describe renal chloride metabolism following cardiopulmonary bypass (CPB) surgery in pediatric patients. A prospective observational trial in a tertiary pediatric intensive care unit (PICU) with 20 recruited patients younger than 2 years following CPB surgery was conducted. Urinary electrolytes, plasma urea, electrolytes, creatinine, and arterial blood gases were collected preoperatively, on admission to PICU and at standardized intervals thereafter. The urinary and plasma strong ion differences (SID) were calculated from these results at each time point. Fluid input and output and electrolyte and drug administration were also recorded. Median chloride administration was 67.7 mmol/kg over the first 24 hours. Urinary chloride (mmol/L; median interquartile range [IQR]) was 30 (19, 52) prior to surgery, 15 (15, 65) on admission, and remained below baseline until 24 hours. Plasma chloride (mmol/L; median [IQR]) was 105 (98, 107) prior to surgery and 101 (101, 106) on admission to PICU. It then increased from baseline, but remained within normal limits, for the remainder of the study. The urinary SID increased from 49.8 (19.1, 87.2) preoperatively to a maximum of 122.7 (92.5, 151.8) at 6 hours, and remained elevated until 48 hours. Plasma and urinary chloride concentrations were not associated with the development of acute kidney injury. Urinary chloride excretion is impaired after CPB. The urinary SID increase associated with the decrease in chloride excretion suggests impaired production and/or excretion of ammonium by the nephron following CPB, with gradual recovery postoperatively.

A proposed framework for advancing acute kidney injury risk stratification and diagnosis in children: a report from the 26th Acute Disease Quality Initiative (ADQI) conference

Acute kidney injury (AKI) in children is associated with increased morbidity, reduced health-related quality of life, greater resource utilization, and higher mortality. Improvements in the timeliness and precision of AKI diagnosis in children are needed. In this report, we highlight existing, novel, and on-the-horizon diagnostic and risk-stratification tools for pediatric AKI, and outline opportunities for integration into clinical practice. We also summarize pediatric-specific high-risk diagnoses and exposures for AKI, as well as the potential role of real-time risk stratification and clinical decision support to improve outcomes. Lastly, the key characteristics of important pediatric AKI phenotypes will be outlined. Throughout, we identify key knowledge gaps, which represent prioritized areas of focus for future research that will facilitate a comprehensive, timely and personalized approach to pediatric AKI diagnosis and management.

Resistive index as predictor of acute kidney injury in patients with non-ST-segment elevation myocardial infarction

BACKGROUND

Acute kidney injury (AKI) is common in patients with non-ST-segment elevation myocardial infarction (NSTEMI). Early detection of AKI is likely to speed diagnosis and implementation of measures to preserve renal function. To evaluate if renal Doppler resistive index (RI) would predict AKI in patients with NSTEMI on presentation in the emergency department.

METHODS

Patients with NSTEMI at the emergency department were included. The renal Doppler RI was measured. Baseline demographic data and clinical characteristics of patients at admittance were recorded. Based on discharge diagnosis, the patients were divided into AKI group and no-AKI group. Multiple logistic regression analysis was performed to determine predictor variables significantly associated with AKI.

RESULTS

A total of 293 patients were included in the analysis; 44 (15.0%) developed AKI without need for dialysis. There were statistical differences in the age, incidence of diabetes mellitus and cerebrovascular disease, beta-receptor blockers, serum creatinine and renal index between the two groups. Using multivariate logistic regression analysis, age [OR 1.87; 95% confidence interval (CI) 1.595-2.585; p = 0.027], diabetes mellitus (OR 2.007, 95% CI: 1.489-2.793; p = 0.014), serum creatinine (OR 1.817, 95% CI: 1.568-2.319; p = 0.013), and RI (OR 2.168, 95% CI: 1.994-4.019; p = 0.003) predicted AKI in patients with NSTEMI. According to receiver operating characteristic (ROC) analysis, RI showed a significantly increased area under the curve (AUC) compared to serum creatitine (AUC: 0.891 vs 0.679; p < 0.001).

CONCLUSIONS

Renal Doppler RI may be a useful predictor of AKI in patients with NSTEMI in the emergency department.

EARLY TRAJECTORY OF VENOUS EXCESS ULTRASOUND SCORE IS ASSOCIATED WITH CLINICAL OUTCOMES OF GENERAL ICU PATIENTS

ABSTRACT

Background: Systemic venous congestion, assessed by the venous excess ultrasound (VExUS) score, has been associated with adverse effects, including acute kidney injury (AKI), in patients with cardiac disease. In general intensive care unit (ICU) patients, the association between VExUS score and outcomes is understudied. We aimed to investigate the association between the trajectory of VExUS score within the first 3 days of ICU admission and the composite clinical outcome of major adverse kidney events within 30 days (MAKE30). Methods: In this prospective observational study, including patients consecutively admitted to the ICU, VExUS score was calculated within 24 h after ICU admission (day 1) and at 48 to 72 h (day 3). D-VExUS was calculated as the difference between the VExUS score on day 3 minus that on day 1. Development of AKI within 7 days and all-cause mortality within 30 days were recorded. Results: A total of 89 patients (62% men; median age, 62 years; median Acute Physiology and Chronic Health Evaluation II score, 24) were included. Sixty (67%) patients developed AKI within 7 days, and 17 (19%) patients died within 30 days after ICU admission. D-VExUS was associated with MAKE30, even after adjustment for confounders (hazard ratio, 2.07; 95% confidence interval, 1.17-3.66; P = 0.01). VExUS scores on days 1 or 3 were not associated with MAKE30. Also, VExUS scores on day 1 or on day 3 and D-VExUS were not associated with development of AKI or mortality. Conclusions: In a general ICU cohort, early trajectory of VExUS score, but not individual VExUS scores at different time points, was associated with the patient-centered MAKE30 outcome. Dynamic changes rather than snapshot measurements may unmask the adverse effects of systemic venous congestion on important clinical outcomes.

Indexed neutrophil gelatinase associated lipocalin: a novel biomarker for the assessment of acute kidney injury

INTRODUCTION

Acute kidney injury (AKI) is a clinically relevant and common complication among patients with acute coronary syndrome. Neutrophil gelatinase-associated lipocalin (NGAL), secreted from different cells including renal tubules, has been widely studied as an early marker for kidney injury. However, chronic kidney disease (CKD) could impact NGAL levels and alter their predictive performance. Some studies attempted to address this issue by setting different cutoff values for patients with CKD, with limited success to date. Our aim was to evaluate a novel estimated glomerular filtration rate (eGFR)-adjusted "indexed NGAL" and its ability to predict in-hospital AKI among patients with ST elevation myocardial infarction.

METHODS

We performed a prospective, observational, single center study involving patients with ST elevation myocardial infarction admitted to the coronary intensive care unit. Serum samples for baseline NGAL were collected within 24 h following hospital admission. The eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. In-hospital AKI was determined as occurring after ≥ 24 h from admission. To perform an individualized adjustment, we used the result of 24 h NGAL divided by the eGFR measured upon admission to the hospital (Indexed-NGAL; I-NGAL).

RESULTS

Our cohort includes 311 patients, of whom 123 (40%) had CKD, and 66 (21%) suffered in-hospital AKI. NGAL levels as well as I-NGAL levels were significantly higher in patients with AKI (136 vs. 86, p < 0.01 and 3.13 VS. 1.06, p < 0.01, respectively). Multivariate analysis revealed I-NGAL to be independently associated with AKI (OR 1.34 (1.10-1.58), p < 0.01). I-NGAL had a higher predictive ability than simple NGAL results (AUC-ROC of 0.858 vs. 0.778, p < 0.001).

CONCLUSION

Adjusting NGAL values according to eGFR yields a new indexed NGAL value that enables better prediction of AKI regardless of baseline kidney function.

Kidney disease progression in pediatric and adult posterior urethral valves (PUV) patients

BACKGROUND

Posterior urethral valves (PUV) is the most common cause of obstructive uropathy in boys; approximately 15% develop kidney failure by early adulthood. However, rates of kidney function decline are poorly defined in PUV children and adults, as is the impact of potentially modifiable chronic kidney disease (CKD) progression risk factors.

METHODS

We conducted a retrospective review of all PUV patients followed at our institution from 1995 to 2018. Inclusion criteria were estimated glomerular filtration rate (eGFR) > 20 ml/min/1.73 m2 after 1 year of age, no dialysis or kidney transplant history, and ≥ 2 yearly serum creatinine values after age 1 year. eGFRs were calculated using creatinine-based estimating formulas for children (CKID U25) or adults (CKD-EPI). The primary outcome was annualized change in eGFR, assessed with linear mixed effects models. We also examined the association of acute kidney injury (AKI), proteinuria, hypertension (HTN), and recurrent febrile urinary tract infections (UTIs) with eGFR decline.

RESULTS

Fifty-two PUV patients met the inclusion criteria. Median (interquartile range) eGFR decline was 2.6 (2.1, 3.1) ml/min/1.73 m2/year. Children (n = 35) and adults (n = 17) demonstrated progressive decline. Proteinuria and recurrent UTIs were significantly associated with faster progression; AKI and HTN were also associated but did not reach significance.

CONCLUSION

PUV patients show progressive loss of kidney function well into adulthood. Proteinuria and recurrent UTIs are associated with faster progression, suggesting potential modifiable risk factors. This is the first study to report annualized eGFR decline rates in PUV patients, which could help inform the design of clinical trials of CKD therapies.

Postoperative fluid therapy in enhanced recovery after surgery for pancreaticoduodenectomy

Backgrounds/Aims

Optimal intravenous fluid management during the perioperative period for patients undergoing pancreaticoduodenectomy (PD) within the framework of enhanced recovery after surgery (ERAS) is unclear. Studies have indicated that excessive total body salt and water can contribute to the development of oedema, leading to increased morbidity and extended hospital stays. This study aimed to assess the effects of an intravenous therapy regimen during postoperative day (POD) 0 to 2 in PD patients within ERAS.

Methods

A retrospective interventional cohort study was conducted, and it involved all PD patients before and after implementation of ERAS (2009-2017). In the ERAS group, a targeted maintenance fluid regimen of 20 mL/kg/day with a sodium requirement of 0.5 mmoL/kg/day was administered. Outcome measures included the mmol of sodium and chloride administered, length of stay, and morbidity (postoperative pancreatic fistula, POPF; acute kidney injury, AKI; ileus).

Results

The study included 169 patients, with a mean age of 64 ± 11.3 years. Following implementation of the intravenous fluid therapy protocol, there was a significant reduction in chloride and sodium loading. However, in the multivariable analysis, chloride administered (mmoL/kg) did not independently influence the length of stay; or rates of POPF, ileus, or AKI (p > 0.05).

Conclusions

The findings suggested that a postoperative intravenous fluid therapy regimen did not significantly impact morbidity. Notably, there was a trend towards reduced length of stay within an increasingly comorbid patient cohort. This targeted fluid regimen appears to be safe for PD patients within the ERAS program. Further prospective research is needed to explore this area.

Recovery of kidney function after acute kidney disease-a multi-cohort analysis

BACKGROUND

There are no consensus definitions for evaluating kidney function recovery after acute kidney injury (AKI) and acute kidney disease (AKD), nor is it clear how recovery varies across populations and clinical subsets. We present a federated analysis of four population-based cohorts from Canada, Denmark and Scotland, 2011-18.

METHODS

We identified incident AKD defined by serum creatinine changes within 48 h, 7 days and 90 days based on KDIGO AKI and AKD criteria. Separately, we applied changes up to 365 days to address widely used e-alert implementations that extend beyond the KDIGO AKI and AKD timeframes. Kidney recovery was based on resolution of AKD and a subsequent creatinine measurement below 1.2× baseline. We evaluated transitions between non-recovery, recovery and death up to 1 year; within age, sex and comorbidity subgroups; between subset AKD definitions; and across cohorts.

RESULTS

There were 464 868 incident cases, median age 67-75 years. At 1 year, results were consistent across cohorts, with pooled mortalities for creatinine changes within 48 h, 7 days, 90 days and 365 days (and 95% confidence interval) of 40% (34%-45%), 40% (34%-46%), 37% (31%-42%) and 22% (16%-29%) respectively, and non-recovery of kidney function of 19% (15%-23%), 30% (24%-35%), 25% (21%-29%) and 37% (30%-43%), respectively. Recovery by 14 and 90 days was frequently not sustained at 1 year. Older males and those with heart failure or cancer were more likely to die than to experience sustained non-recovery, whereas the converse was true for younger females and those with diabetes.

CONCLUSION

Consistently across multiple cohorts, based on 1-year mortality and non-recovery, KDIGO AKD (up to 90 days) is at least prognostically similar to KDIGO AKI (7 days), and covers more people. Outcomes associated with AKD vary by age, sex and comorbidities such that older males are more likely to die, and younger females are less likely to recover.

Distribution and elimination kinetics of midazolam and metabolites after post-resuscitation care: a prospective observational study

Administration of sedatives for post-resuscitation care can complicate the determination of the optimal timing to avoid inappropriate, pessimistic prognostications. This prospective study aimed to investigate the distribution and elimination kinetics of midazolam (MDZ) and its metabolites, and their association with awakening time. The concentrations of MDZ and its seven metabolites were measured immediately and at 4, 8, 12, and 24 h after the discontinuation of MDZ infusion, using liquid chromatography-tandem mass spectrometry. The area under the time-plasma concentration curve from 0 to 24 h after MDZ discontinuation (AUClast) was calculated based on the trapezoidal rule. Of the 15 enrolled patients, seven awakened after the discontinuation of MDZ infusion. MDZ and three of its metabolites were major compounds and their elimination kinetics followed a first-order elimination profile. In the multivariable analysis, only MDZ was associated with awakening time (AUClast: R2 = 0.59, p = 0.03; AUCinf: R2 = 0.96, p < 0.001). Specifically, a 0.001% increase in MDZ AUC was associated with a 1% increase in awakening time. In the individual regression analysis between MDZ concentration and awakening time, the mean MDZ concentration at awakening time was 16.8 ng/mL. The AUC of MDZ is the only significant factor associated with the awakening time.

Atorvastatin for reduction of 28-day mortality in severe and critical COVID-19 patients: a randomized controlled trial

BACKGROUND

COVID-19 is an abnormal host response to the SARS-CoV-2 infection, which is associated with endothelial dysfunction and multi-organ failure. Atorvastatin has been proposed to reduce COVID-19 severity and mortality in chronic and de-novo users.

METHODS

This randomized double-blind trial included 220 COVID-19 patients admitted to Mansoura University's isolation hospital in Egypt. One hundred and ten cases were given 40 mg of atorvastatin once daily for 28 days (group A), while 110 received a placebo (group B). All patients received treatment as per hospital protocol. The primary outcome is all-cause mortality at 28 days. We also tracked 6-month mortality, time to clinical improvement, the risk of invasive mechanical ventilation, acute kidney injury, potential adverse events, and hospital and intensive care length of stay.

RESULTS

The 28-day all-cause mortality was 52/104 (50%) in group A vs. 54/103 (52.4%) in group B, odds ratio (OR) = 0.907 (0.526, 1.565), P = 0.727; adjusted OR = 0.773 (0.407, 1.47), P = 0.433. Six-month mortality occurred in 53/102 (52%) and 59/79 (60.8%) in group A vs. B, respectively, P = 0.208. Among hospital survivors in group A vs. group B, the median time to clinical improvement was 10 days (7-14) vs. 10 (7-15), P = 0.715; the duration of hospital stay was 10 days (7-14) vs. 10 (8-17), P = 0.378. Discontinuation was higher in group B (four vs. one), but statistically insignificant, P = 0.369.

CONCLUSIONS

In adults with severe or critical COVID-19, atorvastatin did not reduce the risk of 28-day or 6-month mortality and did not shorten the length of hospital stay or time to clinical improvement. Trial registration Clinical Trial Registry (NCT04952350) on July 1st, 2021. https://clinicaltrials.gov/ct2/show/NCT04952350.

Cisplatin Nephrotoxicity Is Critically Mediated by the Availability of BECLIN1

Cisplatin nephrotoxicity is a critical limitation of solid cancer treatment. Until now, the complex interplay of various pathophysiological mechanisms leading to proximal tubular cell apoptosis after cisplatin exposure has not been fully understood. In our study, we assessed the role of the autophagy-related protein BECLIN1 (ATG6) in cisplatin-induced acute renal injury (AKI)-a candidate protein involved in autophagy and with putative impact on apoptosis by harboring a B-cell lymphoma 2 (BCL2) interaction site of unknown significance. By using mice with heterozygous deletion of Becn1, we demonstrate that reduced intracellular content of BECLIN1 does not impact renal function or autophagy within 12 months. However, these mice were significantly sensitized towards cisplatin-induced AKI, and by using Becn1+/-;Sglt2-Cre;Tomato/EGFP mice with subsequent primary cell analysis, we confirmed that nephrotoxicity depends on proximal tubular BECLIN1 content. Mechanistically, BECLIN1 did not impact autophagy or primarily the apoptotic pathway. In fact, a lack of BECLIN1 sensitized mice towards cisplatin-induced ER stress. Accordingly, the ER stress inhibitor tauroursodeoxycholic acid (TUDCA) blunted cisplatin-induced cell death in Becn1 heterozygosity. In conclusion, our data first highlight a novel role of BECLIN1 in protecting against cellular ER stress independent from autophagy. These novel findings open new therapeutic avenues to intervene in this important intracellular stress response pathway with a promising impact on future AKI management.

Blood urea nitrogen to serum albumin ratio is associated with all-cause mortality in patients with AKI: a cohort study

Background

This study aims to investigate the relationship between blood urea nitrogen to serum albumin ratio (BAR) and all-cause mortality in patients with acute kidney injury (AKI) and evaluate the effect of BAR on the prognosis of AKI.

Methods

Adult patients with AKI admitted to the ICU in the Medical Information Mart for Intensive Care IV (MIMIC-IV) were selected in a retrospective cohort study. BAR (mg/g) was calculated using initial blood urea nitrogen (mg/dl)/serum albumin (g/dl). According to the BAR, these patients were divided into quartiles (Q1-Q4). Kaplan-Meier analysis was used to compare the mortality of the above four groups. Multivariate Cox regression analysis was used to evaluate the association between BAR and 28-day mortality and 365-day mortality. The receiver operating characteristic (ROC) curve was plotted and the area under the curve (AUC) was calculated, and the subgroup analysis was finally stratified by relevant covariates.

Results

A total of 12,125 patients with AKI were included in this study. The 28-day and 365-day mortality rates were 23.89 and 39.07%, respectively. Kaplan-Meier analysis showed a significant increase in all-cause mortality in patients with high BAR (Log-rank p < 0.001). Multivariate Cox regression analysis showed that BAR was an independent risk factor for 28-day mortality (4.32 < BAR≤7.14: HR 1.12, 95% CI 0.97-1.30, p = 0.114; 7.14 < BAR≤13.03: HR 1.51, 95% CI 1.31-1.75, p < 0.001; BAR>13.03: HR 2.07, 95% CI 1.74-2.47, p < 0.001; Reference BAR≤4.32) and 365-day mortality (4.32 < BAR≤7.14: HR 1.22, 95% CI 1.09-1.36, p < 0.001; 7.14 < BAR≤13.03: HR 1.63, 95% CI 1.46-1.82, p < 0.001; BAR>13.03: HR 2.22, 95% CI 1.93-2.54, p < 0.001; Reference BAR ≤ 4.32) in patients with AKI. The AUC of BAR for predicting 28-day mortality and 365-day mortality was 0.649 and 0.662, respectively, which is better than that of blood urea nitrogen and sequential organ failure assessment. In addition, subgroup analysis showed a stable relationship between BAR and adverse outcomes in patients with AKI.

Conclusion

BAR is significantly associated with increased all-cause mortality in patients with AKI. This finding suggests that BAR may help identify people with AKI at high risk of mortality.

Individualized Perioperative Hemodynamic Management Using Hypotension Prediction Index Software and the Dynamics of Troponin and NTproBNP Concentration Changes in Patients Undergoing Oncological Abdominal Surgery

INTRODUCTION

Abdominal oncologic surgeries pose significant risks due to the complexity of the surgery and patients' often weakened health, multiple comorbidities, and increased perioperative hazards. Hypotension is a major risk factor for perioperative cardiovascular complications, necessitating individualized management in modern anesthesiology.

AIM

This study aimed to determine the dynamics of changes in troponin and NTproBNP levels during the first two postoperative days in patients undergoing major cancer abdominal surgery with advanced hemodynamic monitoring including The AcumenTM Hypotension Prediction Index software (HPI) (Edwards Lifesciences, Irvine, CA, USA) and their association with the occurrence of postoperative cardiovascular complications.

METHODS

A prospective study was conducted, including 50 patients scheduled for abdominal cancer surgery who, due to the overall risk of perioperative complications (ASA class 3 or 4), were monitored using the HPI software. Hypotension was qualified as at least one ≥ 1 min episode of a MAP < 65 mm Hg. Preoperatively and 24 and 48 h after the procedure, the levels of NTproBNP and troponin were measured, and an ECG was performed.

RESULTS

We analyzed data from 46 patients and found that 82% experienced at least one episode of low blood pressure (MAP < 65 mmHg). However, the quality indices of hypotension were low, with a median time-weighted average MAP < 65 mmHg of 0.085 (0.03-0.19) mmHg and a median of 2 (2-1.17) minutes spent below MAP < 65 mmHg. Although the incidence of perioperative myocardial injury was 10%, there was no evidence to suggest a relationship with hypotension. Acute kidney injury was seen in 23.9% of patients, and it was significantly associated with a number of episodes of MAP < 50 mmHg. Levels of NTproBNP were significantly higher on the first postoperative day compared to preoperative values (285.8 [IQR: 679.8] vs. 183.9 [IQR: 428.1] pg/mL, p < 0.001). However, they decreased on the second day (276.65 [IQR: 609.4] pg/mL, p = 0.154). The dynamics of NTproBNP were similar for patients with and without heart failure, although those with heart failure had significantly higher preoperative concentrations (435.9 [IQR: 711.15] vs. 87 [IQR: 232.2] pg/mL, p < 0.001). Patients undergoing laparoscopic surgery showed a statistically significant increase in NTproBNP.

CONCLUSIONS

This study suggests that advanced HPI monitoring in abdominal cancer surgery effectively minimizes intraoperative hypotension with no significant NTproBNP or troponin perioperative dynamics, irrespective of preoperative heart failure.

Development of a nomogram to predict the incidence of acute kidney injury among ischemic stroke individuals during ICU hospitalization

Background

Limited clinical prediction models exist to assess the likelihood of acute kidney injury (AKI) occurrence in ischemic stroke individuals. In this retrospective study, our aim was to construct a nomogram that utilizes commonly available clinical features to predict the occurrence of AKI during intensive care unit hospitalization among this patient population.

Methods

In this study, the MIMIC-IV database was utilized to investigate potential risk factors associated with the incidence of AKI among ischemic stroke individuals. A predictive nomogram was developed based on these identified risk factors. The discriminative performance of the constructed nomogram was assessed. Calibration analysis was utilized to evaluate the calibration performance of the constructed model, assessing the agreement between predicted probabilities and actual outcomes. Furthermore, decision curve analysis (DCA) was employed to assess the clinical net benefit, taking into account the potential risks and benefits associated with different decision thresholds.

Results

A total of 2089 ischemic stroke individuals were included and randomly allocated into developing (n = 1452) and verification cohorts (n = 637). Risk factors for AKI incidence in ischemic stroke individuals, determined through LASSO and logistic regression. The constructed nomogram had good performance in predicting the occurrence of AKI among ischemic stroke patients and provided significant improvement compared to existing scoring systems. DCA demonstrated satisfactory clinical net benefit of the constructed nomogram in both the validation and development cohorts.

Conclusions

The developed nomogram exhibits robust predictive performance in forecasting AKI occurrence in ischemic stroke individuals.

Acute kidney injury: exploring endoplasmic reticulum stress-mediated cell death

Acute kidney injury (AKI) is a global health problem, given its substantial morbidity and mortality rates. A better understanding of the mechanisms and factors contributing to AKI has the potential to guide interventions aimed at mitigating the risk of AKI and its subsequent unfavorable outcomes. Endoplasmic reticulum stress (ERS) is an intrinsic protective mechanism against external stressors. ERS occurs when the endoplasmic reticulum (ER) cannot deal with accumulated misfolded proteins completely. Excess ERS can eventually cause pathological reactions, triggering various programmed cell death (autophagy, ferroptosis, apoptosis, pyroptosis). This article provides an overview of the latest research progress in deciphering the interaction between ERS and different programmed cell death. Additionally, the report consolidates insights into the roles of ERS in AKI and highlights the potential avenues for targeting ERS as a treatment direction toward for AKI.

Co-Administration of High-Dose Nebulized Colistin for Acinetobacter baumannii Bacteremic Ventilator-Associated Pneumonia: Impact on Outcomes

Acinetobacter baumannii (A. baumannii) is a difficult-to-treat (DTR) pathogen that causes ventilator-associated pneumonia (VAP) associated with high mortality. To improve the outcome of DTR A. Baumannii VAP, nebulized colistin (NC) was introduced with promising but conflicting results on mortality in earlier studies. Currently, NC is used at a much higher daily dose compared to the past. Nevertheless, there is little evidence on the effect of high-dose NC on the outcomes of A. baumannii VAPs, especially in the current era where the percentage of colistin-resistant A. baumannii strains is rising. We conducted a retrospective study comparing bacteremic A. baumannii VAP patients who were treated with and without NC co-administration and were admitted in the Intensive Care Unit of University Hospital of Ioannina from March 2020 to August 2023. Overall, 59 patients (21 and 38 with and without NC coadministration, respectively) were included. Both 28-day and 7-day mortalities were significantly lower in the patient group treated with NC (52.4% vs. 78.9%, p 0.034 and 9.5% vs. 47.4%, p 0.003, respectively). Patients treated with NC had a higher percentage of sepsis resolution by day 7 (38.1% vs. 13.5%, p 0.023) and were more likely to be off vasopressors by day 7 (28.6% vs. 8.1%, p 0.039). The addition of NC in the treatment regime of A. baumannii VAP decreased mortality.

Activation of renal epithelial Na+ channels (ENaC) in infants with congenital heart disease

Introduction

This study was designed to measure the concentration and activity of urinary proteases that activate renal epithelial sodium channel (ENaC) mediated Na+ transport in infants with congenital heart disease, a potential mechanism for fluid retention.

Methods

Urine samples from infants undergoing cardiac surgery were collected at three time points: T1) pre-operatively, T2) 6-8 h after surgery, and T3) 24 h after diuretics. Urine was collected from five heathy infant controls. The urine was tested for four proteases and whole-cell patch-clamp testing was conducted in renal collecting duct M-1 cells to test whether patient urine increased Na+ currents consistent with ENaC activation.

Results

Heavy chain of plasminogen, furin, and prostasin were significantly higher in cardiac patients prior to surgery compared to controls. There was no difference in most proteases before and after surgery. Urine from cardiac patients produced a significantly greater increase in Na+ inward currents compared to healthy controls.

Conclusion

Urine from infants with congenital heart disease is richer in proteases and has the potential to increase activation of ENaC in the nephron to enhance Na+ reabsorption, which may lead to fluid retention in this population.

Global Scientific Trends in Continuous Renal Replacement Therapy from 2000 to 2023: A Bibliometric and Visual Analysis

INTRODUCTION

Continuous renal replacement therapy (CRRT) is one of the most widely used blood purification and organ support methods in the ICU. However, the development process, the current status, hotspots, and future trends of CRRT remain unclear.

METHOD

The WoSCC database was used to analyze CRRT research evolution and theme trends. VOSviewer was used to construct coauthorship, co-occurrence, co-citation, and network visualizations. CiteSpace is used to detect bursts for co-occurrence items. Several important subtopics were reviewed and discussed in more detail.

RESULTS

Global publications increased from 56 in 2000 to 398 in 2023, a 710.71% increase. Blood Purification published the most manuscripts, followed by the International Journal of Artificial Organs. The USA, the San Bortolo Hospital, and Bellomo were the most productive and impactful institution, country, and author, respectively. Based on co-occurrence cluster analysis, five clusters emerged: (1) clinical applications and management of CRRT; (2) sepsis and CRRT; (3) CRRT anticoagulant management; (4) CRRT and antibiotic pharmacokinetics and pharmacodynamics; and (5) comparison of CRRT and intermittent hemodialysis. COVID-19, initiation, ECOMO, cefepime, guidelines, cardiogenic shock, biomarker, and outcome were the latest high-frequency keywords or strongest bursts, indicating the emerging frontiers of CRRT.

CONCLUSIONS

There has been widespread publication and citation of CRRT research in the past 2 decades. We provide an overview of current trends, global collaboration patterns, basic knowledge, research hotspots, and emerging frontiers.

Association between the Triglyceride Glucose Index and All-Cause Mortality in Critically Ill Patients with Acute Kidney Injury

Introduction

The triglyceride glucose (TyG) index is a reliable alternative biomarker of insulin resistance, but the association between the TyG index and acute kidney injury (AKI) in critically ill patients remains unclear.

Methods

The data for the study were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Cox regression and restricted cubic spline (RCS) analysis were performed to analyze the association between the TyG index and all-cause mortality. Besides, Cox regression was carried out in subgroups of age, gender, BMI, diabetes history, and dialysis status.

Results

A total of 7,508 critically ill participants with AKI from the MIMIC-IV database were included in this study, with 3,688 (49.12%) participants failed to survive. In Cox regression, after confounder adjustment, patients with a higher TyG index had a higher risk of all-cause mortality (HR = 1.845, 95% CI = 1.49-2.285, p < 0.001). In RCS, after confounder adjustment, the risk of death was positively correlated with the increased value of the TyG index when TyG index surpassed 10.014. This relationship was validated in age, gender, BMI, diabetes subgroups but not in the dialysis subgroup. Interestingly, RCS analysis demonstrated that, in patients undertaking dialysis, there is a "U"-shaped curve for the value of TyG index and risk of all-cause mortality. When TyG index is less than 10.460, the risk of all-cause mortality would decrease with the increased value of TyG index, while when TyG index is higher than 11.180, the risk of all-cause mortality would increase firmly with the increased value of TyG index.

Conclusion

Overall, a higher TyG index is associated with a higher risk of all-cause mortality in critically ill AKI. Interestingly, the relationship in the dialysis subgroup follows a "U"-shaped curve, indicating the importance of proper clinical blood glucose and lipid management in this particular population.

Restrictive versus standard IV fluid therapy in adult ICU patients with septic shock-Bayesian analyses of the CLASSIC trial

BACKGROUND

The CLASSIC trial assessed the effects of restrictive versus standard intravenous (IV) fluid therapy in adult intensive care unit (ICU) patients with septic shock. This pre-planned study provides a probabilistic interpretation and evaluates heterogeneity in treatment effects (HTE).

METHODS

We analysed mortality, serious adverse events (SAEs), serious adverse reactions (SARs) and days alive without life-support within 90 days using Bayesian models with weakly informative priors. HTE on mortality was assessed according to five baseline variables: disease severity, vasopressor dose, lactate levels, creatinine values and IV fluid volumes given before randomisation.

RESULTS

The absolute difference in mortality was 0.2%-points (95% credible interval: -5.0 to 5.4; 47% posterior probability of benefit [risk difference <0.0%-points]) with restrictive IV fluid. The posterior probabilities of benefits with restrictive IV fluid were 72% for SAEs, 52% for SARs and 61% for days alive without life-support. The posterior probabilities of no clinically important differences (absolute risk difference ≤2%-points) between the groups were 56% for mortality, 49% for SAEs, 90% for SARs and 38% for days alive without life-support. There was 97% probability of HTE for previous IV fluid volumes analysed continuously, that is, potentially relatively lower mortality of restrictive IV fluids with higher previous IV fluids. No substantial evidence of HTE was found in the other analyses.

CONCLUSION

We could not rule out clinically important effects of restrictive IV fluid therapy on mortality, SAEs or days alive without life-support, but substantial effects on SARs were unlikely. IV fluids given before randomisation might interact with IV fluid strategy.

The Treatment of Coronary Artery Disease in Patients with Chronic Kidney Disease: Gaps, Challenges, and Solutions

Background

Chronic kidney disease (CKD) is associated with a high burden of coronary artery disease (CAD), which remains the leading cause of death in CKD patients. Despite the high cardiovascular risk, ACS patients with renal dysfunction are less commonly treated with guideline-based medical therapy and are less frequently referred for coronary revascularization.

Summary

The management of CAD is more challenging in patients with CKD than in the general population due to concerns regarding side effects and renal toxicity, as well as uncertainty regarding clinical benefit of guideline-based medical therapy and interventions. Patients with advanced CKD and especially those receiving dialysis have not traditionally been represented in randomized trials evaluating either medical or revascularization therapies. Thus, only scant data from small prospective studies or retrospective analyses are available. Recently published studies suggest that there are significant opportunities to substantially improve both cardiovascular and renal outcomes of patients with CAD and CKD, including new medications and interventions. Thus, the objective of this review is to summarize the current evidence regarding the management of CAD in CKD patients, in particular with respect to improvement of both cardiovascular and renal outcomes.

Key Messages

Adequate medical therapy and coronary interventions using evidence-based strategies can improve both cardiac and renal outcomes in patients with CAD and CKD.

Midodrine reduces new-onset acute kidney injury and hyponatremia in children with cirrhosis and ascites awaiting liver transplantation: Results from an open-label RCT

OBJECTIVES

Midodrine, an oral α-1-adrenergic receptor agonist, counters arterial hypovolemia and reduces complications in adult patients with cirrhosis. This randomized controlled trial (RCT) aimed to assess the efficacy and safety of midodrine in preventing complications and improving survival in children with cirrhosis and ascites who are awaiting liver transplantation (LT).

METHODS

This open-label RCT conducted from January 2022 to May 2023 included children under 18 years with cirrhosis and ascites. Patients were randomized to receive either midodrine plus standard medical therapies (SMTs) or SMT alone. The primary outcome measure was the incidence of cirrhosis-related complications within 6 months.

RESULTS

Thirty-five subjects were enrolled and randomized. Patients in the midodrine arm had a lower incidence of new-onset acute kidney injury (AKI) compared with the SMT arm (11.1% vs. 41.2%). Patients in the midodrine arm showed a decline in serum creatinine and improvement in glomerular filtration rate, whereas no changes were observed in the SMT arm. There was a lower incidence of new-onset hyponatremia in the midodrine arm (20% vs. 56%). Midodrine led to reduction in plasma rennin activity (PRA) and improvement in systemic hemodynamics. There was no difference in the rate of resolution of ascites, recurrence of ascites, requirement of therapeutic paracentesis, cumulative albumin infusion requirement, episodes of spontaneous bacterial peritonitis, and hepatic encephalopathy between the two arms.

CONCLUSION

Midodrine, when added to SMT, was effective in reducing the incidence of new-onset AKI and hyponatremia in pediatric cirrhotics awaiting LT. It also improved systemic hemodynamics and showed a trend towards reducing PRA.

Alleviation effects of epigallocatechin-3-gallate against acute kidney injury following severe burns

BACKGROUND

Burn patients often face a high risk of acute kidney injury (AKI) after severe burn injuries, meanwhile epigallocatechin-3-gallate (EGCG) has been proven to be effective in alleviating organ injury.

METHODS

This study used the classical burn model in rats. Thirty model rats were randomly divided into a Burn group, a Burn + placebo group, a Burn + EGCG (50 mg/kg) group, and ten non-model rats as Sham group. The urinary excretion of the rats was subsequently monitored for a period of 48 h. After 48 h of different treatments, rat serum and kidneys were taken for the further verification. The efficacy of EGCG was assessed in pathological sections, biochemical indexes, and at the molecular level.

RESULTS

Pathological sections were compared between the Burn group and Burn + placebo group. The rats in the Burn + EGCG group had less kidney damage. Moreover, the EGCG group maintained significantly elevated urine volumes, biochemical indexes manifested that EGCG could reduce serum creatinine (Cr) and neutrophil gelatinase-associated lipocalin (NGAL) level and inhibit the oxidation-related enzyme malondialdehyde (MDA) level, meanwhile the superoxide dismutase (SOD) level was increased. The molecular level showed that EGCG significantly reduced the mRNA expression levels of the inflammation-related molecules interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α).

CONCLUSION

The research indicated that EGCG had an alleviating effect on kidney injury in severely burned rats, and its alleviating effects were related to improving kidney functions, alleviating oxidative stress, and inhibiting the expression of inflammatory factors.

Effect of 5% albumin on endothelial glycocalyx degradation during off-pump coronary artery bypass

PURPOSE

The integrity of the endothelial glycocalyx (EG), a critical player in vascular homeostasis, reportedly influences the outcomes of critically ill patients. We investigated the effect of 5% albumin, which preserved EG integrity in preclinical studies, vs balanced crystalloid solution on EG degradation in patients undergoing off-pump coronary surgery.

METHODS

Patients were randomized to receive either 5% albumin (N = 51) or balanced crystalloid solution (Plasma-Lyte [Baxter Incorporated, Seoul, Republic of Korea]; N = 53) for intravenous volume replacement during surgery (double-blinded). The primary outcome was plasma syndecan-1 concentration, a marker of EG degradation, measured after anesthetic induction (baseline), completion of grafting, and sternal closure. Secondary outcomes were atrial natriuretic peptide (ANP), tumour necrosis factor (TNF)-α, soluble thrombomodulin, and perioperative fluid balance.

RESULTS

The mean (standard deviation) fluid requirements were 833 (270) mL and 1,323 (492) mL in the albumin and Plasma-Lyte group, respectively (mean difference, -489 mL; 95% confidence interval [CI], -643 to -335; P < 0.001). Plasma syndecan-1 concentration increased after completion of grafting (median difference, 116 ng·mL-1; 95% CI, 67 to 184; P < 0.001) and sternal closure (median difference, 57 ng·mL-1; 95% CI, 36 to 80; P < 0.001) compared with those at baseline, without any intergroup differences. Atrial natriuretic peptide, TNF-α, and soluble thrombomodulin concentrations were similar between the two groups. The amount of chest tube drainage was greater in the albumin group than that in the Plasma-Lyte group (median difference, 190 mL; 95% CI, 18 to 276; P = 0.03).

CONCLUSION

Off-pump coronary surgery was associated with significant EG degradation. Yet, intraoperative fluid therapy with 5% albumin could not ameliorate EG degradation when compared with balanced crystalloid solution.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03699462); first posted 9 October 2018.

Kidney Increase Natriuresis but Not Glomerular Filtration Under Veno-venous ECMO, a Retrospective Study

PURPOSE

Acute kidney injury is a frequent complication of acute respiratory distress syndrome (ARDS). We aim to study the evolution of kidney function in patients presenting severe ARDS and requiring veno-venous extracorporeal membrane oxygenation (VV ECMO).

METHODS

We conducted a multicenter retrospective study, including adult patients requiring VV ECMO for ARDS. The primary outcome was the evolution of the serum creatinine level after VV ECMO initiation. Secondary outcomes were change in urine output, and urine biochemical parameters after VV ECMO initiation.

RESULTS

One hundred and two patients were included. VV ECMO was initiated after a median of 6 days of mechanical ventilation, mainly for ARDS caused by COVID-19 (73%). Serum creatinine level did not significantly differ after VV ECMO initiation (P = .20). VV ECMO was associated with a significant increase in daily urine output (+6.6 mL/kg/day, [3.8;9.3] P < .001), even after adjustment for potential confounding factors; with an increase in natriuresis. The increase in urine output under VV ECMO was associated with a reduced risk of receiving kidney replacement therapy (OR 0.4 [0.2;0.8], P = .026).

CONCLUSIONS

VV ECMO initiation in severe ARDS is associated with an increase in daily urine output and natriuresis, without change in glomerular filtration rate.

Furosemide Responsiveness Predicts Acute Kidney Injury Progression After Cardiac Surgery

BACKGROUND

As patients with acute kidney injury (AKI) progress to a higher stage, the risk for poor outcomes dramatically rises. Early identification of patients at high risk for AKI progression remains a major challenge. This study aimed to evaluate the value of furosemide responsiveness (FR) for predicting AKI progression in patients with initial mild and moderate AKI after cardiac surgery.

METHODS

We performed 2 separate exploratory analyses. The Zhongshan cohort was a single-center, prospective, observational cohort, whereas the Beth Israel Deaconess Medical Center cohort was a single-center, retrospective cohort. We calculated 2 FR parameters for each patient, namely the FR index and modified FR index, defined as 2-hour urine output divided by furosemide dose (FR index, mL/mg/2 h) and by furosemide dose and body weight (modified FR index, mL/[mg·kg]/2 h), respectively. The primary outcome was AKI progression within 7 days.

RESULTS

AKI progression occurred in 80 (16.0%) and 359 (11.3%) patients in the Zhongshan and Beth Israel Deaconess Medical Center cohorts, respectively. All FR parameters (considered continuously or in quartiles) were inversely associated with risk of AKI progression in both cohorts (all adjusted P < .01). The addition of FR parameters significantly improved prediction for AKI progression based on baseline clinical models involving C-index, net reclassification improvement, and integrated discrimination improvement index in both cohorts (all P < .01).

CONCLUSIONS

FR parameters were inversely associated with risk of AKI progression in patients with mild and moderate AKI after cardiac surgery. The addition of FR parameters significantly improved prediction for AKI progression based on baseline clinical models.

Receipt of high-frequency ventilation is associated with acute kidney injury in very preterm neonates

BACKGROUND

High-frequency ventilation (HFV) is frequently used in critically ill preterm neonates. We aimed to determine the incidence of acute kidney injury (AKI) in neonates less than 29 weeks gestation who received HFV in the first week of life and to determine if the rates of AKI differed in those who received other forms of respiratory support.

METHODS

This retrospective cohort study of 24 international, level III/IV neonatal intensive care units (NICUs) included neonates less than 29 weeks gestation from the AWAKEN study database. Exclusion criteria included the following: no intravenous fluids ≥ 48 h, admission ≥ 14 days of life, congenital heart disease requiring surgical repair at < 7 days of life, lethal chromosomal anomaly, death within 48 h, severe congenital kidney abnormalities, inability to determine AKI status, insufficient data on ventilation, and when the diagnosis of early AKI was unable to be made. Subjects were grouped into three groups based on ventilation modes (CPAP/no ventilation, conventional ventilation, and HFV).

RESULTS

The incidence of AKI was highest in the CPAP/no ventilation group, followed by HFV, followed by conventional ventilation (CPAP/no ventilation 48.5% vs. HFV 42.6% vs. conventional ventilation 28.4% (p = 0.009). An increased risk for AKI was found for those on HFV compared to CPAP/no ventilation (HR = 2.65; 95% CI:1.22-5.73).

CONCLUSIONS

HFV is associated with AKI in the first week of life. Neonates on HFV should be screened for AKI. The reasons for this association are not clear. Further studies should evaluate the relationship between ventilator strategies and AKI in premature neonates. A higher resolution version of the Graphical abstract is available as Supplementary information.

PROTECTIVE ROLE OF MELATONIN FOR ACUTE KIDNEY INJURY: A SYSTEMATIC REVIEW AND META-ANALYSIS

ABSTRACT

Introduction : Acute kidney injury (AKI) is an important clinical issue that arouses global concerns, which puzzles clinicians and lacks effective drug treatment for AKI until the present. Melatonin has been well recognized to modulate the sleep-wake cycle and had the renal protective effect. However, there are still few clinical trials investigating the relationship between melatonin and AKI. The conclusions drawn in existing clinical studies are still inconsistent. The study systematically reviewed and assessed the efficacy of melatonin in preventing AKI. Methods : A systematic literature search was conducted in the PubMed, Embase, and Cochranelibrary on May 19, 2023. Eligible records were screened according to the inclusion and exclusion criteria. The risk ratio and the corresponding 95% confidence intervals were selected to evaluate the effects of melatonin on AKI. We pooled extracted data using a fixed- or random effects model based on a heterogeneity test. Results : Six randomized controlled trials regarding the use of melatonin in preventing kidney injury met our inclusion criteria. The pooled results showed that melatonin increased the estimated glomerular filtration rate, and effectively inhibited the occurrence of AKI. Melatonin tended to reduce the serum creatinine and urea nitrogen levels, but there was no statistical significance. Conclusions : Melatonin can increase the estimated glomerular filtration rate and effectively inhibit the occurrence of AKI. More well-designed randomized controlled trials are needed to verify the protective effect of melatonin in the future.

Continuous renal replacement therapy in neonates and children: what does the pediatrician need to know? An overview from the Critical Care Nephrology Section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

Continuous renal replacement therapy (CRRT) is the preferred method for renal support in critically ill and hemodynamically unstable children in the pediatric intensive care unit (PICU) as it allows for gentle removal of fluids and solutes. The most frequent indications for CRRT include acute kidney injury (AKI) and fluid overload (FO) as well as non-renal indications such as removal of toxic metabolites in acute liver failure, inborn errors of metabolism, and intoxications and removal of inflammatory mediators in sepsis. AKI and/or FO are common in critically ill children and their presence is associated with worse outcomes. Therefore, early recognition of AKI and FO is important and timely transfer of patients who might require CRRT to a center with institutional expertise should be considered. Although CRRT has been increasingly used in the critical care setting, due to the lack of standardized recommendations, wide practice variations exist regarding the main aspects of CRRT application in critically ill children.     Conclusion: In this review, from the Critical Care Nephrology section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC), we summarize the key aspects of CRRT delivery and highlight the importance of adequate follow up among AKI survivors which might be of relevance for the general pediatric community. What is Known: • CRRT is the preferred method of renal support in critically ill and hemodynamically unstable children in the PICU as it allows for gentle removal of fluids and solutes. • Although CRRT has become an important and integral part of modern pediatric critical care, wide practice variations exist in all aspects of CRRT. What is New: • Given the lack of literature on guidance for a general pediatrician on when to refer a child for CRRT, we recommend timely transfer to a center with institutional expertise in CRRT, as both worsening AKI and FO have been associated with increased mortality. • Adequate follow-up of PICU patients with AKI and CRRT is highlighted as recent findings demonstrate that these children are at increased risk for adverse long-term outcomes.

Epidemiology and outcomes of early versus late septic acute kidney injury in critically ill patients: A retrospective cohort study

BACKGROUND

It was recently proposed to distinguish early from late sepsis-associated acute kidney injury (SA-AKI). We aimed to determine the relative frequency of these entities in critically ill patients and to describe their characteristics and outcomes.

METHODS

We included in this retrospective cohort study all adult patients admitted for sepsis in a tertiary ICU between 2010 and 2020. We excluded those on chronic dialysis or without consent. We extracted serum creatinine, hourly urinary output, and clinical and socio-demographic data from medical records until day 7 or ICU discharge. AKI presence and characteristics were assessed daily using KDIGO criteria. We compared patients with early (occurring within 2 days of admission) or late (occurring between day 2 and day 7) SA-AKI. We conducted sensitivity analyses using different definitions for early/late SA-AKI.

RESULTS

Among 1835 patients, 1660 (90%) fulfilled SA-AKI criteria. Of those, 1610 (97%) had early SA-AKI, and 50 (3%) had late SA-AKI. Similar proportions were observed when only considering AKI with elevated sCr (71% vs. 3%), severe AKI (67% vs. 6%), or different time windows for early SA-AKI. Compared with early SA-AKI patients, those with late SA-AKI were younger (median age [IQR] 59 [49-70] vs. 69 [58-76] years, p < 0.001), had lower Charlson comorbidity index (3 [1-5] vs. 5 [3-7], p < 0.001) and lower SAPSII scores (41 [34-50] vs. 53 [43-64], p < 0.001). They had similar (24% vs. 26%, p = 0.75) in-hospital mortality.

CONCLUSIONS

AKI is almost ubiquitous in septic critically ill patients and present within two days of admission. The timing from ICU admission might not be relevant to distinguish different phenotypes of SA-AKI.

ETHICS APPROVAL

Ethics Committee Vaud, Lausanne, Switzerland (n°2017-00008).

A research definition and framework for acute paediatric critical illness across resource-variable settings: a modified Delphi consensus

The true global burden of paediatric critical illness remains unknown. Studies on children with life-threatening conditions are hindered by the absence of a common definition for acute paediatric critical illness (DEFCRIT) that outlines components and attributes of critical illness and does not depend on local capacity to provide critical care. We present an evidence-informed consensus definition and framework for acute paediatric critical illness. DEFCRIT was developed following a scoping review of 29 studies and key concepts identified by an interdisciplinary, international core expert panel (n=24). A modified Delphi process was then done with a panel of multidisciplinary health-care global experts (n=109) until consensus was reached on eight essential attributes and 28 statements as the basis of DEFCRIT. Consensus was reached in two Delphi rounds with an expert retention rate of 89%. The final consensus definition for acute paediatric critical illness is: an infant, child, or adolescent with an illness, injury, or post-operative state that increases the risk for or results in acute physiological instability (abnormal physiological parameters or vital organ dysfunction or failure) or a clinical support requirement (such as frequent or continuous monitoring or time-sensitive interventions) to prevent further deterioration or death. The proposed definition and framework provide the conceptual clarity needed for a unified approach for global research across resource-variable settings. Future work will centre on validating DEFCRIT and determining high priority measures and guidelines for data collection and analysis that will promote its use in research.

Battle of polymyxin induced nephrotoxicity: Polymyxin B versus colistin

OBJECTIVES

Nephrotoxicity is the most serious and common adverse effect that limits the use of polymyxins. This study compared polymyxin E (colistin) and polymyxin B regarding drug-related nephrotoxicity.

METHODS

This study was conducted as a retrospective cohort study in a university hospital between January 2020 and July 2022. Patients older than 18 years and who received colistin or polymyxin B were identified using electronic hospital records. Kidney disease improving global outcome criteria were used for assessing nephrotoxicity.

RESULTS

A total of 190 patients, 95 in both groups, were evaluated. The incidence of acute kidney injury during the treatment was higher in the colistin group [52.6% (n = 50) and 34.7% (n = 33), P = 0.013]. In patients who were exposed to high-dose, the rate of nephrotoxicity was higher in patients receiving colistin [25% (n = 3) vs. 76.9% (n = 10); P = 0.017]. Nephrotoxicity was reversible in 64.4% (n = 38) of patients and the reversibility rate was similar (70% and 52.6% for colistin and polymyxin; P = 0.248). In the multivariable analysis, colistin treatment [odds ratio (OR): 3.882, 95% confidence interval (95% CI) = (1.829-8.241)], concomitant vasopressor use (OR = 2.08, CI: 1.036-4.179), and age (OR=1.036, CI: 1.014-1.058) were found to be independent markers of nephrotoxicity.

CONCLUSION

Nephrotoxicity was more common in patients receiving high-dose colistin than polymyxin B. Therefore, the use of appropriate doses of colistin is important in terms of preventing nephrotoxicity. In addition, advancing age and concomitant use of vasopressors contribute to polymyxin-related nephrotoxicity.

Peritoneal catheters in neonates undergoing complex cardiac surgery: a multi-centre descriptive study

BACKGROUND

The use of peritoneal catheters for prophylactic dialysis or drainage to prevent fluid overload after neonatal cardiac surgery is common in some centres; however, the multi-centre variability and details of peritoneal catheter use are not well described.

METHODS

Twenty-two-centre NEonatal and Pediatric Heart Renal Outcomes Network (NEPHRON) study to describe multi-centre peritoneal catheter use after STAT category 3-5 neonatal cardiac surgery using cardiopulmonary bypass. Patient characteristics and acute kidney injury/fluid outcomes for six post-operative days are described among three cohorts: peritoneal catheter with dialysis, peritoneal catheter with passive drainage, and no peritoneal catheter.

RESULTS

Of 1490 neonates, 471 (32%) had an intraoperative peritoneal catheter placed; 177 (12%) received prophylactic dialysis and 294 (20%) received passive drainage. Sixteen (73%) centres used peritoneal catheter at some frequency, including six centres in >50% of neonates. Four centres utilised prophylactic peritoneal dialysis. Time to post-operative dialysis initiation was 3 hours [1, 5] with the duration of 56 hours [37, 90]; passive drainage cohort drained for 92 hours [64, 163]. Peritoneal catheter were more common among patients receiving pre-operative mechanical ventilation, single ventricle physiology, and higher complexity surgery. There was no association with adverse events. Serum creatinine and daily fluid balance were not clinically different on any post-operative day. Mortality was similar.

CONCLUSIONS

In neonates undergoing complex cardiac surgery, peritoneal catheter use is not rare, with substantial variability among centres. Peritoneal catheters are used more commonly with higher surgical complexity. Adverse event rates, including mortality, are not different with peritoneal catheter use. Fluid overload and creatinine-based acute kidney injury rates are not different in peritoneal catheter cohorts.

Prenatal diagnosis of coarctation: Impact on early and late cardiovascular outcome

BACKGROUND

Prenatal diagnosis (PND) of aortic coarctation (AoCo) has been associated with a significant improvement in early results, but there is limited information on the long-term cardiovascular outcome.

METHODS

We studied 103 patients with simple AoCo, operated in the neonatal period, with a median follow-up of 8,5 years (2 to 23,7 years), with 47% followed for over 10 years. PND was made in 35%. The primary aim was to determine the short and long-term cardiovascular impact of PND of AoCo.

RESULTS

Neonates with PND had less preoperative neonatal complications, with only 2,8% incidence of a composite preoperative severe morbidity course, compared to 28% in the postnatal group. PND patients underwent surgery 8 days earlier and had a shorter length of stay in ICU. PND did not impact the incidence of post-operative complications. On the long-term, prevalence of hypertension, left ventricular hypertrophy and rate of recoarctation were not influenced by PND. The PND group had mean 24 h diastolic BP 9 mmHg lower and mean daytime diastolic BP 11 mmHg lower. In the final multivariable model, PND was the single independent variable correlating with daytime diastolic BP.

CONCLUSION

PND of AoCo effectively leads to a better pre-operative course with less pre-operative morbidity. We found no significant differences in immediate post-operative cardiovascular outcomes. A better initial course of patients with PND does not have a major long-term impact on cardiovascular outcomes, nevertheless, at late follow-up PND patients had lower diastolic BP values on ambulatory monitoring, which may have an impact on long-term cardiovascular risk.

Association between triglyceride-glucose index and acute kidney injury in patients with acute myocardial infarction based on medical information mart for intensive care database: A cross-sectional study

Background

The relationship between triglyceride glucose (TyG) index and the incidence of acute kidney injury (AKI) in patients with acute myocardial infarction (AMI) is unclear. This study aims to explore the relationship between the two.

Methods

Participants were enrolled from Medical Information Mart for Intensive Care IV (MIMICIV) and grouping of subjects based on the quartile interval of the TyG index. With the presence of AKI as the main outcome, a logistic regression model was constructed. The correlation of the TyG index with the results obtained was examined by using a restricted cubic spline (RCS) model.

Serum total protein-to-albumin ratio predicts risk of death in septic acute kidney injury patients: A cohort study

OBJECTIVE

Sepsis is the leading cause of acute kidney injury (AKI). Increasing evidence shows that serum total protein-to-albumin ratio (TAR) could serve as an inflammation- and nutrition-based prognostic marker in various diseases. The purpose of this study was to assess the prognostic value of TAR in predicting the clinical outcomes of septic AKI patients.

METHODS

We retrospectively enrolled septic AKI patients between August 2015 and August 2022 at West China Hospital of Sichuan University. Patients admitted between August 2015 and August 2021 were defined as the original cohort. The primary outcomes were 30-day and 90-day all-cause mortality of septic AKI patients. The secondary outcomes were septic shock, transfer to the intensive care unit, mechanical ventilation, requirement for renal replacement therapy, and stage 3 AKI. The utility of TAR was further verified in a validation cohort of septic AKI patients admitted between September 2021 and August 2022.

RESULTS

In the original cohort, a total of 309 eligible patients with a median age of 58 years were enrolled, of which 70.2 % were males. In multivariate Cox analysis, after adjustments for age, sex, and other confounding factors, higher TAR at admission was associated with an increased risk of 30-day and 90-day all-cause mortality in septic AKI patients (HR 1.91, 95 % CI 1.18-3.09, P = 0.008; HR 1.54, 95 % CI 1.01-2.34, P = 0.043, respectively). Subgroup analysis revealed no significant interactions in most strata. TAR at AKI diagnosis or discharge was not significantly related to 30-day (P = 0.120 and 0.153, respectively) or 90-day mortality (P = 0.147 and 0.124, respectively). We found no relationship between baseline TAR and septic shock, transfer to the intensive care unit, mechanical ventilation, requirement for renal replacement therapy, or stage 3 AKI (all P > 0.05). In the validation cohort of 81 septic AKI patients, TAR at admission remained a significant prognosticator for 30-day and 90-day mortality (HR 4.367, 95 % CI 1.20-15.87, P = 0.025; HR 4.237, 95 % CI 1.59-11.27, P = 0.004).

CONCLUSIONS

TAR at admission is an independent risk factor for 30-day and 90-day mortality in septic AKI patients and could be used as a convenient and economic septic AKI prognostic indicator.

Effect of norepinephrine, vasopressin, and dopamine for survivals of the elderly with sepsis and pre-existing heart failure

Our study focused on evaluating the effect of three common vasoactive drugs on the prognosis of elderly patients with sepsis and pre-existing heart failure. The Medical Information Mart for Intensive Care III database, Version 1.4, was used. Our study included critically ill older patients (aged ≥ 65 years) with sepsis and heart failure treated with vasoactive drugs. Patients were divided into norepinephrine group, norepinephrine combined with vasopressin group, and dopamine group. The baseline characteristics, primary outcome, and secondary outcome measures were compared among the three groups. In total, 1357 elderly patients were included (766 in norepinephrine group, 250 in norepinephrine combined with vasopressin group, and 341 in dopamine group). After propensity score matching, statistically significant differences in 28-d and 90-d mortality (P = 0.046, P = 0.031) were observed; meanwhile, there was a significant difference in the incidence of mechanical ventilation, AKI, and malignant arrhythmias. Cox regression analysis revealed that norepinephrine combined with vasopressin decreased 5-year survival statistically(P = 0.001). Multiple linear regression analysis indicated dopamine as an independent risk factor in reducing ICU and hospital length of stay (P = 0.001, P = 0.017). Logistic regression analysis showed dopamine was an independent risk factor for new-onset arrhythmias (P < 0.001), while norepinephrine combined with vasopressin was an independent risk factor for new-onset malignant arrhythmias (P < 0.001). Norepinephrine in combination with vasopressin decreased survival and increased the incidence of malignant arrhythmias in elderly sepsis patients with pre-existing heart failure. Dopamine alone reduces ICU and hospital length of stay but increases the new-onset arrhythmias.

Impact of intraoperative fluid management on postoperative complications in patients undergoing minimally invasive esophagectomy for esophageal cancer: a retrospective single-center study

BACKGROUND

Esophagectomy is a high-risk procedure that can involve serious postoperative complications. There has been an increase in the number of minimally invasive esophagectomies (MIEs) being performed. However, the relationship between intraoperative management and postoperative complications in MIE remains unclear.

METHODS

After the institutional review board approval, we enrolled 300 patients who underwent MIE at Tohoku University Hospital between April 2016 and March 2021. The relationships among patient characteristics, intraoperative and perioperative factors, and postoperative complications were retrospectively analyzed. The primary outcome was the relationship between intraoperative fluid volume and anastomotic leakage, and the secondary outcomes included the associations between other perioperative factors and postoperative complications.

RESULTS

Among 300 patients, 28 were excluded because of missing data; accordingly, 272 patients were included in the final analysis. The median [interquartile range] operative duration was 599 [545-682] minutes; total intraoperative infusion volume was 3,747 [3,038-4,399] mL; total infusion volume per body weight per hour was 5.48 [4.42-6.73] mL/kg/h; and fluid balance was + 2,648 [2,015-3,263] mL. The postoperative complications included anastomotic leakage in 68 (25%) patients, recurrent nerve palsy in 91 (33%) patients, pneumonia in 62 (23%) patients, cardiac arrhythmia in 13 (5%) patients, acute kidney injury in 5 (2%) patients, and heart failure in 5 (2%) patients. The Cochrane-Armitage trend test indicated significantly increased anastomotic leakage among patients with a relatively high total infusion volume (P = 0.0085). Moreover, anastomotic leakage was associated with male sex but not with peak serum lactate levels. Patients with a longer anesthesia duration or recurrent nerve palsy had a significantly higher incidence of postoperative pneumonia than those without. Further, the incidence of postoperative pneumonia was not associated with the operative duration, total infusion volume, or fluid balance. The operative duration and blood loss were related to the total infusion volume. Acute kidney injury was not associated with the total infusion volume or serum lactate levels.

CONCLUSIONS

Among patients who underwent MIE, the total infusion volume was positively correlated with the incidence of anastomotic leakage. Further, postoperative pneumonia was associated with recurrent nerve palsy but not total infusion volume or fluid balance.

The influence of gender on the epidemiology of and outcome from sepsis associated acute kidney injury in ICU: a retrospective propensity-matched cohort study

PURPOSES

The influence of gender on the epidemiology of and outcome from SA-AKI in ICU has not been fully clarified. Our aim is to elucidate these differences.

METHODS

This study included adult patients with sepsis in MIMIC IV (V 2.2), and propensity matching analysis, cox regression and logistic regression were used to analyze gender differences in incidence, mortality and organ support rate.

RESULTS

Of the 24,467 patients included in the cohort, 18,128 were retained after propensity score matching. In the matched cohort, the incidence of SA-AKI in males is higher than that in females (58.6% vs. 56.2%; P = 0.001).males were associated with a higher risk of SA-AKI (OR:1.07(1.01-1.14), P = 0.026;adjusted OR:1.07(1.01-1.14), P < 0.033).In SA-AKI patients, males were associated with a lower risk of ICU mortality(HR:0.803(0.721-0.893), P < 0.001;adjusted HR:0.836(0.746-0.937), P = 0.002) and in-hospital mortality(HR: 0.820(0.748-0.899), P < 0.001;adjusted HR:0.853(0.775-0.938), P = 0.003).there were no statistically significant differences between male and female patients in 1-year all-cause mortality (36.9% vs. 35.8%, P = 0.12), kidney replacement therapy rate (7.8% vs.7.4%, P = 0.547), mechanical ventilation rate 64.8% vs.63.9%, P = 0.369), and usage of vasoactive drugs (55.4% vs. 54.6%, P = 0.418).

CONCLUSIONS

Gender may affect the incidence and outcomes of SA-AKI, further research is needed to fully understand the impact of gender on SA-AKI patients.

Patient characteristics associated with acute kidney injury following coronary angiography

Objective

The objective of this study was to identify patient characteristics associated with acute kidney injury (AKI) post-coronary angiography with or without percutaneous coronary intervention.

Methods

This retrospective, single-center study analyzed 350 patients from October 1, 2017 to September 30, 2018. The primary endpoint was AKI, defined as a rise in creatinine >0.3 mg/dL within 48 hours of coronary angiography.

Results

AKI occurred in 41 of 350 patients (8.8%). Patients experiencing AKI had a higher incidence of hypertension (100%; P = 0.005), hyperlipidemia (98%; P = 0.001), diabetes mellitus (68%; P = 0.0005), and heart failure (37%; P = 0.0057). AKI occurred in 30 of 185 (16%) and 11 of 165 (6.7%) patients undergoing femoral and radial access, respectively. AKI incidence was not significantly affected by contrast dose (99 ± 9 vs 93 ± 3 mL; P = 0.52), fluoroscopy time (10.3 min [IQR 6.3, 17.7] vs 8.5 min [IQR 4.5, 13.9]; P = 0.2), or preprocedural computed tomography with contrast (P = 0.66). Multivariable regression showed significantly higher AKI among patients with peripheral artery disease (odds ratio [OR] = 12.4; 95% confidence interval [CI] 3.4-33.6; P = 0.0001), multivessel coronary artery disease (OR = 11.9; 95% CI 2.3-61.1; P = 0.003), and initial creatinine >1.5 mg/dL (OR = 4.4; 95% CI 1.4-13.6; P = 0.01).

Conclusion

Peripheral artery disease, multivessel disease, and creatinine >1.5 mg/dL were associated with a higher risk of AKI in patients undergoing coronary angiography in this single-center retrospective cohort.

Protein Kinase N1 Level Predicts Acute Kidney Injury in Patients Undergoing Cardiac Surgery: A Prospective Cohort Study

INTRODUCTION

The objective of this study was to examine the utility of protein kinase N1 (PKN1) as a biomarker of cardiac surgery-associated AKI (CSA-AKI).

METHODS

A prospective cohort study of 110 adults undergoing on-pump cardiac surgery was conducted. The associations between post-operative PKN1 and CSA-AKI, AKI severity, need for renal replacement therapy (RRT), duration of AKI, length of ICU stay, and post-operative hospital stay were evaluated.

RESULTS

Patients were categorized into three groups according to PKN1 tertiles. The incidence of CSA-AKI in the third tertile was 3.4-fold higher than that in the first. PKN1 was an independent risk factor for CSA-AKI. The discrimination of PKN1 to CSA-AKI assessed by ROC curve indicated that the AUC was 0.70, and the best cutoff was 5.025 ng/mL. This group (>5.025 ng/mL) was more likely to develop CSA-AKI (p < 0.001). The combined AUC of EuroSCORE, aortic cross-clamp time, and PKN1 was 0.82 (p < 0.001). A higher level of PKN1 was related to increased need for RRT, longer duration of AKI, and length of ICU and post-operative hospital stays.

CONCLUSIONS

PKN1 could be a potential biomarker for the prediction of CSA-AKI. The combination of PKN1, EuroSCORE, and aortic cross-clamp time was likely to predict the occurrence of CSA-AKI.

ELMO CPAP: an innovative type of ventilatory support for COVID-19-related acute respiratory distress syndrome

OBJECTIVE

To assess whether the use of ELMO, a helmet for noninvasive ventilation created in Brazil, had a positive impact on the prognosis of patients with hypoxemic respiratory failure caused by severe COVID-19.

METHODS

This is a retrospective study of 50 critically ill COVID-19 patients. Epidemiological, clinical, and laboratory data were collected on ICU admission, as well as before, during, and after ELMO use. Patients were divided into two groups (success and failure) according to the outcome.

RESULTS

ELMO use improved oxygenation parameters such as Pao2, Fio2, and the Pao2/Fio2 ratio, and this contributed to a gradual reduction in Fio2, without an increase in CO2, as determined by arterial blood gas analysis. Patients in the success group had significantly longer survival (p < 0.001), as determined by the Kaplan-Meier analysis, less need for intubation (p < 0.001), fewer days of hospitalization, and a lower incidence of acute kidney injury in comparison with those in the failure group.

CONCLUSIONS

The significant improvement in oxygenation parameters, the longer survival, as reflected by the reduced need for intubation and by the mortality rate, and the absence of acute kidney injury suggest that the ELMO CPAP system is a promising tool for treating ARDS and similar clinical conditions.

COVID-19 in Children with Chronic Kidney Disease; Does it Differ Much?

BACKGROUND

COVID-19 is known to have a mild course in children, however more data on pediatric chronic kidney disease (CKD) is needed. We aimed to assess the incidence and severity of COVID-19 in pediatric CKD patients.

METHODS

A questionnaire including demographics, COVID-19 history, symptoms, and vaccination status was applied to patients with CKD. We also retrospectively reviewed the presentation and outcomes of SARS-CoV-2 infection in this patient group from March 2020 to December 2021.

RESULTS

220 patients were included, 48 were found to have experienced COVID-19. There was no significant difference regarding age, gender, underlying kidney disease, CKD stage, dialysis status, type or number of immunosuppressive medications, and glomerular filtration rate between patients with and without COVID-19. Most were infected by a household member (43.8%) and during outpatient or inpatient care (18.8%). Four (8.3%) were asymptomatic, and 43 (89.6%) had mild infection. Severe COVID-19 was observed in only one patient. Eleven (22.9%) patients with COVID-19 were previously vaccinated. Acute kidney injury was detected in 4 (8.3%); as stage 1 in all. Median follow-up after COVID-19 was 4.6 months. All patients fully recovered, and no renal disease flare or death was observed.

CONCLUSIONS

Although the vaccination rate was low in our cohort, the majority of the children with COVID-19 showed a mild course. Along with the vaccination, general precautions seemed to be successful for this population.

Dynamic increase in myoglobin level is associated with poor prognosis in critically ill patients: a retrospective cohort study

Background

Myoglobin is an important biomarker for monitoring critically ill patients. However, the relationship between its dynamic changes and prognosis remains unclear.

Methods

We retrospectively enrolled 11,218 critically ill patients from a general and surgical intensive care unit (ICU) of a tertiary hospital between June 2016 and May 2020. Patients with acute cardiovascular events, cardiac and major vascular surgeries, and rhabdomyolysis were excluded. To investigate the early myoglobin distribution, the critically ill patients were stratified according to the highest myoglobin level within 48 h after ICU admission. Based on this, the critically ill patients with more than three measurements within 1 week after ICU admission were included, and latent class trajectory modeling was used to classify the patients. The characteristics and outcomes were compared among groups. Sensitivity analysis was performed to exclude patients who had died within 72 h after ICU admission. Restricted mean survival time regression model based on pseudo values was used to determine the 28-day relative changes in survival time among latent classes. The primary outcome was evaluated with comparison of in-hospital mortality among each Trajectory group, and the secondary outcome was 28-day mortality.

Results

Of 6,872 critically ill patients, 3,886 (56.5%) had an elevated myoglobin level (≥150 ng/mL) at admission to ICU, and the in-hospital mortality significantly increased when myoglobin level exceeded 1,000 μg/mL. In LCTM, 2,448 patients were unsupervisedly divided into four groups, including the steady group (n = 1,606, 65.6%), the gradually decreasing group (n = 523, 21.4%), the slowly rising group (n = 272, 11.1%), and the rapidly rising group (n = 47, 1.9%). The rapidly rising group had the largest proportion of sepsis (59.6%), the highest median Sequential Organ Failure Assessment (SOFA) score (10), and the highest in-hospital mortality (74.5%). Sensitivity analysis confirmed that 98.2% of the patients were classified into the same group as in the original model. Compared with the steady group, the rapidly rising group and the slowly rising group were significantly related to the reduction in 28-day survival time (β = -12.08; 95% CI -15.30 to -8.86; β = -4.25, 95% CI -5.54 to -2.97, respectively).

Conclusion

Elevated myoglobin level is common in critically ill patients admitted to the ICU. Dynamic monitoring of myoglobin levels offers benefit for the prognosis assessment of critically ill patients.

Development and validation of a novel combinatorial nomogram model to predict in-hospital deaths in heart failure patients

BACKGROUND

The purpose of this study was to develop a Nomogram model to identify the risk of all-cause mortality during hospitalization in patients with heart failure (HF).

METHODS

HF patients who had been registered in the Medical Information Mart for Intensive Care (MIMIC) III and IV databases were included. The primary outcome was the occurrence of all-cause mortality during hospitalization. Two Logistic Regression models (LR1 and LR2) were developed to predict in-hospital death for HF patients from the MIMIC-IV database. The MIMIC-III database were used for model validation. The area under the receiver operating characteristic curve (AUC) was used to compare the discrimination of each model. Calibration curve was used to assess the fit of each developed models. Decision curve analysis (DCA) was used to estimate the net benefit of the predictive model.

RESULTS

A total of 16,908 HF patients were finally enrolled through screening, of whom 2,283 (13.5%) presented with in-hospital death. Totally, 48 variables were included and analyzed in the univariate and multifactorial regression analysis. The AUCs for the LR1 and LR2 models in the test cohort were 0.751 (95% CI: 0.735∼0.767) and 0.766 (95% CI: 0.751-0.781), respectively. Both LR models performed well in the calibration curve and DCA process. Nomogram and online risk assessment system were used as visualization of predictive models.

CONCLUSION

A new risk prediction tool and an online risk assessment system were developed to predict mortality in HF patients, which performed well and might be used to guide clinical practice.

Retention of Agricultural Workers Participating in a Renal Longitudinal Study

OBJECTIVES

The relationship between heat stress, chronic kidney diseases and acute kidney injury has been documented in cross-sectional studies with agricultural workers. However, only a few international studies have assessed renal function in agricultural workers longitudinally. Our research study, Occupational Heat Exposure and Renal Dysfunction (OHEaRD) is the first longitudinal study in the U.S. that monitored renal function in agricultural workers five times over the course of 32-months. The main objectives of this study were to evaluate the rate of retention and identify predictors associated with retention in a longitudinal study with agricultural workers.

METHODS

In January 2020, we enrolled 119 Florida agricultural workers to observe on 5 workdays over 32 months. Retention was defined by the number of follow-up visits that a participant attended, the consistency of visit attendance, and attendance at the last visit. Participants were provided hemoglobin A1C, lipid panel, creatinine measurement, glomerular filtration rate (eGFR), blood pressure, and body mass index results and an incentive gift card were handed out to participants at each visit.

RESULTS

Four enrollees did not participate on any workday, thus analysis concentrated on the remaining 115 participants. The majority of participants (64%) completed the 32-month study, 78% completed at least 4 visits, and 55% completed all 5 visits. The statistically significant predictors of higher retention among this study were being older in age (p=0.02), Mexican nationality (p=0.004), working in ferneries (p=0.009), more years working in agriculture (p=0.02), and higher total cholesterol (p=0.02). Appreciation for the health tests was associated with greater participation at the final visit (p=0.01).

CONCLUSION

Retention in longitudinal studies is crucial to better understand kidney disease among agricultural workers, an understudied population. Participants reported valuing the access to health results, indicating that implementing point-of-care health screenings and providing the health results to each participant is a good retention strategy. There was some evidence that a participant living with or being related to a fellow co-participant could impact retention as they either showed up or missed visits together, suggesting recruiting from the same household may reduce retention.

Renal Functional Reserve in Acute Kidney Injury Patients Requiring Dialysis

The incidence of acute kidney injury (AKI) has increased in the recent past. Patients with AKI have an increased risk of mortality. They are also at increased risk of developing chronic kidney disease (CKD). AKI can lead to irreversible loss of renal function despite complete clinical recovery. Currently, no tools are available to diagnose this subclinical loss of renal function. Renal functional reserve (RFR) can serve as an essential tool for analyzing this subclinical loss of renal function, and patients with loss of RFR post-AKI may be closely followed for the development of CKD. This prospective observational study, conducted at the Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), aimed to investigate RFR in 223 patients with AKI requiring dialysis. The study excluded patients with CKD and obstructive uropathy. Methods included RFR assessment three months post-AKI recovery, utilizing technetium-99m (Tc-99m) diethylenetriaminepentaacetic acid (DTPA) plasma clearance during amino acid infusion. Statistical analyses and logistic regression were applied, receiving ethical approval. Results revealed a high in-hospital mortality rate of 78.02%, associated with elevated Sequential Organ Failure Assessment (SOFA) scores. Among 24 patients with complete AKI recovery, the RFR at three months was 10.06% (interquartile range (IQR) 5.60-20.15), with the measured GFR significantly lower than the estimated glomerular filtration rate (GFR). The study concludes that AKI requiring dialysis is linked to high mortality and emphasizes the predictive value of SOFA scores. Additionally, RFR testing at three months post-recovery provides insights into potential long-term impacts on renal function. This study contributes valuable insights into the prognosis of AKI patients requiring dialysis. It underscores the need for further research on RFR as a diagnostic tool and the lasting consequences of AKI.