Sepsis-Induced Acute Kidney Injury

Fractional excretion of sodium and potassium and urinary strong ion difference in the evaluation of persistent AKI in sepsis

OBJECTIVE

To evaluate the diagnostic performance of FENa (Fractional excretion of sodium), FEK (fractional excretion of potassium) and uSID (urinary strong ion difference) in predicting pAKI in sepsis and septic shock.

DESIGN

Retrospective cohort study.

SETTING

Two intensive care units in Argentina.

PATIENTS

Adult patients with a confirmed diagnosis of sepsis or septic shock and AKI, and had a urinary biochemistry within 24h of the AKI diagnosis.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

We evaluated the diagnostic accuracy of FENa, FEK and uSID through a ROC (Receiver Operating Characteristic) curve analysis.

RESULTS

80 patients were included. 40 patients presented pAKI. pAKI group had higher APACHE, SOFA score, and mortality rate. In the ROC curve analysis, uSID had no diagnostic utility (AUC=0.52, p=0.69). FENa presented moderate accuracy showing an AUC of 0.71 (95% CI 0.60-0.83; p=0.001), while FEK presented low accuracy with an AUC of 0.69 (95% CI 0.57-0.80; p=0.04). The optimal Youden point for identifying pAKI was at a FENa higher than 0.51 % with a specificity of 72.5% and a sensitivity of 65.0%. In the case of FEK, a value higher than 21.9 % presented the best relation, with a specificity of 67.5% and a sensitivity of 65.0%.

CONCLUSIONS

urine biochemistry interpretation in septic patients must be revised. FENa and FEK are related to the severity of AKI and could be helpful complementary tools for diagnosing pAKI.

Septic acute kidney injury and gut microbiome: Should we change our approach?

Incidence of acute kidney injury (AKI) remained relatively stable over the last decade and the adjusted risks for it and mortality are similar across different continents and regions. Also, the mortality of septic-AKI can reach 70% in critically-ill patients. These sole facts can give rise to a question: is there something we do not understand yet? Currently, there are no specific therapies for septic AKI and the treatment aims only to maintain the mean arterial pressure over 65mmHg by ensuring a good fluid resuscitation and by using vasopressors, along with antibiotics. On the other hand, there is an increased concern about the different hemodynamic changes in septic AKI versus other forms and the link between the gut microbiome and the severity of septic AKI. Fortunately, progress has been made in the form of administration of pre- and probiotics, short chain fatty acids (SCFA), especially acetate, and also broad-spectrum antibiotics or selective decontaminants of the digestive tract in a successful attempt to modulate the microbial flora and to decrease both the severity of AKI and mortality. In conclusion, septic-AKI is a severe form of kidney injury, with particular hemodynamic changes and with a strong link between the kidney and the gut microbiome. By modulating the immune response we could not only treat but also prevent severe forms. The most difficult part is to categorize patients and to better understand the key mechanisms of inflammation and cellular adaptation to the injury, as these mechanisms can serve in the future as target therapies.

The attributable mortality of sepsis for acute kidney injury: a propensity-matched analysis based on multicenter prospective cohort study

BACKGROUND

Both sepsis and AKI are diseases of major concern in intensive care unit (ICU). This study aimed to evaluate the excess mortality attributable to sepsis for acute kidney injury (AKI).

METHODS

A propensity score-matched analysis on a multicenter prospective cohort study in 18 Chinese ICUs was performed. Propensity score was sequentially conducted to match AKI patients with and without sepsis on day 1, day 2, and day 3-5. The primary outcome was hospital death of AKI patients.

RESULTS

A total of 2008 AKI patients (40.9%) were eligible for the study. Of the 1010 AKI patients with sepsis, 619 (61.3%) were matched to 619 AKI patients in whom sepsis did not develop during the screening period of the study. The hospital mortality rate of matched AKI patients with sepsis was 205 of 619 (33.1%) compared with 150 of 619 (24.0%) for their matched AKI controls without sepsis (p = 0.001). The attributable mortality of total sepsis for AKI patients was 9.1% (95% CI: 4.8-13.3%). Of the matched patients with sepsis, 328 (53.0%) diagnosed septic shock. The attributable mortality of septic shock for AKI was 16.2% (95% CI: 11.3-20.8%, p < 0.001). Further, the attributable mortality of sepsis for AKI was 1.4% (95% CI: 4.1-5.9%, p = 0.825).

CONCLUSIONS

The attributable hospital mortality of total sepsis for AKI were 9.1%. Septic shock contributes to major excess mortality rate for AKI than sepsis.

REGISTRATION FOR THE MULTICENTER PROSPECTIVE COHORT STUDY

registration number ChiCTR-ECH-13003934.

Evaluation of the Efficiency of TIMP-2 as a Biomarker for Acute Kidney Injury in Sepsis

The aim of this study was to evaluate the biomarker potential of TIMP-2 in septic-induced acute kidney injury (AKI). Healthy male rats (n=56, age 8-10 weeks, body weight 250-300 g) were randomized into 3 groups: controls (intact rats, n=6), sham-operated (SO, n=24), and sepsis model (cecum ligation and perforation, CLP, n=24). Thirty minutes before and 6, 12, 24, and 48 h after surgery, blood samples were collected to measure serum creatinine, blood urea nitrogen (BUN), and TIMP-2 and the kidneys were isolated for histopathological analysis and Western blotting. The key sepsis-related genes were screened through bioinformatics analysis. In 24 and 48 h after surgery, 2 rats in the SO group reached the diagnostic criteria of AKI (increased levels of serum creatinine and BUN). In the CLP group, serum creatinine in 6 h after the surgery was slightly higher than 30 min before the surgery, but this change did not meet the diagnostic criteria for AKI. In the CLP group, BUN was normal 6 h after the surgery, but increased after 12 h. In more than 50% rats of the CLP group, serum creatinine and BUN significantly increased 12 h after operation, so this can be diagnosed as AKI. In rats of the CLP group, plasma TIMP-2 was elevated 6 h after surgery and increased with time, suggesting that plasma TIMP-2 can be used as an early marker of AKI. Histological examination of the kidneys in this group revealed destruction of the renal tubular structure, swelling of renal tubular epithelium, the disappearance of brush edge and collapse of necrotic epithelial cells, etc., and the degree of damage increased with time. Immunohistochemistry showed that TIMP-2 was expressed in rats of the CLP group at all terms of the experiment. The expression of TIMP-2 and pyroptosis-related proteins (NLRP3, IL-1β, caspase-1, and GSDMD) in the CLP group was higher than in the SO group (p<0.05) and increased with time, suggesting that pyroptosis is involved in AKI. Thus, plasma TIMP-2 is sensitive indicator for the early detection of kidney injury and can be used as an early biomarker of AKI.

Renal venous density in the arterial phase of contrast-enhanced CT predicts prognosis in septic shock

OBJECTIVE

To evaluate a series of vascular parameters derived from abdominal dual-phase contrast-enhanced CT as predictors of 14-day mortality and AKI within 7 days in septic shock.

METHODS

144 patients with septic shock and 60 negative cases were included. The vascular parameters from CT were measured and calculated, including aortic density in arterial (Dena-A) and venous phase (Dena-V), renal vein density in arterial (Denrv-A) and venous phase (Denrv-V), and renal vein-to-aortic density ratio in arterial (DenRrv/a-A) and venous phase (DenRrv/a-V). The parameters were compared between patients and controls, and between patients with different clinical outcomes, and assessed for predictive value of 14-day mortality and AKI within 7 days.

RESULTS

Patients with septic shock presented significantly lower Denrv-A (p < 0.001) and DenRrv/a-A (p = 0.002) levels than the controls. In the septic shock group, patients who died had significantly lower Denrv-A (p = 0.001) and lower DenRrv/a-A (p < 0.001) than those who survived. Patients who developed AKI had significantly lower Denrv-A (p < 0.001) and DenRrv/a-A (p = 0.011) than those who did not. Multivariate analysis suggested DenRrv/a-A as an independent predictor of 14-day mortality (OR 0.012; 95% confidence interval [CI]:0.002,0.086; p < 0.001) and Denrv-A as an independent predictor of AKI (OR 0.989;95% CI:0.982,0.997; p = 0.006).

CONCLUSION

In septic shock, significant decreases in Denrv-A and DenRrv/a-A were associated with the onset of AKI and predicted higher 14-day mortality.

ADVANCES IN KNOWLEDGE

The renal vein density and renal vein-aortic density ratio in arterial phase of dual-phase contrast-enhanced CT may serve as good predictors of AKI and mortality in septic shock.

Cystatin C and derived measures of renal function as risk factors for mortality and acute kidney injury in sepsis - A post-hoc analysis of the FINNAKI cohort

PURPOSE

To assess the association between cystatin C-derived estimates of kidney function and mortality and acute kidney injury (AKI) in sepsis.

MATERIALS AND METHODS

Post-hoc analysis of sepsis patients in the FINNAKI-cohort (n = 802). Primary outcome was 90-day mortality. We measured plasma cystatin C and creatinine at intensive care unit (ICU) admission and estimated glomerular filtration rates (eGFR_cys, eGFR_crea) and shrunken pore syndrome (SPS; defined as eGFR_cys/eGFR_crea ratio < 0.7). Associations were assessed using Cox- or logistic regression.

RESULTS

Increased cystatin C and decreased eGFR_cys were associated with mortality in unadjusted analyses and in analyses adjusted for illness severity and creatinine. Hazard ratios (HRs) in unadjusted analyses were 3.30 (95% CI; 2.12-5.13, p < 0.001) and 3.26 (95% CI; 2.12-5.02, p < 0.001) respectively. SPS was associated with mortality in an unadjusted- (HR 1.78, 95% CI; 1.33-2.37, p < 0.001) and in an adjusted analysis (HR 1.54, 95% CI; 1.07-2.22, p = 0.021). All cystatin C-derived measures were associated with mortality also after adjustment for AKI development. Cystatin C was associated with AKI in unadjusted analyses but not in analyses adjusted for creatinine.

CONCLUSION

Cystatin C and derived measures of kidney function at ICU admission are associated with an increased 90-day mortality. Increased AKI incidence does not fully explain this association.

Extracorporeal organ support and the kidney

The concept of extracorporeal organ support (ECOS) encompasses kidney, respiratory, cardiac and hepatic support. In an era of increasing incidence and survival of patients with single or multiple organ failure, knowledge on both multiorgan crosstalk and the physiopathological consequences of extracorporeal organ support have become increasingly important. Immerse within the cross-talk of multiple organ failure (MOF), Acute kidney injury (AKI) may be a part of the clinical presentation in patients undergoing ECOS, either as a concurrent clinical issue since the very start of ECOS or as a de novo event at any point in the clinical course. At any point during the clinical course of a patient with single or multiple organ failure undergoing ECOS, renal function may improve or deteriorate, as a result of the interaction of multiple factors, including multiorgan crosstalk and physiological consequences of ECOS. Common physiopathological ways in which ECOS may influence renal function includes: 1) multiorgan crosstalk (preexisting or de-novo 2)Hemodynamic changes and 3) ECOS-associated coagulation abnormalities and 3) Also, cytokine profile switch, neurohumoral changes and toxins clearance may contribute to the expected physiological changes related to ECOS. The main objective of this review is to summarize the described mechanisms influencing the renal function during the course of ECOS, including renal replacement therapy, extracorporeal membrane oxygenation/carbon dioxide removal and albumin dialysis.

Mesenchymal stem cells-derived exosomes prevent sepsis-induced myocardial injury by a CircRTN4/miR-497-5p/MG53 pathway

Sepsis is a life-threatening organ function dysfunction featured by stimulated oxidative stress and inflammatory responses, in which about 40%-60% of sepsis patients are accompanied with cardiac dysfunction. Mesenchymal stem cells (MSCs)-derived exosomes exert critical roles in the treatment of multiple diseases through transferring non-coding RNAs. Circular RNA (circRNA) is a novel form of functional RNAs that involves in the progression of multiple cardiac pathological condition. Nevertheless, the function of MSCs-derived exosomal circRTN4 in sepsis-induced myocardial injury is still obscure. Significantly, FISH assay demonstrated the location of circRTN4 in cytoplasm of cardiomyocytes. The expression of circRTN4 was reduced in the cardiac tissues from caecal ligation and puncture (CLP) rats and LPS-treated cardiomyocytes. CircRTN4 could be delivered to cardiomyocytes cells via MSCs-derived exosomes. The cardiac injury and apoptosis were induced in the CLP rats and the treatment of MSCs-derived exosomal circRTN4 relieved the phenotypes. MSCs-derived exosomal circRTN4 notably suppressed the upregulated ROS level in the CLP rats. The activity of SOD and GSH was repressed in CLP rats, in which MSCs-derived exosomal circRTN4 rescued the activity in the rats. The upregulated IL-1β, IL-6, and TNF-α levels in CLP rats were reduced by the treatment of MSCs-derived exosomal circRTN4. MSCs-derived exosomal circRTN4 improved cell survival and suppressed apoptosis of LPS-treated cardiomyocytes. CircRTN4 direct interact with miR-497-5p to upregulate MG53 expression in cardiomyocytes. MSCs-derived exosomal circRTN4 relieves LPS-stimulated cardiomyocyte damage via targeting miR-497-5p/MG53 axis. Therefore, we determine that MSCs-derived exosomes prevent sepsis-induced myocardial injury by a circRTN4/miR-497-5p/MG53 pathway. Our data provides novel insight into the regulatory mechanism by which MSCs-derived exosomal circRTN4 regulates sepsis-induced myocardial injury. MSCs-derived exosomal circRTN4 may be applied as a promising therapeutic approach for sepsis-induced myocardial injury.

Innovations and Emerging Therapies to Combat Renal Cell Damage: NAD+ As a Drug Target

Significance: Acute kidney injury (AKI) is a common and life-threatening complication in hospitalized and critically ill patients. It is defined by an abrupt deterioration in renal function, clinically manifested by increased serum creatinine levels, decreased urine output, or both. To execute all its functions, namely excretion of waste products, fluid/electrolyte balance, and hormone synthesis, the kidney requires incredible amounts of energy in the form of adenosine triphosphate. Recent Advances: Adequate mitochondrial functioning and nicotinamide adenine dinucleotide (NAD+) homeostasis are essential to meet these high energetic demands. NAD+ is a ubiquitous essential coenzyme to many cellular functions. NAD+ as an electron acceptor mediates metabolic pathways such as oxidative phosphorylation (OXPHOS) and glycolysis, serves as a cosubstrate of aging molecules (i.e., sirtuins), participates in DNA repair mechanisms, and mediates mitochondrial biogenesis. Critical Issues: In many forms of AKI and chronic kidney disease, renal function deterioration has been associated with mitochondrial dysfunction and NAD+ depletion. Based on this, therapies aiming to restore mitochondrial function and increase NAD+ availability have gained special attention in the last two decades. Future Directions: Experimental and clinical studies have shown that by restoring mitochondrial homeostasis and increasing renal tubulo-epithelial cells, NAD+ availability, AKI incidence, and chronic long-term complications are significantly decreased. This review covers some general epidemiological and pathophysiological concepts; describes the role of mitochondrial homeostasis and NAD+ metabolism; and analyzes the underlying rationale and role of NAD+ aiming therapies as promising preventive and therapeutic strategies for AKI. Antioxid. Redox Signal. 35, 1449-1466.

[Acute kidney injury in intensive care unit: A review]

Acute kidney injury is a common complication in intensive care unit. Its incidence is variable according to the studies. It is considered to occur in more than 50 % of patients. Acute kidney injury is responsible for an increase in morbidity (length of hospitalization, renal replacement therapy) but also for excess mortality. The commonly accepted definition of acute kidney injury comes from the collaborative workgroup named Kidney Disease: Improving Global Outcomes (KDIGO). It made it possible to standardize practices and raise awareness among practitioners about monitoring plasma creatinine and also diuresis. Acute kidney injury in intensive care unit is a systemic disease including circulatory, endothelial, epithelial and cellular function involvement and an acute kidney injury is not accompanied by ad integrum repair. After prolonged injury, inadequate repair begins with a fibrotic process. Several mechanisms are involved (cell cycle arrest, epithelial-mesenchymal transition, mitochondrial dysfunction) and result in improper repair. A continuum exists between acute kidney disease and chronic kidney disease, characterized by different renal recovery phenotypes. Thus, preventive measures to prevent the occurrence of kidney damage play a major role in management. The nephrologist must be involved at every stage, from the prevention of the first acute kidney injury (upon arrival in intensive care unit) to long-term follow-up and the care of a chronic kidney disease.

MIR210HG Aggravates Sepsis-Induced Inflammatory Response of Proximal Tubular Epithelial Cell via the NF-κB Signaling Pathway

PURPOSE

Acute kidney injury (AKI) is a serious complication of sepsis and is characterized by inflammatory response. MicroRNA-210 host gene (MIR210HG) is upregulated in human proximal tubular epithelial cells under treatment of inflammatory cytokines. This study aimed to explore the role of MIR210HG in sepsis-induced AKI.

MATERIALS AND METHODS

Cell viability was detected by a cell counting kit 8 assay. The levels of proinflammatory cytokines were detected by enzyme-linked immunosorbent assay kits. The protein levels of p65, IκBα, and p-IκBα were examined by western blot analysis. The nuclear translocation of nuclear factor kappa B (NF-κB) was detected by immunofluorescence assay. The histological changes of kidneys were analyzed by hematoxylin and eosin staining assay.

RESULTS

Lipopolysaccharide (LPS) treatment significantly inhibited cell viability and increased productions of proinflammatory cytokines in proximal tubular epithelial cells (HKC-8). Additionally, MIR210HG levels in HKC-8 cells were increased by LPS treatment. MIR210HG silencing inhibited the LPS-induced cell inflammatory response. MIR210HG activated the NF-κB signaling pathway by promoting the phosphorylation of IκBα and nuclear translocation of p65. Rescue assays revealed that the MIR210HG-induced increase of cytokines levels and decline of cell viability were rescued by QNZ treatment. Knockdown of MIR210HG decreased blood urea nitrogen, serum creatinine, and proinflammatory cytokine levels in AKI rats. Moreover, the knockdown of MIR210HG protected against AKI-induced histological changes of kidneys in rats.

CONCLUSION

MIR210HG promotes sepsis-induced inflammatory response of HKC-8 cells by activating the NF-κB signaling pathway. This novel discovery may be helpful for the improvement of sepsis-induced AKI.

Sepsis-Associated Acute Kidney Injury

Sepsis-associated acute kidney injury (S-AKI) is a common and life-threatening complication in hospitalized and critically ill patients. It is characterized by rapid deterioration of renal function associated with sepsis. The pathophysiology of S-AKI remains incompletely understood, so most therapies remain reactive and nonspecific. Possible pathogenic mechanisms to explain S-AKI include microcirculatory dysfunction, a dysregulated inflammatory response, and cellular metabolic reprogramming. In addition, several biomarkers have been developed in an attempt to improve diagnostic sensitivity and specificity of S-AKI. This article discusses the current understanding of S-AKI, recent advances in pathophysiology and biomarker development, and current preventive and therapeutic approaches.

Inhibiting miR-22 Alleviates Cardiac Dysfunction by Regulating Sirt1 in Septic Cardiomyopathy

High morbidity and mortality are the most typical characteristics of septic cardiomyopathy. We aimed to reveal the role of miR-22 in septic cardiomyopathy and to explore the underlying mechanisms. miR-22 cardiac-specific knockout (miR-22^cKO) mice and miR-22 cardiac-specific transgenic (miR-22^cOE) mice were subjected to a cecal ligation and puncture (CLP) operation, while a sham operation was used in the control group. The echocardiogram results suggested that miR-22^cKO CLP mice cardiac dysfunction was alleviated. The serum LDH and CK-MB were reduced in the miR-22^cKO CLP mice. As expected, there was reduced apoptosis, increased autophagy and alleviated mitochondrial dysfunction in the miR-22^cKO CLP mice, while it had contrary role in the miR-22^cOE group. Inhibiting miR-22 promoted autophagy by increasing the LC3II/GAPDH ratio and decreasing the p62 level. Additionally, culturing primary cardiomyocytes with lipopolysaccharide (LPS) simulated sepsis-induced cardiomyopathy in vitro. Inhibiting miR-22 promoted autophagic flux confirmed by an increased LC3II/GAPDH ratio and reduced p62 protein level under bafilomycin A1 conditions. Knocking out miR-22 may exert a cardioprotective effect on sepsis by increasing autophagy and decreasing apoptosis via sirt1. Our results revealed that targeting miR-22 may become a new strategy for septic cardiomyopathy treatment.

Highly efficient magnetic labelling allows MRI tracking of the homing of stem cell-derived extracellular vesicles following systemic delivery

Human stem‐cell‐derived extracellular vesicles (EVs) are currently being investigated for cell‐free therapy in regenerative medicine applications, but the lack of noninvasive imaging methods to track EV homing and uptake in injured tissues has limited the refinement and optimization of the approach. Here, we developed a new labelling strategy to prepare magnetic EVs (magneto‐EVs) allowing sensitive yet specific MRI tracking of systemically injected therapeutic EVs. This new labelling strategy relies on the use of ‘sticky’ magnetic particles, namely superparamagnetic iron oxide (SPIO) nanoparticles coated with polyhistidine tags, to efficiently separate magneto‐EVs from unencapsulated SPIO particles. Using this method, we prepared pluripotent stem cell (iPSC)‐derived magneto‐EVs and subsequently used MRI to track their homing in different animal models of kidney injury and myocardial ischemia. Our results showed that iPSC‐derived EVs preferentially accumulated in the injury sites and conferred substantial protection. Our study paves a new pathway for preparing highly purified magnetic EVs and tracking them using MRI towards optimized, systemically administered EV‐based cell‐free therapies.

The role of phytochemicals in sepsis: A mechanistic and therapeutic perspective

Sepsis and septic shock are still a leading cause of mortality and morbidity in intensive care units worldwide. Sepsis is an uncontrolled and excessive response of the innate immune system toward the invading infectious microbes, characterized by the hyper-production of pro-inflammatory mediators such as interleukin (IL)-1β, IL-6, tumor-necrosis factor (TNF)-α, and high-mobility group box 1 (HMGB1). In severe sepsis, the overwhelming production of pro-inflammatory cytokines and reactive oxygen species may compromise organ function and lead to the induction of abnormal apoptosis in different organs, resulting in multiple organ dysfunction syndrome and death. Hence, compounds that are able to attenuate inflammatory responses may have therapeutic potential for sepsis treatment. Understanding the pathophysiology and underlying molecular mechanisms of sepsis may provide useful insights in the discovery and development of new effective therapeutics. Therefore, numerous studies have invested much effort into elucidating the mechanisms involved with the onset and development of sepsis. The present review mainly focuses on the molecules and signaling pathways involved in the pathogenicity of sepsis. Additionally, several well-known natural bioactive herbal compounds and phytochemicals, which have shown protective and therapeutic effects with regard to sepsis, as well as their mechanisms of action, are presented. This review suggests that these phytochemicals are able to attenuate the overwhelming inflammatory responses developed during sepsis by modulating different signaling pathways. Moreover, the anti-inflammatory and cytoprotective activities of phytochemicals make them potent compounds to be included as complementary therapeutic agents in the diets of patients suffering from sepsis in an effort to alleviate sepsis and its life-threatening complications, such as multi-organ failure.

Roflumilast, a Phosphodiesterases-4 (PDE4) Inhibitor, Alleviates Sepsis‑induced Acute Kidney Injury

BACKGROUND Sepsis causes acute kidney injury (AKI) in critically ill patients. Roflumilast, a phosphodiesterases-4 (PDE4) inhibitor, has been shown to be therapeutically effective in sepsis-induced organ injury. However, the function of roflumilast in sepsis-induced AKI is not clearly understood. The present study aimed to explore the protective effect of roflumilast on sepsis-induced AKI in mice. MATERIAL AND METHODS A sepsis model was established by cecal ligation and puncture surgery. Roflumilast (1 mg/kg and 3 mg/kg) was used once daily for 7 consecutive days for treatment. Kidney tissues were pathologically examined by hematoxylin and eosin (H&E) and periodic acid-Schiff (PAS) staining. The levels of kidney injury markers including blood urea nitrogen (BUN), creatinine (Cre), kidney injury molecule-1 (KIM-1), and neutrophil gelatinase-associated lipocalin (NGAL), and inflammatory cytokines including interleukin (IL)-6, tumor necrosis factor (TNF)-alpha, and IL-1ß were detected by their corresponding test kits. The protein expression was measured using western blot and cell apoptosis of kidney tissue was determined by TUNEL (terminal deoxynucleotidyl transferase dUTP nick end labeling) assay. RESULTS Roflumilast was demonstrated to alleviate sepsis-induced AKI by reducing histopathological changes and decreasing the levels of kidney injury markers in a concentration-dependent way. The production of TNF-alpha, IL-6, and IL-1ß was significantly suppressed by roflumilast. Besides, roflumilast inhibited the activation of NLRP3 (nucleotide-binding domain (NOD)-like receptor protein 3) and NF-kappaB (nuclear factor kappa-light-chain-enhancer of activated B cells). Additionally, roflumilast inhibited cell apoptosis and changes in expression of apoptosis related proteins induced by sepsis. Finally, high concentration of roflumilast (3 mg/kg) did not have an adverse effect on liver, heart, lung, or spleen. CONCLUSIONS Our study indicated that roflumilast could ameliorate AKI induced by sepsis through restraining inflammatory response and apoptosis of the kidney, providing a molecular basis for a novel medical treatment of septic AKI.

SIKIAT1/miR-96/FOXA1 axis regulates sepsis-induced kidney injury through induction of apoptosis

OBJECTIVE AND DESIGN

Nowadays, sepsis-induced acute kidney injury (AKI) has gradually become a global problem for its high incidence and increasing mortality. Previous study has reported lncRNA ENST00000452391.1 in sepsis patients. However, its potential biological function and downstream molecular mechanism are still mysterious. METHODS AND RESULTS: Our study found that it was upregulated in sepsis-induced AKI patients, so it was identified as "sepsis-induced kidney injury associated transcript 1 (SIKIAT1)". We used lipopolysaccharide (LPS) stimulated HK-2 cells as an in vitro model to demonstrated that SIKIAT1 acts as a ceRNA for miR-96-3p to enhance FOXA1 expression and promote HK-2 cell apoptosis.

CONCLUSION

Therefore, it could be a potential biomarker and therapeutic target for sepsis-induced AKI in the development of disease.

Diagnostics, Risk Factors, Treatment and Outcomes of Acute Kidney Injury in a New Paradigm

Acute kidney injury (AKI) is a common clinical condition among patients admitted in the hospitals. The condition is associated with both increased short-term and long-term mortality. With the development of a standardized definition for AKI and the acknowledgment of the impact of AKI on patient outcomes, there has been increased recognition of AKI. Two advances from past decades, the usage of computer decision support and the discovery of AKI biomarkers, have the ability to advance the diagnostic method to and further management of AKI. The increasingly widespread use of electronic health records across hospitals has substantially increased the amount of data available to investigators and has shown promise in advancing AKI research. In addition, progress in the finding and validation of different forms of biomarkers of AKI within diversified clinical environments and has provided information and insight on testing, etiology and further prognosis of AKI, leading to future of precision and personalized approach to AKI management. In this this article, we discussed the changing paradigms in AKI: from mechanisms to diagnostics, risk factors, and management of AKI.

Gold Clusters Attenuate Inflammation in Rat Mesangial Cells via Inhibiting the Activation of NF-κB Pathway

Sepsis-induced acute kidney injury (AKI) with high incidence and mortality rates remains a great challenge in the clinic; thus, novel therapies need to be developed urgently. This complication is associated with an overwhelming systemic inflammatory response. The aim of this study was to evaluate the potential effects and possible mechanisms of gold clusters on septic AKI in vitro. Rat mesangial HBZY-1 cells were treated with peptide-templated gold clusters under lipopolysaccharide (LPS) stimulation. The LPS-induced expression of pro-inflammatory cytokines was measured, including tumor necrosis factor alpha (TNF-α), interleukin-1 beta (IL-1β) and interleukin-6 (IL-6). Our data showed that the LPS-induced transcription and secretion of these cytokines were suppressed by pretreatment of gold clusters in a dose-dependent manner. Cyclooxygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS) also play key roles in septic AKI and both of them are induced upon LPS-stimulation in mesangial cells. Our results further showed that pretreatment with gold clusters dramatically inhibited the LPS-stimulated transcription and expression of COX2 and iNOS, and the subsequent prostaglandin E2 (PGE2) and nitric oxide (NO) production in HBZY-1 cells. Since these factors are involved in the NF-κB pathway upon LPS stimulation, the potential roles of gold clusters on the NF-κB pathway were further determined. We found that LPS-induced NF-κB activation was suppressed in gold clusters-pretreated HBZY-1 cells. These results demonstrated that gold clusters can attenuate LPS-induced inflammation in mesangial cells, probably via inhibiting the activation of the NF-κB pathway, suggesting a potential therapeutic approach for septic AKI.

Red Blood Cell Dysfunction in Critical Illness

Oxygen (O2) delivery, which is fundamental to supporting patients with critical illness, is a function of blood O2 content and flow. This article reviews red blood cell (RBC) physiology and dysfunction relevant to disordered O2 delivery in the critically ill. Flow is the focus of O2 delivery regulation: O2 content is relatively fixed, whereas flow fluctuates greatly. Thus, blood flow volume and distribution vary to maintain coupling between O2 delivery and demand. This article reviews conventional RBC physiology influencing O2 delivery and introduces a paradigm for O2 delivery homeostasis based on coordinated gas transport and vascular signaling by RBCs.

The Acute Phase Response Is a Prominent Renal Proteome Change in Sepsis in Mice

(1) Background: Sepsis-induced acute kidney injury (AKI) is the most common form of acute kidney injury (AKI). We studied the temporal profile of the sepsis-induced renal proteome changes. (2) Methods: Male mice were injected intraperitoneally with bacterial lipopolysaccharide (LPS) or saline (control). Renal proteome was studied by LC-MS/MS (ProteomeXchange: PXD014664) at the early phase (EP, 1.5 and 6 h after 40 mg/kg LPS) and the late phase (LP, 24 and 48 h after 10 mg/kg LPS) of LPS-induced AKI. Renal mRNA expression of acute phase proteins (APP) was assessed by qPCR. (3) Results: Renal proteome change was milder in EP vs. LP. APPs dominated the proteome in LP (proteins upregulated at least 4-fold (APPs/all): EP, 1.5 h: 0/10, 6 h: 1/10; LP, 24 h: 22/47, 48 h: 17/44). Lipocalin-2, complement C3, fibrinogen, haptoglobin and hemopexin were the most upregulated APPs. Renal mRNA expression preceded the APP changes with peak effects at 24 h, and indicated renal production of the majority of APPs. (4) Conclusions: Gene expression analysis revealed local production of APPs that commenced a few hours post injection and peaked at 24 h. This is the first demonstration of a massive, complex and coordinated acute phase response of the kidney involving several proteins not identified previously.

O-GlcNAc stimulation: A new metabolic approach to treat septic shock

Septic shock is a systemic inflammation associated with cell metabolism disorders and cardiovascular dysfunction. Increases in O-GlcNAcylation have shown beneficial cardiovascular effects in acute pathologies. We used two different rat models to evaluate the beneficial effects of O-GlcNAc stimulation at the early phase of septic shock. Rats received lipopolysaccharide (LPS) to induce endotoxemic shock or saline (control) and fluid resuscitation (R) with or without O-GlcNAc stimulation (NButGT-10 mg/kg) 1 hour after shock induction. For the second model, rats received cecal ligature and puncture (CLP) surgery and fluid therapy with or without NButGT. Cardiovascular function was evaluated and heart and blood samples were collected and analysed. NButGT treatment efficiently increased total O-GlcNAc without modification of HBP enzyme expression.Treatment improved circulating parameters and cardiovascular function in both models, and restored SERCA2a expression levels. NButGT treatment also reduced animal mortality. In this study, we demonstrate that in septic shock O-GlcNAc stimulation improves global animal and cardiovascular function outcomes associated with a restoration of SERCA2a levels. This pre-clinical study opens avenues for a potential therapy of early-stage septic shock.

Value of early diagnosis of sepsis complicated with acute kidney injury by renal contrast-enhanced ultrasound

BACKGROUND

The incidence of acute kidney injury (AKI) in patients with sepsis is high, and the prognosis of patients with septic AKI is poor. The early diagnosis and treatment of septic AKI is of great significance in improving the prognosis of patients with sepsis.

AIM

To explore the value of contrast-enhanced ultrasound (CEUS), serum creatinine (Scr), and other indicators in the early diagnosis of septic AKI.

METHODS

Ninety patients with sepsis during hospitalization at Tongji Hospital of Tongji University were recruited as subjects. Each patient was recorded with relevant basic data, clinical indicators, and CEUS results. The patients were divided into AKI group and non-AKI group according to the results of renal function diagnosis after 48 h. On the 7th day, the renal function of the non-AKI group was re-evaluated and the patients were further divided into AKI subgroup and non-AKI subgroup. The differences of the indicators in different groups were compared, and the diagnostic value of each indicator and their combination for septic AKI was analyzed.

RESULTS

Systemic inflammatory response score (2.58 ± 0.75), blood lactic acid (3.01 ± 1.33 mmol/L), Scr (141.82 ± 27.19 μmol/L), blood urea nitrogen (4.41 ± 0.81mmol/L), and rise time (10.23 ± 2.63 s) in the AKI group were higher than those in the non-AKI group. Peak intensity (PI) (10.78 ± 3.98 dB) and wash in slope (WIS) (1.07 ± 0.53 dB/s) were lower than those in the non-AKI group. The differences were statistically significant (P < 0.05). The PI (12.83 ± 3.77 dB) and WIS (1.22 ± 0.68 dB/s) in the AKI subgroup were lower than those in the non-AKI subgroup, and the differences were statistically significant (P < 0.05). The area under curve (AUC) of Scr for the diagnosis of septic AKI was 0.825 with a sensitivity of 56.76% and a specificity of 100%. The AUCs of WIS and PI (0.928 and 0.912) were higher than those of Scr. Their sensitivities were 100%, but the specificities were 71.70% and 75.47%. The AUC of the combination of three indicators for the diagnosis of septic AKI was 0.943, which was significantly higher than the AUC diagnosed by each single indicator. The sensitivity was 94.59%, and the specificity was 81.13%.

CONCLUSION

The combination of Scr, PI, and WIS can improve the diagnostic accuracy of septic AKI. PI and WIS are expected to predict the occurrence of early septic AKI.

Nicotine reverses the enhanced renal vasodilator capacity in endotoxic rats: Role of α7/α4β2 nAChRs and HSP70

BACKGROUND

Nicotine alleviates renal inflammation and injury induced by endotoxemia. This study investigated (i) the nicotine modulation of hemodynamic and renal vasodilatory responses to endotoxemia in rats, and (ii) roles of α7 or α4β2-nAChRs and related HSP70/TNFα/iNOS signaling in the interaction.

METHODS

Endotoxemia was induced by ip lipopolysaccharide (5 mg/kg/day, for 2 days) and changes in systolic blood pressure and vasodilator responsiveness of isolated perfused kidney to acetylcholine or 5'-N-ethylcarboxamidoadenosine (NECA, adenosine receptor agonist) were evaluated.

RESULTS

Lipopolysaccharide had no effect on serum creatinine, reduced blood pressure, and increased renal vasodilations induced by acetylcholine or NECA in male and female preparations. Immunohistochemical analyses showed that lipopolysaccharide reduced renal HSP70 expression, but increased α7-nAChRs, α4β2-nAChRs and iNOS expressions. The co-administration of aminoguanidine (iNOS inhibitor), pentoxifylline (TNFα inhibitor), or nicotine attenuated lipopolysaccharide mediation of renal vasodilations and elevations in α7/α4β2-nAChR and iNOS expressions. Nicotine also reversed the downregulating effect of lipopolysaccharide on HSP70 expression. α7-nAChRs (methyllycaconitine citrate, MLA) or α4β2-nAChRs (dihydro-β-erythroidine, DHβE) blockade potentiated the lipopolysaccharide enhancement of renal vasodilations, and abolished the depressant effect of nicotine on lipopolysaccharide responses. A similar abolition of nicotine effects was seen after HSP70 inhibition by quercetin. Alternatively, lipopolysaccharide hypotension was eliminated in rats treated with DHβE/nicotine or quercetin/nicotine regimen in contrast to no effect for nicotine alone or combined with MLA.

CONCLUSIONS

These findings establish that nicotine offsets lipopolysaccharide facilitation of renal vasodilations possibly through a crosstalk between HSP70 and nAChRs of the α7 and α4β2 types.

The Impact of Acute Organ Dysfunction on Long-Term Survival in Sepsis

OBJECTIVES

To estimate the impact of each of six types of acute organ dysfunction (hepatic, renal, coagulation, neurologic, cardiac, and respiratory) on long-term mortality after surviving sepsis hospitalization.

DESIGN

Multicenter, retrospective study.

SETTINGS

Twenty-one hospitals within an integrated healthcare delivery system in Northern California.

PATIENTS

Thirty thousand one hundred sixty-three sepsis patients admitted through the emergency department between 2010 and 2013, with mortality follow-up through April 2015.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Acute organ dysfunction was quantified using modified Sequential Organ Failure Assessment scores. The main outcome was long-term mortality among sepsis patients who survived hospitalization. The estimates of the impact of each type of acute organ dysfunction on long-term mortality were based on adjusted Cox proportional hazards models. Sensitivity analyses were conducted based on propensity score-matching and adjusted logistic regression. Hospital mortality was 9.4% and mortality was 31.7% at 1 year. Median follow-up time among sepsis survivors was 797 days (interquartile range: 384-1,219 d). Acute neurologic (odds ratio, 1.86; p < 0.001), respiratory (odds ratio, 1.43; p < 0.001), and cardiac (odds ratio, 1.31; p < 0.001) dysfunction were most strongly associated with short-term hospital mortality, compared with sepsis patients without these organ dysfunctions. Evaluating only patients surviving their sepsis hospitalization, acute neurologic dysfunction was also most strongly associated with long-term mortality (odds ratio, 1.52; p < 0.001) corresponding to a marginal increase in predicted 1-year mortality of 6.0% for the presence of any neurologic dysfunction (p < 0.001). Liver dysfunction was also associated with long-term mortality in all models, whereas the association for other organ dysfunction subtypes was inconsistent between models.

CONCLUSIONS

Acute sepsis-related neurologic dysfunction was the organ dysfunction most strongly associated with short- and long-term mortality and represents a key mediator of long-term adverse outcomes following sepsis.

Basic Principles of Antibiotics Dosing in Patients with Sepsis and Acute Kidney Damage Treated with Continuous Venovenous Hemodiafiltration

Sepsis is the leading cause of acute kidney damage in patients in intensive care units. Pathophysiological mechanisms of the development of acute kidney damage in patients with sepsis may be hemodynamic and non-hemodynamic. Patients with severe sepsis, septic shock and acute kidney damage are treated with continuous venovenous hemodiafiltration. Sepsis, acute kidney damage, and continuous venovenous hemodiafiltration have a significant effect on the pharmacokinetics and pharmacodynamics of antibiotics. The impact dose of antibiotics is increased due to the increased volume of distribution (increased administration of crystalloids, hypoalbuminemia, increased capillary permeability syndrome toproteins). The dose of antibiotic maintenance depends on renal, non-renal and extracorporeal clearance. In the early stage of sepsis, there is an increased renal clearance of antibiotics, caused by glomerular hyperfiltration, while in the late stage of sepsis, as the consequence of the development of acute renal damage, renal clearance of antibiotics is reduced. The extracorporeal clearance of antibiotics depends on the hydrosolubility and pharmacokinetic characteristics of the antibiotic, but also on the type of continuous dialysis modality, dialysis dose, membrane type, blood flow rate, dialysis flow rate, net filtration rate, and effluent flow rate. Early detection of sepsis and acute kidney damage, early target therapy, early administration of antibiotics at an appropriate dose, and early extracorporeal therapy for kidney replacement and removal of the inflammatory mediators can improve the outcome of patients with sepsis in intensive care units.

RIPK3 mediates renal tubular epithelial cell apoptosis in endotoxin‑induced acute kidney injury

Renal tubular epithelial cell apoptosis is an important pathological mechanism of septic acute kidney injury (AKI). Endotoxin, also known as lipopolysaccharide (LPS), has a key role in septic AKI and can directly induce tubular epithelial cell apoptosis. The upregulation of receptor-interacting protein kinase 3 (RIPK3) in tubular epithelial cells has been reported in septic AKI, with RIPK3 mediating apoptosis in several cell types. In the present study, the effect of RIPK3 on endotoxin-induced AKI was investigated in mouse tubular epithelial cell apoptosis in vitro and in vivo. It was found that the expression of RIPK3 was markedly increased in endotoxin-induced AKI. Endotoxin-induced AKI and tubular epithelial cell apoptosis could be attenuated by GSK′872, a RIPK3 inhibitor. LPS stimulation also upregulated RIPK3 expression in tubular epithelial cells in a time-dependent manner. Both RIPK3 inhibitor and small interfering RNA (siRNA) targeting RIPK3 reduced LPS-induced tubular epithelial cell apoptosis in vitro. The expression of the proapoptotic protein Bax was induced by LPS and reversed by GSK′872 or RIPK3-siRNA. The present study revealed that RIPK3 mediated renal tubular cell apoptosis in endotoxin-induced AKI. RIPK3 may be a potential target for the prevention of renal tubular cell apoptosis in endotoxin-induced AKI.

Acute kidney injury from sepsis: current concepts, epidemiology, pathophysiology, prevention and treatment

Sepsis-associated acute kidney injury (S-AKI) is a frequent complication of the critically ill patient and is associated with unacceptable morbidity and mortality. Prevention of S-AKI is difficult because by the time patients seek medical attention, most have already developed acute kidney injury. Thus, early recognition is crucial to provide supportive treatment and limit further insults. Current diagnostic criteria for acute kidney injury has limited early detection; however, novel biomarkers of kidney stress and damage have been recently validated for risk prediction and early diagnosis of acute kidney injury in the setting of sepsis. Recent evidence shows that microvascular dysfunction, inflammation, and metabolic reprogramming are 3 fundamental mechanisms that may play a role in the development of S-AKI. However, more mechanistic studies are needed to better understand the convoluted pathophysiology of S-AKI and to translate these findings into potential treatment strategies and add to the promising pharmacologic approaches being developed and tested in clinical trials.

Protective Role of Hepcidin in Polymicrobial Sepsis and Acute Kidney Injury

Background: Acute kidney injury (AKI) portends worse prognosis following sepsis, with limited available interventions. Host iron acquisition by pathogens and systemic inflammatory response are key events in the pathogenesis of sepsis. In sepsis, hepcidin induces iron sequestration to limit iron availability to pathogens. Hepcidin is also known to limit inflammation. Since its role in pathophysiology of sepsis-associated AKI is unknown, we investigated the effect of exogenous hepcidin in endotoxin- and peritonitis-induced pathology and AKI.

Methods: C57BL/6 mice were treated with saline or 50–100 µg of hepcidin, pre- and post-LPS injection, or cecal ligation and puncture (CLP, model of peritonitis). Splenectomized mice were challenged with LPS, with and without hepcidin. Mice were euthanized at 24 h after LPS injection and at different time points after CLP. Systemic inflammation and renal injury markers were assessed. Direct effect of hepcidin on renal tubular and endothelial cells was evaluated using endotoxin-induced cytotoxic serum. Role of heavy chain ferritin (H-ferritin) in mediating hepcidin-induced anti-inflammatory effect on LPS stimulated macrophages was evaluated with siRNA studies.

Results: Twenty-four hours pretreatment with hepcidin significantly reduced LPS-induced AKI. Hepcidin ameliorated LPS-induced increase in serum TNFα and renal Cox-2, and prevented loss in PGC1α and cytochrome c oxidase activity. This was associated with reduced glomerular injury and preserved mitochondrial structure. Hepcidin did not exert direct protection on the renal parenchymal cells but reduced endotoxin-induced serum cytotoxicity to mitigate renal injury. Splenectomy reduced LPS-induced early inflammation and AKI, independent of hepcidin, indicating the importance of systemic inflammation. Higher splenic H-ferritin in hepcidin-treated animals was associated with reduced splenocytes apoptosis and inflammation. Hepcidin reduced LPS-induced IL-6 secretion in macrophages in H-ferritin dependent manner. Hepcidin significantly reduced CLP-induced AKI, and mortality (20% hepcidin treated vs 80% PBS treated). Importantly hepcidin reduced bacteremia and AKI even when administered after onset of sepsis.

Conclusion: We demonstrate a protective role of hepcidin in endotoxin- and peritonitis-induced pathologies and AKI, exerted primarily through its anti-inflammatory effects, and antibacterial property. Macrophage H-ferritin plays an important role in hepcidin-mediated protection against endotoxin-induced inflammation. We uncover a novel prophylactic and therapeutic role of hepcidin in sepsis-associated bacteremia, AKI, and mortality.

[Predictive value of plasma cytokines for acute kidney injury following lung resection surgery: prospective observational study]

BACKGROUND AND OBJECTIVES

Patients undergoing lung resection surgery are at risk of developing postoperative acute kidney injury. Determination of cytokine levels allows the detection of an early inflammatory response. We investigated any temporal relationship among perioperative inflammatory status and development of acute kidney injury after lung resection surgery. Furthermore, we evaluated the impact of acute kidney injury on outcome and analyzed the feasibility of cytokines to predict acute kidney injury.

METHODS

We prospectively analyzed 174 patients scheduled for elective lung resection surgery with intra-operative periods of one-lung ventilation. Fiberoptic broncho-alveolar lavage was performed in each lung before and after one-lung ventilation periods for cytokine analysis. As well, cytokine levels were measured from arterial blood samples at five time points. Acute kidney injury was diagnosed within 48h of surgery based estabilished criteria for its diagnosis. We analyzed the association between acute kidney injury and cardiopulmonary complications, length of intensive care unit and hospital stays, intensive care unit re-admission, and short-term and long-term mortality.

RESULTS

The incidence of acute kidney injury in our study was 6.9% (12/174). Acute kidney injury patients showed higher plasma cytokine levels after surgery, but differences in alveolar cytokines were not detected. Although no patient required renal replacement therapy, acute kidney injury patients had higher incidence of cardiopulmonary complications and increased overall mortality. Plasma interleukin-6 at 6h was the most predictive cytokine of acute kidney injury (cut-off point at 4.89pg.mL^-1).

CONCLUSIONS

Increased postoperative plasma cytokine levels are associated with acute kidney injury after lung resection surgery in our study, which worsens the prognosis. Plasma interleukin-6 may be used as an early indicator for patients at risk of developing acute kidney injury after lung resection surgery.

IGFBP7 regulates sepsis-induced acute kidney injury through ERK1/2 signaling

IGFBP7 as an early biomarker has been used to identify patients at risk of developing acute kidney injury (AKI). Nevertheless, its role in AKI remains obscure. The aim of our study is to determine the role and mechanism of IGFBP7 in lipopolysaccharide (LPS)-induced HK-2 cells in vitro and on sepsis-induced AKI by cecal ligation and puncture (CLP) in vivo. Here, we identified that IGFBP7 expression was increased in patients with AKI and HK-2 cells with LPS (1, 2, and 5 μg/mL) induction. HK-2 cells with LPS induction showed cell cycle arrest at G1-G0 phases and cell apoptosis and activated ERK1/2 parallel with the changes in the proteins belonging to the ERK1/2 pathway, including Cyclin D1, P21, Bax, and Bcl-2, which were inhibited by the IGFBP7 knockdown. Moreover, IGFBP7 overexpression significantly induced cell cycle arrest at G1-G0 phases and cell apoptosis of HK-2 cells, which were inhibited by PD98509, an ERK1/2 signaling inhibitor. IGFBP7 knockdown effectively alleviated the severity of the renal injury, evidenced by decreases in the urinary levels of creatinine, blood urea nitrogen, and albumin, cell apoptosis, and activation of ERK1/2 signaling in CLP mice. Taken together, our findings indicate that IGFBP7 regulates sepsis-induced AKI through ERK1/2 signaling.

Predictive value of plasma cytokines for acute kidney injury following lung resection surgery: prospective observational study

Background and objectives

Patients undergoing lung resection surgery are at risk of developing postoperative acute kidney injury. Determination of cytokine levels allows the detection of an early inflammatory response. We investigated any temporal relationship among perioperative inflammatory status and development of acute kidney injury after lung resection surgery. Furthermore, we evaluated the impact of acute kidney injury on outcome and analyzed the feasibility of cytokines to predict acute kidney injury.

Methods

We prospectively analyzed 174 patients scheduled for elective lung resection surgery with intra-operative periods of one-lung ventilation periods. Fiberoptic broncho-alveolar lavage was performed in each lung before and after one-lung ventilation periods for cytokine analysis. As well, cytokine levels were measured from arterial blood samples at five time points. acute kidney injury was diagnosed within 48 h of surgery based on acute kidney injury criteria. We analyzed the association between acute kidney injury and cardiopulmonary complications, length of intensive care unit and hospital stays, intensive care unit re-admission, and short-term and long-term mortality.

Results

The incidence of acute kidney injury in our study was 6.9% (12/174). Acute kidney injury patients showed higher plasma cytokine levels after surgery but differences in alveolar cytokines were not detected. Although no patient required renal replacement therapy, acute kidney injury patients had higher incidence of cardiopulmonary complications and increased overall mortality. Plasma interleukin-6 at 6 h was the most predictive cytokine of acute kidney injury (cut-off point at 4.89 pg.mL⁻¹).

Conclusions

Increased postoperative plasma cytokine levels are associated with acute kidney injury after lung resection surgery in our study, which worsens the prognosis. Plasma interleukin-6 may be used as an early indicator for patients at risk of developing acute kidney injury after lung resection surgery.

Guanylyl Cyclase A in Both Renal Proximal Tubular and Vascular Endothelial Cells Protects the Kidney against Acute Injury in Rodent Experimental Endotoxemia Models

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Natriuretic peptides are used, based on empirical observations, in intensive care units as antioliguric treatments. We hypothesized that natriuretic peptides prevent lipopolysaccharide-induced oliguria by activating guanylyl cyclase A, a receptor for natriuretic peptides, in proximal tubules and endothelial cells.

METHODS

Normal Sprague-Dawley rats and mice lacking guanylyl cyclase A in either endothelial cells or proximal tubular cells were challenged with lipopolysaccharide and assessed for oliguria and intratubular flow rate by intravital imaging with multiphoton microscopy.

RESULTS

Recombinant atrial natriuretic peptide efficiently improved urine volume without changing blood pressure after lipopolysaccharide challenge in rats (urine volume at 4 h, lipopolysaccharide: 0.6 ± 0.3 ml · kg · h; lipopolysaccharide + fluid resuscitation: 4.6 ± 2.0 ml · kg · h; lipopolysaccharide + fluid resuscitation + atrial natriuretic peptide: 9.0 ± 4.8 ml · kg · h; mean ± SD; n = 5 per group). Lipopolysaccharide decreased glomerular filtration rate and slowed intraproximal tubular flow rate, as measured by in vivo imaging. Fluid resuscitation restored glomerular filtration rate but not tubular flow rate. Adding atrial natriuretic peptide to fluid resuscitation improved both glomerular filtration rate and tubular flow rate. Mice lacking guanylyl cyclase A in either proximal tubules or endothelium demonstrated less improvement of tubular flow rate when treated with atrial natriuretic peptide, compared with control mice. Deletion of endothelial, but not proximal tubular, guanylyl cyclase A augmented the reduction of glomerular filtration rate by lipopolysaccharide.

CONCLUSIONS

Both endogenous and exogenous natriuretic peptides prevent lipopolysaccharide-induced oliguria by activating guanylyl cyclase A in proximal tubules and endothelial cells.

Prevalence of and Risk Factors for Abdominal Bleeding in Patients with External Duodenal Fistula

Background

Abdominal bleeding is a severe complication of duodenal fistula, but few studies have focused on this problem. The purpose of the present study was to investigate the prevalence of and risk factors for intra-abdominal bleeding in patients with external duodenal fistula.

Material/Methods

From January 2014 to December 2016, medical records of 97 patients with external duodenal fistula were retrospectively reviewed and analyzed. The prevalence and risk factors for intra-abdominal bleeding were evaluated.

Results

The prevalence of abdominal bleeding in patients with external duodenal fistula was 31.9% (95%CI: 22.5–41.4%). A total of 31 patients had intra-abdominal bleeding. Results revealed that acute kidney failure (OR: 8.462, 95% CI: 1.921–37.28, p=0.005) and retroperitoneal infection (OR: 5.373, 95% CI: 1.504–19.197, p=0.010) were associated with abdominal bleeding.

Conclusions

The prevalence of abdominal bleeding in patients with external duodenal fistula was 31.9%, and acute kidney failure and retroperitoneal infection were found to be risk factors for intra-abdominal bleeding.

LncRNA HOX transcript antisense RNA accelerated kidney injury induced by urine-derived sepsis through the miR-22/high mobility group box 1 pathway

OBJECTIVE

This study investigated the role of long noncoding RNA (lncRNA) HOX transcript antisense RNA (HOTAIR) in kidney injury induced by urine-derived sepsis (US).

MATERIALS AND METHODS

An Escherichia coli suspension was injected into the distal ureter of adult male Sprague Dawley rats to establish a US model. Lipopolysaccharides (LPSs) were used to induce an in vitro septic model. The interaction between HOTAIR and microRNA 22 (miR-22) was detected by RNA precipitation and RNA pull-down assays. The expression of HOTAIR, miR-22, and high mobility group box 1 (HMGB1) were detected by quantitative real time polymerase chain reaction (qRT-PCR) and Western blot analyses.

RESULTS

Compared with a sham group, HOTAIR was upregulated in kidney tissues of the US group. HOTAIR was also upregulated in LPS-induced human renal tubular epithelial cells (HK-2). Furthermore, HOTAIR negatively regulated miR-22 and promoted apoptosis of HK-2 cells. HOTAIR also promoted HMGB1 expression and HK-2 cell apoptosis by inhibiting miR-22. In addition, the miR-22/HMGB1 pathway was involved in LPS-induced HK-2 cell apoptosis. In vivo experiments showed that HOTAIR negatively modulated miR-22 and positively modulated HMGB1 and that HOTAIR knockdown decreased renal function indicators (blood urea nitrogen [BUN] and serum creatinine).

CONCLUSION

HOTAIR was upregulated in sepsis-induced kidney injury, which promoted HK-2 cell apoptosis in kidney injury through the miR-22/HMGB1 pathway.

CEST MRI of sepsis-induced acute kidney injury

Sepsis-induced acute kidney injury (SAKI) is a major complication of kidney disease associated with increased mortality and faster progression. Therefore, the development of imaging biomarkers to detect septic AKI is of great clinical interest. In this study, we aimed to characterize the endogenous chemical exchange saturation transfer (CEST) MRI contrast in the lipopolysaccharide (LPS)-induced SAKI mouse model and to investigate the use of CEST MRI for detecting such injury. We used a SAKI mouse model that was generated by i.p. injection of 10 mg/kg LPS. The resulting kidney injury was confirmed by the elevation of serum creatinine and histology. MRI assessments were performed 24 h after LPS injection, including CEST MRI at different B₁ strengths (1, 1.8 and 3 μT), T₁ mapping, T₂ mapping and conventional magnetization transfer contrast (MTC) MRI. The CEST MRI results were analyzed using Z-spectra, in which the normalized water signal saturation (S_sat /S₀ ) is measured as a function of saturation frequency. Substantial decreases in CEST contrast were observed at both 3.5 and - 3.5 ppm frequency offset from water at all B₁ powers, with the most significant difference obtained at a B₁ of 1.8 μT. The average S_sat /S₀ differences between injured and normal kidneys were 0.07 (0.55 ± 0.04 versus 0.62 ± 0.04, P = 0.0028) and 0.07 (0.50 ± 0.04 versus 0.57 ± 0.03, P = 0.0008) for 3.5 and - 3.5 ppm, respectively. In contrast, the T₁ and T₂ relaxation times and MTC contrast in the injured kidneys did not show a significant change compared with the normal control. Our results showed that CEST MRI is more sensitive to the pathological changes in injured kidneys than the changes in T₁ , T₂ and MTC effect, indicating its potential clinical utility for molecular imaging of renal diseases.

Rutin, a quercetin glycoside, alleviates acute endotoxemic kidney injury in C57BL/6 mice via suppression of inflammation and up-regulation of antioxidants and SIRT1

Acute kidney injury (AKI) is a common complication following severe sepsis, its incidence is increasing, and it is associated with a high rate of morbidity and mortality. Rutin is a glycoside of the bioflavonoid quercetin with various protective effects due to its antioxidant and anti-inflammatory potential. In this research, we tried to assess the protective effect of rutin administration in a model of AKI in C57BL/6 mice. For induction of AKI, lipopolysaccharide (LPS) was injected once (10 mg/kg, i.p.) and rutin was p.o. given at doses of 50 or 200 mg/kg. Treatment of LPS-challenged group with rutin lowered serum level of creatinine and blood urea nitrogen (BUN), restored to some extent renal oxidative stress-related indices such as malondialdehyde (MDA), glutathione (GSH), and activity of superoxide dismutase (SOD) and catalase. In addition, rutin brought back renal nuclear factor-kappaB (NF-κB), toll-like receptor 4 (TLR4), cyclooxygenase-2 (COX2), sirtuin 1 (SIRT1), tumor necrosis factor α (TNFα), interleukin-6, and caspase 3 activity to their control levels. Moreover, protective effect of rutin was in accordance to a dose-dependent manner. Collectively, rutin is capable to mitigate LPS-induced AKI via appropriate modulation of renal oxidative stress, inflammation, and apoptosis.

Sepsis-induced acute kidney injury

PURPOSE OF REVIEW

Sepsis is a common and frequently fatal condition in which mortality has been consistently linked to increasing organ dysfunction. For example, acute kidney injury (AKI) occurs in 40-50% of septic patients and increases mortality six to eight-fold. However, the mechanisms by which sepsis causes organ dysfunction are not well understood and hence current therapy remains reactive and nonspecific.

RECENT FINDINGS

Recent studies have challenged the previous notion that organ dysfunction is solely secondary to hypoperfusion, by showing, for example, that AKI occurs in the setting of normal or increased renal blood flow; and that it is characterized not by acute tubular necrosis or apoptosis, but rather by heterogeneous areas of colocalized sluggish peritubular blood flow and tubular epithelial cell oxidative stress. Evidence has also shown that microvascular dysfunction, inflammation, and the metabolic response to inflammatory injury are fundamental pathophysiologic mechanisms that may explain the development of sepsis-induced AKI.

SUMMARY

The implications of these findings are significant because in the context of decades of negative clinical trials in the field, the recognition that other mechanisms are at play opens the possibility to better understand the processes of injury and repair, and provides an invaluable opportunity to design mechanism-targeted therapeutic interventions.

Resveratrol protects against early polymicrobial sepsis-induced acute kidney injury through inhibiting endoplasmic reticulum stress-activated NF-κB pathway

Resveratrol, a polyphenol compound derived from various edible plants, protects against sepsis-induced acute kidney injury (AKI) via its anti-inflammatory activity, but the underlying mechanisms remain largely unknown. In this study, a rat model of sepsis was established by cecal ligation and puncture (CLP), 30 mg/kg resveratrol was intraperitoneally administrated immediately after the CLP operation. HK-2 cells treated by 1 μg/ml lipopolysaccharide, 0.2 μM tunicamycin, 2.5 mM irestatin 9389 and 20 μM resveratrol were used for in vitro study. The results demonstrated that resveratrol significantly improved the renal function and tubular epithelial cell injury and enhanced the survival rate of CLP-induced rat model of sepsis, which was accompanied by a substantial decrease of the serum content and renal mRNA expressions of TNF-α, IL-1β and IL-6. In addition, resveratrol obviously relieved the endoplasmic reticulum stress, inhibited the phosphorylation of inositol-requiring enzyme 1(IRE1) and nuclear factor-κB (NF-κB) in the kidney. In vitro studies showed that resveratrol enhanced the cell viability, reduced the phosphorylation of NF-κB and production of inflammatory factors in lipopolysaccharide and tunicamycin-induced HK-2 cells through inhibiting IRE1 activation. Taken together, administration of resveratrol as soon as possible after the onset of sepsis could protect against septic AKI mainly through inhibiting IRE1-NF-κB pathway-triggered inflammatory response in the kidney. Resveratrol might be a readily translatable option to improve the prognosis of sepsis.

Protective role of tenuigenin on sepsis-induced acute kidney injury in mice

Acute kidney injury (AKI) is a severe complication of sepsis, which largely contributes to the associated high mortality rate. Tenuigenin (TNG) is a natural product isolated from Polygala tenuifolia root, which possesses anti-inflammatory and anti-oxidant properties. The present study investigated the effects of TNG on sepsis-associated AKI in mice subjected to cecal ligation and puncture (CLP). TNG was demonstrated to alleviate sepsis-induced AKI by reducing pathological changes and significantly decreasing the levels of blood urea nitrogen, serum creatinine and kidney coefficient. The production of inflammatory cytokines, including tumor necrosis factor α and interleukin-6, was markedly inhibited by TNG. Hematoxylin-eosin staining revealed that the morphological changes of kidney tissues in CLP mice were reversed following TNG treatment. Furthermore, treatment with TNG inhibited the production of nitric oxide and prostaglandin E₂. Finally, TNG inhibited the activation of the nuclear factor-κB (NF-κB) signaling pathway. The present study suggested that TNG alleviates sepsis-induced AKI by inhibiting the NF-κB signaling pathway, which provides a novel approach for treating sepsis-induced AKI.

Anti-inflammatory effects of curcumin are associated with down regulating microRNA-155 in LPS-treated macrophages and mice

CONTEXT

The natural polyphenolic compound curcumin has been proved to modulate innate immune responses and possess anti-inflammatory properties. Nevertheless, the mechanism remains poorly understood, particularly regarding curcumin-regulated miRNAs under inflammatory response.

OBJECTIVE

This study investigates the role of miRNA-155 in the effects of curcumin on inflammatory response in cell and a mouse model.

MATERIALS AND METHODS

The anti-inflammatory activity of curcumin (5, 10 and 15 μM, 2 h) in lipopolysaccharide (LPS, 200 ng/mL)-induced cells were measured by quantitative PCR. The animals were treated orally by 20 mg/kg curcumin for 3 days before an LPS intraperitoneal injection (10 mg/kg, 16 h). MicroRNA (miRNA) expression and the underlying molecular mechanisms were assessed using transfection technique and western blotting.

RESULTS AND DISCUSSION

Curcumin efficiently inhibited LPS-induced cytokines (TNF-α, IL-6) and microRNA-155 (miR-155) expression (p < 0.05) without affecting the normally growth of Raw264.7 and THP-1 cells (IC₅₀ 21.8 and 22.3 μM at 48 h, respectively). Moreover, the levels of cytokines were suppressed by curcumin in miR-155 mimics transfected cells (p < 0.05). A blockade of PI3K/AKT signalling pathways resulted in a decreased level of miR-155 (p < 0.05). Curcumin effectively protected mice from sepsis as evidenced by decreasing histological damage, reducing AST (352.0 vs 279.3 U/L), BUN (14.8 vs 10.8 mmol/L) levels and the proportion of macrophages in spleen (31.1% vs 13.5%). MicroRNA-155 level and cytokines were also reduced in curcumin-treated mice (p < 0.05).

CONCLUSIONS

Curcumin's ability to suppress LPS-induced inflammatory response may be due to the inhibition of miR-155.

Impact of systemic inflammatory response syndrome and surgical Apgar score on post-operative acute kidney injury

BACKGROUND

Surgical Apgar Score (SAS) is relatively weakly associated with post-operative outcomes in emergency surgery, compared with elective surgery. A combination of systemic inflammatory response syndrome (SIRS) and SAS may be useful for prediction of poor outcomes after emergency surgery.

METHODS

A retrospective study was conducted in patients who underwent emergency abdominal or cerebral surgery from January 2005 to December 2010. AKI was diagnosed using Acute Kidney Injury Network criteria for 2 days after surgery. Pre-operative SIRS was defined as SIRS score ≥ 2. Patients were divided into those with SAS ≥ 5 and < 5. Independent risk factors for post-operative AKI were identified. Ability to predict post-operative AKI was determined using receiver operating characteristic (ROC) curve analysis.

RESULTS

Of 742 patients, 175 (24%) had post-operative AKI. Pre-operative SIRS (OR 1.9, 95% CI: 1.2-2.9, P < 0.01) and SAS < 5 (OR 2.6, 95% CI: 1.7-4.1, P < 0.01) were independent risk factors for post-operative AKI. Patients without SIRS and SAS < 5 had an increased risk of post-operative AKI (odds ratio (OR) 3.6, 95% confidence interval (CI) 1.9-6.7, P < 0.01) and those with SIRS and SAS < 5 had increased risks of post-operative AKI (OR 5.9, 95% CI: 3.7-9.3, P < 0.01) and hospital mortality (OR 3.5, 95% CI: 1.9-6.3, P < 0.01). In ROC analysis, the c-statistic using both SIRS and SAS < 5 was 0.81 (95% CI: 0.77-0.84, P < 0.01) and higher than without use of these factors (P < 0.01).

CONCLUSION

Pre-operative SIRS and SAS are independently associated with post-operative AKI. Simultaneous use of pre-operative SIRS and SAS may improve prediction of poor post-operative outcomes.

Angiopoietin Balance in Septic Shock Patients With Acute Kidney Injury: Effects of Direct Hemoperfusion With Polymyxin B-Immobilized Fiber

Acute kidney injury (AKI) occurs in approximately 50% of patients in septic shock, and mortality from septic AKI is extremely high. Angiopoietin levels may play a role in the pathogenesis of vascular permeability. It was reported that direct hemoperfusion with a polymyxin B-immobilized fiber column (DHP-PMX) therapy ameliorates the angiopoietin balance in patients with sepsis. Although dysregulated angiopoietin balance in sepsis has been demonstrated, mechanisms underlying the development of AKI in sepsis have not been identified. We investigated angiopoietin levels in septic patients with/without AKI treated with DHP-PMX therapy. We used an enzyme-linked immunoassay to measure serum angiopoietin-1 and -2 levels in 38 septic shock patients treated with DHP-PMX. The renal function of all patients was normal for less than 3 months. Twenty-seven of the patients were diagnosed with AKI. The angiopoietin-1 level of the AKI group was significantly lower than that of the non-AKI group at the initiation of DHP-PMX therapy, but there was no significant difference between the two groups at the end of DHP-PMX therapy. In the AKI group with recovery, the mean angiopoietin-1 level at the end of DHP-PMX therapy was significantly elevated compared to the level before DHP-PMX therapy, and the mean angiopoietin-2 level at the end of DHP-PMX therapy was significantly decreased compared to the level before DHP-PMX therapy. These results suggest that angiopoietins may play a role in the pathogenesis of AKI and that DHP-PMX therapy may ameliorate the angiopoietin balance in AKI patients with sepsis.

Epidemiology of acute kidney injury and chronic kidney disease in the intensive care unit

OBJECTIVE

To describe the epidemiology of acute kidney injury, its relationship to chronic kidney disease, and the factors associated with its incidence.

METHODS

A cohort study and follow-up were conducted in an intensive care unit in Montevideo, Uruguay. We included patients admitted between November 2014 and October 2015 who were older than 15 years of age and who had at least two measurements of serum creatinine. We excluded patients who were hospitalized for less than 48 hours, patients who died at the time of hospitalization, and patients with chronic renal disease who were on hemodialysis or peritoneal dialysis. There were no interventions. Acute kidney injury was defined according to the criteria set forth in Acute Kidney Injury Disease: Improving Global Outcomes, and chronic kidney disease was defined according to the Chronic Kidney Disease Work Group.

RESULTS

We included 401 patients, 56.6% male, median age of 68 years (interquartile range (IQR) 51-79 years). The diagnosis at admission was severe sepsis 36.3%, neurocritical 16.3%, polytrauma 15.2%, and other 32.2%. The incidence of acute kidney injury was 50.1%, and 14.1% of the patients suffered from chronic kidney disease. The incidence of acute septic kidney injury was 75.3%. Mortality in patients with or without acute kidney injury was 41.8% and 14%, respectively (p < 0.001). In the multivariate analysis, the most significant variables for acute kidney injury were chronic kidney disease (odds ratio (OR) 5.39, 95%CI 2.04 - 14.29, p = 0.001), shock (OR 3.94, 95%CI 1.72 - 9.07, p = 0.001), and severe sepsis (OR 7.79, 95%CI 2.02 - 29.97, p = 0.003).

CONCLUSION

The incidence of acute kidney injury is high mainly in septic patients. Chronic kidney disease was independently associated with the development of acute kidney injury.

Actin dynamics in the regulation of endothelial barrier functions and neutrophil recruitment during endotoxemia and sepsis

Sepsis is a leading cause of death worldwide. Increased vascular permeability is a major hallmark of sepsis. Dynamic alterations in actin fiber formation play an important role in the regulation of endothelial barrier functions and thus vascular permeability. Endothelial integrity requires a delicate balance between the formation of cortical actin filaments that maintain endothelial cell contact stability and the formation of actin stress fibers that generate pulling forces, and thus compromise endothelial cell contact stability. Current research has revealed multiple molecular pathways that regulate actin dynamics and endothelial barrier dysfunction during sepsis. These include intracellular signaling proteins of the small GTPases family (e.g., Rap1, RhoA and Rac1) as well as the molecules that are directly acting on the actomyosin cytoskeleton such as myosin light chain kinase and Rho kinases. Another hallmark of sepsis is an excessive recruitment of neutrophils that also involves changes in the actin cytoskeleton in both endothelial cells and neutrophils. This review focuses on the available evidence about molecules that control actin dynamics and regulate endothelial barrier functions and neutrophil recruitment. We also discuss treatment strategies using pharmaceutical enzyme inhibitors to target excessive vascular permeability and leukocyte recruitment in septic patients.