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White KC, Serpa-Neto A, Hurford R, Clement P, Laupland KB, Ostermann M, Sanderson B, Gatton M, Bellomo R. How a positive fluid balance develops in acute kidney injury: A binational, observational study. J Crit Care 2024; 82:154809. [PMID: 38609773 DOI: 10.1016/j.jcrc.2024.154809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/03/2023] [Accepted: 01/12/2024] [Indexed: 04/14/2024]
Abstract
PURPOSE A positive fluid balance (FB) is associated with harm in intensive care unit (ICU) patients with acute kidney injury (AKI). We aimed to understand how a positive balance develops in such patients. METHODS Multinational, retrospective cohort study of critically ill patients with AKI not requiring renal replacement therapy. RESULTS AKI occurred at a median of two days after admission in 7894 (17.3%) patients. Cumulative FB became progressively positive, peaking on day three despite only 848 (10.7%) patients receiving fluid resuscitation in the ICU. In those three days, persistent crystalloid use (median:60.0 mL/h; IQR 28.9-89.2), nutritional intake (median:18.2 mL/h; IQR 0.0-45.9) and limited urine output (UO) (median:70.8 mL/h; IQR 49.0-96.7) contributed to a positive FB. Although UO increased each day, it failed to match input, with only 797 (10.1%) patients receiving diuretics in ICU. After adjustment, a positive FB four days after AKI diagnosis was associated with an increased risk of hospital mortality (OR 1.12;95% confidence intervals 1.05-1.19;p-value <0.001). CONCLUSION Among ICU patients with AKI, cumulative FB increased after diagnosis and was associated with an increased risk of mortality. Continued crystalloid administration, increased nutritional intake, limited UO, and minimal use of diuretics all contributed to positive FB. KEY POINTS Question How does a positive fluid balance develop in critically ill patients with acute kidney injury? Findings Cumulative FB increased after AKI diagnosis and was secondary to persistent crystalloid fluid administration, increasing nutritional fluid intake, and insufficient urine output. Despite the absence of resuscitation fluid and an increasing cumulative FB, there was persistently low diuretics use, ongoing crystalloid use, and a progressive escalation of nutritional fluid therapy. Meaning Current management results in fluid accumulation after diagnosis of AKI, as a result of ongoing crystalloid administration, increasing nutritional fluid, limited urine output and minimal diuretic use.
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Affiliation(s)
- Kyle C White
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Queensland University of Technology (QUT), Brisbane, Queensland, Australia.
| | - Ary Serpa-Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Rod Hurford
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Pierre Clement
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Kevin B Laupland
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia; Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, Department of Critical Care, London, UK
| | - Barnaby Sanderson
- King's College London, Guy's & St Thomas' Hospital, Department of Critical Care, London, UK
| | - Michelle Gatton
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Heidelberg, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
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Pasten C, Lozano M, Osorio LA, Cisterna M, Jara V, Sepúlveda C, Ramírez-Balaguera D, Moreno-Hidalgo V, Arévalo-Gil D, Soto P, Hurtado V, Morales A, Méndez GP, Busso D, Leon P, Michea L, Corvalán D, Luarte A, Irarrazabal CE. The protective effect of 1400W against ischaemia and reperfusion injury is countered by transient medullary kidney endothelial dysregulation. J Physiol 2024. [PMID: 39057844 DOI: 10.1113/jp285944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 06/12/2024] [Indexed: 07/28/2024] Open
Abstract
Renal ischaemia and reperfusion (I/R) is caused by a sudden temporary impairment of the blood flow. I/R is a prevalent cause of acute kidney injury. As nitric oxide generated by inducible nitric oxide synthase (iNOS) has detrimental effects during I/R, the pharmacological blockade of iNOS has been proposed as a potential strategy to prevent I/R injury. The aim of this study was to improve the understanding of 1400W (an iNOS inhibitor) on renal I/R as a pharmacological strategy against kidney disease. BALB/c mice received 30 min of bilateral ischaemia, followed by 48 h or 28 days of reperfusion. Vehicle or 1400W (10 mg/kg) was administered 30 min before inducing ischaemia. We found that after 48 h of reperfusion 1400W decreased the serum creatinine, blood urea nitrogen, neutrophil gelatinase-associated lipocalin and proliferating cell nuclear antigen 3 in the I/R animals. Unexpectedly, we observed mRNA upregulation of genes involved in kidney injury, cell-cycle arrest, inflammation, mesenchymal transition and endothelial activation in the renal medulla of sham animals treated with 1400W. We also explored if 1400W promoted chronic kidney dysfunction 28 days after I/R and did not find significant alterations in renal function, fibrosis, blood pressure or mortality. The results provide evidence that 1400W may have adverse effects in the renal medulla. Importantly, our data point to 1400W-induced endothelial dysfunction, establishing therapeutic limitations for its use. KEY POINTS: Acute kidney injury is a global health problem associated with high morbidity and mortality. The pharmacological blockade of inducible nitric oxide synthase (iNOS) has been proposed as a potential strategy to prevent AKI induced by ischaemia and reperfusion (I/R). Our main finding is that 1400W, a selective and irreversible iNOS inhibitor with low toxicity that is proposed as a therapeutic strategy to prevent kidney I/R injury, produces aberrant gene expression in the medulla associated to tissue injury, cell cycle arrest, inflammation, mesenchymal transition and endothelial activation. The negative effect of 1400W observed in the renal medulla at 48 h from drug administration, is transient as it did not translate into a chronic kidney disease condition.
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Affiliation(s)
- Consuelo Pasten
- Centro de Investigación e Innovación Biomédica (CiiB), Programa de Fisiología, Laboratorio de Fisiología Integrativa y Molecular, Universidad de los Andes, Chile
- Facultad de Medicina, Universidad de los Andes, Chile
| | - Mauricio Lozano
- Centro de Investigación e Innovación Biomédica (CiiB), Programa de Fisiología, Laboratorio de Fisiología Integrativa y Molecular, Universidad de los Andes, Chile
| | - Luis A Osorio
- Centro de Investigación e Innovación Biomédica (CiiB), Programa de Fisiología, Laboratorio de Fisiología Integrativa y Molecular, Universidad de los Andes, Chile
| | - Matías Cisterna
- Centro de Investigación e Innovación Biomédica (CiiB), Programa de Fisiología, Laboratorio de Fisiología Integrativa y Molecular, Universidad de los Andes, Chile
| | - Valeria Jara
- Centro de Investigación e Innovación Biomédica (CiiB), Programa de Fisiología, Laboratorio de Fisiología Integrativa y Molecular, Universidad de los Andes, Chile
| | - Catalina Sepúlveda
- Centro de Investigación e Innovación Biomédica (CiiB), Programa de Fisiología, Laboratorio de Fisiología Integrativa y Molecular, Universidad de los Andes, Chile
| | - Daniela Ramírez-Balaguera
- Centro de Investigación e Innovación Biomédica (CiiB), Programa de Fisiología, Laboratorio de Fisiología Integrativa y Molecular, Universidad de los Andes, Chile
| | - Viviana Moreno-Hidalgo
- Centro de Investigación e Innovación Biomédica (CiiB), Programa de Fisiología, Laboratorio de Fisiología Integrativa y Molecular, Universidad de los Andes, Chile
| | - Dayana Arévalo-Gil
- Centro de Investigación e Innovación Biomédica (CiiB), Programa de Fisiología, Laboratorio de Fisiología Integrativa y Molecular, Universidad de los Andes, Chile
| | - Paola Soto
- Centro de Investigación e Innovación Biomédica (CiiB), Programa de Fisiología, Laboratorio de Fisiología Integrativa y Molecular, Universidad de los Andes, Chile
| | - Valeria Hurtado
- Centro de Investigación e Innovación Biomédica (CiiB), Programa de Fisiología, Laboratorio de Fisiología Integrativa y Molecular, Universidad de los Andes, Chile
| | - Antonia Morales
- Centro de Investigación e Innovación Biomédica (CiiB), Programa de Fisiología, Laboratorio de Fisiología Integrativa y Molecular, Universidad de los Andes, Chile
| | | | - Dolores Busso
- Centro de Investigación e Innovación Biomédica (CiiB), Programa de Biología de la Reproducción, Universidad de los Andes, Chile
| | - Pablo Leon
- Programa de Fisiología y Biofísica, ICBM, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Luis Michea
- Programa de Fisiología y Biofísica, ICBM, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Daniela Corvalán
- Neuroscience Program, Center of Interventional Medicine for Precision and Advanced Cellular Therapy (IMPACT), Universidad de los Andes, Chile
| | - Alejandro Luarte
- Neuroscience Program, Center of Interventional Medicine for Precision and Advanced Cellular Therapy (IMPACT), Universidad de los Andes, Chile
| | - Carlos E Irarrazabal
- Centro de Investigación e Innovación Biomédica (CiiB), Programa de Fisiología, Laboratorio de Fisiología Integrativa y Molecular, Universidad de los Andes, Chile
- Facultad de Medicina, Universidad de los Andes, Chile
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3
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Bem RA, Lemson J. Evaluating fluid overload in critically ill children. Curr Opin Pediatr 2024; 36:266-273. [PMID: 38655808 DOI: 10.1097/mop.0000000000001347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW To review the evaluation and management of fluid overload in critically ill children. RECENT FINDINGS Emerging evidence associates fluid overload, i.e. having a positive cumulative fluid balance, with adverse outcome in critically ill children. This is most likely the result of impaired organ function due to increased extravascular water content. The combination of a number of parameters, including physical, laboratory and radiographic markers, may aid the clinician in monitoring and quantifying fluid status, but all have important limitations, in particular to discriminate between intra- and extravascular water volume. Current guidelines advocate a restrictive fluid management, initiated early during the disease course, but are hampered by the lack of high quality evidence. SUMMARY Recent advances in early evaluation of fluid status and (tailored) restrictive fluid management in critically ill children may decrease complications of fluid overload, potentially improving outcome. Further clinical trials are necessary to provide the clinician with solid recommendations.
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Affiliation(s)
- Reinout A Bem
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam Academic Medical Centers, location University of Amsterdam, Amsterdam
| | - Joris Lemson
- Department of Intensive Care, Radboud university medical center, Nijmegen, The Netherlands
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Gu XR, Tai YF, Liu Z, Zhang XY, Liu K, Zhou LY, Yin WJ, Deng YX, Kong DL, Midgley AC, Zuo XC. Layer-by-Layer Assembly of Renal-Targeted Polymeric Nanoparticles for Robust Arginase-2 Knockdown and Contrast-Induced Acute Kidney Injury Prevention. Adv Healthc Mater 2024:e2304675. [PMID: 38688026 DOI: 10.1002/adhm.202304675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 04/27/2024] [Indexed: 05/02/2024]
Abstract
The mitochondrial enzyme arginase-2 (Arg-2) is implicated in the pathophysiology of contrast-induced acute kidney injury (CI-AKI). Therefore, Arg-2 represents a candid target for CI-AKI prevention. Here, layer-by-layer (LbL) assembled renal-targeting polymeric nanoparticles are developed to efficiently deliver small interfering RNA (siRNA), knockdown Arg-2 expression in renal tubules, and prevention of CI-AKI is evaluated. First, near-infrared dye-loaded poly(lactic-co-glycolic acid) (PLGA) anionic cores are electrostatically coated with cationic chitosan (CS) to facilitate the adsorption and stabilization of Arg-2 siRNA. Next, nanoparticles are coated with anionic hyaluronan (HA) to provide protection against siRNA leakage and shielding against early clearance. Sequential electrostatic layering of CS and HA improves loading capacity of Arg-2 siRNA and yields LbL-assembled nanoparticles. Renal targeting and accumulation is enhanced by modifying the outermost layer of HA with a kidney targeting peptide (HA-KTP). The resultant kidney-targeting and siRNA loaded nanoparticles (PLGA/CS/HA-KTP siRNA) exhibit proprietary accumulation in kidneys and proximal tubular cells at 24 h post-tail vein injection. In iohexol-induced in vitro and in vivo CI-AKI models, PLGA/CS/HA-KTP siRNA delivery alleviates oxidative and nitrification stress, and rescues mitochondrial dysfunction while reducing apoptosis, thereby demonstrating a robust and satisfactory therapeutic effect. Thus, PLGA/CS/HA-KTP siRNA nanoparticles offer a promising candidate therapy to protect against CI-AKI.
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Affiliation(s)
- Xu-Rui Gu
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, China
| | - Yi-Fan Tai
- Key Laboratory of Bioactive Materials for the Ministry of Education and State Key Laboratory of Medicinal Chemical Biology, College of Life Sciences, Nankai University, Tianjin, 300071, China
| | - Zhen Liu
- Key Laboratory of Bioactive Materials for the Ministry of Education and State Key Laboratory of Medicinal Chemical Biology, College of Life Sciences, Nankai University, Tianjin, 300071, China
| | - Xin-Yan Zhang
- Key Laboratory of Bioactive Materials for the Ministry of Education and State Key Laboratory of Medicinal Chemical Biology, College of Life Sciences, Nankai University, Tianjin, 300071, China
| | - Kun Liu
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, China
| | - Ling-Yun Zhou
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, China
| | - Wen-Jun Yin
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, China
| | - Yi-Xuan Deng
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, China
| | - De-Ling Kong
- Key Laboratory of Bioactive Materials for the Ministry of Education and State Key Laboratory of Medicinal Chemical Biology, College of Life Sciences, Nankai University, Tianjin, 300071, China
| | - Adam C Midgley
- Key Laboratory of Bioactive Materials for the Ministry of Education and State Key Laboratory of Medicinal Chemical Biology, College of Life Sciences, Nankai University, Tianjin, 300071, China
| | - Xiao-Cong Zuo
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, China
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5
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Tamargo C, Hanouneh M, Cervantes CE. Treatment of Acute Kidney Injury: A Review of Current Approaches and Emerging Innovations. J Clin Med 2024; 13:2455. [PMID: 38730983 PMCID: PMC11084889 DOI: 10.3390/jcm13092455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/12/2024] [Accepted: 04/18/2024] [Indexed: 05/13/2024] Open
Abstract
Acute kidney injury (AKI) is a complex and life-threatening condition with multifactorial etiologies, ranging from ischemic injury to nephrotoxic exposures. Management is founded on treating the underlying cause of AKI, but supportive care-via fluid management, vasopressor therapy, kidney replacement therapy (KRT), and more-is also crucial. Blood pressure targets are often higher in AKI, and these can be achieved with fluids and vasopressors, some of which may be more kidney-protective than others. Initiation of KRT is controversial, and studies have not consistently demonstrated any benefit to early start dialysis. There are no targeted pharmacotherapies for AKI itself, but some do exist for complications of AKI; additionally, medications become a key aspect of AKI management because changes in renal function and dialysis support can lead to issues with both toxicities and underdosing. This review will cover existing literature on these and other aspects of AKI treatment. Additionally, this review aims to identify gaps and challenges and to offer recommendations for future research and clinical practice.
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Affiliation(s)
- Christina Tamargo
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Mohamad Hanouneh
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Nephrology Center of Maryland, Baltimore, MD 21239, USA
| | - C. Elena Cervantes
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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6
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Bhat AA, Riadi Y, Afzal M, Bansal P, Kaur H, Deorari M, Ali H, Shahwan M, Almalki WH, Kazmi I, Alzarea SI, Dureja H, Singh SK, Dua K, Gupta G. Exploring ncRNA-mediated pathways in sepsis-induced pyroptosis. Pathol Res Pract 2024; 256:155224. [PMID: 38452584 DOI: 10.1016/j.prp.2024.155224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 02/08/2024] [Accepted: 02/21/2024] [Indexed: 03/09/2024]
Abstract
Sepsis, a potentially fatal illness caused by an improper host response to infection, remains a serious problem in the world of healthcare. In recent years, the role of ncRNA has emerged as a pivotal aspect in the intricate landscape of cellular regulation. The exploration of ncRNA-mediated regulatory networks reveals their profound influence on key molecular pathways orchestrating pyroptotic responses during septic conditions. Through a comprehensive analysis of current literature, we navigate the diverse classes of ncRNAs, including miRNAs, lncRNAs, and circRNAs, elucidating their roles as both facilitators and inhibitors in the modulation of pyroptotic processes. Furthermore, we highlight the potential diagnostic and therapeutic implications of targeting these ncRNAs in the context of sepsis, aiming to cover the method for novel and effective strategies to mitigate the devastating consequences of septic pathogenesis. As we unravel the complexities of this regulatory axis, a deeper understanding of the intricate crosstalk between ncRNAs and pyroptosis emerges, offering promising avenues for advancing our approach to sepsis intervention. The intricate pathophysiology of sepsis is examined in this review, which explores the dynamic interaction between ncRNAs and pyroptosis, a highly regulated kind of programmed cell death.
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Affiliation(s)
- Asif Ahmad Bhat
- School of Pharmacy, Suresh Gyan Vihar University, Jagatpura, Mahal Road, Jaipur, India
| | - Yassine Riadi
- Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al Kharj 11942, Saudi Arabia
| | - Muhammad Afzal
- Department of Pharmaceutical Sciences, Pharmacy Program, Batterjee Medical College, P.O. Box 6231, Jeddah 21442, Saudi Arabia
| | - Pooja Bansal
- Department of Biotechnology and Genetics, Jain (Deemed-to-be) University, Bengaluru, Karnataka 560069, India; Department of Allied Healthcare and Sciences, Vivekananda Global University, Jaipur, Rajasthan 303012, India
| | - Harpreet Kaur
- School of Basic & Applied Sciences, Shobhit University, Gangoh, Uttar Pradesh 247341, India; Department of Health & Allied Sciences, Arka Jain University, Jamshedpur, Jharkhand 831001, India
| | - Mahamedha Deorari
- Uttaranchal Institute of Pharmaceutical Sciences, Uttaranchal University, Dehradun, India
| | - Haider Ali
- Centre for Global Health Research, Saveetha Medical College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, India; Department of Pharmacology, Kyrgyz State Medical College, Bishkek, Kyrgyzstan
| | - Moyad Shahwan
- Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman 3467, United Arab Emirates; Centre of Medical and Bio-allied Health Sciences Research, Ajman University, Ajman, Ajman 3469, United Arab Emirates
| | - Waleed Hassan Almalki
- Department of Pharmacology, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Imran Kazmi
- Department of Biochemistry, Faculty of Science, King Abdulaziz University, Jeddah, 21589, Saudi Arabia
| | - Sami I Alzarea
- Department of Pharmacology, College of Pharmacy, Jouf University, Sakaka, Aljouf 72341, Saudi Arabia
| | - Hairsh Dureja
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak 124001, India
| | - Sachin Kumar Singh
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara 144411, India; Faculty of Health, Australian Research Centre in Complementary and Integrative Medicine, University of Technology, Sydney, Ultimo-NSW 2007, Australia
| | - Kamal Dua
- Faculty of Health, Australian Research Centre in Complementary and Integrative Medicine, University of Technology, Sydney, Ultimo-NSW 2007, Australia; Discipline of Pharmacy, Graduate School of Health, University of Technology, Sydney, Ultimo-NSW 2007, Australia
| | - Gaurav Gupta
- Centre of Medical and Bio-allied Health Sciences Research, Ajman University, Ajman, Ajman 3469, United Arab Emirates; School of Pharmacy, Graphic Era Hill University, Dehradun 248007, India.
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Ji X, Zhang Y, Xie Y, Wang W, Tan Y, Xie M, Zhang L. Feasibility Value of Right Ventricular Longitudinal Shortening Fraction and the Prognostic Implications in Patients With Heart Transplantation. J Am Heart Assoc 2024; 13:e032402. [PMID: 38456455 PMCID: PMC11009997 DOI: 10.1161/jaha.123.032402] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 12/08/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND Right ventricular longitudinal shortening fraction (RVLSF) is a 2-dimensional speckle tracking echocardiography parameter based on tricuspid annular displacement analysis that could be used to assess right ventricular (RV) systolic function. The value of RVLSF in the assessment of RV systolic function in recipients of heart transplantation (HT) and whether RVLSF can replace strain parameters remains unknown. METHODS AND RESULTS A total of 153 adult patients who underwent HT were consecutively enrolled in this prospective longitudinal study. All subjects were examined by conventional transthoracic 2-dimensional echocardiography and 2-dimensional speckle tracking echocardiography to evaluate the RV end-diastolic basal diameter, RV end-diastolic area, fractional area change, peak systolic velocity of tricuspid annulus, tricuspid annular plane systolic excursion, RV free wall strain, and RVLSF. Cox proportional hazards regression was used to test if the parameters of interest had independent prognostic value for adverse outcome prediction in patients who underwent HT. A significant positive correlation was found between the measurements of RVLSF and RV free wall strain (r=0.927, P<0.001). Compared with the event-free group, the adverse outcome group displayed reduced RVLSF and RV free wall strain and higher age (P<0.001, <0.001, =0.016, respectively) in patients who underwent HT. RVLSF and RV free wall strain were independently associated with poor prognosis in multivariable analysis (both P<0.001). CONCLUSIONS RVLSF assessment provides an effective evaluation of RV longitudinal systolic function in the transplanted hearts and has prognostic value for adverse outcomes in patients undergoing HT.
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Affiliation(s)
- Xiang Ji
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Center for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Yiwei Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Center for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Yuji Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Center for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Wenyuan Wang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Center for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Yuting Tan
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Center for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Mingxing Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Center for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Li Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Center for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
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8
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Martos-Benítez FD, Burgos-Aragüez D, García-Mesa L, Orama-Requejo V, Cárdenas-González RC, Michelena-Piedra JC, Izquierdo-Castañeda J, Sánchez-de-la-Rosa E, Corrales-González O. Fluid balance, biomarkers of renal function and mortality in critically ill patients with AKI diagnosed before, or within 24 h of intensive care unit admission: a prospective study. J Nephrol 2024; 37:439-449. [PMID: 38189864 DOI: 10.1007/s40620-023-01829-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/08/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND To evaluate fluid balance, biomarkers of renal function and its relation to mortality in patients with acute kidney injury (AKI) diagnosed before, or within 24 h of intensive care unit admission. METHODS A prospective cohort study considered 773 critically ill patients observed over six years. Pre-intensive care unit-onset AKI was defined as AKI diagnosed before, or within 24 h of intensive care unit admission. Body weight-adjusted fluid balance and fluid balance-adjusted biomarkers of renal function were measured daily for the first three days of intensive care unit admission. Primary outcome was mortality in the intensive care unit. RESULTS Prevalence of pre-intensive care unit-onset AKI was 55.1%, of which 55.6% of cases were hospital-acquired and 44.4% were community-acquired. Fluid balance was higher in AKI patients than in non-AKI patients (p < 0.001) and had a negative correlation with urine output (p < 0.01). Positive fluid balance and biomarkers of renal function were independently related to mortality. Multivariate analysis identified the following AKI-related variables associated with increased mortality: (1) In AKI patients: type 1 cardiorenal syndrome (OR 2.00), intra-abdominal hypertension (OR 1.71), AKI stage 3 (OR 2.15) and increase in AKI stage (OR 4.99); 2) In patients with community-acquired AKI: type 1 cardiorenal syndrome (OR 5.16), AKI stage 2 (OR 2.72), AKI stage 3 (OR 4.95) and renal replacement therapy (OR 3.05); and 3) In patients with hospital-acquired AKI: intra-abdominal hypertension (OR 2.31) and increase in AKI stage (OR 4.51). CONCLUSIONS In patients with pre-intensive care unit-onset AKI, positive fluid balance is associated with worse renal outcomes. Positive fluid balance and decline in biomarkers of renal function are related to increased mortality, thus in this subpopulation of critically ill patients, positive fluid balance is not recommended and renal function must be closely monitored.
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Affiliation(s)
- Frank Daniel Martos-Benítez
- Intensive Care Unit, National Institute of Neurology and Neurosurgery, 29 St. and D St., Vedado, Plaza, 10400, Havana, Cuba.
| | - Dailé Burgos-Aragüez
- Intensive Care Unit-8, Hermanos Ameijeiras Hospital, San Lázaro St., Centro Havana, 10200, Havana, Cuba
| | - Liselotte García-Mesa
- Intensive Care Unit-8, Hermanos Ameijeiras Hospital, San Lázaro St., Centro Havana, 10200, Havana, Cuba
| | | | | | - Juan Carlos Michelena-Piedra
- Intensive Care Unit, National Institute of Neurology and Neurosurgery, 29 St. and D St., Vedado, Plaza, 10400, Havana, Cuba
| | - Judet Izquierdo-Castañeda
- Intensive Care Unit, National Institute of Neurology and Neurosurgery, 29 St. and D St., Vedado, Plaza, 10400, Havana, Cuba
| | - Ernesto Sánchez-de-la-Rosa
- Intensive Care Unit, National Institute of Neurology and Neurosurgery, 29 St. and D St., Vedado, Plaza, 10400, Havana, Cuba
| | - Olivia Corrales-González
- Intensive Care Unit, National Institute of Neurology and Neurosurgery, 29 St. and D St., Vedado, Plaza, 10400, Havana, Cuba
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Lu R, Ren J, Zhou X, Zheng B, Peng F. Risk factors for acute kidney injury associated with intravenous vancomycin in neurosurgical inpatients: a retrospective study. Eur J Clin Pharmacol 2024; 80:65-73. [PMID: 37889297 PMCID: PMC10781849 DOI: 10.1007/s00228-023-03581-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/15/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE Vancomycin (VAN) is widely used in neurosurgical patients for intracranial infections. We aimed to assess the incidence and risk factors for VAN-associated acute kidney injury (VA-AKI) in this population. METHODS A case-control study of patients who treated with vancomycin in neurosurgery from January 2020 to December 2022 was conducted. Demographics and potential risk factors were collected. Multivariate logistic regression analyses were performed to identify risk factors for VA-AKI. AKI was defined according to the Kidney Disease Improving Global Outcomes Guidelines (KDIGO). RESULTS A total of 345 patients participated with a VA-AKI incidence of 17.1% (59 cases). Among them, 15 patients had renal impairment (Stage 2 or higher), and 2 required dialysis. With univariate analysis and binary logistic regression analysis, we found that the use of mannitol (OR: 4.164; 95% CI: 1.606-10.792; P = 0.003), loop diuretics (OR: 3.371; 95% CI: 1.633-6.958; P = 0.001), three or more antimicrobial applications (OR: 3.623; 95% CI: 1.600-8.206; P = 0.002), diastolic blood pressure 80-89 mm Hg (OR: 5.532; 95% CI: 1.677-18.250; P = 0.005) and diastolic blood pressure ≥ 90 mm Hg (OR: 6.845; 95% CI: 1.518-30.866; P = 0.012) were independent risk factors for VA-AKI. In addition, according to the Youden Index, the trough concentration of vancomycin should not exceed 15.845 mg/L. CONCLUSION The incidence of VA-AKI in neurosurgical patients was 17.1%. The concomitant use of mannitol and loop diuretics, along with higher diastolic blood pressure and the combined use of more than three antimicrobial agents, were associated with an increased risk of neurosurgical VA-AKI.
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Affiliation(s)
- Ruqi Lu
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, 030001, China
| | - Junli Ren
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, 030001, China
| | - Xuanping Zhou
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, 030001, China
| | - Bin Zheng
- Department of Pharmacy, Shanxi Provincial People's Hospital, Shuangtasi Street 29#, Taiyuan, Shanxi, 030012, China
| | - Fangchen Peng
- Department of Pharmacy, Shanxi Provincial People's Hospital, Shuangtasi Street 29#, Taiyuan, Shanxi, 030012, China.
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Teixeira JP, Zeidman A, Beaubien-Souligny W, Cerdá J, Connor MJ, Eggleston K, Juncos LA, da Silva JR, Wells C, Yessayan L, Barker AB, McConville W, Speer R, Wille KM, Neyra JA, Tolwani A. Proceedings of the 2022 UAB CRRT Academy: Non-Invasive Hemodynamic Monitoring to Guide Fluid Removal with CRRT and Proliferation of Extracorporeal Blood Purification Devices. Blood Purif 2023; 52:857-879. [PMID: 37742622 DOI: 10.1159/000533573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/29/2023] [Indexed: 09/26/2023]
Abstract
In 2022, we celebrated the 15th anniversary of the University of Alabama at Birmingham (UAB) Continuous Renal Replacement Therapy (CRRT) Academy, a 2-day conference attended yearly by an international audience of over 100 nephrology, critical care, and multidisciplinary trainees and practitioners. This year, we introduce the proceedings of the UAB CRRT Academy, a yearly review of select emerging topics in the field of critical care nephrology that feature prominently in the conference. First, we review the rapidly evolving field of non-invasive hemodynamic monitoring and its potential to guide fluid removal by renal replacement therapy (RRT). We begin by summarizing the accumulating data associating fluid overload with harm in critical illness and the potential for harm from end-organ hypoperfusion caused by excessive fluid removal with RRT, underscoring the importance of accurate, dynamic assessment of volume status. We describe four applications of point-of-care ultrasound used to identify patients in need of urgent fluid removal or likely to tolerate fluid removal: lung ultrasound, inferior vena cava ultrasound, venous excess ultrasonography, and Doppler of the left ventricular outflow track to estimate stroke volume. We briefly introduce other minimally invasive hemodynamic monitoring technologies before concluding that additional prospective data are urgently needed to adapt these technologies to the specific task of fluid removal by RRT and to learn how best to integrate them into practical fluid-management strategies. Second, we focus on the growth of novel extracorporeal blood purification devices, starting with brief reviews of the inflammatory underpinnings of multiorgan dysfunction and the specific applications of pathogen, endotoxin, and/or cytokine removal and immunomodulation. Finally, we review a series of specific adsorptive technologies, several of which have seen substantial clinical use during the COVID-19 pandemic, describing their mechanisms of target removal, the limited existing data supporting their efficacy, ongoing and future studies, and the need for additional prospective trials.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology and Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Amanda Zeidman
- Division of Nephrology, Department of Medicine, Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Jorge Cerdá
- Department of Medicine, Nephrology, Albany Medical College, Albany, New York, USA
| | - Michael J Connor
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine and Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Luis A Juncos
- Division of Nephrology, Department of Internal Medicine, Central Arkansas Veterans' Healthcare System, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Catherine Wells
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew B Barker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Wendy McConville
- School of Nursing, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Rajesh Speer
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Keith M Wille
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Ashita Tolwani
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
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White KC, Nasser A, Gatton ML, Laupland KB. Current management of fluid balance in critically ill patients with acute kidney injury: A scoping review. CRIT CARE RESUSC 2023; 25:126-135. [PMID: 37876369 PMCID: PMC10581269 DOI: 10.1016/j.ccrj.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objective The overall objective of this scoping review is to assess the extent of the literature related to the fluid management of critically ill patients with acute kidney injury (AKI). Introduction AKI is common in critically ill patients where fluid therapy is a mainstay of treatment. An association between fluid balance (FB) and adverse patient-centred outcomes in critically ill patients with AKI regardless of severity has been demonstrated. The evidence for the prospective intervention of FB and its impact on outcomes is unknown. Inclusion criteria All studies investigating FB in patients with AKI admitted to an intensive care unit were included. Literature not related to FB in the critically ill patient with AKI population was excluded. Methods We searched MEDLINE, EMBASE, and CINAHL from January 1st, 2012, onwards. We included primary research studies, experimental and observational, recruiting adult participants admitted to an intensive care unit who had an AKI. We extracted data on study and patient characteristics, as well as FB, renal-based outcomes, and patient-centred outcomes. Two reviewers independently screened citations for eligible studies and performed data extraction. Results Of the 13,767 studies reviewed, 22 met the inclusion criteria. Two studies examined manipulation of fluid input, 18 studies assessed enhancing fluid removal, and two studies applied a restrictive fluid protocol. Sixteen studies examined patients receiving renal replacement therapy, five studies included non-renal replacement therapy patients, and one study included both. Current evidence is broad with varied approaches to managing fluid input and fluid removal. The studies did not demonstrate a consensus approach for any aspect of the fluid management of critically ill patients. There was a limited application of a restrictive fluid protocol with no conclusions possible. Conclusions The current body of evidence for the management of FB in critically ill patients with AKI is limited in nature. The current quality of evidence is unable to guide current clinical practice. The key outcome of this review is to highlight areas for future research.
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Affiliation(s)
- Kyle C. White
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- Intensive Care Unit, Queen Elizabeth II Jubilee Hospital, Coopers Plains, Queensland, Australia
| | - Ahmad Nasser
- Intensive Care Unit, Queen Elizabeth II Jubilee Hospital, Coopers Plains, Queensland, Australia
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Michelle L. Gatton
- Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Kevin B. Laupland
- Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Zhang Y, Ghahramani N, Razjouyan H, Ba DM, Chinchilli VM. The association between proton pump inhibitor use and risk of post-hospitalization acute kidney injury: a multicenter prospective matched cohort study. BMC Nephrol 2023; 24:150. [PMID: 37237361 DOI: 10.1186/s12882-023-03211-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/22/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Proton Pump Inhibitors (PPI) are among the most commonly used drugs to treat acid-related gastrointestinal disorders in the USA. Although PPI use has been linked to acute interstitial nephritis, the side effects of post-hospitalization acute kidney injury (AKI) and the progression of kidney disease still are controversial. We conducted a matched cohort study to examine the associations between PPI use and the side effects, especially in post-hospitalization AKI. METHODS We investigated 340 participants from the multicenter, prospective, matched-cohort ASSESS-AKI study, which enrolled participants from December 2009 to February 2015. After the baseline index hospitalization, follow-up visits were conducted every six months, and included a collection of self-reported PPI use by participants. Post-hospitalization AKI was defined as the percentage increase from the nadir to peak inpatient SCr value was ≥ 50% and/or absolute increase ≥ 0.3 mg/dL in peak inpatient serum creatinine compared with baseline outpatient serum creatinine. We applied a zero-inflated negative binomial regression model to test the relationship between PPI use and post-hospitalization AKI. Stratified Cox proportional hazards regression models also were conducted to examine the association between PPI use and the risk of progression of kidney disease. RESULTS After controlling for demographic variables, baseline co-morbidities and drug use histories, there was no statistically significant association between PPI use and risk of post-hospitalization AKI (risk ratio [RR], 0.91; 95% CI, 0.38 to 1.45). Stratified by AKI status at baseline, no significant relationships were confirmed between PPI use and the risk of recurrent AKI (RR, 0.85; 95% CI, 0.11 to 1.56) or incidence of AKI (RR, 1.01; 95% CI, 0.27 to 1.76). Similar non-significant results also were observed in the association between PPI use and the risk of progression of kidney diseases (Hazard Ratio [HR], 1.49; 95% CI, 0.51 to 4.36). CONCLUSION PPI use after the index hospitalization was not a significant risk factor for post-hospitalization AKI and progression of kidney diseases, regardless of the AKI status of participants at baseline.
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Affiliation(s)
- Yue Zhang
- Department of Public Health Sciences, Penn State College of Medicine, 90 Hope Drive, Hershey, PA, 17033, USA.
| | - Nasrollah Ghahramani
- Department of Public Health Sciences, Penn State College of Medicine, 90 Hope Drive, Hershey, PA, 17033, USA
- Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Hadie Razjouyan
- Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Djibril M Ba
- Department of Public Health Sciences, Penn State College of Medicine, 90 Hope Drive, Hershey, PA, 17033, USA
| | - Vernon M Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, 90 Hope Drive, Hershey, PA, 17033, USA
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13
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Guinot PG, Huette P, Bouhemad B, Abou-Arab O, Nguyen M. A norepinephrine weaning strategy using dynamic arterial elastance is associated with reduction of acute kidney injury in patients with vasoplegia after cardiac surgery: A post-hoc analysis of the randomized SNEAD study. J Clin Anesth 2023; 88:111124. [PMID: 37099874 DOI: 10.1016/j.jclinane.2023.111124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/23/2023] [Accepted: 04/07/2023] [Indexed: 04/28/2023]
Abstract
STUDY OBJECTIVE To evaluate the impact of a dynamic arterial elastance guided norepinephrine weaning strategy on the occurrence of acute kidney injury (AKI) in patients with vasoplegia after cardiac surgery. DESIGN A post-hoc analysis of a monocentric randomized controlled trial. SETTING A tertiary care hospital in France. PARTICIPANTS Vasoplegic cardiac surgical patients treated with norepinephrine. INTERVENTION Patients were randomized to an algorithm-based norepinephrine weaning intervention (dynamic arterial elastance) group or a control group. MEASUREMENTS The primary endpoint was the number of patients with AKI defined according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. The secondary endpoint were major adverse cardiac post-operative events (new onset of atrial fibrillation or flutter, low cardiac output syndrome, and in-hospital death). End points were evaluated during the first seven post-operative days. RESULTS 118 patients were analyzed. In the overall study population, the mean age was 70 (62-76) years, 65% were male and the median EuroSCORE was 7 (5-10). Overall, 46 (39%) patients developed AKI (30 KDIGO 1, 8 KDIGO 2, 8 KDIGO 3), and 6 patients required renal replacement therapy. The incidence of AKI was significantly lower in the intervention group than in the control group (16 patients (27%) vs 30 patients (51%), p = 0.12). Higher dose and longer duration of norepinephrine were associated with AKI severity. CONCLUSION Decreasing norepinephrine exposure by using a dynamic arterial elastance guided norepinephrine weaning strategy was associated with a reduced incidence of acute kidney injury in patients with vasoplegia after cardiac surgery. Further prospective multicentric studies are needed to confirm these results.
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Affiliation(s)
- Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France.
| | - Pierre Huette
- Department of Anaesthesiology and Critical Care Medicine, Amiens University Medical Centre, 80000 Amiens, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France
| | - Osama Abou-Arab
- Department of Anaesthesiology and Critical Care Medicine, Amiens University Medical Centre, 80000 Amiens, France
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France
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14
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Jiang X, Zhang W, Pan Y, Cheng X. Identification of subphenotypes in critically ill thrombocytopenic patients with different responses to therapeutic interventions: a retrospective study. Front Med (Lausanne) 2023; 10:1166896. [PMID: 37181358 PMCID: PMC10174319 DOI: 10.3389/fmed.2023.1166896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/10/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction The causes of thrombocytopenia (TP) in critically ill patients are numerous and heterogeneous. Currently, subphenotype identification is a popular approach to address this problem. Therefore, this study aimed to identify subphenotypes that respond differently to therapeutic interventions in patients with TP using routine clinical data and to improve individualized management of TP. Methods This retrospective study included patients with TP admitted to the intensive care unit (ICU) of Dongyang People's Hospital during 2010-2020. Subphenotypes were identified using latent profile analysis of 15 clinical variables. The Kaplan-Meier method was used to assess the risk of 30-day mortality for different subphenotypes. Multifactorial Cox regression analysis was used to analyze the relationship between therapeutic interventions and in-hospital mortality for different subphenotypes. Results This study included a total of 1,666 participants. Four subphenotypes were identified by latent profile analysis, with subphenotype 1 being the most abundant and having a low mortality rate. Subphenotype 2 was characterized by respiratory dysfunction, subphenotype 3 by renal insufficiency, and subphenotype 4 by shock-like features. Kaplan-Meier analysis revealed that the four subphenotypes had different in-30-day mortality rates. The multivariate Cox regression analysis indicated a significant interaction between platelet transfusion and subphenotype, with more platelet transfusion associated with a decreased risk of in-hospital mortality in subphenotype 3 [hazard ratio (HR): 0.66, 95% confidence interval (CI): 0.46-0.94]. In addition, there was a significant interaction between fluid intake and subphenotype, with a higher fluid intake being associated with a decreased risk of in-hospital mortality for subphenotype 3 (HR: 0.94, 95% CI: 0.89-0.99 per 1 l increase in fluid intake) and an increased risk of in-hospital mortality for high fluid intake in subphenotypes 1 (HR: 1.10, 95% CI: 1.03-1.18 per 1 l increase in fluid intake) and 2 (HR: 1.19, 95% CI: 1.08-1.32 per 1 l increase in fluid intake). Conclusion Four subphenotypes of TP in critically ill patients with different clinical characteristics and outcomes and differential responses to therapeutic interventions were identified using routine clinical data. These findings can help improve the identification of different subphenotypes in patients with TP for better individualized treatment of patients in the ICU.
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Xie CM, Yao YT, Yang K, Shen MQ, He LX, Dai Z. Furosemide does not reduce the incidence of postoperative acute kidney injury in adult patients undergoing cardiac surgery: A PRISMA-compliant systematic review and meta-analysis. J Card Surg 2022; 37:4850-4860. [PMID: 36345680 DOI: 10.1111/jocs.17120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/27/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Acute kidney injury (AKI) is a common complication of cardiac surgical patients, the occurrence of which is multifactorial. Furosemide is the most common loop diuretic and widely used in cardiac surgery to reduce fluid overload, increase tubular flow and urine output. It remains unknown whether furosemide affects the incidence or prognosis of cardiac surgery-induced acute kidney injury (CS-AKI). Therefore, the current study was performed to address this question. METHODS PubMed, Embase, Scopus, Cochrane Library, and Web of Science databases were searched for relevant studies. Primary outcomes of interest included postoperative CS-AKI incidence, need for renal replacement therapy (RRT) rate. Secondary outcomes of interest included postoperative serum creatinine (Scr) and blood urea nitrogen (BUN) levels, postoperative mechanical ventilation duration (MVD), length of stay (LOS) in intensive care unit (ICU) and in hospital, and mortality. The odds ratio (OR) and/or the weighted mean difference (WMD) with 95% confidence interval (CI) were used to pool the data. RESULTS Database search yielded six studies including 566 adult patients, and 283 patients were allocated into Group Furosemide and 283 into Group Control (Placebo). Heterogeneity between studies was deemed acceptable, and the publication bias was low. Meta-analysis suggested that furosemide administration in adult cardiac surgical patients had no effect on CS-AKI incidence (n = 4 trials; OR = 0.92; 95% CI: 0.37-2.30; p = .86; I2 = 57%) and need for RRT rate (n = 2 trials; OR = 4.13; 95% CI: 0.44-38.51; p = .21; I2 = 0%). Diversely, furosemide administration in adult cardiac surgical patients significantly decreased postoperative BUN level (n = 3 trials; WMD = 0.71; 95% CI: 0.10-1.33; p = .02; I2 = 0%), postoperative MVD (n = 2 trials; WMD = -3.13; 95% CI: -3.78 to -2.49; p < .00001; I2 = 0%) and postoperative LOS in ICU (n = 3 trials; WMD = -0.47; 95% CI: -0.76 to -0.18; p = .001; I2 = 0%). However, it had no significant impact on postoperative Scr level, postoperative LOS in hospital, and postoperative mortality. CONCLUSION This meta-analysis suggested that furosemide administration in adult cardiac surgical patients had no significant effect on CS-AKI incidence, need for RRT rate, postoperative Scr level, LOS in hospital and mortality, but could reduce postoperative BUN level, MVD, and LOS in ICU. As only a limited number of studies were included, these results should be interpreted carefully and cautiously. Future high-quality randomized controlled trials are needed to define the role of furosemide in CS-AKI prevention and management.
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Affiliation(s)
- Chun-Mei Xie
- Department of Anesthesiology, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, China
| | - Yun-Tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ke Yang
- Department of Anesthesiology, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, China
| | - Meng-Qi Shen
- Department of Anesthesiology, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, China
| | - Li-Xian He
- Department of Anesthesiology, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, China
| | - Zhen Dai
- Department of Anesthesiology, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, China
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Carter AW, Engoren M. Factors associated with occurrence and severity of acute kidney injury in patients with Sepsis - A retrospective database study. J Crit Care 2022; 72:154150. [PMID: 36244255 DOI: 10.1016/j.jcrc.2022.154150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/12/2022] [Accepted: 09/04/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Sepsis remains the most common cause of acute kidney injury (AKI) and is associated with a high mortality. This study aims to identify laboratory, clinical and demographic factors that are associated with the different stages of AKI in sepsis. METHODS We studied patients >18 years who met Sepsis-3 criteria between July 10, 2009 and September 7, 2019 using ordinal logistic regression to determine the factors associated with different stages of AKI. Sensitivity analyses for development of any stage vs no AKI and, separately, the factors associated with receipt of kidney replacement therapy were also done. RESULTS Of 31,228 patients meeting Sepsis-3 criteria, 4684 (15%) developed AKI. Of the AKI patients, 53% were KDIGO stage 1, 9% stage 2, and 37% stage 3, with 27% of AKI patients receiving kidney replacement therapy (Stage 3b). Several comorbidities, mechanical ventilation, and pre-sepsis creatinine levels were associated with AKI occurrence and severity. Positive blood culture was associated with a higher risk (OR 1.10 [1.06, 1.15], p < 0.001), while positive respiratory, urine, and wound cultures were associated with lower risks of developing AKI and with lower severity. CONCLUSION Presepsis creatinine levels, mechanical ventilation, comorbidities, and positive blood cultures were associated with AKI.
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Affiliation(s)
- Adam W Carter
- Department of Anesthesiology, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI 48109, United States.
| | - Milo Engoren
- Department of Anesthesiology, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI 48109, United States.
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Zhu S, Zhang Y, Qiao W, Wang Y, Xie Y, Zhang X, Wu C, Wang G, Li Y, Dong N, Xie M, Zhang L. Incremental value of preoperative right ventricular function in predicting moderate to severe acute kidney injury after heart transplantation. Front Cardiovasc Med 2022; 9:931517. [PMID: 36017097 PMCID: PMC9398196 DOI: 10.3389/fcvm.2022.931517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/18/2022] [Indexed: 11/21/2022] Open
Abstract
Background Acute kidney injury (AKI) commonly occurs after heart transplantation (HTx), but its association with preoperative right ventricular (RV) function remains unknown. Consequently, we aimed to determine the predictive value of preoperative RV function for moderate to severe AKI after HTx. Materials and methods From 1 January 2016 to 31 December 2019, all the consecutive HTx recipients in our center were enrolled and analyzed for the occurrence of postoperative AKI staged by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Conventional RV function parameters, including RV fractional area change (RVFAC) and tricuspid annular plane systolic excursion (TAPSE), were obtained. The primary endpoint was moderate to severe AKI (the KDIGO stage 2 or 3). The secondary endpoints included the impact of AKI on intensive care unit (ICU) mortality, in-hospital mortality, and 1-year mortality. Results A total of 273 HTx recipients were included in the study. Postoperative AKI occurred in 209 (77%) patients, including 122 (45%) patients in stage 1 AKI, 49 (18%) patients in stage 2 AKI, and 38 (14%) patients in stage 3 AKI. Patients with higher AKI stage had lower baseline estimated glomerular filtration rate (eGFR), more frequent diabetes, higher right atrial pressure (RAP), longer cardiopulmonary bypass (CPB) duration, more perioperative red blood cell (RBC) transfusions, and worse preoperative RV function. A multivariate logistic regression model incorporating previous diabetes mellitus [odds ratio (OR): 2.21; 95% CI: 1.06–4.61; P = 0.035], baseline eGFR (OR: 0.99; 95% CI: 0.97–0.10; P = 0.037), RAP (OR: 1.05; 95% CI: 1.00–1.10; P = 0.041), perioperative RBC (OR: 1.18; 95% CI: 1.08–1.28; P < 0.001), and TAPSE (OR: 0.84; 95% CI: 0.79–0.91; P < 0.001) was established to diagnose moderate to severe AKI more accurately [the area under the curve (AUC) = 79.8%; Akaike information criterion: 274]. Conclusion Preoperative RV function parameters provide additional predicting value over clinical and hemodynamic parameters, which are imperative for risk stratification in patients with HTx at higher risk of AKI.
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Affiliation(s)
- Shuangshuang Zhu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yanting Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Weihua Qiao
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yixuan Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuji Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Xin Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chun Wu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Guohua Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuman Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Nianguo Dong,
| | - Mingxing Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
- Mingxing Xie,
| | - Li Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
- Li Zhang,
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18
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Macdonald DB, Hurrell C, Costa AF, McInnes MDF, O'Malley ME, Barrett B, Brown PA, Clark EG, Hadjivassiliou A, Kirkpatrick IDC, Rempel JL, Jeon PM, Hiremath S. Canadian Association of Radiologists Guidance on Contrast Associated Acute Kidney Injury. Can Assoc Radiol J 2022; 73:499-514. [PMID: 35608223 DOI: 10.1177/08465371221083970] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Iodinated contrast media (ICM) is one of the most frequently administered pharmaceuticals. In Canada, over 5.4 million computed tomography (CT) examinations were performed in 2019, of which 50% were contrast enhanced. Acute kidney injury (AKI) occurring after ICM administration was historically considered a common iatrogenic complication which was managed by screening patients, prophylactic strategies, and follow up evaluation of renal function. The Canadian Association of Radiologists (CAR) initially published guidelines on the prevention of contrast induced nephropathy in 2007, with an update in 2012. However, new developments in the field have led to the availability of safer contrast agents and changes in clinical practice, prompting a complete revision of the earlier recommendations. This revised guidance document was developed by a multidisciplinary CAR Working Group of radiologists and nephrologists, and summarizes changes in practice related to contrast administration, screening, and risk stratification since the last guideline. It reviews the scientific evidence for contrast associated AKI and provides consensus-based recommendations for its prevention and management in the Canadian healthcare context. This article is a joint publication in the Canadian Association of Radiologists Journal and Canadian Journal of Kidney Health and Disease, intended to inform both communities of practice.
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Affiliation(s)
- D Blair Macdonald
- 6363Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Casey Hurrell
- Canadian Association of Radiologists, Ottawa, ON, Canada
| | - Andreu F Costa
- Department of Radiology, Queen Elizabeth II Health Sciences Centre, 3688Dalhousie University, Halifax, NS, Caanada
| | - Matthew D F McInnes
- 6363Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Martin E O'Malley
- Princess Margaret Hospital, Joint Department of Medical Imaging, 7938University of Toronto, Toronto, ON, Canada
| | | | - Pierre Antoine Brown
- Department of Medicine, University of Ottawa, 12365The Ottawa Hospital, Ottawa, ON, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, 153006University of Ottawa, Ottawa, ON, Canada
| | | | | | - Jeremy L Rempel
- 3158Department of Radiology, University of Alberta Hospital, University of Alberta, Edmonton, AB, Canada
| | - Paul M Jeon
- 7512Memorial University, St John's, NL, Canada
| | - Swapnil Hiremath
- Department of Medicine, University of Ottawa, 12365The Ottawa Hospital, Ottawa, ON, Canada
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Zhou L, Li Y, Gao Q, Lin Y, Su L, Chen R, Cao Y, Xu R, Luo F, Gao P, Zhang X, Li P, Nie S, Tang Y, Xu X. Loop Diuretics Are Associated with Increased Risk of Hospital-Acquired Acute Kidney Injury in Adult Patients: A Retrospective Study. J Clin Med 2022; 11:jcm11133665. [PMID: 35806949 PMCID: PMC9267783 DOI: 10.3390/jcm11133665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/08/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023] Open
Abstract
Background: The association between loop diuretics and acute kidney injury (AKI) remains unclear. Methods: The population studied was selected from the Epidemiology of AKI in Chinese Hospitalized patients (EACH) study. Exposure to loop diuretics was defined as any filled prescription prior to the date when AKI was detected in patients with HA-AKI, and prior to the last date of SCr testing in those without AKI. The outcome was AKI, defined by the Kidney Disease Improving Global Outcomes criteria. Associations between loop diuretics and HA-AKI were examined by Cox proportional hazards models adjusted for baseline and time-dependent covariates. Results: Of the 150,020 patients, 16,437 (11.0%) were prescribed loop diuretics, and 5717 (3.8%) experienced HA-AKI events. The crude rates of HA-AKI in patients who were and were not prescribed loop diuretics were 1632 (9.9%) and 3262 (2.8%), respectively. A multivariate cox proportional hazards analysis showed that exposure to loop diuretics was associated with significantly increased risks of HA-AKI compared with non-users (hazard ratio (HR), 1.61; 95% CI (confidence interval), 1.55–1.67), other diuretics (HR, 1.09; 95% CI, 1.03–1.15), and osmotic diuretics (HR, 1.30; 95% CI, 1.20–1.42). Compared with other diuretics, the use of loop diuretics was associated with higher risks of HA-AKI in women, in patients without hypertension, in patients without heart failure, in patients without liver cirrhosis, and in patients not requiring surgery. Conclusions: Loop diuretics are widely used and are associated with increased risks of HA-AKI in hospitalized adults. Renal function should be more closely monitored during the use of loop diuretics.
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Affiliation(s)
- Liping Zhou
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Division of Nephrology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China; (L.Z.); (Y.L.); (Q.G.); (Y.L.); (L.S.); (R.C.); (Y.C.); (R.X.); (F.L.); (P.G.); (X.Z.); (P.L.); (S.N.)
| | - Yanqin Li
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Division of Nephrology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China; (L.Z.); (Y.L.); (Q.G.); (Y.L.); (L.S.); (R.C.); (Y.C.); (R.X.); (F.L.); (P.G.); (X.Z.); (P.L.); (S.N.)
| | - Qi Gao
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Division of Nephrology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China; (L.Z.); (Y.L.); (Q.G.); (Y.L.); (L.S.); (R.C.); (Y.C.); (R.X.); (F.L.); (P.G.); (X.Z.); (P.L.); (S.N.)
| | - Yuxin Lin
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Division of Nephrology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China; (L.Z.); (Y.L.); (Q.G.); (Y.L.); (L.S.); (R.C.); (Y.C.); (R.X.); (F.L.); (P.G.); (X.Z.); (P.L.); (S.N.)
| | - Licong Su
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Division of Nephrology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China; (L.Z.); (Y.L.); (Q.G.); (Y.L.); (L.S.); (R.C.); (Y.C.); (R.X.); (F.L.); (P.G.); (X.Z.); (P.L.); (S.N.)
| | - Ruixuan Chen
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Division of Nephrology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China; (L.Z.); (Y.L.); (Q.G.); (Y.L.); (L.S.); (R.C.); (Y.C.); (R.X.); (F.L.); (P.G.); (X.Z.); (P.L.); (S.N.)
| | - Yue Cao
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Division of Nephrology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China; (L.Z.); (Y.L.); (Q.G.); (Y.L.); (L.S.); (R.C.); (Y.C.); (R.X.); (F.L.); (P.G.); (X.Z.); (P.L.); (S.N.)
| | - Ruqi Xu
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Division of Nephrology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China; (L.Z.); (Y.L.); (Q.G.); (Y.L.); (L.S.); (R.C.); (Y.C.); (R.X.); (F.L.); (P.G.); (X.Z.); (P.L.); (S.N.)
| | - Fan Luo
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Division of Nephrology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China; (L.Z.); (Y.L.); (Q.G.); (Y.L.); (L.S.); (R.C.); (Y.C.); (R.X.); (F.L.); (P.G.); (X.Z.); (P.L.); (S.N.)
| | - Peiyan Gao
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Division of Nephrology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China; (L.Z.); (Y.L.); (Q.G.); (Y.L.); (L.S.); (R.C.); (Y.C.); (R.X.); (F.L.); (P.G.); (X.Z.); (P.L.); (S.N.)
| | - Xiaodong Zhang
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Division of Nephrology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China; (L.Z.); (Y.L.); (Q.G.); (Y.L.); (L.S.); (R.C.); (Y.C.); (R.X.); (F.L.); (P.G.); (X.Z.); (P.L.); (S.N.)
| | - Pingping Li
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Division of Nephrology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China; (L.Z.); (Y.L.); (Q.G.); (Y.L.); (L.S.); (R.C.); (Y.C.); (R.X.); (F.L.); (P.G.); (X.Z.); (P.L.); (S.N.)
| | - Sheng Nie
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Division of Nephrology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China; (L.Z.); (Y.L.); (Q.G.); (Y.L.); (L.S.); (R.C.); (Y.C.); (R.X.); (F.L.); (P.G.); (X.Z.); (P.L.); (S.N.)
| | - Ying Tang
- Division of Nephrology, The Third Affiliated Hospital of Southern Medical University, Guangzhou 510515, China
- Correspondence: (Y.T.); (X.X.)
| | - Xin Xu
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Division of Nephrology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China; (L.Z.); (Y.L.); (Q.G.); (Y.L.); (L.S.); (R.C.); (Y.C.); (R.X.); (F.L.); (P.G.); (X.Z.); (P.L.); (S.N.)
- Correspondence: (Y.T.); (X.X.)
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20
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Macdonald DB, Hurrell CD, Costa AF, McInnes MDF, O’Malley M, Barrett BJ, Brown PA, Clark EG, Hadjivassiliou A, Kirkpatrick IDC, Rempel J, Jeon P, Hiremath S. Canadian Association of Radiologists Guidance on Contrast-Associated Acute Kidney Injury. Can J Kidney Health Dis 2022; 9:20543581221097455. [PMID: 35646375 PMCID: PMC9134018 DOI: 10.1177/20543581221097455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/28/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose Iodinated contrast media is one of the most frequently administered pharmaceuticals. In Canada, over 5.4 million computed tomography (CT) examinations were performed in 2019, of which 50% were contrast enhanced. Acute kidney injury (AKI) occurring after iodinated contrast administration was historically considered a common iatrogenic complication which was managed by screening patients, prophylactic strategies, and follow-up evaluation of renal function. The Canadian Association of Radiologists (CAR) initially published guidelines on the prevention of contrast induced nephropathy in 2007, with an update in 2012. However, new developments in the field have led to the availability of safer contrast agents and changes in clinical practice, prompting a complete revision of the earlier recommendations. Information sources Published literature, including clinical trials, retrospective cohort series, review articles, and case reports, along with expert opinions from radiologists and nephrologists across Canada. Methods The leadership of the CAR formed a working group of radiologists and nephrologists with expertise in contrast administration and patient management related to contrast-associated AKI. We conducted a comprehensive review of the published literature to evaluate the evidence about contrast as a cause of AKI, and to inform evidence-based recommendations. Based on the available literature, the working group developed consensus recommendations. Key Findings The working group developed 21 recommendations, on screening, choice of iodinated contrast media, prophylaxis, medication considerations, and post contrast administration management. The key changes from the 2012 guidelines were (1) Simplification of screening to a simple questionnaire, and not delaying emergent examinations due to a need for creatinine measurements (2) Prophylaxis considerations only for patients with estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m2 (3) Not recommending the routine discontinuation of any drugs to decrease risk of AKI, except metformin when eGFR is less than 30 mL/min/1.73 m2 and (4) Not requiring routine follow up serum creatinine measurements post iodinated contrast administration. Limitations We did not conduct a formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment. Implications Given the importance of iodinated contrast media use in diagnosis and management, and the low risk of AKI after contrast use, these guidelines aim to streamline the processes around iodinated contrast use in most clinical settings. As newer evidence arises that may change or add to the recommendations provided, the working group will revise these guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Paul Jeon
- Memorial University of Newfoundland, Saint John’s, NL, Canada
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21
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Abstract
The definition of sepsis has evolved significantly over the past three decades. Today, sepsis is defined as a dysregulated host immune response to microbial invasion leading to end organ dysfunction. Septic shock is characterized by hypotension requiring vasopressors after adequate fluid resuscitation with elevated lactate. Early recognition and intervention remain hallmarks for sepsis management. We addressed the current literature and assimilated thought regarding optimum initial resuscitation of the patient with sepsis. A nuanced understanding of the physiology of lactate is provided in our review. Physiologic and practical knowledge of steroid and vasopressor therapy for sepsis is crucial and addressed. As blood purification may interest the nephrologist treating sepsis, we have also added a brief discussion of its status.
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Affiliation(s)
- Sharad Patel
- Department of Critical Care, Rowan University Cooper Medical School, Camden, New Jersey
| | - Nitin Puri
- Department of Critical Care, Cooper Hospital University Medical Center, Camden, New Jersey
| | - R Phillip Dellinger
- Department of Critical Care, Cooper Hospital University Medical Center, Camden, New Jersey
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22
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Fu S, Wang Q, Chen W, Liu H, Li H. Development and External Validation of a Nomogram for Predicting Acute Kidney Injury in Cardiogenic Shock Patients in Intensive Care Unit. Int J Gen Med 2022; 15:3965-3975. [PMID: 35431570 PMCID: PMC9012501 DOI: 10.2147/ijgm.s353697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/24/2022] [Indexed: 11/25/2022] Open
Abstract
Background The aim of this study was to construct and external validate a nomogram for predicting cardiogenic shock acute kidney injury (CS-AKI) in patients in intensive care unit (ICU). Methods All patients diagnosed with CS from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database and the eICU Collaborative Research Database (eICU-CRD) were included in this study. Least absolute shrinkage and selection operator (LASSO) regression and recursive feature elimination for support vector machine (SVM-RFE) were used to determine the overlapping clinical features associated with CS-AKI. The predictive nomogram was established based on the significant clinical parameters and externally verified in this study. Results LASSO regression and SVM-RFE demonstrated that Charlson Comorbidity Index (CCI), usage of mechanical ventilation, SOFA score, white blood cell, albumin, eGFR, anion gap, and positive fluid balance were closely associated with CS-AKI in the training cohort. The predictive nomogram based on the eight parameters showed good predictive performance as calculated by C-index were 0.823 (95% confidence index, 95% CI 0.798–0.849), 0.819 (95% CI 0.769–0.849), and 0.733 (95% CI 0.704–0.763) in the training set, in the internal validation set and in the external validation sets, respectively. Moreover, the nomogram exhibited not only encouraging calibration ability but also great clinical utility in the training set and in the validation sets. Conclusion CCI, usage of mechanical ventilation, SOFA score, white blood cell, albumin, eGFR, anion gap, and positive fluid balance were closely associated with CS-AKI. The predictive nomogram for CS-AKI manifested well-predictive ability for the identification of ICU patients with CS-AKI.
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Affiliation(s)
- Shuai Fu
- Department of Nephrology, Wuhan, People’s Republic of China
| | - Quan Wang
- Department of Nephrology, Wuhan, People’s Republic of China
| | - Weidong Chen
- Department of Nephrology, Wuhan, People’s Republic of China
| | - Hong Liu
- Department of Nephrology, Wuhan, People’s Republic of China
| | - Hongbo Li
- Department of Nephrology, Wuhan, People’s Republic of China
- Correspondence: Hongbo Li, Department of Nephrology, Wuhan No. 1 Hospital, No.215 Zhongshan Avenue, Wuhan, Hubei, 430022, People’s Republic of China, Tel +86-27-85332343, Email
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23
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Wang J, Zheng X, Jiang Y, Jia H, Shi X, Han Y, Li Q, Li W. Soluble Programmed Cell Death Protein 1 and Its Ligand: Potential Biomarkers to Predict Acute Kidney Injury After Surgery in Critically Ill Patients. J Inflamm Res 2022; 15:1995-2008. [PMID: 35356070 PMCID: PMC8959723 DOI: 10.2147/jir.s356475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/11/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Jingyi Wang
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xi Zheng
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yijia Jiang
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Huimiao Jia
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaocui Shi
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yue Han
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Qingping Li
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Wenxiong Li
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
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24
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Nentwich J, John S. [Acute Kidney Injury]. Dtsch Med Wochenschr 2021; 147:26-33. [PMID: 34963171 DOI: 10.1055/a-1226-8905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
"Acute kidney injury" (AKI) describes any acute deterioration in kidney function but also only injury to the kidneys without a severe loss of function. It is a common and severe complication in patients on the intensive care unit with a significant impact on patient's mortality and morbidity. Since no specific pharmacological therapy exists, the early identification of patients at risk for AKI or with acute kidney damage is most important before renal function further deteriorates. A stage-based management of AKI comprises more general measures like discontinuation of nephrotoxic agent but most importantly early hemodynamic stabilization. Recent research has contradicted that AKI is renal ischemia caused by vasoconstriction with consecutive tubular necrosis. In septic AKI renal blood flow is even increased. Intrarenal vasodilation together with microcirculatory changes and redistribution of blood flow are leading to a drop in glomerular filtration by functional changes. Accordingly, it had to be learned that not vasodilators, but vasoconstrictors are beneficial in AKI. A mean arterial blood pressure target of > 65 mmHg is often recommended but exact targets are not known and patients with preexisting hypertension do even need a higher perfusion pressure. Also, the concept that fluid therapy is always beneficial for the kidney in shock states had to be revised. A volume restrictive therapy with balanced, chloride restricted crystalloids only, is important also in AKI. Exposure to contrast material is often associated with AKI but less common the direct cause of AKI, so if indicated, contrast material should not be withheld in patients at risk for AKI.
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25
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Gorga SM, Carlton EF, Kohne JG, Barbaro RP, Basu RK. Renal angina index predicts fluid overload in critically ill children: an observational cohort study. BMC Nephrol 2021; 22:336. [PMID: 34635072 PMCID: PMC8502791 DOI: 10.1186/s12882-021-02540-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 09/13/2021] [Indexed: 01/13/2023] Open
Abstract
Background Fluid overload and acute kidney injury are common and associated with poor outcomes among critically ill children. The prodrome of renal angina stratifies patients by risk for severe acute kidney injury, but the predictive discrimination for fluid overload is unknown. Methods Post-hoc analysis of patients admitted to a tertiary care pediatric intensive care unit (PICU). The primary outcome was the performance of renal angina fulfillment on day of ICU admission to predict fluid overload ≥15% on Day 3. Results 77/139 children (55%) fulfilled renal angina (RA+). After adjusting for covariates, RA+ was associated with increased odds of fluid overload on Day 3 (adjusted odds ratio (aOR) 5.1, 95% CI 1.23–21.2, p = 0.025, versus RA-). RA- resulted in a 90% negative predictive value for fluid overload on Day 3. Median fluid overload was significantly higher in RA+ patients with severe acute kidney injury compared to RA+ patients without severe acute kidney injury (% fluid overload on Day 3: 8.8% vs. 0.73%, p = 0.002). Conclusion Among critically ill children, fulfillment of renal angina was associated with increased odds of fluid overload versus the absence of renal angina and a higher fluid overload among patients who developed acute kidney injury. Renal angina directed risk classification may identify patients at highest risk for fluid accumulation. Expanded study in larger populations is warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02540-6.
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Affiliation(s)
- Stephen M Gorga
- Department of Pediatrics, University of Michigan Medical School, 1500 E. Medical Center Drive, F-6890, Ann Arbor, MI, 48109, USA.
| | - Erin F Carlton
- Department of Pediatrics, University of Michigan Medical School, 1500 E. Medical Center Drive, F-6890, Ann Arbor, MI, 48109, USA.,Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, MI, USA
| | - Joseph G Kohne
- Department of Pediatrics, University of Michigan Medical School, 1500 E. Medical Center Drive, F-6890, Ann Arbor, MI, 48109, USA.,Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, MI, USA
| | - Ryan P Barbaro
- Department of Pediatrics, University of Michigan Medical School, 1500 E. Medical Center Drive, F-6890, Ann Arbor, MI, 48109, USA.,Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, MI, USA
| | - Rajit K Basu
- Children's Healthcare of Atlanta/Emory University, Atlanta, GA, USA
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26
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Mayerhöfer T, Wiedermann CJ, Joannidis M. [Use of albumin : State of the art]. Med Klin Intensivmed Notfmed 2021; 116:655-664. [PMID: 34618163 PMCID: PMC8496431 DOI: 10.1007/s00063-021-00875-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 08/19/2021] [Accepted: 09/06/2021] [Indexed: 01/01/2023]
Abstract
The Saline versus Albumin Fluid Evaluation (SAFE) study has demonstrated that the use of albumin as an infusion solution in volume therapy can be regarded as safe. An exception is hypo-oncotic albumin in traumatic brain injury. While clear indications of albumin exist for some patients with liver cirrhosis, large studies that demonstrate a clinically relevant advantage beyond hemodynamic effects and would therefore justify wider use in many other areas are still lacking. In large-volume paracentesis, spontaneous bacterial peritonitis, but also in hepatorenal syndrome, use of albumin is recommended and established due to clinical benefit in randomized controlled trials. In septic shock, use of albumin may be considered, with two large studies addressing this issue in Germany and Italy being still in the recruitment phase. For volume therapy, albumin can be used primarily when other measures for hemodynamic stabilization have been exhausted. This applies to volume resuscitation in hypovolemia as well as in conservative fluid management in the so-called "de-resuscitation" phase. The extent to which the correction of severe hypoalbuminemia with exogenous albumin can improve the impaired outcome of these patients is also part of ongoing studies. On the way to a more individualized medicine, hypoalbuminemia may serve as a parameter in future decision making for or against the use of albumin in volume therapy.
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Affiliation(s)
- Timo Mayerhöfer
- Gemeinsame Einrichtung für Intensiv- und Notfallmedizin, Abteilung für Innere Medizin I, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Christian J Wiedermann
- Institut für Public Health, Medical Decision Making und HTA, UMIT Private Universität für Gesundheitswissenschaften, Medizinische Informatik und Technik, Hall in Tirol, Österreich.,Institut für Allgemeinmedizin, Landesfachhochschule für Gesundheitsberufe Claudiana, Bozen, Italien
| | - Michael Joannidis
- Gemeinsame Einrichtung für Intensiv- und Notfallmedizin, Abteilung für Innere Medizin I, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
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Zhao Y, Pu M, Wang Y, Yu L, Song X, He Z. Application of nanotechnology in acute kidney injury: From diagnosis to therapeutic implications. J Control Release 2021; 336:233-251. [PMID: 34171444 DOI: 10.1016/j.jconrel.2021.06.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 06/18/2021] [Accepted: 06/19/2021] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI), a major health issue concerning ~50% of patients treated in intensive care units, generally leads to severe renal damage associated with high mortality rate. The application of nanotechnology for the management of AKI has profound potential of further development, providing innovative strategies for predicting the early onset and progression of renal disease and improving the treatment efficacy of the life-threating AKI. This review has comprehensively summarized the nanomedicines in the application of AKI diagnosis and emphatically discussed the unique potential of various nanotechnology-based drug delivery systems (e.g., polymeric nanoparticles, organic nanoparticles, inorganic nanoparticles, lipid-based nanoparticles, hydrogels etc.) in the treatment of AKI, allowing for improved therapeutic index by enhancing both efficacy and safety concurrently. These approaches may mechanically mitigate oxidative stress, inflammation, and mitochondrial and other organellar damage, etc. In addition, the combination of nanotechnology with stem cells-based therapy or gene therapy has been explored for reducing renal tissues damage and promoting kidney repair or recovery from AKI. The review provides insights into the synthesis, advantages, and limitations of innovative nanomedicine application in the early detection and effective treatment of AKI.
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Affiliation(s)
- Yi Zhao
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, Qingdao 266100, China; College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao 266100, China
| | - Mingju Pu
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, Qingdao 266100, China; College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao 266100, China
| | - Yanan Wang
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, Qingdao 266100, China; College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao 266100, China
| | - Liangmin Yu
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, Qingdao 266100, China; College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao 266100, China.
| | - Xinyu Song
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, Qingdao 266100, China; College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao 266100, China
| | - Zhiyu He
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, Qingdao 266100, China; College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao 266100, China.
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Langston C, Gordon D. Effects of IV Fluids in Dogs and Cats With Kidney Failure. Front Vet Sci 2021; 8:659960. [PMID: 33959654 PMCID: PMC8093391 DOI: 10.3389/fvets.2021.659960] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/18/2021] [Indexed: 12/25/2022] Open
Abstract
Intravenous fluid therapy has long been the mainstay of treatment of kidney disease, including acute kidney injury and uremic crisis associated with chronic kidney disease. Careful management of fluid dose is critical, as animals with kidney disease may have marked derangements in their ability to regulate fluid homeostasis and acid-base status. Understanding of the physiology of renal fluid handling is necessary, along with repeated attention to parameters of fluid status, electrolytes, and acid-base balance, to achieve optimal hydration status and avoid further damage or decrease in function from dehydration or overhydration.
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Affiliation(s)
- Cathy Langston
- The Ohio State University College of Veterinary Medicine, Columbus, OH, United States
| | - Daniel Gordon
- The Ohio State University College of Veterinary Medicine, Columbus, OH, United States
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Felice VB, Lisboa TC, Souza LVD, Sell LC, Friedman G. Hemodynamically stable oliguric patients usually do not respond to fluid challenge. Rev Bras Ter Intensiva 2021; 32:564-570. [PMID: 33470358 PMCID: PMC7853676 DOI: 10.5935/0103-507x.20200094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 05/20/2020] [Indexed: 11/20/2022] Open
Abstract
Objective To evaluate renal responsiveness in oliguric critically ill patients after a fluid challenge. Methods We conducted a prospective observational study in one university intensive care unit. Patients with urine output < 0.5mL/kg/h for 3 hours with a mean arterial pressure > 60mmHg received a fluid challenge. We examined renal fluid responsiveness (defined as urine output > 0.5mL/kg/h for 3 hours) after fluid challenge. Results Forty-two patients (age 67 ± 13 years; APACHE II score 16 ± 6) were evaluated. Patient characteristics were similar between renal responders and renal nonresponders. Thirteen patients (31%) were renal responders. Hemodynamic or perfusion parameters were not different between those who did and those who did not increase urine output before the fluid challenge. The areas under the receiver operating characteristic curves were calculated for mean arterial pressure, heart rate, creatinine, urea, creatinine clearance, urea/creatinine ratio and lactate before the fluid challenge. None of these parameters were sensitive or specific enough to predict reversal of oliguria. Conclusion After achieving hemodynamic stability, oliguric patients did not increase urine output after a fluid challenge. Systemic hemodynamic, perfusion or renal parameters were weak predictors of urine responsiveness. Our results suggest that volume replacement to correct oliguria in patients without obvious hypovolemia should be done with caution.
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Affiliation(s)
- Vinicius Brenner Felice
- Unidade Central de Terapia Intensiva, Complexo Hospitalar Santa Casa de Porto Alegre - Porto Alegre (RS), Brasil.,Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Thiago Costa Lisboa
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Rede Institucional de Pesquisa e Inovação em Terapia Intensiva, Complexo Hospitalar Santa Casa de Porto Alegre - Porto Alegre (RS), Brasil
| | - Lucas Vieira de Souza
- Unidade Central de Terapia Intensiva, Complexo Hospitalar Santa Casa de Porto Alegre - Porto Alegre (RS), Brasil
| | - Luana Canevese Sell
- Unidade Central de Terapia Intensiva, Complexo Hospitalar Santa Casa de Porto Alegre - Porto Alegre (RS), Brasil
| | - Gilberto Friedman
- Unidade Central de Terapia Intensiva, Complexo Hospitalar Santa Casa de Porto Alegre - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
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30
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Zhao BC, Lei SH, Yang X, Zhang Y, Qiu SD, Liu WF, Li C, Liu KX. Assessment of prognostic value of intraoperative oliguria for postoperative acute kidney injury: a retrospective cohort study. Br J Anaesth 2020; 126:799-807. [PMID: 33342539 DOI: 10.1016/j.bja.2020.11.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 11/01/2020] [Accepted: 11/15/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Oliguria is often viewed as a sign of renal hypoperfusion and an indicator for volume expansion during surgery. However, the prognostic association and the predictive utility of intraoperative oliguria for postoperative acute kidney injury (AKI) are unclear. METHODS We conducted a retrospective cohort study on patients undergoing major thoracic surgery in an academic hospital to assess the association of intraoperative oliguria with postoperative AKI and its predictive value. To contextualise our findings, we included our results in a meta-analysis of observational studies on the importance of oliguria during noncardiac surgery. RESULTS In our cohort study, 3862 patients were included; 205 (5.3%) developed AKI after surgery. Intraoperative urine output of 0.3 ml kg-1 h-1 was the optimal threshold for oliguria in multivariable analysis. Patients with oliguria had an increased risk of AKI (adjusted odds ratio: 2.60; 95% confidence interval: 1.24-5.05). However, intraoperative oliguria had a sensitivity of 5.9%, specificity of 98%, positive likelihood ratio of 2.74, and negative likelihood ratio of 0.96, suggesting poor predictive ability. Moreover, it did not improve upon the predictive performance of a multivariable model, based on discrimination and reclassification indices. Our findings were generally consistent with the results of a systematic review and meta-analysis, including six additional studies. CONCLUSIONS Intraoperative oliguria has moderate association with, but poor predictive ability for, postoperative AKI. It remains of clinical interest as a risk factor potentially modifiable to interventions.
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Affiliation(s)
- Bing-Cheng Zhao
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shao-Hui Lei
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiao Yang
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ya Zhang
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shi-Da Qiu
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei-Feng Liu
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Cai Li
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ke-Xuan Liu
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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Abstract
Sepsis is a major cause of acute kidney injury (AKI) among patients in the intensive care unit. However, the numbers of basic science papers for septic AKI account for only 1% of all publications on AKI. This may be partially attributable to the specific pathophysiology of septic AKI as compared to that of the other types of AKI because it shows only modest histological changes despite functional decline and often requires real-time functional analysis. To increase the scope of research in this field, this article reviews the basic research information that has been reported thus far on the subject of septic AKI, mainly from the viewpoint of functional dysregulation, including some knowledge acquired with multiphoton intravital imaging. Moreover, the efficacy and limitation of the potential novel therapies are discussed. Finally, the author proposes several points that should be considered when designing the study, such as monitoring the long-term effects of the intervention and reflecting the clinical settings for identifying the molecular mechanisms and for challenging the intervention effects.
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Affiliation(s)
- Daisuke Nakano
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793, Japan.
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32
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Huang D, Ma H, Ma J, Hong L, Lian X, Wu Y, Wu Y, Wang S, Qin T, Tan N. A novel supplemental maneuver to predict fluid responsiveness in critically ill patients: blood pump-out test performed before renal replacement therapy. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:786. [PMID: 32647711 PMCID: PMC7333114 DOI: 10.21037/atm.2020.04.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Passive leg raising (PLR) test, known as reversible increasing venous return, could predict hemodynamic intolerance induced by renal replacement therapy (RRT). Oppositely, blood drainage procedure at the start of RRT cuts down intravascular capacity which is likely to have changes in fluid responsiveness has been little studied. Our study aimed to determine whether blood drainage procedure, defined as blood pump-out test, which is essential and inevitable at the beginning of RRT could predict fluid responsiveness in critically ill patients. Methods Critically ill patients underwent RRT with pulse contour analysis were included. During PLR, an increase of cardiac output (CO, derived from pulse contour analysis) ≥10% compared to baseline was considered responders as the gold standard. BPT was performed at a constant speed after the increase of CO induced by PLR returned to baseline and the maximal of CO within 2 minutes was recorded. Then area under ROC curve of CO changes to identify responders from non-responders in BPT was calculated based on the results from PLR test. Results Sixty-five patients were enrolled. Thirty-one/sixty-five patients (47.7%) were considered responders during PLR. And after analysis by ROC curve, a decrease in CO greater than 11.0% during BPT predicted fluid responsiveness with 70.9% sensitivity and 76.5% specificity. The highest area under the curve (AUC) was found for an increase in CO (0.74±0.06; 95% CI: 0.62 to 0.84). Conclusions BPT could be a supplement to PLR, providing a novel maneuver to predict fluid responsiveness in critically ill patients underwent RRT. (Trial registration: ChiCTR-DDD-17010534). Registered 30 January 2017 (retrospective registration).
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Affiliation(s)
- Daozheng Huang
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences/Guangdong Provincial Geriatrics Institute, Guangzhou 510080, China.,Department of Cardiology, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences/Guangdong Provincial Cardiovascular Institute, Guangzhou 510080, China
| | - Huan Ma
- Department of Cardiology, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences/Guangdong Provincial Cardiovascular Institute, Guangzhou 510080, China
| | - Jie Ma
- Department of Critical Care Medicine, Jiangmen Central Hospital, Jiangmen 529000, China
| | - Liyan Hong
- Department of Critical Care Medicine, Changjiang County People's Hospital, Changjiang 572700, China
| | - Xingji Lian
- Department of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Yanhua Wu
- Department of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Yan Wu
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences/Guangdong Provincial Geriatrics Institute, Guangzhou 510080, China
| | - Shouhong Wang
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences/Guangdong Provincial Geriatrics Institute, Guangzhou 510080, China
| | - Tiehe Qin
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences/Guangdong Provincial Geriatrics Institute, Guangzhou 510080, China
| | - Ning Tan
- Department of Cardiology, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences/Guangdong Provincial Cardiovascular Institute, Guangzhou 510080, China
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Vincent JL, Ferguson A, Pickkers P, Jakob SM, Jaschinski U, Almekhlafi GA, Leone M, Mokhtari M, Fontes LE, Bauer PR, Sakr Y. The clinical relevance of oliguria in the critically ill patient: analysis of a large observational database. Crit Care 2020; 24:171. [PMID: 32326981 PMCID: PMC7181534 DOI: 10.1186/s13054-020-02858-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 03/30/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Urine output is widely used as one of the criteria for the diagnosis and staging of acute renal failure, but few studies have specifically assessed the role of oliguria as a marker of acute renal failure or outcomes in general intensive care unit (ICU) patients. Using a large multinational database, we therefore evaluated the occurrence of oliguria (defined as a urine output < 0.5 ml/kg/h) in acutely ill patients and its association with the need for renal replacement therapy (RRT) and outcome. METHODS International observational study. All adult (> 16 years) patients in the ICON audit who had a urine output measurement on the day of admission were included. To investigate the association between oliguria and mortality, we used a multilevel analysis. RESULTS Of the 8292 patients included, 2050 (24.7%) were oliguric during the first 24 h of admission. Patients with oliguria on admission who had at least one additional 24-h urine output recorded during their ICU stay (n = 1349) were divided into three groups: transient-oliguria resolved within 48 h after the admission day (n = 390 [28.9%]), prolonged-oliguria resolved > 48 h after the admission day (n = 141 [10.5%]), and permanent-oliguria persisting for the whole ICU stay or again present at the end of the ICU stay (n = 818 [60.6%]). ICU and hospital mortality rates were higher in patients with oliguria than in those without, except for patients with transient oliguria who had significantly lower mortality rates than non-oliguric patients. In multilevel analysis, the need for RRT was associated with a significantly higher risk of death (OR = 1.51 [95% CI 1.19-1.91], p = 0.001), but the presence of oliguria on admission was not (OR = 1.14 [95% CI 0.97-1.34], p = 0.103). CONCLUSIONS Oliguria is common in ICU patients and may have a relatively benign nature if only transient. The duration of oliguria and need for RRT are associated with worse outcome.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Andrew Ferguson
- Department of Intensive Care Medicine, Belfast City Hospital, Belfast, UK
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stephan M Jakob
- Department of Intensive Care Medicine, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Ulrich Jaschinski
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik Augsburg, Universität Augsburg, Augsburg, Germany
| | | | - Marc Leone
- Service d'Anesthésie et de Réanimation, APHM, Hôpital Nord, Aix Marseille Université, Marseille, France
| | | | - Luis E Fontes
- Departamento de Medicina Baseada em Evidências, Medicina Intensiva, Urgência e Emergência - Faculdade de Medicina de Petrópolis, Petrópolis, Brazil
| | - Philippe R Bauer
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yasser Sakr
- Departament of Anaesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany
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Oyama Y, Iwafuchi Y, Morioka T, Narita I. Acute Kidney Injury Associated with Minimal Change Nephrotic Syndrome in an Elderly Patient Successfully Treated with both Fluid Management and Specific Therapy Based on Kidney Biopsy Findings. Case Rep Nephrol Dial 2020; 10:42-50. [PMID: 32399474 PMCID: PMC7204776 DOI: 10.1159/000507426] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 03/22/2020] [Indexed: 01/04/2023] Open
Abstract
Oliguric acute kidney injury (AKI) with minimal change nephrotic syndrome (MCNS) has long been recognized. Several mechanisms such as hypovolemia due to hypoalbuminemia and the nephrosarca hypothesis have been proposed. However, the precise mechanism by which MCNS causes AKI has not been fully elucidated. Herein, we describe an elderly patient with AKI caused by MCNS who fully recovered after aggressive volume withdrawal by hemodialysis and administration of a glucocorticoid. A 75-year-old woman presented with diarrhea and oliguria, and laboratory examination revealed nephrotic syndrome (NS) and severe azotemia. Fluid administration had no effect on renal dysfunction, and hemodialysis was initiated. Her renal function improved upon aggressive fluid removal through hemodialysis. Renal pathological findings revealed minimal change disease with faint mesangial deposits of IgA. After administration of methylprednisolone pulse therapy followed by oral prednisolone, she achieved complete remission from NS. The clinical course of this case supports the nephrosarca hypothesis regarding the mechanism of AKI caused by MCNS. Furthermore, appropriate fluid management and kidney biopsy are also important in elderly patients with AKI caused by NS.
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Affiliation(s)
- Yuko Oyama
- Department of Internal Medicine, Koseiren Sanjo General Hospital, Sanjo, Japan
| | - Yoichi Iwafuchi
- Department of Internal Medicine, Koseiren Sanjo General Hospital, Sanjo, Japan
| | - Tetsuo Morioka
- Department of Internal Medicine, Kidney Center, Shinrakuen Hospital, Niigata, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Major Adverse Kidney Events Are Associated with the Aquaporin 5 -1364A/C Promoter Polymorphism in Sepsis: A Prospective Validation Study. Cells 2020; 9:cells9040904. [PMID: 32272738 PMCID: PMC7226758 DOI: 10.3390/cells9040904] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 04/05/2020] [Indexed: 12/29/2022] Open
Abstract
Since the functionally important AQP5 -1364A/C single nucleotide promoter polymorphism alters key mechanisms of inflammation and survival in sepsis, it may affect the risk of an acute kidney injury. Accordingly, we tested the hypothesis in septic patients that this AQP5 polymorphism is associated with major adverse kidney events and also validated its impact on 90-day survival. In this prospective observational monocentric genetic association study 282 septic patients were included and genotyped for the AQP5 –1364A/C polymorphism (rs3759129). The primary endpoint was the development of major adverse kidney events within 30 days. In AC/CC genotypes, major adverse kidney events were less frequent (41.7%) than in AA genotypes (74.3%; OR:0.34; 95%-CI: 0.18–0.62; p < 0.001). Ninety-day survival was also associated with the AQP5 polymorphism (p = 0.004), with 94/167 deaths (56.3%) in AA genotypes, but only 46/115 deaths (40.0%) in C-allele carriers. Multiple proportional hazard analysis revealed AC/CC genotypes to be at significantly lower risk for death within 90 days (HR: 0.60; 95%-CI: 0.42-0.86; p = 0.006). These findings confirm the important role of the AQP5 -1364A/C polymorphism as an independent prognostic factor in sepsis. Furthermore, we demonstrate a strong association between this AQP5 polymorphism and susceptibility for major adverse kidney events suggesting a promising characteristic in terms of precision medicine.
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Baar W, Kaufmann K, Silbach K, Jaenigen B, Pisarski P, Goebel U, Kalbhenn J, Heinrich S, Knoerlein J. Early Postoperative Use of Diuretics After Kidney Transplantation Showed Increase in Delayed Graft Function. Prog Transplant 2020; 30:95-102. [PMID: 32242491 DOI: 10.1177/1526924820913505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE In acute renal injury, diuretics are widely considered to be harmful. Nevertheless, they are used frequently after kidney transplantation. We hypothesized that diuretics administered in the early postoperative treatment after kidney transplantation increase the incidence of delayed graft function (DGF). METHODS In this monocentric, retrospective cohort analysis, we screened the closed files of all consecutive patients who underwent kidney transplantation from 2011 to 2017. The outcome variable was DGF, defined as at least 1 hemodialysis within 7 days postoperatively. To stratify for baseline characteristics such as waiting time or cold ischemic period, we employed a propensity score-matched analysis. Further statistical processing included basic descriptive statistics, Mann-Whitney U test, and binary logistic regression analysis. RESULTS The unmatched cohort included 445 patients and showed a significantly increased rate of DGF for patients who received either furosemide or mannitol or a combination of both (5% vs 25%; P < .001). Mannitol (odds ratio [OR]: 4.094) and furosemide (OR: 2.915) showed a significant correlation with DGF in the multivariate regression analysis. Propensity score-based matching resulted in a matched cohort of 214 patients with balanced baseline risk variables. In this matched cohort, the rate of DGF was significantly increased in patients who received diuretics in the early postoperative treatment (7% vs 16%; P = .031). CONCLUSION Our results show that postoperatively administered diuretics are associated with an increased rate of DGF even in a cohort with balanced preoperative risk variables. This study supports recently published reviews, which call diuretics in the transplantation process into question.
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Affiliation(s)
- Wolfgang Baar
- Faculty of Medicine, Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Breisgau, Germany
| | - Kai Kaufmann
- Faculty of Medicine, Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Breisgau, Germany
| | - Kai Silbach
- Faculty of Medicine, Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Breisgau, Germany
| | - Bernd Jaenigen
- Faculty of Medicine, Department of General and Visceral Surgery, Medical Center, University of Freiburg, Hugstetter Strasse, Freiburg, Germany
| | - Przemyslaw Pisarski
- Faculty of Medicine, Department of General and Visceral Surgery, Medical Center, University of Freiburg, Hugstetter Strasse, Freiburg, Germany
| | - Ulrich Goebel
- Faculty of Medicine, Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Breisgau, Germany
| | - Johannes Kalbhenn
- Faculty of Medicine, Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Breisgau, Germany
| | - Sebastian Heinrich
- Faculty of Medicine, Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Breisgau, Germany
| | - Julian Knoerlein
- Faculty of Medicine, Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Breisgau, Germany
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John S. Lessons learned from kidney dysfunction : Preventing organ failure. Med Klin Intensivmed Notfmed 2020; 115:21-27. [PMID: 32052096 DOI: 10.1007/s00063-020-00659-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/14/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common and severe complication in patients in the intensive care unit with a significant impact on patient's mortality and morbidity. Therefore renal protective therapy is very important in these severely ill patients. AIM Several renal protective strategies have been postulated during recent decades, which came from pathophysiologic concepts and have been contradicted or changed during the last few years. So lessons had to be learned in AKI, leading to new, in many cases completely reversed preventive and therapeutic concepts which may also be important for protection in other organs. RECENT FINDINGS Most important for renal protection is the early identification of patients at risk for AKI or with acute kidney damage before renal function further deteriorates. A stage-based management of AKI comprises more general measures like discontinuation of the nephrotoxic agent but most importantly early hemodynamic stabilization. Recent research has contradicted that AKI is renal ischemia caused by vasoconstriction with consecutive tubular necrosis. In septic AKI, renal blood flow is even increased. Intrarenal vasodilation together with microcirculatory changes and redistribution of blood flow lead to a drop in glomerular filtration by functional changes. Accordingly it had to be learned that not vasodilators but vasoconstrictors are beneficial in AKI. A mean arterial blood pressure target of >65 mm Hg is often recommended but exact targets are not known, and patients with pre-existing hypertension even need higher perfusion pressure. Also the concept that fluid therapy is always beneficial for the kidney in shock states had to be revised. A volume restrictive therapy with only balanced crystalloids is also becoming more important in AKI. Still no specific pharmacological therapy for renal protection is available. Inflammation and mitochondrial dysfunction appear to play a significant role in AKI. Anti-inflammatory strategies are under investigation and may become more important for AKI prevention and therapy in the future. (This article is freely available.).
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Affiliation(s)
- Stefan John
- Medical Intensive Care, Medical Department 8, Klinikum Nuernberg-Sued, Paracelsus Medical University and University of Erlangen-Nuernberg, Breslauerstr. 201, 90471, Nuernberg, Germany.
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Husain‐Syed F, Rosner MH, Ronco C. Distant organ dysfunction in acute kidney injury. Acta Physiol (Oxf) 2020; 228:e13357. [PMID: 31379123 DOI: 10.1111/apha.13357] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/13/2019] [Accepted: 07/31/2019] [Indexed: 12/28/2022]
Abstract
Acute kidney injury (AKI) is a common complication in critically ill patients and it is associated with increased morbidity and mortality. Epidemiological and clinical data show that AKI is linked to a wide range of distant organ injuries, with the lungs, heart, liver, and intestines representing the most clinically relevant affected organs. This distant organ injury during AKI predisposes patients to progression to multiple organ dysfunction syndrome and ultimately, death. The strongest direct evidence of distant organ injury occurring in AKI has been obtained from animal models. The identified mechanisms include systemic inflammatory changes, oxidative stress, increases in leucocyte trafficking and the activation of proapoptotic pathways. Understanding the pathways driving AKI-induced distal organ injury are critical for the development and refinement of therapies for the prevention and attenuation of AKI-related morbidity and mortality. The purpose of this review is to summarize both clinical and preclinical studies of AKI and its role in distant organ injury.
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Affiliation(s)
- Faeq Husain‐Syed
- Division of Nephrology, Pulmonology, and Critical Care Medicine, Department of Internal Medicine II University Hospital Giessen and Marburg Giessen Germany
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV) San Bortolo Hospital Vicenza Italy
| | - Mitchell H. Rosner
- Department of Medicine University of Virginia Health System Charlottesville Virginia
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV) San Bortolo Hospital Vicenza Italy
- Department of Medicine Università degli Studi di Padova Padova PD Italy
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Jhee JH, Lee HA, Kim S, Kee YK, Lee JE, Lee S, Kim SJ, Kang DH, Choi KB, Oh HJ, Ryu DR. The interactive effects of input and output on managing fluid balance in patients with acute kidney injury requiring continuous renal replacement therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:329. [PMID: 31665065 PMCID: PMC6819592 DOI: 10.1186/s13054-019-2633-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 10/01/2019] [Indexed: 11/23/2022]
Abstract
Background The interactive effect of cumulative input and output on achieving optimal fluid balance has not been well elucidated in patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). This study evaluated the interrelation of fluid components with mortality in patients with AKI requiring CRRT. Methods This is a retrospective observational study conducted with a total of 258 patients who were treated with CRRT due to AKI between 2016 and 2018 in the intensive care unit of Ewha Womans University Mokdong Hospital. The amounts of fluid input and output were assessed at 24-h and 72-h from the initiation of CRRT. The study endpoints were 7- and 28-day all-cause mortality. Results The mean patient age was 64.7 ± 15.8 years, and 165 (64.0%) patients were male. During the follow-up, 7- and 28-day mortalities were observed in 120 (46.5%) and 157 (60.9%) cases. The patients were stratified into two groups (28-day survivors vs. non-survivors), and the cumulative fluid balances (CFBs) at 24 h and 72 h were significantly higher in the 28-day non-survivors compared with the survivors. The increase in 24-h and 72-h CFB was significantly associated with an increase in 7- and 28-day mortality risks. To examine the interactive effect of cumulative input or output on the impact of CFB on mortality, we also stratified patients into three groups based on the tertile of 24-h and 72-h cumulative input or output. The increases in 24-h and 72-h CFBs were still significantly related to the increases in 7-day and 28-day mortality, irrespective of the cumulative input. However, we did not find significant associations between increase in 24-h and 72-h CFB and increase in mortality risk in the groups according to cumulative output tertile. Conclusions The impact of cumulative fluid balance on mortality might be more dependent on cumulative output. The physicians need to decrease the cumulative fluid balance of CRRT patients as much as possible and consider increasing patient removal.
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Affiliation(s)
- Jong Hyun Jhee
- Division of Nephrology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Ah Lee
- Clinical Trial Center, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Seonmi Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, Republic of Korea
| | - Youn Kyung Kee
- Department of Internal Medicine, Hangang Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
| | - Ji Eun Lee
- Department of Internal Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, Republic of Korea
| | - Shina Lee
- Department of Internal Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, Republic of Korea
| | - Seung-Jung Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, Republic of Korea
| | - Duk-Hee Kang
- Department of Internal Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, Republic of Korea
| | - Kyu Bok Choi
- Department of Internal Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, Republic of Korea
| | - Hyung Jung Oh
- Ewha Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, Republic of Korea.
| | - Dong-Ryeol Ryu
- Department of Internal Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, Republic of Korea. .,Research Institute for Human Health Information, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea.
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Schlader ZJ, Hostler D, Parker MD, Pryor RR, Lohr JW, Johnson BD, Chapman CL. The Potential for Renal Injury Elicited by Physical Work in the Heat. Nutrients 2019; 11:nu11092087. [PMID: 31487794 PMCID: PMC6769672 DOI: 10.3390/nu11092087] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 02/06/2023] Open
Abstract
An epidemic of chronic kidney disease (CKD) is occurring in laborers who undertake physical work in hot conditions. Rodent data indicate that heat exposure causes kidney injury, and when this injury is regularly repeated it can elicit CKD. Studies in humans demonstrate that a single bout of exercise in the heat increases biomarkers of acute kidney injury (AKI). Elevations in AKI biomarkers in this context likely reflect an increased susceptibility of the kidneys to AKI. Data largely derived from animal models indicate that the mechanism(s) by which exercise in the heat may increase the risk of AKI is multifactorial. For instance, heat-related reductions in renal blood flow may provoke heterogenous intrarenal blood flow. This can promote localized ischemia, hypoxemia and ATP depletion in renal tubular cells, which could be exacerbated by increased sodium reabsorption. Heightened fructokinase pathway activity likely exacerbates ATP depletion occurring secondary to intrarenal fructose production and hyperuricemia. Collectively, these responses can promote inflammation and oxidative stress, thereby increasing the risk of AKI. Equivalent mechanistic evidence in humans is lacking. Such an understanding could inform the development of countermeasures to safeguard the renal health of laborers who regularly engage in physical work in hot environments.
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Affiliation(s)
- Zachary J Schlader
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY 14214, USA.
- Department of Kinesiology, School of Public Health, Indiana University, Bloomington, IN 47405, USA.
| | - David Hostler
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - Mark D Parker
- Department of Physiology and Biophysics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14214, USA
- Department of Ophthalmology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - Riana R Pryor
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - James W Lohr
- Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - Blair D Johnson
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - Christopher L Chapman
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY 14214, USA
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Hoste EAJ, Kellum JA, Selby NM, Zarbock A, Palevsky PM, Bagshaw SM, Goldstein SL, Cerdá J, Chawla LS. Global epidemiology and outcomes of acute kidney injury. Nat Rev Nephrol 2019; 14:607-625. [PMID: 30135570 DOI: 10.1038/s41581-018-0052-0] [Citation(s) in RCA: 651] [Impact Index Per Article: 130.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute kidney injury (AKI) is a commonly encountered syndrome associated with various aetiologies and pathophysiological processes leading to decreased kidney function. In addition to retention of waste products, impaired electrolyte homeostasis and altered drug concentrations, AKI induces a generalized inflammatory response that affects distant organs. Full recovery of kidney function is uncommon, which leaves these patients at risk of long-term morbidity and death. Estimates of AKI prevalence range from <1% to 66%. These variations can be explained by not only population differences but also inconsistent use of standardized AKI classification criteria. The aetiology and incidence of AKI also differ between high-income and low-to-middle-income countries. High-income countries show a lower incidence of AKI than do low-to-middle-income countries, where contaminated water and endemic diseases such as malaria contribute to a high burden of AKI. Outcomes of AKI are similar to or more severe than those of patients in high-income countries. In all resource settings, suboptimal early recognition and care of patients with AKI impede their recovery and lead to high mortality, which highlights unmet needs for improved detection and diagnosis of AKI and for efforts to improve care for these patients.
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Affiliation(s)
- Eric A J Hoste
- Intensive Care Unit, Ghent University Hospital, Ghent University, Ghent, Belgium.
| | - John A Kellum
- Center for Critical Care Nephrology, Pittsburgh, PA, USA
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Campus, Nottingham, UK
| | - Alexander Zarbock
- University of Münster, Department of Anesthesiology, Intensive Care and Pain Medicine, Münster, Germany
| | - Paul M Palevsky
- VA Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jorge Cerdá
- Division of Nephrology and Hypertension, Albany Medical College, Albany, NY, USA
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Jiang D, Shen M, Yuan X, Wang M, Li S, Jiang W, Zhou Z, Xi P, Wang T, Shen Y. Serum heart-type fatty acid-binding protein as a predictor for the development of sepsis-associated acute kidney injury. Expert Rev Mol Diagn 2019; 19:757-765. [PMID: 31288580 DOI: 10.1080/14737159.2019.1642750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background: We analyzed the correlation between heart-type fatty acid-binding protein (HFABP) and the development of acute kidney injury (AKI) in patients with sepsis and estimated the predictive capacity of HFABP for sepsis-associated acute kidney injury (SAKI). Methods: In this retrospective observational study, we screened 2,452 patients who received the HFABP test in the emergency department. 442 admitted patients with sepsis were finally enrolled. Based on the diagnostic criteria for AKI in Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, patients were divided into the no-AKI group (n = 317) and AKI group (n = 125). We analyzed the correlation between HFABP and SAKI occurrence by logistic regression analysis and evaluated the predictive ability of HFABP to SAKI using c-index, net reclassification improvement index (NRI) and integrated discrimination improvement index (IDI). Results: Patients in the AKI group with significantly higher the level of HFABP and in-hospital mortality. HFABP concentration is an independent risk factor for SAKI (OR: 11.398; 95% CI: 6.218-20.891, P < 0.001), but not for in-hospital mortality (OR: 1.189, 95%CI: 0.954-2.607, P = 0.076). The addition of HFABP to the prediction model significantly improved the ROC area (0.867 vs 0.755, P < 0.001), NRI 25.03% (95% CI 9.72-38.51%) and IDI 14.33 (95% CI 11.04-17.62). Conclusion: Serum HFABP is correlated with SAKI development and could become a potential predictive biomarker.
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Affiliation(s)
- Daishan Jiang
- Department of Emergency Medicine, Affiliated Hospital of Nantong University , Nantong City , Jiangsu Province , China
| | - Mengzhu Shen
- Medical School of Nantong University , Nantong City , Jiangsu Province , China
| | - Xiaoyu Yuan
- Department of Emergency Medicine, Affiliated Hospital of Nantong University , Nantong City , Jiangsu Province , China
| | - Meng Wang
- Department of Emergency Medicine, Affiliated Hospital of Nantong University , Nantong City , Jiangsu Province , China
| | - Shanfeng Li
- Department of Emergency Medicine, Affiliated Hospital of Nantong University , Nantong City , Jiangsu Province , China
| | - Wei Jiang
- Department of Emergency Medicine, Affiliated Hospital of Nantong University , Nantong City , Jiangsu Province , China
| | - Zhongxia Zhou
- Department of Emergency Medicine, Affiliated Hospital of Nantong University , Nantong City , Jiangsu Province , China
| | - Peipei Xi
- Department of Emergency Medicine, Affiliated Hospital of Nantong University , Nantong City , Jiangsu Province , China
| | - Ting Wang
- Department of Emergency Medicine, Affiliated Hospital of Nantong University , Nantong City , Jiangsu Province , China
| | - Yan Shen
- Department of Emergency Medicine, Affiliated Hospital of Nantong University , Nantong City , Jiangsu Province , China
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Rundgren M, Ullén S, Morgan MPG, Glover G, Cranshaw J, Al-Subaie N, Walden A, Joannidis M, Ostermann M, Dankiewicz J, Nielsen N, Wise MP. Renal function after out-of-hospital cardiac arrest; the influence of temperature management and coronary angiography, a post hoc study of the target temperature management trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:163. [PMID: 31068215 PMCID: PMC6506949 DOI: 10.1186/s13054-019-2390-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 03/11/2019] [Indexed: 12/29/2022]
Abstract
Background To elucidate the incidence of acute kidney injury (AKI) after out-of-hospital cardiac arrest (OHCA) and to examine the impact of target temperature management (TTM) and early coronary angiography on renal function. Methods Post hoc analysis of the TTM trial, a multinational randomised controlled trial comparing target temperature of 33 °C versus 36 °C in patients with return of spontaneous circulation after OHCA. The impact of TTM and early angiography (within 6 h of OHCA) versus late or no angiography on the development of AKI during the 7-day period after OHCA was analysed. AKI was defined according to modified KDIGO criteria in patients surviving beyond day 2 after OHCA. Results Following exclusions, 853 of 939 patients enrolled in the main trial were analysed. Unadjusted analysis showed that significantly more patients in the 33 °C group had AKI compared to the 36 °C group [211/431 (49%) versus 170/422 (40%) p = 0.01], with a worse severity (p = 0.018). After multivariable adjustment, the difference was not significant (odds ratio 0.75, 95% confidence interval 0.54–1.06, p = 0.10]. Five hundred seventeen patients underwent early coronary angiography. Although the unadjusted analysis showed less AKI and less severe AKI in patients who underwent early angiography compared to patients with late or no angiography, in adjusted analyses, early angiography was not an independent risk factor for AKI (odds ratio 0.73, 95% confidence interval 0.50–1.05, p = 0.09). Conclusions In OHCA survivors, TTM at 33 °C compared to management at 36 °C did not show different rates of AKI and early angiography was not associated with an increased risk of AKI. Trial registration NCT01020916. Registered on www.ClinicalTrials.gov 26 November 2009 (main trial). Electronic supplementary material The online version of this article (10.1186/s13054-019-2390-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Malin Rundgren
- Department of Clinical Sciences, Anaesthesia and Intensive Care, Skane University Hospital, Lund University, 221 85, Lund, Sweden. .,Department of Intensive and Perioperative Care, Skane University Hospital, Lund University, 221 85, Lund, Sweden.
| | - Susann Ullén
- Foprum South, Skane University Hospital, Lund, Sweden
| | - Matt P G Morgan
- Honorary Research Fellow, Cardiff University School of Medicine, Cardiff, UK
| | - Guy Glover
- Department of Intensive Care, Guys and St Thomas' Hospital, Kings College London, London, UK
| | - Julius Cranshaw
- Department of Anaesthetics and Intensive Care Medicine, Royal Bournemouth Hospital, Bournemouth, UK
| | - Nawaf Al-Subaie
- Adult Intensive Care Directorate, St George's Hospital London, London, UK
| | - Andrew Walden
- Department of Intensive Care Medicine, Royal Berkshire Hospital, Reading, UK
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Marlies Ostermann
- Department of Critical Care and Nephrology, Guy's and St Thomas' Hospital, King's College London, London, UK
| | - Josef Dankiewicz
- Department of Cardiology, Skane University Hospital, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Department of Anaesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Matthew P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
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The search for the holy grail continues: The difficult journey towards the ideal fluid! J Crit Care 2019; 52:254-257. [PMID: 31010724 DOI: 10.1016/j.jcrc.2019.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/08/2019] [Accepted: 04/10/2019] [Indexed: 11/24/2022]
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Ostermann M, Liu K, Kashani K. Fluid Management in Acute Kidney Injury. Chest 2019; 156:594-603. [PMID: 31002784 DOI: 10.1016/j.chest.2019.04.004] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/24/2019] [Accepted: 04/04/2019] [Indexed: 01/02/2023] Open
Abstract
Correction of intravascular hypovolemia is a key component of the prevention and management of acute kidney injury (AKI), but excessive fluid administration is associated with poor outcomes, including the development and progression of AKI. There is growing evidence that fluid administration should be individualized and take into account patient characteristics, nature of the acute illness and trajectories, and risks and benefits of fluids. Existing data support the preferential use of buffered solutions for fluid resuscitation of patients at risk of AKI who do not have hypochloremia. There is a limited role for albumin, and starches should be avoided. Fluids should only be administered until intravascular hypovolemia has been corrected and euvolemia has been achieved using the minimum amount of fluid required to achieve and maintain euvolemia. Oliguria alone should not be viewed as a trigger for fluid administration. If fluid overload occurs, fluid therapy needs to be discontinued, and fluid removal using diuretic agents or extracorporeal therapies should be considered.
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Affiliation(s)
- Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, Department of Critical Care, London, England.
| | - Kathleen Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, NY
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Wiersema R, Koeze J, Hiemstra B, Pettilä V, Perner A, Keus F, van der Horst ICC. Associations between tricuspid annular plane systolic excursion to reflect right ventricular function and acute kidney injury in critically ill patients: a SICS-I sub-study. Ann Intensive Care 2019; 9:38. [PMID: 30868290 PMCID: PMC6419793 DOI: 10.1186/s13613-019-0513-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 03/05/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) occurs in up to 50% of all critically ill patients and hemodynamic abnormalities are assumed to contribute, but their nature and share is still unclear. We explored the associations between hemodynamic variables, including cardiac index and right ventricular function, and the occurrence of AKI in critically ill patients. METHODS In this prospective cohort study, we included all patients acutely admitted to an intensive care unit (ICU). Within 24 h after ICU admission clinical and hemodynamic variables were registered including ultrasonographic measurements of cardiac index and right ventricular function, assessed using tricuspid annular plane systolic excursion (TAPSE) and right ventricular systolic excursion (RV S'). Maximum AKI stage was assessed according to the KDIGO criteria during the first 72 h after admission. Multivariable logistic regression modeling was used including both known predictors and univariable significant predictors of AKI. Secondary outcomes were days alive outside ICU and 90-day mortality. RESULTS A total of 622 patients were included, of which 338 patients (54%) had at least AKI stage 1 within 72 h after ICU admission. In the final multivariate model higher age (OR 1.01, 95% CI 1.00-1.03, for each year), higher weight (OR 1.03 CI 1.02-1.04, for each kg), higher APACHE IV score (OR 1.02, CI 1.01-1.03, per point), lower mean arterial pressure (OR 1.02, CI 1.01-1.03, for each mmHg decrease) and lower TAPSE (OR 1.05, CI 1.02-1.09 per millimeter decrease) were all independent predictors for AKI in the final multivariate logistic regression model. Sepsis, cardiac index, RV S' and use of vasopressors were not significantly associated with AKI in our data. AKI patients had fewer days alive outside of ICU, and their mortality rate was significantly higher than those without AKI. CONCLUSIONS In our cohort of acutely admitted ICU patients, the incidence of AKI was 54%. Hemodynamic variables were significantly different between patients with and without AKI. A worse right ventricle function was associated with AKI in the final model, whereas cardiac index was not.
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Affiliation(s)
- Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jacqueline Koeze
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anders Perner
- Department of Intensive Care 4131, Centre for Research in Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Iwan C. C. van der Horst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - SICS Study Group
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Intensive Care 4131, Centre for Research in Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Kim HY, Kong YG, Park JH, Kim YK. Acute kidney injury after burn surgery: Preoperative neutrophil/lymphocyte ratio as a predictive factor. Acta Anaesthesiol Scand 2019; 63:240-247. [PMID: 30203468 DOI: 10.1111/aas.13255] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 06/29/2018] [Accepted: 08/08/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Severe inflammation and acute kidney injury (AKI) are serious adverse events after burn injuries. The neutrophil/lymphocyte ratio (NLR) is a marker of inflammation. We evaluated the independent risk factors for postoperative AKI, including NLR, in burn-injured patients. METHODS The preoperative, intraoperative, and postoperative variables of 473 burn-injured patients were collected. The risk factors for AKI after burn surgery were evaluated using univariate and multivariate logistic regression analyses. The receiver operating characteristic (ROC) curve analysis of preoperative NLR was performed. The 3-month mortality after surgery was also compared between AKI and non-AKI groups using Kaplan-Meier analysis with a log-rank test. RESULTS Postoperative AKI occurred in 71 of 473 (15.0%) burn patients. The total body surface area burned (odds ratio (OR), 1.013; 95% confidence interval (CI), 1.001-1.026; P = 0.037), inhalation injury (OR, 1.821; 95% CI, 1.008-3.292; P = 0.047), and preoperative NLR (OR, 1.094; 95% CI, 1.064-1.125; P < 0.001) were risk factors for AKI after surgery. The area under the ROC curve was 0.767, with an optimal cut-off value of 11.7. Moreover, the 3-month mortality after surgery was significantly higher in the AKI group than in the non-AKI group (49.3% vs 14.9%, P < 0.001). CONCLUSION Total body surface area burned, inhalation injury, and preoperative NLR are risk factors for AKI after burn surgery, which is associated with early postoperative mortality. Preoperative NLR can provide useful information for the early detection of postoperative AKI and subsequent mortality in burn-injured patients.
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Affiliation(s)
- Hee Yeong Kim
- Department of Anesthesiology and Pain Medicine; Hangang Sacred Heart Hospital; Hallym University College of Medicine; Seoul Korea
| | - Yu-Gyeong Kong
- Department of Anesthesiology and Pain Medicine; Hangang Sacred Heart Hospital; Hallym University College of Medicine; Seoul Korea
| | - Ji Hyun Park
- Department of Anesthesiology and Pain Medicine; Hangang Sacred Heart Hospital; Hallym University College of Medicine; Seoul Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
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Abstract
Sepsis is defined as organ dysfunction resulting from the host's deleterious response to infection. One of the most common organs affected is the kidneys, resulting in sepsis associated acute kidney injury (SA-AKI) that contributes to the morbidity and mortality of sepsis. A growing body of knowledge has illuminated the clinical risk factors, pathobiology, response to treatment, and elements of renal recovery that have advanced our ability to prevent, detect, and treat SA-AKI. Despite these advances, SA-AKI remains an important concern and clinical burden, and further study is needed to reduce the acute and chronic consequences. This review summarizes the relevant evidence, with a focus on the risk factors, early recognition and diagnosis, treatment, and long term consequences of SA-AKI. In addition to literature pertaining to SA-AKI specifically, pertinent sepsis and acute kidney injury literature relevant to SA-AKI was included.
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Affiliation(s)
- Jason T Poston
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago
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Abou Arkoub R, Xiao CW, Claman P, Clark EG. Acute Kidney Injury Due to Ovarian Hyperstimulation Syndrome. Am J Kidney Dis 2019; 73:416-420. [PMID: 30600106 DOI: 10.1053/j.ajkd.2018.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/16/2018] [Indexed: 01/15/2023]
Abstract
Ovarian hyperstimulation syndrome (OHSS) is a complication of assisted reproductive treatments such as in vitro fertilization (IVF). The pathophysiology of severe OHSS includes a humorally mediated capillary leak syndrome that is predominantly centered on the intra-abdominal space. Severe OHSS is frequently complicated by acute kidney injury (AKI), which can be due to any of a variety of mechanisms, each requiring a different management strategy. Mechanisms of AKI in severe OHSS include intravascular volume depletion, kidney edema due to capillary leak, intra-abdominal hypertension or compartment syndrome, and obstructive uropathy due to ovarian enlargement. We present a teaching case of severe OHSS complicated by AKI in a woman with underlying stage 4 chronic kidney disease. She had been undergoing IVF with plans to subsequently use a gestational carrier (surrogate) for pregnancy. We use this case to review the presentation and pathophysiology of OHSS complicated by AKI. In addition, we review the management of AKI in OHSS, in particular, the role of paracentesis and/or culdocentesis to manage tense ascites. Last, we highlight that similar cases may occur more frequently in the future given that IVF with subsequent use of a gestational carrier is increasingly being used for patients with comorbid conditions that can be exacerbated by pregnancy, such as advanced chronic kidney disease.
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Affiliation(s)
- Rima Abou Arkoub
- Division of Nephrology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Cheng Wei Xiao
- Department of Obstetrics and Gynecology, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Paul Claman
- Department of Obstetrics and Gynecology, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada; Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
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Teixeira JP, Ambruso S, Griffin BR, Faubel S. Pulmonary Consequences of Acute Kidney Injury. Semin Nephrol 2019; 39:3-16. [DOI: 10.1016/j.semnephrol.2018.10.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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