Risk, Predictors, and Outcomes of Acute Kidney Injury in Patients Admitted to Intensive Care Units in Egypt

Protective effect of Huashi Baidu formula against AKI and active ingredients that target SphK1 and PAI-1

BACKGROUND

Huashi Baidu Formula (HBF) is a clinical formula known for its efficacy against coronavirus disease 2019 (COVID-19). HBF may reduce the number of patients with abnormal serum creatinine while improving respiratory symptoms, suggesting that this formula may have potential for treating acute kidney injury (AKI). However, the protective effect of HBF on AKI has not been definitively confirmed, and the mechanism remains unclear. Therefore, the present study explored the renoprotective effects and molecular mechanisms of HBF and screened for its active ingredients to identify new potential applications of renoprotection by HBF.

METHODS

The present study first assessed the protective effects of HBF on AKI in a DOX-induced mouse model. Then, RNA-seq and bioinformatics analyses were used to explore the related pathological processes and potential molecular mechanisms, which were subsequently validated using qRT-PCR and Western blotting. Furthermore, candidate compounds with potential binding affinity to two pivotal targets, sphingosine kinase 1 (SphK1) and plasminogen activator inhibitor-1 (PAI-1), were screened from the 29 constituents present in the blood using Microscale Thermophoresis (MST). Finally, to identify the active ingredients, the candidate components were re-screened using the SphK1 kinase activity detection system or the uPA/PAI-1 substrate colorimetric assay system.

RESULTS

In the DOX-induced AKI mouse model, therapeutic administration of HBF significantly reduced the levels of CRE, BUN, TNF-α, IL-1β, IL-6, and UA in plasma and the levels of MDA, T-CHO, and TG in kidney tissue. Additionally, the levels of TP and Alb in plasma and SOD and CAT in the kidney tissue were significantly increased. Histopathological assessment revealed that HBF reduced tubular vacuolation, renal interstitial inflammatory cell infiltration, tubular atrophy, and positive staining of renal interstitial collagen. RNA-seq and bioinformatics analyses showed that oxidative stress, the immune-inflammatory response, and extracellular matrix (ECM) formation could be the pathological processes that HBF targets to exerts its renoprotective effects. Furthermore, HBF regulated the APJ/SPHK1/NF-κB and APJ/PAI-1/TGFβ signaling axes and reduced the phosphorylation levels of NF-κB p65 and SMAD2 and the expression of cytokines and the ECM downstream of the axis. Finally, six SphK1 inhibitors (paeoniflorin, astragalin, emodin, glycyrrhisoflavone, quercetin, and liquiritigenin) and three PAI-1 inhibitors (glycyrrhisoflavone, licochalcone B, and isoliquiritigenin) were identified as potentially active ingredients in HBF.

CONCLUSION

In brief, our investigation underscores the renoprotective effect of HBF in a DOX-induced AKI model mice, elucidating its mechanisms through distinct pathological processes and identifying key bioactive compounds. These findings offer new insights for broadening the clinical applications of HBF and unravelling its molecular mode of action.

Characteristics, Risk Factors, and Outcomes in Acute Kidney Injury Patients: A Retrospective Cross-Sectional Study, Palestine

Background

Acute kidney injury (AKI) is a major medical problem affecting patients' quality of life and healthcare costs.

Objectives

This study evaluated the severity, risk factors, and outcomes of patients diagnosed with acute kidney injury (AKI), including community-acquired AKI (CA-AKI) and hospital-acquired AKI (HA-AKI), who were admitted to tertiary institutions in Palestine.

Methods

This retrospective cross-sectional study was conducted at multiple tertiary care hospitals in Palestine by reviewing patient charts from January 2020 to March 2023. The study included all patients aged ≥18 years who were admitted to the hospital and diagnosed with AKI at admission (CA-AKI) or who developed AKI 48 hours after admission (HA-AKI). Patients with incomplete medical records and those with no reported creatinine levels during their stay, pregnant women, kidney transplant patients, and end-stage renal disease patients were excluded. Data were analyzed using SPSS v22.0. The incidence of AKI in each group was compared using the chi-squared test.

Results

This study included 259 participants. HA-AKI was present in 27.3% of the patients, while CA-AKI was 72.7%. The most common stage among patients was stage 3 (55.7%, HA-AKI) (42.9%, CA-AKI), and the most common comorbidity contributing to AKI was CKD. NSAIDs, ACE-I/ARBs, and DIURETICs were the most nephrotoxic drugs contributing to AKI. Patients with hyperphosphatemia, hyperkalemia, severe metabolic acidosis, or stage 3 AKI require renal replacement therapy. In addition, our findings revealed a significant association among AKI mortality, age, and heart disease.

Conclusion

CA-AKI was more prevalent than HA-AKI in Palestinian patients admitted for AKI. Risk factors for AKI included diabetes, CKD, and medications (antibiotics, NSAID, diuretics, and ACE-I/ARB). Preventive measures, medication management, and disease state management are necessary to minimize AKI during hospital admission or in the community.

Epidemiology, patterns of care and prognosis of acute kidney injury in critically ill patients: A multicenter study in Argentina (The EPIRA study)

BACKGROUND

Acute kidney injury (AKI) is associated with high morbidity and mortality rates in the intensive care unit (ICU). In low- and middle-income countries (LMICs), epidemiological information about this condition is still scarce. Our main objective was to characterize its epidemiology, prognosis, and its treatment.

METHODS

This multicenter prospective cohort study included 1466 patients from 35 ICUs during 6 months in Argentina in 2018. Risk factors and outcomes in patients with and without AKI, and between AKI on admission (AKIadm) and that developed during hospitalization (AKIhosp) were analyzed.

RESULTS

AKI occurred in 61.3% of patients (900/1466); 72.6% were AKIadm and 27.3% AKIhosp. Risk factors were age, BMI, arterial hypertension, cardiovascular diseases, diabetes, SOFA, APACHE II, dehydration, sepsis, vasopressor use, radiocontrast, diuresis/h and mechanical ventilation. Independent predictors for AKI were sepsis, diabetes, dehydration, vasopressors on admission, APACHE II and radiocontrast use. Renal replacement therapies (RRT) requirement in AKI patients was 14.8%. Hospital mortality in AKI vs. non-AKI was 38.7% and 23.3% (p < 0.001); and in AKIadm vs. AKIhosp, 41.2% and 37.8% (p = 0.53).

CONCLUSIONS

ICU-acquired AKI has high incidence, complications and mortality. Risk factors for AKI and RRT utilization were similar to those described in other epidemiological studies. AKIadm was more frequent than AKIhosp, but had equal prognosis.

Clinical profile and predictors of renal failure in emergency department patients at a tertiary level hospital, a cross sectional study

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Our study was able to highlight the profile of patients at risk of renal failure who were likely older, hypertensive, oliguric and with low hemoglobin compared to those without.

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This Knowledge can help care givers and policy makers to pay particular attention and institute interventions targeted at treating non communicable diseases (that lead to renal failure) and infections there by reducing progressing to renal failure and end stage renal disease with need for renal replacement therapy.

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In addition, it also showed that simple bedside tests like dip stick urinalysis and urine output monitoring are key in surveillance of renal failure.

Background

Since establishment of the emergency departments (ED) in the country, there is lack of information on clinical profile of patients admitted to the ED and predictors of renal failure in these patients. Renal failure is prevalent in critical patients and a cause of significant mortality and morbidity. The aim of this study was to assess the clinical profile and predictors of renal failure in admissions to the ED.

Methods

This was a cross-sectional study that was conducted at a tertiary level hospital in Zambia from January to December, 2019 among admissions to the ED after ethical approval. The primary outcome of the study was to describe the clinical profile of admissions to the ED and proportion of renal failure defined as estimated glomerular filtration rate (eGFR) < 60 mls/1.72 m²

Results

The final analysis includes 152 patients, 7 excluded for missing key data. The median age was 43.5 years (IQR 32.5-59.5) and 94.7% of patients were medical. Nearly 70.0% of the patients were triaged as emergency (red) or very urgent (orange). The reason for admission to the ED were sepsis and/or sepsis shock in 25.0%, diabetic hyperglycaemia emergencies in 20.0%, hypertensive crisis in 10.5%, respiratory failure (9.9%), severe malaria (7.9%) and poisoning (5.0%). The prevalence of renal failure was 36.1% and proteinuria was observed in 23.0%. Oliguria and hypertension were 5.9-fold and 1.7-fold independent predictors of renal failure in the ED. Patients with renal failure were likely older, hypertensive, oliguric and anaemic compared to those without. During admission to the ED, 19.1% died.

Conclusion

Sepsis and diabetic and hypertensive emergencies accounted for nearly half of ED admissions. Hypertension and oliguria were key predictors of renal failure. Early diagnosis, management and follow-up of hypertension including urine output monitoring for high-risk patients is key in surveillance and prevention of renal failure.

Impact of Different KDIGO Criteria on Clinical Outcomes for Early Identification of Acute Kidney Injury after Non-Cardiac Surgery

The Kidney Disease Improving Global Outcomes (KDIGO) guidelines are currently used in acute kidney injury (AKI) diagnosis and include both serum creatinine (SCR) and urine output (UO) criteria. Currently, many AKI-related studies have inconsistently defined AKI, which possibly affects the comparison of their results. Therefore, we hypothesized that the different criteria in the KDIGO guidelines vary in measuring the incidence of AKI and its association with clinical outcomes. We retrospectively analyzed that data of patients admitted to the intensive care unit after non-cardiac surgery in 2019. Three different criteria used to define AKI were included: UOmean, mean UO < 0.5 mL/kg/h over time; UOcont, hourly UO < 0.5 mL/kg/h over time; or SCR, KDIGO guidelines SCR criteria. A total of 777 patients were included, and the incidence of UOmean-AKI was 33.1%, the incidence of UOcont-AKI was 7.9%, and the incidence of SCR-AKI was 2.0%. There were differences in the length of ICU stay and hospital stay between AKI and non-AKI patients under different criteria. We found differences in the incidence and clinical outcomes of AKI after non-cardiac surgery when using different KDIGO criteria.

Nomogram Prediction Model of Serum Chloride and Sodium Ions on the Risk of Acute Kidney Injury in Critically Ill Patients

Purpose

This study aims to investigate the effect of serum chloride and sodium ions on AKI occurrence in ICU patients, and further constructs a prediction model containing these factors to explore the predictive value of these ions in AKI.

Methods

The clinical information of patients admitted to ICU of Beijing Friendship Hospital Affiliated to Capital Medical University was collected for retrospective analysis. Logistic regression analysis was used to analyzing the influencing factors. A nomogram for predicting AKI risk was constructed with R software and validated by repeated sampling. Afterwards, the effectiveness and accuracy of the model were tested and evaluated.

Results

A total of 446 cases met the requirements of this study, of which 178 developed AKI during their stay in ICU, with an incidence rate of 39.9%. Hypernatremia, heart failure, sepsis, APACHE II score, and initial creatinine value and BE value at ICU admission before the diagnosis of AKI were identified as independent risk factors for developing AKI during ICU stay. These predictors were incorporated into the nomogram of AKI risk in critically ill patients, which was constructed by using R software. Receiver operating characteristic curve analysis was further used and showed that the area under the curve of the model was 0.7934 (95% CI 0.742–0.8447), indicating that the model had an ideal value. Finally, further evaluated its clinical effectiveness. The clinical effect curve and decision curve showed that most areas of the decision curve of this model were greater than 0, indicating that this model owned a certain clinical effectiveness.

Conclusion

The nomogram based on hypernatremia, heart failure, sepsis, APACHE II score, and initial creatinine and BE value in ICU can predict the individualized risk of AKI with satisfactory distinguishability and accuracy.

A LASSO-derived clinical score to predict severe acute kidney injury in the cardiac surgery recovery unit: a large retrospective cohort study using the MIMIC database

OBJECTIVES

We aimed to develop an effective tool for predicting severe acute kidney injury (AKI) in patients admitted to the cardiac surgery recovery unit (CSRU).

DESIGN

A retrospective cohort study.

SETTING

Data were extracted from the Medical Information Mart for Intensive Care (MIMIC)-III database, consisting of critically ill participants between 2001 and 2012 in the USA.

PARTICIPANTS

A total of 6271 patients admitted to the CSRU were enrolled from the MIMIC-III database.

PRIMARY AND SECONDARY OUTCOME

Stages 2-3 AKI.

RESULT

As identified by least absolute shrinkage and selection operator (LASSO) and logistic regression, risk factors for AKI included age, sex, weight, respiratory rate, systolic blood pressure, diastolic blood pressure, central venous pressure, urine output, partial pressure of oxygen, sedative use, furosemide use, atrial fibrillation, congestive heart failure and left heart catheterisation, all of which were used to establish a clinical score. The areas under the receiver operating characteristic curve of the model were 0.779 (95% CI: 0.766 to 0.793) for the primary cohort and 0.778 (95% CI: 0.757 to 0.799) for the validation cohort. The calibration curves showed good agreement between the predictions and observations. Decision curve analysis demonstrated that the model could achieve a net benefit.

CONCLUSION

A clinical score built by using LASSO regression and logistic regression to screen multiple clinical risk factors was established to estimate the probability of severe AKI in CSRU patients. This may be an intuitive and practical tool for severe AKI prediction in the CSRU.

Mortality and predictors of acute kidney injury in adults: a hospital-based prospective observational study

Acute kidney injury (AKI) is a major global public health problem. It is expensive to manage and associated with a high rate of prolonged hospitalization and in-hospital mortality. Little is known about the burden of acute kidney injury in moderate to low-income countries. We aim to assess predictors of in-hospital mortality among AKI patients admitted to the medical ward. We prospectively identified patients meeting kidney disease improving global outcomes (KIDGO) AKI definitions from April to August 2019. Patients with underlying CKD and patients hospitalized for less than 48 h were excluded. The Cox regression model was fitted to identify predictors of mortality and statistical significance was considered at the p-value of less than 0.05. A total of 203 patients were enrolled over 5 months. Out of this, 121(59.6%) were males, 58(28.6%) were aged greater than 60 years, and 141(69.5%) had community-acquired acute kidney injury. The most common causes of AKI were Hypovolemia 99(48.77%), Glomerulonephritis 51(25.11%), and sepsis 32(15.79%). The overall in-hospital mortality rate was 12.8%. Stage 3 AKI (AHR = 9.61, 95% CI 1.17-28.52, p = 0.035), duration of AKI (AHR = 7.04, 95% CI 1.37-36.08, p = 0.019), length of hospital stay (AHR = 0.19, 95% CI 0.05-0.73, p = 0.012), and hyperkalemia (AHR = 3.61, 95% CI 1.12-11.71, p = 0.032) were significantly associated with in-hospital mortality. There is a high rate of acute kidney injury-related in-hospital mortality in adult patients admitted to the medical ward. The severity of AKI, hyperkalemia duration of AKI, and a short length of hospital stay were predictors of 30-days in-hospital mortality. Most of the causes of AKI are preventable and patients may benefit from early identification and treatment of these reversible causes.

Acute Kidney Injury and Associated Factors in Intensive Care Units at a Tertiary Hospital in Northern Tanzania

Background

Acute kidney injury (AKI) is a recognized complication in critically ill patients. The epidemiology of AKI varies worldwide, depending on the diagnostic criteria used and the setting. The International Society of Nephrology has called for a reduction in preventable deaths from AKI to zero by the year 2025. It is suspected that the majority of AKI cases are in limited-resource countries, but the true burden of AKI in these settings remains unknown.

Objective

We aimed to determine, using standardized KDIGO (Kidney Disease Improving Global Outcomes) criteria, the prevalence of AKI, associated factors, and clinical characteristics of adult (≥18 years) patients admitted to intensive care units (ICUs) at a tertiary hospital in Tanzania.

Design

Prospective observational study from November 2017 to May 2018.

Methods

In all, 320 patients admitted to medical and surgical ICUs were consecutively enrolled. Baseline, clinical, and laboratory data were collected on admission and during their ICU stay. Serum creatinine and urine output were measured, and KDIGO criteria were used to determine AKI status.

Results

More than half (55.3%) of ICU patients were diagnosed with AKI. Of these, 80% were diagnosed within 24 hours of admission. Acute kidney injury stage 3 accounted for 35% of patients with AKI. Patients with AKI were older, more likely to have cardiovascular comorbidities, and with higher baseline serum levels of creatinine, potassium, universal vital assessment admission scores, and total white cell count ≥12. Sepsis (odds ratio [OR] = 3.81; confidence interval [CI] = 1.21-11.99), diabetes (OR = 2.54; CI = 1.24-5.17), and use of vasopressors (OR = 3.78; CI = 1.36-10.54) were independently associated with AKI in multivariable logistic regression. Less than one-third of those who needed dialysis received it. There was 100% mortality in those who needed dialysis but did not receive (n = 19).

Limitations

Being based at a referral center, the findings do not represent the true burden of AKI in the community.

Conclusion

The prevalence of AKI was very high in ICUs in Northern Tanzania. The majority of patients presented with AKI and were severely ill, suggesting late presentation, underscoring the importance of prioritizing prevention and early intervention. Further studies should explore locally suitable AKI risk scores that could be used to identify high-risk patients in the community health centers from where patients are referred.

Risk factors and prognosis assessment for acute kidney injury: The 2020 consensus of the Taiwan AKI Task Force

Risk and prognostic factors for acute kidney injury (AKI) have been published in various studies across various populations. We aimed to explore recent advancements in and provide updated recommendations on AKI risk stratification and information about local AKI risk factors. The Taiwan Acute Kidney Injury Task Force reviewed relevant recently published literature and reached a consensus after group meetings. Systemic review and group discussion were performed. We conducted a meta-analysis according to the PRISMA statement for evaluating the diagnostic performance of the furosemide stress test. Several risk and susceptibility factors were identified through literature review. Contrast-associated AKI prediction models after coronary angiography were one of the most discussed prediction models we found. The basic approach and evaluation of patients with AKI was also discussed. Our meta-analysis found that the furosemide stress test can be used as a prognostic tool for AKI progression and to identify patients with AKI who are at low risk of renal replacement therapy. Factors associated with de novo chronic kidney injury or renal non-recovery after AKI were identified and summarized. Our review provided practical information about early identification of patients at high risk of AKI or disease progression for Taiwan local clinics.

Outcomes Among Patients Hospitalized With COVID-19 and Acute Kidney Injury

RATIONALE & OBJECTIVE

Outcomes of patients hospitalized with coronavirus disease 2019 (COVID-19) and acute kidney injury (AKI) are not well understood. The goal of this study was to investigate the survival and kidney outcomes of these patients.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Patients (aged≥18 years) hospitalized with COVID-19 at 13 hospitals in metropolitan New York between March 1, 2020, and April 27, 2020, followed up until hospital discharge.

EXPOSURE

AKI.

OUTCOMES

Primary outcome: in-hospital death.

SECONDARY OUTCOMES

requiring dialysis at discharge, recovery of kidney function.

ANALYTICAL APPROACH

Univariable and multivariable time-to-event analysis and logistic regression.

RESULTS

Among 9,657 patients admitted with COVID-19, the AKI incidence rate was 38.4/1,000 patient-days. Incidence rates of in-hospital death among patients without AKI, with AKI not requiring dialysis (AKI stages 1-3), and with AKI receiving dialysis (AKI 3D) were 10.8, 31.1, and 37.5/1,000 patient-days, respectively. Taking those without AKI as the reference group, we observed greater risks for in-hospital death for patients with AKI 1-3 and AKI 3D (HRs of 5.6 [95% CI, 5.0-6.3] and 11.3 [95% CI, 9.6-13.1], respectively). After adjusting for demographics, comorbid conditions, and illness severity, the risk for death remained higher among those with AKI 1-3 (adjusted HR, 3.4 [95% CI, 3.0-3.9]) and AKI 3D (adjusted HR, 6.4 [95% CI, 5.5-7.6]) compared with those without AKI. Among patients with AKI 1-3 who survived, 74.1% achieved kidney recovery by the time of discharge. Among those with AKI 3D who survived, 30.6% remained on dialysis at discharge, and prehospitalization chronic kidney disease was the only independent risk factor associated with needing dialysis at discharge (adjusted OR, 9.3 [95% CI, 2.3-37.8]).

LIMITATIONS

Observational retrospective study, limited to the NY metropolitan area during the peak of the COVID-19 pandemic.

CONCLUSIONS

AKI in hospitalized patients with COVID-19 was associated with significant risk for death.

Prognostic nutritional index predicts acute kidney injury and mortality of patients in the coronary care unit

The current study aimed to investigate whether prognostic nutritional index (PNI) is an independent predictor of acute kidney injury (AKI) and mortality of patients in the coronary care unit (CCU). In the present two-stage observational study of patients in the CCU, 6,444 patients from the Medical Information Mart for Intensive Care (MIMIC) III database were first enrolled (test cohort), after which 412 patients from Zhongnan Hospital of Wuhan University were recruited in the validation cohort. AKI was defined based on the Kidney Disease Improving Global Outcomes AKI criteria. The primary endpoint was the incidence of AKI stratified by severity, while the second endpoint included in-hospital mortality and 2-year mortality. In the test cohort, 4,457 (69.2%) patients developed AKI during hospitalization. Following multivariable adjustment, the highest quartile of the PNI value was associated with a 1.8-fold increased risk of AKI compared with the lowest quartile. For the prediction of AKI, the area under the receiver operating characteristic curve outperformed the acute physiology score III score and clinical model in patients with or without preexisting chronic kidney disease, and this was further validated in the hospital cohort used in the present study. A total of 2,219 patients suffered mortality during the 2-year follow-up, and PNI was indicated to independently predict the risk of in-hospital mortality and 2-year mortality in the test cohort and in the validation cohort. Decision curve analysis indicated that the PNI values were clinically useful; Therefore, the current study demonstrated that the PNI value is an independent predictor of AKI and mortality in patients within the CCU.

The incidence, risk factors, and outcomes of acute kidney injury in the intensive care unit in Sudan

Background There is a paucity of studies in acute kidney injury in the intensive care unit, particularly in Sudan. Objectives The current study has estimated the incidence; risk factors and outcomes of subjects with acute kidney injury developed during admission to the intensive care unit at Fedail Hospital, Khartoum, Sudan. Methodology This was a cross-sectional study conducted in the intensive care unit during the period from July 2018 to June 2019. The data was collected from the clinical profiles of all adult subjects' who have met the published criteria for acute kidney injury. Analysis of association (Chi square test χ²) and multivariate logistic regression were used to analyze data. Main outcome measure The development of acute kidney injury during the subjects' stay in the intensive care unit, length of hospital stay and death. Results From a total of 187 subjects admitted to the intensive care unit; only (105, 56.2%) have met the inclusion criteria (mean age was 61 ± 3.5 years). The main finding of the study was the high incidence of acute kidney injury 39%. The major significant predictors for the development of acute kidney injury with respective odds ratio (OR) were: sepsis (OR 7.5 [95% CI 3-19.7]; P .001); hypovolemia (OR 5.1 [95% CI 2-15.7]; P .001); chronic cardiovascular diseases (OR 3.4 [95% CI 1.2-9.4]; P .017); age > 60 years (OR 2.7 [95% CI 1.2-6.3]; P .018); diabetes mellitus (OR 2.6 [95% CI 1.2-6]; P .02); hypertension (OR 2.4 [95% CI 1.2-5.4]; P .028); and renal replacement therapy (OR 0.2 [95% CI 0.15-0.3]; P .001). The length of hospital stay within the AKI cohort was (6.7 ± 3.8; [range 2-17]) and the mortality rate was (36, 87.8%). Conclusion The major significant predictors for the development of acute kidney injury in the intensive care unit were: sepsis; hypovolemia; chronic cardiovascular diseases; age > 60 years; diabetes mellitus; hypertension; and renal replacement therapy. Sepsis and hypovolemia were common etiologies for acute kidney injury post-admission to the intensive care unit. Acute kidney injury was associated with increased length of hospital stay and a very high absolute mortality rate.

Histological and SEM Assessment of Blood Stasis in Kidney Blood Vessels after Repeated Intra-Arterial Application of Radiographic Contrast Media

BACKGROUND

After application of iodinated contrast media (CM), a pronounced deterioration of the microcirculation in skin and myocardium was reported. Clinically, the repeated application of CM, especially, led to an increase of the renal resistance index (RRI). With respect to the transiency of the RRI increase, it is reasonable to assume that the deterioration of blood flow could be due to transient blood stasis caused by reversible morphologic cell alterations due to osmotic discrepancies between CM and human blood. Therefore, the hypothesis was investigated whether CM are able to induce in vivo such blood stasis and cell deformations in the renal vasculature of well-hydrated pigs.

METHODS

The in vivo study was performed as a prospective randomized examination to compare the effects of two different CM in 16 pigs (German Landrace). Pigs were randomized to receive either Iodixanol (n = 8), or Iopromide (n = 8). Each animal received 10 injections separated by 5-min intervals via the suprarenal aorta at a rate of 10 mL/s according to the usual procedure during a cardiac catheter examination. Finally, the kidneys were explanted and processed for histology (H & E staining and fibrin staining according to Weigert) as well as for scanning electron microscopy (SEM) with regards to morphologic correlates explaining the changes in the microcirculation.

RESULTS

In each of the predefined four categories of vascular diameters, blood stasis were found, but clearly more often after application of Iopromide than after application of Iodixanol (p < 0.001). In addition, Iopromide induced more blood stasis in all of the examined kidney regions compared to Iodixanol (p = 0.0001). There were no obstructive events in the middle cortex following the application of Iodixanol. Except for the region around a puncture channel of a placed-in catheter probe, no fibrin was detected in Weigert's fibrin-stained samples, neither around the histologically assessed thrombi nor in vessels with blood stasis. Complementary SEM analyses revealed in a few cases only a slight generation of fibrin and thrombi and deformations, such as echinocyte and "box-like" deformations.

CONCLUSIONS

According to previous in vitro studies, pathological erythrocyte deformations, such as echinocyte and box-like formation of erythrocytes, were observed also in vivo. In addition, blood stasis and/or thrombi could be detected in histological samples from explanted kidneys from young pigs after repeated in vivo administration of CM. In only a few cases, mural platelet aggregates within minimal fibrin meshes occurred only after the application of Iopromide.

Glycogen synthase kinase-3β inhibits tubular regeneration in acute kidney injury by a FoxM1-dependent mechanism

Acute kidney injury (AKI) is characterized by injury to the tubular epithelium that leads to the sudden loss of renal function. Proper tubular regeneration is essential to prevent progression to chronic kidney disease. In this study, we examined the role of FoxM1, a forkhead box family member transcription factor in tubular repair after AKI. Renal FoxM1 expression increased after renal ischemia/reperfusion (I/R)-induced AKI in mouse kidneys. Treatment with thiostrepton, a FoxM1 inhibitor, reduced FoxM1 regulated pro-proliferative factors and cell proliferation in vitro, and tubular regeneration in mouse kidneys after AKI. Glycogen synthase kinase-3 (GSK3) was found to be an upstream regulator of FoxM1 because GSK3 inhibition or renal tubular GSK3β gene deletion significantly increased FoxM1 expression, and improved tubular repair and renal function. GSK3 inactivation increased β-catenin, Cyclin D1, and c-Myc, and reduced cell cycle inhibitors p21 and p27. Importantly, thiostrepton treatment abolished the improved tubular repair in GSK3β knockout mice following AKI. These results demonstrate that FoxM1 is important for renal tubular regeneration following AKI and that GSK3β suppresses tubular repair by inhibiting FoxM1.

Incidence, Risk Factors, and Outcome of Acute Kidney Injury in the Intensive Care Unit: A Single-Center Study from Jordan

Background

Acute kidney injury (AKI) is a common serious problem affecting critically ill patients in intensive care unit (ICU). It increases their morbidity, mortality, length of ICU stay, and long-term risk of chronic kidney disease (CKD).

Methods

A retrospective study was carried out in a tertiary hospital in Jordan. Medical records of patients admitted to the medical ICU between 2013 and 2015 were reviewed. We aimed to identify the incidence, risk factors, and outcomes of AKI. Acute kidney injury network (AKIN) classification was used to define and stage AKI.

Results

2530 patients were admitted to medical ICU, and the incidence of AKI was 31.6%, mainly in stage 1 (59.4%). In multivariate analysis, increasing age (odds ratio (OR) = 1.2 (95% CI 1.1–1.3), P = 0.0001) and higher APACHE II score (OR = 1.5 (95% CI 1.2–1.7), P = 0.001) were predictors of AKI, with 20.4% of patients started on hemodialysis. At the time of discharge, 58% of patients with AKI died compared to 51.3% of patients without AKI (P = 0.05). 88% of patients with AKIN 3 died by the time of discharge compared to patients with AKIN 2 and 1 (75.3% and 61.2% respectively, P = 0.001).

Conclusion

AKI is common in ICU patients, and it increases mortality and morbidity. Close attention for earlier detection and addressing risk factors for AKI is needed to decrease incidence, complications, and mortality.

Predictors of Acute Kidney Injury and Mortality in Intensive Care Unit at a Teaching Tertiary Hospital_ID

BACKGROUND AND AIMS

Despite the increased rates of acute kidney injury (AKI) in intensive care units (ICU) and associated mortality, information on the epidemiology of AKI is sparse in sub-Saharan Africa (SSA). We investigated the rates and predictors of AKI and associated mortality in a tertiary ICU.

MATERIALS AND METHODS

This retrospective study analyzed 280 hospital records of patients admitted to the ICU at a tertiary teaching hospital who were aged ≥15 years from January 2017 to May 31, 2018. The outcome parameters of the study were rates of AKI in the ICU, associated risk factors, and mortalities. Acute kidney injury and ICU mortality were established by the multivariate logistic analysis.

RESULTS

The median age was 36 years (IQR 28, 52). The rate of AKI was 52.9%, and the presence of human immunodeficiency virus (HIV) and oliguria was 2.3-fold (0.004) and 4-fold (0.016) positive predictors of ICU-AKI, respectively. Male gender (0.003), diabetes mellitus (DM) (0.010), respiratory disease (0.001), inotropes (0.004), and ventilator support (0.017) were predictors for ICU mortality after controlling for confounders.

CONCLUSION

The rate of AKI is significantly higher in a referral tertiary hospital in Zambia compared to developed countries and the presence of HIV and noncommunicable diseases such as DM impacts severely on outcomes.

HOW TO CITE THIS ARTICLE

Banda J, Chenga N, Nambaya S, Bulaya T, Siziya S. Predictors of Acute Kidney Injury and Mortality in Intensive Care Unit at a Teaching Tertiary Hospital_ID. Indian J Crit Care Med 2020;24(2):116-121.

Risk factors and outcomes of acute kidney injury in South African critically ill adults: a prospective cohort study

Background

There is a marked paucity of data concerning AKI in Sub-Saharan Africa, where there is a substantial burden of trauma and HIV.

Methods

Prospective data was collected on all patients admitted to a multi-disciplinary ICU in South Africa during 2017. Development of AKI (before or during ICU admission) was recorded and renal recovery 90 days after ICU discharge was determined.

Results

Of 849 admissions, the mean age was 42.5 years and mean SAPS 3 score was 48.1. Comorbidities included hypertension (30.5%), HIV (32.6%), diabetes (13.3%), CKD (7.8%) and active tuberculosis (6.2%). The most common reason for admission was trauma (26%). AKI developed in 497 (58.5%). Male gender, illness severity, length of stay, vasopressor drugs and sepsis were independently associated with AKI. AKI was associated with a higher in-hospital mortality rate of 31.8% vs 7.23% in those without AKI. Age, active tuberculosis, higher SAPS 3 score, mechanical ventilation, vasopressor support and sepsis were associated with an increased adjusted odds ratio for death. HIV was not independently associated with AKI or hospital mortality. CKD developed in 14 of 110 (12.7%) patients with stage 3 AKI; none were dialysis-dependent.

Conclusions

In this large prospective multidisciplinary ICU cohort of younger patients, AKI was common, often associated with trauma in addition to traditional risk factors and was associated with good functional renal recovery at 90 days in most survivors. Although the HIV prevalence was high and associated with higher mortality, this was related to the severity of illness and not to HIV status per se.

Cumulative fluid accumulation is associated with the development of acute kidney injury and non-recovery of renal function: a retrospective analysis

Background

Acute kidney injury (AKI) is common in patients in the intensive care unit (ICU) and may be present on admission or develop during ICU stay. Our objectives were (a) to identify factors independently associated with the development of new AKI during early stay in the ICU and (b) to determine the risk factors for non-recovery of AKI.

Methods

We retrospectively analysed prospectively collected data of patients admitted to a multi-disciplinary ICU in a single tertiary care centre in the UK between January 2014 and December 2016. We identified all patients without AKI or end-stage renal failure on admission to the ICU and compared the outcome and characteristics of patients who developed AKI according to KDIGO criteria after 24 h in the ICU with those who did not develop AKI in the first 7 days in the ICU. Multivariable logistic regression was applied to identify factors associated with the development of new AKI during the 24–72-h period after admission. Among the patients with new AKI, we identified those with full, partial or no renal recovery and assessed factors associated with non-recovery.

Results

Among 2525 patients without AKI on admission, the incidence of early ICU-acquired AKI was 33.2% (AKI I 41.2%, AKI II 35%, AKI III 23.4%). Body mass index, Sequential Organ Failure Assessment score on admission, chronic kidney disease (CKD) and cumulative fluid balance (FB) were independently associated with the new development of AKI. By day 7, 69% had fully recovered renal function, 8% had partial recovery and 23% had no renal recovery. Hospital mortality was significantly higher in those without renal recovery. Mechanical ventilation, diuretic use, AKI stage III, CKD, net FB on first day of AKI and cumulative FB 48 h later were independently associated with non-recovery with cumulative fluid balance having a U-shape association.

Conclusions

Early development of AKI in the ICU is common and mortality is highest in patients who do not recover renal function. Extreme negative and positive FB were strong risk factors for AKI non-recovery.

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.

Predictors of Mortality in Acute Kidney Injury Patients in an Intensive Care Unit: Is Hemodialysis No Good?

How to cite this article: Karim HMR, Panda CK. Predictors of Mortality in Acute Kidney Injury Patients in an Intensive Care Unit: Is Hemodialysis No Good? Indian J Crit Care Med 2019;23(9):439.