Etiology and outcomes of anuria in acute kidney injury: a single center study

Construction of a nomogram for predicting catheter-related bladder discomfort in patients with end-stage renal disease after renal transplantation: a retrospective study

Background

The incidence of catheter-related bladder discomfort (CRBD) is relatively high in the end-stage renal disease (ESRD) patients who underwent renal transplantation (RT). This study was designed to establish a nomogram for predicting CRBD after RT among ESRD patients.

Methods

In this retrospective study, we collected 269 ESRD patients who underwent RT between September 2019 and August 2023 in our hospital. The patients were divided into training set (n = 215) and test set (n = 54) based on a ratio of 8:2. Univariate and multivariate logistic regression analyses were utilized to identify the risk factors associated with CRBD after RT, and then a nomogram model was constructed. Receiver operating characteristic (ROC) and calibration curve were used to evaluate the predicting efficiency of the established nomogram.

Results

Multivariate logistic regression analysis showed that aberrant body mass index (BMI) (underweight: OR = 5.25; 95% CI [1.25-22.15], P = 0.024; overweight: OR = 2.75; 95% CI [1.17-6.49], P = 0.021), anuria (OR = 2.86; 95% CI [1.33-5.88]) and application of double J (DJ) stent with a diameter of >5Fr (OR = 15.88; 95% CI [6.47-39.01], P < 0.001) were independent risk factors for CRBD after RT. In contrast, sufentanil utilization (>100 µg) [OR = 0.39; 95% CI [0.17-0.88], P = 0.023] was associated with decreased incidence of CRBD. A nomogram was then established based on these parameters for predicting the occurrence of CRBD after RT. Area under the ROC curve (AUC) values and calibration curves confirmed the prediction efficiency of the nomogram.

Conclusion

A nomogram was established for predicting CRBD after RT in ESRD patients, which showed good prediction efficiency based on AUC and calibration curves.

Acute Kidney Injury in a Previously Healthy 56-Year-Old Male Following a Direct Visual Internal Urethrotomy of a Bulbar Stricture

Acute kidney injury (AKI) is a frequent finding in acutely ill and hospitalized patients arising from various etiologies. Anuric AKI, a more pronounced form of AKI in which less than 100 cc of urine is produced per day, is most frequently encountered in hospitalized, septic, and post-surgical patients, often secondary to shock or bilateral urinary tract obstruction. The development of anuric AKI in previously healthy patients after outpatient urological procedures presents a unique challenge to physicians, as many outpatient procedures require the routine perioperative administration of multiple nephrotoxic medications. Further complicating this clinical scenario, some surgical procedures that intrinsically involve iatrogenic injury to the kidney, ureter, bladder, or nearby organ can rarely lead to a phenomenon known as reflex anuria, an anuric state typically associated with AKI. Here, we report an unusual case of a previously healthy 56-year-old male who developed anuric AKI two days after direct visual internal urethrotomy (DVIU) for the treatment of a bulbar stricture. Non-contrast CT revealed no signs of an obstructive process, and laboratory findings supported an intrarenal cause of AKI. Consideration was given to non-steroidal anti-inflammatory drugs (NSAID)-induced nephrotoxicity, gentamicin-associated acute tubular necrosis, and propofol infusion syndrome, in addition to their potential synergistic effects. We also explore this as the first reported case of reflex anuria occurring at the level of the bulbar urethra, as most cases have involved direct injury to the kidney or ureter. Over the course of 10 days, our patient responded well to treatment with supportive measures and dialysis, with his vomiting, electrolyte abnormalities, renal state, and anuria eventually improving.

Amazonia Phytotherapy Reduces Ischemia and Reperfusion Injury in the Kidneys

Acute kidney injury (AKI) is defined as a sudden decrease in kidney function. Phytomedicines have shown positive effects in the treatment of AKI worldwide. The aim of this study was to evaluate the effect of Abuta grandifolia on the renal function of rats submitted to AKI. A phytochemical study of the plant was performed through liquid chromatography coupled with mass spectrometry (CL-EM) and DPPH and ABTS antioxidant tests. Renal function tests were performed in 20 male adult Wistar rats weighing from 250 to 300 g distributed in the following groups: SHAM (submitted to laparotomy with simulation of renal ischemia); ABUTA (animals that received 400 mg/kg of AG, orally-VO, once a day, for 5 days, with simulation of renal ischemia); I/N (animals submitted to laparotomy for clamping of bilateral renal pedicles for 30 min, followed by reperfusion); ABUTA + I/R (animals that received AG-400 mg/kg, 1× per day, VO, for 5 days, submitted to renal ischemia after treatment with herbal medicine). The results suggest that the consumption of Abuta grandifolia promoted renoprotection, preventing the reduction of renal function induced by ischemia, oxidizing activity, and deleterious effects on the renal tissue, confirmed by the decrease of oxidative metabolites and increase of antioxidants in the animals' organisms.

Clinico-Etiological Spectrum and Outcome in Patients With Septic Acute Kidney Injury and Its Comparison With Non-septic Acute Kidney Injury: A Hospital-Based Prospective Study Conducted in a Tertiary Care Hospital in North India

Background Acute kidney injury (AKI) is a heterogenous syndrome defined by the impairment of kidney filtration and excretory function over days to weeks, resulting in the retention of nitrogenous and other waste products normally cleared by the kidneys. In addition, AKI is frequently recognized to be associated with sepsis and contributes to an unfavorable outcome in sepsis. This study was undertaken to study and compare the etiology and clinical profile of patients with septic and non-septic AKI and to study and compare the outcome in both groups. Materials and methods This is a prospective, observational, and comparative study with a total sample size of 200 patients selected randomly having sustained an acute kidney injury. Data was collected, recorded, analyzed, and compared for two groups of patients with septic and non-septic AKI. Results A total of 200 cases of AKI were enrolled, out of which 120 (60%) were due to non-septic etiology and 80 (40%) were of septic etiology. Urosepsis (37.5%) due to various urinary tract infections including pyelonephritis and chest sepsis (18.75%) including community-acquired pneumonia (CAP) and aspiration pneumonia were the predominant causes of sepsis. AKI secondary to nephrotoxic agents (27.5%) was the commonest cause in the non-septic group, followed by glomerulonephritis (13.3%), vitamin D intoxication-related hypercalcemia (12.5%), acute gastroenteritis (10.8%), etc. Patients of septic AKI had a significantly higher mean of maximum urea and creatinine than their non-septic AKI counterparts. In addition to having an increased duration of hospital stay, mortality was significantly higher in patients with septic AKI (27.5%) than in patients with non-septic AKI (4.1%). However, sepsis had no effect on renal functions, measured by urea and creatinine, at discharge. In patients with AKI, certain factors were found to increase the risk of mortality. These factors include being over 65 years old, needing mechanical ventilation or vasopressors, requiring renal replacement therapy (RRT), and having multiorgan dysfunction syndrome (MODS), septic shock, or acute coronary syndrome (ACS). However, pre-existing conditions such as diabetes, hypertension, malignancy, previous stroke, chronic kidney disease (CKD), and chronic liver disease (CLD) did not affect the overall mortality risk. Conclusion In the septic AKI group, urosepsis was the most frequent etiology of AKI, while the most frequent etiology of AKI in the non-septic group was nephrotoxin exposure. Patients with septic AKI had considerably longer hospital stays and greater in-hospital mortality rates than patients with non-septic AKI. The renal functions as determined by urea and creatinine at discharge were unaffected by sepsis. Finally, death was significantly impacted by age of >65 years, the necessity for mechanical ventilation, the use of vasopressors and RRT, and the presence of MODS, septic shock, and ACS.

Predicting mortality in acute kidney injury patients undergoing continuous renal replacement therapy using a visualization model: A retrospective study

Background: Patients with severe acute kidney injury (AKI) require continuous renal replacement therapy (CRRT) when hemodynamically unstable. We aimed to identify prognostic factors and develop a nomogram that could predict mortality in patients with AKI undergoing CRRT. Methods: Data were extracted from the Dryad Digital Repository. We enrolled 1,002 participants and grouped them randomly into training (n = 670) and verification (n = 332) datasets based on a 2:1 proportion. Based on Cox proportional modeling of the training set, we created a web-based dynamic nomogram to estimate all-cause mortality. Results: The model incorporated phosphate, Charlson comorbidity index, body mass index, mean arterial pressure, levels of creatinine and albumin, and sequential organ failure assessment scores as independent predictive indicators. Model calibration and discrimination were satisfactory. In the training dataset, the area under the curves (AUCs) for estimating the 28-, 56-, and 84-day all-cause mortality were 0.779, 0.780, and 0.787, respectively. The model exhibited excellent calibration and discrimination in the validation dataset, with AUC values of 0.791, 0.778, and 0.806 for estimating 28-, 56-, and 84-day all-cause mortality, respectively. The calibration curves exhibited the consistency of the model between the two cohorts. To visualize the results, we created a web-based calculator. Conclusion: We created a web-based calculator for assessing fatality risk in patients with AKI receiving CRRT, which may help rationalize clinical decision-making and personalized therapy.

An evaluation of sepsis in dentistry

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It is a major health concern and causes substantial morbidity and mortality. It is imperative that the signs of sepsis are identified early in both adult and paediatric patients and appropriately escalated to initiate early treatment and improve prognosis. This paper aims to discuss the change in classification from the previous systemic inflammatory response syndrome (SIRS) criteria to the current definition in adults and also the unchanged definition in children. The hallmark signs of sepsis (both red and amber flags) are discussed in relation to their underlying cellular mechanisms to provide a comprehensive overview for clinicians in primary care, hospital and community settings. The rise of antimicrobial resistance is also an increasing global health concern with resistant bacteria from common infections likely to result in greater patient morbidity and worse outcomes.A literature search identified reported sepsis cases in dentistry through searches in Ovid Medline and Embase from January 1990 to December 2019. Only primary studies were included with no restrictions on languages. Four articles were identified which reported sepsis associated with tooth extractions, dental abscess and submental/submandibular cellulitis. It is well known that locoregional infections of dental origin have the potential to cause sepsis. Therefore, dental healthcare professionals need to be vigilant and understand the specific signs and escalation protocols to ensure patient safety.

Hyperbaric oxygen preconditioning and the role of NADPH oxidase inhibition in postischemic acute kidney injury induced in spontaneously hypertensive rats

Renal ischemia/reperfusion injury is a common cause of acute kidney injury (AKI) and hypertension might contribute to the increased incidence of AKI. The purpose of this study was to investigate the effects of single and combined hyperbaric oxygen (HBO) preconditioning and NADPH oxidase inhibition on oxidative stress, kidney function and structure in spontaneously hypertensive rats (SHR) after renal ischemia reperfusion injury. HBO preconditioning was performed by exposing to pure oxygen (2.026 bar) twice a day for two consecutive days for 60 minutes, and 24h before AKI induction. For AKI induction, the right kidney was removed and ischemia was performed by clamping the left renal artery for 45 minutes. NADPH oxidase inhibition was induced by apocynin (40 mg/kg b.m., intravenously) 5 minutes before reperfusion. AKI significantly increased renal vascular resistance and reduced renal blood flow, which were significantly improved after apocynin treatment. Also, HBO preconditioning, with or without apocynin treatment showed improvement on renal hemodynamics. AKI significantly increased plasma creatinine, urea, phosphate levels and lipid peroxidation in plasma. Remarkable improvement, with decrease in creatinine, urea and phosphate levels was observed in all treated groups. HBO preconditioning, solitary or with apocynin treatment decreased lipid peroxidation in plasma caused by AKI induction. Also, combined with apocynin, it increased catalase activity and solitary, glutathione reductase enzyme activity in erythrocytes. While AKI induction significantly increased plasma KIM– 1 levels, HBO preconditioning, solitary or with apocynin decreased its levels. Considering renal morphology, significant morphological alterations present after AKI induction were significantly improved in all treated groups with reduced tubular dilatation, tubular necrosis in the cortico-medullary zone and PAS positive cast formation. Our results reveal that NADPH oxidase inhibition and hyperbaric oxygen preconditioning, with or without NADPH oxidase inhibition may have beneficial effects, but their protective role should be evaluated in further studies.

Clinical profile and determinants of short-term outcome of acute kidney injury: A hospital-based prospective study from Northeastern India

CONTEXT

Acute kidney injury (AKI) is an outcome of multiple etiologies and is mostly reversible. Data on its incidence and outcome, particularly from India, are limited.

AIMS

To study the etiology, clinical profile, and short-term prognosis in AKI.

SETTINGS AND DESIGN

A hospital-based prospective observational study on AKI.

SUBJECTS AND METHODS

Seventy-five AKI patients diagnosed by Acute Kidney Injury network criteria were selected. Patients with preexisting chronic kidney disease were excluded.

STATISTICAL ANALYSIS USED

Data were compiled using the Statistical Package for the Social Sciences version 17. Regression analysis was done for determining the association of various variables for mortality. P < 0.05 was considered statistically significant.

RESULTS

The mean age of patients was 41.09 ± 16.17 years with a male:female ratio of 1.42:1. Comorbidities were present in 37.3%, with diabetes mellitus (10.6%) and chronic liver disease (10.6%) being the most common. Fever was the most common (40%) presenting symptom, followed by oliguria (25.8%). Infection was the most common cause of AKI (56%), with sepsis in 26.7% followed by acute gastroenteritis in 17.3%. Pneumonia was the primary focus in 50% of cases with sepsis. Mean serum creatinine and urea at admission were 2.37 ± 0.90 and 92.44 ± 39.67 mg/dl, respectively. Serum creatinine rose progressively to 2.96 ± 1.18 and 3.26 ± 1.56 mg/dl at 24 and 48 h, respectively, since hospitalization. Majority of the cases (73.3%) were nonoliguric. Hemodialysis was necessary in 24% of cases. Mean hospital stay was 8.16 days. In-hospital mortality was 24%. Among survivors, 92.9% had complete renal recovery on discharge. Sepsis, need for hemodialysis, urea >100 mg/dl, and peak serum creatinine >3 mg/dl were contributors to mortality (P < 0.01).

CONCLUSIONS

Infections, especially sepsis, were the most common cause of AKI. Hemodialysis was required in one-quarter of the patients. Sepsis, need for hemodialysis, and high creatinine were associated with a significantly higher mortality.

Association between serum levels of interleukin-6 on ICU admission and subsequent outcomes in critically ill patients with acute kidney injury

BACKGROUND

Exacerbated inflammatory response is considered one of the key elements of acute kidney injury (AKI). Interleukin-6 (IL-6) is an inflammatory cytokine that plays important roles in the inflammatory response and may be useful for predicting the clinical outcomes in patients with AKI. However, supporting evidence adapted to the current KDIGO criteria is lacking.

METHODS

AKI patients admitted to the ICU between Jan 2011 and Dec 2015 were retrospectively screened. Patients were assigned to three groups by admission IL-6 tertiles. Associations between IL-6 on ICU admission and in-hospital 90-day mortality, short-term/long-term renal function were analyzed.

RESULTS

Patients (n = 646) were divided into low (1.5-150.2 pg/mL), middle (152.0-1168 pg/mL), and high (1189-2,346,310 pg/mL) IL-6 on ICU admission groups. Patients in the high IL-6 group had higher in-hospital 90-day mortality (low vs. middle vs. high, P = 0.0050), lower urine output (low vs. middle vs. high, P < 0.0001), and an increased probability of persistent of anuria for ≥12 h (low vs. middle vs. high, P < 0.0001) within 72 h after ICU admission. In contrast, the high IL-6 group had a lower incidence of persistent AKI at 90 days after the ICU admission in survivors (low vs. middle vs. high, P = 0.013).

CONCLUSIONS

Serum levels of IL-6 on ICU admission may predict short-term renal function and mortality in AKI patients and were associated with renal recovery in survivors.

In-Hospital Survival and Neurological Recovery Among Patients Requiring Renal Replacement Therapy in Post-Cardiac Arrest Period

Objectives

Acute kidney injury (AKI) is common after cardiac arrest (CA). Few data exist on survival and neurological outcomes measured at hospital discharge of patients with severe AKI requiring renal replacement therapy (RRT) within the first 72 hours (i.e., duration of post-CA syndrome).

Methods

Single-center, prospective, observation cohort of patients with in- or out-of-hospital CA who survived to intensive care unit admission and were considered for targeted temperature management between 2010 and 2016 were reviewed. After excluding preexisting RRT history, patients with new RRT requirements within the first 72 hours after CA were included. Primary outcome of survival and secondary outcome of good neurological recovery defined as cerebral performance category score of 1 to 2, were compared between patients with and without RRT. Within 24 hours of initiating RRT, illness severity, as measured by Sequential Organ Failure Assessment score, Acute Physiology and Chronic Health Evaluation–II, and Charlson Comorbidity Index, was compared between survivors and nonsurvivors.

Results

Of 524 patients, 65 (12.4%) had new RRT requirements within 72 hours. Survival rates and good neurological recovery at discharge were comparable between RRT and non-RRT groups (19 of 65 [29%] vs. 162 of 459 [35%], P = 0.3, and 8 of 19 [42%] vs. 73 of 162 [45%], respectively). Sixty-three percent (12 of 19) of survivors requiring RRT did not need dialysis on discharge. Among patients requiring RRT, prognostic factors, including illness severity scores and indications for RRT, did not differ between survivors and nonsurvivors.

Conclusions

Patients with severe AKI requiring RRT during the post-CA syndrome period were not associated with any significant reduction in survival or poor neurological recovery, compared with those without RRT. Among those requiring RRT, none of the known prognostic factors predicted survival.

Acute kidney injury and disease: Long-term consequences and management

With increasing longevity and the presence of multiple comorbidities, a significant proportion of hospitalized patients, and an even larger population in the community, is at increased risk of developing an episode of acute kidney injury (AKI). Because of improvements in short-term outcomes following an episode of AKI, survivors of an episode of AKI are now predisposed to develop its long-term sequel. The identification of risk for progression to chronic kidney disease (CKD) is complicated by the absence of good biomarkers that identify this risk and the variability of risk associated with clinical factors including, but not limited to, the number of AKI episodes, severity, duration of previous AKI and pre-existing CKD that has made the prediction for long-term outcomes in survivors of AKI more difficult. Being a significant contributor to the growing incidence of CKD, there is a need to implement measures to prevent AKI in both the community and hospital settings, target interventions to treat AKI that are also associated with better long-term outcomes, accurately identify patients at risk of adverse consequences following an episode of AKI and institute therapeutic strategies to improve these long-term outcomes. We discuss the lasting renal and non-renal consequences following an episode of AKI, available biomarkers and non-invasive testing to identify ongoing intra-renal pathology and review the currently available and future treatment strategies to help reduce these adverse long-term outcomes.

Baseline Renal Function Predicts Hyponatremia in Liver Cirrhosis Patients Treated with Terlipressin for Variceal Bleeding

Objectives

Terlipressin is safely used for acute variceal bleeding. However, side effects, such as hyponatremia, although very rare, can occur. We investigated the development of hyponatremia in cirrhotic patients who had acute variceal bleeding treated with terlipressin and the identification of the risk factors associated with the development of hyponatremia.

Design and Methods

This retrospective, case-control study investigated 88 cirrhotic patients who developed hyponatremia and 176 controls that did not develop hyponatremia and were matched in terms of age and gender during the same period following terlipressin administration.

Results

The overall change in serum sodium concentration and the mean lowest serum sodium concentration were 3.44 ± 9.55 and 132.44 ± 8.78 mEq/L during treatment, respectively. Multivariate analysis revealed that baseline serum sodium was an independent positive predictor, and the presence of baseline serum creatinine, HBV, DM, creatinine, and shock on admission was independent negative predictors of hyponatremia (P < 0.05).

Conclusion

The presence of HBV, DM, the baseline serum sodium, shock on admission, and especially baseline creatinine may be predictive of the development of hyponatremia after terlipressin treatment. Therefore, physicians conduct vigilant monitoring associated with severe hyponatremia when cirrhotic patients with preserved renal function are treated with terlipressin for variceal bleeding.

The Effect of Treatment on Short-Term Outcomes in Elderly Patients with Acute Kidney Injury

BACKGROUND

Elderly population (≥ 65) are more prone to develop acute kidney injury (AKI) compared to younger, also elderly with AKI have an increased requirement for dialysis treatment and an elevated risk of short-term and long-term mortality.

AIM

The objectives of this study were to examine the effect of treatment of short-term outcomes and mortality in elderly patients with AKI.

MATERIAL AND METHODS

Seventy elderly AKI patients, that filled one of the criteria of AKI definition and had hospitalization over 24 hours, were enrolled in the study.

RESULTS

The median age of patients was 74.28 ± 6.64, with mean CCI (Charlson Comorbidity Index) score of 6.94 ± 1.94. The majority of patients (70%) were classified at stage 3 of AKIN, 20% of patients were classified at stage 2 and 10% at stage 1. In the groups of patients with death outcome, the chronic cardiomyopathy was more frequently present (p = 0.034). Regarding treatment, 58.6% of the AKI patients underwent hemodialysis while 41.4% received conservative treatment. Mortality rate was 52.8%, out of which 28.6% was in-hospital mortality, while in 24.3% of patients death occurred in the follow-up period of 90 days.

CONCLUSION

In our study, short- term survival is not related to different treatment options. Applied treatment in elderly patients with AKI should be assessed by measuring the long term outcome.

The bladder ran dry: bilateral ureteral obstruction

A relatively young healthy man (barring obesity and distant gouty arthritis) was admitted with severe acute kidney injury (serum creatinine, 15.9 mg/dL) following acute gastroenteritis and occasional use of diclofenac. Abdominal ultrasound revealed mild left hydronephrosis due to staghorn stone and normal right kidney. Soon after, complete anuria necessitating haemodialysis developed without pain or evidence of infection. CT imaging revealed stones obstructing the right ureter. Following urological surgery, postobstructive diuresis developed and the serum creatinine came down to near normal. The stones were identified as uric acid stones.Anuria has a relatively narrow differential and painless (partially non-dilated) bilateral ureteral obstruction is a distinctly unusual cause. A review of the literature to cover all reported causes of bilateral ureteral obstruction is presented. Only a minority of cases were not associated with an underlying malignant disease or its treatment. The multifactorial aetiology of the patient's acute kidney injury (volume depletion, diclofenac and obstructive uropathy) is presented and discussed.

Delta neutrophil index is an independent predictor of mortality in septic acute kidney injury patients treated with continuous renal replacement therapy

Background

Delta neutrophil index (DNI), representing an elevated fraction of circulating immature granulocytes in acute infection, has been reported as a useful marker for predicting mortality in patients with sepsis. The aim of this study was to evaluate the prognostic value of DNI in predicting mortality in septic acute kidney injury (S-AKI) patients treated with continuous renal replacement therapy (CRRT).

Method

This is a retrospective analysis of consecutively CRRT treated patients. We enrolled 286 S-AKI patients who underwent CRRT and divided them into three groups based on the tertiles of DNI at CRRT initiation (high, DNI > 12.0%; intermediate, 3.6–12.0%; low, < 3.6%). Patient survival was estimated with the Kaplan-Meier method and Cox proportional hazards models to determine the effect of DNI on the mortality of S-AKI patients.

Results

Patients in the highest tertile of DNI showed higher Acute Physiology and Chronic Health Evaluation II score (highest tertile, 27.9 ± 7.0; lowest tertile, 24.6 ± 8.3; P = 0.003) and Sequential Organ Failure Assessment score (highest tertile, 14.1 ± 3.0; lowest tertile, 12.1 ± 4.0; P = 0.001). The 28-day mortality rate was significantly higher in the highest tertile group than in the lower two tertile groups (P < 0.001). In the multiple Cox proportional hazard model, DNI was an independent predictor for mortality after adjusting multiple confounding factors (hazard ratio, 1.010; 95% confidence interval, 1.001–1.019; P = 0.036).

Conclusion

This study suggests that DNI is independently associated with mortality of S-AKI patients on CRRT.