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Abdelhafez MO, Alhroob AA, Abu Hawilla MO, Rjoob AA, Abualia NM, Gorman EF, Hamadah AM, Gharaibeh KA. Utility of fractional excretion of urea in acute kidney injury with comparison to fractional excretion of sodium: A systematic review and meta-analysis. Am J Med Sci 2024:S0002-9629(24)01220-5. [PMID: 38768779 DOI: 10.1016/j.amjms.2024.04.021] [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: 09/13/2023] [Revised: 02/28/2024] [Accepted: 04/18/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Differentiating between intrinsic and prerenal acute kidney injury (AKI) presents a challenge. Here, we assessed the performance of the fractional excretion of urea (FEUrea) and compared it to the fractional excretion of sodium (FENa) in distinguishing intrinsic from prerenal AKI. METHODS A thorough search was conducted in several databases until January 16, 2024. We included studies evaluating FEUrea, with or without FENa, for differentiating AKI etiologies in adults. We assessed the methodological quality using the QUADAS-2 and QUADAS-C tools. We performed a meta-analysis using the bivariate random effects model, with subgroup analyses to explore the impact of diuretic therapy on FEUrea, and direct statistical comparisons between FEUrea and FENa involving the subgroups with and without diuretics. RESULTS We included 11 studies with 1108 hospitalized patients. Among eight studies (915 patients) evaluating FEUrea >35% for distinguishing intrinsic from prerenal AKI, the pooled sensitivity and specificity were 66% (95% CI, 49%-79%) and 75% (95% CI, 60%-85%), respectively. In a subset of six studies (302 patients) comparing FEUrea at 35% to FENa at 1% in patients not receiving diuretics, there were no significant differences in sensitivity (77% versus 89%, P = 0.410) or specificity (80% versus 79%, P = 0.956). In four studies, 244 patients on diuretics, FEUrea demonstrated lower sensitivity (52% versus 92%, P < 0.001) but higher specificity (82% versus 44%, P < 0.001) compared to FENa for the diagnosis of intrinsic AKI. CONCLUSIONS FEUrea has limited utility in differentiating intrinsic from prerenal AKI. FEUrea does not provide a superior alternative to FENa, even in patients receiving diuretics.
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Affiliation(s)
- Mohammad O Abdelhafez
- Department of Internal Medicine, Al-Quds University, Abu Dis, Jerusalem, State of Palestine
| | - Asil A Alhroob
- Department of Internal Medicine, Al-Quds University, Abu Dis, Jerusalem, State of Palestine
| | - Mustafa O Abu Hawilla
- Department of Internal Medicine, Al-Quds University, Abu Dis, Jerusalem, State of Palestine
| | - Asmaa A Rjoob
- Department of Internal Medicine, Al-Quds University, Abu Dis, Jerusalem, State of Palestine
| | - Nasser M Abualia
- Department of Internal Medicine, Al-Quds University, Abu Dis, Jerusalem, State of Palestine
| | - Emily F Gorman
- Health Sciences and Human Services Library, University of Maryland, Baltimore, MD, USA
| | | | - Kamel A Gharaibeh
- Department of Internal Medicine, Al-Quds University, Abu Dis, Jerusalem, State of Palestine; Division of Pulmonary & Critical Care Medicine, University of Maryland, School of Medicine, Baltimore, MD, USA.
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2
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Buckenmayer A, Siebler N, Haas CS. Evaluation of simple diagnostic parameters in acute kidney injury in hospitalized patients-diagnostic recommendations for non-nephrologists. Intern Emerg Med 2023; 18:1769-1776. [PMID: 37452960 PMCID: PMC10504189 DOI: 10.1007/s11739-023-03365-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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
Acute kidney injury (AKI) is very common in hospitalized patients, affecting patient's mortality and morbidity. Major causes are prerenal AKI and acute tubular necrosis (ATN). Even though a variety of parameters/indices exist, their reliability and practicability are controversial: in fact, there is a need for a simple diagnostic approach for AKI in in-patients with parameters easily obtained in any hospital. The objective of the study was: (1) to assess reliability of simple laboratory parameters/indices to differentiate pre-/intrarenal AKI; (2) to evaluate the most reliable and feasible parameters/indices; and (3) to identify the possible impact of confounding factors. Retrospectively, in-patients with AKI hospitalized in 2020 in a university nephrology department were included. Spot urine and 24-h collection urine was analyzed with urine sodium (UNa), urine specific gravity (USG), fractional excretion of sodium (FENa), fractional excretion of urea (FEUrea), urine osmolality (UOsm), urine to plasma creatinine ratio (UCr/PCr) and renal failure index (RFI). Overall, 431 patients were included. UNa, UOsm, USG and RFI showed high specificity > 85% for prerenal AKI, UNa and RFI provided good specificity for ATN. Loop diuretics, ACE inhibitors/AT1 blockers or pre-existing chronic kidney disease had no impact. In patients with AKI, UNa, USG and RFI: (1) proved to be very specific for prerenal AKI and showed high sensitivity for ATN; (2) can be easily determined using serum and spot urine; and (3) are not confounded by medication or comorbidities. These parameters/indices are helpful to identify the aetiology of AKI and to guide therapy, thereby improving patients' safety and outcome.
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Affiliation(s)
- Anna Buckenmayer
- Department of Internal Medicine, Nephrology & Intensive Care Medicine, Phillips University, Baldinger Straße 1, 35043, Marburg, Germany.
| | - Nadja Siebler
- Department of Internal Medicine, Nephrology & Intensive Care Medicine, Phillips University, Baldinger Straße 1, 35043, Marburg, Germany
| | - Christian S Haas
- Department of Internal Medicine, Nephrology & Intensive Care Medicine, Phillips University, Baldinger Straße 1, 35043, Marburg, Germany
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Hamadah A, Gharaibeh K. Fractional Excretion of Sodium and Urea are Useful Tools in the Evaluation of AKI: PRO. KIDNEY360 2023; 4:e725-e727. [PMID: 37384887 PMCID: PMC10371381 DOI: 10.34067/kid.0002492022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/29/2022] [Indexed: 07/01/2023]
Affiliation(s)
| | - Kamel Gharaibeh
- University of Maryland School of Medicine, Baltimore, Maryland
- Faculty of Medicine, Al-Quds University, Jerusalem, Israel
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4
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Schnabel K, Garam N, Ledó N, Hajdú N, Kóczy Á, Takács I, Tabák ÁG, Tislér A. Urinary albumin-to-creatinine ratio and serum albumin are predictors of acute kidney injury in non-ventilated COVID-19 patients: a single-center prospective cohort study. Int Urol Nephrol 2023; 55:711-720. [PMID: 36127479 PMCID: PMC9488874 DOI: 10.1007/s11255-022-03348-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 08/19/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Acute kidney injury (AKI) is a frequent complication among COVID-19 patients in the intensive care unit, but it is less frequently investigated in general internal medicine wards. We aimed to examine the incidence, the predictors of AKI, and AKI-associated mortality in a prospective cohort of non-ventilated COVID-19 patients. We aimed to describe the natural history of AKI by describing trajectories of urinary markers of hemodynamic, glomerular, and tubular injury. METHODS 141 COVID-19 patients were enrolled to the study. AKI was defined according to KDIGO guidelines. Urine and renal function parameters were followed twice a week. Multivariate logistic regression was used to determine the predictors of AKI and mortality. Trajectories of urinary markers were described by unadjusted linear mixed models. RESULTS 19.7% patients developed AKI. According to multiple logistic regression, higher urinary albumin-to-creatinine ratio (OR 1.48, 95% CI 1.04-2.12/1 mg/mmol) and lower serum albumin (OR 0.86, 95% CI 0.77-0.94/1 g/L) were independent predictors of AKI. Mortality was 42.8% in the AKI and 8.8% in the group free from AKI (p < 0.0001). According to multiple logistic regression, older age, lower albumin, and AKI (OR 3.9, 95% CI 1.24-12.21) remained independent predictors of mortality. Urinary protein-to-creatinine trajectories were diverging with decreasing values in those without incident AKI. CONCLUSION We found high incidence of AKI and mortality among moderately severe, non-ventilated COVID-19 patients. Its development is predicted by higher albuminuria suggesting that the originally damaged renal structure may be more susceptible for virus-associated effects. No clear relationship was found with a prerenal mechanism, and the higher proteinuria during follow-up may point toward tubular damage.
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Affiliation(s)
- Karolina Schnabel
- Department of Internal Medicine and Oncology, Semmelweis University Faculty of Medicine, Korányi Sándor utca 2/a, Budapest, 1083, Hungary
| | - Nóra Garam
- Department of Internal Medicine and Oncology, Semmelweis University Faculty of Medicine, Korányi Sándor utca 2/a, Budapest, 1083, Hungary.
| | - Nóra Ledó
- Department of Internal Medicine and Oncology, Semmelweis University Faculty of Medicine, Korányi Sándor utca 2/a, Budapest, 1083, Hungary
| | - Noémi Hajdú
- Department of Internal Medicine and Oncology, Semmelweis University Faculty of Medicine, Korányi Sándor utca 2/a, Budapest, 1083, Hungary
| | - Ágnes Kóczy
- Department of Internal Medicine and Oncology, Semmelweis University Faculty of Medicine, Korányi Sándor utca 2/a, Budapest, 1083, Hungary
| | - István Takács
- Department of Internal Medicine and Oncology, Semmelweis University Faculty of Medicine, Korányi Sándor utca 2/a, Budapest, 1083, Hungary
| | - Ádám Gy Tabák
- Department of Internal Medicine and Oncology, Semmelweis University Faculty of Medicine, Korányi Sándor utca 2/a, Budapest, 1083, Hungary
- Department of Public Health, Semmelweis University Faculty of Medicine, Budapest, Hungary
- Department of Epidemiology and Health Care, University College London, London, UK
| | - András Tislér
- Department of Internal Medicine and Oncology, Semmelweis University Faculty of Medicine, Korányi Sándor utca 2/a, Budapest, 1083, Hungary
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5
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Seethapathy H, Fenves AZ. Fractional Excretion of Sodium (FENa): An Imperfect Tool for a Flawed Question. Clin J Am Soc Nephrol 2022; 17:777-778. [PMID: 35613884 PMCID: PMC9269665 DOI: 10.2215/cjn.04750422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Harish Seethapathy
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, and Harvard Medical School, Boston, Massachusetts
| | - Andrew Z Fenves
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, and Harvard Medical School, Boston, Massachusetts
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6
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Abdelhafez M, Nayfeh T, Atieh A, AbuShamma O, Babaa B, Baniowda M, Hrizat A, Hasan B, Hassett L, Hamadah A, Gharaibeh K. Diagnostic Performance of Fractional Excretion of Sodium for the Differential Diagnosis of Acute Kidney Injury: A Systematic Review and Meta-Analysis. Clin J Am Soc Nephrol 2022; 17:785-797. [PMID: 35545442 PMCID: PMC9269645 DOI: 10.2215/cjn.14561121] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 04/06/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES AKI is classified as prerenal, intrinsic, and postrenal. Prerenal AKI and intrinsic AKI represent the most common causes for AKI in hospitalized patients. This study aimed to examine the accuracy of the fractional excretion of sodium for distinguishing intrinsic from prerenal AKI. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, the Cochrane Library, and Scopus for all available studies that met the criteria until December 31, 2021. We included studies that evaluated fractional excretion of sodium in differentiating AKI etiologies in adults, whereas studies that did not have sufficient data to extract a 2×2 table were excluded. We assessed the methodologic quality using the Quality Assessment of Diagnostic Accuracy Studies-2 tool and extracted the diagnostic accuracy data for all included studies. We conducted a meta-analysis using the bivariate random effects model. We performed subgroup analysis to investigate sources of heterogeneity and the effect of the relevant confounders on fractional excretion of sodium accuracy. RESULTS We included 19 studies with 1287 patients. In a subset of 15 studies (872 patients) that used a threshold of 1%, the pooled sensitivity and specificity for differentiating intrinsic from prerenal AKI were 90% (95% confidence interval, 81% to 95%) and 82% (95% confidence interval, 70% to 90%), respectively. In a subgroup of six studies (511 patients) that included CKD or patients on diuretics, the pooled sensitivity and specificity were 83% (95% confidence interval, 64% to 93%) and 66% (95% confidence interval, 51% to 78%), respectively. In five studies with 238 patients on diuretics, the pooled sensitivity and specificity were 80% (95% confidence interval, 69% to 87%) and 54% (95% confidence interval, 31% to 75%), respectively. In eight studies with 264 oliguric patients with no history of CKD or diuretic therapy, the pooled sensitivity and specificity were 95% (95% confidence interval, 82% to 99%) and 91% (95% confidence interval, 83% to 95%), respectively. CONCLUSIONS Fractional excretion of sodium has a limited role for AKI differentiation in patients with a history of CKD or those on diuretic therapy. It is most valuable when oliguria is present.
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Affiliation(s)
- Mohammad Abdelhafez
- Department of Internal Medicine, Al-Quds University, Jerusalem, State of Palestine
| | - Tarek Nayfeh
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Anwar Atieh
- Department of Internal Medicine, Al-Quds University, Jerusalem, State of Palestine
| | - Omar AbuShamma
- Department of Internal Medicine, Al-Quds University, Jerusalem, State of Palestine
| | - Basheer Babaa
- Department of Internal Medicine, Al-Quds University, Jerusalem, State of Palestine
| | - Muath Baniowda
- Department of Internal Medicine, Al-Quds University, Jerusalem, State of Palestine
| | - Alaa Hrizat
- Department of Internal Medicine, Al-Quds University, Jerusalem, State of Palestine
| | - Bashar Hasan
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Leslie Hassett
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota
| | | | - Kamel Gharaibeh
- Department of Internal Medicine, Al-Quds University, Jerusalem, State of Palestine .,Division of Pulmonary & Critical Care, University of Maryland, Baltimore, Maryland
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7
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Moran SM, Scott J, Clarkson MR, Conlon N, Dunne J, Griffin MD, Griffin TP, Groarke E, Holian J, Judge C, Wyse J, McLoughlin K, O’Hara PV, Kretzler M, Little MA. The Clinical Application of Urine Soluble CD163 in ANCA-Associated Vasculitis. J Am Soc Nephrol 2021; 32:2920-2932. [PMID: 34518279 PMCID: PMC8806104 DOI: 10.1681/asn.2021030382] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 08/04/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Up to 70% of patients with ANCA-associated vasculitis (AAV) develop GN, with 26% progressing to ESKD. Diagnostic-grade and noninvasive tools to detect active renal inflammation are needed. Urinary soluble CD163 (usCD163) is a promising biomarker of active renal vasculitis, but a diagnostic-grade assay, assessment of its utility in prospective diagnosis of renal vasculitis flares, and evaluation of its utility in proteinuric states are needed. METHODS We assessed a diagnostic-grade usCD163 assay in (1) a real-world cohort of 405 patients with AAV and 121 healthy and 488 non-AAV disease controls; (2) a prospective multicenter study of 84 patients with potential renal vasculitis flare; (3) a longitudinal multicenter cohort of 65 patients with podocytopathy; and (4) a cohort of 29 patients with AAV (with or without proteinuria) and ten controls. RESULTS We established a diagnostic reference range, with a cutoff of 250 ng/mmol for active renal vasculitis (area under the curve [AUC], 0.978). Using this cutoff, usCD163 was elevated in renal vasculitis flare (AUC, 0.95) but remained low in flare mimics, such as nonvasculitic AKI. usCD163's specificity declined in patients with AAV who had nephrotic-range proteinuria and in those with primary podocytopathy, with 62% of patients with nephrotic syndrome displaying a "positive" usCD163. In patients with AAV and significant proteinuria, usCD163 normalization to total urine protein rather than creatinine provided the greatest clinical utility for diagnosing active renal vasculitis. CONCLUSIONS usCD163 is elevated in renal vasculitis flare and remains low in flare mimics. Nonspecific protein leakage in nephrotic syndrome elevates usCD163 in the absence of glomerular macrophage infiltration, resulting in false-positive results; this can be corrected with urine protein normalization.
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Affiliation(s)
- Sarah M. Moran
- Trinity Health Kidney Centre, Trinity College Dublin, Dublin, Ireland,Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Jennifer Scott
- Trinity Health Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | | | | | | | - Matthew D. Griffin
- REMEDI at CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, National University of Ireland, Galway, Ireland,Department of Nephrology, Saolta University Health Care Group, Galway University Hospitals, Galway, Ireland
| | - Tomas P. Griffin
- REMEDI at CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, National University of Ireland, Galway, Ireland,Centre for Endocrinology, Diabetes and Metabolism, Saolta University Health Care Group, Galway University Hospitals, Galway, Ireland
| | | | - John Holian
- St Vincent’s University Hospital, Dublin, Ireland
| | - Conor Judge
- Department of Nephrology, Saolta University Health Care Group, Galway University Hospitals, Galway, Ireland,Centre for Endocrinology, Diabetes and Metabolism, Saolta University Health Care Group, Galway University Hospitals, Galway, Ireland
| | - Jason Wyse
- Discipline of Statistics and Information Systems, Trinity College Dublin, Dublin, Ireland
| | | | | | - Matthias Kretzler
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan,Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
| | - Mark A. Little
- Trinity Health Kidney Centre, Trinity College Dublin, Dublin, Ireland,Beaumont Kidney Centre, Dublin, Ireland,Tallaght University Hospital, Dublin, Ireland
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8
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George S, Pal AC, Gagnon J, Timalsina S, Singh P, Vydyam P, Munshi M, Chiu JE, Renard I, Harden CA, Ott IM, Watkins AE, Vogels CB, Lu P, Tokuyama M, Venkataraman A, Casanovas-Massana A, Wyllie AL, Rao V, Campbell M, Farhadian SF, Grubaugh ND, Dela Cruz CS, Ko AI, Berna Perez AZ, Akaho EH, Moledina DG, Testani J, John AR, Ledizet M, Mamoun CB. Evidence for SARS-CoV-2 Spike Protein in the Urine of COVID-19 Patients. KIDNEY360 2021; 2:924-936. [PMID: 35373072 PMCID: PMC8791366 DOI: 10.34067/kid.0002172021] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/12/2021] [Indexed: 11/27/2022]
Abstract
Background SARS-CoV-2 infection has, as of April 2021, affected >133 million people worldwide, causing >2.5 million deaths. Because the large majority of individuals infected with SARS-CoV-2 are asymptomatic, major concerns have been raised about possible long-term consequences of the infection. Methods Wedeveloped an antigen capture assay to detect SARS-CoV-2 spike protein in urine samples from patients with COVID-19whose diagnosis was confirmed by positive PCR results from nasopharyngeal swabs (NP-PCR+) forSARS-CoV-2. We used a collection of 233 urine samples from 132 participants from Yale New Haven Hospital and the Children's Hospital of Philadelphia that were obtained during the pandemic (106 NP-PCR+ and 26 NP-PCR-), and a collection of 20 urine samples from 20 individuals collected before the pandemic. Results Our analysis identified 23 out of 91 (25%) NP-PCR+ adult participants with SARS-CoV-2 spike S1 protein in urine (Ur-S+). Interestingly, although all NP-PCR+ children were Ur-S-, one child who was NP-PCR- was found to be positive for spike protein in their urine. Of the 23 adults who were Ur-S+, only one individual showed detectable viral RNA in urine. Our analysis further showed that 24% and 21% of adults who were NP-PCR+ had high levels of albumin and cystatin C, respectively, in their urine. Among individuals with albuminuria (>0.3 mg/mg of creatinine), statistical correlation could be found between albumin and spike protein in urine. Conclusions Together, our data showed that one of four individuals infected with SARS-CoV-2 develop renal abnormalities, such as albuminuria. Awareness about the long-term effect of these findings is warranted.
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Affiliation(s)
- Santosh George
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut
| | - Anasuya Chattopadhyay Pal
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut
| | | | | | - Pallavi Singh
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut
| | - Pratap Vydyam
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut
| | - Muhammad Munshi
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut
| | - Joy E. Chiu
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut
| | - Isaline Renard
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut
| | - Christina A. Harden
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Isabel M. Ott
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Anne E. Watkins
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Chantal B.F. Vogels
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Peiwen Lu
- Department of Immunology, Yale School of Medicine, New Haven, Connecticut
| | - Maria Tokuyama
- Department of Immunology, Yale School of Medicine, New Haven, Connecticut
| | | | - Arnau Casanovas-Massana
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Anne L. Wyllie
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Veena Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Melissa Campbell
- Department of Pediatrics, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut
| | - Shelli F. Farhadian
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut
| | - Nathan D. Grubaugh
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Charles S. Dela Cruz
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, New Haven, Connecticut
| | - Albert I. Ko
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Amalia Z. Berna Perez
- Department of Pediatrics, Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elikplim H. Akaho
- Department of Pediatrics, Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Dennis G. Moledina
- Department of Internal Medicine, Section of Nephrology and Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, Connecticut
| | - Jeffrey Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Audrey R. John
- Department of Pediatrics, Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Choukri Ben Mamoun
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut
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9
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Pool MBF, Hamelink TL, van Goor H, van den Heuvel MC, Leuvenink HGD, Moers C. Prolonged ex-vivo normothermic kidney perfusion: The impact of perfusate composition. PLoS One 2021; 16:e0251595. [PMID: 34003874 PMCID: PMC8130974 DOI: 10.1371/journal.pone.0251595] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/29/2021] [Indexed: 12/22/2022] Open
Abstract
Normothermic machine perfusion (NMP) of donor kidneys provides the opportunity for improved graft preservation and objective pre-transplant ex-vivo organ assessment. Currently, a multitude of perfusion solutions exist for renal NMP. This study aimed to evaluate four different perfusion solutions side-by-side and determine the influence of different perfusate compositions on measured renal perfusion parameters. Porcine kidneys and blood were obtained from a slaughterhouse. Kidneys underwent NMP at 37°C for 7 hours, with 4 different perfusion solutions (n = 5 per group). Group 1 consisted of red blood cells (RBCs) and a perfusion solution based on Williams’ Medium E. Group 2 consisted of RBCs, albumin and a balanced electrolyte composition. Group 3 contained RBCs and a medium based on a British clinical NMP solution. Group 4 contained RBCs and a medium used in 24-hour perfusion experiments. NMP flow patterns for solutions 1 and 2 were similar, solutions 3 and 4 showed lower but more stable flow rates. Thiobarbituric acid reactive substances were significantly higher in solution 1 and 4 compared to the other groups. Levels of injury marker N-acetyl-β-D glucosaminidase were significantly lower in solution 2 in comparison with solution 3 and 4. This study illustrates that the perfusate composition during NMP significantly impacts the measured perfusion and injury parameters and thus affects the interpretation of potential viability markers. Further research is required to investigate the individual influences of principal perfusate components to determine the most optimal conditions during NMP and eventually develop universal organ assessment criteria.
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Affiliation(s)
- Merel B. F. Pool
- Department of Surgery–Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- * E-mail:
| | - Tim L. Hamelink
- Department of Surgery–Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Harry van Goor
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marius C. van den Heuvel
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Henri G. D. Leuvenink
- Department of Surgery–Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cyril Moers
- Department of Surgery–Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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10
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Umbrello M, Formenti P, Chiumello D. Urine Electrolytes in the Intensive Care Unit: From Pathophysiology to Clinical Practice. Anesth Analg 2020; 131:1456-1470. [PMID: 33079869 DOI: 10.1213/ane.0000000000004994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Assessment of urine concentrations of sodium, chloride, and potassium is a widely available, rapid, and low-cost diagnostic option for the management of critically ill patients. Urine electrolytes have long been suggested in the diagnostic workup of hypovolemia, kidney injury, and acid-base and electrolyte disturbances. However, due to the wide range of normal reference values and challenges in interpretation, their use is controversial. To clarify their potential role in managing critical patients, we reviewed existing evidence on the use of urine electrolytes for diagnostic and therapeutic evaluation and assessment in critical illness. This review will describe the normal physiology of water and electrolyte excretion, summarize the use of urine electrolytes in hypovolemia, acute kidney injury, acid-base, and electrolyte disorders, and suggest some practical flowcharts for the potential use of urine electrolytes in daily critical care practice.
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Affiliation(s)
- Michele Umbrello
- From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
| | - Paolo Formenti
- From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
| | - Davide Chiumello
- From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
- Dipartimento di Scienze della Salute
- Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
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11
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Chapman CL, Johnson BD, Parker MD, Hostler D, Pryor RR, Schlader Z. Kidney physiology and pathophysiology during heat stress and the modification by exercise, dehydration, heat acclimation and aging. Temperature (Austin) 2020; 8:108-159. [PMID: 33997113 PMCID: PMC8098077 DOI: 10.1080/23328940.2020.1826841] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/17/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
The kidneys' integrative responses to heat stress aid thermoregulation, cardiovascular control, and water and electrolyte regulation. Recent evidence suggests the kidneys are at increased risk of pathological events during heat stress, namely acute kidney injury (AKI), and that this risk is compounded by dehydration and exercise. This heat stress related AKI is believed to contribute to the epidemic of chronic kidney disease (CKD) occurring in occupational settings. It is estimated that AKI and CKD affect upwards of 45 million individuals in the global workforce. Water and electrolyte disturbances and AKI, both of which are representative of kidney-related pathology, are the two leading causes of hospitalizations during heat waves in older adults. Structural and physiological alterations in aging kidneys likely contribute to this increased risk. With this background, this comprehensive narrative review will provide the first aggregation of research into the integrative physiological response of the kidneys to heat stress. While the focus of this review is on the human kidneys, we will utilize both human and animal data to describe these responses to passive and exercise heat stress, and how they are altered with heat acclimation. Additionally, we will discuss recent studies that indicate an increased risk of AKI due to exercise in the heat. Lastly, we will introduce the emerging public health crisis of older adults during extreme heat events and how the aging kidneys may be more susceptible to injury during heat stress.
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Affiliation(s)
- Christopher L. Chapman
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Human Physiology, University of Oregon, Eugene, OR, USA
| | - Blair D. Johnson
- Department of Kinesiology, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Mark D. Parker
- Department of Physiology and Biophysics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Ophthalmology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - David Hostler
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY, USA
| | - Riana R. Pryor
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY, USA
| | - Zachary Schlader
- Department of Kinesiology, School of Public Health, Indiana University, Bloomington, IN, USA
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12
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Substituting a pasture-based diet with plantain (Plantago lanceolata) reduces nitrogen excreted in urine from dairy cows in late lactation. Livest Sci 2020. [DOI: 10.1016/j.livsci.2020.104093] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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13
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Tinklenberg RL, Murphy SD, Mochel JP, Seo YJ, Mahaffey AL, Yan Y, Ward JL. Evaluation of dose-response effects of short-term oral prednisone administration on clinicopathologic and hemodynamic variables in healthy dogs. Am J Vet Res 2020; 81:317-325. [PMID: 32228253 DOI: 10.2460/ajvr.81.4.317] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether a dose-response relationship exists between short-term oral prednisone administration and common clinicopathologic variables, cardiovascular biomarkers, and systolic arterial blood pressure (SAP) in healthy dogs. ANIMALS 8 healthy Beagles. PROCEDURES Dogs underwent five 5-day experiments (no prednisone treatment [control condition] and prednisone administration at 0.5, 1, 2, and 4 mg/kg, PO, q 24 h), with a 9-day washout period between protocols. Analyses performed before and after treatments included a CBC, serum biochemical analysis, and determination of SAP, fractional excretion of electrolytes, urine protein-to-creatinine ratio, glomerular filtration rate (GFR), serum N-terminal pro B-type natriuretic peptide (NT-proBNP) and plasma cortisol concentrations, and plasma renin activity. Linear mixed-effects modeling was used to compare changes in variables from baseline (day 1 for the same experiment) among treatment conditions. RESULTS Changes in serum glucose concentration and GFR were significantly greater after administration of prednisone at 4 mg/kg than for the control condition. Fractional excretion of sodium was decreased from baseline when dogs received 0.5, 1, or 4 mg of prednisone/kg, compared with results for the control condition. Several expected changes in clinicopathologic values were observed after prednisone administration at any dose. Changes in serum NT-proBNP concentration, plasma renin activity, and SAP did not differ from changes for the control condition at any prednisone dose. CONCLUSIONS AND CLINICAL RELEVANCE Oral prednisone administration did not affect SAP, NT-proBNP concentration, or measures of renin-angiotensin-aldosterone system activation in healthy laboratory-housed dogs but was associated with relative increases in GFR and serum glucose concentration.
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14
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Ranganath LR, Milan AM, Hughes AT, Khedr M, Davison AS, Shweihdi E, Norman BP, Hughes JH, Bygott H, Luangrath E, Fitzgerald R, Psarelli EE, van Kan C, Laan D, Olsson B, Rudebeck M, Mankowitz L, Sireau N, Arnoux JB, Le Quan Sang KH, Jarvis JC, Genovese F, Braconi D, Santucci A, Zatkova A, Glasova H, Stančík R, Imrich R, Rhodes NP, Gallagher JA. Homogentisic acid is not only eliminated by glomerular filtration and tubular secretion but also produced in the kidney in alkaptonuria. J Inherit Metab Dis 2020; 43:737-747. [PMID: 31609457 DOI: 10.1002/jimd.12181] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/01/2019] [Accepted: 10/07/2019] [Indexed: 01/05/2023]
Abstract
The clinical effects of alkaptonuria (AKU) are delayed and ageing influences disease progression. Morbidity of AKU is secondary to high circulating homogentisic acid (HGA) and ochronosis. It is not known whether HGA is produced by or processed in the kidney in AKU. Data from AKU patients from four studies were merged to form a single AKU group. A control group of non-AKU subjects was generated by merging data from two non-AKU studies. Data were used to derive renal clearance and fractional excretion (FE) ratios for creatinine, HGA, phenylalanine (PHE) and tyrosine (TYR) using standard calculations, for comparison between the AKU and the control groups. There were 225 AKU patients in the AKU group and 52 in the non-AKU control group. Circulating HGA increased with age (P < 0.001), and was significantly associated with decreased HGA clearance (CLHGA ) (P < 0.001) and FEHGA (P < 0.001). CLHGA and FEHGA were increased beyond the theoretical maximum renal plasma flow, confirming renal production and emphasising the greater contribution of net tubular secretion than glomerular filtration to renal elimination of HGA. The kidneys are crucial to elimination of HGA. Elimination of HGA is impaired with age resulting in worsening disease over time. The kidney is an important site for production of HGA. Tubular secretion of HGA contributes more to elimination of HGA in AKU than glomerular filtration.
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Affiliation(s)
- Lakshminarayan R Ranganath
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Liverpool, UK
- Department of Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - Anna M Milan
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Liverpool, UK
- Department of Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - Andrew T Hughes
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Liverpool, UK
- Department of Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - Milad Khedr
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Liverpool, UK
| | - Andrew S Davison
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Liverpool, UK
- Department of Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - Ella Shweihdi
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Liverpool, UK
| | - Brendan P Norman
- Department of Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - Juliette H Hughes
- Department of Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - Helen Bygott
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Liverpool, UK
| | - Emily Luangrath
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Liverpool, UK
| | - Richard Fitzgerald
- Clinical Pharmacology, Royal Liverpool University Hospital, Liverpool, UK
| | | | | | | | | | | | | | | | | | | | - Jonathan C Jarvis
- School of Sport and Exercise Science, Liverpool John Moores University, Liverpool, UK
| | | | - Daniela Braconi
- Dipartimento di Biotecnologie, Chimica e Farmacia, Università degli Studi di Siena, Siena, Italy
| | - Annalisa Santucci
- Dipartimento di Biotecnologie, Chimica e Farmacia, Università degli Studi di Siena, Siena, Italy
| | - Andrea Zatkova
- Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Helena Glasova
- Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Roman Stančík
- National Institute of Rheumatic Diseases, Piešťany, Slovakia
| | - Richard Imrich
- Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Nicholas P Rhodes
- Department of Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - James A Gallagher
- Department of Musculoskeletal Biology, University of Liverpool, Liverpool, UK
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15
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Romão CM, Pereira RC, Shimizu MHM, Furukawa LNS. N-acetyl-l-cysteine exacerbates kidney dysfunction caused by a chronic high-sodium diet in renal ischemia and reperfusion rats. Life Sci 2019; 231:116544. [PMID: 31181229 DOI: 10.1016/j.lfs.2019.116544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 06/03/2019] [Accepted: 06/05/2019] [Indexed: 01/01/2023]
Abstract
AIMS To investigate the effect of long-term N-acetyl-l-cysteine (NAC) treatment in Wistar rats subjected to renal ischemia and reperfusion (IR) and a chronic high‑sodium diet (HSD). MAIN METHODS Adult male Wistar rats received an HSD (8.0% NaCl) or a normal‑sodium diet (NSD; 1.3% NaCl) and NAC (600 mg/L) or normal drinking water starting at 8 weeks of age. At 11 weeks of age, the rats from both diet and NAC or water treatment groups underwent renal IR or Sham surgery and were followed for 10 weeks. The study consisted of six animal groups: NSD + Sham + water; NSD + IR + water; NSD + IR + NAC; HSD + Sham + water; HSD + IR + water; and HSD + IR + NAC. KEY FINDINGS Tail blood pressure (tBP) increased with IR and NAC treatment in the NSD group but not in the HSD group. The serum creatinine level was higher after NAC treatment in both diet groups, and creatinine clearance was decreased in only the HSD + IR + NAC group. Albuminuria increased in the HSD + IR + water group and decreased in the HSD + IR + NAC group. Kidney mass was increased in the HSD + IR group and decreased with NAC treatment. Renal fibrosis was prevented with NAC treatment and cardiac fibrosis was decreased with NAC treatment in the HSD + IR group. SIGNIFICANCE NAC treatment promoted structural improvements, such as decreased albuminuria and fibrosis, in the kidney and heart. However, NAC could not recover kidney function or blood pressure from the effects of IR associated with an HSD. Therefore, in general, long-term NAC treatment is not effective and is deleterious to recovery of function after kidney injury.
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Affiliation(s)
- Carolina Martinez Romão
- Laboratory of Renal Pathophysiology, Department of Internal Medicine, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Rafael Canavel Pereira
- Laboratory of Renal Pathophysiology, Department of Internal Medicine, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Maria Heloisa Massola Shimizu
- Laboratory of Renal Pathophysiology, Department of Internal Medicine, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Luzia Naôko Shinohara Furukawa
- Laboratory of Renal Pathophysiology, Department of Internal Medicine, School of Medicine, University of São Paulo, São Paulo, Brazil.
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16
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Palmer BF, Clegg DJ. The Use of Selected Urine Chemistries in the Diagnosis of Kidney Disorders. Clin J Am Soc Nephrol 2019; 14:306-316. [PMID: 30626576 PMCID: PMC6390907 DOI: 10.2215/cjn.10330818] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Urinary chemistries vary widely in both health and disease and are affected by diet, volume status, medications, and disease states. When properly examined, these tests provide important insight into the mechanism and therapy of various clinical disorders that are first detected by abnormalities in plasma chemistries. These tests cannot be interpreted in isolation, but instead require knowledge of key clinical information, such as medications, physical examination, and plasma chemistries, to include kidney function. When used appropriately and with knowledge of limitations, urine chemistries can provide important insight into the pathophysiology and treatment of a wide variety of disorders.
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Affiliation(s)
- Biff F Palmer
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Deborah Joy Clegg
- Department of Internal Medicine, University of California, Los Angeles School of Medicine, Los Angeles, California
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17
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Beaubien-Souligny W, Denault A, Robillard P, Desjardins G. The Role of Point-of-Care Ultrasound Monitoring in Cardiac Surgical Patients With Acute Kidney Injury. J Cardiothorac Vasc Anesth 2018; 33:2781-2796. [PMID: 30573306 DOI: 10.1053/j.jvca.2018.11.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Indexed: 12/15/2022]
Abstract
The approach to the patient with acute kidney injury (AKI) after cardiac surgery involves multiple aspects. These include the rapid recognition of reversible causes, the accurate identification of patients who will progress to severe stages of AKI, and the subsequent management of complications resulting from severe renal dysfunction. Unfortunately, the inherent limitations of physical examination and laboratory parameter results are often responsible for suboptimal clinical management. In this review article, the authors explore how point-of-care ultrasound, including renal and extrarenal ultrasound, can be used to complement all aspects of the care of cardiac surgery patients with AKI, from the initial approach of early AKI to fluid balance management during renal replacement therapy. The current evidence is reviewed, including knowledge gaps and future areas of research.
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Affiliation(s)
- William Beaubien-Souligny
- Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Anesthesiology, Montreal Heart Institute, Montréal, Canada.
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Montréal, Canada; Division of Intensive Care, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Pierre Robillard
- Department of Radiology, Montreal Heart Institute, Montréal, Canada
| | - Georges Desjardins
- Department of Anesthesiology, Montreal Heart Institute, Montréal, Canada
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18
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Urinary Biochemistry in the Diagnosis of Acute Kidney Injury. DISEASE MARKERS 2018; 2018:4907024. [PMID: 30008975 PMCID: PMC6020498 DOI: 10.1155/2018/4907024] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/03/2018] [Accepted: 05/20/2018] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI) is a common complication, impacting short- and long-term patient outcomes. Although the application of the classification systems for AKI has improved diagnosis, early clinical recognition of AKI is still challenging, as increments in serum creatinine may be late and low urine output is not always present. The role of urinary biochemistry has remained unclear, especially in critically ill patients. Differentiating between a transient and persistent acute kidney injury is of great need in clinical practice, and despite studies questioning their application in clinical practice, biochemistry indices continue to be used while we wait for a novel early injury biomarker. An ideal marker would provide more detailed information about the type, intensity, and location of the injury. In this review, we will discuss factors affecting the fractional excretion of sodium (FeNa) and fractional excretion of urea (FeU). We believe that the frequent assessment of urinary biochemistry and microscopy can be useful in evaluating the likelihood of AKI reversibility. The availability of early injury biomarkers could help guide clinical interventions.
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19
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Majumdar I, Black TA, Nair J. Hypernatremia Management: Focus on Etiology. Clin Pediatr (Phila) 2018; 57:96-98. [PMID: 28056559 DOI: 10.1177/0009922816685819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Indrajit Majumdar
- 1 State University of New York, University at Buffalo & Women and Children's Hospital of Buffalo, Buffalo, NY, USA
| | - Thomas A Black
- 1 State University of New York, University at Buffalo & Women and Children's Hospital of Buffalo, Buffalo, NY, USA
| | - Jayasree Nair
- 1 State University of New York, University at Buffalo & Women and Children's Hospital of Buffalo, Buffalo, NY, USA
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20
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Abstract
Acute kidney injury (AKI) occurs frequently in the surgical intensive care unit and results in significant morbidity and mortality. AKI needs to be identified early and underlying causes treated or eliminated. Sepsis, major surgery such as coronary artery bypass, and hypovolemia are the most common causes and patients with underlying comorbidities have increased susceptibility. Treatment should begin by ensuring that patients are adequately resuscitated and all contributing causes are replaced or eliminated. After stabilization of hemodynamic status and elimination of contributing causes, treatment becomes largely supportive and may require the use of a renal replacement therapy.
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Affiliation(s)
- Robert A Maxwell
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, TN, USA.
| | - Christopher Michael Bell
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, TN, USA
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21
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Babar F, Singh G, Noor M, Sabath B. Retrospective analysis of inferior vena cava collapsibility with point of care ultrasound and urine sodium and FENa in patients with early stage acute kidney injury. J Community Hosp Intern Med Perspect 2017; 7:296-299. [PMID: 29147470 PMCID: PMC5676799 DOI: 10.1080/20009666.2017.1378048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 09/01/2017] [Indexed: 01/31/2023] Open
Abstract
Early stage acute kidney injury (AKI) is an independent risk factor for an increase in mortality. Accurate assessment of volume status is a major challenge during the early stages of acute renal injury. Determining volume status based on the history and physical exam lacks accuracy. Urine sodium and free excretion of sodium (FENa) provide objective evidence of intravascular volume status when interpreted carefully and is helpful to delineate prerenal from intrinsic renal failure. In recent years point of care ultrasound has been used to assess volume status. Our team conducted a retrospective chart review to assess the association of inferior vena cava collapsibility by point of care ultrasound (POCUS) and urine electrolytes (urine sodium, fractional excretion of sodium) during early stage AKI (Stage 1–2 of KDIGO guidelines). We reviewed 150 cases based on the provisional diagnosis. 36 patients met the criteria for further review. Using bivariate analysis, we found a strong association between >50% IVC collapsibility with FENa < 0.4% with an odds ratio 5.3 (CI 1.1–24.5, p = 0.04), and urine sodium <20 meq/dl with an odds ratio of 6.7 (Cl 1.5–30, p = 0.02). Subsequently, multivariate analysis and Spearman correlation showed an inverse relation between IVC collapsibility and fractional excretion of sodium FENa (β = −0.4, p = 0.001) and (r = −0.44, p = 0.01). These findings suggest the role of POCUS and urinary markers in determining the intravascular volume status in AKI. POCUS is also valuable to assess volume status in cases of renal failure where urine studies are difficult to interpret.
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Affiliation(s)
- Faizan Babar
- Department of Internal Medicine, Greater Baltimore Medical Center, MD, USA
| | - Gurkeerat Singh
- Department of Internal Medicine, Greater Baltimore Medical Center, MD, USA
| | - Mustafa Noor
- Department of Internal Medicine, Greater Baltimore Medical Center, MD, USA
| | - Bruce Sabath
- Department of Internal Medicine, Greater Baltimore Medical Center, MD, USA
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22
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Jang MY, Shen JT, Geng JH, Wang HS, Chuang SM, Lee YC, Lee CT, Lee YL, Wu WJ, Juan YS. Ketamine induced renal fibrosis in a ketamine addition rat model. UROLOGICAL SCIENCE 2017. [DOI: 10.1016/j.urols.2016.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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23
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Hou FF, Yang X. Advances in the Management of Acute Cardiorenal Syndrome in China: Biomarkers for Predicting Development and Outcomes. KIDNEY DISEASES 2017; 2:145-150. [PMID: 28232931 DOI: 10.1159/000449026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/10/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Acute cardiorenal syndrome (CRS) is a common clinical condition associated with adverse outcomes. Early identification of acute kidney injury in this setting remains challenging given that serum creatinine level is a marker of renal function and not kidney injury. SUMMARY Several renal injury-related molecules are now available, which may help elucidate the complexities of the organ crosstalk, enabling more accurate risk stratification and effective interventions. KEY MESSAGES This review highlights the major studies that have characterized the diagnostic and prognostic predictive power of these biomarkers with reference to acute CRS. Although more research is needed, the current results are very promising.
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Affiliation(s)
- Fan Fan Hou
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangzhou, China
| | - Xiaobing Yang
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangzhou, China
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24
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Parikh CR, Mansour SG. Perspective on Clinical Application of Biomarkers in AKI. J Am Soc Nephrol 2017; 28:1677-1685. [PMID: 28220028 DOI: 10.1681/asn.2016101127] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Several biomarkers of renal injury have been identified but the utility of these biomarkers is largely confined to research studies, whereas widespread clinical applicability is limited. This is partly because the use of serum creatinine as the comparator has several limitations and restricts the full interpretation of biomarker performance. To highlight the potential for clinical application of biomarkers, the most pertinent biomarker data are summarized here, using clinically relevant scenarios in which biomarkers could assist with diagnostic and management dilemmas. The paradigms proposed in this review aim to enhance the clinical diagnosis, management, and prognosis of AKI through the combined use of available clinical markers and novel inflammatory, injury, and repair biomarkers.
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Affiliation(s)
- Chirag R Parikh
- Program of Applied Translational Research, Department of Medicine, and .,Division of Nephrology, Department of Medicine, Yale University, School of Medicine, New Haven, Connecticut; and.,Division of Nephrology, Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Sherry G Mansour
- Program of Applied Translational Research, Department of Medicine, and.,Division of Nephrology, Department of Medicine, Yale University, School of Medicine, New Haven, Connecticut; and
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25
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Abstract
Dehydration is a serious risk for the long-term tube-fed patient who is not allowed oral intake, has an altered mental status, is unable to communicate, is elderly or fluid-restricted, or has thirst impairment. The intent of this review is to provide a case-based discussion regarding the evaluation, treatment, and prevention of dehydration in these types of patients. Identification of risk factors, along with evaluation of subjective, objective, and laboratory parameters, provides the basis for clinical evaluation. "Hidden" sources of fluid intake such as the water content of solid foods and water generated from nutrient oxidation and "hidden" sources of fluid output such as evaporative losses should be considered in waterbalance calculations. The method for treatment and prevention of dehydration depends on the presence or absence of hypovolemia, type of body fluid losses, and whether the patient demonstrates hypernatremia, normonatremia, or hyponatremia.
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Affiliation(s)
- Roland N Dickerson
- Department of Pharmacy, University of Tennessee Health Science Center, Memphis, TN 38163, USA
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26
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Shimizu MHM, Gois PHF, Volpini RA, Canale D, Luchi WM, Froeder L, Heilberg IP, Seguro AC. N-acetylcysteine protects against star fruit-induced acute kidney injury. Ren Fail 2016; 39:193-202. [PMID: 27845599 PMCID: PMC6014349 DOI: 10.1080/0886022x.2016.1256315] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: Star fruit (SF) is a popular fruit, commonly cultivated in many tropical countries, that contains large amount of oxalate. Acute oxalate nephropathy and direct renal tubular damage through release of free radicals are the main mechanisms involved in SF-induced acute kidney injury (AKI). The aim of this study was to evaluate the protective effect of N-acetylcysteine (NAC) on SF-induced nephrotoxicity due to its potent antioxidant effect. Materials and methods: Male Wistar rats received SF juice (4 mL/100 g body weight) by gavage after a 12 h fasting and water deprivation. Fasting and water deprivation continued for 6 h thereafter to warrant juice absorption. Thereafter, animals were allocated to three experimental groups: SF (n = 6): received tap water; SF + NAC (n = 6): received NAC (4.8 g/L) in drinking water for 48 h after gavage; and Sham (n = 6): no interventions. After 48 h, inulin clearance studies were performed to determine glomerular filtration rate. In a second series of experiment, rats were housed in metabolic cages for additional assessments. Results: SF rats showed markedly reduced inulin clearance associated with hyperoxaluria, renal tubular damage, increased oxidative stress and inflammation. NAC treatment ameliorated all these alterations. Under polarized light microscopy, SF rats exhibited intense calcium oxalate birefringence crystals deposition, dilation of renal tubules and tubular epithelial degeneration, which were attenuate by NAC therapy. Conclusions: Our data show that therapeutic NAC attenuates renal dysfunction in a model of acute oxalate nephropathy following SF ingestion by reducing oxidative stress, oxaluria, and inflammation. This might represent a novel indication of NAC for the treatment of SF-induced AKI.
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Affiliation(s)
| | | | - Rildo Aparecido Volpini
- a Department of Nephrology, School of Medicine , University of São Paulo , São Paulo , Brazil
| | - Daniele Canale
- a Department of Nephrology, School of Medicine , University of São Paulo , São Paulo , Brazil
| | - Weverton Machado Luchi
- a Department of Nephrology, School of Medicine , University of São Paulo , São Paulo , Brazil
| | - Leila Froeder
- b Nephrology Division , Federal University of São Paulo , São Paulo , Brazil
| | | | - Antonio Carlos Seguro
- a Department of Nephrology, School of Medicine , University of São Paulo , São Paulo , Brazil
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Chen C, Yang X, Lei Y, Zha Y, Liu H, Ma C, Tian J, Chen P, Yang T, Hou FF. Urinary Biomarkers at the Time of AKI Diagnosis as Predictors of Progression of AKI among Patients with Acute Cardiorenal Syndrome. Clin J Am Soc Nephrol 2016; 11:1536-1544. [PMID: 27538426 PMCID: PMC5012473 DOI: 10.2215/cjn.00910116] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 05/19/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVES A major challenge in early treatment of acute cardiorenal syndrome (CRS) is the lack of predictors for progression of AKI. We aim to investigate the utility of urinary angiotensinogen and other renal injury biomarkers in predicting AKI progression in CRS. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS In this prospective, multicenter study, we screened 732 adults who admitted for acute decompensated heart failure from September 2011 to December 2014, and evaluated whether renal injury biomarkers measured at time of AKI diagnosis can predict worsening of AKI. In 213 patients who developed Kidney Disease Improving Global Outcomes stage 1 or 2 AKI, six renal injury biomarkers, including urinary angiotensinogen (uAGT), urinary neutrophil gelatinase-associated lipocalin (uNGAL), plasma neutrophil gelatinase-associated lipocalin, urinary IL-18 (uIL-18), urinary kidney injury molecule-1, and urinary albumin-to-creatinine ratio, were measured at time of AKI diagnosis. The primary outcome was AKI progression defined by worsening of AKI stage (50 patients). The secondary outcome was AKI progression with subsequent death (18 patients). RESULTS After multivariable adjustment, the highest tertile of three urinary biomarkers remained associated with AKI progression compared with the lowest tertile: uAGT (odds ratio [OR], 10.8; 95% confidence interval [95% CI], 3.4 to 34.7), uNGAL (OR, 4.7; 95% CI, 1.7 to 13.4), and uIL-18 (OR, 3.6; 95% CI, 1.4 to 9.5). uAGT was the best predictor for both primary and secondary outcomes with area under the receiver operating curve of 0.78 and 0.85. These three biomarkers improved risk reclassification compared with the clinical model alone, with uAGT performing the best (category-free net reclassification improvement for primary and secondary outcomes of 0.76 [95% CI, 0.46 to 1.06] and 0.93 [95% CI, 0.50 to 1.36]; P<0.001). Excellent performance of uAGT was further confirmed with bootstrap internal validation. CONCLUSIONS uAGT, uNGAL, and uIL-18 measured at time of AKI diagnosis improved risk stratification and identified CRS patients at highest risk of adverse outcomes.
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Affiliation(s)
- Chunbo Chen
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangzhou, China
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangzhou, China
| | - Xiaobing Yang
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangzhou, China
| | - Ying Lei
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangzhou, China
| | - Yan Zha
- Department of Nephrology, Guizhou Provincial People’s Hospital, Guiyang Medical University, Guiyang, China
| | - Huafeng Liu
- Division of Nephrology, Institute of Nephrology, Guangdong Medical College, Zhanjiang, China
| | - Changsheng Ma
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China; and
| | - Jianwei Tian
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangzhou, China
| | - Pingyan Chen
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangzhou, China
| | - Tiecheng Yang
- Division of Nephrology, The Futian Hospital, Guangdong Medical College, Shenzhen, China
| | - Fan Fan Hou
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangzhou, China
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Leaf DE, Srivastava A, Zeng X, McMahon GM, Croy HE, Mendu ML, Kachalia A, Waikar SS. Excessive diagnostic testing in acute kidney injury. BMC Nephrol 2016; 17:9. [PMID: 26772980 PMCID: PMC4714492 DOI: 10.1186/s12882-016-0224-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 01/08/2016] [Indexed: 11/10/2022] Open
Abstract
Background The patterns, performance characteristics, and yield of diagnostic tests ordered for the evaluation of acute kidney injury (AKI) have not been rigorously evaluated. Methods We characterized the frequency of AKI diagnostic testing for urine, blood, radiology, and pathology tests in all adult inpatients who were admitted with or developed AKI (N = 4903 patients with 5731 AKI episodes) during a single calendar year. We assessed the frequency of abnormal test results overall and by AKI stage. We manually reviewed electronic medical records to evaluate the diagnostic yield of selected urine, blood, and radiology tests. Diagnostic yield of urine and blood tests was determined based on whether an abnormal test affected AKI diagnosis or management, whereas diagnostic yield of radiology tests was based on whether an abnormal test resulted in a procedural intervention. In sensitivity analyses we also evaluated appropriateness of testing using prespecified criteria. Results Frequency of testing increased with higher AKI stage for nearly all diagnostic tests, whereas frequency of detecting an abnormal result increased for some, but not all, tests. Frequency of detecting an abnormal result was highly variable across tests, ranging from 0 % for anti-glomerular basement membrane testing to 71 % for urine protein testing. Many of the tests evaluated had low diagnostic yield. In particular, selected urine and blood tests were unlikely to impact AKI diagnosis or management, whereas radiology tests had greater clinical utility. Conclusions In patients with AKI, many of the diagnostic tests performed, even when positive or abnormal, may have limited clinical utility.
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Affiliation(s)
- David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | - Anand Srivastava
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | - Xiaoxi Zeng
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | - Gearoid M McMahon
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | - Heather E Croy
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | - Mallika L Mendu
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | - Allen Kachalia
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, 02115, USA.
| | - Sushrut S Waikar
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
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Chang CH, Yang CH, Yang HY, Chen TH, Lin CY, Chang SW, Chen YT, Hung CC, Fang JT, Yang CW, Chen YC. Urinary Biomarkers Improve the Diagnosis of Intrinsic Acute Kidney Injury in Coronary Care Units. Medicine (Baltimore) 2015; 94:e1703. [PMID: 26448023 PMCID: PMC4616771 DOI: 10.1097/md.0000000000001703] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Acute kidney injury (AKI) is associated with increased morbidity and mortality and is frequently encountered in coronary care units (CCUs). Its clinical presentation differs considerably from that of prerenal or intrinsic AKI. We used the biomarkers calprotectin and neutrophil gelatinase-associated lipocalin (NGAL) and compared their utility in predicting and differentiating intrinsic AKI. This was a prospective observational study conducted in a CCU of a tertiary care university hospital. Patients who exhibited any comorbidity and a kidney stressor were enrolled. Urinary samples of the enrolled patients collected between September 2012 and August 2013 were tested for calprotectin and NGAL. The definition of AKI was based on Kidney Disease Improving Global Outcomes classification. All prospective demographic, clinical, and laboratory data were evaluated as predictors of AKI. A total of 147 adult patients with a mean age of 67 years were investigated. AKI was diagnosed in 71 (50.3%) patients, whereas intrinsic AKI was diagnosed in 43 (60.5%) of them. Multivariate logistic regression analysis revealed urinary calprotectin and serum albumin as independent risk factors for intrinsic AKI. For predicting intrinsic AKI, both urinary NGAL and calprotectin displayed excellent areas under the receiver operating characteristic curve (AUROC) (0.918 and 0.946, respectively). A combination of these markers revealed an AUROC of 0.946. Our result revealed that calprotectin and NGAL had considerable discriminative powers for predicting intrinsic AKI in CCU patients. Accordingly, careful inspection for medication, choice of therapy, and early intervention in patients exhibiting increased biomarker levels might improve the outcomes of kidney injury.
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Affiliation(s)
- Chih-Hsiang Chang
- From the Department of Nephrology, Kidney Research Center, Taipei, Taiwan (C-HC, H-YY, C-YL, C-CH, J-TF, C-WY, Y-CC); Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan (C-HY, T-HC); Clinical Informatics and Medical Statistics Research Center, Taipei, Taiwan (S-WC); Department of Biomedical Sciences, Chang Gung University, Taoyuan, Taiwan (Y-TC); and College of Medicine, Chang Gung University, Taoyuan, Taiwan (C-HC, H-YY, C-YL, C-CH, J-TF, C-WY, Y-CC)
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Kogawa R, Kinoshita K, Tanjoh K. Increase in urinary sodium excretion in spinal cord injury patients in the emergency department. Eur J Trauma Emerg Surg 2015; 42:61-6. [PMID: 26038023 DOI: 10.1007/s00068-015-0503-2] [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: 07/17/2014] [Accepted: 02/23/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Spinal cord injury (SCI) is a pathological condition known to produce hyponatremia. The aim of this study was to elucidate the dynamics of urinary sodium excretion in patients with spinal cord injury. METHODS SCI patients undergoing intensive care management were enrolled in this study. These patients were divided into two groups: those with Frankel Grade A spinal cord injury manifesting complete, severe motor disorders (FA group) and those with incomplete spinal cord injury (non-FA group). The occurrence of episode of hyponatremia (serum sodium <135 mmol/L), hypotension, and bradycardia during the first 14 hospital days was counted and fractional excretion of sodium (FENa) was calculated on the 1st, 7th, and 14th hospital days. RESULTS Thirty-four patients (FA group, n = 9; non-FA group, n = 25) were included. Eight patients (88.9 %) in the FA group and three patients (12 %) in the non-FA group experienced at least one episode of hyponatremia during the first 14 hospital days. In the FA group, the FENa was significantly increased on the 7th and 14th hospital days compared to the 1st hospital day. FENa on the 14th hospital day was a significant independent predictor of hyponatremic episodes. Hypotension and bradycardia as the symptoms of sympathetic blockade differed significantly as independent predictors of increased FENa on the 14th hospital day. CONCLUSION Urinary sodium excretion calculated by FENa increased in patients with severe spinal cord injury. Sympathetic blockade due to SCI may increase urine sodium excretion and lead to hyponatremia.
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Affiliation(s)
- R Kogawa
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - K Kinoshita
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - K Tanjoh
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
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Tang KWA, Toh QC, Teo BW. Normalisation of urinary biomarkers to creatinine for clinical practice and research--when and why. Singapore Med J 2015; 56:7-10. [PMID: 25640093 PMCID: PMC4325562 DOI: 10.11622/smedj.2015003] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Acute kidney injury (AKI) and chronic kidney disease (CKD) are major health problems. Urinary biomarkers have both diagnostic and prognostic utility in AKI and CKD. However, how biomarker excretion rates should be reported, especially whether they should be normalised to urinary creatinine concentration (uCr), is controversial. Some studies suggest that normalisation to uCr may be inappropriate at times, as urinary creatinine excretion rate may vary greatly, depending on the situation. Notably, recent studies suggest that while normalisation of values to UCr may be valid for the evaluation of CKD and prediction of AKI sequelae and occurrences, it could be inappropriate for the diagnosis of AKI, or in the presence of certain acute kidney disease states.
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Affiliation(s)
| | | | - Boon Wee Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Level 10 NUHS Tower Block, Singapore 119228.
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Cheuvront SN, Kenefick RW. Dehydration: physiology, assessment, and performance effects. Compr Physiol 2014; 4:257-85. [PMID: 24692140 DOI: 10.1002/cphy.c130017] [Citation(s) in RCA: 268] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
This article provides a comprehensive review of dehydration assessment and presents a unique evaluation of the dehydration and performance literature. The importance of osmolality and volume are emphasized when discussing the physiology, assessment, and performance effects of dehydration. The underappreciated physiologic distinction between a loss of hypo-osmotic body water (intracellular dehydration) and an iso-osmotic loss of body water (extracellular dehydration) is presented and argued as the single most essential aspect of dehydration assessment. The importance of diagnostic and biological variation analyses to dehydration assessment methods is reviewed and their use in gauging the true potential of any dehydration assessment method highlighted. The necessity for establishing proper baselines is discussed, as is the magnitude of dehydration required to elicit reliable and detectable osmotic or volume-mediated compensatory physiologic responses. The discussion of physiologic responses further helps inform and explain our analysis of the literature suggesting a ≥ 2% dehydration threshold for impaired endurance exercise performance mediated by volume loss. In contrast, no clear threshold or plausible mechanism(s) support the marginal, but potentially important, impairment in strength, and power observed with dehydration. Similarly, the potential for dehydration to impair cognition appears small and related primarily to distraction or discomfort. The impact of dehydration on any particular sport skill or task is therefore likely dependent upon the makeup of the task itself (e.g., endurance, strength, cognitive, and motor skill).
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Affiliation(s)
- Samuel N Cheuvront
- Thermal and Mountain Medicine Division, U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts
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Giunti M, Troia R, Bergamini PF, Dondi F. Prospective evaluation of the acute patient physiologic and laboratory evaluation score and an extended clinicopathological profile in dogs with systemic inflammatory response syndrome. J Vet Emerg Crit Care (San Antonio) 2014; 25:226-33. [PMID: 25427754 DOI: 10.1111/vec.12257] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 10/06/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate the prognostic value of the acute patient physiologic and laboratory evaluation (APPLE) score and relevant clinicopathological markers in dogs with systemic inflammatory response syndrome (SIRS). DESIGN Prospective observational cohort study. SETTING Veterinary teaching hospital. ANIMALS Thirty-three dogs with SIRS admitted to the intensive care unit (ICU) were compared to 35 healthy control dogs. Dogs with SIRS were divided into septic (n = 20) and nonseptic (n = 13) etiologies and as survivors (alive to discharge, n = 22) and nonsurvivors (n = 11: died, n = 6, or humanely euthanized, n = 5). MEASUREMENTS AND MAIN RESULTS For all dogs, physiological and laboratory parameters were prospectively collected for the calculation of the APPLE fast score. No difference between septic and nonseptic SIRS dogs was detected for any parameter evaluated. Survivors had significantly higher total protein, albumin concentrations, antithrombin activity (ATA), and base excess (BE), as well as significantly lower lactate, urea, creatinine concentrations, urinary protein to creatinine ratio and APPLE fast score compared to nonsurvivors. Higher values of creatinine, lactate, anion gap, alanine transaminase (ALT), and APPLE fast score were significantly associated with an increased risk of death in SIRS dogs, while higher values of total protein, albumin, ATA, and BE were associated with a significantly reduced risk of mortality. When a multivariate binary logistic regression analysis was performed, the APPLE fast score was the only significant parameter retained. CONCLUSIONS The determination of the APPLE fast score in clinical setting, as well as the measurement of APP, ATA, lactate, BE, anion gap, ALT, urinary proteins, and electrolytes may be beneficial for a better assessment of dogs with SIRS. Identified parameters were significantly related with the presence of SIRS and their evaluation should be considered for the assessment of disease severity, and guidance of the decision-making process in critically ill dogs.
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Affiliation(s)
- Massimo Giunti
- From the Department of Veterinary Medical Sciences, Alma Mater Studiorum - University of Bologna, Ozzano dell'Emilia, Bologna, Italy
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Moodley K, Naidoo Y, Mackraj I. Effects of Tulbaghia violacea Harv. (Alliaceae) rhizome methanolic extract on kidney function and morphology in Dahl salt-sensitive rats. JOURNAL OF ETHNOPHARMACOLOGY 2014; 155:1194-1203. [PMID: 25017374 DOI: 10.1016/j.jep.2014.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 06/12/2014] [Accepted: 07/01/2014] [Indexed: 06/03/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Tulbaghia violacea has been used traditionally for the treatment of several ailments, including hypertension. The herb has been shown to have antihypertensive properties which have been attributed to its angiotensin-converting enzymeinhibitory (ACEI) activity. It could, therefore, prove beneficial in ameliorating renal pathology associated with hypertension. To evaluate the effects of long-term administration of Tulbaghia violacea on renal function and morphology in the Dahl salt-sensitive (DSS) rat model. MATERIALS AND METHODS Male DSS rats were treated intra-peritoneally (i.p.) as follows: methanolic extract of Tulbaghia violacea: (TVL) (50 mg/kg/b.w.), captopril: (CAP) (25 mg/kg/b.w.), or distilled water, control: (CON) (3 ml/kg/b.w.). Blood pressure (BP) was measured bi-weekly, whilst 24-h urine volumes and electrolyte concentrations were assessed weekly. Animals were sacrificed on day 49 by halothane overdose. Blood was removed for determination of plasma and serum electrolytes. Left kidney tissues were harvested for the determination of nuclear factor-kappaβ (NF-kβ) and transforming growth factor-β (TGF-β) gene expressions. RESULTS TVL significantly reduced mean arterial pressure (MAP) and diastolic blood pressure (DBP). TVL showed reduced blood urea nitrogen, serum creatinine, total protein in urine as well as increased serum total protein. TVL decreased thiobarbituric acid reactive substances (TBARS) and increased glutathione peroxidase (GPx) and superoxide dismutase (SOD) activity and nitric oxide significantly. NF-kβ and TGF-β) gene expressions were significantly reduced in TVL and CAP treated rats. Moreover, renal morphology improved significantly in TVL and CAP treated animals. CONCLUSION TVL and CAP demonstrated marked improvement in renal function and morphology.
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Affiliation(s)
- Kogi Moodley
- Department of Human Physiology, School of Basic Medical Sciences, Faculty of Health Sciences, University of KwaZulu-Natal, Private Bag X54001, Durban 4000, South Africa
| | - Yougasphree Naidoo
- Department of Biology, School of Biological and Conservation Sciences, Faculty of Science and Agriculture, University of KwaZulu-Natal, Private Bag X54001, Durban 4000, South Africa
| | - Irene Mackraj
- Department of Human Physiology, School of Basic Medical Sciences, Faculty of Health Sciences, University of KwaZulu-Natal, Private Bag X54001, Durban 4000, South Africa.
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Ledeganck KJ, De Winter BY, Van den Driessche A, Jürgens A, Bosmans JL, Couttenye MM, Verpooten GA. Magnesium loss in cyclosporine-treated patients is related to renal epidermal growth factor downregulation. Nephrol Dial Transplant 2013; 29:1097-102. [PMID: 24353324 DOI: 10.1093/ndt/gft498] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cyclosporine (CsA) treatment is associated with hypomagnesaemia due to a renal Mg(2+) leak. In animal studies a role for the Mg(2+) channel TRPM6 localized in the distal convoluted tubule and stimulated by epidermal growth factor (EGF) is suggested. We hypothesize that CsA-induced hypomagnesaemia is due to a renal magnesium leak, also in patients, resulting from a downregulation of the renal EGF production, thereby inhibiting the activation of TRPM6. METHODS Renal transplant patients treated with CsA (n = 55) and 35 chronic kidney disease (CKD) patients were included. At three time points, with an interval of at least 1 month, blood and urine samples were taken to determine creatinine, Mg(2+), sodium and EGF. RESULTS Serum Mg(2+) was significantly lower in the CsA group versus the CKD group with significantly more CsA-treated patients developing hypomagnesaemia. Although the fractional excretion (FE) Mg(2+) did not differ significantly between the two groups, subanalysis of the patients with hypomagnesaemia showed a significantly higher FE Mg(2+) in CsA-treated patients compared with CKD patients (P = 0.05). The urinary EGF excretion was significantly decreased in the CsA group and was a predictor of the FE Mg(2+) in the two groups. Serum sodium was significantly decreased in the CsA group simultaneously with an increased FE Na(+). CONCLUSIONS In CsA-treated patients, the association of a low urinary EGF excretion and a decreased renal Mg(2+) reabsorption is in accordance with in vitro and animal studies. In the whole study population, log urinary EGF excretion is an independent predictor of the FE Mg(2+), supporting the role of EGF in magnesium reabsorption.
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Affiliation(s)
- Kristien J Ledeganck
- Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
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Ohashi N, Tsuji N, Naito Y, Iwakura T, Isobe S, Ono M, Fujikura T, Tsuji T, Sakao Y, Yasuda H, Kawamura K, Sakaguchi T, Kato A, Fujigaki Y. Relationship between urinary fractional excretion of sodium and life prognosis in liver cirrhosis patients. Hepatol Res 2013; 43:1156-62. [PMID: 23387436 DOI: 10.1111/hepr.12068] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Revised: 12/22/2012] [Accepted: 01/03/2013] [Indexed: 12/20/2022]
Abstract
AIM Renal vasoconstriction in generalized vasodilatation with blood pooling and the consequent reduction in effective arterial volume is the pathophysiological basis of liver cirrhosis (LC). Low levels of fractional excretion of sodium (FENa) are an effective marker of hypoperfusion of the renal artery. However, the relationship between levels of FENa, LC severity and life prognosis has not yet been elucidated. METHODS We examined 57 LC patients (39 men and 18 women; mean age, 70.5 ± 8.8 years; underlying liver disease, type B hepatitis in eight patients, type C hepatitis in 37, alcoholic hepatitis in four and others in eight) with renal dysfunction (estimated glomerular filtration rate (eGFR) <60 mL/min) who were admitted to our hospital. RESULTS Nine patients died because of uremia, liver failure, gastrointestinal bleeding and infection. No differences were found in patient background and blood pressure. However, in addition to differences in the levels of aspartate aminotransferase (AST), cholinesterase, albumin, prothrombin time (PT), eGFR and Model for End-Stage Liver Disease (MELD) score, the patients who died had significant differences in levels of FENa. The levels of FENa were significantly and inversely correlated with blood urea nitrogen, total bilirubin, AST, Child-Pugh score and MELD score, and were significantly and positively correlated with cholinesterase, albumin and PT. Moreover, the sensitivity (88%) and specificity (93%) of the levels of FENa of less than 0.4% to predict death were remarkably high. CONCLUSION Levels of FENa may reflect LC severity and may be associated with the life prognosis of LC patients.
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Affiliation(s)
- Naro Ohashi
- Internal Medicine 1, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Park MY, Choi SJ, Kim JK, Hwang SD, Lee YW. Urinary cystatin C levels as a diagnostic and prognostic biomarker in patients with acute kidney injury. Nephrology (Carlton) 2013; 18:256-62. [PMID: 23414098 DOI: 10.1111/nep.12037] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2013] [Indexed: 01/23/2023]
Abstract
AIM Acute kidney injury (AKI) is a frequent complication in critically ill patients and is associated with a high mortality. Clinicians have limited tools to predict the course of AKI at the time of serum creatinine increase. We evaluated the diagnostic and prognostic utility of urinary cystatin C (uCysC) in patients with AKI. METHODS In this study, serum and uCysC and urinary creatinine (uCr) were measured in patients presenting with acute kidney injury. The patients were divided into two groups: those with prerenal AKI and those with an intrinsic AKI. Prerenal AKI was defined as a new-onset increase in serum creatinine (sCr) that resolved within 72 h and returned to the baseline kidney function level. Patients with intrinsic AKI were defined and classified according to the Acute Kidney Injury Network (AKIN) criteria. RESULTS Of the total number of patients (n = 213), 40.4% (n = 86) were judged to have prerenal AKI and 59.6% (n = 127) intrinsic AKI. uCysC values and the uCysC/uCr ratio were significantly higher in intrinsic AKI versus prerenal AKI. In intrinsic AKI, the uCysC concentration increased with AKI severity. The uCysC/uCr ratio was significantly higher in the RRT group versus the non-RRT group (0.15 vs. 0.08, respectively; P = 0.037). In a multivariate analysis, the uCysC/uCr ratio was associated with in-hospital mortality (P = 0.019). CONCLUSIONS uCysC level and the uCysC/uCr ratio were useful biomarkers of intrinsic AKI, and the uCysC/uCr ratio was predictive of in-hospital death in AKI patients.
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Affiliation(s)
- Moo Yong Park
- Department of Internal Medicine, Soonchunhyang University Hospital, Bucheon, Korea
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Rüst CA, Knechtle B, Knechtle P, Wirth A, Rosemann T. Body mass change and ultraendurance performance: a decrease in body mass is associated with an increased running speed in male 100-km ultramarathoners. J Strength Cond Res 2012; 26:1505-16. [PMID: 22614141 DOI: 10.1519/jsc.0b013e318231a7b5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We investigated, in 50 recreational male ultrarunners, the changes in body mass, selected hematological and urine parameters, and fluid intake during a 100-km ultramarathon. The athletes lost (mean and SD) 2.6 (1.8) % in body mass (p < 0.0001). Running speed was significantly and negatively related to the change in body mass (p < 0.05). Serum sodium concentration ([Na⁺]) and the concentration of aldosterone increased with increasing loss in body mass (p < 0.05). Urine-specific gravity increased (p < 0.0001). The change in body mass was significantly and negatively related to postrace serum [Na⁺] (p < 0.05). Fluid intake was significantly and positively related to both running speed (r = 0.33, p = 0.0182) and the change in body mass (r = 0.44, p = 0.0014) and significantly and negatively to both postrace serum [Na⁺] (r = -0.42, p = 0.0022) and the change in serum [Na⁺] (r = -0.38, p = 0.0072). This field study showed that recreational, male, 100-km ultramarathoners dehydrated as evidenced by the decrease in >2 % body mass and the increase in urine-specific gravity. Race performance, however, was not impaired because of the loss in body mass. In contrast, faster athletes lost more body mass compared with slower athletes while also drinking more. The concept that a loss of >2% in body mass leads to dehydration and consequently impairs endurance performance must be questioned for ultraendurance athletes competing in the field. For practical applications, a loss in body mass during a 100-km ultramarathon was associated with a faster running speed.
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Affiliation(s)
- Christoph A Rüst
- Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland
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Abstract
Acute kidney injury is common in the hospital setting and morbidity and mortality outcomes depend on early recognition and early intervention. Identifying patients at risk of acute kidney injury is critical in prevention, early identification, and appropriate treatment.
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Meyer M, Knechtle B, Bürge J, Knechtle P, Mrazek C, Wirth A, Ellenrieder B, Rüst CA, Rosemann T. Ad libitum fluid intake leads to no leg swelling in male Ironman triathletes - an observational field study. J Int Soc Sports Nutr 2012; 9:40. [PMID: 22937792 PMCID: PMC3524467 DOI: 10.1186/1550-2783-9-40] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Accepted: 08/30/2012] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED BACKGROUND An association between fluid intake and limb swelling has been described for 100-km ultra-marathoners. We investigated a potential development of peripheral oedemata in Ironman triathletes competing over 3.8 km swimming, 180 km cycling and 42.2 km running. METHODS In 15 male Ironman triathletes, fluid intake, changes in body mass, fat mass, skeletal muscle mass, limb volumes and skinfold thickness were measured. Changes in renal function, parameters of skeletal muscle damage, hematologic parameters and osmolality in both serum and urine were determined. Skinfold thicknesses at hands and feet were measured using LIPOMETER® and changes of limb volumes were measured using plethysmography. RESULTS The athletes consumed a total of 8.6 ± 4.4 L of fluids, equal to 0.79 ± 0.43 L/h. Body mass, skeletal muscle mass and the volume of the lower leg decreased (p <0.05), fat mass, skinfold thicknesses and the volume of the arm remained unchanged (p >0.05). The decrease in skeletal muscle mass was associated with the decrease in body mass (p <0.05). The decrease in the lower leg volume was unrelated to fluid intake (p >0.05). Haemoglobin, haematocrit and serum sodium remained unchanged (p >0.05). Osmolality in serum and urine increased (p <0.05). The change in body mass was related to post-race serum sodium concentration ([Na+]) (r = -0.52, p <0.05) and post-race serum osmolality (r = -0.60, p <0.05). CONCLUSIONS In these Ironman triathletes, ad libitum fluid intake maintained plasma [Na+] and plasma osmolality and led to no peripheral oedemata. The volume of the lower leg decreased and the decrease was unrelated to fluid intake. Future studies may investigate ultra-triathletes competing in a Triple Iron triathlon over 11.4 km swimming, 540 km cycling and 126.6 km running to find an association between fluid intake and the development of peripheral oedemata.
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Affiliation(s)
- Michael Meyer
- Institute of Primary Care and Health Services Research, University of Zurich, Zurich, Switzerland.
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Barbato A, Galletti F, Iacone R, Cappuccio FP, Rossi G, Ippolito R, Venezia A, Farinaro E, Strazzullo P. Predictors of resistant hypertension in an unselected sample of an adult male population in Italy. Intern Emerg Med 2012; 7:343-51. [PMID: 21547485 DOI: 10.1007/s11739-011-0554-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 02/22/2011] [Indexed: 10/18/2022]
Abstract
Prevalence, incidence and predictors of resistant hypertension (RH), (defined as blood pressure persistently above goal in spite of the concurrent use of three antihypertensive agents of different classes) in the general population remain largely unknown. A complete database including anthropometric and biochemical data was collected in 1994-1995 (baseline examination) in 1,019 participants (mean age 51.8, range: 25-79 years) and again in 2002-2004 in 794 male participants of the Olivetti Heart Study (OHS) in southern Italy. The incidence of RH over the average follow-up time of 7.9 years was 4.8% (38/794) in the whole study population and 10.1% (31/307) among hypertensive participants. Basal blood pressure (systolic, diastolic or pulse pressure), cholesterol and urinary albumin/creatinine ratio (ACR) significantly predicted the risk of developing RH using a logistic regression model that also included age as covariates. If in the same model we added basal pharmacological treatment, the fractional excretion of sodium (FENa) also became a statistically significant predictor, and this last model explained nearly 25% of the risk of developing RH. In this unselected sample of an adult male population, ACR (an early marker of organ damage), an elevated FENa (a proxy for dietary sodium intake), cholesterol and a higher basal blood pressure level were independent predictors of RH.
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Affiliation(s)
- Antonio Barbato
- Department of Clinical and Experimental Medicine, Federico II University of Naples Medical School, Via S. Pansini, 5, 80131 Naples, Italy
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Raman G, Perkins RM, Jaar BG. Acute kidney injury and ESRD management in austere environments. Adv Chronic Kidney Dis 2012; 19:149-57. [PMID: 22578674 DOI: 10.1053/j.ackd.2012.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 03/22/2012] [Accepted: 03/23/2012] [Indexed: 11/11/2022]
Abstract
Current knowledge about managing acute kidney injury in disaster situations stems mostly from lessons learned while taking care of crush syndrome patients during major earthquakes. More recently, there has been a greater focus on emergency preparedness for ESRD management. Natural or man-made disasters create an "austere environment," wherein resources to administer standard of care are limited. Advance planning and timely coordinated intervention during disasters are paramount to administer effective therapies and save lives. This article reviews the presentation and management of disaster victims with acute kidney injury and those requiring renal replacement therapies. Major contributions of some key national and international organizations in the field of disaster nephrology are highlighted. The article intends to increase awareness about nephrology care of disaster victims, among nephrology and non-nephrology providers alike.
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Koyner JL, Garg AX, Coca SG, Sint K, Thiessen-Philbrook H, Patel UD, Shlipak MG, Parikh CR. Biomarkers predict progression of acute kidney injury after cardiac surgery. J Am Soc Nephrol 2012; 23:905-14. [PMID: 22383693 DOI: 10.1681/asn.2011090907] [Citation(s) in RCA: 207] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Being able to predict whether AKI will progress could improve monitoring and care, guide patient counseling, and assist with enrollment into trials of AKI treatment. Using samples from the Translational Research Investigating Biomarker Endpoints in AKI study (TRIBE-AKI), we evaluated whether kidney injury biomarkers measured at the time of first clinical diagnosis of early AKI after cardiac surgery can forecast AKI severity. Biomarkers included urinary IL-18, urinary albumin to creatinine ratio (ACR), and urinary and plasma neutrophil gelatinase-associated lipocalin (NGAL); each measurement was on the day of AKI diagnosis in 380 patients who developed at least AKI Network (AKIN) stage 1 AKI. The primary end point (progression of AKI defined by worsening AKIN stage) occurred in 45 (11.8%) patients. Using multivariable logistic regression, we determined the risk of AKI progression. After adjustment for clinical predictors, compared with biomarker values in the lowest two quintiles, the highest quintiles of three biomarkers remained associated with AKI progression: IL-18 (odds ratio=3.0, 95% confidence interval=1.3-7.3), ACR (odds ratio=3.4, 95% confidence interval=1.3-9.1), and plasma NGAL (odds ratio=7.7, 95% confidence interval=2.6-22.5). Each biomarker improved risk classification compared with the clinical model alone, with plasma NGAL performing the best (category-free net reclassification improvement of 0.69, P<0.0001). In conclusion, biomarkers measured on the day of AKI diagnosis improve risk stratification and identify patients at higher risk for progression of AKI and worse patient outcomes.
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Affiliation(s)
- Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Pritzker School of Medicine, Illinois, USA
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Zaki MA, El-Banawy SEDS, El-Gammal HH. Plasma soluble corin and N-terminal pro-atrial natriuretic peptide levels in pregnancy induced hypertension. Pregnancy Hypertens 2012; 2:48-52. [DOI: 10.1016/j.preghy.2011.10.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Revised: 08/25/2011] [Accepted: 10/02/2011] [Indexed: 01/23/2023]
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Heller F, Frischmann S, Grünbaum M, Zidek W, Westhoff TH. Urinary calprotectin and the distinction between prerenal and intrinsic acute kidney injury. Clin J Am Soc Nephrol 2011; 6:2347-55. [PMID: 21885792 DOI: 10.2215/cjn.02490311] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES To date there is no reliable marker for the differentiation of prerenal and intrinsic acute kidney injury (AKI). We investigated whether urinary calprotectin, a mediator protein of the innate immune system, may serve as a diagnostic marker in AKI. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was a cross-sectional study with 101 subjects including 86 patients with AKI (34 prerenal, 52 intrinsic including 23 patients with urinary tract infection) and 15 healthy controls. Assessment of urinary calprotectin concentration was by ELISA and immunohistochemistry of kidney biopsy specimens using a calprotectin antibody. Inclusion criteria were: admission to hospital for AKI stage 1 to 3 (Acute Kidney Injury Network); exclusion criteria were: prior renal transplantation and obstructive uropathy. RESULTS Median urinary calprotectin was 60.7 times higher in intrinsic AKI (1692 ng/ml) than in prerenal AKI (28 ng/ml, p <0.01). Urinary calprotectin in prerenal disease was not significantly different from healthy controls (45 ng/ml, p = 0.25). Receiver operating curve curve analysis revealed a high accuracy of calprotectin (area under the curve, 0.97) in predicting intrinsic AKI. A cutoff level of 300 ng/ml provided a sensitivity of 92.3% and a specificity of 97.1%. Calculating urinary calprotectin/creatinine ratios did not lead to a further increase of accuracy. Immunostainings of kidney biopsies were positive for calprotectin in intrinsic AKI and negative in prerenal AKI. CONCLUSIONS Accuracy of urinary calprotectin in the differential diagnosis of AKI is high. Whereas calprotectin levels in prerenal disease are comparable with healthy controls, intrinsic AKI leads to highly increased calprotectin concentrations.
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Affiliation(s)
- Frank Heller
- Department of Nephrology, Charite´-Campus Benjamin Franklin, Berlin, Germany
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Abstract
Changes in renal function are one of the most common manifestations of severe illness. There is a clinical need to intervene early with proven treatments in patients with potentially deleterious changes in renal function. Unfortunately progress has been hindered by poor definitions of renal dysfunction and a lack of early biomarkers of renal injury. In recent years, the definitional problem has been addressed with the establishment of a new well-defined diagnostic entity, acute kidney injury (AKI), which encompasses the wide spectrum of kidney dysfunction, together with clearer definition and sub-classification of the cardio-renal syndromes. From the laboratory have emerged new biomarkers which allow early detection of AKI, including neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C. This review describes the new concepts of AKI and the cardio-renal syndromes as well as novel biomarkers which allow early detection of AKI. Panels of AKI biomarker tests are likely to revolutionise the diagnosis and management of critically ill patients in the coming years. Earlier diagnosis and intervention should significantly reduce the morbidity and mortality associated with acute kidney damage.
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Affiliation(s)
- Robert Hawkins
- Department of Laboratory Medicine, Tan Tock Seng Hospital, Jalan Tan Tock Seng, Singapore.
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Patel Manali B, Deshpande S, Shah G. Evaluation of efficacy of vitamin E and N-acetyl cysteine in gentamicin-induced nephrotoxicity in rats. Ren Fail 2011; 33:341-7. [PMID: 21401361 DOI: 10.3109/0886022x.2011.560987] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Gentamicin (GM), an aminoglycoside, is widely employed in clinical practice for the treatment of serious gram-negative infections. The clinical utility of GM is limited by the frequent incidence of acute renal failure. This study was designed to investigate treatment and posttreatment renoprotective potential of vitamin E and N-acetyl cysteine (NAC) against GM-induced oxidative stress and renal dysfunction. Male Sprague-Dawley rats were divided into six groups: first group is the control group that received olive oil (0.1 mL/100 g B.W.), second is the one that was treated with GM (80 mg/kg/i.p./8 days), third is the one that was treated with GM (80 mg/kg/i.p./8 days) and vitamin E (50 mg/kg/i.p./8 days), fourth is the one that was treated with GM (80 mg/kg/i.p./8 days) and NAC (50 mg/kg/i.p./8 days), fifth is the one that was treated with GM (80 mg/kg/i.p./8 days), vitamin E (50 mg/kg/i.p./8 days), and NAC (50 mg/kg/i.p./8 days), and sixth is the one that was treated with GM initially for 8 days (at 80 mg/kg/i.p.) after which vitamin E (at 50 mg/kg/i.p.) and NAC (at 50 mg/kg/i.p.) were administered for 8 days. Serum creatinine, blood urea nitrogen, serum glucose, renal malondialdehyde, renal reduced glutathione, urine sodium, fractional excretion of sodium, and histopathological examination of kidney were performed after treatment. Gentamicin treatment caused nephrotoxicity as evidenced by marked elevation in serum creatinine, blood urea nitrogen, renal malondialdehyde, urine sodium, and fractional excretion of sodium. Study of renal morphology showed marked loss of epithelium in proximal convoluted tubule, inflammatory infiltrate in the form of lymphocytes, mainly in interstitium. Treatment and posttreatment with vitamin E and NAC significantly restored renal functions, reduced lipid peroxidation, enhanced reduced glutathione level, and restored the biochemical parameters. The results of this study demonstrate the therapeutic potential of vitamin E and NAC in gentamicin-induced nephrotoxicity.
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Fläring U, Lönnqvist PA, Frenckner B, Svensson JF, Ingolfsson I, Wallensteen L, Stigzelius S, Kowalski J, Krmar RT. The efficacy of hypotonic and near-isotonic saline for parenteral fluid therapy given at low maintenance rate in preventing significant change in plasma sodium in post-operative pediatric patients: protocol for a prospective randomized non-blinded study. BMC Pediatr 2011; 11:61. [PMID: 21729308 PMCID: PMC3146835 DOI: 10.1186/1471-2431-11-61] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 07/05/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hyponatremia is the most frequent electrolyte abnormality observed in post-operative pediatric patients receiving intravenous maintenance fluid therapy. If plasma sodium concentration (p-Na+) declines to levels below 125 mmol/L in < 48 h, transient or permanent brain damage may occur. There is an intense debate as to whether the administered volume (full rate vs. restricted rate of infusion) and the composition of solutions used for parenteral maintenance fluid therapy (hypotonic vs. isotonic solutions) contribute to the development of hyponatremia. So far, there is no definitive pediatric data to support a particular choice of parenteral fluid for maintenance therapy in post-surgical patients. METHODS/DESIGN Our prospective randomized non-blinded study will be conducted in healthy children and adolescents aged 1 to 14 years who have been operated for acute appendicitis. Patients will be randomized either to intravenous hypotonic (0.23% or 0.40% sodium chloride in glucose, respectively) or near-isotonic (0.81% sodium chloride in glucose) solution given at approximately three-fourths of the average maintenance rate. The main outcome of interest from this study is to evaluate 24 h post-operatively whether differences in p-Na+ between treatment groups are large enough to be of clinical relevance. In addition, water and electrolyte balance as well as regulatory hormones will be measured. DISCUSSION This study will provide valuable information on the efficacy of hypotonic and near-isotonic fluid therapy in preventing a significant decrease in p-Na+. Finally, by means of careful electrolyte and water balance and by measuring regulatory hormones our results will also contribute to a better understanding of the physiopathology of post-operative changes in p-Na+ in a population at risk for hyponatremia. TRIAL REGISTRATION The protocol for this study is registered with the current controlled trials registry; registry number: ISRCTN43896775.
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Affiliation(s)
- Urban Fläring
- Karolinska Institutet, Department for Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska University Hospital, Huddinge, Stockholm, Sweden
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Abstract
OBJECTIVE The prevalence of exercise-associated hyponatremia (EAH) has mainly been investigated in marathoners and Ironman triathletes. The aim of this study was to investigate the prevalence of EAH in male ultraendurance athletes in other disciplines, such as ultraswimming, ultracycling, and ultramarathon running. DESIGN Observational field study. SETTING "Marathon Swim" in Lake Zurich, the "Swiss Cycling Marathon," the "Swiss Bike Masters," the "100-km Lauf Biel," and the "Swiss Jura Marathon." PARTICIPANTS Fifteen ultraswimmers, 28 ultra-road cyclists, 37 ultra-mountain bikers, 95 ultramarathoners, and 25 mountain ultramarathoners. MAIN OUTCOME MEASURES Changes in body mass, plasma sodium, urinary specific gravity, and hematocrit were measured. The athletes recorded their intake of fluids. RESULTS Two swimmers (13%), 3 road cyclists (10.7%), no mountain bikers (0%), 5 ultramarathoners (5%), and 2 mountain ultramarathoners (8%) developed EAH. In the mountain bikers (r = -0.41) and the 100-km ultramarathoners (r = -0.52), fluid intake was significantly and negatively related to race time. In the mountain ultramarathoners, fluid consumption increased during the race. CONCLUSIONS The prevalence of EAH was no higher in ultraendurance athletes compared with existing reports on marathoners and Ironman triathletes. Of the 200 investigated ultraendurance athletes, 12 finishers (6%) developed EAH.
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