Incidence and impact of acute kidney injury in patients with acute coronary syndromes treated with coronary artery bypass grafting: Insights from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) and Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trials

Impact of timing of urgent coronary artery bypass grafting following coronary angiography on acute kidney injury

OBJECTIVES

Prior studies have examined the association between timing of cardiac surgery after coronary angiography with risk of acute kidney injury, but this remains controversial. The purpose of this study was to investigate the association between interval from coronary angiography to urgent coronary artery bypass grafting with acute kidney injury, and to examine this possible effect in patients with preexisting kidney disease.

METHODS

Patients from a single institution undergoing urgent, isolated coronary artery bypass grafting within 7 days of coronary angiography were included. Patients were subdivided by chronic kidney disease stage and angiography-to-surgery interval. Locally estimated scatterplot smoothing was used to evaluate the functional relationship of the probability of acute kidney injury and time interval. Adjusted odds ratios were calculated for each time interval group compared against the Day 0 to 1 interval group, controlling for multiple covariates. Analyses were repeated for each chronic kidney disease subgroup.

RESULTS

A total of 2249 patients were included in this study. There were 271 (12.0%) patients with postoperative acute kidney injury. Plots demonstrated a decreasing risk of kidney injury from Day 0 to 1 to Day 3 following coronary angiography. Adjusted odds ratios also showed a significant decrease in risk of kidney injury on Day 3 compared with Day 0 to 1. Analyses repeated for each chronic kidney disease stage showed similar trends.

CONCLUSIONS

For patients undergoing urgent coronary artery bypass grafting, there is a decreased risk of kidney injury in those having surgery on day 3 after coronary angiography compared with those having surgery on Day 0 to 1, regardless of preexisting kidney disease.

Prognostic nutritional index as a predictive marker for acute kidney injury in adult critical illness population: a systematic review and diagnostic test accuracy meta-analysis

BACKGROUND

The prognostic nutritional index (PNI), integrating nutrition and inflammation markers, has been increasingly recognized as a prognostic predictor in diverse patient cohorts. Recently, its effectiveness as a predictive marker for acute kidney injury (AKI) in various clinical settings has gained attention. This study aims to assess the predictive accuracy of the PNI for AKI in critically ill populations through systematic review and meta-analysis.

METHODS

A systematic review was conducted using the databases MEDLINE, EMBASE, PubMed, and China National Knowledge Infrastructure up to August 2023. The included trials reported the PNI assessment in adult population with critical illness and its predictive capacity for AKI. Data on study characteristics, subgroup covariates, and diagnostic performance of PNI, including sensitivity, specificity, and event rates, were extracted. A diagnostic test accuracy meta-analysis was performed. Subgroup analyses and meta-regression were utilized to investigate the sources of heterogeneity. The GRADE framework evaluated the confidence in the meta-analysis's evidence.

RESULTS

The analysis encompassed 16 studies with 17 separate cohorts, totaling 21,239 patients. The pooled sensitivity and specificity of PNI for AKI prediction were 0.67 (95% CI 0.58-0.74) and 0.74 (95% CI 0.67-0.80), respectively. The pooled positive likelihood ratio was 2.49 (95% CI 1.99-3.11; low certainty), and the negative likelihood ratio was 0.46 (95% CI 0.37-0.56; low certainty). The pooled diagnostic odds ratio was 5.54 (95% CI 3.80-8.07), with an area under curve of summary receiver operating characteristics of 0.76. Subgroup analysis showed that PNI's sensitivity was higher in medical populations than in surgical populations (0.72 vs. 0.55; p < 0.05) and in studies excluding patients with chronic kidney disease (CKD) than in those including them (0.75 vs. 0.56; p < 0.01). Overall, diagnostic performance was superior in the non-chronic kidney disease group.

CONCLUSION

Our study demonstrated that PNI has practical accuracy for predicting the development of AKI in critically ill populations, with superior diagnostic performance observed in medical and non-CKD populations. However, the diagnostic efficacy of the PNI has significant heterogeneity with different cutoff value, indicating the need for further research.

Impact of Contrast-Associated Acute Kidney Injury on One-Year Outcomes in Very Elderly STEMI Patients: Insights From a Multicenter Registry in Northern Italy

Data about contrast-associated acute kidney injury (CA-AKI) in oldest old (age ≥85 years) ST-elevation myocardial infarction (STEMI) patients are scarce. We evaluated the incidence and the 1-year prognostic impact of CA-AKI in this population. Patients were included in a multicenter real-world registry, and CA-AKI was defined according to KDIGO (Kidney Disease Improving Global Outcomes) criteria. Major adverse cardiac and cerebrovascular events (MACCEs) were defined as the composite of all-cause death, stroke, unplanned coronary revascularization, and heart failure hospitalization. The primary outcome was the incidence and impact of CA-AKI on MACCEs at 1 year follow-up. Out of 461 STEMI patients (mean age 88.6 ± 2.9 years), 102 (22.1%) patients developed CA-AKI. Chronic kidney disease was the strongest predictor of CA-AKI (odds ratio [OR]: 4.52, 95% CI: 2.81-7.30, P < .01). The CA-AKI cohort showed a higher risk of MACCEs (adjusted HR: 1.75, 95% CI: 1.13-2.71, P = .01), driven mainly by all-cause death (adjusted hazard ratio [HR]: 2.39, 95% CI: 1.41-4.07, P = .01) and followed by heart failure hospitalization (adjusted HR: 2.01, 95% CI: 1.08-3.76, P = .01). Among oldest old STEMI, CA-AKI was frequent and associated with a higher incidence of MACCEs at 1-year follow-up.

Unraveling Chronic Cardiovascular and Kidney Disorder through the Butterfly Effect

Chronic Cardiovascular and Kidney Disorder (CCKD) represents a growing challenge in healthcare, characterized by the complex interplay between heart and kidney diseases. This manuscript delves into the "butterfly effect" in CCKD, a phenomenon in which acute injuries in one organ lead to progressive dysfunction in the other. Through extensive review, we explore the pathophysiology underlying this effect, emphasizing the roles of acute kidney injury (AKI) and heart failure (HF) in exacerbating each other. We highlight emerging therapies, such as renin-angiotensin-aldosterone system (RAAS) inhibitors, SGLT2 inhibitors, and GLP1 agonists, that show promise in mitigating the progression of CCKD. Additionally, we discuss novel therapeutic targets, including Galectin-3 inhibition and IL33/ST2 pathway modulation, and their potential in altering the course of CCKD. Our comprehensive analysis underscores the importance of recognizing and treating the intertwined nature of cardiac and renal dysfunctions, paving the way for more effective management strategies for this multifaceted syndrome.

Adjusting Acute Kidney Injury Kidney Disease: Improving Global Outcomes Urine Output Criterion for Predicted Body Weight Improves Prediction of Hospital Mortality

BACKGROUND

Based on the Kidney Disease: Improving Global Outcomes (KDIGO) definitions, urine output, serum creatinine, and need for kidney replacement therapy are used for staging acute kidney injury (AKI). Currently, AKI staging correlates strongly with mortality and can be used as a predictive tool. However, factors associated with the development of AKI may affect its predictive ability. We tested whether adjustment for predicted (versus actual) body weight improved the ability of AKI staging to predict hospital mortality.

METHODS

A total of 3279 patients who had undergone cardiac surgery in a university hospital were retrospectively analyzed. AKI was staged according to KDIGO criteria (standard staging) and after adjustment for hourly urine output adjusted by predicted body weight for each patient and each day of their hospital stay.

RESULTS

The incidence of AKI (all stages) was 43% (predicted body weight adjusted) and 50% (standard staging), respectively ( P < .001). In sensitivity-specificity analyses for predicting hospital mortality, the area under the curve was significantly higher after adjustment for predicted body weight than with standard staging ( P = .002).

CONCLUSIONS

Compared to standard staging, adjustment of urine output for predicted body weight increases the specificity and improves prediction of hospital mortality in patients undergoing cardiac surgery.

Machine-learning predictions for acute kidney injuries after coronary artery bypass grafting: a real-life muticenter retrospective cohort study

BACKGROUND

Acute kidney injury (AKI) after coronary artery bypass grafting (CABG) surgery is associated with poor outcomes. The objective of this study was to apply a new machine learning (ML) method to establish prediction models of AKI after CABG.

METHODS

A total of 2,780 patients from two medical centers in East China who underwent primary isolated CABG were enrolled. The dataset was randomly divided for model training (80%) and model testing (20%). Four ML models based on LightGBM, Support vector machine (SVM), Softmax and random forest (RF) algorithms respectively were established in Python. A total of 2,051 patients from two other medical centers were assigned to an external validation group to verify the performances of the ML prediction models. The models were evaluated using the area under the receiver operating characteristics curve (AUC), Hosmer-Lemeshow goodness-of-fit statistic, Bland-Altman plots, and decision curve analysis. The outcome of the LightGBM model was interpreted using SHapley Additive exPlanations (SHAP).

RESULTS

The incidence of postoperative AKI in the modeling group was 13.4%. Similarly, the incidence of postoperative AKI of the two medical centers in the external validation group was 8.2% and 13.6% respectively. LightGBM performed the best in predicting, with an AUC of 0.8027 in internal validation group and 0.8798 and 0.7801 in the external validation group. The SHAP revealed the top 20 predictors of postoperative AKI ranked according to the importance, and the top three features on prediction were the serum creatinine in the first 24 h after operation, the last preoperative Scr level, and body surface area.

CONCLUSION

This study provides a LightGBM predictive model that can make accurate predictions for AKI after CABG surgery. The LightGBM model shows good predictive ability in both internal and external validation. It can help cardiac surgeons identify high-risk patients who may experience AKI after CABG surgery.

Algorithm-based detection of acute kidney injury according to full KDIGO criteria including urine output following cardiac surgery: a descriptive analysis

BACKGROUND

Automated data analysis and processing has the potential to assist, improve and guide decision making in medical practice. However, by now it has not yet been fully integrated in a clinical setting. Herein we present the first results of applying algorithm-based detection to the diagnosis of postoperative acute kidney injury (AKI) comprising patient data from a cardiac surgical intensive care unit (ICU).

METHODS

First, we generated a well-defined study population of cardiac surgical ICU patients by implementing an application programming interface (API) to extract, clean and select relevant data from the archived digital patient management system. Health records of N = 21,045 adult patients admitted to the ICU following cardiac surgery between 2012 and 2022 were analyzed. Secondly, we developed a software functionality to detect the incidence of AKI according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria, including urine output. Incidence, severity, and temporal evolution of AKI were assessed.

RESULTS

With the use of our automated data analyzing model the overall incidence of postoperative AKI was 65.4% (N = 13,755). Divided by stages, AKI 2 was the most frequent maximum disease stage with 30.5% of patients (stage 1 in 17.6%, stage 3 in 17.2%). We observed considerable temporal divergence between first detections and maximum AKI stages: 51% of patients developed AKI stage 2 or 3 after a previously identified lower stage. Length of ICU stay was significantly prolonged in AKI patients (8.8 vs. 6.6 days, p <  0.001) and increased for higher AKI stages up to 10.1 days on average. In terms of AKI criteria, urine output proved to be most relevant, contributing to detection in 87.3% (N = 12,004) of cases.

CONCLUSION

The incidence of postoperative AKI following cardiac surgery is strikingly high with 65.4% when using full KDIGO-criteria including urine output. Automated data analysis demonstrated reliable early detection of AKI with progressive deterioration of renal function in the majority of patients, therefore allowing for potential earlier therapeutic intervention for preventing or lessening disease progression, reducing the length of ICU stay, and ultimately improving overall patient outcomes.

The effect of preoperative statins on postoperative mortality, renal, and neurological complications in patients undergoing cardiac surgeries: a retrospective cohort study

BACKGROUND

Cardiac surgery is performed worldwide to treat severe cases of cardiovascular diseases. Statins have shown controversial effects on complications after cardiac surgeries. We aimed to investigate the effect of preoperative statin therapy on the frequency of postoperative mortality, renal, and neurological complications.

METHODS

In a retrospective cohort study, the database of patients operated on in two hospitals in southern Iran during 2008-2019 was used to compare preoperative statin use with no use on the composite outcome of mortality, renal, and neurological complications as well as on each component of the composite, separately. Effects of low dose (<40 mg simvastatin equivalence) vs. high dose (≥40 mg) statins were also evaluated. Confounders that could affect the outcomes were considered in the logistic regression model, and multiple imputation techniques were used to categorize patients with unknown statin dose use as either high or low-dose users.

RESULTS

Of total 7329 patients, 17.6% of statin users and 17% of non-statin users developed the composite outcome (P=0.51). Statin use had no statistically significant association with the composite outcome (aRR 1.01 [95% CI: 0.88-1.16]). There was no significant association with mortality [aRR: 0.75 (95% CI: 0.34-1.69)], neurological [aRR: 1.25 (95% CI: 0.77-2.12)], or renal complications [aRR: 1.03 (95% CI 0.90-1.19)] after surgery. Neither low nor high doses had any statistically significant effect on the composite or any of its components.

CONCLUSIONS

In this large study, preoperative statin use, either high dose or low dose, did not affect short-term postoperative mortality, neurological, or renal complications.

A Process for the Design and Development of Novel Bone Morphogenetic Protein-7 (BMP-7) Mimetics With an Example: THR-184

Growth Factors have been evaluated as therapeutic targets for the treatment of a broad spectrum of diseases. Because they are proteins with pleiotropic effects, the quest to harness their beneficial effects has presented challenges. Most Growth Factors operate at the extracellular-receptor level and have natural feedback mechanisms that modulate their effects. As proteins, they are difficult and expensive to manufacture. Frequently proteins must be administered parenterally, may invoke an immune response, and may be neutralized by naturally occurring inhibitors. To circumvent these limitations, we have undertaken an effort to develop mimetics for the Bone Morphogenetic Protein (BMP) signaling pathway effects that incorporate the beneficial effects, eliminate the deleterious effects, and thereby create effective drug-like compounds.To this end, we have designed and tested a family of small peptide BMP mimetics. The design used the three-dimensional structure of BMP-7 to identify likely active surface regions. Lead sequences were then optimized based on in vitro assays that examine the selective binding to BMP receptors, demonstrate the phosphorylation of Smad-1,5,8, detect anti-apoptosis and anti-inflammation, and block the epithelial to mesenchymal transition (EMT) in renal tubular epithelial cells. These sequences were further optimized using in vivo assays of the attenuation of acute kidney injury in a rat-model of unilateral clamp ischemic reperfusion. This process uses a Structure Variance Analysis algorithm (SVA) to identify structure/activity relationships. One member of this family, THR-184, is an agonist of BMP signaling and a potent antagonist of TGFβ signaling. This small peptide mimetic inhibits inflammation, apoptosis, fibrosis and reverses epithelial to mesenchymal transition (EMT) by regulating multiple signaling pathways involved in the cellular injury of multiple organs. Its effects have been shown to control Acute Kidney Injury (AKI). THR-184 has progressed through phase I and II clinical trials for the prevention of Cardio-Vascular Surgery (CVS) associated AKI. This work provides a roadmap for the development of other growth factor mimetics and demonstrates how we might harness their therapeutic potential.

Hospitalization Outcomes Related to Acute Kidney Injury in Inpatients With Acute Myocardial Infarction: A Cross-Sectional Nationwide Study

Objective

To delineate the differences in demographic characteristics and hospitalization outcomes in patients with acute myocardial infarction by comorbid acute kidney injury (AKI) and to explore the risk factors for in-hospital mortality due to AKI in acute myocardial infarction (AMI) inpatients.

Methods

We conducted a retrospective cross-sectional study using a nationwide inpatient sample and included 77,585 adult inpatients with AMI and further divided by the presence of a co-diagnosis of AKI. A logistic regression model was used to evaluate the odds ratio (OR) of the association between in-hospital mortality and AKI and other comorbidities.

Results

The prevalence of AKI in AMI inpatients during hospitalization was 11.69%. Among AMI inpatients with AKI, it was prevalent in males (73.9%) and whites (48.8%). Patients with AKI had a higher prevalence of complicated comorbid hypertension (58.7%), diabetes with complications (34.8%), cardiogenic shock (17.4%), and drug abuse (12.3%). Male patients had lower odds of in-hospital mortality (OR 0.69; 95% Cl 0.61-0.79) compared to females. Hispanics had a higher association with mortality (OR 1.45; 95% Cl 1.21-1.74) than whites and other races/ethnicities. Patients who developed cardiogenic shock were at 17 times higher odds of in-hospital mortality (OR 17.25; 95% CI 15.14-19.67), followed by AKI (OR 4.64; 95% CI 4.06-5.31), and alcohol abuse (OR 1.29; 95% CI 1.03-1.64). The in-hospital mortality rate among AMI inpatients with AKI (7.6%) was significantly higher compared to that seen in the non-AKI cohort (0.9%).

Conclusion

AMI inpatients with AKI during hospitalization was prevalent in males and whites. Among the demographic risk factors, females and Hispanics had a higher likelihood of in-hospital mortality during the inpatient management of AMI. Cardiogenic shock and AKI increased the odds of in-hospital mortality compared to other comorbidities in AMI inpatients.

Prevalence and Risk Factors for Acute Kidney Injury Among Adults Undergoing Cardiac Interventions in King Abdulaziz University Hospital: A Retrospective Review

Background

Acute kidney injury (AKI) is a syndrome that has been receiving considerable attention as a common risk in cardiac surgeries, which has consequences for short- and long-term survival implications, even for those who do not progress to renal failure. There have been limited studies in the Middle East, and specifically in the Kingdom of Saudi Arabia (KSA). Therefore, our study aimed to identify the prevalence of and risk factors for AKIs following adult cardiac interventions during 2010-2020 at the King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia.

Methods

Setting and Design: A retrospective medical record review was conducted among all the adult patients who underwent cardiac interventions and developed AKIs between 2010 and 2020. Google forms were used to extract the data from the hospital records. About statistical analysis binary logistic regression analyses, relative risks (RRs), and confidence intervals (CI) were used to determine the associations among the variables.

Results

After applying the inclusion and exclusion criteria, 564 patients were included. Their baseline demographic, clinical, biological, and operative characteristics were analyzed. AKIs developed in 110 (19.5%) patients and patients with diabetes were more likely to develop AKIs (P < 0.012, RR = 2.280, CI = 1.198-4.339). Hypertension showed a strong effect in the development of AKIs (P < 0.004, RR = 2.865, CI = 1.391-5.900). Moreover, patients who suffered from chronic heart failure were more prone to the development of AKIs (P < 0.008, RR = 4.189, CI =1.452-12.087). Furthermore, anemia with significant P-values (<0.002), and CIs of 1.509-6.822, indicated that these patients were more likely to develop AKIs (3.209 times).

Conclusion

We demonstrated that AKIs are frequent complications in adults after cardiac interventions and were associated with poor outcomes. Risk factors for the development of AKIs were identified to be diabetes mellitus, hypertension, chronic heart failure, and anemia. Further investigation of this cohort is necessary to better understand the problem of kidney injuries.

Impact of Acute and Chronic Kidney Disease on Heart Failure Hospitalizations After Acute Myocardial Infarction

Very few studies evaluated the impact of acute kidney injury (AKI) and chronic kidney disease (CKD) on heart failure (HF) hospitalization risk following an acute myocardial infarction (AMI). For this retrospective cohort analysis, we identified adult AMI survivors from January to June 2014 from the United States Nationwide Readmissions Database. Outcomes were a 6-month HF, fatal HF, composite of HF during the AMI or a 6-month HF, and a composite of 6-month HF or death during a non-HF-related admission. We analyzed differences in outcomes across categories of patients without renal injury, AKI without CKD, stable CKD, AKI on CKD, and end-stage renal disease (ESRD). Of 237,549 AMI survivors, AKI was present in 13.8%, CKD in 16.5%, ESRD in 3.4%, and AKI on CKD in 7.7%. Patients with renal failure had lower coronary revascularization rates and higher in-hospital HF. A 6-month HF hospitalization occurred in 12,934 patients (5.4%). Compared with patients without renal failure (3.3%), 6-month HF admission rate was higher in patients with AKI on CKD (14.6%; odds ratio [OR] 1.99; 95% confidence interval [CI] 1.81 to 2.19), ESRD (11.2%; OR 1.57; 95% CI 1.36 to 1.81), stable CKD (10.7%; OR 1.72; 95% CI 1.56 to 1.88), and AKI (8.6%; OR 1.52; 95% CI 1.36 to 1.70). Results were generally homogenous in prespecified subgroups and for the other outcomes. In conclusion, 1 in 4 AMI survivors had either acute or chronic renal failure. The presence of any form of renal failure was associated with a substantially increased risk of 6-month HF hospitalizations and associated mortality with the highest risk associated with AKI on CKD.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

Impact of urgent coronary artery bypass grafting on acute kidney injury : A matched cohort study

OBJECTIVES

There is limited knowledge regarding the specific interrelationships between urgent coronary artery bypass graft (U-CABG) surgery and postoperative acute kidney injury (AKI). We aimed to (1) analyze the impact of urgent CABG (U-CABG) on the incidence and severity of postoperative AKI, (2) estimate the influence of AKI after U‑CABG or elective CABG (E-CABG) on mortality and (3) identify risk factors for AKI depending on the urgency of operation.

RESULTS

U‑CABG patients showed a higher incidence of AKI (49.8% vs. E‑CABG: 39.7%; p = 0.026), especially for higher AKI stages 2 + 3. In-hospital mortality was higher in U‑CABG patients (12.6%) compared to E‑CABG patients (2.3%; p < 0.001). The impact of AKI on mortality did not differ, but showed a strong coherency between higher AKI stages (2 + 3) and mortality (stage 1: OR 2.409, 95% CI 1.017-5.706; p = 0.046 vs. stage 2 + 3: OR 5.577; 95% CI 2.033-15.3; p = 0.001). Univariate logistic regression analysis revealed that preoperative renal impairment, peripheral vascular disease and transfusion of more than two red blood cell concentrates were predictors for postoperative AKI in both groups.

CONCLUSIONS

U‑CABG is a risk factor for postoperative AKI and even "mild" AKI leads to a significantly higher mortality. Hence, the prevention of modifiable risk factors might reduce the incidence of postoperative AKI and thus improve outcome.

Exploring reasons for state-level variation in incidence of dialysis-requiring acute kidney injury (AKI-D) in the United States

BACKGROUND

There is considerable state-level variation in the incidence of dialysis-requiring acute kidney injury (AKI-D). However, little is known about reasons for this geographic variation.

METHODS

National cross-sectional state-level ecological study based on State Inpatient Databases (SID) and the Behavioral Risk Factor Surveillance System (BRFSS) in 2011. We analyzed 18 states and six chronic health conditions (diabetes mellitus [diabetes], hypertension, chronic kidney disease [CKD], arteriosclerotic heart disease [ASHD], cancer (excluding skin cancer), and chronic obstructive pulmonary disease [COPD]). Associations between each of the chronic health conditions and AKI-D incidence was assessed using Pearson correlation and multiple regression adjusting for mean age, the proportion of males, and the proportion of non-Hispanic whites in each state.

RESULTS

The state-level AKI-D incidence ranged from 190 to 1139 per million population. State-level differences in rates of hospitalization with chronic health conditions (mostly < 3-fold difference in range) were larger than the state-level differences in prevalence for each chronic health condition (mostly < 2.5-fold difference in range). A significant correlation was shown between AKI-D incidence and prevalence of diabetes, ASHD, and COPD, as well as between AKI-D incidence and rate of hospitalization with hypertension. In regression models, after adjusting for age, sex, and race, AKI-D incidence was associated with prevalence of and rates of hospitalization with five chronic health conditions--diabetes, hypertension, CKD, ASHD and COPD--and rates of hospitalization with cancer.

CONCLUSIONS

Results from this ecological analysis suggest that state-level variation in AKI-D incidence may be influenced by state-level variations in prevalence of and rates of hospitalization with several chronic health conditions. For most of the explored chronic conditions, AKI-D correlated stronger with rates of hospitalizations with the health conditions rather than with their prevalences, suggesting that better disease management strategies that prevent hospitalizations may translate into lower incidence of AKI-D.

Acute Kidney Injury and Long-Term Risk for Cardiovascular Events in Patients after Kidney Transplantation

BACKGROUND

Acute kidney injury (AKI) was found to be associated with an increased risk of major adverse cardiovascular events (MACE) in the general population. Patients after kidney transplantation are prone to AKI events and are also at an increased risk of cardiovascular (CV) disease. The association between AKI and MACE in kidney transplant patients is yet to be studied.

METHODS

This retrospective single-center cohort study reviewed 416 adult renal allograft recipients transplanted between 2005 and 2010. AKI events were recorded starting 2 weeks after transplantation, or following discharge with a functioning graft. AKI was defined, according to the KDIGO criteria. The primary outcome was the composite of MACE starting 6 months after transplantation and all-cause mortality. For survival analysis, we used univariate and multivariate time varying Cox proportional hazard model.

RESULTS

One hundred and twenty-four patients (29.8%) had at least one episode of AKI. During the median follow-up time of 7.2 years (interquartile range 4.3-9.1), 144 outcome events occurred. By time varying Cox regression analysis, AKI was associated with an increased rate of CV outcomes or death (hazard ratio [HR] 1.96, 95% CI 1.36-2.81, p < 0.001), and the association remained significant by multivariate adjusted model (HR 1.76, 95% CI 1.18-2.63, p = 0.005). As for the different components of MACE, all-cause mortality and CV mortality were the only outcomes that were significantly associated with AKI. No interaction between AKI timing and MACE was found.

CONCLUSION

AKI in kidney transplant recipient is associated with an increased risk of CV disease.

Incidence, determinants and impact of acute kidney injury in patients with diabetes mellitus and multivessel disease undergoing coronary revascularization: Results from the FREEDOM trial

BACKGROUND

The incidence and prognostic significance of acute kidney injury (AKI) in patients with diabetes mellitus and multivessel coronary artery disease undergoing coronary revascularization is not well known. The current analysis included patients randomized to PCI vs. CABG as part of the FREEDOM trial. We sought to examine the impact of AKI and its predictors in diabetic patients with multivessel coronary artery disease undergoing PCI vs. CABG.

METHODS

We conducted a pre-specified subgroup analysis of the FREEDOM trial to examine the incidence, correlates and impact of AKI according to revascularization strategy. AKI predictors were identified using multivariable logistic regression and associations between AKI and outcomes were examined using Cox regression. The primary endpoint was the composite occurrence of all-cause death, stroke or myocardial infarction at 5 years of follow-up.

RESULTS

KI occurred more frequently in patients following CABG (15.6%) compared with PCI (9.1%) (p < 0.001). AKI was associated with a higher risk for major cardiovascular events (MACE) at 5 years (34.6% vs. 20.5%, p < 0.001), an effect that remained large and significant irrespective of CABG (HR = 2.18 95% CI 1.44-3.31, p ≤0.001) or PCI (HR = 2.08 95% CI 1.35-3.21, p < 0.0001). There was a non-significant interaction (p-value = 0.89) between the revascularization method and AKI, supporting that AKI is a significant risk factor in both revascularization methods.

CONCLUSIONS

Although risk for AKI was higher in patients undergoing CABG, the impact of AKI on MACE was substantial irrespective of revascularization strategy. Preventive strategies to identify patients at risk for AKI are warranted to mitigate the long-term effects of this complication.

Nanotechnology-Mediated Drug Delivery for the Treatment of Obesity and Its Related Comorbidities

Obesity is a serious health issue affecting humanity on a global scale. Recognized by the American Medical Association as a chronic disease, the incidence of obesity continues to grow at an accelerating rate and obesity has become one of the major threats to human health. Excessive weight gain is tied to metabolic syndrome, which is shown to increase the risk of chronic diseases, such as heart disease and type 2 diabetes, taxing an already overburdened healthcare system and increasing mortality worldwide. Available treatments such as bariatric surgery and pharmacotherapy are often accompanied by adverse side effects and poor patient compliance. Nanotechnology, an emerging technology with a wide range of biomedical applications, has provided an unprecedented opportunity to improve the treatment of many diseases, including obesity. This review provides an introduction to obesity and obesity-related comorbidities. The most recent developments of nanotechnology-based drug delivery strategies are highlighted and discussed. Additionally, challenges and consideration for the development of nanoformulations with translational potential are discussed. The overall objective of this review is to enhance the understanding of the design and development of nanomedicine for treatments of obesity and related comorbidities.

Acute Kidney Injury and mortality prognosis in Acute Coronary Syndrome patients: A meta-analysis

AIM

The aim of this study is to provide a robust estimate of mortality risk in acute coronary syndrome (ACS)-associated acute kidney injury (AKI) to inform clinical practice and policy.

METHODS

A meta-analysis of cohort studies evaluating outcomes of ACS and which reported AKI and AKI-associated mortality. Studies were excluded if they incorporated patients not admitted through the emergency department (i.e. for elective procedures), were limited to cardiogenic shock or cardiac arrest, or relied on registry data for outcomes without further adjudication. The predictor was ACS-associated AKI and outcomes early (30 day or in-hospital) mortality and late-mortality (post-hospital discharge).

RESULTS

Thirty-six studies with 37 unique cohorts comprising 100 476 patients were included. The pooled rate of ACS-associated AKI was 15.8%. In 32 cohorts reporting early mortality, the crude early mortality rate was 15.0% amongst those with AKI compared with 2.0% amongst those without AKI. The pooled estimate of the relative risk of AKI-associated early mortality was 4.1 (95% confidence interval: 3.3 to 5.0) with high heterogeneity between studies (I ²  = 84% (61% to 88%)). When heterogeneity was accounted for mathematically using credibility ceilings, the risk of mortality was lower, but still clinically significant (3.1 (2.6 to 3.6)). In 19 cohorts reporting late mortality (1 to 10 years), the relative risk of AKI-associated mortality was 2.6 (2.0 to 3.3) with moderate heterogeneity (I ²  = 65 % [35% to 88%]). Following application of credibility ceiling relative risk estimate dropped to 2.2 (1.9 to 2.6).

CONCLUSIONS

Acute coronary syndrome-associated AKI is associated with more than a three-fold increase in early mortality and more than two-fold in long-term mortality.

Acute Kidney Injury and Risk of Heart Failure and Atherosclerotic Events

BACKGROUND AND OBJECTIVES

AKI in the hospital is common and is associated with excess mortality. We examined whether AKI is also independently associated with a higher risk of different cardiovascular events in the first year after discharge.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a retrospective analysis of a cohort between 2006 and 2013 with follow-up through 2014, within Kaiser Permanente Northern California. We identified all adults admitted to 21 hospitals who had one or more in-hospital serum creatinine test result and survived to discharge. Occurrence of AKI was on the basis of Kidney Disease: Improving Global Outcomes diagnostic criteria. Potential confounders were identified from comprehensive inpatient and outpatient, laboratory, and pharmacy electronic medical records. During the 365 days after discharge, we ascertained occurrence of heart failure, acute coronary syndromes, peripheral artery disease, and ischemic stroke events from electronic medical records.

RESULTS

Among a matched cohort of 146,941 hospitalized adults, 31,245 experienced AKI. At 365 days postdischarge, AKI was independently associated with higher rates of the composite outcome of hospitalization for heart failure and atherosclerotic events (adjusted hazard ratio [aHR], 1.18; 95% confidence interval [95% CI], 1.13 to 1.25) even after adjustment for demographics, comorbidities, preadmission eGFR and proteinuria, heart failure and sepsis complicating the hospitalization, intensive care unit (ICU) admission, length of stay, and predicted in-hospital mortality. This was driven by an excess risk of subsequent heart failure (aHR, 1.44; 95% CI, 1.33 to 1.56), whereas there was no significant association with follow-up atherosclerotic events (aHR, 1.05; 95% CI, 0.98 to 1.12).

CONCLUSIONS

AKI is independently associated with a higher risk of cardiovascular events, especially heart failure, after hospital discharge.

Contrast-induced acute kidney injury and mortality in ST elevation myocardial infarction treated with primary percutaneous coronary intervention

Objectives

Contrast-induced acute kidney injury (CI-AKI) is a common and potentially severe complication in patients with ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI). There is no consensus on the best definition of CI-AKI to identify patients at risk of haemodialysis or death. The objective of this study was to assess the association of CI-AKI, using four definitions, on inhospital mortality, mortality or haemodialysis requirement over 1-year follow-up, in patients with STEMI treated with pPCI.

Methods

In this prospective, observational study, all patients with STEMI referred for pPCI were included. We identified independent variables associated with CI-AKI and mortality.

Results

We included 1114 consecutive patients with STEMI treated by pPCI. CI-AKI occurred in 18.3%, 12.2%, 15.6% and 10.5% of patients according to the CIN, Acute Kidney Injury Network (AKIN), Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease (RIFLE) Modification of Diet in Renal Disease (MDRD) and RIFLE Chronic Kidney Disease - Epidemiology Collaboration (CKD-EPI) definitions, respectively. The RIFLE (CKD-EPI) definition was the most discriminant definition to identify patients at higher risk of inhospital mortality (27.1% vs 4.0%; adjusted OR 2.7 (95% CI 1.4 to 5.1), p=0.003), 1-year mortality (27.4% vs 6.6%; adjusted OR 2.8 (95% CI 1.5 to 5.3), p=0.002) and haemodialysis requirement at 1-year follow-up (15.6% vs 2.7%; adjusted OR 6.7 (95% CI 3.3 to 13.6), p=0.001). Haemodynamic instability, cardiac arrest, preexisting renal failure, elderly age and a high contrast media volume were independently associated with 1-year mortality. Of interest, contrast-media volume was not correlated to increase of creatininaemia (r=0.06) or decrease in estimated glomerular filtration rate (r=0.05) after percutaneous coronary intervention in our population.

Conclusions

CI-AKI is a frequent and serious complication of STEMI treated by pPCI. The RIFLE definition is the most accurate definition to identify patients with CI-AKI at high risk of mortality or haemodialysis.