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Granda ML, Tian F, Zelnick LR, Bhatraju PK, Hallowell J, Wurfel MM, Hoofnagle A, Morrell E, Kestenbaum B. Kidney Outcomes and Trajectories of Tubular Injury and Function in Critically Ill Patients With and Without COVID-19. Crit Care Explor 2024; 6:e1109. [PMID: 38922318 PMCID: PMC11210964 DOI: 10.1097/cce.0000000000001109] [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] [Indexed: 06/27/2024] Open
Abstract
IMPORTANCE COVID-19 may injure the kidney tubules via activation of inflammatory host responses and/or direct viral infiltration. Most studies of kidney injury in COVID-19 lacked contemporaneous controls or measured kidney biomarkers at a single time point. OBJECTIVES To better understand mechanisms of acute kidney injury in COVID-19, we compared kidney outcomes and trajectories of tubular injury, viability, and function in prospectively enrolled critically ill adults with and without COVID-19. DESIGN, SETTING, AND PARTICIPANTS The COVID-19 Host Response and Outcomes study prospectively enrolled patients admitted to ICUs in Washington State with symptoms of lower respiratory tract infection, determining COVID-19 status by nucleic acid amplification on arrival. MAIN OUTCOMES AND MEASURES We evaluated major adverse kidney events (MAKE) defined as a doubling of serum creatinine, kidney replacement therapy, or death, in 330 patients after inverse probability weighting. In the 181 patients with available biosamples, we determined trajectories of urine kidney injury molecule-1 (KIM-1) and epithelial growth factor (EGF), and urine:plasma ratios of endogenous markers of tubular secretory clearance. RESULTS At ICU admission, the mean age was 55 ± 16 years; 45% required mechanical ventilation; and the mean serum creatinine concentration was 1.1 mg/dL. COVID-19 was associated with a 70% greater occurrence of MAKE (relative risk 1.70; 95% CI, 1.05-2.74) and a 741% greater occurrence of KRT (relative risk 7.41; 95% CI, 1.69-32.41). The biomarker cohort had a median of three follow-up measurements. Urine EGF, secretory clearance ratios, and estimated glomerular filtration rate (eGFR) increased over time in the COVID-19 negative group but remained unchanged in the COVID-19 positive group. In contrast, urine KIM-1 concentrations did not significantly change over the course of the study in either group. CONCLUSIONS Among critically ill adults, COVID-19 is associated with a more protracted course of proximal tubular dysfunction and reduced eGFR despite similar degrees of kidney injury.
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Affiliation(s)
- Michael L. Granda
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
- Kidney Research Institute, University of Washington, Seattle, WA
| | - Frances Tian
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
- Kidney Research Institute, University of Washington, Seattle, WA
| | - Leila R. Zelnick
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
- Kidney Research Institute, University of Washington, Seattle, WA
| | - Pavan K. Bhatraju
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
- Kidney Research Institute, University of Washington, Seattle, WA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Julia Hallowell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Andrew Hoofnagle
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | - Eric Morrell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Bryan Kestenbaum
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
- Kidney Research Institute, University of Washington, Seattle, WA
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Maeda A, Inokuchi R, Bellomo R, Doi K. Heterogeneity in the definition of major adverse kidney events: a scoping review. Intensive Care Med 2024; 50:1049-1063. [PMID: 38801518 PMCID: PMC11245451 DOI: 10.1007/s00134-024-07480-x] [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: 02/29/2024] [Accepted: 05/03/2024] [Indexed: 05/29/2024]
Abstract
Acute kidney injury (AKI) is associated with persistent renal dysfunction, the receipt of dialysis, dialysis dependence, and mortality. Accordingly, the concept of major adverse kidney events (MAKE) has been adopted as an endpoint for assessing the impact of AKI. However, applied criteria or observation periods for operationalizing MAKE appear to vary across studies. To evaluate this heterogeneity for MAKE evaluation, we performed a systematic scoping review of studies that employed MAKE as an AKI endpoint. Four major academic databases were searched, and we identified 122 studies with increasing numbers over time. We found marked heterogeneity in applied criteria and observation periods for MAKE across these studies, with some even lacking a description of criteria. Moreover, 13 different observation periods were employed, with 30 days and 90 days as the most common. Persistent renal dysfunction was evaluated by estimated glomerular filtration rate (34%) or serum creatinine concentration (48%); however, 37 different definitions for this component were employed in terms of parameters, cut-off criteria, and assessment periods. The definition for the dialysis component also showed significant heterogeneity regarding assessment periods and duration of dialysis requirement (chronic vs temporary). Finally, MAKE rates could vary by 7% [interquartile range: 1.7-16.7%] with different observation periods or by 36.4% with different dialysis component definitions. Our findings revealed marked heterogeneity in MAKE definitions, particularly regarding component assessment and observation periods. Dedicated discussion is needed to establish uniform and acceptable standards to operationalize MAKE in terms of selection and applied criteria of components, observation period, and reporting criteria for future trials on AKI and related conditions.
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Affiliation(s)
- Akinori Maeda
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Emergency and Critical Care Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Ryota Inokuchi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
- Department of Clinical Engineering, The University of Tokyo Hospital, Tokyo, Japan
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
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Mefford B, Wallace KL, Donaldson JC, Bissell Turpin BD, Sen P, Schadler AD, Liu LJ, Thompson Bastin ML. Effect modification of dosing strategy (AUC or trough) on AKI associated with vancomycin in combination with piperacillin/tazobactam or cefepime and meropenem. Antimicrob Agents Chemother 2024; 68:e0108523. [PMID: 38606975 PMCID: PMC11064542 DOI: 10.1128/aac.01085-23] [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: 09/21/2023] [Accepted: 02/06/2024] [Indexed: 04/13/2024] Open
Abstract
Piperacillin-tazobactam (TZP), cefepime (FEP), or meropenem (MEM) and vancomycin (VAN) are commonly used in combination for sepsis. Studies have shown an increased risk of acute kidney injury (AKI) with TZP and VAN compared to FEP or MEM. VAN guidelines recommend area under the curve (AUC) monitoring over trough (Tr) to minimize the risk of AKI. We investigated the association of AKI and MAKE-30 with the two VAN monitoring strategies when used in combination with TZP or FEP/MEM. Adult patients between 2015 and 2019 with VAN > 72 hours were included. Patients with AKI prior to or within 48 hours of VAN or baseline CrCl of ≤30 mL/min were excluded. Four cohorts were defined: FEP/MEM/Tr, FEP/MEM/AUC, TZP/Tr, and TZP/AUC. A Cox Proportional Hazard Model was used to model AKI as a function of the incidence rate of at-risk days, testing monitoring strategy as a treatment effect modification. Multivariable logistic regression was used to model MAKE-30. Overall incidence of AKI was 18.6%; FEP/MEM/Tr = 115 (14.6%), FEP/MEM/AUC = 52 (14.9%), TZP/Tr = 189 (26%), and TZP/AUC = 96 (17.1%) (P < 0.001). Both drug group [(TZP; P = 0.0085)] and monitoring strategy [(Tr; P = 0.0007)] were highly associated with the development of AKI; however, the effect was not modified with interaction term [(TZP*Tr); 0.085)]. The odds of developing MAKE-30 were not different between any group and FEP/MEM/AUC. The effect of VAN/TZP on the development of AKI was not modified by the VAN monitoring strategy (AUC vs trough). MAKE-30 outcomes were not different among the four cohorts.
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Affiliation(s)
- Breanne Mefford
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Katie L. Wallace
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - J. Chris Donaldson
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Brittany D. Bissell Turpin
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Parijat Sen
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Aric D. Schadler
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
- University of Kentucky Children’s Hospital, Lexington, Kentucky, USA
| | - Lucas J. Liu
- Department of Computer Science, University of Kentucky, Lexington, Kentucky, USA
| | - Melissa L. Thompson Bastin
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
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Barea Mendoza JA, Valiente Fernandez M, Pardo Fernandez A, Gómez Álvarez J. Current perspectives on the use of artificial intelligence in critical patient safety. Med Intensiva 2024:S2173-5727(24)00080-8. [PMID: 38677902 DOI: 10.1016/j.medine.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/11/2024] [Indexed: 04/29/2024]
Abstract
Intensive Care Units (ICUs) have undergone enhancements in patient safety, and artificial intelligence (AI) emerges as a disruptive technology offering novel opportunities. While the published evidence is limited and presents methodological issues, certain areas show promise, such as decision support systems, detection of adverse events, and prescription error identification. The application of AI in safety may pursue predictive or diagnostic objectives. Implementing AI-based systems necessitates procedures to ensure secure assistance, addressing challenges including trust in such systems, biases, data quality, scalability, and ethical and confidentiality considerations. The development and application of AI demand thorough testing, encompassing retrospective data assessments, real-time validation with prospective cohorts, and efficacy demonstration in clinical trials. Algorithmic transparency and explainability are essential, with active involvement of clinical professionals being crucial in the implementation process.
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Affiliation(s)
- Jesús Abelardo Barea Mendoza
- UCI de Trauma y Emergencias. Servicio de Medicina Intensiva. Hospital Universitario 12 de Octubre. Instituto de Investigación Hospital 12 de Octubre, Spain.
| | - Marcos Valiente Fernandez
- UCI de Trauma y Emergencias. Servicio de Medicina Intensiva. Hospital Universitario 12 de Octubre. Instituto de Investigación Hospital 12 de Octubre, Spain
| | | | - Josep Gómez Álvarez
- Hospital Universitari de Tarragona Joan XXIII. Universitat Rovira i Virgili. Institut d'Investigació Sanitària Pere i Virgili, Tarragona, Spain
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Granda ML, Tian F, Zelnick LR, Bhatraju PK, Wurfel MM, Hoofnagle A, Morrell E, Kestenbaum B. Kidney Outcomes and Trajectories of Tubular Injury and Function in Critically Ill Persons with and without Coronavirus-2019. RESEARCH SQUARE 2024:rs.3.rs-3974635. [PMID: 38464257 PMCID: PMC10925475 DOI: 10.21203/rs.3.rs-3974635/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Background Coronavirus disease-2019 (COVID-19) may injure the kidney tubules via activation of inflammatory host responses and/or direct viral infiltration. Most studies of kidney injury in COVID-19 lacked contemporaneous controls or measured kidney biomarkers at a single time point. To better understand mechanisms of AKI in COVID-19, we compared kidney outcomes and trajectories of tubular injury, viability, and function in prospectively enrolled critically ill adults with and without COVID-19. Methods The COVID-19 Host Response and Outcomes (CHROME) study prospectively enrolled patients admitted to intensive care units in Washington state with symptoms of lower respiratory tract infection, determining COVID-19 status by nucleic acid amplification on arrival. We evaluated major adverse kidney events (MAKE) defined as a doubling of serum creatinine, kidney replacement therapy, or death, in 330 patients after inverse probability weighting. In the 181 patients with available biosamples, we determined trajectories of urine kidney injury molecule-1 (KIM-1) and epithelial growth factor (EGF), and urine:plasma ratios of endogenous markers of tubular secretory clearance. Results At ICU admission, mean age was 55±16 years; 45% required mechanical ventilation; and mean serum creatinine concentration was 1.1 mg/dL. COVID-19 was associated with a 70% greater incidence of MAKE (95% CI 1.05, 2.74) and a 741% greater incidence of KRT (95% CI 1.69, 32.41). The biomarker cohort had a median of three follow-up measurements. Urine EGF, secretory clearance ratios, and eGFR increased over time in the COVID-19 negative group but remained unchanged in the COVID-19 positive group. In contrast, urine KIM-1 concentrations did not significantly change over the course of the study in either group. Conclusions Among critically ill adults, COVID-19 is associated with a more protracted course of proximal tubular dysfunction.
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Affiliation(s)
| | - Frances Tian
- University of Washington, Kidney Research Institute
| | | | - Pavan K Bhatraju
- University of Washington, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine
| | - Mark M Wurfel
- University of Washington, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine
| | | | - Eric Morrell
- University of Washington, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine
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Yu X, Xin Q, Hao Y, Zhang J, Ma T. An early warning model for predicting major adverse kidney events within 30 days in sepsis patients. Front Med (Lausanne) 2024; 10:1327036. [PMID: 38469459 PMCID: PMC10925638 DOI: 10.3389/fmed.2023.1327036] [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: 10/24/2023] [Accepted: 12/18/2023] [Indexed: 03/13/2024] Open
Abstract
Background In sepsis patients, kidney damage is among the most dangerous complications, with a high mortality rate. In addition, major adverse kidney events within 30 days (MAKE30) served as a comprehensive and unbiased clinical outcome measure for sepsis patients due to the recent shift toward targeting patient-centered renal outcomes in clinical research. However, the underlying predictive model for the prediction of MAKE30 in sepsis patients has not been reported in any study. Methods A cohort of 2,849 sepsis patients from the Medical Information Mart for Intensive Care (MIMIC)-IV database was selected and subsequently allocated into a training set (n = 2,137, 75%) and a validation set (n = 712, 25%) through randomization. In addition, 142 sepsis patients from the Xi'An No. 3 Hospital as an external validation group. Univariate and multivariate logistic regression analyses were conducted to ascertain the independent predictors of MAKE30. Subsequently, a nomogram was developed utilizing these predictors, with an area under curve (AUC) above 0.6. The performance of nomogram was assessed through calibration curve, receiver operating characteristics (ROC) curve, and decision curve analysis (DCA). The secondary outcome was 30-day mortality, persistent renal dysfunction (PRD), and new renal replacement therapy (RRT). MAKE30 were a composite of death, PRD, new RRT. Results The construction of the nomogram was based on several independent predictors (AUC above 0.6), including age, respiratory rate (RR), PaO2, lactate, and blood urea nitrogen (BUN). The predictive model demonstrated satisfactory discrimination for MAKE30, with an AUC of 0.740, 0.753, and 0.821 in the training, internal validation, and external validation cohorts, respectively. Furthermore, the simple prediction model exhibited superior predictive value compared to the SOFA model in both the training (AUC = 0.710) and validation (AUC = 0.692) cohorts. The nomogram demonstrated satisfactory calibration and clinical utility as evidenced by the calibration curve and DCA. Additionally, the predictive model exhibited excellent accuracy in forecasting 30-day mortality (AUC = 0.737), PRD (AUC = 0.639), and new RRT (AUC = 0.846) within the training dataset. Additionally, the model displayed predictive power for 30-day mortality (AUC = 0.765), PRD (AUC = 0.667), and new RRT (AUC = 0.783) in the validation set. Conclusion The proposed nomogram holds the potential to estimate the risk of MAKE30 promptly and efficiently in sepsis patients within the initial 24 h of admission, thereby equipping healthcare professionals with valuable insights to facilitate personalized interventions.
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Affiliation(s)
- Xiaoyuan Yu
- Department of Hematology, The Affiliated Hospital of Northwest University, Xi’an No. 3 Hospital, Shaanxi, Xi’an, China
| | - Qi Xin
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yun Hao
- Department of Nephrology, Yuequn Yuan District, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jin Zhang
- Department of Hematology, The Affiliated Hospital of Northwest University, Xi’an No. 3 Hospital, Shaanxi, Xi’an, China
| | - Tiantian Ma
- Department of Hematology, The Affiliated Hospital of Northwest University, Xi’an No. 3 Hospital, Shaanxi, Xi’an, China
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Kao TW, Huang CC, Leu HB, Yin WH, Tseng WK, Wu YW, Lin TH, Yeh HI, Chang KC, Wang JH, Wu CC, Chen JW. Inflammation and renal function decline in chronic coronary syndrome: a prospective multicenter cohort study. BMC Cardiovasc Disord 2023; 23:564. [PMID: 37974082 PMCID: PMC10655285 DOI: 10.1186/s12872-023-03565-5] [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: 02/27/2023] [Accepted: 10/17/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Renal function decline is a frequently encountered complication in patients with chronic coronary syndrome. Aside from traditional cardiovascular risk factors, the inflammatory burden emerged as the novel phenotype that compromised renal prognosis in such population. METHODS A cohort with chronic coronary syndrome was enrolled to investigate the association between inflammatory status and renal dysfunction. Levels of inflammatory markers, including high-sensitivity C-reactive protein (hs-CRP), tumour necrosis factor-α (TNF-α), adiponectin, matrix metalloproteinase-9, interleukin-6, lipoprotein-associated phospholipase A2, were assessed. Renal event was defined as > 25% decline in estimated glomerular filtration rate (eGFR). Inflammatory scores were calculated based on the aggregate of hs-CRP, TNF-α, and adiponectin levels. RESULTS Among the 850 enrolled subjects, 145 patients sustained a renal event during an averaged 3.5 years follow-up. Multivariate analysis with Cox regression suggested elevations in hs-CRP, TNF-α, and adiponectin levels were independent risk factors for the occurrence of a renal event. Whereas, Kaplan-Meier curve illustrated significant correlation between high TNF-α (P = 0.005), adiponectin (P < 0.001), but not hs-CRP (P = 0.092), and eGFR decline. The aggregative effect of these biomarkers was also distinctly correlated with renal events (score 2: P = 0.042; score 3: P < 0.001). CONCLUSIONS Inflammatory burden was associated with eGFR decline in patients with chronic coronary syndrome.
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Affiliation(s)
- Ting-Wei Kao
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Chou Huang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
- Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Hsin-Bang Leu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Hsian Yin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Cardiology, Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Wei-Kung Tseng
- Department of Medical Imaging and Radiological Sciences, I-Shou University, Kaohsiung, Taiwan
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Yen-Wen Wu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital and Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-I Yeh
- Mackay Memorial Hospital, Mackay Medical College, New Taipei City, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Ji-Hung Wang
- Department of Cardiology, Buddhist Tzu-Chi General Hospital, Tzu-Chi University, Hualien, Taiwan
| | - Chau-Chung Wu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Graduate Institute of Medical Education & Bioethics, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jaw-Wen Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Research and Division of Cardiology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
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Sandal S, Cantarovich M, Cardinal H, Ramankumar AV, Senecal L, Collette S, Saw CL, Paraskevas S, Tchervenkov J. Predicting Long-term Outcomes in Deceased Donor Kidney Transplant Recipients Using Three Short-term Graft Characteristics. KIDNEY360 2023; 4:e809-e816. [PMID: 37211638 PMCID: PMC10371380 DOI: 10.34067/kid.0000000000000154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/28/2023] [Indexed: 05/23/2023]
Abstract
Key Points Delayed graft function is not an ideal measure of graft function, yet is used to assess risk in kidney transplantation. We propose a model that combines it with two other measures of 90-day graft function to identify recipients at incremental risk of inferior long-term outcomes. Background Delayed graft function (DGF) in kidney transplant recipients is used to determine graft prognosis, make organ utilization decisions, and as an important end point in clinical trials. However, DGF is not an ideal measure of graft function. We aimed to develop and validate a model that provides incremental risk assessment for inferior patient and graft outcomes. Methods We included adult kidney-only deceased donor transplant recipients from 1996 to 2016. In addition to DGF, two short-term measures were used to assess risk: renal function recovery <100% (attaining half the donor's eGFR) and recipient's 90-day eGFR <30. Recipients were at no, low, moderate, or high risk if they met zero, one, two, or all criteria, respectively. Cox proportional hazard models were used to assess the independent relationship between exposure and death-censored graft failure (DCGF) and mortality. Results Of the 792 eligible recipients, 24.5% experienced DGF, 40.5% had renal function recovery <100%, and 6.9% had eGFR <30. Over a median follow-up of 7.3 years, the rate of DCGF was 18.7% and mortality was 25.1%. When compared with recipients at no risk, those at low, moderate, and high risk were noted to have an increase in risk of DCGF (adjusted hazard ratio [aHR], 1.53; 95% confidence interval [CI], 1.03 to 2.27; aHR, 2.84; 95% CI, 1.68 to 4.79; aHR, 15.46; 95% CI, 8.04 to 29.71) and mortality (aHR, 1.16; 95% CI, 0.84 to 1.58; aHR, 1.85; 95% CI, 1.13 to 3.07; aHR, 2.66; 95% CI, 1.19 to 5.97). When using a hierarchical approach, each additional exposure predicted the risk of DCGF better than DGF alone and 100 random bootstrap replications supported the internal validity of the risk model. In an external validation cohort deemed to be at lower risk of DCGF, similar nonsignificant trends were noted. Conclusion We propose a risk model that provides an incremental assessment of recipients at higher risk of adverse long-term outcomes than DGF alone. This can help advance the field of risk assessment in transplantation and inform therapeutic decision making in patients at the highest spectrum of inferior outcomes.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Multiorgan Transplant Program, Departments of Medicine and Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Multiorgan Transplant Program, Departments of Medicine and Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Heloise Cardinal
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | | | - Lynne Senecal
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Suzon Collette
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Chee Long Saw
- Multiorgan Transplant Program, Departments of Medicine and Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Hematology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Steven Paraskevas
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Multiorgan Transplant Program, Departments of Medicine and Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jean Tchervenkov
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Multiorgan Transplant Program, Departments of Medicine and Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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Patidar KR, Naved MA, Kabir S, Grama A, Allegretti AS, Cullaro G, Asrani SK, Worden A, Desai AP, Ghabril MS, Nephew LD, Orman ES. Longer time to recovery from acute kidney injury is associated with major adverse kidney events in patients with cirrhosis. Aliment Pharmacol Ther 2023; 57:1397-1406. [PMID: 36883210 PMCID: PMC10441172 DOI: 10.1111/apt.17457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/27/2022] [Accepted: 02/25/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND In patients with cirrhosis and acute kidney injury (AKI), longer time to AKI-recovery may increase the risk of subsequent major-adverse-kidney-events (MAKE). AIMS To examine the association between timing of AKI-recovery and risk of MAKE in patients with cirrhosis. METHODS Hospitalised patients with cirrhosis and AKI (n = 5937) in a nationwide database were assessed for time to AKI-recovery and followed for 180-days. Timing of AKI-recovery (return of serum creatinine <0.3 mg/dL of baseline) from AKI-onset was grouped by Acute-Disease-Quality-Initiative Renal Recovery consensus: 0-2, 3-7, and >7-days. Primary outcome was MAKE at 90-180-days. MAKE is an accepted clinical endpoint in AKI and defined as the composite outcome of ≥25% decline in estimated-glomerular-filtration-rate (eGFR) compared with baseline with the development of de-novo chronic-kidney-disease (CKD) stage ≥3 or CKD progression (≥50% reduction in eGFR compared with baseline) or new haemodialysis or death. Landmark competing-risk multivariable analysis was performed to determine the independent association between timing of AKI-recovery and risk of MAKE. RESULTS 4655 (75%) achieved AKI-recovery: 0-2 (60%), 3-7 (31%), and >7-days (9%). Cumulative-incidence of MAKE was 15%, 20%, and 29% for 0-2, 3-7, >7-days recovery groups, respectively. On adjusted multivariable competing-risk analysis, compared to 0-2-days, recovery at 3-7 and >7-days was independently associated with an increased risk for MAKE: sHR 1.45 (95% CI 1.01-2.09, p = 0.042), sHR 2.33 (95% CI 1.40-3.90, p = 0.001), respectively. CONCLUSION Longer time to recovery is associated with an increased risk of MAKE in patients with cirrhosis and AKI. Further research should examine interventions to shorten AKI-recovery time and its impact on subsequent outcomes.
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Affiliation(s)
- Kavish R. Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mobasshir A. Naved
- Department of Computer Science, Purdue University, West Lafayette, Indiana, USA
| | - Shaowli Kabir
- College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Ananth Grama
- Department of Computer Science, Purdue University, West Lafayette, Indiana, USA
| | - Andrew S. Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Giuseppe Cullaro
- Division of Gastroenterology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | | | - Astin Worden
- Division of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Archita P. Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan S. Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Joo H, Min SY, Park MS. Association between Inflammation-Based Parameters and Prognosis in Patients with Acute Kidney Injury. ACTA ACUST UNITED AC 2021; 57:medicina57090936. [PMID: 34577859 PMCID: PMC8471842 DOI: 10.3390/medicina57090936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/26/2021] [Accepted: 09/03/2021] [Indexed: 11/29/2022]
Abstract
Background and Objectives: this study aimed to clarify the relationship between inflammation-based parameters and prognosis in patients with acute kidney injury (AKI). Materials and Methods: We analyzed the prospectively collected data of patients with AKI, who were admitted through the emergency department between March 2020 and April 2021. Their clinical characteristics, inflammation-based parameters, resolving/non-resolving AKI pattern, and major adverse kidney event (MAKE) rates were analyzed. Results: Among 177 patients, 129 (72.9%) had a resolving AKI pattern and 48 (27.1%) had a non-resolving AKI pattern. The outcome of MAKE occurred in 30 (16.9%) participants. Multivariate analyses showed that the neutrophil-to-monocyte ratio was an independent predictor of resolving AKI, and that the neutrophil-to-monocyte and neutrophil-to-lymphocyte ratios were independent predictors of MAKE occurrence. Conclusions: we demonstrated that inflammation-based parameters are valuable predictors of early recovery and MAKE occurrence in patients with AKI.
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Hossain ME, Khan A, Moni MA, Uddin S. Use of Electronic Health Data for Disease Prediction: A Comprehensive Literature Review. IEEE/ACM TRANSACTIONS ON COMPUTATIONAL BIOLOGY AND BIOINFORMATICS 2021; 18:745-758. [PMID: 31478869 DOI: 10.1109/tcbb.2019.2937862] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Disease prediction has the potential to benefit stakeholders such as the government and health insurance companies. It can identify patients at risk of disease or health conditions. Clinicians can then take appropriate measures to avoid or minimize the risk and in turn, improve quality of care and avoid potential hospital admissions. Due to the recent advancement of tools and techniques for data analytics, disease risk prediction can leverage large amounts of semantic information, such as demographics, clinical diagnosis and measurements, health behaviours, laboratory results, prescriptions and care utilisation. In this regard, electronic health data can be a potential choice for developing disease prediction models. A significant number of such disease prediction models have been proposed in the literature over time utilizing large-scale electronic health databases, different methods, and healthcare variables. The goal of this comprehensive literature review was to discuss different risk prediction models that have been proposed based on electronic health data. Search terms were designed to find relevant research articles that utilized electronic health data to predict disease risks. Online scholarly databases were searched to retrieve results, which were then reviewed and compared in terms of the method used, disease type, and prediction accuracy. This paper provides a comprehensive review of the use of electronic health data for risk prediction models. A comparison of the results from different techniques for three frequently modelled diseases using electronic health data was also discussed in this study. In addition, the advantages and disadvantages of different risk prediction models, as well as their performance, were presented. Electronic health data have been widely used for disease prediction. A few modelling approaches show very high accuracy in predicting different diseases using such data. These modelling approaches have been used to inform the clinical decision process to achieve better outcomes.
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Qian Q, Wu J, Wang J, Sun H, Yang L. Prediction Models for AKI in ICU: A Comparative Study. Int J Gen Med 2021; 14:623-632. [PMID: 33664585 PMCID: PMC7921629 DOI: 10.2147/ijgm.s289671] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/07/2021] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To assess the performance of models for early prediction of acute kidney injury (AKI) in the Intensive Care Unit (ICU) setting. PATIENTS AND METHODS Data were collected from the Medical Information Mart for Intensive Care (MIMIC)-III database for all patients aged ≥18 years who had their serum creatinine (SCr) level measured for 72 h following ICU admission. Those with existing conditions of kidney disease upon ICU admission were excluded from our analyses. Seventeen predictor variables comprising patient demographics and physiological indicators were selected on the basis of the Kidney Disease Improving Global Outcomes (KDIGO) and medical literature. Six models from three types of methods were tested: Logistic Regression (LR), Support Vector Machines (SVM), Random Forest (RF), eXtreme Gradient Boosting (XGBoost), Light Gradient Boosting Decision Machine (LightGBM), and Convolutional Neural Network (CNN). The area under receiver operating characteristic curve (AUC), accuracy, precision, recall and F-measure (F1) were calculated for each model to evaluate performance. RESULTS We extracted the ICU records of 17,205 patients from MIMIC-III dataset. LightGBM had the best performance, with all evaluation indicators achieving the highest value (average AUC = 0.905, F1 = 0.897, recall = 0.836). XGBoost had the second best performance and LR, RF, SVM performed similarly (P = 0.082, 0.158 and 0.710, respectively) on AUC. The CNN model achieved the lowest score for accuracy, precision, F1 and AUC. SVM and LR had relatively low recall compared with that of the other models. The SCr level had the most significant effect on the early prediction of AKI onset in LR, RF, SVM and LightGBM. CONCLUSION LightGBM demonstrated the best capability for predicting AKI in the first 72 h of ICU admission. LightGBM and XGBoost showed great potential for clinical application owing to their high recall value. This study can provide references for artificial intelligence-powered clinical decision support systems for AKI early prediction in the ICU setting.
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Affiliation(s)
- Qing Qian
- Hangzhou Normal University, Hangzhou, People’s Republic of China
- Institute of Medical Information & Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Jinming Wu
- Institute of Medical Information & Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Jiayang Wang
- Institute of Medical Information & Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Haixia Sun
- Institute of Medical Information & Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Lei Yang
- Hangzhou Normal University, Hangzhou, People’s Republic of China
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Flannery AH, Bosler K, Ortiz-Soriano VM, Gianella F, Prado V, Lambert J, Toto RD, Moe OW, Neyra JA. Kidney Biomarkers and Major Adverse Kidney Events in Critically Ill Patients. KIDNEY360 2021; 2:26-32. [PMID: 35368827 PMCID: PMC8785730 DOI: 10.34067/kid.0003552020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 11/02/2020] [Indexed: 02/04/2023]
Abstract
Background Several biomarkers of AKI have been examined for their ability to predict AKI before serum creatinine. Few studies have focused on using kidney biomarkers to better predict major adverse kidney events (MAKE), an increasingly used composite outcome in critical care nephrology research. Methods Single-center prospective study collecting blood and urine samples from critically ill patients with AKI Kidney Disease Improving Global Outcomes stage 2 or above, and matched controls from a single, tertiary care intensive care unit (ICU). Samples were collected at 24-48 hours after AKI diagnosis (patients) or ICU admission (controls), 5-7 days later, and 4-6 weeks after discharge for patients with AKI. The primary outcome of interest was MAKE at hospital discharge (MAKE-DC), consisting of the composite end point of death, RRT dependence, or a decrease in estimated glomerular filtration to <75% of baseline. Results Serum/urinary neutrophil gelatinase-associated lipocalin (NGAL), serum/urinary cystatin C, and urinary kidney injury molecule-1 early in the AKI or ICU course were all significantly higher in patients with MAKE-DC compared with those not experiencing MAKE-DC. Additionally, serum/urinary NGAL and serum cystatin C measurements at the first time point remained significantly associated with MAKE events at 3, 6, and 12 months. Serum cystatin C, and to a lesser extent serum NGAL, significantly improved upon a logistic regression clinical prediction model of MAKE-DC (AUROC 0.94 and 0.87 versus 0.83; P=0.001 and P=0.02, respectively). Patients without MAKE-DC experienced a greater decline in serum NGAL from first to second measurement than those patients experiencing MAKE-DC. Conclusions Early measures of kidney biomarkers in patients who are critically ill are associated with MAKE-DC. This relationship appears to be greatest with serum NGAL and cystatin C, which display additive utility to a clinical prediction model. Trending serum NGAL may also have utility in predicting MAKE-DC.
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Affiliation(s)
- Alexander H. Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Katherine Bosler
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Victor M. Ortiz-Soriano
- Division of Nephrology, Bone and Mineral Metabolism, Department of Internal Medicine, University of Kentucky Medical Center, Lexington, Kentucky
| | - Fabiola Gianella
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Victor Prado
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joshua Lambert
- University of Cincinnati College of Nursing, Cincinnati, Ohio
| | - Robert D. Toto
- Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Orson W. Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
- Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Javier A. Neyra
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
- Division of Nephrology, Bone and Mineral Metabolism, Department of Internal Medicine, University of Kentucky Medical Center, Lexington, Kentucky
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Sukmark T, Lumlertgul N, Praditpornsilpa K, Tungsanga K, Eiam-Ong S, Srisawat N. SEA-MAKE score as a tool for predicting major adverse kidney events in critically ill patients with acute kidney injury: results from the SEA-AKI study. Ann Intensive Care 2020; 10:42. [PMID: 32300902 PMCID: PMC7162998 DOI: 10.1186/s13613-020-00657-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/04/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common problem in critically ill patients and associated with high rates of morbidity and mortality. Recently, Major Adverse Kidney Events (MAKE) were introduced as important kidney endpoints. If these endpoints can be predicted, then it may help the physicians to identify high-risk patients and provide the opportunity to have targeted preventive therapy. The objective of this study was to create a simplified scoring system to predict MAKE within 28 days among AKI patients in ICU. METHODS This is a prospective web-based multicenter cohort study that was conducted in adults who were admitted to the ICU in 17 centers across Thailand from 2013 to 2015. A predicting score was derived from the regression equation with Receiver Operating Characteristic (ROC) analysis to evaluate the diagnostic test and produce predictive models. Internal validation was obtained using the bootstrapping method. RESULTS From 5071 cases, 2856 (56%) had AKI. Among those with AKI, 1749 (61%) had MAKE. Among those that have MAKE, there were 1175 (41.4%) deaths, 414 (14.4%) were on dialysis and 1154 (40.7%) had non-recovery renal function. The simplified score points of low Glasgow coma scale was 3, tachypnea was 1, vasopressor use was 1, on mechanical ventilation was 2, oliguria was 2, serum creatinine rising ≥ 3 times was 5, high blood urea nitrogen was 3, low hematocrit was 2, and thrombocytopenia was 1. The area under ROC curve for optimism corrected performance was 0.80 (0.78, 0.81). When the cut-off value was 7, the sensitivity, specificity, positive likelihood ratio, and positive predictive values were 0.75, 0.76, 3.10, and 0.84, respectively. When the scoring system was calibrated, the α intercept and β slope were 1.001 and 0, respectively. CONCLUSIONS SEA-MAKE scoring system is a new simplified clinical tool that can be used to predict major adverse kidney events in AKI patients. The simplicity of the scoring system is highly likely to be used in resource-limited settings. However, external validation is necessary before widespread use.
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Affiliation(s)
| | - Nuttha Lumlertgul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, 10330 Thailand
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, 10330 Thailand
| | - Kriang Tungsanga
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, 10330 Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, 10330 Thailand
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, 10330 Thailand
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Academic of Science, Royal Society of Thailand, Bangkok, Thailand
- Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand
- Center for Critical Care Nephrology; The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
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Bhatraju PK, Zelnick LR, Chinchilli VM, Moledina DG, Coca SG, Parikh CR, Garg AX, Hsu CY, Go AS, Liu KD, Ikizler TA, Siew ED, Kaufman JS, Kimmel PL, Himmelfarb J, Wurfel MM. Association Between Early Recovery of Kidney Function After Acute Kidney Injury and Long-term Clinical Outcomes. JAMA Netw Open 2020; 3:e202682. [PMID: 32282046 PMCID: PMC7154800 DOI: 10.1001/jamanetworkopen.2020.2682] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE The severity of acute kidney injury (AKI) is usually determined based on the maximum serum creatinine concentration. However, the trajectory of kidney function recovery could be an additional important dimension of AKI severity. OBJECTIVE To assess whether the trajectory of kidney function recovery within 72 hours after AKI is associated with long-term risk of clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS This prospective, multicenter cohort study enrolled 1538 adults with or without AKI 3 months after hospital discharge between December 1, 2009, and February 28, 2015. Statistical analyses were completed November 1, 2018. Participants with or without AKI were matched based on demographic characteristics, site, comorbidities, and prehospitalization estimated glomerular filtration rate. Participants with AKI were classified as having resolving or nonresolving AKI based on previously published definitions. Resolving AKI was defined as a decrease in serum creatinine concentration of 0.3 mg/dL or more or 25% or more from maximum in the first 72 hours after AKI diagnosis. Nonresolving AKI was defined as AKI not meeting the definition for resolving AKI. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of major adverse kidney events (MAKE), defined as incident or progressive chronic kidney disease, long-term dialysis, or all-cause death during study follow-up. RESULTS Among 1538 participants (964 men; mean [SD] age, 64.6 [12.7] years), 769 (50%) had no AKI, 475 (31%) had a resolving AKI pattern, and 294 (19%) had a nonresolving AKI pattern. After a median follow-up of 4.7 years, the outcome of MAKE occurred in 550 (36%) of all participants. The adjusted hazard ratio for MAKE was higher for patients with resolving AKI (adjusted hazard ratio, 1.52; 95% CI, 1.01-2.29; P = .04) and those with nonresolving AKI (adjusted hazard ratio 2.30; 95% CI, 1.52-3.48; P < .001) compared with participants without AKI. Within the population of patients with AKI, nonresolving AKI was associated with a 51% greater risk of MAKE (95% CI, 22%-88%; P < .001) compared with resolving AKI. The higher risk of MAKE among patients with nonresolving AKI was explained by a higher risk of incident and progressive chronic kidney disease. CONCLUSIONS AND RELEVANCE This study suggests that the 72-hour period immediately after AKI distinguishes the risk of clinically important kidney-specific long-term outcomes. The identification of different AKI recovery patterns may improve patient risk stratification, facilitate prognostic enrichment in clinical trials, and enable recognition of patients who may benefit from nephrology consultation.
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Affiliation(s)
- Pavan K. Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle
| | - Leila R. Zelnick
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle
| | - Vernon M. Chinchilli
- Penn State College of Medicine, Department of Public Health Sciences, Hershey, Pennsylvania
| | - Dennis G. Moledina
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Program of Applied Translational Research, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Steve G. Coca
- Section of Nephrology, Department of Internal Medicine, Mount Sinai School of Medicine, New York, New York
| | - Chirag R. Parikh
- Division of Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Amit X. Garg
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - Chi-yuan Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Alan S. Go
- Division of Nephrology, Department of Medicine, University of California, San Francisco
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Kathleen D. Liu
- Division of Nephrology, Department of Medicine, University of California, San Francisco
- Division of Critical Care, Department of Anesthesia, University of California, San Francisco
| | - T. Alp Ikizler
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Edward D. Siew
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James S. Kaufman
- Division of Nephrology, New York University School of Medicine, New York
- Division of Nephrology, Veterans Affairs New York Harbor Healthcare System, New York
| | - Paul L. Kimmel
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University Medical Center, Washington, DC
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle
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McKown AC, Huerta LE, Rice TW, Semler MW. Heterogeneity of Treatment Effect by Baseline Risk in a Trial of Balanced Crystalloids versus Saline. Am J Respir Crit Care Med 2019; 198:810-813. [PMID: 29897785 DOI: 10.1164/rccm.201804-0680le] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Luis E Huerta
- 1 Vanderbilt University Medical Center Nashville, Tennessee
| | - Todd W Rice
- 1 Vanderbilt University Medical Center Nashville, Tennessee
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Abstract
Advanced informatics systems can help improve health care delivery and the environment of care for critically ill patients. However, identifying, testing, and deploying advanced informatics systems can be quite challenging. These processes often require involvement from a collaborative group of health care professionals of varied disciplines with knowledge of the complexities related to designing the modern and "smart" intensive care unit (ICU). In this article, we explore the connectivity environment within the ICU, middleware technologies to address a host of patient care initiatives, and the core informatics concepts necessary for both the design and implementation of advanced informatics systems.
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