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Predisposing Factors and Outcome of Acute Kidney Injury After Blunt Trauma: A 10-Year Study. J Surg Res 2023; 284:193-203. [PMID: 36586312 DOI: 10.1016/j.jss.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Acute kidney injury (AKI) indicates an impairment of the renal function following blunt trauma. It is multifactorial and associated with an increased risk of morbidity and mortality. The incidence and risk factors of AKI in young patients with trauma are not well-described. This study aimed to evaluate the incidence, clinical characteristics, and outcomes of post-traumatic AKI. We hypothesized that AKI is associated with worse outcomes in patients with trauma. METHODS This was a retrospective study of all adult trauma patients admitted to a level 1 trauma center between 2011 and 2021. AKI was diagnosed on the basis of the Kidney Disease Improving Global Outcomes criteria. Data were collected and analyzed for patients with and without AKI using chi-square test and Student's t-test. Multivariate logistic regression analysis and Kaplan-Meier curves were performed. RESULTS A total of 17,341 patients with trauma were evaluated, of which 140 (0.8%) developed AKI. Patients with AKI were older (40 ± 20 versus 32 ± 16 y), had more comorbidities, and had a higher injury severity score (ISS) and in-hospital mortality (65% versus 3.2%) than non-AKI patients. Direct trauma to the kidney was reported in only nine (6.4%) patients in the AKI group. Among patients with AKI, nonsurvivors had a higher ISS and were more likely to have hypotension, elevated serum lactate, positive troponin, and a lower platelet-to-lymphocyte ratio than survivors. Multiple logistic regression analyses showed that age, ISS, acute respiratory distress syndrome, blood transfusion, diabetes mellitus, onadmission Glasgow coma scale score, and shock index were predictors of AKI in trauma patients, whereas ISS (odds ratio (OR) = 1.05; 95% confidence interval (CI):1.003-1.100; P = 0.03), serum lactate level (OR = 1.25; 95% CI: 1.019-1.533; P = 0.03), and hypotension (OR = 3.22; 95% CI: 1.044-9.945; P = 0.04) were independent predictors of mortality in patients with posttraumatic AKI. Kaplan-Meier survival analysis showed significant differences in mortality among the three stages of AKI (P = 0.03), with the worst outcome in stage III. However, after adjusting for age, hypotension, and ISS, the Cox regression model showed that only stage I had better survival than stages II and III, whereas no survival difference was noted between stages II and III (P = 0.06). CONCLUSIONS AKI in young trauma patients is uncommon and associated with a prolonged hospital course and higher mortality. This study identified factors that independently predicted the development of AKI and its outcomes in patients with trauma. However, further prospective and multicenter studies are required to minimize the incidence and complications of posttraumatic AKI.
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Grigorian A, Gabriel V, Nguyen NT, Smith BR, Schubl S, Borazjani B, Joe V, Nahmias J. Black Race and Body Mass Index Are Risk Factors for Rhabdomyolysis and Acute Kidney Injury in Trauma. J INVEST SURG 2020; 33:283-290. [PMID: 30212225 DOI: 10.1080/08941939.2018.1493162] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Purpose: Obesity has been shown in a single-center study to be a risk factor for rhabdomyolysis. More recently, sickle cell trait, known to be more prevalent in blacks, has been shown to be a risk factor for rhabdomyolysis. We hypothesized that in trauma patients, black race and a higher body mass index (BMI) are associated with risk for rhabdomyolysis and acute kidney injury (AKI). Materials and Methods: The National Trauma Data Bank (NTDB) was queried (2013-2015) to identify patients age ≥18 years and grouped by BMI: normal (18.5-24.99 kg/m2), underweight (16.5-18.49 kg/m2), overweight (25-29.99 kg/m2), obese (30-34.99 kg/m2), severely obese (35-39.99 kg/m2), and morbidly obese (≥40 kg/m2). A multivariable logistic regression model was used to assess whether a higher BMI or black race was associated with rhabdomyolysis or AKI. Results: After adjusting for covariates, severe obesity (odds ratio (OR) = 1.42, confidence interval (CI) = 1.01-1.99, p < .001), morbid obesity (OR = 1.46, CI = 1.04-2.06, p < .001), and black race (OR = 1.52, CI = 1.24-1.88, p < .001) were associated with higher risk for rhabdomyolysis. Patients that were overweight (OR = 1.17, CI = 1.11-1.24, p < .001), obese (OR = 1.32, CI = 1.24-1.41, p < .001), severely obese (OR = 1.72, CI = 1.59-1.86, p < .001), morbidly obese (OR = 1.77, CI = 1.64-1.92, p < .001), or black (OR = 1.31, CI = 1.24-1.38, p < .001) were associated with higher risk for AKI. Conclusions: Black race was associated with an increased risk of rhabdomyolysis as well as AKI in trauma. BMI ≥25 kg/m2 was associated with increased risk for AKI with the morbidly obese having the highest risk. BMI ≥35 kg/m2 was found to be associated with increased risk of rhabdomyolysis. Future studies should investigate the role for routine screening of these high-risk populations and other potential associated factors such as adherence to weight-based fluid resuscitation.
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Affiliation(s)
- Areg Grigorian
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California, USA
| | - Viktor Gabriel
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California, USA
| | - Ninh T Nguyen
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California, USA
| | - Brian R Smith
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California, USA
| | - Sebastian Schubl
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California, USA
| | - Boris Borazjani
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California, USA
| | - Victor Joe
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California, USA
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Presentation Coagulopathy and Persistent Acidosis Predict Complications in Orthopaedic Trauma Patients. J Orthop Trauma 2017; 31:617-623. [PMID: 28827507 DOI: 10.1097/bot.0000000000000957] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the ability of measures of coagulopathy and acidosis to predict complications. We hypothesize that increased coagulopathy and acidosis over the first 60 hours of hospitalization will result in increased rates of infection and mortality. DESIGN Prospective, observational. SETTING Level 1 trauma center. PATIENTS Three hundred seventy-six skeletally mature patients with an Injury Severity Score greater than 16, who were surgically treated for high-energy fractures of the femur, pelvic ring, acetabulum, and/or spine. MAIN OUTCOME MEASUREMENTS Data included measures of acidosis, pH, lactate, and base excess, and measures of coagulopathy, Prothrombin (PT), Partial Throunboplastin Time (PTT), International Normalized Ratio (INR), and platelets. Complications including pneumonia, deep venous thrombosis, pulmonary embolism, infection, organ failure, acute renal failure, sepsis, and death were documented. RESULTS Acidosis was common on presentation (88.8%) and decreased over 48 hours (50.4%). Incidence of coagulopathy increased over 48 hours (16.3%-34.3%). Coagulopathy on presentation was associated with complications (54.0% vs. 27.7%) including pneumonia, acute renal failure, multiple organ failure, infection, sepsis, and death. Acidosis was associated with complications if it persisted later in the hospital course. CONCLUSION Coagulopathy on presentation is a stronger predictor of complications, sepsis, and death than acidosis. During the first 48 hours, unresolved acidosis increased the risk of complications and sepsis. Complications were most related to higher Injury Severity Score. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Tatum JM, Barmparas G, Ko A, Dhillon N, Smith E, Margulies DR, Ley EJ. Analysis of Survival After Initiation of Continuous Renal Replacement Therapy in a Surgical Intensive Care Unit. JAMA Surg 2017; 152:938-943. [PMID: 28636702 PMCID: PMC5710279 DOI: 10.1001/jamasurg.2017.1673] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 04/01/2017] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Continuous renal replacement therapy (CRRT) benefits patients with renal failure who are too hemodynamically unstable for intermittent hemodialysis. The duration of therapy beyond which continued use is futile, particularly in a population of patients admitted to and primarily cared for by a surgical service (hereinafter referred to as surgical patients), is unclear. OBJECTIVE To analyze proportions of and independent risk factors for survival to discharge after initiation of CRRT among patients in a surgical intensive care unit (SICU). DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included all patients undergoing CRRT from July 1, 2012, through January 31, 2016, in an SICU of an urban tertiary medical center. The population included patients treated before or after general surgery and patients admitted to a surgical service during inpatient evaluation and care before liver transplant. The pretransplant population was censored from further survival analysis on receipt of a transplant. EXPOSURES Continuous renal replacement therapy. MAIN OUTCOMES AND MEASURES Hospital mortality among patients in an SICU after initiation of CRRT. RESULTS Of 108 patients (64 men [59.3%] and 44 women [40.7%]; mean [SD] age, 62.0 [12.7] years) admitted to the SICU, 53 were in the general surgical group and 55 in the pretransplant group. Thirteen of the 22 patients in the pretransplant group who required 7 or more days of CRRT died (in-hospital mortality, 59.1%); among the 12 patients in the general surgery group who required 7 or more days of CRRT, 12 died (in-hospital mortality, 100%). In the general surgical group, each day of CRRT was associated with an increased adjusted odds ratio of death of 1.39 (95% CI, 1.01-1.90; P = .04). CONCLUSIONS AND RELEVANCE Continuous renal replacement therapy is valuable for surgical patients with an acute and correctable indication; however, survival decreases significantly with increasing duration of CRRT. Duration of CRRT does not correlate with survival among patients awaiting liver transplant.
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Affiliation(s)
- James M. Tatum
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ara Ko
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Navpreet Dhillon
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric Smith
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Evaluation of acute kidney injury (AKI) with RIFLE, AKIN, CK, and KDIGO in critically ill trauma patients. Eur J Trauma Emerg Surg 2017; 44:597-605. [PMID: 28717983 DOI: 10.1007/s00068-017-0820-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 07/11/2017] [Indexed: 01/21/2023]
Abstract
PURPOSE The aim of our study was to evaluate the effects of AKI development on mortality with four different classification systems (RIFLE, AKIN, CK, KDIGO) in critically ill trauma patients followed in the intensive care unit. METHODS A retrospective review of 2034 patients in our intensive care unit was conducted between July 2010 and August 2013. A total of 198 patients with primary trauma were included in the study to evaluate the development of AKI. RESULTS When the presence of AKI was investigated according to the four criteria (RIFLE, AKIN, CK, and KDIGO), the highest incidence of AKI was found according to the KDIGO classification (74.2%), followed by AKIN (72.2%), RIFLE (69.7%), and CK (59.1%). It was observed that more AKI developed according to KDIGO in patients with multiple trauma and thoracic trauma (p = 0.031, p = 0.029). Sixty-two (31%) of the 198 trauma patients monitored in the intensive care unit died; mortality was frequently found high in AKI stage 2 and 3 patients. According to the CK classification, there was a significant increase in mortality in patients with AKI on the first day (p = 0.045). AKI classifications by RIFLE, AKIN, CK, and KDIGO were independently associated with the risk of in-hospital death. CONCLUSION In this study, the presence of AKI was found to be an independent risk factor in the development of in-hospital mortality according to all classification systems (RIFLE, AKIN, CK, and KDIGO) in critically traumatic patients followed in ICU, and the compatibility between RIFLE, AKIN, and KDIGO was the highest among the classification systems.
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Lai WH, Rau CS, Wu SC, Chen YC, Kuo PJ, Hsu SY, Hsieh CH, Hsieh HY. Post-traumatic acute kidney injury: a cross-sectional study of trauma patients. Scand J Trauma Resusc Emerg Med 2016; 24:136. [PMID: 27876077 PMCID: PMC5120453 DOI: 10.1186/s13049-016-0330-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 11/15/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The causes of post-traumatic acute kidney injury (AKI) are multifactorial, and shock associated with major trauma has been proposed to result in inadequate renal perfusion and subsequent AKI in trauma patients. This study aimed to investigate the true incidence and clinical presentation of post-traumatic AKI in hospitalized adult patients and its association with shock at a Level I trauma center. METHODS Detailed data of 78 trauma patients with AKI and 14,504 patients without AKI between January 1, 2009 and December 31, 2014 were retrieved from the Trauma Registry System. Patients with direct renal trauma were excluded from this study. Two-sided Fisher's exact or Pearson's chi-square tests were used to compare categorical data, unpaired Student's t-test was used to analyze normally distributed continuous data, and Mann-Whitney's U test was used to compare non-normally distributed data. Propensity score matching with a 1:1 ratio with logistic regression was used to evaluate the effect of shock on AKI. RESULTS Patients with AKI presented with significantly older age, higher incidence rates of pre-existing comorbidities, higher odds of associated injures (subdural hematoma, intracerebral hematoma, intra-abdominal injury, and hepatic injury), and higher injury severity than patients without AKI. In addition, patients with AKI had a longer hospital stay (18.3 days vs. 9.8 days, respectively; P < 0.001) and intensive care unit (ICU) stay (18.8 days vs. 8.6 days, respectively; P < 0. 001), higher proportion of admission into the ICU (57.7% vs. 19.0%, respectively; P < 0.001), and a higher odds ratio (OR) of short-term mortality (OR 39.0; 95% confidence interval, 24.59-61.82; P < 0.001). However, logistic regression analysis of well-matched pairs after propensity score matching did not show a significant influence of shock on the occurrence of AKI. DISCUSSION We believe that early and aggressive resuscitation, to avoid prolonged untreated shock, may help to prevent the occurrence of post-traumatic AKI. However, more evidence is required to support this observation. CONCLUSION Compared to patients without AKI, patients with AKI presented with different injury characteristics and worse outcome. However, an association between shock and post-traumatic AKI could not be identified.
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Affiliation(s)
- Wei-Hung Lai
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Ta-Pei Road, Niao-Song District Kaohsiung City, 833 Taiwan
| | - Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Yi-Chun Chen
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Ta-Pei Road, Niao-Song District Kaohsiung City, 833 Taiwan
| | - Pao-Jen Kuo
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Ta-Pei Road, Niao-Song District Kaohsiung City, 833 Taiwan
| | - Ching-Hua Hsieh
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Ta-Pei Road, Niao-Song District Kaohsiung City, 833 Taiwan
| | - Hsiao-Yun Hsieh
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Ta-Pei Road, Niao-Song District Kaohsiung City, 833 Taiwan
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Assessment of Modification of Diet in Renal Disease Equation to Predict Reference Serum Creatinine Value in Severe Trauma Patients: Lessons From an Observational Study of 775 Cases. Ann Surg 2016; 263:814-20. [PMID: 26020104 DOI: 10.1097/sla.0000000000001163] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We assessed the Modification of Diet in Renal Disease (MDRD) performance to predict serum creatinine (SCr) in severe trauma population and determined the best theoretical glomerular filtration rate (GFR) to use in this estimation. BACKGROUND Baseline SCr may be misestimated in severe trauma patients because of their specific demographic characteristics including renal hyperfiltration. However, the back-calculated MDRD equation is supposed to estimate SCr using a predetermined GFR of 75 mL/min/1.73 m. METHODS All severe trauma patients with a normal SCr were retrospectively included between January 2005 and January 2011. For each patient, the lowest SCr (oSCr) observed during the first week was used to estimate the GFR. The median GFR in period 1 (2005-2006) was determined. The back-calculated MDRD performance was assessed in period 2 (2007-2011) to predict oSCr by agreement, precision, and accuracy using a GFR of 75 mL/min/1.73 m (eSCr75-MDRD) or the median GFR observed in period 1 (eSCrTRAUMA-MDRD). RESULTS A total of 775 patients were studied: mean age, 37.7 ± 17 years; mean Injury Severity Score, 19 ± 11; 75% of male. In period 1 (n = 243), median GFR was 121 mL/min/1.73 m. In period 2 (n = 532), eSCrTRAUMA-MDRD demonstrated better agreement in predicting oSCr than eSCr75-MDRD (mean bias 2 vs 35 μmol/L; P < 0.001). Both precision (14 vs 39 μmol/L, respectively) and accuracy were significantly improved with eSCrTRAUMA-MDRD. Proportion of estimated SCr values that deviated less than 15%, 30%, or 50% was also higher with eSCrTRAUMA-MDRD (P < 0.001). CONCLUSIONS The eSCr75-MDRD equation systematically overestimates oSCr of severe trauma patients. The eSCrTRAUMA-MDRD equation determined was statistically superior allowing more accurate qualification of acute kidney injury.
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Abstract
OBJECTIVE The objective of this study was to characterize relationships between obesity and initial hospital stay, including complications, in patients with multiple system trauma and surgically treated fractures. DESIGN Prospective, observational. SETTING Level 1 trauma center. PATIENTS Three hundred seventy-six patients with an Injury Severity Score greater than 16 and mechanically unstable high-energy fractures of the femur, pelvic ring, acetabulum, or spine requiring stabilization. MAIN OUTCOME MEASUREMENTS Data for obese (body mass index ≥ 30) versus nonobese patients included presence of pneumonia, deep vein thrombosis, pulmonary embolism, infection, organ failure, and mortality. Days in ICU and hospital, days on ventilator, transfusions, and surgical details were documented. RESULTS Complications occurred more often in obese patients (38.0% vs. 28.4%, P = 0.03), with more acute renal failure (5.70% vs. 1.38%, P = 0.02) and infection (11.4% vs. 5.50%, P = 0.04). Days in ICU and mechanical ventilation times were longer for obese patients (7.06 vs. 5.25 days, P = 0.05 and 4.92 vs. 2.90 days, P = 0.007, respectively). Mean total hospital stay was also longer for obese patients (12.3 vs. 9.79 days, P = 0.009). No significant differences in rates of mortality, multiple organ failure, or pulmonary complications were noted. Medically stable obese patients were almost twice as likely to experience delayed fracture fixation due to preference of the surgeon and were more likely to experience delay overall (26.0% vs. 16.1%; P = 0.02). Mean time from injury to fixation was 34.9 hours in obese patients versus 23.7 hours in nonobese patients (P = 0.03). CONCLUSIONS Obesity was noted among 42% of our trauma patients. In obese patients, complications occurred more often and hospital and ICU stays were significantly longer. These increases are likely to be associated with greater hospital costs. Surgeon decision to delay procedures in medically stable obese patients may have contributed to these findings; definitive fixation was more likely to be delayed in obese patients. Further study to optimize the care of patients with increased body mass index may help to improve outcomes and minimize additional treatment expenses.
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Bolanos JA, Yuan CM, Little DJ, Oliver DK, Howard SR, Abbott KC, Olson SW. Outcomes After Post-Traumatic AKI Requiring RRT in United States Military Service Members. Clin J Am Soc Nephrol 2015; 10:1732-9. [PMID: 26336911 PMCID: PMC4594058 DOI: 10.2215/cjn.00890115] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 06/30/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Mortality and CKD risk have not been described in military casualties with post-traumatic AKI requiring RRT suffered in the Iraq and Afghanistan wars. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This is a retrospective case series of post-traumatic AKI requiring RRT in 51 military health care beneficiaries (October 7, 2001-December 1, 2013), evacuated to the National Capital Region, documenting in-hospital mortality and subsequent CKD. Participants were identified using electronic medical and procedure records. RESULTS Age at injury was 26±6 years; of the participants, 50 were men, 16% were black, 67% were white, and 88% of injuries were caused by blast or projectiles. Presumed AKI cause was acute tubular necrosis in 98%, with rhabdomyolysis in 72%. Sixty-day all-cause mortality was 22% (95% confidence interval [95% CI], 12% to 35%), significantly less than the 50% predicted historical mortality (P<0.001). The VA/NIH Acute Renal Failure Trial Network AKI integer score predicted 60-day mortality risk was 33% (range, 6%-96%) (n=49). Of these, nine died (mortality, 18%; 95% CI, 10% to 32%), with predicted risks significantly miscalibrated (P<0.001). The area under the receiver operator characteristic curve for the AKI integer score was 0.72 (95% CI, 0.56 to 0.88), not significantly different than the AKI integer score model cohort (P=0.27). Of the 40 survivors, one had ESRD caused by cortical necrosis. Of the remaining 39, median time to last follow-up serum creatinine was 1158 days (range, 99-3316 days), serum creatinine was 0.85±0.24 mg/dl, and eGFR was 118±23 ml/min per 1.73 m(2). No eGFR was <60 ml/min per 1.73 m(2), but it may be overestimated because of large/medium amputations in 54%. Twenty-five percent (n=36) had proteinuria; one was diagnosed with CKD stage 2. CONCLUSIONS Despite severe injuries, participants had better in-hospital survival than predicted historically and by AKI integer score. No patient who recovered renal function had an eGFR<60 ml/min per 1.73 m(2) at last follow-up, but 23% had proteinuria, suggesting CKD burden.
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Affiliation(s)
- Jonathan A Bolanos
- Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Christina M Yuan
- Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Dustin J Little
- Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - David K Oliver
- Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Steven R Howard
- Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Kevin C Abbott
- Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Stephen W Olson
- Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
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Cost-effectiveness of endovascular versus open repair of acute complicated type B aortic dissections. J Vasc Surg 2014; 59:1247-55. [DOI: 10.1016/j.jvs.2013.11.086] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 11/22/2013] [Accepted: 11/26/2013] [Indexed: 11/22/2022]
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Medha, Subramanian A, Pandey RM, Sawhney C, Upadhayay AD, Albert V. Incidence, clinical predictors and outcome of acute renal failure among North Indian trauma patients. J Emerg Trauma Shock 2013; 6:21-8. [PMID: 23492778 PMCID: PMC3589854 DOI: 10.4103/0974-2700.106321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Accepted: 07/11/2012] [Indexed: 12/22/2022] Open
Abstract
Context: There is a need for identifying risk factors aggravating development of acute renal failure after attaining trauma and defining new parameters for better assessment and management. Aim of the study was to determine the incidence of acute renal failure among trauma patients, and its correlation with various laboratory and clinical parameters recorded at the time of admission and in-hospital mortality. Subjects and Methods: The retrospective cohort study included admitted 208 trauma patients over a period of one year. 135 trauma patients at the serum creatinine level >2.0 mg/dL were enrolled in under the group of acute renal failure. 73 patients who had normal creatinine level made the control group. They were further assessed with clinical details and laboratory investigations. Results: Incidence of acute renal failure was 3.1%. There were 118 (87.4%) males and average length of stay was 9 (1, 83) days. Severity of injury (ISS, GCS) was relatively more among the renal failure group. Renal failure was transient in 35 (25.9%) patients. They had higher incidence of bone fracture (54.0%) (P= 0.04). Statistically significant association was observed between patients with head trauma and mortality 72 (59.0%) (P= 0.001). Prevalence of septic 24 (59.7%) and hemorrhagic 9 (7.4%) shock affected the renal failure group. Conclusion: Trauma patients at the urea level >50 mg/dL, ISS >24 on the first day of admission had 23 times and 7 times the risk of developing renal failure. Similarly, patients with hepatic dysfunction and pulmonary dysfunction were 12 times and 6 times. Patients who developed cardiovascular dysfunction, hematological dysfunction and post-trauma renal failure during the hospital stay had risk for mortality 29, 7 and 8 times, respectively. The final prognostic score obtained was: 14*hepatic dysfunction + 11*cISS + 18*cUrea + 12*cGlucose + 10*pulmonary dysfunction. Optimal score cut-off for prediction of renal failure was found to be ≥25 with specificity, sensitivity and positive likelihood ratio to be 84.9%, 78.4% and 3.9, respectively.
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Affiliation(s)
- Medha
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
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Shashaty MGS, Meyer NJ, Localio AR, Gallop R, Bellamy SL, Holena DN, Lanken PN, Kaplan S, Yarar D, Kawut SM, Feldman HI, Christie JD. African American race, obesity, and blood product transfusion are risk factors for acute kidney injury in critically ill trauma patients. J Crit Care 2012; 27:496-504. [PMID: 22591570 PMCID: PMC3472045 DOI: 10.1016/j.jcrc.2012.02.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Revised: 01/02/2012] [Accepted: 02/04/2012] [Indexed: 01/24/2023]
Abstract
PURPOSE Acute kidney injury (AKI) is a common source of morbidity after trauma. We sought to determine novel risk factors for AKI, by Acute Kidney Injury Network (AKIN) criteria, in critically ill trauma patients. MATERIALS AND METHODS A prospective cohort of 400 patients admitted to the intensive care unit of a level 1 trauma center was followed for the development of AKI over 5 days. RESULTS Acute kidney injury developed in 147 (36.8%) of 400 patients. In multivariable regression analysis, independent risk factors for AKI included African American race (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.08-3.18; P = .024), body mass index of 30 kg/m(2) or greater (OR, 4.72 versus normal body mass index; 95% CI, 2.59-8.61; P < .001), diabetes mellitus (OR, 3.26; 95% CI, 1.30-8.20; P = .012), abdominal Abbreviated Injury Scale score of 4 or more (OR, 3.78; 95% CI, 1.79-7.96; P < .001), and unmatched packed red blood cells administered during resuscitation (OR, 1.13 per unit; 95% CI, 1.04-1.23; P = .004). Acute Kidney Injury Network stages 1, 2, and 3 were associated with hospital mortality rates of 9.8%, 13.7%, and 30.4%, respectively, compared with 3.8% for those without AKI (P < .001). CONCLUSIONS Acute kidney injury in critically ill trauma patients is associated with substantial mortality. The findings of African American race, obesity, and blood product administration as independent risk factors for AKI deserve further study to elucidate underlying mechanisms.
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Affiliation(s)
- Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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The impact of injury severity and transfer status on reimbursement for care of femur fractures. J Trauma Acute Care Surg 2012; 73:957-65. [DOI: 10.1097/ta.0b013e31825a7723] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Bajwa SJS, Kulshrestha A. Renal endocrine manifestations during polytrauma: A cause of concern for the anesthesiologist. Indian J Endocrinol Metab 2012; 16:252-7. [PMID: 22470863 PMCID: PMC3313744 DOI: 10.4103/2230-8210.93744] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Nowadays, an increasing number of patients get admitted with polytrauma, mainly due to road traffic accidents. These polytrauma victims may exhibit associated renal injuries, in addition to bone injuries and injuries to other visceral organs. Nevertheless, even in cases of polytrauma, renal tissue is hyperfunctional as part of the normal protective responses of the body to external insults. Both polytrauma and renal injuries exhibit widespread renal, endocrine, and metabolic responses. The situation is very challenging for the attending anesthesiologist, as he is expected to contribute immensely, not only in the resuscitation of such patients, but if required, to allow the operative procedures in case of life-threatening injuries. During administration of anesthesia, care has to be taken, not only to maintain hemodynamic stability, but equal attention has to be paid to various renal protection strategies. At the same time, various renoendocrine manifestations have to be taken into account, so that a judicious use of anesthesia drugs can be made, to minimize the renal insults.
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Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
| | - Ashish Kulshrestha
- Department of Anesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
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Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries. ACTA ACUST UNITED AC 2011; 71:175-85. [PMID: 21336198 DOI: 10.1097/ta.0b013e3181fc93a2] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Type and timing of treatment of femur fractures is controversial. Although reported as safe and effective in many reports, others have suggested that early definitive stabilization may cause complications, particularly in patients with chest and head injuries. Damage control orthopedics was proposed as an alternative in unstable patients. This study examines the effects of timing of fixation and investigates risk factors for complications. METHODS Seven hundred fifty patients with femur fractures treated between 1999 and 2006 were reviewed. Skeletally mature patients with mean age 35.8 years and mean Injury Severity Score (ISS) 23.7 were included. Four hundred ninety-two patients had ISS ≥18. Early stabilization (n = 656) was defined as definitive treatment of the femur fracture within 24 hours of injury. RESULTS Early definitive stabilization in patients with multiple injuries was associated with fewer complications than delayed stabilization (18.9% vs. 42.9%, p < 0.037) after adjusting for patient age and ISS. Early treatment was also associated with shorter hospital stay, intensive care unit stay, and ventilator days (p < 0.001). Severe (Abbreviated Injury Scale score ≥3) abdominal injury was associated with more complications than severe head (Glasgow Coma Scale score ≤8) and chest (Abbreviated Injury Scale score ≥3) injuries (44.2% vs. 40.9%, p = 0.68, and 34.4%, p = 0.024, respectively) and was an independent risk factor for complications (p < 0.0001). Chest injury was an independent risk factor for pulmonary complications (p < 0.001), but surgical delay in patients with chest injury was also associated with pulmonary complications (p = 0.04). More sepsis was noted patients with severe head injury (22.7% vs. 4.5%, p = 0.037) or severe chest injury (10.2% vs. 2.5%, p = 0.044) when treated on a delayed basis. More patients transferred from other hospitals were treated on a delayed basis (48.9% vs. 37.5%, p = 0.04). CONCLUSIONS Early definitive stabilization is associated with acceptably low rates of complications and is safe in most patients with multiple injuries, including some with severe abdominal, chest, or head injuries with attention to resuscitation before surgery. More complications and longer hospital stay were noted with delayed fixation after adjusting for age and ISS. Chest injury was associated with pulmonary complications; however, the presence of severe abdominal injury was the greatest risk factor for complications. Expediting access to definitive care may reduce complications and expenses.
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Aberrant Obturator Artery Is a Common Arterial Variant That May Be a Source of Unidentified Hemorrhage in Pelvic Fracture Patients. ACTA ACUST UNITED AC 2011; 70:366-72. [DOI: 10.1097/ta.0b013e3182050613] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Beitland S, Moen H, Os I. Acute kidney injury with renal replacement therapy in trauma patients. Acta Anaesthesiol Scand 2010; 54:833-40. [PMID: 20528778 DOI: 10.1111/j.1399-6576.2010.02253.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) with renal replacement therapy (RRT) is rare in trauma patients. The primary aim of the study was to assess incidence, mortality and chronic RRT dependency in this patient group. METHODS Adult trauma patients with AKI receiving RRT at a regional trauma referral center over a 12-year period were retrospectively reviewed. RESULTS Population-based incidence of post-traumatic AKI with RRT was 1.8 persons per million inhabitants per year (p.p.m./year) [95% confidence the interval (CI) 1.5-2.1 p.p.m./year]. In trauma patients admitted to hospital, incidence was 0.5 per thousand (95% CI 0.3-0.7 per thousand) of those treated in intensive care unit (ICU), it was 8.3% (95% CI 5.9-10.8%). The median age was 46 years. Odds ratio (OR) for post-traumatic AKI requiring RRT was higher in males than in females in general population (OR 5.6, 95% CI 2.2-14.0), and in trauma patients admitted to hospital (OR 4.4, 95% CI 1.9-10.3) and ICU (OR 4.5, 95% CI 1.9-10.7). The in-hospital mortality rate was 24% (95% CI 11-37%), 3-month mortality 36% (95% CI 21-51%) and 1-year mortality 40% (95% CI 25-55%). Age was a risk factor for death after 1 year, with 57% (95% CI 7-109%) increased risk for each 10 years added. None of the survivors was dialysis-dependent 3 months or 1 year after trauma. CONCLUSION AKI in trauma patients requiring RRT was rare in this single-center study. More males than females were affected. Mortality was modest, and renal recovery was excellent as none of the survivors became dependent on chronic RRT.
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Affiliation(s)
- S Beitland
- Department of Anaesthesiology, Oslo University Hospital Ullevaal, Oslo, Norway.
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de Abreu KLS, Silva Júnior GB, Barreto AGC, Melo FM, Oliveira BB, Mota RMS, Rocha NA, Silva SL, Araújo SMHA, Daher EF. Acute kidney injury after trauma: Prevalence, clinical characteristics and RIFLE classification. Indian J Crit Care Med 2010; 14:121-8. [PMID: 21253345 PMCID: PMC3021827 DOI: 10.4103/0972-5229.74170] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is an uncommon but serious complication after trauma. The objective of this study was to evaluate the prevalence, clinical characteristics and outcome of AKI after trauma. PATIENTS AND METHODS This was a retrospective study performed from January 2006 to January 2008 in an emergency specialized hospital in Fortaleza city, northeast of Brazil. All patients with AKI admitted in the study period were included. Prevalence of AKI, clinical characteristics and outcome were investigated. RESULTS Of the 129 patients admitted to the intensive care unit (ICU), 52 had AKI. The mean age was 30.1 ± 19.2 years, and 79.8% were males. The main causes of AKI were sepsis in 27 cases (52%) and hypotension in 18 (34%). Oliguria was observed in 33 cases (63%). Dialysis was required for 19 patients (36.5%). Independent risk factors associated with AKI were abdominal trauma [odds ratio (OR) = 3.66, P = 0.027] and use of furosemide (OR = 4.10, P = 0.026). Patients were classified according to RIFLE criteria as Risk in 12 cases (23%), Injury in 13 (25%), Failure in 24 (46%), Loss in 1 (2%) and End-stage in 2 (4%). Overall in-hospital mortality was 95.3%. The main cause of death was sepsis (24%). Mortality was 100% among patients with AKI. CONCLUSIONS AKI is a fatal complication after trauma, which presented with a high mortality in the studied population. A better comprehension of factors associated with death in trauma-associated AKI is important, and more effective measures of prevention and treatment of AKI in this population are urgently needed.
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Affiliation(s)
- Krasnalhia Lívia S. de Abreu
- From:Division of Nephrology, Department of Internal Medicine, School of Medicine, Walter Cantídio University Hospital, Ceará, Brazil
| | - Geraldo B. Silva Júnior
- From:Division of Nephrology, Department of Internal Medicine, School of Medicine, Walter Cantídio University Hospital, Ceará, Brazil
| | - Adller G. C. Barreto
- From:Division of Nephrology, Department of Internal Medicine, School of Medicine, Walter Cantídio University Hospital, Ceará, Brazil
| | - Fernanda M. Melo
- From:Division of Nephrology, Department of Internal Medicine, School of Medicine, Walter Cantídio University Hospital, Ceará, Brazil
| | - Bárbara B. Oliveira
- From:Division of Nephrology, Department of Internal Medicine, School of Medicine, Walter Cantídio University Hospital, Ceará, Brazil
| | - Rosa M. S. Mota
- Department of Statistics, Science Center, Federal University of Ceará – UFC, Ceará, Brazil
| | - Natália A. Rocha
- From:Division of Nephrology, Department of Internal Medicine, School of Medicine, Walter Cantídio University Hospital, Ceará, Brazil
| | - Sônia L. Silva
- From:Division of Nephrology, Department of Internal Medicine, School of Medicine, Walter Cantídio University Hospital, Ceará, Brazil
- Department of Internal Medicine, School of Medicine, University of Fortaleza – UNIFOR, Fortaleza, Ceará, Brazil
| | - Sônia M. H. A. Araújo
- From:Division of Nephrology, Department of Internal Medicine, School of Medicine, Walter Cantídio University Hospital, Ceará, Brazil
| | - Elizabeth F. Daher
- From:Division of Nephrology, Department of Internal Medicine, School of Medicine, Walter Cantídio University Hospital, Ceará, Brazil
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Tong MZY, Koka P, Forbes TL. Economic evaluation of open vs endovascular repair of blunt traumatic thoracic aortic injuries. J Vasc Surg 2010; 52:31-38.e3. [DOI: 10.1016/j.jvs.2010.01.087] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2009] [Revised: 01/27/2010] [Accepted: 01/28/2010] [Indexed: 11/29/2022]
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Gomes E, Antunes R, Dias C, Araújo R, Costa-Pereira A. Acute kidney injury in severe trauma assessed by RIFLE criteria: a common feature without implications on mortality? Scand J Trauma Resusc Emerg Med 2010; 18:1. [PMID: 20051113 PMCID: PMC2823674 DOI: 10.1186/1757-7241-18-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Accepted: 01/05/2010] [Indexed: 11/19/2022] Open
Abstract
Background Acute kidney injury (AKI) has been hard to assess due to the lack of standard definitions. Recently, the Risk, Injury, Failure, Loss and End-Stage Kidney (RIFLE) classification has been proposed to classify AKI in a number of clinical settings. This study aims to estimate the frequency and levels of severity of AKI and to study its association with patient mortality and length of stay (LOS) in a cohort of trauma patients needing intensive care. Methods Between August 2001 and September 2007, 436 trauma patients consecutively admitted to a general intensive care unit (ICU), were assessed using the RIFLE criteria. Demographic data, characteristics of injury, and severity of trauma variables were also collected. Results Half of all ICU trauma admissions had AKI, which corresponded to the group of patients with a significantly higher severity of trauma. Among patients with AKI, RIFLE class R (Risk) comprised 47%, while I (Injury) and F (Failure) were, 36% and 17%, respectively. None of these patients required renal replacement therapy. No significant differences were found among these three AKI classes in relation to patient's age, gender, type and mechanism of injury, severity of trauma or mortality. Nevertheless, increasing severity of acute renal injury was associated with a longer ICU stay. Conclusions AKI is a common feature among trauma patients requiring intensive care. Although the development of AKI is associated with an increased LOS it does not appear to influence patient mortality.
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Affiliation(s)
- Ernestina Gomes
- Unidade de Cuidados Intensivos Polivalente, Hospital de Santo António, Centro Hospitalar do Porto, 4099 - 001 Porto, Portugal.
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