Evaluation of acute kidney injury (AKI) with RIFLE, AKIN, CK, and KDIGO in critically ill trauma patients

Intraoperative hypotension associated with postoperative acute kidney injury in hypertension patients undergoing non-cardiac surgery: a retrospective cohort study

Background

Acute kidney injury (AKI) is a common surgical complication and is associated with intraoperative hypotension. However, the total duration and magnitude of intraoperative hypotension associated with AKI remains unknown. In this study, the causal relationship between the intraoperative arterial pressure and postoperative AKI was investigated among chronic hypertension patients undergoing non-cardiac surgery.

Methods

A retrospective cohort study of 6552 hypertension patients undergoing non-cardiac surgery (2011 to 2019) was conducted. The primary outcome was AKI as diagnosed with the Kidney Disease-Improving Global Outcomes criteria and the primary exposure was intraoperative hypotension. Patients' baseline demographics, pre- and post-operative data were harvested and then analyzed with multivariable logistic regression to assess the exposure-outcome relationship.

Results

Among 6552 hypertension patients, 579 (8.84%) had postoperative AKI after non-cardiac surgery. The proportions of patients admitted to ICU (3.97 vs. 1.24%, p < 0.001) and experiencing all-cause death (2.76 vs. 0.80%, p < 0.001) were higher in the patients with postoperative AKI. Moreover, the patients with postoperative AKI had longer hospital stays (13.50 vs. 12.00 days, p < 0.001). Intraoperative mean arterial pressure (MAP) < 60 mmHg for >20 min was an independent risk factor of postoperative AKI. Furthermore, MAP <60 mmHg for >10 min was also an independent risk factor of postoperative AKI in patients whose MAP was measured invasively in the subgroup analysis.

Conclusions

Our work suggested that MAP < 60 mmHg for >10 min measured invasively or 20 min measured non-invasively during non-cardiac surgery may be the threshold of postoperative AKI development in hypertension patients. This work may serve as a perioperative management guide for chronic hypertension patients.

Trial registration

clinical trial number: ChiCTR2100050209 (8/22/2021). http://www.chictr.org.cn/showproj.aspx?proj=132277.

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).

MicroRNAs as Biomarkers and Therapeutic Targets for Acute Kidney Injury

Acute kidney injury (AKI) is a clinical syndrome where a rapid decrease in kidney function and/or urine output is observed, which may result in the imbalance of water, electrolytes and acid base. It is associated with poor prognosis and prolonged hospitalization. Therefore, an early diagnosis and treatment to avoid the severe AKI stage are important. While several biomarkers, such as urinary L-FABP and NGAL, can be clinically useful, there is still no gold standard for the early detection of AKI and there are limited therapeutic options against AKI. miRNAs are non-coding and single-stranded RNAs that silence their target genes in the post-transcriptional process and are involved in a wide range of biological processes. Recent accumulated evidence has revealed that miRNAs may be potential biomarkers and therapeutic targets for AKI. In this review article, we summarize the current knowledge about miRNAs as promising biomarkers and potential therapeutic targets for AKI, as well as the challenges in their clinical use.

Health Care Resource Utilization and Costs of Persistent Severe Acute Kidney Injury (PS-AKI) Among Hospitalized Stage 2/3 AKI Patients

Key Points

Among hospitalized patients with stage 2/3 AKI, persistent severe acute kidney injury (PS-AKI) is associated with significantly longer length of stay (LOS) and higher costs during index hospitalization and 30 days postdischarge. Relative differences in LOS and costs for PS-AKI versus NPS-AKI were similar for intensive care (ICU) and non-ICU patients. Preventing PS-AKI among patients with stage 2/3 AKI may reduce hospital LOS and costs.

Background

Persistent severe acute kidney injury (PS-AKI) is associated with worse clinical outcomes, but there are no data on costs of PS-AKI. We compared costs and health care resource utilization for inpatients with PS-AKI versus not persistent severe AKI (NPS-AKI) overall and by ICU use.

Methods

This retrospective observational study included 126,528 adult US inpatients in the PINC AI Healthcare Database (PHD), discharged from January 1, 2017, to December 31, 2019, with KDIGO stage 2 or 3 AKI (by serum creatinine [SCr] criteria) during hospitalization, length of stay (LOS) ≥3 days, and ≥3 SCr measurements. Patients were categorized as PS-AKI (defined as stage 3 AKI lasting ≥3 days or with death within 3 days or stage 2/3 AKI (by SCr criteria) with dialysis within 3 days) or NPS-AKI. Generalized linear model regression compared LOS and costs during index hospitalization (total cohort) and 30 days postdischarge (survivors of index hospitalization), adjusted for patient, hospital, and clinical characteristics.

Results

Among 126,528 patients with stage 2/3 AKI, 30,916 developed PS-AKI. In adjusted models, compared with NPS-AKI, patients with PS-AKI had 32% longer total LOS (+3.3 days), 45% longer ICU LOS (+2.6 days), 46% higher total costs (+$13,143), 58% higher ICU costs (+$15,908), and during 30 days postdischarge 13% longer readmission LOS (+1.0 day), 22% higher readmission costs (+$4049), and 12% higher outpatient costs (+$206) (P <0.005 for all). Relative LOS and cost differences for PS-AKI versus NPS-AKI were similar for ICU (n=57,947) and non-ICU (n =68,581) patients.

Conclusions:

Among hospitalized patients with stage 2/3 AKI, PS-AKI was associated with significantly longer LOS and higher costs during index hospitalization and 30 days postdischarge, overall, and in ICU and non-ICU patients. Preventing PS-AKI among patients with stage 2/3 AKI may reduce hospital LOS and costs.

Outcomes, Healthcare Resource Utilization, and Costs of Overall, Community-Acquired, and Hospital-Acquired Acute Kidney Injury in COVID-19 Patients

Background: In hospitalized patients with COVID-19, acute kidney injury (AKI) is associated with higher mortality, but data are lacking on healthcare resource utilization (HRU) and costs related to AKI, community-acquired AKI (CA-AKI), and hospital-acquired AKI (HA-AKI). Objectives: To quantify the burden of AKI, CA-AKI, and HA-AKI among inpatients with COVID-19. Methods: This retrospective cohort study included inpatients with COVID-19 discharged from US hospitals in the Premier PINC AI™ Healthcare Database April 1-October 31, 2020, categorized as AKI, CA-AKI, HA-AKI, or no AKI by ICD-10-CM diagnosis codes. Outcomes were assessed during index (initial) hospitalization and 30 days postdischarge. Results: Among 208 583 COVID-19 inpatients, 30%, 25%, and 5% had AKI, CA-AKI, and HA-AKI, of whom 10%, 7%, and 23% received dialysis, respectively. Excess mortality, HRU, and costs were greater for HA-AKI than CA-AKI. In adjusted models, for patients with AKI vs no AKI and HA-AKI vs CA-AKI, odds ratios (ORs) (95% CI) were 3.70 (3.61-3.79) and 4.11 (3.92-4.31) for intensive care unit use and 3.52 (3.41-3.63) and 2.64 (2.52-2.78) for in-hospital mortality; mean length of stay (LOS) differences and LOS ratios (95% CI) were 1.8 days and 1.24 (1.23-1.25) and 5.1 days and 1.57 (1.54-1.59); and mean cost differences and cost ratios were $7163 and 1.35 (1.34-1.36) and $19 127 and 1.78 (1.75-1.81) (all P < .001). During the 30 days postdischarge, readmission LOS was ≥6% longer for AKI vs no AKI and HA-AKI vs CA-AKI; outpatient costs were ≥41% higher for HA-AKI vs CA-AKI or no AKI. Only 30-day new dialysis (among patients without index hospitalization dialysis) had similar odds for HA-AKI vs CA-AKI (2.37-2.8 times higher for AKI, HA-AKI, or CA-AKI vs no AKI). Discussion: Among inpatients with COVID-19, HA-AKI had higher excess mortality, HRU, and costs than CA-AKI. Other studies suggest that interventions to prevent HA-AKI could decrease excess morbidity, HRU, and costs among inpatients with COVID-19. Conclusions: In adjusted models among COVID-19 inpatients, AKI, especially HA-AKI, was associated with significantly higher mortality, HRU, and costs during index admission, and higher dialysis and longer readmission LOS during the 30 days postdischarge. These findings support implementation of interventions to prevent HA-AKI in COVID-19 patients.

Risk Score for Prediction of Acute Kidney Injury in Patients with Acute ST-Segment Elevation Myocardial Infarction

Background

Acute kidney injury (AKI) is an important comorbidity of ST-Segment Elevation Myocardial Infarction (STEMI) and worsens the prognosis. The purpose of this study was to investigate the relationship between clinical data, test results, surgical findings, and AKI in STEMI patients and to develop a simple, practical model for predicting the risk of AKI.

Method

Prognostic prediction research with clinical risk score development was conducted. The data used for model development was derived from the database of the Henan Province Cardiovascular Disease Clinical Data and Sample Resource Bank Engineering Research Center. The data used for external validation was derived from the China Chest Pain Center database. The study endpoint was defined as the occurrence of AKI. Logistic regression analysis was used to identify independent predictors of AKI. Logistic coefficients of each predictor were used for score weighting and transformation. The predictive performance of the newly derived risk scores was validated, respectively, by receiver operating characteristic (ROC) regression in the development population and the external validation population.

Result

A total of 364 patients, 57 (15.6%) with AKI and 307 (84.4%) without AKI, were included for score derivation. The validation crowd includes 88 STEMI patients in different institutions. A total of 11 potential predictors were explored under the multivariable logistic regression model. The new risk score was based on five final predictors which were age > 72 years, ejection fraction of no more than 40%, baseline serum creatinine > 102.7 mmol/L, red blood cell distribution width > 13.15, and culprit lesion located in the middistal segment. With only five predictor variables, the score predicted the risk of AKI with the effective discriminative ability (area under the receiver operating characteristic curve (AuROC): 0.721, 95% confidence interval (CI): 0.652-0.790). In the external validation, the newly developed score confirmed a similar discrimination as the crowd used for derivation (AuROC: 0.731, 95% CI: 0.624-0.838).

Conclusion

The newly developed score was proved to have good predictive performance and could be practically applied for risk stratification of AKI in STEMI patients.

Acute Kidney Injury Among Patients with Multi-Drug Resistant Infection: A Study from Jordan

Background

Acute kidney injury (AKI) is a well-known complication for hospitalized patients. Sepsis and various infections play a significant role in increasing the incidence of AKI. The present study evaluated the risk for Multidrug-resistant (MDR) infections and its effect on the incidence of AKI, hospitalization, need for dialysis, and mortality.

Methods

In a retrospective study design, data were collected from all adult patients with a positive multi-drug resistant culture who were admitted to King Abdullah University Hospital (KAUH). Records of 436 patients were reviewed between January 2017 - December 2018 with at least one year of follow-up.

Results

The mean age was 57.3 years (SD± 23.1), and 58.5% were males. The most common source of positive cultures was sputum, with 50% positive cultures. The incidence of AKI was 59.2%. The most isolated microorganism was Acinetobacter baumannii (76.8%), followed by Pseudomonas aeruginosa (14.9%).On multivariate analysis, age (OR 1.1, 95% CI 1.1-1.2, P=0.001), HTN (OR 1.8, 95% CI 1.0-3.3, P=0.02), DM (OR 1.1, 95% CI 0.6-1.9, P=0.69) and the use of Foley catheter on chronic bases (OR 4.3, 95% CI 2.6-6.8, P<0.0001) were strong predictors of AKI. Among patients with AKI, 74.4% died compared to 44.4% among non-AKI patients (p<0.001).

Conclusion

In patients with MDR, AKI incidence, hospitalization, and mortality were high. Early detection and addressing the problem may decrease bad outcomes, and health education for reducing antibiotic abuse is needed to lower MDR.

Prehospital Tourniquet Usage and Diabetes Mellitus Associated with Increased Incidence, Odds, and Risk of Acute Kidney Injury: A Pilot Study

INTRODUCTION

Tourniquets are the standard of care for civilian and military prehospital treatment of massive extremity hemorrhages. Over the past 17 years, multiple military studies have demonstrated rare complications related to tourniquet usage. These studies may not translate well to civilian populations due to differences in baseline health. Experimental studies have demonstrated increased rates of post-traumatic acute kidney injuries (AKIs) in rats with obesity and increased oxidative stress, suggesting that comorbidities may affect AKI incidence with tourniquet usage. Two recently published retrospective studies, focused on the safety of tourniquets deployed within civilian sectors, documented increased incidence of AKI in patients with a prehospital tourniquet as compared to previously published military results. This study aimed to provide descriptive data concerning the association between the use of prehospital tourniquets and AKIs amongst civilian patient populations as AKIs increase mortality in hospitalized patients.

METHODS

This was a single-center, observational, cross-sectional, pilot study involving chart review of participants presenting to a tertiary Level 1 trauma center. Patient data were extracted from prehospital and hospital electronic medical records. For this study, AKI was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines.

RESULTS

A total of 255 participants were included. Participants with a history of diabetes mellitus had a significantly higher incidence of AKI as compared to those without. Analysis revealed an increased odds of AKI with diabetes in association to the use of a prehospital tourniquet. Participants with diabetes had an increased relative risk of AKI in association to the use of a prehospital tourniquet. The incidence of AKI was statistically higher than what was previous reported in the military population in association with the use of a prehospital tourniquet.

CONCLUSION

The incidence of AKIs was higher than previously reported. Patients with diabetes had an associated higher risk and incidence of sustaining an AKI after the use of a prehospital tourniquet in association with the use of a prehospital tourniquet. This may be due to the known deleterious effects of diabetes mellitus on renal function. This study provides clinically relevant data that warrant further multi-site investigations to further investigate this study's associated findings and potential causation. It also stresses the need to assess whether renally-impacting environmental and nutritional stressors affect AKI rates amongst military personnel and others in which prehospital tourniquets are used.

Acute kidney injury in traumatic brain injury intensive care unit patients

BACKGROUND

The exact definition of Acute kidney injury (AKI) for patients with traumatic brain injury (TBI) is unknown.

AIM

To compare the power of the “Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease” (RIFLE), Acute Kidney Injury Network (AKIN), Creatinine kinetics (CK), and Kidney Disease Improving Global Outcomes (KDIGO) to determine AKI incidence/stage and their association with the in-hospital mortality rate of patients with TBI.

METHODS

This retrospective study collected the data of patients admitted to the intensive care unit for neurotrauma from 2001 to 2012, and 1648 patients were included. The subjects in this study were assessed for the presence and stage of AKI using RIFLE, AKIN, CK, and KDIGO. In addition, the propensity score matching method was used.

RESULTS

Among the 1648 patients, 291 (17.7%) had AKI, according to KDIGO. The highest incidence of AKI was found by KDIGO (17.7%), followed by AKIN (17.1%), RIFLE (12.7%), and CK (11.5%) (P = 0.97). Concordance between KDIGO and RIFLE/AKIN/CK was 99.3%/99.1%/99.3% for stage 0, 36.0%/91.5%/44.5% for stage 1, 35.9%/90.6%/11.3% for stage 2, and 47.4%/89.5%/36.8% for stage 3. The in-hospital mortality rates increased with the AKI stage in all four definitions. The severity of AKI by all definitions and stages was not associated with in-hospital mortality in the multivariable analyses (all P > 0.05).

CONCLUSION

Differences are seen in AKI diagnosis and in-hospital mortality among the four AKI definitions or stages. This study revealed that KDIGO is the best method to define AKI in patients with TBI.

Soluble Programmed Cell Death Protein 1 and Its Ligand: Potential Biomarkers to Predict Acute Kidney Injury After Surgery in Critically Ill Patients

Purpose

Programmed cell death protein 1 (PD-1) and programmed death-ligand 1 (PD-L1) have been detected in injury kidney. However, their expressions are unclear in mice kidneys under renal ischemia-reperfusion injury (IRI). In this study, we would observe the expressions of PD-1 and PD-L1 in kidney tissues and analyze the association between the concentrations of PD-1 and PD-L1 in mouse kidney homogenate and the corresponding concentrations of soluble PD-1 (sPD-1) and soluble PD-L1 (sPD-L1) in plasma after renal IRI. Further, we explored the predictive value of sPD-1 and sPD-L1 for acute kidney injury (AKI) in high-risk patients after surgery.

Methods

This study established an AKI model induced by IRI in mice. Plasma, kidney samples, and homogenate were collected 0h, 24h, and 48h after surgery for immunohistochemistry and enzyme-linked immunosorbent assay. Then, we continuously enrolled 88 AKI high-risk patients who underwent noncardiac surgery. The biomarkers, including sPD-1, sPD-L1, and urine neutrophil gelatinase-associated lipocalin (NGAL), tissue inhibitor of metalloproteinase-2 (TIMP-2), insulin-like growth factor-binding protein 7 (IGFBP7), were detected immediately after surgery.

Results

Our data revealed the concentrations of PD-1 and PD-L1 in kidney homogenate, and sPD-1 and sPD-L1 in plasma significantly increased at 0h, 24h, and 48h after IRI. A positive association was found between PD-1 and sPD-1 (r = 0.774, p < 0.001), and between PD-L1 and sPD-L1 (r = 0.881, p < 0.001). Compared to NGAL, [TIMP-2]*[IGFBP7], sPD-1 and sPD-L1 showed better predictive abilities for AKI with an area under the ROC curve of 0.856 (95% confidence interval [CI]: 0.825-0.958, p < 0.001) and 0.906 (95% CI: 0.764-0.921, p < 0.001).

Conclusion

The increased expressions of PD-1 and PD-L1 in kidneys under IRI suggested they may play essential roles in AKI development. sPD-1 and sPD-L1 can indirectly reflect the expressions of PD-1 and PD-L1 in kidneys, respectively. sPD-1 and sPD-L1 showed excellent predictive ability for AKI in high-risk patients.

Ambiguous definitions for baseline serum creatinine affect acute kidney diagnosis at the emergency department

Background

Acute kidney injury (AKI) incidence is increasing, however AKI is often missed at the emergency department (ED). AKI diagnosis depends on changes in kidney function by comparing a serum creatinine (SCr) measurement to a baseline value. However, it remains unclear to what extent different baseline values may affect AKI diagnosis at ED.

Methods

Routine care data from ED visits between 2012 and 2019 were extracted from the Utrecht Patient Oriented Database. We evaluated baseline definitions with criteria from the RIFLE, AKIN and KDIGO guidelines. We evaluated four baseline SCr definitions (lowest, most recent, mean, median), as well as five different time windows (up to 365 days prior to ED visit) to select a baseline and compared this to the first measured SCr at ED. As an outcome, we assessed AKI prevalence at ED.

Results

We included 47,373 ED visits with both SCr-ED and SCr-BL available. Of these, 46,100 visits had a SCr-BL from the − 365/− 7 days time window. Apart from the lowest value, AKI prevalence remained similar for the other definitions when varying the time window. The lowest value with the − 365/− 7 time window resulted in the highest prevalence (21.4%). Importantly, applying the guidelines with all criteria resulted in major differences in prevalence ranging from 5.9 to 24.0%.

Conclusions

AKI prevalence varies with the use of different baseline definitions in ED patients. Clinicians, as well as researchers and developers of automatic diagnostic tools should take these considerations into account when aiming to diagnose AKI in clinical and research settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02581-x.

Additional benefit of induced pluripotent stem cell-derived mesenchymal stem cell therapy on sepsis syndrome-associated acute kidney injury in rat treated with antibiotic

BACKGROUND

This study tested whether human induced-pluripotent stem-cell-derived mesenchymal-stem-cells (iPS-MSCs) would offer an additional benefit to the rodent with acute kidney injury (AKI) (ischemia for 1 h followed by reperfusion for 120 h) associated sepsis syndrome (SS) (by cecal-ligation-puncture immediately after AKI-induction) undergoing ciprofloxacin therapy.

RESULTS

Male-adult SD rats (n = 80) were categorized into group 1 (sham-operated-control, n = 10), group 2 (AKI + SS, n = 24), group 3 (AKI + SS + ciprofloxacin/3 mg/kg, orally for 120 h, n = 12), group 4 (AKI + SS + iPS-MSCs/1.2 × 10⁶/intravenously administered by 3 h after AKI, n = 12), group 5 (AKI + SS + iPS-MSCs/1.2 × 10⁶/intravenously administered by 18 h after AKI, n = 12), group 6 (AKI + SS + iPS-MSCs/1.2 × 10⁶/intravenously administered by 3 h after AKI induction + ciprofloxacin, n = 10] and euthanized by 120 h. The result showed that the mortality was significantly higher in group 2 than in other groups (all p < 0.01). The creatinine level was highest in group 2, lowest in group 1, significantly lower in group 6 than in groups 3, 4 and 5, (all p < 0.0001), but it showed no difference among the latter 3 groups. Flow cytometric analysis showed that the circulatory inflammatory cells (Ly6G/CD11^b/c), early (AN-V+/PI-)/late (AN-V+/PI+) apoptosis, and circulatory/splenic immune cells (CD3+/CD4+, CD3+/CD8a+) were highest in group 2, lowest in group 1, significantly lower in group 6 than in groups 3/4/5 and significantly lower in group 4 than in groups 3/5 (all p < 0.0001), but they showed no difference between groups 3/5. Protein expressions of oxidative-stress (NOX-1/NOX2/oxidized protein), apoptotic (cleaved-caspase3/cleaved-PARP/mitochondrial-Bax), fibrotic (TGF-ß/Smad3), inflammatory (MMP-9/IL-6/TNF-α) and autophagic (Atg5/Beclin) biomarkers in kidney exhibited an identical pattern of circulatory inflammatory cells (all p < 0.0001).

CONCLUSION

Combined iPS-MSCs-ciprofloxacin therapy was superior to either one alone for protecting AKI complicated by SS.

Catechins: Therapeutic Perspectives in COVID-19-Associated Acute Kidney Injury

Data obtained from several intensive care units around the world have provided substantial evidence of the strong association between impairment of the renal function and in-hospital deaths of critically ill COVID-19 patients, especially those with comorbidities and requiring renal replacement therapy (RRT). Acute kidney injury (AKI) is a common renal disorder of various etiologies characterized by a sudden and sustained decrease of renal function. Studies have shown that 5-46% of COVID-19 patients develop AKI during hospital stay, and the mortality of those patients may reach up to 100% depending on various factors, such as organ failures and RRT requirement. Catechins are natural products that have multiple pharmacological activities, including anti-coronavirus and reno-protective activities against kidney injury induced by nephrotoxic agents, obstructive nephropathies and AKI accompanying metabolic and cardiovascular disorders. Therefore, in this review, we discuss the anti-SARS-CoV-2 and reno-protective effects of catechins from a mechanistic perspective. We believe that catechins may serve as promising therapeutics in COVID-19-associated AKI due to their well-recognized anti-SARS-CoV-2, and antioxidant and anti-inflammatory properties that mediate their reno-protective activities.

Meta-Analysis of Renal Replacement Therapy for Burn Patients: Incidence Rate, Mortality, and Renal Outcome

Background: Renal replacement therapy (RRT) was often needed by some severe burn patients with acute kidney injury (AKI). The primary aim of this study was to review incidence rate and mortality of RRT in severe burn patients. Second aims were to review RRT complications and renal outcome.

Methods: We searched multiple databases for studies published between 1 January 1960 and 31 December 2019. Studies about adult populations with burn injury, providing epidemiologic data on prevalence or mortality of RRT, were included.

Results: A total of selected 57 studies, including 27,437 patients were enrolled in our analysis. The prevalence rates of RRT were 8.34% (95% CI 7.18–9.5%) in all burn patients and 37.05% (95% CI 29.85–44.24%) in AKI patients. The mortality of all burn patients with RRT was 65.52% (95% CI 58.41–72.64%). The prevalence rates of RRT in sample size≥100 group were 6.86% (95% CI 5.70–8.03%), which was lower than that of <100 group (17.61%, 95% CI 13.39–21.82%). With the increase of TBSA, the prevalence of RRT may have the increasing trend. The prevalence rates of RRT in Asian group was 12.75% (95% CI 9.50–16.00%), which was higher than that of European (10.45%, 95% CI 7.30–13.61%) and North America group (5.61%, 95% CI 4.27–6.95%). The prevalence rates of RRT in 2010–2019 group was 12.22% (95% CI 10.09–14.35%), which was higher than that of 2009–2000 group (5.17%, 95% CI 2.88–7.46%). The prevalence rates of RRT in 1989 and before group was the lowest, which was 1.56% (95% CI 0–3.68%). However, there was no significant correlation between the year of publication and the mortality of burn patients with RRT. Dialysis-requiring AKI in burn patients could increases the risk of chronic kidney disease progression and end-stage renal disease. About 35% of RRT patients need to maintain haemodialysis temporarily, even if they survive and leave hospital.

Conclusions: The prevalence rate of RRT is about 6–8%; approximately, one-third of burn patients with AKI need RRT. The prevalence rate of RRT increased over time, but the mortality did not change. The prevalence rates of RRT in Asian group was higher than that of European and North America group.

Increased Carotid Intima-Media Thickness was not Associated With Cognitive Dysfunction After Off-Pump Coronary Surgery in Older Adult Patients Without Carotid Stenosis

Increased carotid intima-media thickness (C-IMT), a marker of atherosclerosis, is known to be associated with cerebrovascular and cortical abnormalities and cognitive impairment. This prospective observational study investigated the association between increased C-IMT and postoperative cognitive dysfunction (POCD) in older adult patients undergoing off-pump coronary artery bypass surgery. A total of 201 patients (57 females, 144 males; >60 years) were classified into increased (n = 105) or normal (n = 96) C-IMT groups by a cut-off value of 0.9 mm (bilateral C-IMT mean). Cognitive function was serially assessed with the Korean Mini-Mental State Examination, and Korean Montreal Cognitive Assessment scores preoperatively and at 7 days and 3 months postoperatively. POCD was defined as the deterioration of 1 standard deviation in at least one of the postoperative tests compared with their corresponding baseline scores. Independent risk factors for POCD were evaluated using multivariable analysis. Overall, POCD occurred in 46 patients (23%) over the 3 months. The incidences of POCD at 7 days and 3 months after surgery were similar, and there was no difference in both Korean Mini-Mental State Examination and Korean Montreal Cognitive Assessment test scores before and after surgery between groups. Chronic obstructive lung disease and intraoperative hyperglycemia episodes (>180 mg/dL), but not increased C-IMT, were independent risk factors for POCD. Unlike in nonsurgical cohorts, increased C-IMT was not significantly associated with the occurrence of POCD in older adult patients undergoing off-pump coronary artery bypass surgery.

Prevalence and risk factors of acute kidney injury in polytrauma patients at Muhimbili Orthopedic Institute, Tanzania

Background

Polytrauma can lead to multi-organ dysfunction in addition to the local injuries. Acute kidney injury (AKI) is one of the most common causes and contributors to the high morbidity and mortality. Prevalence of acute kidney injury in trauma patients is as reported to be as high as 40.3%. Early detection and management leads to better outcomes. The prevalence of AKI among polytrauma patients remains unknown in our setting.

Methodology

A cross-sectional study involving all adults with polytrauma who presented at the emergency department at Muhimbili Orthopedic Institute (MOI) was designed. A score of ≥18 on the New Injury Severity Score (NISS) screening tool was used to identify polytrauma patients. The Kidney Disease Improving Global Outcomes (KDIGO) criteria was used to identify patient with polytrauma who developed acute kidney injury. Descriptive statistics were then obtained followed by hypothesis testing between variables with the chi squared test. Logistic regression models were used to determine factors associated with acute kidney injury.

Results

More than half (56.4%) of the patients were between 26 and 40 years and 92.3% of the polytrauma patients were males. Almost 2/5th (38.5%) of the polytrauma patients had acute kidney injury – half of these had stage 1 AKI, 33.3% had stage 2 AKI and the remaining 16.7% had stage 3 AKI. On multivariate logistic regression, it was found that patients who were older than 45 years (OR 8.53, CI 1.65–43.89, p = 0.01) and those patients with Systemic Inflammatory Response Syndrome (SIRS) (OR 21.83, CI 1.66–286.2, p = 0.019) had higher risk of acute kidney injury.

Conclusion

There is high prevalence of AKI among polytrauma patients. Elderly patients and those with SIRS were seen to have higher likelihood of AKI.

Mechanistic Aspects and Therapeutic Potential of Quercetin against COVID-19-Associated Acute Kidney Injury

The inflammatory mediator and oxidant agent storm caused by the SARS-CoV-2 infection has been strongly associated with the failure of vital organs observed in critically ill patients with coronavirus disease 2019 (COVID-19) and the death of thousands of infected people around the world. Acute kidney injury (AKI) is a common renal disorder characterized by a sudden and sustained decrease in renal function with a critical influence on poor prognosis and lethal clinical outcomes of various etiologies, including some viral infection diseases. It is known that oxidative stress and inflammation play key roles in the pathogenesis and development of AKI. Quercetin is a natural substance that has multiple pharmacological properties, such as anti-inflammatory action, and is used as a dietary supplement. There is evidence of the anti-coronavirus activities of this compound, including against the target SARS-CoV-2 3CLpro. The ability to inhibit coronavirus and its inflammatory processes is strongly desired in a new drug for the treatment of COVID-19. Therefore, in this review, the dual effect of quercetin is discussed from a mechanistic perspective in relation to AKI kidney injury and its nephroprotective potential to SARS-CoV-2 patients.

Polymyxin-induced nephrotoxicity and its predictors: a systematic review and meta-analysis of studies conducted using RIFLE criteria of acute kidney injury

Polymyxins are last-resort antibiotics re-emerged to treat infections caused by multidrug resistant (MDR) and extensively drug-resistant (XDR) Gram-negative bacterial infections. However, polymyxin-associated nephrotoxicity has become the main safety concern. Therefore, we conducted this systematic review and meta-analysis on polymyxin-induced nephrotoxicity and its predictors using studies conducted based on the validated RIFLE (Risk, Injury, Failure, Loss of Function and End-stage renal disease) criteria of acute kidney damage. Literature search was carried out through visiting legitimate databases and indexing services including PubMed, MEDLINE (Ovid®), EMBASE (Ovid®), and Scopus to retrieve relevant studies. Following screening and eligibility evaluation, relevant data were extracted from included studies and analyzed using STATA 15.0 and Rev-Man 5.3. Inverse variance method with random effects pooling model was used for the analysis of outcome measures at 95% confidence interval. Besides, meta-regression, meta-influence, and publication bias analyses were conducted. A total of 48 studies involving 6,199 adult patients aged ≥ 18 years were included for systematic review and meta-analysis. The pooled incidence of polymyxin-induced nephrotoxicity was found to be 45% (95% CI: 41- 49%; I² = 92.52%). Stratifying with RIFLE severity scales, pooled estimates of polymyxin-treated patients identified as 'risk', 'injury' and 'failure' were 17% (95% CI: 14-20%), 13% (95% CI: 11-15%), and 10% (95% CI: 9-11%), respectively. Besides, the pooled incidence of colistin-induced nephrotoxicity was about 48% (95% CI: 42-54%), whereas that of polymyxin B was 38% (95% CI: 32-44%). Likewise, colistin had 37% increased risk of developing nephrotoxicity compared to the polymyxin B treated cohorts (RR = 1.37, 95% CI: 1.13-1.67; I² = 57%). Older age (AOR = 1.03, 95% CI: 1.01-1.05), daily dose (AOR = 1.46, 95% CI: 1.09-1.96), underlying diabetes mellitus (AOR = 1.81, 95% CI: 1.25-2.63), and concomitant nephrotoxic drugs (AOR = 2.31, 95% CI: 1.79-3.00) were independent risk factors for polymyxin-induced nephrotoxicity. Patients with high serum albumin level were less likely (AOR = 0.69, 95% CI: 0.56-0.85] to experience nephrotoxicity compared to those with low albumin level. Despite the resurgence of these antibiotics for the chemotherapy of MDR/XDR-Gram-negative superbugs, the high incidence of nephrotoxicity has become a contemporary clinical concern. Being elderly, high daily dose, having underlying diseases such as diabetes, and use of concomitant nephrotoxic drugs were independent predictors of nephrotoxicity. Therefore, therapeutic drug monitoring should be done to these patients to outweigh the potential benefits of polymyxin therapy from its risk.

Incidence, Risk Factors, and Outcome of Acute Kidney Injury in the Intensive Care Unit: A Single-Center Study from Jordan

Background

Acute kidney injury (AKI) is a common serious problem affecting critically ill patients in intensive care unit (ICU). It increases their morbidity, mortality, length of ICU stay, and long-term risk of chronic kidney disease (CKD).

Methods

A retrospective study was carried out in a tertiary hospital in Jordan. Medical records of patients admitted to the medical ICU between 2013 and 2015 were reviewed. We aimed to identify the incidence, risk factors, and outcomes of AKI. Acute kidney injury network (AKIN) classification was used to define and stage AKI.

Results

2530 patients were admitted to medical ICU, and the incidence of AKI was 31.6%, mainly in stage 1 (59.4%). In multivariate analysis, increasing age (odds ratio (OR) = 1.2 (95% CI 1.1–1.3), P = 0.0001) and higher APACHE II score (OR = 1.5 (95% CI 1.2–1.7), P = 0.001) were predictors of AKI, with 20.4% of patients started on hemodialysis. At the time of discharge, 58% of patients with AKI died compared to 51.3% of patients without AKI (P = 0.05). 88% of patients with AKIN 3 died by the time of discharge compared to patients with AKIN 2 and 1 (75.3% and 61.2% respectively, P = 0.001).

Conclusion

AKI is common in ICU patients, and it increases mortality and morbidity. Close attention for earlier detection and addressing risk factors for AKI is needed to decrease incidence, complications, and mortality.

Incidence and Risk Factors for Acute Kidney Injury in Severely Injured Patients Using Current Kidney Disease: Improving Global Outcomes Definitions

BACKGROUND

Acute kidney injury (AKI) is a significant cause of morbidity and mortality for critically injured trauma patients. The Kidney Disease: Improving Global Outcomes (KDIGO) practice guideline is the most up-to-date classification for AKI. The aims of this study were to determine the incidence and risk factors for AKI in critically injured trauma patients using the current KDIGO definitions.

STUDY DESIGN

A prospective cohort study was performed at our academic, level 1 trauma center, from September 2017 to August 2018. All adult trauma patients admitted to the surgical ICU were included. The primary outcome was the development of AKI, as defined by KDIGO. Secondary outcomes included hospital and ICU length of stay, ventilator days, and mortality.

RESULTS

There were 466 patients included and 314 (67%) developed AKI. Those who developed AKI were more often hypotensive on admission (7% vs 2%), had higher Injury Severity Scores (ISS) (19 vs 13), were more likely to have severe injuries to the chest (40% vs 24%) and extremities (20% vs 6%), received transfusion (41% vs 21%), sustained crush injuries (8% vs 1%), received radiocontrast (75% vs 47%), nephrotoxic medication (74% vs 60%), or vasopressors (15% vs 3%). After multivariate analysis, risk factors independently associated with AKI include age, Injury Severity Score (ISS), severe extremity injuries, radiocontrast, and vasopressors. Those who developed AKI had higher mortality (9% vs 2%).

CONCLUSIONS

Using current KDIGO criteria, the incidence of AKI in critically injured trauma patients was higher than previously reported. Older patients, with more severe injuries to their extremities and chest and who have suffered crush injuries, appear to be the most a risk. AKI in the critically injured patient results in an almost 5-fold increase in mortality.

Choice of Reference Creatinine for Post-Traumatic Acute Kidney Injury Diagnosis

BACKGROUND

Acute kidney injury (AKI) after trauma is associated with poor outcomes. According to current guidelines, a diagnosis of AKI should be made based on an increase in serum creatinine from a reference value. However, a true reference is often unknown in patients presenting with traumatic injury. The aim of this study was to determine the optimal reference creatinine estimate for post-traumatic AKI diagnosis and staging. The optimal reference estimate was defined by a high incidence, strong prognostic ability, and incrementality at each stage.

STUDY DESIGN

This was a cohort study of adult trauma patients (older than 16 years) requiring ICU admission between 2009 and 2018 (n = 8,026) at a single Level I trauma center. AKI was determined using the following 4 reference creatinine estimates: Modified Diet of Renal Diseases (MDRD), Trauma MDRD, admission creatinine, and the first-day creatinine nadir. Inclusivity was assessed by incidence of AKI diagnosed with different reference creatinine estimates; prognostic ability was assessed by multivariable modified Poisson regression; and incrementality was assessed by correlation of mortality risk by AKI stage.

RESULTS

There was a wide range of AKI incidence, from 21% when using admission creatinine to 76% using the Trauma MDRD. The MDRD reference creatinine estimate resulted in an AKI incidence of 41% and a diagnosis that was both prognostic of mortality and incremental with each AKI stage. All other reference estimates resulted in AKI diagnoses that were either not prognostic or not incremental.

CONCLUSIONS

Reference creatinine estimate determines the clinical importance of AKI diagnoses. In this study, the MDRD reference resulted in optimal AKI diagnoses.

Acute kidney injury in trauma patients admitted to the ICU: a systematic review and meta-analysis

PURPOSE

To perform a systematic review and meta-analysis of acute kidney injury (AKI) in trauma patients admitted to the intensive care unit (ICU).

METHODS

We conducted a systematic literature search of studies on AKI according to RIFLE, AKIN, or KDIGO criteria in trauma patients admitted to the ICU (PROSPERO CRD42017060420). We searched PubMed, Cochrane Database of Systematic Reviews, UpToDate, and NICE through 3 December 2018. Data were collected on incidence of AKI, risk factors, renal replacement therapy (RRT), renal recovery, length of stay (LOS), and mortality. Pooled analyses with random effects models yielded mean differences, OR, and RR, with 95% CI.

RESULTS

Twenty-four observational studies comprising 25,182 patients were included. Study quality (Newcastle-Ottawa scale) was moderate. Study heterogeneity was substantial. Incidence of post-traumatic AKI in the ICU was 24% (20-29), of which 13% (10-16) mild, 5% (3-7) moderate, and 4% (3-6) severe AKI. Risk factors for AKI were African American descent, high age, chronic hypertension, diabetes mellitus, high Injury Severity Score, abdominal injury, shock, low Glasgow Coma Scale (GCS) score, high APACHE II score, and sepsis. AKI patients had 6.0 (4.0-7.9) days longer ICU LOS and increased risk of death [RR 3.4 (2.1-5.7)] compared to non-AKI patients. In patients with AKI, RRT was used in 10% (6-15). Renal recovery occurred in 96% (78-100) of patients.

CONCLUSIONS

AKI occurred in 24% of trauma patients admitted to the ICU, with an RRT use among these of 10%. Presence of AKI was associated with increased LOS and mortality, but renal recovery in AKI survivors was good.

Is the risk of contrast-induced nephropathy a real contraindication to perform intravenous contrast enhanced Computed Tomography for non-traumatic acute abdomen in Emergency Surgery Department?

BACKGROUND

Contrast enhanced Computed Tomography (CCT) is the most used imaging test to investigate acute abdominal clinical conditions, because of its high sensitivity and specificity. It is mandatory to make a correct and prompt diagnosis when life threatening abdominal diseases as mesenteric ischemia are suspected. Contrast medium administration was linked to acute renal failure, therefore radiologist often prefer to perform CCT without contrast in patients needing to undergo the exam with increased serum creatinine.  The aim of the review was to focus on the incidence of contrast induced nephropathy in patients presenting non-traumatic acute abdominal clinical conditions, who underwent CCT with intravenous contrast agent administration in emergency setting.

MATERIALS AND METHODS

The systematic review protocol was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocol (PRISMA-P). Quality of the evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

The strongest currently available evidence on the incidence of post-contrast acute kidney injury (AKI) following intravenous contrast agent administration consists in a meta-analysis of observational studies. Data extracted from meta-analyses demonstrate that, compared with non-contrast CT, CCT was not significantly associated with AKI. Moreover, the risk of AKI (RR=0.79; 95% confidence interval [CI]: 0.62, 1.02; P=.07), death (RR=0.95; 95% CI: 0.55, 1.67; P=.87), and dialysis (RR=0.88; 95% CI: 0.23, 3.43; P=.85) is similar, compared with the risk of AKI in the non-contrast medium group. Furthermore, intravenous low-osmolality iodinated contrast material is a nephrotoxic risk factor, but not in patients with a stable SCr level less than 1.5 mg/dL, therefore many factors other than contrast material could affect PC-AKI rates.

DISCUSSION AND CONCLUSIONS

The benefits of diagnostic information gained from contrast enhanced TC in assessing AA are fundamental in some clinical scenarios. The risk of contrast induced nephropathy (CIN) is negligible in patients with normal renal function but the incidence appears to rise to as high as 25% in patients with pre-existing renal impairment or in the presence of risk factors such as diabetes, advanced age, vascular disease and use of certain concurrent medications. The incidence of CIN/AKI after intravenous contrast administration is very low in general population. Radiologists and referring physicians should be familiar with the risk factors for renal disease, CIN and preventing measures.

Hyperchloremia and postoperative acute kidney injury: a retrospective analysis of data from the surgical intensive care unit

Background

Whether perioperative hyperchloremia can induce postoperative acute kidney injury (AKI) is controversial. We investigated the association between perioperative hyperchloremia and postoperative AKI in patients admitted to the intensive care unit (ICU) after surgery.

Methods

We performed a retrospective observational study of patients admitted to the surgical ICU at a single tertiary care hospital between January 2011 and June 2016. Our primary objective was to determine whether hyperchloremia or an increase in serum chloride levels was associated with postoperative AKI. Perioperative hyperchloremia was defined as serum chloride levels ≥ 110 mmol·L^− 1 during postoperative days (PODs) 0–3. The increase in serum chloride levels was defined as the difference between preoperative and maximum postoperative serum chloride levels during the first 3 days after surgery.

Results

Of the 7991 patients included in the final analysis, 1876 (23.5%) developed hyperchloremia during PODs 0–3, and 1187 (14.9%) developed postoperative AKI. Exposure to hyperchloremia during the first 3 days after surgery was not associated with postoperative AKI (odds ratio, 1.09; 95% confidence interval, 0.80–1.49; P = 0.571). However, among patients with preoperative chronic kidney disease stage ≥ 3 (estimated glomerular filtration rate < 60 mL·min^− 1·1.73·m^− 2), the incidence of postoperative AKI was higher in patients with an increase > 6 mmol·L^− 1 in serum chloride levels than in patients with an increase ≤ 1 mmol·L^− 1 (odds ratio, 1.42; 95% confidence interval, 1.09–1.84; P = 0.009). In addition, the incidence of postoperative AKI stage ≥ 2 was not associated with exposure to hyperchloremia or with the increase in serum chloride levels during PODs 0–3, regardless of preoperative kidney function.

Conclusions

Exposure to perioperative hyperchloremia is not associated with postoperative AKI in surgical ICU patients. However, in patients with moderate-to-severe chronic kidney disease (stage ≥ 3), a substantial perioperative increase in serum chloride levels may reflect a higher risk of AKI.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2216-5) contains supplementary material, which is available to authorized users.