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Cho JM, Koh JH, Kim M, Jung S, Cho S, Lee S, Kim Y, Kim YC, Lee H, Han SS, Oh KH, Joo KW, Kim YS, Kim DK, Park S. Evaluation of risk stratification for acute kidney injury: a comparative analysis of EKFC, 2009 and 2021 CKD-EPI glomerular filtration estimating equations. J Nephrol 2024; 37:681-693. [PMID: 38345686 DOI: 10.1007/s40620-023-01883-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/26/2023] [Indexed: 06/05/2024]
Abstract
BACKGROUND The adoption of the 2021 CKD-EPIcr equation for glomerular filtration rate (GFR) estimation provided a race-free eGFR calculation. However, the discriminative performance for AKI risk has been rarely validated. We aimed to evaluate the differences in acute kidney injury (AKI) prediction or reclassification power according to the three eGFR equations. METHODS We performed a retrospective observational study within a tertiary hospital from 2011 to 2021. Acute kidney injury was defined according to KDIGO serum creatinine criteria. Glomerular filtration rate estimates were calculated by three GFR estimating equations: 2009 and 2021 CKD-EPIcr, and EKFC. In three equations, AKI prediction performance was evaluated with area under receiver operator curves (AUROC) and reclassification power was evaluated with net reclassification improvement analysis. RESULTS A total of 187,139 individuals, including 27,447 (14.7%) AKI and 159,692 (85.3%) controls, were enrolled. In the multivariable regression prediction model, the 2009 CKD-EPIcr model (continuous eGFR model 2, 0.7583 [0.755-0.7617]) showed superior performance in AKI prediction to the 2021 CKD-EPIcr (0.7564 [0.7531-0.7597], < 0.001) or EKFC model in AUROC (0.7577 [0.7543-0.761], < 0.001). Moreover, in reclassification of AKI, the 2021 CKD-EPIcr and EKFC models showed a worse classification performance than the 2009 CKD-EPIcr model. (- 7.24 [- 8.21-- 6.21], - 2.38 [- 2.72-- 1.97]). CONCLUSION Regarding AKI risk stratification, the 2009 CKD-EPIcr equation showed better discriminative performance compared to the 2021 CKD-EPIcr equation in the study population.
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Affiliation(s)
- Jeong Min Cho
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea
| | - Jung Hun Koh
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea
| | - Minsang Kim
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea
| | - Sehyun Jung
- Department of Internal Medicine, Gyeongsang National University College of Medicine, Jinju, South Korea
| | - Semin Cho
- Department of Internal Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Soojin Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Department of Internal Medicine, Uijeongbu Eulji University Medical Center, Uijeongbu, South Korea
| | - Yaerim Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, South Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Sehoon Park
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea.
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.
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Ivica J, Sanmugalingham G, Selvaratnam R. Alerting to Acute Kidney Injury - Challenges, benefits, and strategies. Pract Lab Med 2022; 30:e00270. [PMID: 35465620 PMCID: PMC9020093 DOI: 10.1016/j.plabm.2022.e00270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/12/2022] [Accepted: 03/30/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Josko Ivica
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton Health Sciences and St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Geetha Sanmugalingham
- Division of Nephrology, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Rajeevan Selvaratnam
- University Health Network, Laboratory Medicine Program, Division of Clinical Biochemistry, Toronto, Ontario, Canada
- University of Toronto, Department of Laboratory Medicine and Pathobiology, Toronto, Ontario, Canada
- Corresponding author. University Health Network, Laboratory Medicine Program, Division of Clinical Biochemistry, Toronto, Ontario, Canada.
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Ruth A, Basu RK, Gillespie S, Morgan C, Zaritsky J, Selewski DT, Arikan AA. Early and late acute kidney injury: temporal profile in the critically ill pediatric patient. Clin Kidney J 2022; 15:311-319. [PMID: 35145645 PMCID: PMC8825224 DOI: 10.1093/ckj/sfab199] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Indexed: 01/31/2023] Open
Abstract
Background Increasing AKI diagnosis precision to refine the understanding of associated epidemiology and outcomes is a focus of recent critical care nephrology research. Timing of onset of acute kidney injury (AKI) during pediatric critical illness and impact on outcomes has not been fully explored. Methods This was a secondary analysis of the Assessment of Worldwide Acute Kidney Injury, Renal Angina and Epidemiology (AWARE) database. AKI was defined as per Kidney Disease: Improving Global Outcomes criteria. Early AKI was defined as diagnosed at ≤48 h after intensive care unit (ICU) admission, with any diagnosis >48 h denoted as late AKI. Transient AKI was defined as return to baseline serum creatinine ≤48 h of onset, and those without recovery fell into the persistent category. A second incidence of AKI ≥48 h after recovery was denoted as recurrent. Patients were subsequently sorted into distinct phenotypes as early-transient, late-transient, early-persistent, late-persistent and recurrent. Primary outcome was major adverse kidney events (MAKE) at 28 days (MAKE28) or at study exit, with secondary outcomes including AKI-free days, ICU length of stay and inpatient renal replacement therapy. Results A total of 1262 patients had AKI and were included. Overall mortality rate was 6.4% (n = 81), with 34.2% (n = 432) fulfilling at least one MAKE28 criteria. The majority of patients fell in the early-transient cohort (n = 704, 55.8%). The early-persistent phenotype had the highest odds of MAKE28 (odds ratio 7.84, 95% confidence interval 5.45–11.3), and the highest mortality rate (18.8%). Oncologic and nephrologic/urologic comorbidities at AKI diagnosis were associated with MAKE28. Conclusion Temporal nature and trajectory of AKI during a critical care course are significantly associated with patient outcomes, with several subtypes at higher risk for poorer outcomes. Stratification of pediatric critical care-associated AKI into distinct phenotypes is possible and may become an important prognostic tool.
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Affiliation(s)
- Amanda Ruth
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Rajit K Basu
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, GA, USA
| | - Scott Gillespie
- Biostatistics core of Emory Pediatric Research Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Catherine Morgan
- Department of Pediatrics, Division of Pediatric Nephrology, University of Alberta, Alberta, Canada
| | - Joshua Zaritsky
- St Christophers Children Hospital for Children, Philadelphia, PA, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Ayse Akcan Arikan
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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Ribeiro-Mourão F, Vaz AC, Azevedo A, Pinto H, Silva MJ, Jardim J, Ribeiro A. Assessment of the renal angina index for the prediction of acute kidney injury in patients admitted to a European pediatric intensive care unit. Pediatr Nephrol 2021; 36:3993-4001. [PMID: 34105013 DOI: 10.1007/s00467-021-05116-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/13/2021] [Accepted: 04/30/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is associated with worse outcomes and increased morbidity and mortality in pediatric intensive care unit (PICU) patients. The renal angina index (RAI) has been proposed as an early prediction tool for AKI development. OBJECTIVES The objective was to evaluate outcomes of RAI-positive patients and to compare RAI performance with traditional AKI markers across different patient groups (medical/post-surgical). This was an observational retrospective study. All children admitted to a tertiary hospital PICU over a 3-year period were included. Electronic medical records were reviewed. Day 1 RAI was calculated, as was the presence and staging of day 3 AKI. RESULTS A total of 593 patients were included; 56% were male, the mean age was 55 months, and 17% had a positive RAI. This was associated with day 3 AKI development and worse outcomes, such as greater need for kidney replacement therapy, longer duration of mechanical ventilation, vasoactive support and PICU stay, and higher mortality. For all-stage kidney injury, RAI presented a sensitivity of 87.5% and a specificity of 88.1%. Prediction of day 3 all-stage AKI by RAI had an AUC=0.878; its performance increased for severe AKI (AUC = 0.93). RAI was superior to serum creatinine increase and KDIGO AKI staging on day 1 in predicting severe AKI development. The performance remained high irrespective of the type of admission. CONCLUSIONS The RAI is a simple and inexpensive tool that can be used with medical and post-surgical PICU patients to predict AKI development and anticipate complications, allowing for the adoption of preventive measures.
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Affiliation(s)
- Francisco Ribeiro-Mourão
- Pediatric Intensive Care Unit, Centro Hospitalar e Universitário de São João, Porto, Portugal.
- Pediatrics Department, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal.
| | - Ana Carvalho Vaz
- Pediatric Intensive Care Unit, Centro Hospitalar e Universitário de São João, Porto, Portugal
- Pediatrics Department, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal
| | - André Azevedo
- Pediatrics Department, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal
| | - Helena Pinto
- Pediatrics Department, Pediatric Nephrology Unit, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Marta João Silva
- Pediatric Intensive Care Unit, Centro Hospitalar e Universitário de São João, Porto, Portugal
- Obstetrics & Gynecology Department and Paediatrics Department, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Joana Jardim
- Pediatrics Department, Pediatric Nephrology Unit, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Augusto Ribeiro
- Pediatric Intensive Care Unit, Centro Hospitalar e Universitário de São João, Porto, Portugal
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Pon AG, Vairakkani R, Mervin EF, Srinivasaprasad ND, Kaliaperumal T. Clinical significance of frusemide stress test in predicting the severity of acute kidney injury. ACTA ACUST UNITED AC 2021; 43:470-477. [PMID: 33877260 PMCID: PMC8940118 DOI: 10.1590/2175-8239-jbn-2021-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/04/2021] [Indexed: 11/22/2022]
Abstract
Introduction: The outcomes of Acute Kidney Injury (AKI) remain dismal even today, owing in part due to the lack of an ideal biomarker for detecting renal damage early enough. We conducted this pilot study to determine the clinical significance of Frusemide Stress Test (FST) to predict the severity of AKI. Methods: A total of 80 patients with AKI-KDIGO (Kidney Disease: Improving Global Outcomes) stage 1 or stage 2 underwent FST by administering a bolus dose of frusemide (1mg/kg for frusemide naïve and 1.5mg/kg for prior frusemide exposure in the past week), and urine output was then measured for the next two hours with volume replacement as desirable. The progression to AKI-KDIGO stage 3 within 14 days of FST was studied as the primary outcome. The composite end point of achieving AKI-KDIGO stage 3 or death within 14 days of FST was studied as the secondary outcome. Results: Out of 80 patients, 28(35%) patients met the primary outcome, and 34(42.5%) patients met the secondary composite outcome. Except for baseline Chronic Kidney Disease (CKD) status (p=0.018), other demographic characteristics were comparable between progressors and non-progressors group. Using receiver operating characteristics (ROC) curve analysis, a cumulative 2-hour post-FST urine output of ≤300 mL predicted progression to stage 3 AKI with 82.14% sensitivity, 82.69% specificity, and AUC of 0.89±0.03 (p<0.0001). Conclusion: The FST showed promising results as a novel tubular biomarker to identify progression to severe AKI with good predictive ability.
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Affiliation(s)
- Arun Gokul Pon
- Government Stanley Medical College and Hospital, General Medicine, Chennai, Tamilnadu, India
| | - Raveendran Vairakkani
- Government Stanley Medical College and Hospital, Nephrology, Chennai, Tamilnadu, India
| | - Edwin Fernando Mervin
- Government Stanley Medical College and Hospital, Nephrology, Chennai, Tamilnadu, India
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Koyner JL, Zarbock A, Basu RK, Ronco C. The impact of biomarkers of acute kidney injury on individual patient care. Nephrol Dial Transplant 2020; 35:1295-1305. [PMID: 31725154 DOI: 10.1093/ndt/gfz188] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 08/10/2019] [Indexed: 12/20/2022] Open
Abstract
Acute kidney injury (AKI) remains a common clinical syndrome associated with increased morbidity and mortality. In the last several years there have been several advances in the identification of patients at increased risk for AKI through the use of traditional and newer functional and damage biomarkers of AKI. This article will specifically focus on the impact of biomarkers of AKI on individual patient care, focusing predominantly on the markers with the most expansive breadth of study in patients and reported literature evidence. Several studies have demonstrated that close monitoring of widely available biomarkers such as serum creatinine and urine output is strongly associated with improved patient outcomes. An integrated approach to these biomarkers used in context with patient risk factors (identifiable using electronic health record monitoring) and with tests of renal reserve may guide implementation and targeting of care bundles to optimize patient care. Besides traditional functional markers, biochemical injury biomarkers have been increasingly utilized in clinical trials both as a measure of kidney injury as well as a trigger to initiate other treatment options (e.g. care bundles and novel therapies). As the novel measures are becoming globally available, the clinical implementation of hospital-based real-time biomarker measurements involves a multidisciplinary approach. This literature review discusses the data evidence supporting both the strengths and limitations in the clinical implementation of biomarkers based on the authors' collective clinical experiences and opinions.
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Affiliation(s)
- Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Rajit K Basu
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Claudio Ronco
- Department of Medicine, University of Padova, International Renal Research Institute (IRRIV), San Bortolo Hospital, Vicenza, Italy
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Coca A, Aller C, Reinaldo Sánchez J, Valencia AL, Bustamante-Munguira E, Bustamante-Munguira J. Role of the Furosemide Stress Test in Renal Injury Prognosis. Int J Mol Sci 2020; 21:E3086. [PMID: 32349337 PMCID: PMC7247682 DOI: 10.3390/ijms21093086] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 02/02/2023] Open
Abstract
Risk stratification and accurate patient prognosis are pending issues in the management of patients with kidney disease. The furosemide stress test (FST) has been proposed as a low-cost, fast, safe, and easy-to-perform test to assess tubular integrity, especially when compared to novel plasma and urinary biomarkers. However, the findings regarding its clinical use published so far provide insufficient evidence to recommend the generalized application of the test in daily clinical routine. Dosage, timing, and clinical outcomes of the FST proposed thus far have been significantly different, which further accentuates the need for standardization in the application of the test in order to facilitate the comparison of results between series. This review will summarize published research regarding the usefulness of the FST in different settings, providing the reader some insights about the possible implications of FST in clinical decision-making in patients with kidney disease and the challenges that research will have to address in the near future before widely applying the FST.
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Affiliation(s)
- Armando Coca
- Department of Nephrology, Hospital Clinico Universitario de Valladolid, 47003 Valladolid, Spain; (A.C.); (C.A.); (J.R.S.); (A.L.V.)
| | - Carmen Aller
- Department of Nephrology, Hospital Clinico Universitario de Valladolid, 47003 Valladolid, Spain; (A.C.); (C.A.); (J.R.S.); (A.L.V.)
| | - Jimmy Reinaldo Sánchez
- Department of Nephrology, Hospital Clinico Universitario de Valladolid, 47003 Valladolid, Spain; (A.C.); (C.A.); (J.R.S.); (A.L.V.)
| | - Ana Lucía Valencia
- Department of Nephrology, Hospital Clinico Universitario de Valladolid, 47003 Valladolid, Spain; (A.C.); (C.A.); (J.R.S.); (A.L.V.)
| | - Elena Bustamante-Munguira
- Department of Intensive Care Medicine, Hospital Clinico Universitario de Valladolid, 47003 Valladolid, Spain;
| | - Juan Bustamante-Munguira
- Department of Cardiac Surgery, Hospital Clinico Universitario de Valladolid, 47003 Valladolid, Spain
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Early-Stage Acute Kidney Injury Adversely Affects Thoracoabdominal Aortic Aneurysm Repair Outcomes. Ann Thorac Surg 2019; 107:1720-1726. [DOI: 10.1016/j.athoracsur.2018.11.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 10/29/2018] [Accepted: 11/26/2018] [Indexed: 12/20/2022]
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Gonsalez SR, Cortês AL, Silva RCD, Lowe J, Prieto MC, Silva Lara LD. Acute kidney injury overview: From basic findings to new prevention and therapy strategies. Pharmacol Ther 2019; 200:1-12. [PMID: 30959059 PMCID: PMC10134404 DOI: 10.1016/j.pharmthera.2019.04.001] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/27/2019] [Indexed: 01/24/2023]
Abstract
Acute kidney injury (AKI) is defined as a decrease in kidney function within hours, which encompasses both injury and impairment of renal function. AKI is not considered a pathological condition of single organ failure, but a syndrome in which the kidney plays an active role in the progression of multi-organ dysfunction. The incidence rate of AKI is increasing and becoming a common (8-16% of hospital admissions) and serious disease (four-fold increased hospital mortality) affecting public health costs worldwide. AKI also affects the young and previously healthy individuals affected by infectious diseases in Latin America. Because of the multifactorial pathophysiological mechanisms, there is no effective pharmacological therapy that prevents the evolution or reverses the injury once established; therefore, renal replacement therapy is the only current alternative available for renal patients. The awareness of an accurate and prompt recognition of AKI underlying the various clinical phenotypes is an urgent need for more effective therapeutic interventions to diminish mortality and socio-economic impacts of AKI. The use of biomarkers as an indicator of the initial stage of the disease is critical and the cornerstone to fulfill the gaps in the field. This review discusses emerging strategies from basic science toward the anticipation of features, treatment of AKI, and new treatments using pharmacological and stem cell therapies. We will also highlight bioartificial kidney studies, addressing the limitations of the development of this innovative technology.
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Affiliation(s)
- Sabrina Ribeiro Gonsalez
- Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Avenida Carlos Chagas Filho 373, Bloco J, sala 26, Rio de Janeiro, RJ 21941-902, Brazil
| | - Aline Leal Cortês
- Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Avenida Carlos Chagas Filho 373, Bloco J, sala 26, Rio de Janeiro, RJ 21941-902, Brazil
| | - Raquel Costa da Silva
- Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Avenida Carlos Chagas Filho 373, Bloco J, sala 26, Rio de Janeiro, RJ 21941-902, Brazil
| | - Jennifer Lowe
- Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Avenida Carlos Chagas Filho 373, sala I2-035, Rio de Janeiro, RJ 21941-902, Brazil
| | - Minolfa C Prieto
- Department of Physiology & Tulane Renal and Hypertension Center of Excellence, School of Medicine, Tulane University, New Orleans, LA 70112, USA
| | - Lucienne da Silva Lara
- Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Avenida Carlos Chagas Filho 373, Bloco J, sala 26, Rio de Janeiro, RJ 21941-902, Brazil.
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10
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What Are the Long-Term Outcomes After Acute, Severe Kidney Injury and What Should We Be Doing About Them? Crit Care Med 2019; 45:136-137. [PMID: 27984283 DOI: 10.1097/ccm.0000000000002116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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11
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Abstract
Sepsis is defined as organ dysfunction resulting from the host's deleterious response to infection. One of the most common organs affected is the kidneys, resulting in sepsis associated acute kidney injury (SA-AKI) that contributes to the morbidity and mortality of sepsis. A growing body of knowledge has illuminated the clinical risk factors, pathobiology, response to treatment, and elements of renal recovery that have advanced our ability to prevent, detect, and treat SA-AKI. Despite these advances, SA-AKI remains an important concern and clinical burden, and further study is needed to reduce the acute and chronic consequences. This review summarizes the relevant evidence, with a focus on the risk factors, early recognition and diagnosis, treatment, and long term consequences of SA-AKI. In addition to literature pertaining to SA-AKI specifically, pertinent sepsis and acute kidney injury literature relevant to SA-AKI was included.
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Affiliation(s)
- Jason T Poston
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago
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12
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Basu RK. Dynamic Biomarker Assessment: A Diagnostic Paradigm to Match the AKI Syndrome. Front Pediatr 2019; 7:535. [PMID: 32039106 PMCID: PMC6986245 DOI: 10.3389/fped.2019.00535] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 12/09/2019] [Indexed: 12/21/2022] Open
Abstract
Acute kidney injury (AKI) affects one in four neonates, children, and adults admitted to the intensive care unit (ICU). AKI-associated outcomes, including mortality, are significantly worsened. Several decades of research demonstrate evidence for a need to rethink the pathophysiology and drivers of injury as well as to reconsider the existing diagnostic framework. Novel urinary and serum biomarkers of injury have, however, not been readily integrated into practice-partially because of the limited scope to current testing. The predominant focus to date has been the adjudication of a single biomarker measured at a single point of time for the prediction of either AKI progression or disease-related mortality. This approach is pragmatically problematic. The imprecise, umbrella classification of AKI diagnosis coupled with the absence of a consistently effective set of therapies creates a difficult rubric for biomarkers to demonstrate value in the scope of practice. AKI is, however, not a binary process but more an ICU syndrome-with complex biology underpinning injury, interacting and disrupting other organ function, multidimensional in manifestation, and varying in severity over time. As such, a more appropriate diagnostic paradigm is needed. In this minireview, the status quo for AKI diagnosis and associated limitations will be discussed, and a novel, dynamic, and multidimensional paradigm will be presented. Appreciation of AKI as an ICU syndrome and creation of an appropriately matching and sophisticated diagnostic platform of injury assessment are possible and represent the next step in AKI management.
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Affiliation(s)
- Rajit K Basu
- Division of Critical Care, Department of Pediatrics, Emory School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
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13
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Tai Q, Yi H, Wei X, Xie W, Zeng O, Zheng D, Sun J, Wang G, Wang S, Liu G. The Accuracy of Urinary TIMP-2 and IGFBP7 for the Diagnosis of Cardiac Surgery-Associated Acute Kidney Injury: A Systematic Review and Meta-Analysis. J Intensive Care Med 2018; 35:1013-1025. [PMID: 30376758 DOI: 10.1177/0885066618807124] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7) are recent promising markers for identification of cardiac surgery-associated acute kidney injury (CSA-AKI). The aim of this study was systematically and quantitatively to evaluate the accuracy of urinary TIMP-2 and IGFBP7 for the diagnosis of CSA-AKI. Methods: Three databases including PubMed, ISI web of knowledge, and Embase were systematically searched from inception to March 2018. Two investigators conducted the processes of literature search study selection, data extraction, and quality evaluation independently. Meta-DiSc and STATA were used for all statistical analyses. Results: A total of 8 studies comprising 552 patients were included in this meta-analysis. Pooled sensitivity and specificity with corresponding 95% confidence intervals (CIs) were 0.79 (95% CI, 0.71-0.86, I 2 = 74.2%) and 0.76 (95% CI, 0.72-0.80, I 2 = 80.8%), respectively. Pooled positive likelihood ratio (LR), negative LR, and diagnostic odds ratio were 3.49 (95% CI, 2.44-5.00, I 2 = 61.5%), 0.31(95% CI, 0.19-0.51, I 2 = 51.8%), and 14.89 (95% CI, 7.31-30.32, I 2 = 27.9%), respectively. The area under curve estimated by summary receiver operating characteristic was 0.868 (standard error [SE] 0.032) with a Q* value of 0.799 (SE 0.032). Sensitivity analysis demonstrated that one study notably affected the stability of pooled results. One of the subgroups investigated—AKI threshold—could account for partial heterogeneity. Conclusion: Urinary TIMP-2 and IGFBP7 is a helpful biomarker for early diagnosis of CSA-AKI. And, the potential of this biomarker with a broader spectrum of clinical settings may be the focus of future studies.
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Affiliation(s)
- Qiang Tai
- Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Province, PR China
- Significance for "*" refer to co-first author
| | - Huimin Yi
- Surgical Intensive Care Unit, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province, PR China
- Significance for "*" refer to co-first author
| | - Xuxia Wei
- Surgical Intensive Care Unit, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province, PR China
| | - Wenfeng Xie
- Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Province, PR China
| | - Ou Zeng
- Department of Cardiology Intensive Care Unit, First People's Hospital of Chenzhou, Hunan Province, PR China
| | - Donghua Zheng
- Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Province, PR China
| | - Jiaqi Sun
- Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Province, PR China
| | - Ganping Wang
- Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Province, PR China
| | - Siqi Wang
- Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Province, PR China
| | - Genglong Liu
- Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Province, PR China
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14
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Johnson ACM, Zager RA. Mechanisms Underlying Increased TIMP2 and IGFBP7 Urinary Excretion in Experimental AKI. J Am Soc Nephrol 2018; 29:2157-2167. [PMID: 29980651 DOI: 10.1681/asn.2018030265] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 06/15/2018] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Recent clinical data support the utility/superiority of a new AKI biomarker ("NephroCheck"), the arithmetic product of urinary TIMP × IGFBP7 concentrations. However, the pathophysiologic basis for its utility remains ill defined. METHODS To clarify this issue, CD-1 mice were subjected to either nephrotoxic (glycerol, maleate) or ischemic AKI. Urinary TIMP2/IGFBP7 concentrations were determined at 4 and 18 hours postinjury and compared with urinary albumin levels. Gene transcription was assessed by measuring renal cortical and/or medullary TIMP2/IGFBP7 mRNAs (4 and 18 hours after AKI induction). For comparison, the mRNAs of three renal "stress" biomarkers (NGAL, heme oxygenase 1, and p21) were assessed. Renal cortical TIMP2/IGFBP7 protein was gauged by ELISA. Proximal tubule-specific TIMP2/IGFBP7 was assessed by immunohistochemistry. RESULTS Each AKI model induced prompt (4 hours) and marked urinary TIMP2/IGFBP7 increases without an increase in renal cortical concentrations. Furthermore, TIMP2/IGFBP7 mRNAs remained at normal levels. Endotoxemia also failed to increase TIMP2/IGFBP7 mRNAs. In contrast, each AKI model provoked massive NGAL, HO-1, and p21 mRNA increases, confirming that a renal "stress response" had occurred. Urinary albumin rose up to 100-fold and strongly correlated (r=0.87-0.91) with urinary TIMP2/IGFBP7 concentrations. Immunohistochemistry showed progressive TIMP2/IGFBP7 losses from injured proximal tubule cells. Competitive inhibition of endocytic protein reabsorption in normal mice tripled urinary TIMP2/IGFBP7 levels, confirming this pathway's role in determining urinary excretion. CONCLUSIONS AKI-induced urinary TIMP2/IGFBP7 elevations are not due to stress-induced gene transcription. Rather, increased filtration, decreased tubule reabsorption, and proximal tubule cell TIMP2/IGFBP7 urinary leakage seem to be the most likely mechanisms.
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Affiliation(s)
- Ali C M Johnson
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington; and
| | - Richard A Zager
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington; and .,Department of Medicine, University of Washington, Seattle, Washington
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15
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Vincent JL. The coming era of precision medicine for intensive care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:314. [PMID: 29297399 PMCID: PMC5751549 DOI: 10.1186/s13054-017-1910-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Recent advances in technology and better understanding of mechanisms underlying disease are beginning to enable us to better characterize critically ill patients. Instead of using nonspecific syndromic groupings, such as sepsis or acute respiratory distress syndrome, we can now classify individual patients according to various specific characteristics, such as immune status. This "personalized" medicine approach will enable us to distinguish patients who have similar clinical presentations but different cellular and molecular responses that will influence their need for and responses (both negative and positive) to specific treatments. Treatments will be able to be chosen more accurately for each patient, resulting in more rapid institution of appropriate, effective therapy. We will also increasingly be able to conduct trials in groups of patients specifically selected as being most likely to respond to the intervention in question. This has already begun with, for example, some new interventions being tested only in patients with coagulopathy or immunosuppressive patterns. Ultimately, as we embrace this era of precision medicine, we may be able to offer precision therapies specifically designed to target the molecular set-up of an individual patient, as has begun to be done in cancer therapeutics.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université libre de Bruxelles, route de Lennik 808, 1070, Bruxelles, Belgium.
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16
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McMahon BA, Koyner JL, Novick T, Menez S, Moran RA, Lonze BE, Desai N, Alasfar S, Borja M, Merritt WT, Ariyo P, Chawla LS, Kraus E. The prognostic value of the furosemide stress test in predicting delayed graft function following deceased donor kidney transplantation. Biomarkers 2017; 23:61-69. [PMID: 29034718 DOI: 10.1080/1354750x.2017.1387934] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES AND METHODS The Furosemide Stress Test (FST) is a novel dynamic assessment of tubular function that has been shown in preliminary studies to predict patients who will progress to advanced stage acute kidney injury, including those who receive renal replacement therapy (RRT). The aim of this study is to investigate if the urinary response to a single intraoperative dose of intravenous furosemide predicts delayed graft function (DGF) in patients undergoing deceased donor kidney transplant. RESULTS On an adjusted multiple logistic regression, a single 100 mg dose of intraoperative furosemide after the anastomosis of the renal vessels (FST) predicted the need for RRT at 2 and 6 h post kidney transplantation (KT). Recipient urinary output was measured at 2 and 6 h post furosemide administration. In receiver-operating characteristic (ROC) analysis, the FST predicted DGF with an area-under-the curve of 0.85 at an optimal urinary output cut-off of <600 mls at 6 h with a sensitivity of and a specificity of 83% and 74%, respectively. CONCLUSIONS The FST is a predictor of DGF post kidney transplant and has the potential to identify patients requiring RRT early after KT.
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Affiliation(s)
- Blaithin A McMahon
- a Division of Nephrology , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Jay L Koyner
- b Section of Nephrology, Department of Medicine , University of Chicago , Chicago , IL , USA
| | - Tessa Novick
- a Division of Nephrology , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Steve Menez
- a Division of Nephrology , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Robert A Moran
- c Division of Gastroenterology, Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Bonnie E Lonze
- d Comprehensive Renal Transplantation Unit , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Niraj Desai
- d Comprehensive Renal Transplantation Unit , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Sami Alasfar
- a Division of Nephrology , Johns Hopkins University School of Medicine , Baltimore , MD , USA.,d Comprehensive Renal Transplantation Unit , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Marvin Borja
- d Comprehensive Renal Transplantation Unit , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - William T Merritt
- e Johns Hopkins Anesthesiology and Critical Care Medicine , Baltimore , MD , USA
| | - Promise Ariyo
- e Johns Hopkins Anesthesiology and Critical Care Medicine , Baltimore , MD , USA
| | - Lakhmir S Chawla
- f Department of Medicine, Division of Intensive Care Medicine and Division of Nephrology , Veterans Affairs Medical Center , Washington DC , USA
| | - Edward Kraus
- a Division of Nephrology , Johns Hopkins University School of Medicine , Baltimore , MD , USA.,d Comprehensive Renal Transplantation Unit , Johns Hopkins University School of Medicine , Baltimore , MD , USA
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17
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Hertzberg D, Rydén L, Pickering JW, Sartipy U, Holzmann MJ. Acute kidney injury-an overview of diagnostic methods and clinical management. Clin Kidney J 2017; 10:323-331. [PMID: 28616210 PMCID: PMC5466115 DOI: 10.1093/ckj/sfx003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 01/13/2017] [Indexed: 12/12/2022] Open
Abstract
Acute kidney injury (AKI) is a common condition in multiple clinical settings. Patients with AKI are at an increased risk of death, over both the short and long term, and of accelerated renal impairment. As the condition has become more recognized and definitions more unified, there has been a rapid increase in studies examining AKI across many different clinical settings. This review focuses on the classification, diagnostic methods and clinical management that are available, or promising, for patients with AKI. Furthermore, preventive measures with fluids, acetylcysteine, statins and remote ischemic preconditioning, as well as when dialysis should be initiated in AKI patients are discussed. The classification of AKI includes both changes in serum creatinine concentrations and urine output. Currently, no kidney injury biomarkers are included in the classification of AKI, but proposals have been made to include them as independent diagnostic markers. Treatment of AKI is aimed at addressing the underlying causes of AKI, and at limiting damage and preventing progression. The key principles are: to treat the underlying disease, to optimize fluid balance and optimize hemodynamics, to treat electrolyte disturbances, to discontinue or dose-adjust nephrotoxic drugs and to dose-adjust drugs with renal elimination.
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Affiliation(s)
- Daniel Hertzberg
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Linda Rydén
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Anesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - John W. Pickering
- Deparment of Medicine, University of Otago Christchurch and Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Ulrik Sartipy
- Section of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Martin J. Holzmann
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Emergency Medicine, Huddinge, Karolinska University Hospital, Stockholm, Sweden
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18
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Perazella MA. Diagnostic Testing in AKI: Let's Move the Field Forward. J Hosp Med 2017; 12:380-381. [PMID: 28459911 DOI: 10.12788/jhm.2735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Mark A Perazella
- Section of Nephrology, Yale University School of Medicine, New Haven, CT
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19
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McMahon BA, Koyner JL. Have biomarkers failed in acute kidney injury? No. Intensive Care Med 2017; 43:887-889. [PMID: 28439644 DOI: 10.1007/s00134-017-4792-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/01/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Blaithin A McMahon
- Division of Nephrology, Johns Hopkins University School of Medicine, 1830 East Monument St, Suite 416, Baltimore, MD, 21287, USA
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, 5841 South Maryland Ave, Suite S-506, MC 5100, Chicago, IL, 60637, USA.
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20
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Affiliation(s)
- Zhi-Yong Peng
- Department of Critical Care Medicine, Zhongnan Hospital, Wuhan University School of Medicine, Wuhan 430071, Hubei Province, China; Center of Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States of America
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