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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; 368:224-234. [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] [MESH Headings] [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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Watanabe Y, Kubota Y, Nishino T, Tara S, Kato K, Hayashi D, Matsuda J, Miyachi H, Tokita Y, Iwasaki Y, Asai K. Fractional excretion of urea nitrogen can identify true worsening renal function in patients with heart failure. ESC Heart Fail 2024; 11:2043-2054. [PMID: 38522427 PMCID: PMC11287315 DOI: 10.1002/ehf2.14755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/18/2024] [Accepted: 02/29/2024] [Indexed: 03/26/2024] Open
Abstract
AIMS Fractional excretion of urea nitrogen (FEUN), used to differentiate the cause of acute kidney injury, has emerged as a useful fluid index in patients with heart failure (HF). We hypothesized that FEUN could be useful in identifying worsening renal function (WRF) associated with poor outcomes in patients with acute HF (AHF). METHODS AND RESULTS Overall, 1103 patients with AHF (median age, 78 years; male proportion, 60%) were categorized into six groups according to the presence of WRF and FEUN values (low, ≤32.1%; medium, >32.1% and ≤38.0%; and high, >38.0%) at discharge. WRF was defined as an increase of ≥0.3 mg/dL in the serum creatinine level from admission to discharge. FEUN was calculated by the following formula: (urinary urea × serum creatinine) × 100/(serum urea × urinary creatinine). The cut-off values for low, medium, and high FEUN were based on a previous study. The primary outcome of this study was HF readmission after hospital discharge. During the 1 year follow-up, 170 HF readmissions occurred. Kaplan-Meier analysis revealed significantly higher HF readmission rates in patients with WRF than in those without WRF (log-rank test, P < 0.001). Additionally, among patients with WRF, HF readmission rates were lowest in those with medium FEUN values, followed by those with low FEUN values and those with high FEUN values. On multivariable analysis, the presence of WRF with low or high FEUN values was independently associated with increased HF readmission, as compared with the absence of WRF with medium FEUN values. Notably, no association was noted between WRF with medium FEUN values and HF readmission. CONCLUSIONS The prognostic impact of WRF was significantly mediated by the FEUN values and was associated with worse outcomes only when the FEUN values were either low or high. Our study suggests that FEUN can identify prognostically relevant WRF in patients with AHF.
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Affiliation(s)
- Yukihiro Watanabe
- Department of Cardiovascular MedicineNippon Medical SchoolTokyoJapan
| | - Yoshiaki Kubota
- Department of Cardiovascular MedicineNippon Medical SchoolTokyoJapan
| | - Takuya Nishino
- Department of Health Care AdministrationNippon Medical SchoolTokyoJapan
| | - Shuhei Tara
- Department of Cardiovascular MedicineNippon Medical SchoolTokyoJapan
| | - Katsuhito Kato
- Department of Hygiene and Public HealthNippon Medical SchoolTokyoJapan
| | - Daisuke Hayashi
- Department of Pharmaceutical ServiceNippon Medical School HospitalTokyoJapan
| | - Junya Matsuda
- Department of Cardiovascular MedicineNippon Medical SchoolTokyoJapan
| | - Hideki Miyachi
- Department of Cardiovascular MedicineNippon Medical SchoolTokyoJapan
- Division of Cardiovascular Intensive CareNippon Medical School HospitalTokyoJapan
| | - Yukichi Tokita
- Department of Cardiovascular MedicineNippon Medical SchoolTokyoJapan
| | - Yu‐ki Iwasaki
- Department of Cardiovascular MedicineNippon Medical SchoolTokyoJapan
| | - Kuniya Asai
- Department of Cardiovascular MedicineNippon Medical SchoolTokyoJapan
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Aron AW, Amatruda JG. Fractional Excretion of Sodium and Urea are Useful Tools in the Evaluation of AKI: CON. KIDNEY360 2023; 4:e728-e730. [PMID: 37384888 PMCID: PMC10371370 DOI: 10.34067/kid.0002512022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 07/01/2023]
Affiliation(s)
- Abraham W. Aron
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jonathan G. Amatruda
- Division of Nephrology, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California
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Brown RS. Fractional Excretion of Sodium and Urea are Useful Tools in the Evaluation of AKI: COMMENTARY. KIDNEY360 2023; 4:e731-e733. [PMID: 37384889 PMCID: PMC10371367 DOI: 10.34067/kid.0002502022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/20/2022] [Indexed: 07/01/2023]
Affiliation(s)
- Robert S Brown
- Nephrology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Maciel AT, Vitorio D, Osawa EA. Urine biochemistry assessment in the sequential evaluation of renal function: Time to think outside the box. Front Med (Lausanne) 2022; 9:912877. [PMID: 35957852 PMCID: PMC9360530 DOI: 10.3389/fmed.2022.912877] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/05/2022] [Indexed: 12/12/2022] Open
Abstract
Urine biochemistry (UB) remains a controversial tool in acute kidney injury (AKI) monitoring, being considered to be of limited value both in terms of AKI diagnosis and prognosis. However, many criticisms can be made to the studies that have established the so called “pre-renal paradigm” (used for decades as the essential physiological basis for UB assessment in AKI) as well as to more recent studies suggesting that UB has no utility in daily clinical practice. The aim of this article is to describe our hypothesis on how to interpret simple and widely recognized urine biochemical parameters from a novel perspective, propose the rationale for their sequential assessment and demonstrate their usefulness in AKI monitoring, especially in the critical care setting.
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Affiliation(s)
- Alexandre T. Maciel
- Research Department, Imed Group, São Paulo, Brazil
- Adult Intensive Care Unit, São Camilo Hospital–Pompéia Unit, São Paulo, Brazil
- *Correspondence: Alexandre T. Maciel,
| | - Daniel Vitorio
- Research Department, Imed Group, São Paulo, Brazil
- Adult Intensive Care Unit, São Camilo Hospital–Pompéia Unit, São Paulo, Brazil
| | - Eduardo A. Osawa
- Research Department, Imed Group, São Paulo, Brazil
- Adult Intensive Care Unit, São Camilo Hospital–Pompéia Unit, São Paulo, Brazil
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Gowda YH, Jagtap N, Karyampudi A, Rao NP, Deepika G, Sharma M, Gupta R, Tandan M, Ramchandani M, John P, Kulkarni A, Kumar P, Bhaware B, Turpati MV, Reddy DN. Fractional Excretion of Sodium and Urea in Differentiating Acute Kidney Injury Phenotypes in Decompensated Cirrhosis. J Clin Exp Hepatol 2022; 12:899-907. [PMID: 35677524 PMCID: PMC9168716 DOI: 10.1016/j.jceh.2021.09.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 09/20/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Prerenal acute kidney injury (prerenal AKI), hepatorenal syndrome (HRS-AKI), and acute tubular necrosis (ATN-AKI) are the various phenotypes of acute kidney injury, which are described in decompensated cirrhosis. It has therapeutic and prognostic implications. We aimed to evaluate the diagnostic utility of fractional excretion of sodium and urea (FENa and FEUrea) for differentiating AKI phenotypes. METHODS A prospective analysis was performed in 200 patients with decompensated cirrhosis with AKI to derive receiver operating curve, optimal cut-off, sensitivity, and specificity. These findings were validated in an independent cohort (n = 50) to differentiate ATN-AKI, HRS-AKI, and prerenal AKI. RESULTS The incidence of prerenal AKI, HRS-AKI, and ATN-AKI were 37.5%, 34%, and 28.5% in the derivation cohort and 28%, 38%, and 34% in the validation cohort respectively. The median FENa was significantly different in various phenotypes of AKI in the derivation and validation cohort (P 0.001); FEUrea was significantly different in the derivation cohort (P 0.0001), not in the validation cohort (P 0.106). The AUC for FENa (cut-off, sensitivity/specificity) was 86.6% (0.567, 89/71) and for FEUrea was 60.3% (34.73, 70/58) for ATN-AKI vs. non-ATN-AKI. The area under the curve for FENa to differentiate between HRS-AKI vs. non-HRS-AKI was 74.5%. FEUrea could not differentiate HRS-AKI vs. non-HRS-AKI (AUC 60.4%) satisfactorily. FENa and FEUrea were unable to differentiate between prerenal AKI and HRS-AKI (AUC <70%). CONCLUSION Among cirrhotics FENa at admission is a simple, commonly available clinical tool that can be used to differentiate structural AKI from prerenal AKI and HRS-AKI. The newly derived lowered cut-off value of FENa makes the diagnosis of ATN-AKI easier, faster and thus obviates the need for extensive workup in a significant proportion of patients. FENa appears better than FEUrea in decompensated cirrhosis with AKI.
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Key Words
- AKI, Acute Kidney Injury
- ATN–AKI, Acute Tubular Necrosis – Acute Kidney Injury
- AUC, Area Under Curve
- FENa, Fractional Excretion of Sodium
- FEUrea, Fractional Excretion of Urea
- HRS–AKI, Hepato Renal Syndrome Acute Kidney Injury
- ICA, International Club of Ascites
- IL-18, Interleukin-18
- IQR, Interquartile range
- KIM-1, Kidney Injury Molecule – 1
- L-FABP, Liver Type Fatty Acid-Binding Protein
- NGAL, Neutrophil Gelatinase – Associated lipocalin
- Prerenal AKI, Prerenal Acute Kidney Injury
- ROC, Receiver Operating Curve
- acute kidney injury
- cirrhosis
- fractional excretion of sodium
- fractional excretion of urea
- hepatorenal syndrome
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Affiliation(s)
- Yashavanth H.S. Gowda
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Nitin Jagtap
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India,Address for correspondence: Dr. Nitin Jagtap, MD, DNB, Consultant Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, 500082, India. Tel.: +91 9182859523.
| | - Arun Karyampudi
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Nagaraja P. Rao
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Gujjarapudi Deepika
- Department of Biochemistry, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mithun Sharma
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rajesh Gupta
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Manu Tandan
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan Ramchandani
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Priyadarshini John
- Department of Nephrology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Anand Kulkarni
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Pramod Kumar
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Bhushan Bhaware
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan V. Turpati
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D. Nageshwar Reddy
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
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