Acute kidney injury in elderly intensive care patients: a review

Effects of 24-hour urine-output trajectories on the risk of acute kidney injury in critically ill patients with cirrhosis: a retrospective cohort analysis

BACKGROUND

Acute kidney injury (AKI) is one of the most common complications for critically ill patients with cirrhosis, but it has remained unclear whether urine output fluctuations are associated with the risk of AKI in such patients. Thus, we explored the influence of 24-h urine-output trajectory on AKI in patients with cirrhosis through latent category trajectory modeling.

MATERIALS AND METHODS

This retrospective cohort study examined patients with cirrhosis using the MIMIC-IV database. Changes in the trajectories of urine output within 24 h after admission to the intensive care unit (ICU) were categorized using latent category trajectory modeling. The outcome examined was the occurrence of AKI during ICU hospitalization. The risk of AKI in patients with different trajectory classes was explored using the cumulative incidence function (CIF) and the Fine-Gray model with the sub-distribution hazard ratio (SHR) and the 95% confidence interval (CI) as size effects.

RESULTS

The study included 3,562 critically ill patients with cirrhosis, of which 2,467 (69.26%) developed AKI during ICU hospitalization. The 24-h urine-output trajectories were split into five classes (Classes 1-5). The CIF curves demonstrated that patients with continuously low urine output (Class 2), a rapid decline in urine output after initially high levels (Class 3), and urine output that decreased slowly and then stabilized at a lower level (Class 4) were at higher risk for AKI than those with consistently moderate urine output (Class 1). After fully adjusting for various confounders, Classes 2, 3, and 4 were associated with a higher risk of AKI compared with Class 1, and the respective SHRs (95% CIs) were 2.56 (1.87-3.51), 1.86 (1.34-2.59), and 1.83 1.29-2.59).

CONCLUSIONS

The 24-h urine-output trajectory is significantly associated with the risk of AKI in critically ill patients with cirrhosis. More attention should be paid to the dynamic nature of urine-output changes over time, which may help guide early intervention and improve patients' prognoses.

Application of Artificial Intelligence to Advance Individualized Diagnosis and Treatment in Emergency and Critical Care Medicine

Emergency and critical illnesses refer to severe diseases or conditions characterized by rapid changes in health that may endanger life within a short period [...].

PAI-1 as a critical factor in the resolution of sepsis and acute kidney injury in old age

Elevated plasma levels of plasminogen activator inhibitor type 1 (PAI-1) are documented in patients with sepsis and levels positively correlate with disease severity and mortality. Our prior work demonstrated that PAI-1 in plasma is positively associated with acute kidney injury (AKI) in septic patients and mice. The objective of this study was to determine if PAI-1 is causally related to AKI and worse sepsis outcomes using a clinically-relevant and age-appropriate murine model of sepsis. Sepsis was induced by cecal slurry (CS)-injection to wild-type (WT, C57BL/6) and PAI-1 knockout (KO) mice at young (5-9 months) and old (18-22 months) age. Survival was monitored for at least 10 days or mice were euthanized for tissue collection at 24 or 48 h post-insult. Contrary to our expectation, PAI-1 KO mice at old age were significantly more sensitive to CS-induced sepsis compared to WT mice (24% vs. 65% survival, p = 0.0037). In comparison, loss of PAI-1 at young age had negligible effects on sepsis survival (86% vs. 88% survival, p = 0.8106) highlighting the importance of age as a biological variable. Injury to the kidney was the most apparent pathological consequence and occurred earlier in aged PAI-1 KO mice. Coagulation markers were unaffected by loss of PAI-1, suggesting thrombosis-independent mechanisms for PAI-1-mediated protection. In summary, although high PAI-1 levels are clinically associated with worse sepsis outcomes, loss of PAI-1 rendered mice more susceptible to kidney injury and death in a CS-induced model of sepsis using aged mice. These results implicate PAI-1 as a critical factor in the resolution of sepsis in old age.

Risk factors of perioperative acute kidney injury in elderly patients: a single-center retrospective study

PURPOSE

The elderly are vulnerable to perioperative acute kidney injury. The aim of this study was to determine the risk factors that associated with acute kidney injury among elderly patients.

METHODS

Clinical data of elderly patients (> 65 years) who underwent noncardiac, nonrenal surgery between Dec 1 2009 and July 1 2016 were collected for this single-centered historical cohort study. Univariate and multivariate analyses were conducted to explore the risk factors that contribute to acute kidney injury, which was defined as a serum creatinine increase >0.3 mg/dL within 48 h or 1.5 times increase in serum creatinine within 7 days after surgery.

RESULTS

7775 patients were eligible for the final analysis, among which 511 (6.57%) patients developed acute kidney injury. We observed 21 risk factors being associated with perioperative acute kidney injury, with the most important disposing factors being history of kidney disease (adjusted OR = 2.94, 95% CI 2.25-3.84), operation time > 180 min (aOR = 2.93, 95% CI 2.04-4.24), preoperative eGFR [15, 30) (aOR = 2.43, 95% CI 1.29-4.45), and protective factor being intraoperative use of sufentanil (aOR = 0.35, 95% CI 0.23-0.54).

CONCLUSION

This study determined risk factors for perioperative acute kidney injury among the elderly in the Second Xiangya Hospital and visualized the risk factors using nomogram and Excel calculator, which may provide some clues to further investigations. Overall, the prevalence of AKI among this large cohort is 6.57%.

CLINICAL TRIALS REGISTRATION

http://www.chictr.org.cn ; ChiCTR1900027007; October 28, 2019.

Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges

There is a growing population of older adults requiring admission to the intensive care unit (ICU). This population outpaces the ability of clinicians with geriatric training to assist in their management. Specific training and education for intensivists in the care of older patients is valuable to help understand and inform clinical care, as physiologic changes of aging affect each organ system. This review highlights some of these aging processes and discusses clinical implications in the vulnerable older population. Other considerations when caring for these older patients in the ICU include functional outcomes and morbidity, as opposed to merely a focus on mortality. An overall holistic approach incorporating physiology of aging, applying current evidence, and including the patient and their family in care should be used when caring for older adults in the ICU.

Future insights of pharmacological prevention for AKI post cardiopulmonary bypass surgery (based on PK/PD approach)

The incidence of acute kidney injury (AKI) post-cardiopulmonary bypass (CPB) can cause an increase in the rate of renal replacement therapy (RRT) and mortality rate. Compared to brain and liver damage post-CPB, AKI has the highest incidence of 83%. Based on this phenomenon, various efforts have been made to reduce the incidence of AKI post-CPB, both pharmacologically and non-pharmacologically interventions. The purpose of this review is to emphasize several renal protector agents which under optimal conditions can provide significant benefits in reducing the incidence of AKI post-CPB. This article was obtained by conducting a study on several kinds of literature, including the original article, RCT study, systematic review and meta-analysis, and other review articles. There are five renal protector agents that are the focus of this article, those are fenoldopam which effectively works to prevent the incidence of AKI post-CPB, while furosemide has shown satisfactory results in patients with decreased renal function when administered in the Renal Guard (RG) system, mannitol, and nitric oxide, both of these can also effectively reduce the incidence of AKI post‐CPB by controlling its blood concentration and timing of administration, and another form of N-Acetylcysteine, namely N‐Acetylcysteine amide has better activity as a renoprotective agent than N‐Acetylcysteine itself. The benefits of these agents can be obtained by developing devices that can control drug levels in the blood and create optimal conditions for drugs during the use of a CPB machine.

Evaluation of amikacin dosing schedule in critically ill elderly patients with different stages of renal dysfunction

OBJECTIVES

Amikacin is still a widely used aminoglycoside for the treatment of life-threatening infections. The pharmacokinetic parameters of this antibiotic may be altered in critically ill conditions. Moreover, in the elderly population, pathophysiological changes affect these pharmacokinetic variables, making it difficult to predict the appropriate dose and dosing schedule for amikacin. This study aimed to characterise the pharmacokinetics of amikacin in critically ill elderly patients with renal dysfunction, and to evaluate if the available dose adjustment schedules dependent on renal function would be appropriate for empirical dosing.

METHODS

Critically ill patients aged >60 years with a creatinine clearance of >20 mL/min in need of treatment with amikacin were randomly enrolled. All the patients received approximately 25 mg/kg amikacin. The patients were then divided into three groups according to the stages of their renal dysfunction based on creatinine clearance, and the optimum time to re-dosing was calculated for each group. The pharmacokinetic parameters of the patients were calculated and estimated as population pharmacokinetic data.

RESULTS

Of 30 patients, only 20% attained the target peak levels of amikacin of >64 mg/L. In addition, the mean volume of distribution was 0.47 L/kg. There was a poor correlation between amikacin clearance and creatinine clearance. The difference in amikacin half-life was not statistically significant among any of the stages of renal impairment.

CONCLUSIONS

The initial dosing of amikacin in critically ill elderly patients should not be reduced, even in the context of renal impairment. Regarding the dose adjustment in renal impairment, dosing intervals estimation, no decision can be made based on the creatinine clearance and the first dose individualisation method in terms of the two-sample measurements may be considered as an appropriate strategy.

Visceral fat-specific regulation of plasminogen activator inhibitor-1 in aged septic mice

Elevated plasma levels of plasminogen activator inhibitor-1 (PAI-1) are documented in patients with sepsis and levels positively correlate with disease severity and mortality. Our previous work demonstrated that visceral adipose tissues (VAT) are a major source of PAI-1, especially in the aged (murine endotoxemia), that circulating PAI-1 protein levels match the trajectory of PAI-1 transcript levels in VAT (clinical sepsis), and that PAI-1 in both VAT and plasma are positively associated with acute kidney injury (AKI) in septic patients. In the current study utilizing preclinical sepsis models, PAI-1 tissue distribution was examined and cellular sources, as well as mechanisms mediating PAI-1 induction in VAT, were identified. In aged mice with sepsis, PAI-1 gene expression was significantly higher in VAT than in other major organs. VAT PAI-1 gene expression correlated with PAI-1 protein levels in both VAT and plasma. Moreover, VAT and plasma levels of PAI-1 were positively associated with AKI markers, modeling our previous clinical data. Using explant cultures of VAT, we determined that PAI-1 is secreted robustly in response to recombinant transforming growth factor β (TGFβ) and tumor necrosis factor α (TNFα) treatment; however, neutralization was effective only for TNFα indicating that TGFβ is not an endogenous modulator of PAI-1. Within VAT, TNFα was localized to neutrophils and macrophages. PAI-1 protein levels were fourfold higher in stromal vascular fraction (SVF) cells compared with mature adipocytes, and among SVF cells, both immune and nonimmune compartments expressed PAI-1 in a similar fashion. PAI-1 was localized predominantly to macrophages within the immune compartment and preadipocytes and endothelial cells within the nonimmune compartment. Collectively, these results indicate that induction and secretion of PAI-1 from VAT is facilitated by a complex interaction among immune and nonimmune cells. As circulating PAI-1 contributes to AKI in sepsis, understanding PAI-1 regulation in VAT could yield novel strategies for reducing systemic consequences of PAI-1 overproduction.

Development of mortality prediction model in the elderly hospitalized AKI patients

Acute kidney injury (AKI) correlates with increased health-care costs and poor outcomes in older adults. However, there is no good scoring system to predict mortality within 30-day, 1-year after AKI in older adults. We performed a retrospective analysis screening data of 53,944 hospitalized elderly patients (age > 65 years) from multi-centers in China. 944 patients with AKI (acute kidney disease) were included and followed up for 1 year. Multivariable regression analysis was used for developing scoring models in the test group (a randomly 70% of all the patients). The established models have been verified in the validation group (a randomly 30% of all the patients). Model 1 that consisted of the risk factors for death within 30 days after AKI had accurate discrimination (The area under the receiver operating characteristic curves, AUROC: 0.90 (95% CI 0.875–0.932)) in the test group, and performed well in the validation groups (AUROC: 0.907 (95% CI 0.865–0.949)). The scoring formula of all-cause death within 1 year (model 2) is a seven-variable model including AKI type, solid tumor, renal replacement therapy, acute myocardial infarction, mechanical ventilation, the number of organ failures, and proteinuria. The area under the receiver operating characteristic (AUROC) curves of model 2 was > 0.80 both in the test and validation groups. Our newly established risk models can well predict the risk of all-cause death in older hospitalized AKI patients within 30 days or 1 year.

Exploration of the Relationship Among Key Risk Factors of Acute Kidney Injury for Elderly Patients Considering Covid-19

Background: Previous systematic reviews and meta-analyses supported the relationship between frailty and risk of acute kidney injury (AKI) in elderly patients. However, few studies evaluated proactive management to wear down AKI risk in such frail populations.

Purpose: To understand how AKI risk factors might influence each other and to identify the source factors for clinical decision aids.

Methods: This study uses the decision-making trial and evaluation laboratory (DEMATEL) method to establish influential network-relationship diagrams (INRDs) to form the AKI risk assessment model for the elderly.

Results: Based on the DEMATEL approach, the results of INRD identified the six key risk factors: comorbidity, malignancy, diabetes, creatinine, estimated glomerular filtration rate, and nutritional assessment. (The statistical significance confidence is 98.423%, which is higher than 95%; the gap error is 1.577%, which is lower than 5%). After considering COVID-19 as an additional risk factor in comorbidity, the INRD revealed a similar influential relationship among the essential aspects.

Conclusion: While evaluating the geriatric population, physicians need to pay attention to patients' comorbidities and nutritional assessment; also, they should note patients' creatinine values and glomerular filtration rate. Physicians could establish a preliminary observation index and then design a series of preventive guidelines to reduce the incidence of AKI risk for the elderly.

Prognostic factors associated with six month mortality of critically ill elderly patients admitted to the intensive care unit with severe acute cholangitis

BACKGROUND

Little is known about the outcomes of elderly patients admitted to the intensive care unit (ICU) with severe acute cholangitis (SAC). The objectives were to describe the 6-month mortality in patients with SAC ≥75 years and to identify factors associated with this mortality.

METHODS

Bi-center retrospective study of critically ill elderly patients with SAC conducted between 2013 and 2017. Demographic and clinical variables of ICU and hospital stays with a 6-month follow-up were analyzed.

RESULTS

85 patients, with a median [Q1-Q3] age of 83 [80-89] years were enrolled of whom 51 (60%) were men. SAC was due to choledocholithiasis in 72 (85%) patients. Median [Q1-Q3] ICU length of stay was 3 [2-6] days. Median [Q1-Q3] admission SAPS II was 50 [42-70]. The ICU and 6-month mortality rates were 18% and 48% respectively. Multivariate analysis showed that malnutrition (OR = 34.5, 95% CI [1.4-817.9]) and a decrease in SOFA score at 48 h (OR by unit 0.7, 95% CI [0.5-0.9]) were associated with higher 6-month mortality.

CONCLUSION

In their decision-making process, ICU physicians and hepato-pancreato-biliary surgeons could use these data to estimate the probability of survival of an elderly patient presenting with SAC and to offer time-limited trials of intensive care.

TRIAL REGISTRATION

NCT03831529.

The Effect of Aging Physiology on Critical Care

Older patients experience a decline in their physiologic reserves as well as chronic low-grade inflammation named "inflammaging." Both of these contribute significantly to aging-related factors that alter the acute, subacute, and chronic response of these patients to critical illness, such as sepsis. Unfortunately, this altered response to stressors can lead to chronic critical illness followed by dismal outcomes and death. The primary goal of this review is to briefly highlight age-specific changes in physiologic systems majorly affected in critical illness, especially because it pertains to sepsis and trauma, which can lead to chronic critical illness and describe implications in clinical management.

Risk factors and long-term outcomes of elderly patients complicating with acute kidney injury after type A acute aortic dissection surgery: a retrospective study

Background

To identify risk factors and long-term outcomes for acute kidney injury (AKI) in elderly patients who underwent type A acute aortic dissection (TA-AAD) emergency surgeries.

Methods

This retrospective study enrolled 214 consecutive patients who underwent TA-AAD emergency surgeries between January 2014 to December 2018 in Nanjing Drum Tower hospital. The diagnosis of AKI was made based on the Kidney Disease: Improving Global Outcomes definition (KDIGO) criteria. Multivariable regression analysis was performed to identify risk factors for postoperative AKI. Kaplan-Meier curves were generated to compare the long-term outcomes between patients with and without AKI complication after TA-AAD surgeries.

Results

Among all enrolled patients, 114 (53.3%) developed AKI during postoperative period. The median age of patients with or without AKI was 68.0 (64.0, 74.0) and 66.0 (62.0, 72.8) years respectively. Renal replacement therapy (RRT) was required in 43 patients (20.1%). The 30-day mortality rate was 21.5% in all enrolled patients with 26.3% in AKI group and 16.0% in non-AKI group (P=0.067) respectively. Longer mechanical ventilation duration was identified as the only independent risk factor for developing AKI by multivariable logistic regression analysis. In addition, our data suggested that the long-term cumulative survival rate was different between two groups.

Conclusions

Postoperative AKI after TA-AAD surgeries was common and associated with worsened long-term mortality in elderly patients. Longer postoperative mechanical ventilation duration was identified as the only independent risk factor for the development of AKI.

Clinical features, risk factors, and clinical burden of acute kidney injury in older adults

Background: Few epidemiologic studies on acute kidney injury (AKI) have focused on the older adult population. This study investigated the clinical features, risk factors, and clinical burden in this population. Methods: A retrospective observational study was performed with the clinical data of inpatients at Guangdong Geriatrics Institute from 1 August 2012, to 31 December 2016. AKI was classified into community-acquired AKI (CA-AKI) and hospital-acquired AKI (HA-AKI), and the risk factors for AKI were ranked by weight. The relationships between AKI and adverse outcomes during hospitalization were analyzed using univariate and multivariate logistic regression. Results: In total, 6126 patients were enrolled, and 1704 patients developed AKI (27.8%): 6.3% had CA-AKI, and 21.5% had HA-AKI. In total, 1425 (23.3%), 202 (3.3%), and 77 (1.3%) patients had stage 1, 2 and 3 AKI, respectively. Age, dementia, moderate/severe renal disease, moderate/severe liver disease, metastatic solid tumor, female sex, congestive heart failure, chronic pulmonary disease, diabetes mellitus with chronic complications, non-metastatic tumor and lymphoma were independent risk factors for HA-AKI. The first five were also independent risk factors for CA-AKI. After multiple adjustment, AKI was associated with intensive care admission (CA-AKI: OR 5.688, 95% CI 3.122-10.361; HA-AKI: OR 4.704, 95% CI 3.023-7.298) and in-hospital mortality (CA-AKI: OR 5.073, 95% CI 2.447-10.517; HA-AKI: OR 13.198, 95% CI 8.133-21.419). Conclusion: AKI occurs in >25% of older adults in the geriatric ward. In addition to traditional risk factors, dementia and tumors were risk factors for AKI in older adults. AKI is closely related to a poor prognosis.

[Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]

The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.

Clinical characteristics and cost of hospital stay of octogenarians and nonagenarians in intensive care nephrology unit

PURPOSE

As the population gets older, the elderly and very elderly patients are increasingly been treated in nephrology intensive care units (ICU). In this study we evaluated the characteristics and outcomes of the octogenarians (80-89 years old), nonagenarians (≥ 90 years old) and compared them with elderly (65-79 years old) patients treated in nephrology ICU.

METHODS

Eighteen nonagenarians, 70 octogenarians and 88 elderly patients were included in the study. Indication for hospitalization, presence of comorbid diseases, and requirement for acute dialysis treatment were investigated. Need for mechanical ventilation, vasopressors, central venous catheterization, urinary catheterization, anticoagulation, and transfusion of blood products were evaluated. Mortality rate and hospital cost were calculated. Data about survival at 1 month after discharge was collected.

RESULTS

Causes of hospitalization, need for dialysis treatment, mechanical ventilation, vasopressors, central venous catheterization, urinary catheterization, anticoagulation, and transfusion of blood products were not different between age groups. Diabetes mellitus and malignancy were more frequent in elderly, whereas dementia/Alzheimer's disease was more common in nonagenarians. Although, mortality in ICU was increased as the age increased, it was statistically insignificant. However, 1 month mortality rate after discharge from hospital was increased especially in nonagenarians. In nonagenarians infection, whereas in octogenarians need for dialysis treatment, were related with mortality. Length of intensive care stay and hospital cost did not differ between age groups.

CONCLUSION

Length of nephrology intensive care stay, mortality rate and hospital cost did not differ for very elderly age groups, but mortality risk was higher for nonagenarians after discharge from hospital.

Molecular Mechanisms of AKI in the Elderly: From Animal Models to Therapeutic Intervention

Acute kidney injury (AKI), a critical syndrome characterized by a sudden reduction of renal function, is a common disorder among elderly patients particularly in Intensive Care Unit (ICU). AKI is closely associated with both short- and long-term mortality and length of hospital stay and is considered a predictor of chronic kidney disease (CKD). Specific hemodynamic, metabolic, and molecular changes lead to increased susceptibility to injury in the aged kidney; therefore, certain causes of AKI such as the prerenal reduction in renal perfusion or vascular obstructive conditions are more common in the elderly; moreover, AKI is often multifactorial and iatrogenic. Older patients present several comorbidities (diabetes, hypertension, heart failure) and are exposed to multiple medical interventions such as the use of nephrotoxic contrasts media and medications, which can also trigger AKI. Considering the emerging relevance of this condition, prevention and treatment of AKI in the elderly should be crucial in the internist and emergency setting. This review article summarizes the incidence, the risk factors, the pathophysiology, the molecular mechanisms and the strategies of prevention and treatment of AKI in elderly patients.

Baseline and clinical characteristics of older adults admitted to the intensive care unit through the emergency room: Analysis based on age groups

Background and Objectives:

There is currently no consensus on the criteria for admitting older adults to the intensive care unit.

Methods:

This single-center retrospective study evaluated the baseline and clinical characteristics of older adults admitted to the intensive care unit between January 2017 and June 2017; patients were analyzed according to their age group. Factors associated with in-hospital mortality were specifically determined using logistic regression analysis.

Results:

Among 582 patients included in the present study, 34.2%, 46.6%, and 19.2% were aged 65–74, 75–84, and over 84 years, respectively. In terms of clinical outcomes, although there were no significant differences in the length of intensive care unit and hospital stay and intensive care unit mortality, significant differences were observed in terms of in-hospital mortality, hospital discharge disposition, and neurologic outcomes at discharge ( p = 0.039, p = 0.005, and p = 0.032, respectively). Predictive factors for in-hospital mortality were age (⩾85 years), initial mental status (stupor to coma), a Korean Triage and Acuity Scale level of 1, underlying diagnosis of cancer, abdominal pain or discomfort, apnea, and a chief compliant of dyspnea.

Conclusion:

Compared to those aged 65–84 years, in-hospital mortality was 1.96-fold higher in those aged over 84 years. However, the overall mortality in our cohort was not considerably different from that of the younger population. Intensive care unit admission should be considered in selected older adults after evaluating the risk factors for mortality.

[Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]

The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.

Cumulative Prognostic Score Predicting Mortality in Patients Older Than 80 Years Admitted to the ICU

OBJECTIVES

To develop a scoring system model that predicts mortality within 30 days of admission of patients older than 80 years admitted to intensive care units (ICUs).

DESIGN

Prospective cohort study.

SETTING

A total of 306 ICUs from 24 European countries.

PARTICIPANTS

Older adults admitted to European ICUs (N = 3730; median age = 84 years [interquartile range = 81‐87 y]; 51.8% male).

MEASUREMENTS

Overall, 24 variables available during ICU admission were included as potential predictive variables. Multivariable logistic regression was used to identify independent predictors of 30‐day mortality. Model sensitivity, specificity, and accuracy were evaluated with receiver operating characteristic curves.

RESULTS

The 30‐day‐mortality was 1562 (41.9%). In multivariable analysis, these variables were selected as independent predictors of mortality: age, sex, ICU admission diagnosis, Clinical Frailty Scale, Sequential Organ Failure Score, invasive mechanical ventilation, and renal replacement therapy. The discrimination, accuracy, and calibration of the model were good: the area under the curve for a score of 10 or higher was .80, and the Brier score was .18. At a cut point of 10 or higher (75% of all patients), the model predicts 30‐day mortality in 91.1% of all patients who die.

CONCLUSION

A predictive model of cumulative events predicts 30‐day mortality in patients older than 80 years admitted to ICUs. Future studies should include other potential predictor variables including functional status, presence of advance care plans, and assessment of each patient's decision‐making capacity.

Acute kidney injury in elderly patients: narrative review on incidence, risk factors, and mortality

Acute kidney injury (AKI) is characterized by a sudden renal dysfunction with consequent increase of nitrogenous products, hydroelectrolytic and acid–base disorders. Its prevalence is high in hospitalized populations (4.9%–7.2%), especially in intensive care units (ICUs). Despite all the technical and therapeutic advances that have occurred in the last few decades, the overall mortality of AKI patients remains high, reaching 80% in ICU patients. Several conditions predispose a patient to progress with AKI, including age, sepsis, surgeries, and comorbidities, such as systemic arterial hypertension, diabetes mellitus, heart disease, neoplasia, and chronic renal disease. Among these risk factors, age is emphasized, since, due to advances in the health area, there has been an increase in life expectancy, hence an increase in the demand of the elderly population for health services. At the same time, the elderly present a greater predisposition to the development of AKI, either due to kidney senility, or because of the high prevalence of comorbidities present, and medical interventions such as the use of contrasts and medications, which can also trigger AKI. Considering the relevance of the social role of the elderly and the scarcity of studies on AKI in the elderly admitted to the ICU, further studies are needed. This review article was elaborated considering the purpose: to assess incidence, risk factors, and mortality of AKI in elderly patients admitted to ICUs. Published studies were collected using the following inclusion criteria: be accessible in online databases (Lilacs, Scielo, and PubMed), have been published since 2000 and written in English, Portuguese, or Spanish. The descriptors used for the survey were “Acute Kidney Injury”, “Aging”, and “Elderly”. All items that did not fit in the above inclusion criteria were discarded. We have also presented a synthesis of the knowledge acquired during this review.

Urinary Neutrophil Gelatinase-Associated Lipocalin Is Excellent Predictor of Acute Kidney Injury in Septic Elderly Patients

Elderly is the main age group affected by acute kidney injury (AKI). There are no studies that investigated the predictive properties of urinary (u) NGAL as an AKI marker in septic elderly population. This study aimed to evaluate the efficacy of uNGAL as predictor of AKI diagnosis and prognosis in elderly septic patients admitted to ICUs. We prospectively studied elderly patients with sepsis admitted to ICUs from October 2014 to November 2015. Assessment of renal function was performed daily by serum creatinine and urine output. The level of uNGAL was performed within the first 48 hours of the diagnosis of sepsis (NGAL1) and between 48 and 96 hours (NGAL2). The results were presented using descriptive statistics and area under the receiver operating characteristic curve (AUC-ROC) and p value was 5%. Seventy-five patients were included, 47 (62.7%) developed AKI. At logistic regression, chronic kidney disease and low mean blood pressure at admission were identified as factors associated with AKI (OR=0.05, CI=0.01-0.60, p=0.045 and OR=0.81, CI=0,13-0.47; p=0.047). The uNGAL was excellent predictor of AKI diagnosis (AUC-ROC >0.95, and sensitivity and specificity>0.89), anticipating the AKI diagnosis in 2.1±0.3 days. Factors associated with mortality in the logistic regression were presence of AKI (OR=2.14, CI=1.42-3.98, p=0.04), chronic obstructive pulmonary disease (OR = 9.37, CI =1.79-49.1, p=0.008) and vasoactive drugs (OR=2.06, CI=0.98-1.02, p=0.04). The accuracy of NGALu 1 and 2 as predictors of death was intermediate, with AUC-ROC of 0.61 and 0.62; sensitivity between 0.65 and 0.77 and specificity lower than 0.6. The uNGAL was excellent predictor of AKI in septic elderly patients in ICUs and can anticipate the diagnosis of AKI in 2.1 days.

Characteristics of and risk factors for death in elderly patients with acute kidney injury: a multicentre retrospective study in China

Purpose of the study

The incidence of acute kidney injury (AKI) with a poor prognosis in the elderly has been increasing each year. This study aimed to investigate the clinical characteristics of and risk factors for death from AKI in the elderly and help improve prognosis.

Study design

This study was a retrospective cohort study based on data from adult patients (≥18 years old) admitted to 15 hospitals in China between 1 January 2009 and 31 December 2011. The characteristics of AKI in the elderly were compared with those in younger patients.

Results

In elderly patients with AKI, rates of hypertension, cardiovascular disease and multiple organ dysfunction syndrome (MODS) were higher than in younger patients (44.2% vs 31.2%, 16.1% vs 4.6% and 20.9% vs 16.9%, respectively), the length of ICU stay was longer (3.8 days vs 2.7 days, P=0.019) and renal biopsy (1.0% vs 7.13%, P<0.001) and dialysis (9.6% vs 19.2%, P<0.001) were performed less. Hospital-acquired (HA) AKI was more common than community-acquired (CA) AKI (60.3% vs 39.7%), while the most common cause of AKI was pre-renal (53.5%). Multiple logistic regression analysis showed that age (OR 1.041, 95% CI 1.023 to 1.059), cardiovascular disease (OR 1.980, 95% CI 1.402 to 2.797), cancer (OR 2.302, 95% CI 1.654 to 3.203), MODS (OR 3.023, 95% CI 1.627 to 5.620) and mechanical ventilation (OR 2.408, 95% CI 1.187 to 4.887) were significant risk factors for death.

Conclusions

HA-AKI and pre-renal AKI were more common in the elderly. Age, cardiovascular disease, cancer, MODS and mechanical ventilation were independent risk factors for death in the elderly with AKI.

Interventions of the clinical pharmacist in an Intermediate Care Unit for elderly patients

Objective

To discuss the role of the clinical pharmacist in hospital care of critical elderly patients.

Methods

Critical patients aged 60 years and over admitted by the clinical staff to an Intermediate Care Unit were followed-up for 4 months regarding their drug therapies. Medical prescriptions were reviewed daily on the basis of patients’ clinical conditions, with the view to identify opportunities for optimization of drug therapies, contributing to safer prescribing, reduced discomfort and correct and rational use of drugs.

Results

A total of 386 prescriptions were reviewed and 212 pharmaceutical interventions performed; 64.3% of prescriptions were classified as accepted with changes, 28.5% not accepted and 7.2% verbally accepted with no changes. Interventions included drug therapy indications, directions for dose adjustment, reduction of the use of potentially inappropriate medications for older patients, prescription adjustments, discontinuing unnecessary drugs, among others.

Conclusion

The significant number of interventions accepted by the healthcare staff supports the relevance of the clinical pharmacist as a member of the multiprofessional team, especially in care of the elderly.

Acute Kidney Injury in Elderly Population: A Prospective Observational Study

BACKGROUND/AIMS

Acute kidney injury (AKI) has been reported as a recognized condition among the elderly population; however, its clinical epidemiology is still poorly evaluated. We propose to evaluate the epidemiological profile of AKI in hospitalized elderly patients and the variables associated with renal replacement therapy (RRT) dependency at discharge after an episode of AKI.

METHODS

This prospective observational study enrolled 286 elderly patients (aged ≥60 years), who had a diagnosis of AKI and were admitted to a tertiary care hospital. Clinical data were analyzed, which included RRT indication, referral time to nephrologist support, standby period in the emergency care units (ECU) before a transfer to an intensive care unit, staff criteria used to indicate palliative care, and the incidence of patients who stayed on chronic dialysis for at least 6 months after discharge.

RESULTS

The overall hospital mortality was 56.3%. Acute Kidney Injury Network (AKIN) 3 at the time of admission was significantly higher in patients who underwent RRT. Intrinsic AKI (p < 0.001), AKIN 3 (p < 0.001), RRT (p < 0.001), and increased length of stay in ECUs (p = 0.01) all had a significantly higher prevalence among non-survivors. On multivariate analysis, however, only renal aetiology (intrinsic AKI) was independently associated with mortality (OR 2.88; 95% CI [1.29-6.13]). Approximately 85% of the discharged patients (n = 125) were dialysis free and 36.4% of them who had a previous diagnosis of chronic kidney disease (CKD) upon admission had a worse renal function. Age, AKIN 3, RRT, prior history of CKD, diabetes mellitus, and the number of hemodialysis sessions showed to have an impact on dialysis dependence. Furthermore, 24 of 161 patients who had a dialysis indication were placed on palliative care.

CONCLUSIONS

The severity of AKI and the need for RRT were risk factors for mortality and dependence on dialysis. Antecedents of CKD seem to be associated with a poor renal outcome following an AKI episode. Starting RRT had an impact on the clinical decision to enroll these patients into palliative care.

Acute kidney injury and inflammatory response of sepsis following cecal ligation and puncture in d-galactose-induced aging rats

Background

Recently, the d-galactose (d-gal)-induced mimetic aging rat model has been widely used in studies of age-associated diseases, which have shown that chronic d-gal exposure induces premature aging similar to natural aging in rats. With the increasing rate of sepsis in the geriatric population, an easy-access animal model for preclinical studies of elderly sepsis is urgently needed. This study investigates whether a sepsis model that is established in d-gal-induced aging rats can serve as a suitable model for preclinical studies of elderly patients with sepsis.

Objective

To investigate the acute kidney injury (AKI) and inflammatory response of sepsis following cecal ligation and puncture (CLP) in d-gal-induced aging rats.

Methods

Twelve-week-old male Sprague Dawley rats were divided into low-dose d-gal (L d-gal, 125 mg/kg/d), high-dose d-gal (H d-gal, 500 mg/kg/d), and control groups. After daily subcutaneous injection of d-gal for 6 weeks, the CLP method was used to establish a sepsis model.

Results

The mortality was 73.3%, 40%, and 33.3% in the H d-gal, L d-gal, and control groups, respectively. Blood urea nitrogen, creatinine, plasma neutrophil gelatinase-associated lipocalin, interleukin-6, interleukin-10, and tumor necrosis factor-α were markedly increased in the H d-gal group after establishment of the sepsis model (H d-gal vs control, P<0.05 at 12 h and 24 h post-CLP). The rate of severe AKI (RIFLE-F) at 24 h post-CLP was 43% for both the control and L d-gal groups and 80% for the H d-gal group.

Conclusion

High-dose- d-gal-induced aging rats are more likely to die from sepsis than are young rats, and probably this is associated with increased severity of septic AKI and an increased inflammatory response. Therefore, use of the high-dose- d-gal-induced aging rat model of sepsis for preclinical studies can provide more useful information for the treatment of sepsis in elderly patients.

Thrombocytopenia on the first day of emergency department visit predicts higher risk of acute kidney injury among elderly patients

Background

Few studies have addressed risk factors for acute kidney injury (AKI) in geriatric patients. We investigated whether thrombocytopenia was a risk factor for AKI in geriatric patients with medical illnesses.

Methods

A prospective cohort study was conducted, by recruiting elderly (≥65 years) patients who visited the emergency department (ED) for medical illnesses during 2014. They all received hemogram for platelet count determination, and were stratified according to the presence of thrombocytopenia (platelets, <150 K/μL) during their initial ED evaluation. They were prospectively followed up during their ED stay. We analyzed the relationship between the diagnosis of thrombocytopenia and subsequent AKI after ED stay, using Cox proportional hazard modeling, with platelet count as a continuous variable or thrombocytopenia as a categorical variable.

Results

Of 136 elderly patients (mean age of 80.7 ± 8.2 years, 40% with chronic kidney disease, and 39% with diabetes) enrolled, 22.8% presented with thrombocytopenia, without differences in baseline renal function. After a mean ED stay of 4.4 ± 2.1 days, 41.9% developed AKI (52.6% Kidney Disease Improving Global Outcomes [KDIGO] grade 1, 24.6% grade 2, and 22.8% grade 3). Patients with higher AKI severity had stepwise lower platelet counts compared to those without AKI. The Cox proportional hazard model revealed that lower platelet count as a continuous variable (hazard ratio [HR] 0.984, 95% confidence interval [CI] 0.975–0.994) and as a categorical variable (presence of thrombocytopenia) (HR 1.86, 95% CI 1.06–3.27) increased the risk of AKI. The sensitivity analyses accounting for nephrotoxic medications use, including non-steroidal anti-inflammatory drugs, vancomycin, and contrast, yielded similar results.

Discussion

Thrombocytopenia is common among ED-visiting elderly, and the potential relationship between platelet counts and the risk of AKI suggests the utility of checking hemogram for those at-risk ofdeveloping adverse renal events.

Conclusion

Thrombocytopenia on initial presentation might indicate an increased risk of AKI among elderly patients with medical illnesses.

Acute kidney injury in elderly intensive care patients from a developing country: clinical features and outcome

AIM

The elderly are at high risk of acute kidney injury (AKI) because of structural and functional degeneration over time and with the aging of the population, the demand for intensive care unit (ICU) admission for older patients has risen recently. However, data from developing countries are scarce. This study aimed to describe the incidence of AKI in elderly patients admitted to ICU from a developing country, to determine the most frequent etiologies for renal impairment and identify its risk factors and outcome.

METHODS

All patients admitted to the ICU at a Brazilian teaching hospital for 12 consecutive months were followed prospectively from the time of admission until ICU discharge. Elderly was defined as aged >60 years and AKI was defined according to the Kidney Disease Improving Global Outcomes 2012 criteria. Multivariable logistic regression was used to adjust confounding and selection bias.

RESULTS

Two hundred elderly patients were included in the study. AKI incidence was 27% and the main etiology was sepsis (48.1%). At logistic regression, baseline creatinine (odds ratio [OR]=5.17, p<0.0001), Acute Physiology and Chronic Health Evaluation (APACHE) II (OR=1.20, p<0.0001), sepsis (OR=2.96, p<0.0001), and longer ICU stay (OR=1.68, p<0.0001) were associated with AKI in elderly patients. Baseline creatinine (OR=1.97, p=0.018), APACHE II (OR=1.29, p<0.0001), sepsis (OR=1.87, p<0.0001), and AKI severity (OR=2.57, p=0.027) were identified as predictors of death.

CONCLUSION

AKI was frequent in elderly patients admitted to ICU from a developing country, and it was identified as a risk factor for death. Sepsis was an important risk factor for both AKI and mortality, similar to developed countries and in younger populations.

Comparison of clinical characteristics of patients with acute kidney injury after intravenous versus inhaled colistin therapy

Background

The aim of this study was to investigate the incidence and clinical characteristics of intravenous (IV) or inhaled (IH) colistin-associated acute kidney injury (AKI) using the Risk, Injury, Failure, Loss, End-stage Renal Disease criteria.

Methods

From 2010 to 2014, 160 patients were treated with IV or IH colistin. Of these, we included 126 patients who received colistin for > 72 hours for the treatment of pneumonia and compared the incidence and clinical characteristics of patients in the IV (n = 107) and IH (n = 19) groups.

Results

The patients included 104 men and 22 women, with a mean age of 69 years (range, 24–91 years). The mortality rate was 45%, and AKI occurred in 75 (60%) patients. At the end of therapy, the bacteriologic cure rate was 66%. There were no differences in the clinical characteristics between the IV and IH groups except for age. In comparison with patients in the IV group, the patients in the IH group were older (74 ± 8 vs. 68 ± 12 years, P = 0.026). The incidence of AKI was not different between the 2 groups (62 vs. 47%, P = not significant), and there was no difference in the severity of AKI according to the Risk, Injury, Failure, Loss, End-stage Renal Disease criteria. Of the 83 patients with AKI, 6 and 1 patients underwent renal replacement therapy, respectively.

Conclusion

The incidence of AKI in patients with colistin therapy is 60% in our center. It seems that IH colistin therapy could not be better in safety than IV colistin therapy.

Targeting Endogenous Repair Pathways after AKI

AKI remains a highly prevalent disease associated with poor short- and long-term outcomes and high costs. Although significant advances in our understanding of repair after AKI have been made over the last 5 years, this knowledge has not yet been translated into new AKI therapies. A consensus conference held by the Acute Dialysis Quality Initiative was convened in April of 2014 and reviewed new evidence on successful kidney repair to identify the most promising pathways that could be translated into new treatments. In this paper, we provide a summary of current knowledge regarding successful kidney repair and offer a framework for conceptualizing the therapeutic targeting that may facilitate this process. We outline gaps in knowledge and suggest a research agenda to more efficiently bring new discoveries regarding repair after AKI to the clinic.

Critical Care Issues of the Geriatric Patient

Medical care of the geriatric patient is an important area of focus as the population ages and life expectancy increases. In particular, critical care of the geriatric patient will be especially affected, because geriatric patients will consume most critical care beds in the future and subsequently require increased use of resources. This review focuses on the physiologic effects of aging on all body systems. Focus on frailty and its effect on recovery from critical illness and its potential to modify the course of patient care will be important areas of research in the future.

Geriatric patients with known acute kidney injury and normal renal function at the time of admittance to the intensive care unit/assessment of RRT requirement and mortality: retrospective case-control study

BACKGROUND

The objective of our study was to investigate the renal functions on admittance, chronic disease status, the diagnosis on admittance to the intensive care unit (ICU), need for mechanical ventilation and medication groups and their impact over mortality and renal replacement treatment (RRT) requirement in geriatric patients with and without known acute kidney injury (AKI) at the time of admittance.

METHODS

A total of 168 patients over 65 years of age having been monitored for more than 24 h in our Respiratory ICU and were assessed retrospectively. Factors influencing the RRT requirement and the mortality rates of patients with known AKI and normal renal function at the time of admittance were reviewed.

RESULTS

Of 80 patients, 8 (10 %) without AKI at the time of admittance to the ICU required RRT during the follow-up, however, 72 of those (90 %) completed the follow-up without developing AKI. Of 88 patients, 29 (33 %) with AKI at the time of admittance to the ICU required RRT, however, 59 of those (67 %) completed the follow-up without any need for RRT.

CONCLUSIONS

Presence of known AKI in the geriatric population at the time of their admittance to the respiratory ICU remarkably increased both the need for RRT and the mortality with respect to the geriatric population with normal renal functions. After having assessed the reasons justifying RRT and increasing the mortality during the intensive care, gastrointestinal bleeding and hypotension which necessitate the combined use of dopamine and noradrenaline were concluded to be prominent.

Role of COX-2/mPGES-1/prostaglandin E2 cascade in kidney injury

COX-2/mPGES-1/PGE2 cascade plays critical roles in modulating many physiological and pathological actions in different organs. In the kidney, this cascade is of high importance in regulating fluid metabolism, blood pressure, and renal hemodynamics. Under some disease conditions, this cascade displays various actions in response to the different pathological insults. In the present review, the roles of this cascade in the pathogenesis of kidney injuries including diabetic and nondiabetic kidney diseases and acute kidney injuries were introduced and discussed. The new insights from this review not only increase the understanding of the pathological role of the COX-2/mPGES-1/PGE2 pathway in kidney injuries, but also shed new light on the innovation of the strategies for the treatment of kidney diseases.

Acute kidney injury in the elderly hospitalized patients

OBJECTIVE

We aimed to evaluate acute kidney injury (AKI), occurrence of recovery and risk factors associated with permanent kidney injury and mortality in the elderly individuals.

DESIGN

Evidence for this study was obtained from retrospective cohort study from our center.

PATIENTS

A total of 193 patients (>65 years, mean age: 79.99 ± 6.93) with acute kidney injury were enrolled in this study between 2011 and 2012. PATIENTS with kidney failure or renal replacement therapy (RRT) history at admission were excluded.

INTERVENTION

Main outcome measurements: serum creatinine (SCr), estimated GFR (with CKD-Epi) and complete blood counts were evaluated at baseline and daily basis thereafter. The AKI was defined based on Kidney Disease Improving Global Outcomes (KDIGO) classification.

RESULTS

Among 193 patients, 43 (22%) patients required RRT. Mortality rate was 18% (n = 36) SCr levels were restored within 9.9 ± 6.7days on average (8-39 days). Sixteen patients (12.7%) required RRT after discharge. The mean hospital stay was 10.1 ± 8.6 days (7-41 days). Mortality rate of patients who have no renal recovery was higher (44.8% vs. 4.8%) than renal recovery group (p < 0.01).

CONCLUSION

The AKI represents a frequent complication in the elderly patients with longer hospital stay and increased mortality and morbidity. Our results show that dialytic support requirement is an independent predictor of permeant kidney injury in the elderly AKI patients. Older age, low diastolic blood pressure, high CRP and low hemoglobin levels were independent risk factors for mortality.

Incidence of nonconfounded post-computed tomography acute kidney injury in hospitalized patients with stable renal function receiving intravenous iodinated contrast material

OBJECTIVE

The purpose of our investigation was to determine the frequency of proximate acute and chronic confounding risk factors for acute kidney injury (AKI) in a cohort of adult hospitalized patients with stable renal function who developed AKI following an intravenous (IV) contrast-enhanced computed tomography (CT) examination.

MATERIALS AND METHODS

Institutional review board approval was obtained for this retrospective, Health Insurance Portability and Accountability Act-compliant investigation. Overall, 100 adult inpatients (50 males [mean age = 61 years, range: 24-94 years] and 50 females [mean age = 60 years, range: 20-95 years]) with stable pre-CT renal function who developed post-CT AKI using the Acute Kidney Injury Network (AKIN) laboratory criteria following an IV contrast-enhanced CT examination comprised the study population. Electronic International Classification of Disease-9 analysis followed by a comprehensive manual electronic medical record review was systematically performed by 5 radiologists to identify known acute (n = 24, within 5 days before or 3 days after CT) and chronic (n = 21) risk factors for AKI other than contrast material administration that might confound a diagnosis of contrast-induced nephrotoxicity. Descriptive statistics were performed.

RESULTS

Of 100 inpatients with post-CT AKI, 99 (99%) had 1 or more acute risk factor(s) for AKI other than contrast material administration (median = 3 risk factors, range: 0-8) and 86 (86%) had one or more chronic risk factor(s) for AKI (median = 2 risk factors, range: 0-7). The median number of risk factors (acute or chronic) per patient was 5 (range: 1-13). Only 1 inpatient (1%) developed post-CT AKI without a confounding acute risk factor (estimated glomerular filtration rate = 62-71 mL/min/1.73 m(2), 4 chronic risk factors, and CT 7 days after pancreaticoduodenectomy). The most common acute risk factors were nephrotoxic medications (83%) and parenteral blood product administration (30%). The most common chronic risk factors were hypertension (59%) and chronic kidney disease (56%).

CONCLUSION

Nonconfounded post-CT AKI is rare in hospitalized adults with stable renal function who have been exposed to IV low- or iso-osmolality iodinated contrast material.

Outcome from spontaneous subarachnoid haemorrhage--results from 2007-2011 and comparison with our previous series

OBJECTIVES

The management of patients with spontaneous subarachnoid haemorrhage (SAH) has changed, in part due to interventions now being extended to patients who are older and in a worse clinical condition. This study evaluates the effects of these changes on a complete 5-year patient material.

METHODS

Demographic data and results from 615 patients with SAH admitted from 2007 to 2011 were put together. Aneurysms were found in 448 patients (72.8%). They were compared with the aneurysm group (n = 676) from a previously published series from our centre (2001-2006). Linear regression was used to determine variables predicting functional outcome in the whole aneurysm group (2001-2011).

RESULTS

Patients in the more recent aneurysm group were older, and they were in a worse clinical condition on admission. Regarding younger patients admitted in World Federation of Neurosurgical Societies SAH grading (WFNS) 3, there were fewer with a good outcome. In the whole aneurysm group 2001-2011, outcome was best predicted by age, clinical condition at admission, and the size of the bleeding, and not by treatment mode or localization of aneurysm.

CONCLUSION

It seems important for the outcome that aneurysms are treated early. The clinical course after that depends largely on the condition of the patient on admission rather than on aneurysm treatment method. This, together with the fact that older patients and those in worse condition are now being admitted, increases demands on neurointensive care. Further improvement in patient outcome depends on better understanding of acute brain injury mechanisms and improved neurointensive care as well as rehabilitation measures.

[Acute kidney injury in elderly patient: Diagnostic and therapeutic aspects]

Acute renal failure in elderly patient is a public health problem. It is worsen by physiological status and anatomical changes associated with age, polymedication and chronic diseases. The etiologies of acute renal failure in the elderly are the same as in adults. Their distribution is specific with a large proportion of obstructive acute renal failure. The diagnostic and therapeutic strategies are the same as for young adults; the injection of iodinated-contrast should be avoided. Therapeutic strategies are discussed in terms of quality of life pre-morbid. Age is not considered a determinant of intensive treatment decisions. Renal replacement therapy in the elderly is not associated with excess mortality. Prevention of acute renal failure should be a permanent concern.

Renal issues in older adults in critical care

Renal issues are among the most commonly encountered complications in the intensive care unit, increasing mortality, morbidity, and health care costs. Older adult patients face an increased risk because of several factors, including the normal effects of aging and a higher rate of comorbid conditions that may affect kidney function. This article describes the classification of renal dysfunction, the effects of aging on kidney function, as well as additional risk factors, management strategies, and outcomes in the older adult population.

Advances in critical care for the older patient

As the proportion of elderly people in the general population increases, so does the number admitted to critical care. In caring for an older patient, the intensivist has to balance the complexities of an acute illness, pre-existing co-morbidities and patient preference for life-sustaining treatment with the chances of survival, quality of life after critical illness and rationing of expensive, limited resources. This remains one of the most challenging areas of critical care practice.

Type 2 diabetes mellitus in mice aggravates the renal impact of hemorrhagic shock

The objectives of this study were to determine whether type 2 diabetic mice would exhibit a more severe renal impact of hemorrhagic shock (HS) based on a recently described model of acute kidney injury and to determine the impact of HS on renal responses to hypoxia. We induced HS or sham procedure in type 2 diabetic and obese db/db mice. Creatininemia, glomerular filtration rate, urine output, histologic injury score, and kidney inductible molecule 1 mRNA were used to investigate the renal impact of HS. Tissular hypoxia and its impact were quantified using pimonidazole immunostaining and mRNA of hypoxic inducible factor, vascular endothelial growth factor receptors 1 and 2, Tie-2, endothelial nitric oxide synthase, and inducible nitric oxide synthase. Diabetic mice exhibiting mild diabetic nephropathy express hypoxic signals at baseline. The renal impact of HS was more severe in diabetic mice, with a worsening of tissular hypoxia and an altered response to hypoxia. Furthermore, endothelial nitric oxide synthase was highly overexpressed in diabetic shocked mice when compared with nondiabetic shocked mice. Renal impact of HS in type 2 diabetic mice is more intense than in nondiabetic ones. Preexisting hypoxia during diabetes could result in a renal preconditioning that modifies endothelial and tissular responses to acute kidney injury.

Dialysis by the book? Treatment of renal failure in a 101-year-old patient

While dialysis historically began as treatment intended for younger patients, it has, over time, increasingly been extended to treat elderly patients with a high comorbidity burden. Data on the outcomes of dialysis in these patients show that in some cases it confers no benefit and may be associated with functional decline. We describe a 101-year-old male patient with chronic kidney disease (CKD), admitted to the intensive care unit (ICU) with exacerbation of heart failure and sepsis. He experienced acute deterioration of renal function, with oliguria and acidosis. The patient's healthcare proxy insisted that dialysis be initiated despite his extremely advanced age, citing the patient's devout religious beliefs. He underwent 56 dialysis treatments over the course of ∼4 months after which he died as a result of septic and cardiogenic shock. Our case is unique, in that it may represent the oldest individual ever reported to start haemodialysis. It illustrates the ever-growing clinical and ethical challenges posed by the treatment of renal failure in the geriatric population.