Risk factors and outcome of acute renal failure in patients with severe acute pancreatitis

Breaking the chain in organ failure: Role of umbilical cord and bone marrow derived mesenchymal stem cells in treatment of severe acute pancreatitis

Background

Previous studies showed that MSCs could mitigate damage in the pancreas during acute pancreatitis (AP). However, acute mortality associated with AP was more often a result of persistent failure of remote organs, rather than local damage, especially in severe acute pancreatitis (SAP), and the effect of MSCs may vary depending on their origin.

Methods

An SAP model was induced in 8-week C57BL/6 J male mice by retrograde injection of 5 % sodium taurocholate solution through the bile duct. SAP mice were divided into the SAP group, UC-MSCs group, and BMSCs group, which were treated with saline, 1 × 106 UC-MSCs, and 1 × 106 BMSCs respectively, through the tail vein. After treatment, serum markers, inflammation, and morphology were assessed in the pancreas, kidneys, lungs, and hearts.

Results

MSCs infusion ameliorated the systemic inflammatory response in SAP mice. In the MSCs-treated SAP mice, local tissue injury and inflammation response in the pancreas were alleviated. But more importantly, the renal and lung injury were all significantly and drastically mitigated, and the levels of pro-inflammatory factors such as IL-6, MCP-1, IL-1β, and TNF-α in the kidney, lung and heart were sharply decreased. In terms of origin, UC-MSCs exhibited superior efficacy compared with BMSCs. Furthermore, compared to the normal control mice, UC-MSCs showed an earlier appearance, higher distribution densities, and longer duration of presence in the injured tissue.

Conclusions

This study provides compelling evidence supporting the therapeutic potential of MSCs in SAP treatment and particularly their ability to mitigate multi-organ failure. Our results also suggested that UC-MSCs may offer greater advantages over BMSCs in SAP therapy.

The role of Interleukin-22 in severe acute pancreatitis

Severe acute pancreatitis (SAP) begins with premature activation of enzymes, promoted by the immune system, triggering a potential systemic inflammatory response that leads to organ failure with increased mortality and a bleak prognosis. Interleukin-22 (IL-22) is a cytokine that may have a significant role in SAP. IL-22, a member of the IL-10 cytokine family, has garnered growing interest owing to its potential tissue-protective properties. Recently, emerging research has revealed its specific effects on pancreatic diseases, particularly SAP. This paper provides a review of the latest knowledge on the role of IL-22 and its viability as a therapeutic target in SAP.

Association between serum creatinine to albumin ratio and short- and long-term all-cause mortality in patients with acute pancreatitis admitted to the intensive care unit: a retrospective analysis based on the MIMIC-IV database

Background

Serum creatinine (Cr) and albumin (Alb) are important predictors of mortality in individuals with various diseases, including acute pancreatitis (AP). However, most previous studies have only examined the relationship between single Cr or Alb levels and the prognosis of patients with AP. To our knowledge, the association between short- and long-term all-cause mortality in patients with AP and the blood creatinine to albumin ratio (CAR) has not been investigated. Therefore, this study aimed to evaluate the short- and long-term relationships between CAR and all-cause mortality in patients with AP.

Methods

We conducted a retrospective study utilizing data from the Medical Information Market for Intensive Care (MIMIC-IV) database. The study involved analyzing various mortality variables and obtaining CAR values at the time of admission. The X-tile software was used to determine the optimal threshold for the CAR. Kaplan-Meier (K-M) survival curves and multivariate Cox proportional hazards regression models were used to assess the relationship between CAR and both short- and long-term all-cause mortality. The predictive power, sensitivity, specificity, and area under the curve (AUC) of CAR for short- and long-term mortality in patients with AP after hospital admission were investigated using Receiver Operating Characteristic analysis. Additionally, subgroup analyses were conducted.

Results

A total of 520 participants were included in this study. The CAR ideal threshold, determined by X-tile software, was 0.446. The Cox proportional hazards model revealed an independent association between CAR≥0.446 and all-cause mortality at 7-day (d), 14-d, 21-d, 28-d, 90-d, and 1-year (y) before and after adjustment for confounders. K-M survival curves showed that patients with CAR≥0.446 had lower survival rates at 7-d, 14-d, 21-d, 28-d, 90-d, and 1-y. Additionally, CAR demonstrated superior performance, with higher AUC values than Cr, Alb, serum total calcium, Glasgow Coma Scale, Systemic Inflammatory Response Syndrome score, and Sepsis-related Organ Failure Assessment score at 7-d, 14-d, 21-d, 28-d, 90-d, and 1-y intervals. Subgroup analyses showed that CAR did not interact with a majority of subgroups.

Conclusion

The CAR can serve as an independent predictor for short- and long-term all-cause mortality in patients with AP. This study enhances our understanding of the association between serum-based biomarkers and the prognosis of patients with AP.

Automated machine learning for early prediction of acute kidney injury in acute pancreatitis

BACKGROUND

Acute kidney injury (AKI) represents a frequent and grave complication associated with acute pancreatitis (AP), substantially elevating both mortality rates and the financial burden of hospitalization. The aim of our study is to construct a predictive model utilizing automated machine learning (AutoML) algorithms for the early prediction of AKI in patients with AP.

METHODS

We retrospectively analyzed patients who were diagnosed with AP in our hospital from January 2017 to December 2021. These patients were randomly allocated into a training set and a validation set at a ratio of 7:3. To develop predictive models for each set, we employed the least absolute shrinkage and selection operator (LASSO) algorithm along with AutoML. A nomogram was developed based on multivariate logistic regression analysis outcomes. The model's efficacy was assessed using receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). Additionally, the performance of the model constructed via AutoML was evaluated using decision curve analysis (DCA), feature importance, SHapley Additive exPlanations (SHAP) plots, and locally interpretable model-agnostic explanations (LIME).

RESULTS

This study incorporated a total of 437 patients who met the inclusion criteria. Out of these, 313 were assigned to the training cohort and 124 to the validation cohort. In the training and validation cohorts, AKI occurred in 68 (21.7%) and 29(23.4%) patients, respectively. Comparative analysis revealed that the AutoML models exhibited enhanced performance over traditional logistic regression (LR). Furthermore, the deep learning (DL) model demonstrated superior predictive accuracy, evidenced by an area under the ROC curve of 0.963 in the training set and 0.830 in the validation set, surpassing other comparative models. The key variables identified as significant in the DL model within the training dataset included creatinine (Cr), urea (Urea), international normalized ratio (INR), etiology, smoking, alanine aminotransferase (ALT), hypertension, prothrombin time (PT), lactate dehydrogenase (LDH), and diabetes.

CONCLUSION

The AutoML model, utilizing DL algorithm, offers considerable clinical significance in the early detection of AKI among patients with AP.

Impact of contrast-enhanced versus non-contrast computed tomography on acute kidney injury in acute necrotizing pancreatitis: A randomized controlled trial

BACKGROUND

The data evaluating contrast-induced-acute kidney injury (AKI) in patients with acute pancreatitis is scarce. This study aimed to compare the frequency of AKI in patients with acute necrotizing pancreatitis undergoing non-contrast computed tomography (NCCT) with those undergoing contrast-enhanced computed tomography (CECT) during hospitalization.

METHODS

This prospective randomized controlled trial (CTRI/2019/12/022206) screened consecutive patients with acute pancreatitis for eligibility and randomly allocated patients with acute necrotizing pancreatitis (based on CECT in the first week of illness) and normal renal functions to receive either NCCT or CECT during hospitalization. The incidence of development of new AKI and clinical outcomes was compared between the two groups. Post-hoc analysis was done to adjust for disease severity.

RESULTS

As many as 105 patients completed the study as per protocol (NCCT = 45 and CECT = 60). AKI occurred in 36 (34.3%) patients, nine (20%) in the NCCT and 27 (45%) in the CECT group. Contrast induced-AKI occurred in 11 (18.3%) patients, while 25 had AKI secondary to acute pancreatitis. The relative risk (RR) of AKI in the CECT group was 2.25 (95% CI 1.17-4.30, p = .0142). The frequency of intensive care unit (ICU) admission (RR = 2.1, 95% CI 1.34-3.27, p = .0001) and need for drainage of collections (RR = 1.39, 95% CI 1.1-1.7, p = .005) was significantly higher and the length of hospitalization (p = .001) and ICU admission (p = 0.001) were significantly longer in the CECT group. However, when adjusted for the severity of acute pancreatitis, there was no difference in AKI and clinical outcomes between the NCCT and CECT groups. The duration of AKI was significantly longer and the need for dialysis was significantly higher in patients who had AKI secondary to acute pancreatitis compared to those with contrast induced-AKI (p = .003).

CONCLUSION

CECT is not significantly associated with AKI in acute necrotizing pancreatitis.

Serum Cys C predicts acute kidney injury in patients with acute pancreatitis: A retrospective study

BACKGROUND AND STUDY AIMS

We investigated the value of the serum cystatin C level as a potential predictor of acute kidney injury (AKI) in patients with acute pancreatitis (AP).

PATIENTS AND METHODS

We retrospectively examined patients diagnosed with AP between January 2013 and December 2018. Patients were categorized into two groups based on their serum cystatin C levels after admission: the normal (n-Cys C group) and high serum cystatin C levels groups (h-Cys C group). Patients in the h-Cys C group demonstrated serum cystatin C levels ≥1.05 mg/L. Demographic parameters, laboratory data, and AP severity were compared between the two groups. Receiver operating curve (ROC) analysis was used to evaluate the efficacy of serum cystatin C in predicting persistent AKI.

RESULTS

A total of 379 patients with AP were enrolled: 319 in the n-Cys C group and 60 in the h-Cys C group. Serum cystatin C levels were significantly higher in patients with severe acute pancreatitis (SAP) compared to moderate acute pancreatitis (MAP) (P< 0.05). The h-Cys C group had a higher BISAP score (P < 0.001). Incidences of organ failure and SAP were significantly higher in the h-Cys C group (P < 0.05). ROC analysis indicated that a serum cystatin C cutoff point of 1.055 mg/L optimally predicted persistent AKI (AUC = 0.711). For internal validation, we selected 545 AP patients, treated at our center from 2019 to 2022, including 54 AKI patients. ROC analysis in this validation group yielded a sensitivity of 100% and specificity of 90.9% (AUC = 0.916, 95% CI: 0.894-0.937).

CONCLUSION

Elevated serum cystatin C levels are sensitive indicators of adverse AKI prognosis in AP patients. The cystatin C level at admission can reflect a patient's initial renal function status.

Application of logistic regression, support vector machine and random forest on the effects of titanium dioxide nanoparticles using macroalgae in treatment of certain risk factors associated with kidney injuries

The use of titanium dioxide (TiO₂) nanoparticles in many biological and technical domains is on the rise. There hasn't been much research on the toxicity of titanium dioxide nanoparticles in biological systems, despite their ubiquitous usage. In the current investigation, samples were exposed to various dosages of TiO₂ nanoparticles for 4 days, 1 month, and 2 months following treatment. ICP-AES was used to dose TiO₂ into the tissues, and the results showed that the kidney had a significant TiO₂ buildup. On the other hand, apoptosis of renal tubular cells is one of the most frequent cellular processes contributing to kidney disease (KD). Nevertheless, the impact of macroalgal seaweed extract on KD remains undetermined. In this work, machine learning (ML) approaches have been applied to develop prediction algorithms for acute kidney injury (AKI) by use of titanium dioxide and macroalgae in hospitalized patients. Fifty patients with (AKI) and 50 patients (non-AKI group) have been admitted and considered. Regarding demographic data, and laboratory test data as input parameters, support vector machine (SVM), and random forest (RF) are utilized to build models of AKI prediction and compared to the predictive performance of logistic regression (LR). Due to its strong antioxidant and anti-inflammatory powers, the current research ruled out the potential of using G. oblongata red macro algae as a source for a variety of products for medicinal uses. Despite a high and fast processing of algorithms, logistic regression showed lower overfitting in comparison to SVM, and Random Forest. The dataset is subjected to algorithms, and the categorization of potential risk variables yields the best results. AKI samples showed significant organ defects than non-AKI ones. Multivariate LR indicated that lymphocyte, and myoglobin (MB) ≥ 1000 ng/ml were independent risk parameters for AKI samples. Also, GCS score (95% CI 1.4-8.3 P = 0.014) were the risk parameters for 60-day mortality in samples with AKI. Also, 90-day mortality in AKI patients was significantly high (P < 0.0001). In compared to the control group, there were no appreciable changes in the kidney/body weight ratio or body weight increases. Total thiol levels in kidney homogenate significantly decreased, and histopathological analysis confirmed these biochemical alterations. According to the results, oral TiO₂ NP treatment may cause kidney damage in experimental samples.

Acute Kidney Injury Complicating Severe Acute Pancreatitis: Clinical Profile and Factors Predicting Mortality

Introduction

Acute kidney injury (AKI) frequently complicates severe acute pancreatitis (SAP) among the critically ill. We studied clinical profile and risk factors predicting mortality in SAP-AKI.

Materials and Methods

We conducted a prospective observational study of 68 patients with SAP-AKI from September 2015 to September 2019. Patient data and outcomes grouped as survivors and deceased were analyzed.

Results

SAP-AKI constituted 2.14% (68 of 3,169) of all AKIs with 1.5%, 20.6%, and 77.9% in Kidney Disease Improving Global Outcomes (KDIGO) Stages I, II and III respectively. The mean age was 39.93 ± 11.79 years with males 65 (95.6%). The causes of acute pancreatitis were alcohol addiction 59 (86.8%), highly active antiretroviral therapy 1 (1.4%), hypercalcemia 1 (1.4%), IgG4-related disease 1 (1.4%), and unidentified 6 (8.8%). Complications were volume overload, shock, respiratory failure, and necrotizing pancreatitis in 21 (30.9%), 10 (14.7%), 6 (8.8%), and 14 (20.5%), respectively. Kidney replacement therapy done in 40 (58%), with intermittent hemodialysis 36 (53%) and acute intermittent peritoneal dialysis 4 (6%). The overall mortality was 23 (33.8%), three progressed to chronic kidney disease (thrombotic microangiopathy 2; biopsy inconclusive 1). In 45 survivors, AKI recovered in 22.7 ± 9.6 days. Death occurred within first 6 days. The risk factors associated with in-hospital mortality was necrotizing pancreatitis (odds ratio [OR] = 5.143; 95% confidence interval 1.472-17.972; P = 0.01), circulatory failure (OR = 6.125; P = 0.016), peak creatinine >3 mg/dL (OR = 7.118; P = 0.068), Bedside Index of Severity for Acute Pancreatitis score >3 (OR = 8.472; P = 0.001), need for kidney replacement therapy (OR = 3.764; P = 0.024), KDIGO III (OR = 9.935; P = 0.03).

Conclusions

Alcohol addiction was the commonest cause of severe acute pancreatitis. The overall mortality was 33.8%. Necrotizing pancreatitis, circulatory failure, peak creatinine >3 mg/dL, BISAPs >3, KDIGO III, and the need for kidney replacement therapy were independent risk factors for mortality.

Baseline Serum Estradiol Level Is Associated with Acute Kidney Injury in Patients with Moderately Severe and Severe Acute Pancreatitis

Background. Sexual dimorphism with critical diseases has been documented. However, the role of serum sex hormones for the presence of acute kidney injury (AKI) in moderately or severe acute pancreatitis (MSAP and SAP) patients remains controversial. Here we set out to evaluate whether early (first 48 h) serum estradiol level is associated with AKI in patients with MSAP and SAP. Patients and Methods. We retrospectively collected data from patients with preliminary diagnosis of MSAP and SAP from the Affiliated Hospital of Yangzhou University between January 2014 and June 2018. Serum sex hormones were extracted for further assessment within first 48 h following admission. Logistic regression analysis and the receiving operating characteristic (ROC) curve were applied to evaluate the association and correlation between serum sex hormones and AKI. Results. Data from a total of 122 patients with MSAP or SAP were enrolled in this study. There were no differences in the incidence of AKI between males and females. However, comparing with patients without AKI, those with AKI saw higher estradiol level ( $p\le 0.01$ ) and slight higher progesterone level ( $p=0.014$ ) but similar testosterone level ( $p=0.668$ ). Interestingly, during both the manual selection and the stepwise backward logistic regression analysis, serum estradiol level was independently associated with AKI in patients with MSAP and SAP (OR 4.699, CI 1.783-12.386, and $p=0.002$ ). Additionally, area under the curve of ROC (AUCROC) showed that serum estradiol level was a proper predictor for AKI (area under the curve 0.875). Specifically, the serum estradiol level of 223.15 pg/mL demonstrated a 92.3% sensitive and a 79.3% specificity in predicting AKI of MSAP and SAP patients, respectively. Conclusions. High baseline serum estradiol level appears to be an independent risk factor for AKI in patients with MSAP and SAP. It also tends to be an appropriate indicator for AKI.

Machine Learning-Assisted Ensemble Analysis for the Prediction of Acute Pancreatitis with Acute Kidney Injury

Purpose

Acute kidney injury (AKI) is a frequent complication of severe acute pancreatitis (AP) and carries a very poor prognosis. The present study aimed to construct a model capable of accurately identifying those patients at high risk of harboring occult acute kidney injury (AKI) characteristics.

Patients and Methods

We retrospectively recruited a total of 424 consecutive patients at the Gezhouba central hospital of Sinopharm and Xianning central hospital between January 1, 2016, and October 30, 2021. ML-assisted models were developed from candidate clinical features using two-step estimation methods. The receiver operating characteristic curve (ROC), decision curve analysis (DCA), and clinical impact curve (CIC) were performed to evaluate the robustness and clinical practicability of each model.

Results

Finally, a total of 30 candidate variables were included, and the AKI prediction model was established by an ML-based algorithm. The areas under the ROC curve (AUCs) of the random forest classifier (RFC) model, support vector machine (SVM), eXtreme gradient boosting (XGBoost), artificial neural network (ANN), and decision tree (DT) ranged from 0.725 (95% CI 0.223–1.227) to 0.902 (95% CI 0.400–1.403). Among them, RFC obtained the optimal prediction efficiency via adding inflammatory factors, which are serum creatinine (Scr), C-reactive protein (CRP), platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), neutrophil-to-albumin ratio (NAR), and CysC, respectively.

Conclusion

We successfully developed ML-based prediction models for AKI, particularly the RFC, which can improve the prediction of AKI in patients with AP. The practicality of prediction and early detection may be greatly beneficial to risk stratification and management decisions.

The Impact of Normal Saline or Balanced Crystalloid on Plasma Chloride Concentration and Acute Kidney Injury in Patients With Predicted Severe Acute Pancreatitis: Protocol of a Phase II, Multicenter, Stepped-Wedge, Cluster-Randomized, Controlled Trial

Introduction/aim: The supraphysiologic chloride concentration of normal saline may contribute to acute kidney injury (AKI). Balanced crystalloids can decrease chloride concentration and AKI in critically ill patients. We aim to test the hypothesis that, in patients with predicted severe acute pancreatitis (pSAP), compared with saline, fluid therapy with balanced crystalloids will decrease plasma chloride concentration. Methods/Design: This is a multicenter, stepped-wedge, cluster-randomized, controlled trial. All eligible patients presenting to the 11 participating sites across China during the study period will be recruited. All sites will use saline for the first month and sequentially change to balanced crystalloids at the pre-determined and randomly allocated time point. The primary endpoint is the plasma chloride concentration on day 3 of enrollment. Secondary endpoints will include major adverse kidney events on hospital discharge or day 30 (MAKE 30) and free and alive days to day 30 for intensive care admission, invasive ventilation, vasopressors, and renal replacement therapy. Additional endpoints include daily serum chloride and sequential organ failure assessment (SOFA) score over the first seven days of enrollment. Discussion: This study will provide data to define the impact of normal saline vs. balanced crystalloids on plasma chloride concentration and clinical outcomes in pSAP patients. It will also provide the necessary data to power future large-scale randomized trials relating to fluid therapy. Ethics and Dissemination: This study was approved by the ethics committee of Jinling Hospital, Nanjing University (2020NZKY-015-01) and all the participating sites. The results of this trial will be disseminated in peer-reviewed journals and at scientific conferences. Trial registration: The trial has been registered at the Chinese Clinical Trials Registry (ChiCTR2100044432).

Effects of acute kidney injury on acute pancreatitis patients’ survival rate in intensive care unit: A retrospective study

BACKGROUND

Acute kidney injury (AKI) is one of the most common acute pancreatitis (AP)-associated complications that has a significant effect on AP, but the factors affecting the AP patients’ survival rate remains unclear.

AIM

To assess the influences of AKI on the survival rate in AP patients.

METHODS

A total of 139 AP patients were included in this retrospective study. Patients were divided into AKI group (n = 72) and non-AKI group (n = 67) according to the occurrence of AKI. Data were collected from medical records of hospitalized patients. Then, these data were compared between the two groups and further analysis was performed.

RESULTS

AKI is more likely to occur in male AP patients (P = 0.009). AP patients in AKI group exhibited a significantly higher acute physiologic assessment and chronic health evaluation II score, higher Sequential Organ Failure Assessment score, lower Glasgow Coma Scale score, and higher demand for mechanical ventilation, infusion of vasopressors, and renal replacement therapy than AP patients in non-AKI group (P < 0.01, P < 0.01, P = 0.01, P = 0.001, P < 0.01, P < 0.01, respectively). Significant differences were noted in dose of norepinephrine and adrenaline, duration of mechanical ventilation, maximum and mean values of intra-peritoneal pressure (IPP), maximum and mean values of procalcitonin, maximum and mean serum levels of creatinine, minimum platelet count, and length of hospitalization. Among AP patients with AKI, the survival rate of surgical intensive care unit and in-hospital were only 23% and 21% of the corresponding rates in AP patients without AKI, respectively. The factors that influenced the AP patients’ survival rate included body mass index (BMI), mean values of IPP, minimum platelet count, and hospital day, of which mean values of IPP showed the greatest impact.

CONCLUSION

AP patients with AKI had a lower survival rate and worse relevant clinical outcomes than AP patients without AKI, which necessitates further attention to AP patients with AKI in surgical intensive care unit.

Initial Renal Function (eGFR) Is a Prognostic Marker of Severe Acute Pancreatitis: A Cohort-Analysis of 1,224 Prospectively Collected Cases

Background: Acute pancreatitis (AP) is a life-threatening disease. We aimed to explore the prognostic relevance of renal function based on estimated glomerular filtration rate (eGFR). Methods: A prospective registry of AP patients was established by the Hungarian Pancreatic Study Group. Data of 1,224 consecutive patients were collected between 2012 and 2017. Patients were divided into 3 groups according to their eGFR measured within 24 h of hospitalization: normal renal function: >90 mL/min, mild to moderate renal functional impairment: 30-90 mL/min and severe renal dysfunction: <30 mL/min. Associations of eGFR with outcome (survival, length of hospitalization, AP severity, blood glucose), inflammatory markers (erythrocyte sedimentation rate, white blood cell count), anemia and organ failure (heart, kidney, liver) were analyzed. Results: Death, longer hospitalization and severe AP, but not the cause of AP, were significantly associated with lower eGFR. The inflammatory markers (CRP, WBC count) but not anemia (Hb, Htk) were closely associated with severe renal dysfunction. Renal function was associated with heart and renal failure but not with other complications of AP such as respiratory failure, local pancreatic complications, diabetes or peptic ulcer. eGFR was not associated with liver damage (ALAT, γ-GT) or liver function (serum bilirubin) although biliary complications, alcohol and metabolic syndrome were the most common etiologies of AP. Conclusions: Our study suggests a useful prognostic value of initial eGFR in AP patients. Even mild eGFR reduction predicted mortality, severity of AP and the length of hospitalization. Thus, precise evaluation of renal function should be considered for assessing AP severity and outcome.

Inhibition of the p38 MAPK pathway attenuates renal injury in pregnant rats with acute necrotizing pancreatitis

The p38 mitogen-activated protein kinase (MAPK) pathway is an important intracellular signalling pathway that leads to increased expression of pro-inflammatory mediators. Our previous studies have shown that the p38 MAPK pathway was changed in the acute renal injury (ARI) in acute pancreatitis in late pregnancy (APIP), whereas the role of p38 MAPK in APIP-induced ARI has been poorly understood. The present study was undertaken to investigate the participation of the p38 MAPK signalling pathway and the protective effect of SB203580, an inhibitor of p38 MAPK in ARI in APIP. Twenty-four late-gestation SD rats were randomly assigned to four groups: the normal group (N), sham-operated group (SO), acute necrotizing pancreatitis (ANP) group, and p38 MAPK inhibitor (SB203580) treatment group (T). The results showed that serum amylase, lipase, urea, and creatinine levels of p38 inhibitor of T groups were markedly lower than the ANP groups. Additionally, the expression of phosphorylated p38 and myeloperoxidase (MPO), tumour necrosis factor alpha (TNF-α), interleukin (IL)-1β, IL-6, nuclear factor kappa-B (NF-κB), caspase-3, and terminal deoxynucleotidyl TUNEL-positive cells was markedly lower in the T group than in the ANP group. Our results suggest that SB203580 can inhibit renal injury by inhibiting the P38 MAPK signalling pathway and blocking the inflammatory responses in APIP.

Early Prediction of Organ Failures in Patients with Acute Pancreatitis Using Text Mining

It is of great significance to establish an assessment model for organ failures in the early stage of admission in acute pancreatitis (AP). And the clinical notes are underutilized. To predict organ failures for AP patients using early clinical notes in hospital, early text features obtained from the pretrained Chinese Bidirectional Encoder Representations from Transformers model and attention-based LSTM were combined with early structured features (laboratory tests, vital signs, and demographic characteristics) to predict organ failures (respiratory, cardiovascular, and renal) in 12,748 AP inpatients in West China Hospital, Sichuan University, from 2008 to 2018. The text plus structured features fusion model was used to predict organ failures, compared to the baseline model with only structured features. The performance of the model with text features added is superior to the model that only includes structured features.

Pleural Effusion Is Associated with Severe Renal Dysfunction in Patients with Acute Pancreatitis

BACKGROUND Renal dysfunction is a leading cause of death in patients with acute pancreatitis (AP) and often occurs later than respiratory complications. Whether respiratory complications can predict renal impairment remains unclear. The aim of this study was to investigate the association between pleural effusion and renal dysfunction in AP. MATERIAL AND METHODS Medical records were reviewed from individuals who were hospitalized with AP from January 1, 2015 to December 31, 2019. The patients were divided into 2 groups, based on the presence or absence of pleural effusion on admission. Disease severity, renal function parameters, and outcomes were compared between the 2 groups. RESULTS A total of 222 patients were enrolled, 25 of whom had pleural effusion on admission and 197 who did not. Patients with AP who had pleural effusion had more serious illness (higher incidences of pancreatic inflammation, pancreatic fluid collection, and moderate-to-severe AP; worse Bedside Index for Severity in Acute Pancreatitis score; and a higher modified computed tomography severity index [all P<0.05]) plus worse outcomes (higher incidences of ventilation and vasopressor use [both P<0.05]). Moreover, patients with pleural effusion had a higher level of blood urea nitrogen and lower estimated glomerular filtration rate (both P<0.05). After adjustment for potential confounders, pleural effusion was a risk factor for renal failure in patients with AP (odds ratio 6.32, 95% confidence interval 1.08-36.78, P=0.040). CONCLUSIONS Pleural effusion is associated with severe renal dysfunction in AP. Therefore, efforts should be made to improve early recognition and timely treatment of renal failure by closely monitoring renal function in patients with AP and pleural effusion on admission.

Potential role of imaging for assessing acute pancreatitis-induced acute kidney injury

Acute kidney injury (AKI) is a common complication of acute pancreatitis (AP) that is associated with increased mortality. Conventional assessment of AKI is based on changes in serum creatinine concentration and urinary output. However, these examinations have limited accuracy and sensitivity for the diagnosis of early-stage AKI. This review summarizes current evidence on the use of advanced imaging approaches and artificial intelligence (AI) for the early prediction and diagnosis of AKI in patients with AP. CT scores, CT post-processing technology, Doppler ultrasound, and AI technology provide increasingly valuable information for the diagnosis of AP-induced AKI. Magnetic resonance imaging (MRI) also has potential for the evaluation of AP-induced AKI. For the accurate diagnosis of early-stage AP-induced AKI, more studies are needed that use these new techniques and that use AI in combination with advanced imaging technologies.

Inhibition of Ferroptosis Attenuates Acute Kidney Injury in Rats with Severe Acute Pancreatitis

BACKGROUND

Acute kidney injury (AKI) is a frequent complication of severe acute pancreatitis (SAP). Ferroptosis is involved in a range of diseases. However, the role of ferroptosis in SAP-induced AKI has yet to be elucidated.

AIMS

We aimed to investigate whether ferroptosis is induced in the kidney after SAP and whether inhibition of ferroptosis ameliorates AKI in a rat model of SAP.

METHODS

Sodium taurocholate (5%) was retrogradely perfused into the biliopancreatic duct to establish a model of SAP with AKI in rats. The levels of serum amylase, lipase, tumor necrosis factor (TNF)-α, interleukin (IL)-6, creatinine (Cr) and blood urea nitrogen (BUN) in rats were measured. We also determined the biochemical and morphological changes associated with ferroptosis in renal tissue, including iron accumulation, lipid peroxidation assays, and mitochondrial shrinkage. H&E staining was used to assess pancreatic and renal histological changes. Western blot analysis, RT-PCR, and immunofluorescence staining were performed to analyze the expression of ferroptosis-related proteins and genes.

RESULTS

SAP-induced AKI was followed by iron accumulation, increased lipid peroxidation, and upregulation of ferroptosis-related proteins and genes. Twenty-four hours after SAP, TEM confirmed the presence of typical shrunken mitochondria. Furthermore, treatment with liproxstatin-1 lowered the levels of serum amylase, TNF-α, IL-6, Cr and BUN, decreased kidney lipid peroxidation and alleviated pancreatic and renal histopathology injury in SAP rats.

CONCLUSION

Our findings are the first to demonstrate the involvement of ferroptosis in SAP-associated renal damage and present ferroptosis as a therapeutic target for effective treatment of SAP-induced AKI.

Renal doppler changes in patients with acute pancreatitis: A prospective study

BACKGROUND

Renal Doppler to assess renal resistive index (RRI) is an attractive option to prognosticate acute kidney injury (AKI) in acute pancreatitis (AP) as it is feasible within scope of point-of-care ultrasound. However, RRI has been infrequently evaluated in AP.

OBJECTIVE

Prospectively study diagnostic and prognostic performance of RRI in patients with AP.

METHODOLOGY

75 patients with AP were prospectively enrolled and followed till recovery/death. All patients were subjected to renal Doppler and RRI was compared between patients with and without AKI.

RESULTS

Thirty six patients developed AKI and 39 patients did not develop AKI. AKI network stage 1, 2 and 3 AKI was seen in 7(19.4%), 12(33.3%) and 17 (47.2%) patients respectively. Prognostic scoring done at admission by SIRS, modified marshal score, and BISAP scores, as well as duration of hospitalization and mortality rates were significantly higher in patients with AKI. Mean peak systolic velocity and RRI at upper, middle and lower poles of bilateral kidneys were comparable between patients with and without AKI. The RRI was abnormal in 46 (66.6%) patients and it was <0.6 in 35/46 (76%) and >0.7 in 11/46 (24%) patients respectively. RRI <0.6 was observed in 16 (53.3%) and 19 (48.7%) patients with and without AKI respectively (p = 0.80). RRI >0.7 was observed in 4 (53.3%) and 7 (48.7%) patients with and without AKI respectively (p = 0.74).

CONCLUSIONS

AKI is associated with poor prognosis in AP. RRI on renal Doppler at admission seems to have poor diagnostic as well as prognostic performance for AKI in patients with AP.

Impact of the Human Immunodeficiency Viruses Status on Outcomes in Patients Hospitalized With Acute Pancreatitis: A Propensity-Matched Analysis

OBJECTIVES

We aimed to examine the clinical characteristics and outcomes of patients admitted for acute pancreatitis (AP) in the population with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS).

METHODS

The National Inpatient Sample from 2010 to 2014 was used to identify adult patients admitted with AP. Patients were grouped based on the HIV status. Primary outcomes were mortality, length of stay (LOS), disposition and total hospitalization charges. Secondary outcomes included acute kidney injury, septic shock, respiratory failure and pancreatic procedures.

RESULTS

After matching and weighting, a total of 14,152 HIV-positive patients (6904 with AIDS and 7248 with asymptomatic HIV [aHIV]) with AP were identified. Acute pancreatitis with AIDS were associated with a higher rate of acute kidney injury, longer LOS, higher hospitalization charges, and less routine disposition compared with HIV-negative AP. Patients with aHIV had less septic shock, shorter LOS, and less hospitalization charges compared with HIV-negative patients and less respiratory failure, shorter LOS, and less hospitalization charges compared with AIDS patients.

CONCLUSIONS

Patients admitted for AP with AIDS have worse outcomes. On the contrary, aHIV status was not only associated with better outcomes when compared with AIDS, but to HIV-negative status as well.

Machine Learning Models of Acute Kidney Injury Prediction in Acute Pancreatitis Patients

Background. Acute kidney injury (AKI) has long been recognized as a common and important complication of acute pancreatitis (AP). In the study, machine learning (ML) techniques were used to establish predictive models for AKI in AP patients during hospitalization. This is a retrospective review of prospectively collected data of AP patients admitted within one week after the onset of abdominal pain to our department from January 2014 to January 2019. Eighty patients developed AKI after admission (AKI group) and 254 patients did not (non-AKI group) in the hospital. With the provision of additional information such as demographic characteristics or laboratory data, support vector machine (SVM), random forest (RF), classification and regression tree (CART), and extreme gradient boosting (XGBoost) were used to build models of AKI prediction and compared to the predictive performance of the classic model using logistic regression (LR). XGBoost performed best in predicting AKI with an AUC of 91.93% among the machine learning models. The AUC of logistic regression analysis was 87.28%. Present findings suggest that compared to the classical logistic regression model, machine learning models using features that can be easily obtained at admission had a better performance in predicting AKI in the AP patients.

Predictors and outcomes of acute respiratory failure in hospitalised patients with acute pancreatitis

BACKGROUND AND AIM

Acute pancreatitis (AP) is associated with organ failures and systemic complications, most commonly acute respiratory failure (ARF) and acute kidney injury. So far, no studies have analysed the predictors and hospitalisation outcomes, of patients with AP who developed ARF. The aim of this study was to measure the prevalence of ARF in AP and to determine the clinical predictors for ARF and mortality in AP.

METHODS

This is a retrospective cohort study using the Nationwide Inpatient Sample database from the year 2005-2014. The study population consisted of all hospitalisations with a primary or secondary discharge diagnosis of AP, which is further stratified based on the presence of ARF. The outcome measures include in-hospital mortality, hospital length of stay and hospitalisation cost.

RESULTS

In our study, about 5.4% of patients with AP had a codiagnosis of ARF, with a mortality rate of 26.5%. The significant predictors for ARF include sepsis, pleural effusion, pneumonia and cardiogenic shock. Key variables that were associated with a higher risk of mortality include mechanical ventilation, age more than 65 years, sepsis and cancer (excluding pancreatic cancer). The presence of ARF increased hospital stay by 8.3 days and hospitalisation charges by US$103 460.

CONCLUSION

In this study, we demonstrate that ARF is a significant risk factor for increased hospital mortality, greater length of stay and higher hospitalisation charges in patients with AP. This underlines significantly higher resource utilisation in patients with a dual diagnosis of AP-ARF.

Natural history and profile of selective cytokines in patients of acute pancreatitis with acute kidney injury

OBJECTIVES

To study the natural course of patients with acute pancreatitis (AP) with acute kidney injury (AKI) and their cytokine profile.

METHODS

Natural course of patients with AP and AKI was studied in 97 individuals. Levels of TNFα, IL-6, IL-10, IL-8 and IL-1β were measured at presentation and at 72 h in patients who developed AKI.

RESULTS

Amongst the entire cohort, 16.4% patients developed AKI (persistent AKI - 11 patients, transient AKI - 5 patients). Mortality rate was 25% amongst patients with AKI. Levels of IL-6 (p = 0.035) and IL-8 (p = 0.002) were found to be significantly higher in the AKI group. On multivariate analysis, IL-8 levels at baseline were found to be an independent predictor of AKI. AKI group had significant rise of TNF-α (P < 0.001), IL-6 (P < 0.001) and IL- 1β (P < 0.001) on day 3 whereas persistent-AKI group had significant rise of TNF-α (p = 0.031), IL-6 (p = 0.001) and IL-1β on day 3 and significant decline of IL-10 (p = 0.015). Using a cut-off of 105 pg/ml, IL-8 levels at baseline could predict AKI with a sensitivity of 87.5% and specificity of 59.2%, with area under the curve being 0.744 (p = 0.002).

CONCLUSION

AP patients developing AKI have poor prognosis. IL-8 levels can predict AKI in patients with AP.

Potential therapeutic effects of curcumin mediated by JAK/STAT signaling pathway: A review

Curcumin is a naturally occurring nutraceutical compound with a number of therapeutic and biological activities such as antioxidant, anti-inflammatory, anti-diabetic, antitumor, and cardioprotective. This plant-derived chemical has demonstrated great potential in targeting various signaling pathways to exert its protective effects. Signal transducers and activator of transcription (STAT) is one of the molecular pathways involved in a variety of biological processes such as cell proliferation and cell apoptosis. Accumulating data demonstrates that the STAT pathway is an important target in treatment of a number of disorders, particularly cancer. Curcumin is capable of affecting STAT signaling pathway in induction of its therapeutic impacts. Curcumin is able to enhance the level of anti-inflammatory cytokines and improve inflammatory disorders such as colitis by targeting STAT signaling pathway. Furthermore, studies show that inhibition of JAK/STAT pathway by curcumin is involved in reduced migration and invasion of cancer cells. Curcumin normalizes the expression of JAK/STAT signaling pathway to exert anti-diabetic, renoprotective, and neuroprotective impacts. At the present review, we provide a comprehensive discussion about the effect of curcumin on JAK/STAT signaling pathway to direct further studies in this field.

Chaiqin chengqi decoction alleviates severe acute pancreatitis associated acute kidney injury by inhibiting endoplasmic reticulum stress and subsequent apoptosis

BACKGROUND

Acute kidney injury (AKI), characterized by an increase of serum creatinine and urea, is a severe complication of severe acute pancreatitis (SAP) with high mortality. Endoplasmic reticulum (ER) stress has been considered as a key pathologic process in AKI. Chaiqin chengqi decoction (CQCQD) is an effective Chinese medicine formula for SAP treatment in China and has been used for many years. Our goal is to explore the role of CQCQD on ER stress of AKI in experimental SAP.

MATERIALS & METHODS

SAP was induced in rats by retrograde duct injection of 5% sodium taurocholate (NaTC, 1 ml/kg), sham operation (SO) rats simultaneously received saline infusion. Intraperitoneal injection of 4-PBA (50 mg/kg, once a day for three days before the surgery) or intragastric gavage of CQCQD (1 g/kg, 2 hourly × 3 after disease induction) was used to treat SAP rats. All animals were humanely sacrificed 12 h after disease induction. Histopathology scores of kidney and pancreas; serum biochemical indices and kidney protein levels of ER stress and apoptosis markers were assessed. Tubular epithelial cell line (HK-2) was treated either with TNF-α (10 ng/ml) or IL-6 (10 ng/ml) for 12 h plus either 4-PBA (0.1 M) or CQCQD (1 mg/ml) for in vitro study. Cell viability and markers of ER stress and apoptosis were measured.

RESULTS

Ductal perfusion of NaTC caused significant increases in serum lipase, amylase and pancreatic histopathology (inflammatory cell infiltration, interstitial edema, and acinar cell necrosis). Kidney histopathology (tubular dilation, brush border loss, little tubular necrosis, and cast formation), serum creatine and urea levels were raised when compared with the SO group. Moreover, apoptotic cell death markers (caspase-9, cleaved-caspase-3, and TUNEL) and kidney ER stress proteins (BIP, IRE1-α, XBP1s, and CHOP) were elevated after NaTC administration. 4-PBA and CQCQD significantly alleviated histopathological changes of kidney and pancreas, inflammatory cytokines, biochemical markers of AKI, ER stress proteins and apoptotic cell death markers. They also protected HK-2 cells from injury of TNF-α and IL-6, and alleviated both ER stress and apoptosis proteins in vitro.

CONCLUSION

CQCQD may alleviate SAP-related AKI by inhibiting ER stress-related apoptosis.

MiR-214-3p exacerbates kidney damages and inflammation induced by hyperlipidemic pancreatitis complicated with acute renal injury

AIMS

Acute pancreatitis (AP) is usually complicated with multiple organ insufficiency, including renal injury. Hyperlipidemia is regarded as a risk factor to induce AP. High-fat diet-induced hyperlipidemic pancreatitis (HP) increased nowadays and showed more severe symptoms and complications than other AP. However, detailed mechanisms or mediators involved in HP complicated with acute renal injury were less studied. Here, we aimed to study how miR-214 expresses in the HP and whether miR-214 has functions to regulate pathological kidney damages induced by HP.

MAIN METHODS

Sprague-Dawley rats were adopted to establish HP model complicated with acute renal injury through long-term high-fat diet and sodium taurocholic injection. Models were injected with LV-rno-miR-214-3p or LV-anti-rno-miR-214-3p to exogenously regulate miR-214-3p to study its impacts on HP via a series of molecular and histological experiments.

KEY FINDINGS

MiR-214-3p was found to be up-regulated in the kidney, pancreas and serum of HP rats and also could intensify the pathological alterations, kidney and pancreas damages and fibrosis induced by HP. Inflammatory response in HP was enhanced when miR-214-3p was overexpressed. Besides, miR-214-3p up-regulation was showed to inhibit PTEN expression but increased P-Akt levels in the HP kidney, which might be a possible mechanism to induce severe symptoms of pancreatitis. Knockdown of miR-214-3p showed opposite effects.

SIGNIFICANCE

MiR-214-3p is indicated to exacerbate the tissue damages and inflammatory response caused by HP complicated with acute renal injury, which may provide a novel therapeutic perspective targeting miR-214-3p to treat HP with acute renal injury.

AKI Associated with Acute Pancreatitis

Acute pancreatitis is a common disorder of the pancreas. It is the most frequent gastrointestinal cause for hospitalization and one of the leading causes of in-hospital deaths. Its severity ranges from mild self-limited disease to severe acute necrotizing pancreatitis characterized by systemic complications and multiorgan failure. Severe acute pancreatitis develops in about 20% of patients with acute pancreatitis and may be associated with multiorgan failure (respiratory, cardiovascular, and kidney). AKI is a frequent complication of severe acute pancreatitis and develops late in the course of the disease, usually after the failure of other organs. It carries a very poor prognosis, particularly if kidney replacement therapy is required, with mortality rates exceeding 75%. The exact pathophysiology of AKI in acute pancreatitis remains unclear but appears to result from initial volume depletion followed by complex vascular and humoral factors. Here, we provide an overview of the epidemiology, pathogenesis, causes, and management of AKI in patients with severe acute pancreatitis.

Baseline Serum Cystatin C Is a Potential Predictor for Acute Kidney Injury in Patients with Acute Pancreatitis

Aims

The study is aimed at studying the incidence of acute kidney injury (AKI) and exploring the potential predictor for AKI in patients with acute pancreatitis.

Methods

A retrospective study adopting a stratified cohort sampling design was performed in a cohort of patients (n = 237) diagnosed with acute pancreatitis without any renal injury. The following information including age, gender, serum creatinine, serum urea nitrogen, serum uric acid, serum cystatin C, fasting serum glucose, serum amylase, serum lipase, serum choline esterase, total protein, albumin, globulin, total bilirubin, direct bilirubin, total bile acids, glutamic-pyruvic transaminase, glutamic-oxaloacetic transaminase, gamma glutamyl transpeptidase, and alkaline phosphatase were collected from each patient when they were diagnosed with acute pancreatitis. Student t-test was conducted to figure out the difference between patients with and without AKI. Univariate and multivariate logistic regression analyses were used for investigating the predictors for AKI in patients with acute pancreatitis.

Results

18 (7.6%) patients in total had developed AKI among the study group. Compared with patients without AKI (1.01 ± 0.26 mg/L), the level of baseline serum cystatin C (CYS-C) was significantly higher in patients with AKI (3.64 ± 2.17 mg/L, P < 0.001). Baseline serum CYS-C (OR = 203.594, P < 0.001) was the independent and significant predictor for AKI in patients with acute pancreatitis. AKI in patients with acute pancreatitis could be identified with a sensitivity of 88.9% at specificity of 100% (AUC = 0.948, 95% CI 0.879–1.000) by baseline serum CYS-C (cut-off value = 1.865 mg/L).

Conclusions

Baseline serum CYS-C shall be adopted to predict the potential risk of AKI in patients with acute pancreatitis.

Effect of Da-Cheng-Qi decoction for treatment of acute kidney injury in rats with severe acute pancreatitis

Background

The traditional Chinese formula Da-Cheng-Qi-decoction (DCQD) has been used to treat acute pancreatitis for decades. DCQD could ameliorate the disease severity and the complications of organ injuries, including those of the liver and lungs. However, the pharmacological effects in the kidney, a target organ, are still unclear. This study aimed to investigate the herbal tissue pharmacology of DCQD for acute kidney injury (AKI) in rats with severe acute pancreatitis (SAP).

Methods

Rats were randomly divided into the sham-operation group (SG), the model group (MG) and the low-, medium- and high-dose treatment groups (LDG, MDG, and HDG, respectively). Sodium taurocholate (3.5%) was retrogradely perfused into the biliopancreatic duct to establish the model of SAP in rats. Different doses of DCQD were administered to the treatment groups 2 h after the induction of SAP. The major components of DCQD in kidney tissues were detected by HPLC–MS/MS. Inflammatory mediators in the kidney tissues, as well as serum creatinine (Scr), blood urea nitrogen (BUN) and pathologic scores, were also evaluated.

Results

Ten components of DCQD were detected in the kidneys of the treatment groups, and their concentrations increased dose-dependently. Compared with the SG, the levels of inflammatory mediators, Scr, BUN and pathological scores in the MG were obviously increased (p < 0.05). The high dose of DCQD showed a maximal effect in downregulating the pro-inflammatory mediators interleukin-6 (IL)-6 and tumour necrosis factor-α (TNF-α), upregulating anti-inflammatory mediators IL-4 and IL-10 in the kidney and alleviating the pathological damages. DCQD decreased the pancreas and kidney pathological scores of rats with SAP, especially in the HDG (p < 0.05). Compared with the MG, the level of Scr in the HDG was significantly decreased (p < 0.05).

Conclusions

DCQD ameliorated AKI in rats with SAP via regulating the inflammatory response, which might be closely related to the distribution of its components in the kidney.

Electronic supplementary material

The online version of this article (10.1186/s13020-018-0195-8) contains supplementary material, which is available to authorized users.

The Value of Modified Renal Rim Grade in Predicting Acute Kidney Injury Following Severe Acute Pancreatitis

OBJECTIVE

To retrospectively determine the value of modified renal rim grade (MRRG) in predicting acute kidney injury (AKI) in the early phase of severe acute pancreatitis (SAP).

METHODS

This institutional review board-approved retrospective study included patients with SAP who underwent abdominal contrast-enhanced computed tomography (CT) within 48 hours after disease onset. Modified renal rim grade, renal rim grade, CT severity index, modified CT severity index, extrapancreatic inflammation on CT scores, and posterior pararenal (PPR) space involvement were assessed. Clinical data, including bedside index of severity in acute pancreatitis and New Japanese Severity Scoring system scores, were collected. Primary end points were AKI and mortality. Scores were evaluated by receiver operating characteristic curve analysis. Correlational analyses between MRRG scores and the other scores were performed with Spearman analysis.

RESULT

One hundred five consecutive patients were enrolled in our study. The areas under the curve (AUCs) of MRRG in predicting AKI (0.90) and mortality (0.83) were comparable to extrapancreatic inflammation on CT (0.89 and 0.85, P > 0.05) and were higher than those of the other CT scores (P < 0.05). Modified renal rim grade score of greater than 4 yielded sensitivities and specificities of 81% and 89% for predicting AKI and 88% and 66% for mortality. Modified renal rim grade correlated moderately with bedside index of severity in acute pancreatitis (Spearman r = 0.47) and New Japanese Severity Scoring system (r = 0.43) scores. Besides, the prevalence of PPR space involvement in nonrecovery AKI patients was higher than that in recovery patients (94% vs 36%, P < 0.05).

CONCLUSIONS

Modified renal rim grade is well correlated with the occurrence of AKI and mortality in SAP. The PPR space involvement is a promising prognostic factor for nonrecovery of AKI in SAP patients.

Clinical outcomes of isolated renal failure compared to other forms of organ failure in patients with severe acute pancreatitis

AIM

To assess differences in clinical outcomes of isolated renal failure (RF) compared to other forms of organ failure (OF) in patients with severe acute pancreatitis (SAP).

METHODS

Using a prospectively maintained database of patients with acute pancreatitis admitted to a tertiary medical center between 2003 and 2016, those with evidence of persistent OF were classified to renal, respiratory, cardiovascular, or multi-organ (2 or more organs). Data regarding demographics, comorbidities, etiology of acute pancreatitis, and clinical outcomes were prospectively recorded. Differences in clinical outcomes after development of isolated RF in comparison to other forms of OF were determined using independent t and Mann-Whitney U tests for continues variables, and χ² test for discrete variables.

RESULTS

Among 500 patients with acute pancreatitis, 111 patients developed persistent OF: mean age was 54 years, and 75 (67.6%) were male. Forty-three patients had isolated OF: 17 (15.3%) renal, 25 (21.6%) respiratory, and 1 (0.9%) patient with cardiovascular failure. No differences in demographics, etiology of acute pancreatitis, systemic inflammatory response syndrome scores, or development of pancreatic necrosis were seen between patients with isolated RF vs isolated respiratory failure. Patients with isolated RF were less likely to require nutritional support (76.5% vs 96%, P = 0.001), ICU admission (58.8% vs 100%, P = 0.001), and had shorter mean ICU stay (2.4 d vs 15.7 d, P < 0.001), compared to isolated respiratory failure. None of the patients with isolated RF or isolated respiratory failure died.

CONCLUSION

Among patients with SAP per the Revised Atlanta Classification, approximately 15% develop isolated RF. This subgroup seems to have a less protracted clinical course compared to other forms of OF. Isolated RF might be weighed less than isolated respiratory failure in risk predictive modeling of acute pancreatitis.

The emerging role of endoscopic ultrasound for pancreaticobiliary diseases in the pediatric population

BACKGROUND

Endoscopic ultrasound (EUS) is a useful diagnostic and therapeutic tool in the pediatric population. Given the high accuracy and sensitivity of EUS, it is particularly effective in evaluating pancreaticobiliary disease. Published literature in the use of pediatric EUS is limited. Therefore we aimed to review the current literature for EUS indications, safety, and effectiveness for the pediatric population.

DATA SOURCES

English language articles on the use of pediatric endoscopic ultrasound in evaluating pancreaticobiliary diseases were retrieved from PubMed/ MEDLINE.

RESULTS

We analyzed various retrospective studies and case series publications. Data were extrapolated for pediatric patients with pancreaticobiliary diseases.

CONCLUSIONS

EUS offers superior imaging. It is comparible to magnetic resonance imaging and/or pancreatic-protocol computed tomography. In the current literature, there are a variety of pancreaticobiliary conditions where EUS was utilized to make a diagnosis. These include recurrent pancreatitis, congenital anomalies, microlithiasis, pancreatic pseudocysts, and pancreatic mass lesions. EUS was shown to be a safe and cost-effective modality with both diagnostic and therapeutic capabilities in the pediatric population. EUS is now increasingly being recognized as a standard of care when evaluating pancreaticobiliary conditions in children.

Curcumin protects against acute renal injury by suppressing JAK2/STAT3 pathway in severe acute pancreatitis in rats

The aim of the present study was to investigate the effect of curcumin on acute renal injury in a rat model of severe acute pancreatitis (SAP). A SAP model with acute kidney injury was established in rats by retrograde injection of 5% sodium taurocholate into the pancreatic duct. The serum amylase, creatinine (Cr) and blood urea nitrogen (BUN) levels in rats were measured. Hematoxylin and eosin staining was used to assess pancreatic and renal histological changes. Serum tumor necrosis factor (TNF)-α and interleukin (IL)-6 levels were measured using ELISA kits. Renal protein levels of Janus kinase (JAK) 2/signal transducer and activator of transcription (STAT) 3 pathway components were determined by western blot assay. The results showed that curcumin significantly decreased serum amylase, Cr and BUN levels, and alleviated pancreatic and renal histological changes in SAP rats. Furthermore, curcumin markedly decreased serum TNF-α and IL-6 levels and downregulated renal protein levels of JAK2/STAT3 pathway components. These results proved that curcumin ameliorates acute renal injury in a rat model of SAP. The molecular mechanism of its effect may be associated with the suppression of the JAK2/STAT3 pathway to reduce TNF-α and IL-6 levels in SAP-induced acute renal injury. Therefore, the findings of the present study revealed the potential use of curcumin for the prevention and treatment of SAP and the associated renal injury.

EFFECTS OF SALVIA MILTIORRHIZAE ON THE KIDNEY OF RATS WITH SEVERE ACUTE PANCREATITIS AND OBSTRUTIVE JAUNDICE

Background:

Severe acute pancreatitis (SAP) and obstructive jaundice (OJ) are frequent recurring diseases that bring about huge threat to human health. Some reports have demonstrated that Salviae miltiorrhizae can protect multiple organs of SAP and OJ model animals or patients, but their related mechanisms were not clear. In this study, we observed the effects of Salvia miltiorrhizae injection on apoptosis and NF-κB expression in kidney and explored the protective effect and mechanism of Salvia miltiorrhizae on the kidney of SAP or OJ rats. The results obtained will provide a theoretical basis for clinical application of Salvia miltiorrhizae.

Material and Methods:

A total of 288 rats were used for SAP -and OJ-associated experiments. The mortality rates of rats, the contents of serum BUN and CREA, the expression levels of Bax, NF-κB proteins and the apoptosis index were observed, respectively.

Results:

The pathological changes in the kidney of SAP or OJ rats in treated group were mitigated to varying degrees. At 6 and 12 hours after operation in SAP rats or on 21 and 28 days after operation in OJ rats, the contents of serum CREA in treated group were significantly lower than those in model control group; At 3 and 6 hours after operation, the staining intensity of Bax protein of kidney in treated group was significantly lower than that in model control group; on 14 days after operation, the apoptosis index in the kidney of OJ rats in treated group was significantly lower than that in model control group.

Conclusion:

Salvia miltiorrhizae can exert protective effects on the kidney of SAP and OJ rats.

Effect of tiron on remote organ injury in rats with severe acute pancreatitis induced by L-arginine

Acute pancreatitis (AP) is an acute inflammatory disorder of the pancreas that can be complicated by involvement of other remote organs. Oxidative stress is known to have a crucial role in the development of pancreatic acinar damage and one of the main causes in multisystem organ failure in experimental AP. The aim of the study was to determine the effect of tiron on pancreas and remote organ damage in L-arginine (L-Arg) induced AP rat model. Thirty-two male rats were divided in random into four groups: control, tiron, L-Arg, and tiron with L-Arg. At the end of the experiment, blood samples were withdrawn for biochemical analysis. The pancreas, lung, kidney, and liver were collected for histopathological examination. Estimation of pancreatic water content was done. Analysis of pulmonary, hepatic, renal, and pancreatic lipid peroxide levels (MDA), superoxide dismutase (SOD), and reduced glutathione (GSH) were carried out. Finally, nuclear factor kappa B (NF-κB) and transforming growth factor β1 (TGF-β1) expression in pancreatic tissue was determined. Results indicated that treatment with tiron significantly decreased lipid peroxide levels and markedly increased both SOD activity and GSH level. Moreover, histopathological analysis further confirmed that administration of tiron relatively ameliorates pancreatic acinar cells and remote organ damage. Increased immunoreactivity of NF-κB and TGF-β1 were reduced also by tiron treatment. These findings pointed out the protective role of the mitochondrial antioxidant, tiron against AP induced by L-Arg.

Effect of acute kidney injury on mortality and hospital stay in patient with severe acute pancreatitis

AIM

Severe acute pancreatitis (SAP) is believed to be a major risk factor leading to acute kidney injury (AKI) among critically ill patients, but little is known about SAP-induced AKI. We study the incidence of AKI defined by the Acute Kidney Injury Network (AKIN) criteria and the risk factors associated with outcomes among SAP-induced AKI patients.

METHOD

We conducted a multicenter retrospective study of critically ill SAP-induced AKI patients during the period August 2009 to June 2013. Data on enrolled patients were retrieved from electronic records. Univariate and multiple regression analyses were performed.

RESULTS

Among a total of 414 SAP patients admitted to intensive care units(ICU), 287 (69.3%) developed AKI during their ICU stay, with 16.7%, 18.4%, and 34.3% classified as AKI stage I,II, and III, respectively. SAP-induced AKI patients experienced a significantly higher ICU mortality than those without AKI. The risk factors associated with ICU mortality among SAP-induced AKI patients included ACS (odds ratio (OR) 10.58), RRT (OR 3.31), sepsis (OR 2.46), CTSI (OR 3.01), APACHE II score (OR 1.82), AKI III (OR 1.38), ICU-length-of-stay (OR 1.04), and multi-organ failure.

CONCLUSIONS

The paper represents the first attempt to investigate the etiology and epidemiology of AKI following SAP under the AKIN criteria among critically ill patients. Several independent risk factors were found to be associated with ICU mortality for AKI patients. The findings may pinpoint crucial therapeutic measures for preventing AKI among a vulnerable population and for more effective management of SAP-induced AKI to improve the quality of intensive care.

The Role of Eugenol in the Prevention of Acute Pancreatitis-Induced Acute Kidney Injury: Experimental Study

Aim. Acute pancreatitis is an inflammatory intra-abdominal disease, which takes a severe form in 15–20% of patients and can result in high mortality especially when complicated by acute renal failure. The aim of this study is to assess the possible reduction in the extent of acute kidney injury after administration of eugenol in an experimental model of acute pancreatitis. Materials and Methods. 106 male Wistar rats weighing 220–350 g were divided into 3 groups: (1) Sham, with sham surgery; (2) Control, with induction of acute pancreatitis, through ligation of the biliopancreatic duct; and (3) Eugenol, with induction of acute pancreatitis and eugenol administration at a dose of 15 mg/kg. Serum urea and creatinine, histopathological changes, TNF-α, IL-6, and MPO activity in the kidneys were evaluated at predetermined time intervals. Results. The group that was administered eugenol showed milder histopathological changes than the Control group, TNF-α activity was milder in the Eugenol group, and there was no difference in activity for MPO and IL-6. Serum urea and creatinine levels were lower in the Eugenol group than in the Control group. Conclusions. Eugenol administration was protective for the kidneys in an experimental model of acute pancreatitis in rats.

Matrix Metalloproteinase 9 and Vasodilator-Stimulated Phosphoprotein Related to Acute Kidney Injury in Severe Acute Pancreatitis Rats

BACKGROUND

Severe acute pancreatitis (SAP) usually results in acute renal failure. Matrix metalloproteinase 9 (MMP-9) and vasodilator-stimulated phosphoprotein (VASP) may participate in disease progression.

AIM

To investigate the renal expression of MMP-9 and VASP in SAP rats with acute kidney injury.

METHODS

A total of 100 rats were randomly assigned to sham 6-h, sham 12-h, sham 24-h, sham 36-h, sham 48-h, SAP 6-h, SAP 12-h, SAP 24-h, SAP 36-h, and SAP 48-h treatment groups (n = 10 per group). Levels of serum amylase (AMY), creatinine (Cr), and blood urea nitrogen (BUN) were determined. Renal pathology and ultrastructural examinations were performed, and renal mRNA and protein expression of MMP-9 and VASP were determined by real-time RT-PCR and Western blot, respectively. The activity of MMP-9 was assessed by gelatin zymography.

RESULTS

In the SAP groups, serum levels of AMY, Cr, and BUN were markedly higher than in the sham groups. The peak value of AMY was observed from 12 to 24 h, but that of Cr and BUN was observed at 36 h. Capillary endothelial cells in the renal interstitium were impaired and expression of MMP-9 and VASP in the kidney was significantly increased when compared with the sham groups. Expression of MMP-9 and VASP declined when renal damage reached a maximum after 24 h.

CONCLUSIONS

In the presence of acute kidney injury in SAP, the renal expression of MMP-9 and VASP is related to damage of endothelial cells in capillaries, which reached a maximum at 24 h and declined afterwards.

Influence of comorbidity on outcomes of older patients with acute pancreatitis based on a national administrative database

BACKGROUND

Little information is available on the influence of comorbidities on outcomes of older patients with acute pancreatitis. This study aimed to investigate the influence of comorbidities on outcomes of older patients with acute pancreatitis using data from a national Japanese administrative database.

METHODS

A total of 14 322 older patients (≥70 years) with acute pancreatitis were referred to 1090 hospitals between 2010 and 2012 in Japan. We collected patients' data from the administrative database to compare the in-hospital mortality and length of stay of older patients with acute pancreatitis. The patients were categorized into four groups according to comorbidity level using the Charlson Comorbidity Index (CCI): none (CCI score=0; n=6890); mild (1; n=3874); moderate (2; n=2192) and severe (≥3; n=1366).

RESULTS

Multiple logistic and linear regression analyses revealed that severe comorbidity was significantly associated with higher in-hospital mortality and longer length of stay [odds ratio (OR)=2.26; 95% confidence interval (CI): 1.75-2.92, P<0.001 and coefficient 4.37 days; 95% CI: 2.89-5.85, P<0.001, respectively]. In addition, cardiovascular and renal diseases were the most significant comorbidities affecting outcomes of the older patients. ORs of cardiovascular and renal diseases for mortality were 1.44 (95% CI: 1.13-1.85, P=0.003) and 2.69 (95% CI: 1.88-3.85, P<0.001), respectively, and coefficients for length of stay were 3.01 days (95% CI: 1.34-4.67, P<0.001) and 3.72 days (95% CI: 1.01-6.42, P=0.007), respectively.

CONCLUSION

This study demonstrated that comorbidities significantly influenced outcomes of older patients with acute pancreatitis and cardiovascular and renal comorbidities were significant factors affecting outcomes.

Correlation analysis of computed tomography imaging score with the presence of acute kidney injury in severe acute pancreatitis

OBJECTIVES

The aim of the study is to investigate the CT imaging findings of severe acute pancreatitis (SAP) complicated with acute kidney injury (AKI) and evaluate the correlation between the CT imaging score and the presence of AKI in SAP.

MATERIALS AND METHODS

Contrast-enhanced CT scanning was performed for all 145 patients. Related CT indices such as Balthazar CT grading, CTSI and EPIC scores were calculated. Clinical data, including APACHE II, Ranson scores, serum creatinine levels, urine output, and mortality, were then collected and compared with CT indices.

RESULTS

The EPIC score showed a larger area under the receiver operating characteristic curve than either of the CTSI or Balthazar score. However, the change of APACHE II score, but not EPIC score, was significantly associated with the prognosis of AKI and eventual clinical outcome. In addition, the CT manifestation of fluid encapsulation was a good predictor of recovery from AKI.

CONCLUSIONS

Among the CT indices, the EPIC score, which possessed a good correlation with both APACHE II and Ranson scores, provided a better prediction of AKI in SAP patients than CTSI and Balthazar scores. Encapsulation of inflammatory exudates might be used in the future as imaging-based prognostic criteria of recovering from AKI in patients with SAP.

Clodronate-superparamagnetic iron oxide-containing liposomes attenuate renal injury in rats with severe acute pancreatitis

BACKGROUND AND OBJECTIVE

It has been shown that macrophages play an important role in the development of severe acute pancreatitis (SAP), and eventually lead to multiple organ failure (MOF). Clodronate-liposome selectively depleted macrophages. This study was to investigate the role of renal macrophage infiltration in acute renal injury in rats with SAP and to evaluate the potential of superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance imaging (MRI) for diagnosis.

METHODS

Superparamagnetic Fe3O4 nanoparticles were prepared by chemical coprecipitation. SPIO-liposomes and SPIO-clodronate-liposomes were prepared by the thin film method. SAP models were prepared by injection of sodium taurocholate into the subcapsular space of rat pancreas. Sprague-Dawley rats were randomly divided into a control group, SAP plus SPIO-liposome (P) group, and SAP plus SPIO-clodronate-containing liposome (T) group. Kidney injury was evaluated by T2-weighted MRI scan. The levels of serum amylase (SAM), blood urea nitrogen (BUN), and serum creatinine (SCr) were measured by an automated enzymatic method. Serum tumor necrosis factor-α (TNF-α) was measured by enzyme-linked immunosorbent assay (ELISA). Pathological changes in the pancreas and kidney were observed using hematoxylin and eosin (H&E) staining, while cell apoptosis was detected with terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining. In addition, the macrophage markers (CD68) of the renal tissue were detected with immunohistochemistry.

RESULTS

The pathological changes in the pancreas and kidneys of rats in the T group were milder than those in the P group. The MRI signal intensity of the kidneys in the P and T groups was significantly lower than that in the control group. There were significant changes in the two experimental groups (P<0.01). The levels of SAM, Bun, SCr, and TNF-α in rats in the P group were higher than those in the control group (P<0.01) and in the T group (P<0.01). The apoptosis of the kidney in the T group was higher than that in the P group at 2 and 6 h (P<0.01).

CONCLUSIONS

Clodronate-containing liposomes protected against renal injury in SAP rats, and SPIO can be used as a tracer for MRI examination to detect renal injury in SAP rats. SPIO-aided MRI provided an efficient non-invasive way to monitor the migration of macrophages after renal injury in rats with SAP.

Hypertriglyceridemia is a risk factor for acute kidney injury in the early phase of acute pancreatitis

OBJECTIVE

The aim of this study was to investigate the risk factors for acute kidney injury (AKI) in patients with acute pancreatitis (AP).

METHODS

Patients with AP were retrospectively divided into AKI group and non-AKI group. To investigate the risk factors for AKI, logistic regression analysis was performed with demography, etiologies, and comorbidities. Mortalities of patients with different body mass indexes were compared.

RESULTS

There were 43 patients with AKI and 202 patients without AKI. The risk factor for AKI in AP was hypertriglyceridemia (odds ratio, 2.964; 95% confidence interval, 1.485-5.915; P = 0.007). Forty-two patients developed AKI within the first 48 hours. The mortalities of normal weight, overweight, and obese groups in patients with AKI were 16.7%, 17.4%, and 62.5%, respectively. All the 4 patients who died in the non-AKI group were of normal weight.

CONCLUSIONS

Hypertriglyceridemia is an independent risk factor for AKI in the early phase of AP. Obesity does not increase mortality of patients without AKI. We hypothesize that the role of pancreatic enzymes on triglyceride accumulated in renal may be an explanation for AKI in the early phase of AP.

Inhibition of glycogen synthase kinase-3β attenuates acute kidney injury in sodium taurocholate‑induced severe acute pancreatitis in rats

The aim of the present study was to investigate the efficacy of 4‑benzyl‑2‑methyl‑1,2,4‑thiadiazolidine‑3,5‑dione (TDZD‑8), the selective inhibitor of glycogen synthase kinase‑3β (GSK‑3β), on the development of acute kidney injury in an experimental model of sodium taurocholate‑induced severe acute pancreatitis (SAP) in rats. The serum amylase, lipase, interleukin‑1β and interleukin‑6 levels, and the pancreatic pathological score were examined to determine the magnitude of pancreatitis injury. The serum creatinine and blood urea nitrogen levels, myeloperoxidase (MPO) activity and renal histological grading were measured to assess the magnitude of SAP‑induced acute kidney injury. The activation of nuclear factor‑κB (NF‑κB) was examined using an immunohistochemistry assay. The expression of GSK‑3β, phospho‑GSK‑3β (Ser9), tumour necrosis factor‑α (TNF‑α), intercellular adhesion molecule‑1 (ICAM‑1) and inducible nitric oxide synthase (iNOS) protein in the kidney was characterised using western blot analysis. TDZD‑8 attenuated (i) serum amylase, lipase and renal dysfunction; (ii) the serum concentrations of proinflammatory cytokines; (iii) pancreatic and renal pathological injury; (iv) renal MPO activity and (v) NF‑κB activation and TNF‑α, ICAM‑1 and iNOS protein expression in the kidney. The results obtained in the present study suggest that the inhibition of GSK‑3β attenuates renal disorders associated with SAP through the inhibition of NF‑κB activation and the downregulation of the expression of proinflammatory cytokines, TNF‑α, ICAM‑1 and iNOS in rats. Blocking GSK‑3β protein kinase activity may be a novel approach to the treatment of this inflammatory condition.

Procalcitonin levels predict acute kidney injury and prognosis in acute pancreatitis: a prospective study

Background

Acute kidney injury (AKI) has been proposed as a leading cause of mortality for acute pancreatitis (AP) patients admitted to the intensive care unit (ICU). This study investigated the predictive value of procalcitonin (PCT) for AKI development and relevant prognosis in patients with AP, and compared PCT’s predictive power with that of other inflammation-related variables.

Methods

Between January 2011 and March 2013, we enrolled 305 cases with acute pancreatitis admitted to ICU. Serum levels of PCT, serum amyloid A (SAA), interleukin-6 (IL-6), and C reactive protein (CRP) were determined on admission. Serum PCT was tested in patients who developed AKI on the day of AKI occurrence and on either day 28 after occurrence (for survivors) or on the day of death (for those who died within 28 days).

Results

Serum PCT levels were 100-fold higher in the AKI group than in the non-AKI group on the day of ICU admission (p<0.05). The area under the receiver-operating characteristic (ROC) curve of PCT for predicting AKI was 0.986, which was superior to SAA, CRP, and IL-6 (p<0.05). ROC analysis revealed all variables tested had lower predictive performance for AKI prognosis. The average serum PCT level on day 28 (2.67 (0.89, 7.99) ng/ml) was significantly (p<0.0001) lower than on the day of AKI occurrence (43.71 (19.24,65.69) ng/ml) in survivors, but the serum PCT level on death (63.73 (34.22,94.30) ng/ml) was higher than on the day of AKI occurrence (37.55 (18.70,74.12) ng/ml) in non-survivors, although there was no significant difference between the two days in the latter group (p = 0.1365).

Conclusion

Serum PCT is superior to CRP, IL-6, and SAA for predicting the development of AKI in patients with AP, and also can be used for dynamic evaluation of AKI prognosis.

Acute kidney injury following acute pancreatitis: A review

BACKROUND. Acute kidney injury (AKI) is a common serious complication of severe acute pancreatitis (SAP) and an important marker of morbidity and mortality in critically ill septic patients. AKI due to severe acute pancreatitis can be the result of hypoxemia, release of pancreatic amylase from the injured pancreas with impairment of renal microcirculation, decrease in renal perfusion pressure due to abdominal compartment syndrome, intraabdominal hypertension or hypovolemia. Endotoxins and reactive oxygen species (ROS) also play an important role in the pathophysiology of SAP and AKI. Knowledge of the pathophysiology and diagnosis of AKI following SAP might improve the therapeutic outcome of critically ill patients.

METHODS AND RESULTS

An overview of the pathophysiology, diagnosis and potential treatment options based on a literature search of clinical human and experimental studies from 1987 to 2013.

CONCLUSIONS

Early recognition of AKI and SAP in order to prevent severe complication like septic shock, intraabdominal hypertension or abdominal compartment syndrome leading to multiple organ dysfunction syndrome is a crucial tool of therapeutic measures in intensive care.

Association of endotoxin and endothelin-1 with acute kidney injury in patients with acute pancreatitis

AIM: To investigate the association of endotoxin and endothelin-1 with acute kidney injury in patients with acute pancreatitis (AP).

METHODS: Fifty-two AP patients with acute kidney injury and equal number of AP patients without acute kidney injury were enrolled in this study. Blood samples were obtained from all patients for laboratory analysis of liver function, renal function, electrolytes, procalcitonin (PCT) and endothelin-1 (ET-1).

RESULTS: The SIRS score showed no significant difference between cases and controls (2.66 ± 0.86 vs 2.30 ± 1.00, t = 1.90, P > 0.05), indicating that both groups suffered from systemic inflammatory response. The levels of PCT (23.24 ng/mL vs 0.23 ng/mL, Z = -7.31, P < 0.05) , ET-1 (7.61 pg/mL ± 2.17 pg/mL vs 2.34 pg/mL ± 1.28 pg/mL, t = 4.98, P < 0.05), urea (Z = -2.17), creatinine (Z = -7.69) and cystatin C (Z = -8.39) were significantly higher in cases than in controls. The mortality and improvement rates also differed significantly between cases and controls (36.5% vs 5.8%; 21.2% vs 94.2%, χ² = 141.92, P < 0.05).

CONCLUSION: Endotoxin and ET-1 are closely associated with the development of acute kidney injury possibly by inducing severe renal vasoconstriction.

Biopsy-proven drug-induced tubulointerstitial nephritis in a patient with acute kidney injury and alcoholic severe acute pancreatitis

We report a 49-year-old man with alcoholic severe acute pancreatitis (SAP) complicated by drug-induced acute tubulointerstitial nephritis (DI-AIN). Oliguria persisted and became anuric again on day 17 despite improvement of pancreatitis. He presented rash, fever and eosinophilia from day 20. Renal biopsy was performed for dialysis-dependent acute kidney injury (AKI), DI-AIN was revealed, and prompt use of corticosteroids fully restored his renal function. This diagnosis might be missed because it is difficult to perform renal biopsy in such a clinical situation. If the patient's general condition allows, renal biopsy should be performed and reversible AKI must be distinguished from many cases of irreversible AKI complicated by SAP. This is the first report of biopsy-proven DI-AIN associated with SAP, suggesting the importance of biopsy for distinguishing DI-AIN in persisting AKI of SAP.