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Ageena SA, Bakr AG, Mokhlis HA, Abd-Ellah MF. Renoprotective effects of apocynin and/or umbelliferone against acrylamide-induced acute kidney injury in rats: role of the NLRP3 inflammasome and Nrf-2/HO-1 signaling pathways. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024:10.1007/s00210-024-03271-9. [PMID: 39028331 DOI: 10.1007/s00210-024-03271-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 07/01/2024] [Indexed: 07/20/2024]
Abstract
Acrylamide (ACR) is a toxic, probably carcinogenic compound commonly found in fried foods and used in the production of many industrial consumer products. ACR-induced acute kidney injury is mediated through several signals. In this research, we investigated, for the first time, the therapeutic effects of phytochemicals apocynin (APO) and/or umbelliferone (UMB) against ACR-induced nephrotoxicity in rats and emphasized the underlying molecular mechanism. To achieve this goal, five groups of rats were randomly assigned: the control group received vehicle (0.5% CMC; 1 ml/rat), ACR (40 mg/kg, i.p.), ACR + APO (100 mg/kg, P.O.), ACR + UMB (50 mg/kg, P.O.), and combination group for 10 days. In ACR-intoxicated rats, there was a significant reduction in weight gain while the levels of blood urea, uric acid, creatinine, and Kim-1 were elevated, indicating renal injury. Histopathological injury was also observed in the kidneys of ACR-intoxicated rats, confirming the biochemical data. Moreover, MDA, TNF-α, and IL-1β levels were raised; and GSH and SOD levels were decreased. In contrast, treatment with APO, UMB, and their combination significantly reduced the kidney function biomarkers, prevented tissue damage, and decreased inflammatory cytokines and MDA. Mechanistically, it suppressed the expression of NLRP-3, ASC, GSDMD, caspase-1, and IL-1β, while it upregulated Nrf-2 and HO-1 in the kidneys of ACR-intoxicated rats. In conclusion, APO, UMB, and their combination prevented ACR-induced nephrotoxicity in rats by attenuating oxidative injury and inflammation, suppressing NLRP-3 inflammasome signaling, enhancing antioxidants, and upregulating Nrf-2 and HO-1 in the kidneys of ACR-induced rats.
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Affiliation(s)
- Saad A Ageena
- Department of Pharmacology & Toxicology, Faculty of Pharmacy, Al Azhar University, Assiut Branch, Assiut, 71524, Egypt.
| | - Adel G Bakr
- Department of Pharmacology & Toxicology, Faculty of Pharmacy, Al Azhar University, Assiut Branch, Assiut, 71524, Egypt
| | - Hamada A Mokhlis
- Department of Pharmacology & Toxicology, Faculty of Pharmacy (Boys), Al-Azhar University, Cairo, Egypt
- Department of Pharmacy Practice, Faculty of Pharmacy, Kantara Branch, Sinai University, Cairo, Egypt
| | - Mohamed F Abd-Ellah
- Department of Pharmacology & Toxicology, Faculty of Pharmacy (Boys), Al-Azhar University, Cairo, Egypt
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de Rooij ENM, Hoogeveen EK, Romijn FPHTM, van der Kooy SW, Veighey KV, Dekker FW, van Kooten C, Cobbaert CM, de Fijter JW. Urinary beta-2 microglobulin increases whereas TIMP-2 and IGFBP7 decline after unilateral nephrectomy in healthy kidney donors. Sci Rep 2024; 14:12901. [PMID: 38839764 PMCID: PMC11153551 DOI: 10.1038/s41598-024-62246-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 05/15/2024] [Indexed: 06/07/2024] Open
Abstract
Early kidney injury may be detected by urinary markers, such as beta-2 microglobulin (B2M), tissue inhibitor of metalloproteinases-2 (TIMP-2), insulin-like growth factor-binding protein 7 (IGFBP7), kidney injury molecule-1 (KIM-1) and/or neutrophil gelatinase-associated lipocalin (NGAL). Of these biomarkers information on pathophysiology and reference ranges in both healthy and diseased populations are scarce. Differences in urinary levels of B2M, TIMP-2, IGFBP7, KIM-1 and NGAL were compared 24 h before and after nephrectomy in 38 living kidney donors from the REnal Protection Against Ischaemia-Reperfusion in transplantation study. Linear regression was used to assess the relation between baseline biomarker concentration and kidney function 1 year after nephrectomy. Median levels of urinary creatinine and creatinine standardized B2M, TIMP-2, IGFBP7, KIM-1, NGAL, and albumin 24 h before nephrectomy in donors were 9.4 mmol/L, 14 μg/mmol, 16 pmol/mmol, 99 pmol/mmol, 63 ng/mmol, 1390 ng/mmol and 0.7 mg/mmol, with median differences 24 h after nephrectomy of - 0.9, + 1906, - 7.1, - 38.3, - 6.9, + 2378 and + 1.2, respectively. The change of donor eGFR after 12 months per SD increment at baseline of B2M, TIMP-2, IGFBP7, KIM-1 and NGAL was: - 1.1, - 2.3, - 0.7, - 1.6 and - 2.8, respectively. Urinary TIMP-2 and IGFBP7 excretion halved after nephrectomy, similar to urinary creatinine, suggesting these markers predominantly reflect glomerular filtration. B2M and NGAL excretion increased significantly, similar to albumin, indicating decreased proximal tubular reabsorption following nephrectomy. KIM-1 did not change considerably after nephrectomy. Even though none of these biomarkers showed a strong relation with long-term donor eGFR, these results provide valuable insight into the pathophysiology of these urinary biomarkers.
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Affiliation(s)
- Esther N M de Rooij
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Ellen K Hoogeveen
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Nephrology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Fred P H T M Romijn
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Kristin V Veighey
- Wessex Kidney Centre, Portsmouth Hospitals NHS Trust, Portsmouth, Hampshire, UK
- Research and Development, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Cees van Kooten
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Christa M Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Johan W de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Nephrology, Antwerp University Hospital, Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), University of Antwerp, Wilrijk, Belgium
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Mekonnen ND, Leulseged TW, Hassen BA, Yemaneberhan KH, Berhe HS, Mera NA, Beyene AA, Getachew LZ, Habtezgi BG, Abriha FN. Hospital-Acquired Acute Kidney Injury in Non-Critical Medical Patients in a Developing Country Tertiary Hospital: Incidence and Predictors. Int J Nephrol Renovasc Dis 2024; 17:125-133. [PMID: 38685967 PMCID: PMC11057508 DOI: 10.2147/ijnrd.s454987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/24/2024] [Indexed: 05/02/2024] Open
Abstract
Background Acute kidney injury (AKI) is a frequent complication in critical patients, leading to a worse prognosis. Although its consequences are worse among critical patients, AKI is also associated with less favorable outcomes in non-critical patients. Therefore, understanding the magnitude of the problem in these patients is crucial, yet there is a scarcity of evidence in non-critical settings, especially in resource limited countries. Hence, the study aimed at determining the incidence and predictors of hospital acquired acute kidney injury (HAAKI) in non-critical medical patients who were admitted at a large tertiary hospital in Ethiopia. Methods A retrospective chart review study was conducted from September 25, 2022 to January 20, 2023 among 232 hospitalized non-critical medical patients admitted to St. Paul's Hospital Millennium Medical College between January 2020 and January 2022. The incidence of HAAKI was estimated using incidence density per total person day (PD) observation of the study participants. To identify predictors of HAAKI, a log binomial regression model was fitted at a p value of ≤0.05. The magnitude of association was measured using adjusted relative risk (ARR) with its 95% CI. Results During the median follow-up duration of 11 days (IQR, 6-19 days), the incidence of HAAKI was estimated to be 6.0 per 100 PD (95% CI = 5.5 to 7.2). Significant predictors of HAAKI were found to be having type 2 diabetes mellitus (ARR = 2.36, 95% CI = 1.03, 5.39, p-value=0.042), and taking vancomycin (ARR = 3.04, 95% CI = 1.38, 6.72, p-value=0.006) and proton pump inhibitors (ARR = 3.80, 95% CI = 1.34,10.82, p-value=0.012). Conclusion HAAKI is a common complication in hospitalized non-critical medical patients, and is associated with a common medical condition and commonly prescribed medications. Therefore, it is important to remain vigilant in the prevention and timely identification of these cases and to establish a system of rational prescribing habits.
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Affiliation(s)
- Nahom Dessalegn Mekonnen
- Department of Internal Medicine, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Tigist Workneh Leulseged
- Department of Internal Medicine, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
- Clinical Research Capacity Building Unit, Medical Research Lounge (MRL), Addis Ababa, Ethiopia
| | | | - Kidus Haile Yemaneberhan
- Department of Internal Medicine, Myungsung Medical College Comprehensive Specialized Hospital, Addis Ababa, Ethiopia
| | | | - Nebiat Adane Mera
- Department of Internal Medicine, Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia
| | - Anteneh Abera Beyene
- Department of Internal Medicine, Myungsung Medical College Comprehensive Specialized Hospital, Addis Ababa, Ethiopia
| | | | | | - Feven Negasi Abriha
- Department of Internal Medicine, Jimma University School of Medicine, Jimma, Ethiopia
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Wainstein M, Flanagan E, Johnson DW, Shrapnel S. Systematic review of externally validated machine learning models for predicting acute kidney injury in general hospital patients. FRONTIERS IN NEPHROLOGY 2023; 3:1220214. [PMID: 37675372 PMCID: PMC10479567 DOI: 10.3389/fneph.2023.1220214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/03/2023] [Indexed: 09/08/2023]
Abstract
Acute kidney injury (AKI) is one of the most common and consequential complications among hospitalized patients. Timely AKI risk prediction may allow simple interventions that can minimize or avoid the harm associated with its development. Given the multifactorial and complex etiology of AKI, machine learning (ML) models may be best placed to process the available health data to generate accurate and timely predictions. Accordingly, we searched the literature for externally validated ML models developed from general hospital populations using the current definition of AKI. Of 889 studies screened, only three were retrieved that fit these criteria. While most models performed well and had a sound methodological approach, the main concerns relate to their development and validation in populations with limited diversity, comparable digital ecosystems, use of a vast number of predictor variables and over-reliance on an easily accessible biomarker of kidney injury. These are potentially critical limitations to their applicability in diverse socioeconomic and cultural settings, prompting a need for simpler, more transportable prediction models which can offer a competitive advantage over the current tools used to predict and diagnose AKI.
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Affiliation(s)
- Marina Wainstein
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Medicine, West Moreton Kidney Health Service, Ipswich Hospital, Brisbane, QLD, Australia
| | - Emily Flanagan
- Faculty of Science, University of Queensland, Brisbane, QLD, Australia
| | - David W. Johnson
- Metro South Kidney and Transplant Services (MSKATS), Princess Alexandra Hospital, Brisbane, QLD, Australia
- Centre for Kidney Disease Research, University of Queensland at Princess Alexandra Hospital, Brisbane, QLD, Australia
- Centre for Kidney Disease Research, Translational Research Institute, Brisbane, QLD, Australia
| | - Sally Shrapnel
- Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia
- Australian Research Council (ARC) Centre of Excellence for Engineered Quantum Systems, School of Mathematics and Physics, University of Queensland, Brisbane, QLD, Australia
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De Arteaga J, Lombi F, Avila R. Global Perspectives in AKI: Argentina. KIDNEY360 2023; 4:e833-e837. [PMID: 37221633 PMCID: PMC10371359 DOI: 10.34067/kid.0000000000000140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/10/2023] [Indexed: 05/25/2023]
Affiliation(s)
- Javier De Arteaga
- Hospital Privado Universitario de Córdoba: Hospital Privado Centro Medico de Cordoba, Córdoba, Argentina
| | - Fernando Lombi
- Hospital Británico de Buenos Aires: Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | - Rafael Avila
- Hospital Privado Universitario de Córdoba: Hospital Privado Centro Medico de Cordoba, Córdoba, Argentina
- Hospital Jose Maria Cullen, Santa Fe, Argentina
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Renoprotective effect of Tanshinone IIA against kidney injury induced by ischemia-reperfusion in obese rats. Aging (Albany NY) 2022; 14:8302-8320. [DOI: 10.18632/aging.204304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/12/2022] [Indexed: 11/25/2022]
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Ang Y, Li S, Ong MEH, Xie F, Teo SH, Choong L, Koniman R, Chakraborty B, Ho AFW, Liu N. Development and validation of an interpretable clinical score for early identification of acute kidney injury at the emergency department. Sci Rep 2022; 12:7111. [PMID: 35501411 PMCID: PMC9061747 DOI: 10.1038/s41598-022-11129-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/12/2022] [Indexed: 12/24/2022] Open
Abstract
Acute kidney injury (AKI) in hospitalised patients is a common syndrome associated with poorer patient outcomes. Clinical risk scores can be used for the early identification of patients at risk of AKI. We conducted a retrospective study using electronic health records of Singapore General Hospital emergency department patients who were admitted from 2008 to 2016. The primary outcome was inpatient AKI of any stage within 7 days of admission based on the Kidney Disease Improving Global Outcome (KDIGO) 2012 guidelines. A machine learning-based framework AutoScore was used to generate clinical scores from the study sample which was randomly divided into training, validation and testing cohorts. Model performance was evaluated using area under the curve (AUC). Among the 119,468 admissions, 10,693 (9.0%) developed AKI. 8491 were stage 1 (79.4%), 906 stage 2 (8.5%) and 1296 stage 3 (12.1%). The AKI Risk Score (AKI-RiSc) was a summation of the integer scores of 6 variables: serum creatinine, serum bicarbonate, pulse, systolic blood pressure, diastolic blood pressure, and age. AUC of AKI-RiSc was 0.730 (95% CI 0.714–0.747), outperforming an existing AKI Prediction Score model which achieved AUC of 0.665 (95% CI 0.646–0.679) on the testing cohort. At a cut-off of 4 points, AKI-RiSc had a sensitivity of 82.6% and specificity of 46.7%. AKI-RiSc is a simple clinical score that can be easily implemented on the ground for early identification of AKI and potentially be applied in international settings.
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Yan X, Ma X, Hao Y, Liu J, Fang H, Lu D, Shen W, Zhang H, Ge W, Zhao Y. Alginate oligosaccharides ameliorate busulfan-induced renal tubule injury. J Funct Foods 2022. [DOI: 10.1016/j.jff.2022.105048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Tso M, Sud K, Van C, Patekar A, Tesfaye W, Castelino RL. Hospital-Acquired Acute Kidney Injury in Noncritical Care Setting: Clinical Characteristics and Outcomes. Int J Clin Pract 2022; 2022:7077587. [PMID: 35685550 PMCID: PMC9159216 DOI: 10.1155/2022/7077587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/01/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is limited Australian data on the incidence and outcomes of hospital-acquired acute kidney injury (HA-AKI) in noncritically ill patients. AIMS This study aimed to characterise HA-AKI and assess the impact of nephrology consultations on outcomes. METHODS A retrospective cohort of all noncritically ill patients with HA-AKI admitted to a large tertiary hospital in 2018 were followed up from hospital admission to discharge. HA-AKI was defined using the Kidney Disease Improving Global Outcomes (KDIGO) criteria. The primary outcome of this study was the clinical characteristics of patients who developed HA-AKI and the difference in these characteristics by nephrology consultation. RESULTS A total of 222 noncritically ill patients were included in the study. The mean age of included patients was 74.8 ± 15.8 years and 57.2% were females. While most patients (92%)were characterised to have KDIGO stage 1, 14% received a nephrology consultation, and 80% had complete or partial recovery of kidney function at discharge. Lower recovery rates (65% versus 83%, P = 0.022), longer hospitalisations (10 versus 5 days, P = 0.001), and higher serum creatinine values on discharge (152 versus 101 μmol/L, P < 0.001) were associated with receipt of nephrology consultation. There was no difference in mortality rates (13% versus 11%, P = 0.754) between those with and without nephrology consultation. CONCLUSIONS Our findings indicate that signficant proportion of noncritically ill patients experience mild form of AKI and have good recovery of kidney function during hospitalisation. Although severity of AKI and length of hospitalisation were associated with nephrology interventions, large scale study is required to understand the impact of such interventions on clinical outcomes, such as hospital readmission and mortality.
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Affiliation(s)
- Maggie Tso
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Camperdown, Australia
| | - Kamal Sud
- The University of Sydney Nepean Clinical School, Faculty of Medicine and Health, Kingswood, Australia
- Renal Medicine, Nepean Hospital, Kingswood, Australia
| | - Connie Van
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Camperdown, Australia
| | - Abhijit Patekar
- Transplantation Medical Unit, Westmead Hospital, Westmead, Australia
| | - Wubshet Tesfaye
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Camperdown, Australia
- The University of Canberra, Health Research Institute, Faculty of Health, Canberra, Australia
| | - Ronald L. Castelino
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Camperdown, Australia
- Department of Pharmacy, Blacktown Hospital, Blacktown, Australia
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Uremic Toxins and Protein-Bound Therapeutics in AKI and CKD: Up-to-Date Evidence. Toxins (Basel) 2021; 14:toxins14010008. [PMID: 35050985 PMCID: PMC8780792 DOI: 10.3390/toxins14010008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/17/2021] [Accepted: 12/18/2021] [Indexed: 12/28/2022] Open
Abstract
Uremic toxins are defined as harmful metabolites that accumulate in the human body of patients whose renal function declines, especially chronic kidney disease (CKD) patients. Growing evidence demonstrates the deteriorating effect of uremic toxins on CKD progression and CKD-related complications, and removing uremic toxins in CKD has become the conventional treatment in the clinic. However, studies rarely pay attention to uremic toxin clearance in the early stage of acute kidney injury (AKI) to prevent progression to CKD despite increasing reports demonstrating that uremic toxins are correlated with the severity of injury or mortality. This review highlights the current evidence of uremic toxin accumulation in AKI and the therapeutic value to prevent CKD progression specific to protein-bound uremic toxins (PBUTs).
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Pistolesi V, Artegiani F, Di Napoli A, Zeppilli L, Santoboni F, Somma S, Di Mario F, Regolisti G, Fiaccadori E, Morabito S. Acute kidney injury referred to the nephrologist: A single centre experience in a tertiary care hospital. Nephrology (Carlton) 2021; 27:145-154. [PMID: 34792220 DOI: 10.1111/nep.14005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/27/2021] [Accepted: 11/15/2021] [Indexed: 11/29/2022]
Abstract
AIM Acute kidney injury (AKI) shows an increasing incidence, accounting for a remarkable proportion of nephrology team in-hospital activity. The aim was to describe main features and outcomes of AKI observed in patients admitted to a tertiary care hospital. METHODS We conducted a retrospective analysis in all consecutive AKI patients referred for nephrology consultation (November 2018-February 2020) focusing on the factors associated with in-hospital mortality within 90 days and kidney function recovery (KFR) upon discharge. Demographic, clinical and laboratory data, as well as main features of AKI episodes, were collected from medical records of the entire hospital stay. AKI was defined according to KDIGO Clinical Practice Guideline. RESULTS Among 1145 patients referred for nephrology consultation, 559 were evaluated for AKI (598 episodes). Pre-existing CKD was present in 54.7% of patients. In 69.2% of cases AKI was evaluated within 48 h from its onset. Most of the episodes (66.6%) were classified as KDIGO Stage 3. In-hospital mortality within 90 days since admission was 43.3%. Multivariate Cox regression analysis showed a higher mortality risk for advancing age (HR 1.02/unit, 95% CI 1.01-1.03) and oliguria (HR 1.91, 95% CI 1.45-2.52), while a higher eGFR (HR 0.72/unit, 95% CI 0.54-0.95) and KFR within 7 days (HR 0.62, 95% CI 0.41-0.94) were associated to a lower mortality. KFR was observed in 96.4% of survivors. In patients with partial KFR, the loss of eGFR was -29.2 ± 17.9 ml/min. KFR incidence rate was 6.79 per 100-person days (95% CI 6.72-6.87) in survivors and 2.30 (95% CI 2.25-2.35) in non-survivors. CONCLUSION AKI-related nephrology activity accounts for most of the nephrologist workload as consultant. Referred AKI episodes are frequently severe and superimposed on CKD, carrying a relatively high mortality in a patient population developing AKI outside ICU. Early KFR appears strongly associated with a favourable impact upon in-hospital survival.
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Affiliation(s)
- Valentina Pistolesi
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università̀ di Roma, Rome, Italy
| | - Federica Artegiani
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università̀ di Roma, Rome, Italy
| | - Anteo Di Napoli
- Istituto Nazionale Salute Migrazione e Povertà (INMP), Rome, Italy
| | - Laura Zeppilli
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università̀ di Roma, Rome, Italy
| | - Francesca Santoboni
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università̀ di Roma, Rome, Italy
| | - Sara Somma
- UOC Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesca Di Mario
- Dipartimento di Medicina e Chirurgia, Università di Parma, UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Giuseppe Regolisti
- UO Clinica e Immunologia Medica, Università di Parma, Azienda Ospedaliero-Universitaria, Parma, Italy
| | - Enrico Fiaccadori
- Dipartimento di Medicina e Chirurgia, Università di Parma, UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Santo Morabito
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università̀ di Roma, Rome, Italy
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Baranwal G, Creed HA, Black LM, Auger A, Quach AM, Vegiraju R, Eckenrode HE, Agarwal A, Rutkowski JM. Expanded renal lymphatics improve recovery following kidney injury. Physiol Rep 2021; 9:e15094. [PMID: 34806312 PMCID: PMC8606868 DOI: 10.14814/phy2.15094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 12/14/2022] Open
Abstract
Acute kidney injury (AKI) is a major cause of patient mortality and a major risk multiplier for the progression to chronic kidney disease (CKD). The mechanism of the AKI to CKD transition is complex but is likely mediated by the extent and length of the inflammatory response following the initial injury. Lymphatic vessels help to maintain tissue homeostasis through fluid, macromolecule, and immune modulation. Increased lymphatic growth, or lymphangiogenesis, often occurs during inflammation and plays a role in acute and chronic disease processes. What roles renal lymphatics and lymphangiogenesis play in AKI recovery and CKD progression remains largely unknown. To determine if the increased lymphatic density is protective in the response to kidney injury, we utilized a transgenic mouse model with inducible, kidney-specific overexpression of the lymphangiogenic protein vascular endothelial growth factor-D to expand renal lymphatics. "KidVD" mouse kidneys were injured using inducible podocyte apoptosis and proteinuria (POD-ATTAC) or bilateral ischemia reperfusion. In the acute injury phase of both models, KidVD mice demonstrated a similar loss of function measured by serum creatinine and glomerular filtration rate compared to their littermates. While the initial inflammatory response was similar, KidVD mice demonstrated a shift toward more CD4+ and fewer CD8+ T cells in the kidney. Reduced collagen deposition and improved functional recovery over time was also identified in KidVD mice. In KidVD-POD-ATTAC mice, an increased number of podocytes were counted at 28 days post-injury. These data demonstrate that increased lymphatic density prior to injury alters the injury recovery response and affords protection from CKD progression.
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Affiliation(s)
- Gaurav Baranwal
- Division of Lymphatic BiologyDepartment of Medical PhysiologyTexas A&M University College of MedicineBryanTexasUSA
| | - Heidi A. Creed
- Division of Lymphatic BiologyDepartment of Medical PhysiologyTexas A&M University College of MedicineBryanTexasUSA
| | - Laurence M. Black
- Department of MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Nephrology Research and Training CenterUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Alexa Auger
- Division of Lymphatic BiologyDepartment of Medical PhysiologyTexas A&M University College of MedicineBryanTexasUSA
| | - Alexander M. Quach
- Division of Lymphatic BiologyDepartment of Medical PhysiologyTexas A&M University College of MedicineBryanTexasUSA
| | - Rahul Vegiraju
- Division of Lymphatic BiologyDepartment of Medical PhysiologyTexas A&M University College of MedicineBryanTexasUSA
| | - Han E. Eckenrode
- Department of MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Nephrology Research and Training CenterUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Anupam Agarwal
- Department of MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Nephrology Research and Training CenterUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Department of Veterans AffairsBirmingham Veterans Administration Medical CenterBirminghamAlabamaUSA
| | - Joseph M. Rutkowski
- Division of Lymphatic BiologyDepartment of Medical PhysiologyTexas A&M University College of MedicineBryanTexasUSA
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Kelly YP, Sharma S, Mothi SS, McCausland FR, Mendu ML, McMahon GM, Palevsky PM, Waikar SS. Hypocalcemia is associated with hypotension during CRRT: A secondary analysis of the Acute Renal Failure Trial Network Study. J Crit Care 2021; 65:261-267. [PMID: 34274834 DOI: 10.1016/j.jcrc.2021.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/22/2021] [Accepted: 07/06/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE We investigated the effect of potentially modifiable continuous renal replacement therapy (CRRT)-related treatment factors on the risk of severe hypotension. MATERIALS AND METHODS We carried out a secondary statistical analysis of the Acute Renal Failure Trial Network (ATN) trial. The primary exposures of interest were CRRT treatment dose, ultrafiltration rate, blood flow rate, ionized calcium level and type of anti-coagulation used. The primary outcome was severe hypotension, defined as vasopressor-inotropic score > 18 and calculated based on treatment doses of vasopressor and inotropic agents. RESULTS Of 1124 individuals enrolled in the ATN Trial, 786 were managed with CRRT. 265/786 (33.7%) patients experienced severe hypotension during the trial. A serum ionized calcium <1.02 mmol/l was associated with a higher risk of severe hypotension compared to a serum calcium >1.02 mmol/l (hazard ratio 2.9; 95% CI 1.5-5.7). There was no significant difference in the risk of hypotension associated with other CRRT treatment factors. CONCLUSIONS Of the CRRT treatment factors studied, hypocalcemia with a serum ionized calcium <1.02 mmol/l was associated with a significantly increased risk of treatment-associated hypotension. Further studies will be required to assess whether treatment targets for serum calcium improve the risk of hypotension during CRRT.
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Affiliation(s)
- Yvelynne P Kelly
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America; Department of Critical Care Medicine, St. James's Hospital, James's Street, Dublin 8, Ireland.
| | - Shilpa Sharma
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Suraj S Mothi
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Finnian R McCausland
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Mallika L Mendu
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Gearoid M McMahon
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Paul M Palevsky
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine and Kidney Medicine Section, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
| | - Sushrut S Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, 650 Albany Street, EBRC 526, Boston, MA 02118, United States of America
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Tai H, Jiang XL, Song N, Xiao HH, Li Y, Cheng MJ, Yin XM, Chen YR, Yang GL, Jiang XY, Kuang JS, Lan ZM, Jia LQ. Tanshinone IIA Combined With Cyclosporine A Alleviates Lung Apoptosis Induced by Renal Ischemia-Reperfusion in Obese Rats. Front Med (Lausanne) 2021; 8:617393. [PMID: 34012969 PMCID: PMC8126627 DOI: 10.3389/fmed.2021.617393] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/19/2021] [Indexed: 11/16/2022] Open
Abstract
Acute lung injury (ALI), which is induced by renal ischemia-reperfusion (IR), is one of the leading causes of acute renal IR-related death. Obesity raises the frequency and severity of acute kidney injury (AKI) and ALI. Tanshinone IIA (TIIA) combined with cyclosporine A (CsA) was employed to lessen the lung apoptosis led by renal IR and to evaluate whether TIIA combined with CsA could alleviate lung apoptosis by regulating mitochondrial function through the PI3K/Akt/Bad pathway in obese rats. Hematoxylin-eosin (HE) staining was used to assess the histology of the lung injury. Terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) was used to assess apoptosis of the lung. Electron microscopy was used to assess mitochondrial morphology in lung cells. Arterial blood gas and pulmonary function were used to assess the external respiratory function. Mitochondrial function was used to assess the internal respiratory function and mitochondrial dynamics and biogenesis. Western blot (WB) was used to examine the PI3K/Akt/Bad pathway-related proteins. TIIA combined with CsA can alleviate lung apoptosis by regulating mitochondrial function through the PI3K/Akt/Bad pathway in obese rats.
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Affiliation(s)
- He Tai
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Xiao-Lin Jiang
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China.,Department of Nephrology, The Fourth of Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine (Shenzhen Traditional Chinese Medicine Hospital), Guangzhou University of Traditional Chinese Medicine, Shenzhen, China
| | - Nan Song
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Hong-He Xiao
- School of Pharmacy, Liaoning University of Traditional Chinese Medicine, Dalian, China
| | - Yue Li
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Mei-Jia Cheng
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Xiao-Mei Yin
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Yi-Ran Chen
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Guan-Lin Yang
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Xiao-Yu Jiang
- Department of Foreign Languages, Dalian Medical University, Dalian, China
| | - Jin-Song Kuang
- Department of Endocrinology and Metabolism, The Fourth People's Hospital of Shenyang, Shenyang, China
| | - Zhi-Ming Lan
- Department of Medical Laboratory, The Fourth Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine (Shenzhen Traditional Chinese Medicine Hospital), Guangzhou University of Traditional Chinese Medicine, Shenzhen, China
| | - Lian-Qun Jia
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
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Tai H, Jiang XL, Lan ZM, Li Y, Kong L, Yao SC, Song N, Lv MJ, Wu J, Yang P, Xiao XS, Yang GL, Kuang JS, Jia LQ. Tanshinone IIA combined with CsA inhibit myocardial cell apoptosis induced by renal ischemia-reperfusion injury in obese rats. BMC Complement Med Ther 2021; 21:100. [PMID: 33752661 PMCID: PMC7986523 DOI: 10.1186/s12906-021-03270-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 03/07/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Acute myocardial injury (AMI), which is induced by renal ischemia-reperfusion (IR), is a significant cause of acute kidney injury (AKI)-related associated death. Obesity increases the severity and frequency of AMI and AKI. Tanshinone IIA (TIIA) combined with cyclosporine A (CsA) pretreatment was used to alleviate myocardial cell apoptosis induced by renal IR, and to determine whether TIIA combined with CsA would attenuate myocardial cell apoptosis by modulating mitochondrial function through the PI3K/Akt/Bad pathway in obese rats. METHODS Male rates were fed a high fat diet for 8 weeks to generate obesity. AKI was induced by 30 min of kidney ischemia followed 24 h of reperfusion. Obese rats were given TIIA (10 mg/kg·d) for 2 weeks and CsA (5 mg/kg) 30 min before renal IR. After 24 h of reperfusion, the rats were anaesthetized, the blood were fetched from the abdominal aorta and kidney were fetched from abdominal cavity, then related indicators were examined. RESULTS TIIA combined with CsA can alleviate the pathohistological injury and apoptosis induced by renal IR in myocardial cells. TIIA combined with CsA improved cardiac function after renal ischemia (30 min)-reperfusion (24 h) in obese rats. At the same time, TIIA combined with CsA improved mitochondrial function. Abnormal function of mitochondria was supported by decreases in respiration controlling rate (RCR), intracellular adenosine triphosphate (ATP), oxygen consumption rate, and mitochondrial membrane potential (MMP), and increases in mitochondrial reactive oxygen species (ROS), opening of the mitochondrial permeability transition pore (mPTP), mitochondrial DNA damage, and mitochondrial respiratory chain complex enzymes. The injury of mitochondrial dynamic function was assessed by decrease in dynamin-related protein 1 (Drp1), and increases in mitofusin1/2 (Mfn1/2), and mitochondrial biogenesis injury was assessed by decreases in PPARγ coactivator-1-α (PGC-1), nucleo respiratory factor1 (Nrf1), and transcription factor A of mitochondrial (TFam). CONCLUSION We used isolated mitochondria from rat myocardial tissues to demonstrate that myocardial mitochondrial dysfunction occurred along with renal IR to induce myocardial cell apoptosis; obesity aggravated apoptosis. TIIA combined with CsA attenuated myocardial cell apoptosis by modulating mitochondrial function through the PI3K/Akt/Bad pathway in obese rats.
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Affiliation(s)
- He Tai
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Xiao-Lin Jiang
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China.,Department of Nephrology, The fourth of Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine (Shenzhen Traditional Chinese Medicine Hospital), Guangzhou University of Traditional Chinese Medicine, Shenzhen, China
| | - Zhi-Ming Lan
- Department of Medical laboratory, The fourth of Affiliated Hospital, Guangzhou University of Traditional Chinese Medicine (Shenzhen Traditional Chinese Medicine Hospital), Guangzhou University of Traditional Chinese Medicine, Shenzhen, China
| | - Yue Li
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Liang Kong
- School of Pharmacy, Liaoning University of Traditional Chinese Medicine, Dalian, China
| | - Si-Cheng Yao
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Nan Song
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Mei-Jun Lv
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Jin Wu
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Ping Yang
- Department of Cardiovascular Medicine, The Affiliated Hospital of Liaoning Traditional Chinese Medicine, Shenyang, China
| | - Xuan-Si Xiao
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Guan-Lin Yang
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Jin-Song Kuang
- Department of Endocrinology and Metabolic, Shenyang the Fourth Hospital of People, Shenyang, China
| | - Lian-Qun Jia
- Key Laboratory of Ministry of Education for Traditional Chinese Medicine Viscera-State Theory and Applications, Liaoning University of Traditional Chinese Medicine, Shenyang, China.
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16
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Tsujimoto H, Tsujimoto Y, Nakata Y, Fujii T, Takahashi S, Akazawa M, Kataoka Y. Pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy. Cochrane Database Syst Rev 2020; 12:CD012467. [PMID: 33314078 PMCID: PMC8812343 DOI: 10.1002/14651858.cd012467.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a major comorbidity in hospitalised patients. Patients with severe AKI require continuous renal replacement therapy (CRRT) when they are haemodynamically unstable. CRRT is prescribed assuming it is delivered over 24 hours. However, it is interrupted when the extracorporeal circuits clot and the replacement is required. The interruption may impair the solute clearance as it causes under dosing of CRRT. To prevent the circuit clotting, anticoagulation drugs are frequently used. OBJECTIVES To assess the benefits and harms of pharmacological interventions for preventing clotting in the extracorporeal circuits during CRRT. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We selected randomised controlled trials (RCTs or cluster RCTs) and quasi-RCTs of pharmacological interventions to prevent clotting of extracorporeal circuits during CRRT. DATA COLLECTION AND ANALYSIS Data were abstracted and assessed independently by two authors. Dichotomous outcomes were calculated as risk ratio (RR) with 95% confidence intervals (CI). The primary review outcomes were major bleeding, successful prevention of clotting (no need of circuit change in the first 24 hours for any reason), and death. Evidence certainty was determined using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. MAIN RESULTS A total of 34 completed studies (1960 participants) were included in this review. We identified seven ongoing studies which we plan to assess in a future update of this review. No included studies were free from risk of bias. We rated 30 studies for performance bias and detection bias as high risk of bias. We rated 18 studies for random sequence generation,ÃÂ ÃÂ six studies for the allocation concealment, three studies for performance bias, three studies for detection bias,ÃÂ nine studies for attrition bias,ÃÂ 14 studies for selective reporting and nine studies for the other potential source of bias, as having low risk of bias. We identified eight studies (581 participants) that compared citrate with unfractionated heparin (UFH). Compared to UFH, citrate probably reduces major bleeding (RR 0.22, 95% CI 0.08 to 0.62; moderate certainty evidence) and probably increases successful prevention of clotting (RR 1.44, 95% CI 1.10 to 1.87; moderate certainty evidence). Citrate may have little or no effect on death at 28 days (RR 1.06, 95% CI 0.86 to 1.30, moderate certainty evidence). Citrate versus UFH may reduce the number of participants who drop out of treatment due to adverse events (RR 0.47, 95% CI 0.15 to 1.49; low certainty evidence). Compared to UFH, citrate may make little or no difference to the recovery of kidney function (RR 1.04, 95% CI 0.89 to 1.21; low certainty evidence). Compared to UFH, citrate may reduceÃÂ thrombocytopenia (RR 0.39, 95% CI 0.14 to 1.03; low certainty evidence). It was uncertain whether citrate reduces a cost to health care services because of inadequate data. For low molecular weight heparin (LMWH) versus UFH, six studies (250 participants) were identified. Compared to LMWH, UFH may reduce major bleeding (0.58, 95% CI 0.13 to 2.58; low certainty evidence). It is uncertain whether UFH versus LMWH reduces death at 28 days or leads to successful prevention of clotting. Compared to LMWH, UFH may reduce the number of patient dropouts from adverse events (RR 0.29, 95% CI 0.02 to 3.53; low certainty evidence). It was uncertain whether UFH versus LMWH leads to the recovery of kidney function because no included studies reported this outcome. It was uncertain whether UFH versus LMWH leads to thrombocytopenia. It was uncertain whether UFH reduces a cost to health care services because of inadequate data. For the comparison of UFH to no anticoagulation, one study (10 participants) was identified. It is uncertain whether UFH compare to no anticoagulation leads to more major bleeding. It is uncertain whether UFH improves successful prevention of clotting in the first 24 hours, death at 28 days, the number of patient dropouts due to adverse events, recovery of kidney function, thrombocytopenia, or cost to health care services because no study reported these outcomes. For the comparison ofÃÂ citrate to no anticoagulation,ÃÂ no completed study was identified. AUTHORS' CONCLUSIONS Currently,ÃÂ available evidence does not support the overall superiority of any anticoagulant to another. Compared to UFH, citrate probably reduces major bleeding and prevents clotting and probably has little or no effect on death at 28 days. For other pharmacological anticoagulation methods, there is no available data showing overall superiority to citrate or no pharmacological anticoagulation. Further studies are needed to identify patient populations in which CRRT should commence with no pharmacological anticoagulation or with citrate.
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Affiliation(s)
- Hiraku Tsujimoto
- Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Yasushi Tsujimoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yukihiko Nakata
- Department of Mathematics, Shimane University, Matsue, Japan
| | - Tomoko Fujii
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sei Takahashi
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence (CiRC2LE), Fukushima Medical University, Fukushima, Japan
| | - Mai Akazawa
- Department of Anesthesia, Shiga University of Medical Science Hospital, Otsu, Japan
| | - Yuki Kataoka
- Department of Respiratory Medicine, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
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17
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Liu KD, Goldstein SL, Vijayan A, Parikh CR, Kashani K, Okusa MD, Agarwal A, Cerdá J. AKI!Now Initiative: Recommendations for Awareness, Recognition, and Management of AKI. Clin J Am Soc Nephrol 2020; 15:1838-1847. [PMID: 32317329 PMCID: PMC7769012 DOI: 10.2215/cjn.15611219] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The American Society of Nephrology has established a new initiative, AKI!Now, with the goal of promoting excellence in the prevention and treatment of AKI by building a foundational program that transforms education and delivery of AKI care, aiming to reduce morbidity and associated mortality and to improve long-term outcomes. In this article, we describe our current efforts to improve early recognition and management involving inclusive interdisciplinary collaboration between providers, patients, and their families; discuss the ongoing need to change some of our current AKI paradigms and diagnostic methods; and provide specific recommendations to improve AKI recognition and care. In the hospital and the community, AKI is a common and increasingly frequent condition that generates risks of adverse events and high costs. Unfortunately, patients with AKI may frequently have received less than optimal quality of care. New classifications have facilitated understanding of AKI incidence and its impact on outcomes, but they are not always well aligned with AKI pathophysiology. Despite ongoing research efforts, treatments to promote or hasten kidney recovery remain ineffective. To avoid progression, the current approach to AKI emphasizes the promotion of early recognition and timely response. However, a lack of awareness of the importance of early recognition and treatment among health care team members and the heterogeneity of approaches within the health care teams assessing the patient remains a major challenge. Early identification is further complicated by differences in settings where AKI occurs (the community or the hospital), and by differences in patient populations and cultures between the intensive care unit and ward environments. To address these obstacles, we discuss the need to improve education at all levels of care and to generate specific guidance on AKI evaluation and management, including the development of a widely applicable education and an AKI management toolkit, engaging hospital administrators to incorporate AKI as a quality initiative, and raising awareness of AKI as a complication of other disease processes.
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Affiliation(s)
- Kathleen D. Liu
- University of California at San Francisco School of Medicine, University of California San Francisco, San Francisco, California
| | - Stuart L. Goldstein
- Center for Acute Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Anitha Vijayan
- Division of Nephrology, Washington University in St. Louis, St. Louis, Missouri
| | - Chirag R. Parikh
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark D. Okusa
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Anupam Agarwal
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jorge Cerdá
- St. Peter’s Health Partners, Albany, New York
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18
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Tsujimoto H, Tsujimoto Y, Nakata Y, Fujii T, Takahashi S, Akazawa M, Kataoka Y. Pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy. Cochrane Database Syst Rev 2020; 3:CD012467. [PMID: 32164041 PMCID: PMC7067597 DOI: 10.1002/14651858.cd012467.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a major comorbidity in hospitalised patients. Patients with severe AKI require continuous renal replacement therapy (CRRT) when they are haemodynamically unstable. CRRT is prescribed assuming it is delivered over 24 hours. However, it is interrupted when the extracorporeal circuits clot and the replacement is required. The interruption may impair the solute clearance as it causes under dosing of CRRT. To prevent the circuit clotting, anticoagulation drugs are frequently used. OBJECTIVES To assess the benefits and harms of pharmacological interventions for preventing clotting in the extracorporeal circuits during CRRT. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We selected randomised controlled trials (RCTs or cluster RCTs) and quasi-RCTs of pharmacological interventions to prevent clotting of extracorporeal circuits during CRRT. DATA COLLECTION AND ANALYSIS Data were abstracted and assessed independently by two authors. Dichotomous outcomes were calculated as risk ratio (RR) with 95% confidence intervals (CI). The primary review outcomes were major bleeding, successful prevention of clotting (no need of circuit change in the first 24 hours for any reason), and death. Evidence certainty was determined using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. MAIN RESULTS A total of 34 completed studies (1960 participants) were included in this review. We identified seven ongoing studies which we plan to assess in a future update of this review. No included studies were free from risk of bias. We rated 30 studies for performance bias and detection bias as high risk of bias. We rated 18 studies for random sequence generation, six studies for the allocation concealment, three studies for performance bias, three studies for detection bias, nine studies for attrition bias, 14 studies for selective reporting and nine studies for the other potential source of bias, as having low risk of bias. We identified eight studies (581 participants) that compared citrate with unfractionated heparin (UFH). Compared to UFH, citrate probably reduces major bleeding (RR 0.22, 95% CI 0.08 to 0.62; moderate certainty evidence). Citrate may have little or no effect on death at 28 days (RR 1.06, 95% CI 0.86 to 1.30, moderate certainty evidence), while citrate versus UFH may have little or no effect on successful prevention of clotting (RR 1.01, 95% CI 0.77 to 1.32; moderate certainty evidence). Citrate versus UFH may reduce the number of participants who drop out of treatment due to adverse events (RR 0.47, 95% CI 0.15 to 1.49; low certainty evidence). Compared to UFH, citrate may make little or no difference to the recovery of kidney function (RR 0.95, 95% CI 0.66 to 1.36; low certainty evidence). Compared to UFH, citrate may reduce thrombocytopenia (RR 0.39, 95% CI 0.14 to 1.03; low certainty evidence). It was uncertain whether citrate reduces a cost to health care services because of inadequate data. For low molecular weight heparin (LMWH) versus UFH, six studies (250 participants) were identified. Compared to LMWH, UFH may reduce major bleeding (0.58, 95% CI 0.13 to 2.58; low certainty evidence). It is uncertain whether UFH versus LMWH reduces death at 28 days or leads to successful prevention of clotting. Compared to LMWH, UFH may reduce the number of patient dropouts from adverse events (RR 0.29, 95% CI 0.02 to 3.53; low certainty evidence). It was uncertain whether UFH versus LMWH leads to the recovery of kidney function because no included studies reported this outcome. It was uncertain whether UFH versus LMWH leads to thrombocytopenia. It was uncertain whether UFH reduces a cost to health care services because of inadequate data. For the comparison of UFH to no anticoagulation, one study (10 participants) was identified. It is uncertain whether UFH compare to no anticoagulation leads to more major bleeding. It is uncertain whether UFH improves successful prevention of clotting in the first 24 hours, death at 28 days, the number of patient dropouts due to adverse events, recovery of kidney function, thrombocytopenia, or cost to health care services because no study reported these outcomes. For the comparison of citrate to no anticoagulation, no completed study was identified. AUTHORS' CONCLUSIONS Currently, available evidence does not support the overall superiority of any anticoagulant to another. Compared to UFH, citrate probably reduces major bleeding and probably has little or no effect on preventing clotting or death at 28 days. For other pharmacological anticoagulation methods, there is no available data showing overall superiority to citrate or no pharmacological anticoagulation. Further studies are needed to identify patient populations in which CRRT should commence with no pharmacological anticoagulation or with citrate.
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Affiliation(s)
- Hiraku Tsujimoto
- Hyogo Prefectural Amagasaki General Medical CenterHospital Care Research UnitHigashi‐Naniwa‐Cho 2‐17‐77AmagasakiHyogoHyogoJapan606‐8550
| | - Yasushi Tsujimoto
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
| | - Yukihiko Nakata
- Shimane UniversityDepartment of Mathematics1060 Nishikawatsu choMatsue690‐8504Japan
| | - Tomoko Fujii
- Monash UniversityAustralian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive MedicineMelbourneVICAustralia
| | - Sei Takahashi
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
- Fukushima Medical UniversityCenter for Innovative Research for Communities and Clinical Excellence (CiRC2LE)1 HikarigaokaFukushimaFukushimaJapan960‐1295
| | - Mai Akazawa
- Shiga University of Medical Science HospitalDepartment of AnesthesiaSeta‐Tsukinowa‐choOtsuShigaJapan520‐2192
| | - Yuki Kataoka
- Hyogo Prefectural Amagasaki General Medical CenterDepartment of Respiratory Medicine2‐17‐77, Higashi‐Naniwa‐ChoAmagasakiHyogoJapan660‐8550
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19
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Hsu CY, Chinchilli VM, Coca S, Devarajan P, Ghahramani N, Go AS, Hsu RK, Ikizler TA, Kaufman J, Liu KD, Parikh CR, Reeves WB, Wurfel M, Zappitelli M, Kimmel PL, Siew ED. Post-Acute Kidney Injury Proteinuria and Subsequent Kidney Disease Progression: The Assessment, Serial Evaluation, and Subsequent Sequelae in Acute Kidney Injury (ASSESS-AKI) Study. JAMA Intern Med 2020; 180:402-410. [PMID: 31985750 PMCID: PMC6990681 DOI: 10.1001/jamainternmed.2019.6390] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE Among patients who had acute kidney injury (AKI) during hospitalization, there is a need to improve risk prediction such that those at highest risk for subsequent loss of kidney function are identified for appropriate follow-up. OBJECTIVE To evaluate the association of post-AKI proteinuria with increased risk of future loss of renal function. DESIGN, SETTING, AND PARTICIPANTS The Assessment, Serial Evaluation, and Subsequent Sequelae in Acute Kidney Injury (ASSESS-AKI) Study was a multicenter prospective cohort study including 4 clinical centers in North America included 1538 patients enrolled 3 months after hospital discharge between December 2009 and February 2015. EXPOSURES Urine albumin-to-creatinine ratio (ACR) quantified 3 months after hospital discharge. MAIN OUTCOMES AND MEASURES Kidney disease progression defined as halving of estimated glomerular filtration rate (eGFR) or end-stage renal disease. RESULTS Of the 1538 participants, 769 (50%) had AKI durring hospitalization. The baseline study visit took place at a mean (SD) 91 (23) days after discharge. The mean (SD) age was 65 (13) years; the median eGFR was 68 mL/min/1.73 m2; and the median urine ACR was 15 mg/g. Overall, 547 (37%) study participants were women and 195 (13%) were black. After a median follow-up of 4.7 years, 138 (9%) participants had kidney disease progression. Higher post-AKI urine ACR level was associated with increased risk of kidney disease progression (hazard ratio [HR], 1.53 for each doubling; 95% CI, 1.45-1.62), and urine ACR measurement was a strong discriminator for future kidney disease progression (C statistic, 0.82). The performance of urine ACR was stronger in patients who had had AKI than in those who had not (C statistic, 0.70). A comprehensive model of clinical risk factors (eGFR, blood pressure, and demographics) including ACR provided better discrimination for predicting kidney disease progression after hospital discharge among those who had had AKI (C statistic, 0.85) vs those who had not (C statistic, 0.76). In the entire matched cohort, after taking into account urine ACR, eGFR, demographics, and traditional chronic kidney risk factors determined 3 months after discharge, AKI (HR, 1.46; 95% CI, 0.51-4.13 for AKI vs non-AKI) or severity of AKI (HR, 1.54; 95% CI, 0.50-4.72 for AKI stage 1 vs non-AKI; HR, 0.56; 95% CI, 0.07-4.84 for AKI stage 2 vs non-AKI; HR, 2.24; 95% CI, 0.33-15.29 for AKI stage 3 vs non-AKI) was not independently associated with more rapid kidney disease progression. CONCLUSIONS AND RELEVANCE Proteinuria level is a valuable risk-stratification tool in the post-AKI period. These results suggest there should be more widespread and routine quantification of proteinuria after hospitalized AKI.
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Affiliation(s)
- Chi-Yuan Hsu
- Division of Nephrology, University of California School of Medicine, San Francisco, San Francisco.,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Vernon M Chinchilli
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey
| | - Steven Coca
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Prasad Devarajan
- Cincinnati Children's Hospital, Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, Ohio
| | - Nasrollah Ghahramani
- Division of Nephrology, Department of Medicine, Pennsylvania State University College of Medicine, Hershey
| | - Alan S Go
- Division of Nephrology, University of California School of Medicine, San Francisco, San Francisco.,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Raymond K Hsu
- Division of Nephrology, University of California School of Medicine, San Francisco, San Francisco
| | - T Alp Ikizler
- Vanderbilt Center for Kidney Disease, Division of Nephrology & Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James Kaufman
- Renal Section, Veterans Affairs New York Harbor Health Care System, New York University School of Medicine, New York
| | - Kathleen D Liu
- Division of Nephrology, University of California School of Medicine, San Francisco, San Francisco
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - W Brian Reeves
- University of Texas, Long School of Medicine, San Antonio
| | - Mark Wurfel
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle
| | - Michael Zappitelli
- Hospital for Sick Children, Division of Nephrology, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Paul L Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Edward D Siew
- Vanderbilt Center for Kidney Disease, Division of Nephrology & Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee.,Tennessee Valley Health Services, Nashville Veterans Affairs Hospital, Nashville, Tennessee
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Ruan H, Wang L, Wang J, Sun H, He X, Li W, Zhang J. Sika deer antler protein against acetaminophen-induced oxidative stress and apoptosis in HK-2 cells via activating Nrf2/keap1/HO-1 pathway. J Food Biochem 2019; 43:e13067. [PMID: 31599006 DOI: 10.1111/jfbc.13067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/03/2019] [Accepted: 09/12/2019] [Indexed: 12/22/2022]
Abstract
Nf-E2-related transcription factor 2 (Nrf2) helps cells fight oxidative stress events in vivo and in vitro by promoting the expression of antioxidants and detoxification enzymes. The necessary factors regulating Nrf2 activity and stability during analgesic nephropathy are not fully understood. Our results suggest that acetaminophen produces nephrotoxicity in HK-2 cells by inhibiting keap1 degradation. APAP subsided Nrf2 nuclear accumulation by inhibition of keap1 degradation, thereby reducing the binding of Nrf2 to ARE, leading to the loss of expression of antioxidant proteins such as HO-1, inducing a series of oxidative stress and apoptosis events. Therefore, Nrf2/keap1/HO-1 signal transduction pathway has a poor prognosis during analgesic nephrotoxicity. Sika deer antler protein (SDAPR) significantly prevented APAP-induced HK-2 cell damage by constitutively stabilized Nrf2 nuclear retention. Excess APAP leads to a decrease in Nrf2 nuclear translocation, leading to severe oxidative stress, increasing the levels of GSH and MDA in HK-2 cells, and reducing the enzyme activities of SOD and CAT in HK-2 cells. Increased biomarker levels of acute kidney injury (AKI) in HK-2 cells, including kidney injury molecule-1, neutrophil gelatinase-associated lipocalin and cystatin C, decrease the mitochondrial membrane potential in HK-2 cells, and cause mitochondrial dysfunction, it also reduced the ratio of mitochondria-associated apoptotic protein Bax/Bcl-2, leading to cell apoptosis. SDAPR dose dependently accorded protection against acetaminophen-induced nephrotoxicity, oxidative damage, and cell apoptosis by its molecular intervention with Nrf2/keap1/HO-1 pathway via keap1 degradation. PRACTICAL APPLICATIONS: In this paper, we investigated the protective effect of SDAPR on APAP-induced AKI in HK-2 cells, and briefly explained its possible mechanism of action, providing a basis for future clinical trials and the development of anti-APAP AKI drugs.
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Affiliation(s)
- Haonan Ruan
- College of Chinese Medicine Materials, Jilin Agricultural University, Chang Chun, China
| | - Lulu Wang
- College of Medicine, Changchun Sci-Tech University, Chang Chun, China
| | - Jing Wang
- Department of Neurology, Jilin Province FAW General Hospital, Chang Chun, China
| | - Hang Sun
- College of Chinese Medicine Materials, Jilin Agricultural University, Chang Chun, China
| | - Xiaofeng He
- College of Chinese Medicine Materials, Jilin Agricultural University, Chang Chun, China
| | - Wei Li
- College of Chinese Medicine Materials, Jilin Agricultural University, Chang Chun, China
| | - Jing Zhang
- College of Chinese Medicine Materials, Jilin Agricultural University, Chang Chun, China.,College of Medicine, Changchun Sci-Tech University, Chang Chun, China
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21
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Griffin BR, Thomson A, Yoder M, Francis I, Ambruso S, Bregman A, Feller M, Johnson-Bortolotto S, King C, Bonnes D, Dufficy L, Wu C, Bansal A, Tad-Y D, Faubel S, Jalal D. Continuous Renal Replacement Therapy Dosing in Critically Ill Patients: A Quality Improvement Initiative. Am J Kidney Dis 2019; 74:727-735. [PMID: 31540789 DOI: 10.1053/j.ajkd.2019.06.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 06/20/2019] [Indexed: 02/08/2023]
Abstract
RATIONALE & OBJECTIVE Clinical practice guidelines recommend delivering a continuous renal replacement therapy (CRRT) dose of 20 to 25mL/kg/h. However, practice patterns nationwide are highly variable; this inconsistent prescribing may lead to errors in medication dosing and increase rates of electrolyte and acid-base abnormalities. We describe an initiative to standardize CRRT practice patterns and reduce dosing variability. STUDY DESIGN Quality improvement study. SETTING & PARTICIPANTS Adult patients treated with CRRT at the University of Colorado Hospital between January 2016 and October 2017. QUALITY IMPROVEMENT ACTIVITIES An assessment of the magnitude of the variability in CRRT dosing and the following specific interventions were implemented during the course of 1 year: (1) modification of the electronic medical record (EMR) to include calculated average 24-hour dose in real time, (2) modification of the CRRT procedure note to include comments on dosing, (3) modification of the CRRT order set to display calculations, and (4) yearly educational sessions for renal fellows outlining CRRT-specific dosing targets. OUTCOMES The primary outcome was weekly percentage of CRRT treatments with an average delivered daily dose of 20 to 25mL/kg/h. Process and balancing outcomes included CRRT flowsheet accuracy, documentation of rates of delivered dose, and nursing satisfaction. ANALYTICAL APPROACH Rates of weekly CRRT dosing in compliance with national guidelines were determined and used to create run charts showing compliance rates before and after the quality improvement interventions. RESULTS Among 837 treatments before the intervention, 279 (33%) daily CRRT sessions achieved an average dose of 20 to 25mL/kg/h. Following implementation of interventions, 631 of 952 (66%) treatments achieved this goal. Week-to-week variation in dosing was significantly reduced. LIMITATIONS A single-center study generating data that may not be generalizable to institutions with different CRRT nursing models or different EMR systems. CONCLUSIONS Changes to the EMR and documentation templates and education of CRRT providers about dosing were associated with doubling of the rate of appropriate CRRT dosing and reduction in dosing variability.
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Affiliation(s)
- Benjamin R Griffin
- Division of Renal Diseases and Hypertension/Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.
| | | | - Mark Yoder
- University of Colorado Health, Aurora, CO
| | - Isaiah Francis
- University of Colorado School of Public Health, Aurora, CO
| | - Sophia Ambruso
- Division of Renal Diseases and Hypertension/Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Renal Section, Rocky Mountain Regional VA Medical Center, Aurora, CO
| | - Adam Bregman
- Division of Renal Diseases and Hypertension/Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | | | | | | | | | - Chaorong Wu
- Department of Biostatistics, Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA
| | - Anip Bansal
- Division of Renal Diseases and Hypertension/Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Darlene Tad-Y
- Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sarah Faubel
- Division of Renal Diseases and Hypertension/Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Renal Section, Rocky Mountain Regional VA Medical Center, Aurora, CO
| | - Diana Jalal
- Division of Nephrology/Department of Medicine, University of Iowa, Iowa City, IA
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Garay OU, Palacios A, Pichon-Riviere A, Augustovski F, Martí SG, Hernández-Vásquez A, López ET, Rosa-Díez G, Bardach A. The Cost-Effectiveness of Continuous Versus Intermittent Renal Replacement Therapies in Acute Kidney Injury: Perspective of the Social Services for the Elderly in Argentina. Value Health Reg Issues 2019; 20:142-148. [PMID: 31426017 DOI: 10.1016/j.vhri.2019.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 02/01/2019] [Accepted: 03/08/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a public health problem that affects millions of hospitalized patients worldwide. In Argentina, evidence suggests that its incidence has risen in recent years. When severe, AKI may require a renal replacement therapy (RRT) where continuous RRT (CRRT) and intermittent RRT (IRRT) are plausible options for patients in the intensive care unit. OBJECTIVE To evaluate the cost utility of CRRT versus IRRT for the National Institute of Social Services for Retirees and Pensioners, the largest social security health insurance for elders in Argentina. METHODS This was a model-based cost-utility analysis. Long-term costs and health outcomes were estimated for a hypothetical cohort with a Markov model. Parameters used were obtained from published literature and validated with local experts. Local costs were estimated and expressed in $AR of 2016. Several sensitivity analyses were run to analyze the impact of uncertainty on results. RESULTS Continuous RRT dominated IRRT by cumulating over the model more quality-adjusted life years and less costs. Total discounted quality-adjusted life years for both cohorts were 1049 and 1034, respectively, and total costs were $95 362 and $103 871. Cost-effectiveness (CE) results reflect these differences in favor of CRRT with a deterministic cost-saving incremental CE ratio and a probability of CRRT being CE of 65.4%, considering a CE threshold of 1 gross domestic product per capita. CONCLUSIONS Continuous RRT for patients with AKI eligible for CRRT or IRRT would probably be a cost-effective intervention for the National Institute of Social Services for Retirees and Pensioners' view. Nevertheless, there is considerable uncertainty around results, mainly due to the lack of adequate controlled studies and local data on the prognosis of these patients in Argentina.
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23
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Chicoric acid prevents methotrexate-induced kidney injury by suppressing NF-κB/NLRP3 inflammasome activation and up-regulating Nrf2/ARE/HO-1 signaling. Inflamm Res 2019; 68:511-523. [DOI: 10.1007/s00011-019-01241-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/22/2019] [Accepted: 04/24/2019] [Indexed: 12/15/2022] Open
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24
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Mahmoud AM, Germoush MO, Al-Anazi KM, Mahmoud AH, Farah MA, Allam AA. Commiphora molmol protects against methotrexate-induced nephrotoxicity by up-regulating Nrf2/ARE/HO-1 signaling. Biomed Pharmacother 2018; 106:499-509. [DOI: 10.1016/j.biopha.2018.06.171] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 06/28/2018] [Accepted: 06/29/2018] [Indexed: 12/19/2022] Open
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Abstract
PURPOSE OF REVIEW Quality measure assessment and reporting is evolving in end-stage renal disease care and is inchoate in ambulatory nephrology clinic care. Acute kidney injury (AKI) quality measures have not received sufficient attention, yet deserve consideration in view of the substantial proportion of effort nephrology providers devote to AKI care. RECENT FINDINGS Accumulating literature permits consideration of timing of nephrology consultation, follow-up after AKI hospitalization, early detection, medication dosing, hospital readmissions and length of stay, cost, and mortality as potential AKI quality measures. SUMMARY We review candidate AKI quality measures and assess the strength of evidence supporting the use of each measure as a standard for AKI care.
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26
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Koyner JL, Carey KA, Edelson DP, Churpek MM. The Development of a Machine Learning Inpatient Acute Kidney Injury Prediction Model. Crit Care Med 2018; 46:1070-1077. [PMID: 29596073 DOI: 10.1097/ccm.0000000000003123] [Citation(s) in RCA: 171] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To develop an acute kidney injury risk prediction model using electronic health record data for longitudinal use in hospitalized patients. DESIGN Observational cohort study. SETTING Tertiary, urban, academic medical center from November 2008 to January 2016. PATIENTS All adult inpatients without pre-existing renal failure at admission, defined as first serum creatinine greater than or equal to 3.0 mg/dL, International Classification of Diseases, 9th Edition, code for chronic kidney disease stage 4 or higher or having received renal replacement therapy within 48 hours of first serum creatinine measurement. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographics, vital signs, diagnostics, and interventions were used in a Gradient Boosting Machine algorithm to predict serum creatinine-based Kidney Disease Improving Global Outcomes stage 2 acute kidney injury, with 60% of the data used for derivation and 40% for validation. Area under the receiver operator characteristic curve (AUC) was calculated in the validation cohort, and subgroup analyses were conducted across admission serum creatinine, acute kidney injury severity, and hospital location. Among the 121,158 included patients, 17,482 (14.4%) developed any Kidney Disease Improving Global Outcomes acute kidney injury, with 4,251 (3.5%) developing stage 2. The AUC (95% CI) was 0.90 (0.90-0.90) for predicting stage 2 acute kidney injury within 24 hours and 0.87 (0.87-0.87) within 48 hours. The AUC was 0.96 (0.96-0.96) for receipt of renal replacement therapy (n = 821) in the next 48 hours. Accuracy was similar across hospital settings (ICU, wards, and emergency department) and admitting serum creatinine groupings. At a probability threshold of greater than or equal to 0.022, the algorithm had a sensitivity of 84% and a specificity of 85% for stage 2 acute kidney injury and predicted the development of stage 2 a median of 41 hours (interquartile range, 12-141 hr) prior to the development of stage 2 acute kidney injury. CONCLUSIONS Readily available electronic health record data can be used to predict impending acute kidney injury prior to changes in serum creatinine with excellent accuracy across different patient locations and admission serum creatinine. Real-time use of this model would allow early interventions for those at high risk of acute kidney injury.
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Affiliation(s)
- Jay L Koyner
- All authors: Department of Medicine, University of Chicago, Chicago, IL
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27
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Mallappallil MC, Fishbane S, Wanchoo R, Lerma E, Roche-Recinos A, Salifu M. Practice patterns in transitioning patients from chronic kidney disease to dialysis: a survey of United States nephrologists. BMC Nephrol 2018; 19:147. [PMID: 29929485 PMCID: PMC6013940 DOI: 10.1186/s12882-018-0943-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 06/07/2018] [Indexed: 11/15/2022] Open
Abstract
Background There are no guidelines for transitioning patients from chronic kidney disease stage 5 to hemodialysis. We conducted this study to determine if there are uniform patterns in how nephrologists transition patients to dialysis. Methods We designed an electronic survey with 39 questions and sent it to a database of practicing nephrologists at the National Kidney Foundation. Factors that were important for transitioning a patient to hemodialysis were evaluated, including medication changes on dialysis initiation, dry weight and dialysis prescription. Results 160 US Nephrologists replied to the survey; 18% (29/160) of the responses were completed via social media sites. Prior to dialysis, 74% (118/160), prescribed furosemide and 67% (107/160) used furosemide with metolazone. Once dialysis started, only 46% (74/160) of the responders continued patients on diuretics daily. Hypertension medications prescribed in dialysis were calcium channel blockers 69% (112/160), beta blockers 36% (58/160), angiotensin converting enzyme inhibitor 32% (53/160), angiotensin receptor blocker 29% (46/160) and diuretics 25% (42/160). Once dialysis started, 68% (109/160) routinely changed medications. Most, 67% (107/160) ordered patients to avoid anti-hypertensive medications on dialysis days to allow for ultrafiltration. Dry weight was determined in the first week by 29% (46/160) and in the first month by 53% (85/160). Most, 59% (94/160) felt that multiple causes lead to hypertension. Most nephrologists would prescribe small dialyzers and a shorter period of time for the first dialysis session. Conclusion The transition period to chronic hemodialysis has variations in practice patterns and may benefit from further studies to optimize clinical practice. Electronic supplementary material The online version of this article (10.1186/s12882-018-0943-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mary C Mallappallil
- Division of Nephrology, State University of New York at Downstate, 450 Clarkson Avenue, Box 52, Brooklyn, New York, 11203, USA.
| | - Steven Fishbane
- Division of Nephrology, Hofstra Northwell School of Medicine, Manhasset, USA
| | - Rimda Wanchoo
- Division of Nephrology, Hofstra Northwell School of Medicine, Manhasset, USA
| | - Edgar Lerma
- Division of Nephrology, University of Illinois at Chicago, Chicago, USA
| | - Andrea Roche-Recinos
- Division of Nephrology, State University of New York at Downstate, 450 Clarkson Avenue, Box 52, Brooklyn, New York, 11203, USA
| | - Moro Salifu
- Division of Nephrology, State University of New York at Downstate, 450 Clarkson Avenue, Box 52, Brooklyn, New York, 11203, USA
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Kishore BK, Robson SC, Dwyer KM. CD39-adenosinergic axis in renal pathophysiology and therapeutics. Purinergic Signal 2018; 14:109-120. [PMID: 29332180 PMCID: PMC5940625 DOI: 10.1007/s11302-017-9596-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 11/28/2017] [Indexed: 12/12/2022] Open
Abstract
Extracellular ATP interacts with purinergic type 2 (P2) receptors and elicits many crucial biological functions. Extracellular ATP is sequentially hydrolyzed to ADP and AMP by the actions of defined nucleotidases, such as CD39, and AMP is converted to adenosine, largely by CD73, an ecto-5'-nucleotidase. Extracellular adenosine interacts with P1 receptors and often opposes the effects of P2 receptor activation. The balance between extracellular ATP and adenosine in the blood and extracellular fluid is regulated chiefly by the activities of CD39 and CD73, which constitute the CD39-adenosinergic axis. In recent years, several studies have shown this axis to play critical roles in transport of water/sodium, tubuloglomerular feedback, renin secretion, ischemia reperfusion injury, renal fibrosis, hypertension, diabetic nephropathy, transplantation, inflammation, and macrophage transformation. Important developments include global and targeted gene knockout and/or transgenic mouse models of CD39 or CD73, biological or small molecule inhibitors, and soluble engineered ectonucleotidases to directly impact the CD39-adenosinergic axis. This review presents a comprehensive picture of the multiple roles of CD39-adenosinergic axis in renal physiology, pathophysiology, and therapeutics. Scientific advances and greater understanding of the role of this axis in the kidney, in both health and illness, will direct development of innovative therapies for renal diseases.
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Affiliation(s)
- Bellamkonda K. Kishore
- Departments of Internal Medicine and Nutrition & Integrative Physiology, and Center on Aging, University of Utah Health, Salt Lake City, UT USA
- Nephrology Research, VA Salt Lake City Health Care System, 500 Foothill Drive (151M), Salt Lake City, UT 84148 USA
| | - Simon C. Robson
- Division of Gastroenterology/Hepatology and Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215 USA
| | - Karen M. Dwyer
- School of Medicine, Faculty of Health, Deakin University, Geelong, VIC 3220 Australia
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Goldstein SL. The Renal Angina Index to Predict Acute Kidney Injury: Are Adults Just Large Children? Kidney Int Rep 2018; 3:516-518. [PMID: 29854959 PMCID: PMC5976853 DOI: 10.1016/j.ekir.2018.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Stuart L. Goldstein
- Center for Acute Care Nephrology, Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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Costa E Silva VT, Caires RA, Bezerra JS, Costalonga EC, Oliveira APL, Oliveira Coelho F, Fukushima JT, Soares CM, Oikawa L, Hajjar LA, Burdmann EA. Use of regional citrate anticoagulation for continuous venovenous hemodialysis in critically ill cancer patients with acute kidney injury. J Crit Care 2018; 47:302-309. [PMID: 29859647 DOI: 10.1016/j.jcrc.2018.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/27/2018] [Accepted: 04/04/2018] [Indexed: 01/22/2023]
Abstract
PURPOSE This study aimed to evaluate the safety and efficacy of a regional citrate anticoagulation (RCA) protocol for continuous venovenous hemodialysis (CVVHD) in cancer patients with acute kidney injury (AKI) in the intensive care unit (ICU) setting. MATERIAL AND METHODS One hundred twenty two consecutive ICU cancer patients with AKI treated with citrate-based CVVHD were prospectively evaluated in this prospective observational study. RESULTS A total of 7198 h of CVVHD therapy (250 filters) were performed. Patients were 61.3 ± 15.7 years old, 78% had solid cancer and the main AKI cause was sepsis (50%). The in-hospital mortality was 78.7%. Systemic ionized calcium (SCai) was 4.35 (4.10-4.60) mg/dL, severe hypocalcemia (SCai <3.6 mg/dL) was observed in 4.3% of procedures and post-filter ionized calcium was 1.60 (1.40-1.80) mg/dL. Median filter patency was 24.8 (11-43) hours. Factors related to filter clotting were: no tumor evidence (OR 0.44, CI 0.18-0.99); genitourinary tumor (OR 1.83, CI 1.18-2.81); platelets number (each 10,000/mm3) (OR 1.02, CI 1.00-1.04); International Normatized Ratio (INR) (OR 0.59, CI 0.41-0.85) and citrate dose (each 10 mL/h) (OR 0.88, CI 0.82-0.95). CONCLUSION Filter patency was relatively short and clotting was associated with active cancer disease, genitourinary tumor, lower citrate dose and lower INR.
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Affiliation(s)
- Verônica Torres Costa E Silva
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil.
| | - Renato Antunes Caires
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Juliana Silva Bezerra
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Elerson C Costalonga
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Ana Paula Leandro Oliveira
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Fernanda Oliveira Coelho
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Julia T Fukushima
- Intensive Care Unit Department, Sao Paulo State Cancer Institute, University of Sao Paulo School Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Cilene Muniz Soares
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Luciane Oikawa
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Ludhmila Abrahão Hajjar
- Intensive Care Unit Department, Sao Paulo State Cancer Institute, University of Sao Paulo School Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Emmanuel A Burdmann
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil; LIM 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
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Li J, Chen Q, He X, Alam A, Ning J, Yi B, Lu K, Gu J. Dexmedetomidine attenuates lung apoptosis induced by renal ischemia-reperfusion injury through α 2AR/PI3K/Akt pathway. J Transl Med 2018; 16:78. [PMID: 29566706 PMCID: PMC5865375 DOI: 10.1186/s12967-018-1455-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 03/19/2018] [Indexed: 01/09/2023] Open
Abstract
Background Acute lung injury caused by renal ischemia–reperfusion is one of the leading causes of acute kidney injury-related death. Dexmedetomidine, an α2-adrenergic agonist sedative, has been found to have protective effects against acute kidney injury and remote lung injury. We sought to determine whether dexmedetomidine can exert its anti-apoptotic effects in acute lung injury after acute kidney injury, in addition to its common anti-inflammatory effects, and to determine the underlying mechanisms. Methods In vivo, acute kidney injury was induced by 60 min of kidney ischemia (bilateral occlusion of renal pedicles) followed by 24 h of reperfusion. Mice received dexmedetomidine (25 µg/kg, i.p.) in the absence or presence of α2-adrenergic antagonist atipamezole (250 µg/kg, i.p.) before IR. Histological assessment of the lung was conducted by HE staining and arterial blood gases were measured. Lung apoptosis was assessed by terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling assay. The expression of caspase 3 and p-Akt in lung tissue was detected by western blot. In vitro, C57BL/6J mice pulmonary microvascular endothelial cells were treated with serum from mice obtained following sham or IR. Dexmedetomidine was given before serum stimulation in cells, alone or with atipamezole or LY294002. Cell viability was assessed by CCK 8 assay. Cell apoptosis was examined by Hoechst staining and Annexin V-FITC/PI staining flow cytometry analysis. Mitochondrial membrane potential was measured by flow cytometry. The expression of p-Akt, caspase 3, Bcl-2 and Bax was measured by western blot. Results In vivo, dexmedetomidine remarkably mitigated pathohistological changes and apoptosis and significantly increased p-Akt expression in the lung. In addition, dexmedetomidine also slightly improved oxygenation in mice after IR, which can be abolished by atipamezole. In vitro, dexmedetomidine significantly inhibited IR serum-induced loss of viability and apoptosis in PMVECs. Dexmedetomidine increased p-Akt in a time- and dose-dependent manner, and down-regulated the expression of caspase 3 and Bax and up-regulated the Bcl-2 expression in PMVECs. The changes of MMP were also improved by dexmedetomidine. Whilst these effects were abolished by Atipamezole or LY294002. Conclusion Our results demonstrated that dexmedetomidine attenuates lung apoptosis induced by IR, at least in part, via α2AR/PI3K/Akt pathway.
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Affiliation(s)
- Juanjuan Li
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038, China
| | - Qian Chen
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038, China
| | - Xinhai He
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038, China
| | - Azeem Alam
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Campus, London, UK
| | - Jiaolin Ning
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038, China
| | - Bin Yi
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038, China
| | - Kaizhi Lu
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038, China
| | - Jianteng Gu
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038, China.
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Padalhin AR, Park CM, Lee BT. Streamlined System for Conducting In Vitro Studies Using Decellularized Kidney Scaffolds. Tissue Eng Part C Methods 2018; 24:42-55. [DOI: 10.1089/ten.tec.2017.0252] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Andrew R. Padalhin
- Institute of Tissue Regeneration, College of Medicine, Soonchunhyang University, Cheonan, South Korea
| | - Chan-Mi Park
- Institute of Tissue Regeneration, College of Medicine, Soonchunhyang University, Cheonan, South Korea
| | - Byong-Taek Lee
- Institute of Tissue Regeneration, College of Medicine, Soonchunhyang University, Cheonan, South Korea
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Lesión renal aguda en Latinoamérica en la era del big data. Nefrologia 2017; 37:461-464. [DOI: 10.1016/j.nefro.2017.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/16/2017] [Indexed: 11/22/2022] Open
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Affiliation(s)
- Jay L Koyner
- Section of Nephrology, University of Chicago Medicine and Biological Sciences Division, Chicago, Illinois
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Adejumo O, Akinbodewa A, Alli O, Olufemi P, Olatunji A. Assessment of Knowledge of Acute Kidney Injury among Non-Nephrology Doctors in Two Government Hospitals in Ondo City, Southwest, Nigeria. Ethiop J Health Sci 2017; 27:147-154. [PMID: 28579710 PMCID: PMC5440829 DOI: 10.4314/ejhs.v27i2.7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 11/21/2016] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Adequate knowledge of acute kidney injury (AKI) among doctors is essential for its prevention, early diagnosis and management. Assessing knowledge of AKI among doctors is necessary to identify areas of deficiencies and key areas to be emphasized when organizing educational programs aimed at improving AKI care. This study determined the knowledge of AKI among non-nephrology doctors in Ondo City, Southwest Nigeria. MATERIALS AND METHODS This was a cross-sectional descriptive study carried out in two government hospitals in Ondo City using a self-administered pretested questionnaire that assessed knowledge of AKI among non-nephrology doctors. P-value of < 0.05 was taken as significant. RESULTS Eighty-one doctors participated in the study with a median post-graduation experience of 5.5 years. Sixty-one (78.2%) were in surgical specialty while the remaining worked in medical specialty. Only 1(1.2%) of the respondents had good knowledge of AKI, 56(69.2%) had fair knowledge while the remaining 24 (29.6%) had poor knowledge of AKI. Identified areas of deficiencies in knowledge of AKI were in mode of presentation, risk factors, potentially nephrotoxic medications, criteria for AKI definition and staging, newer AKI biomarkers and indications for renal replacement therapy. There was no significant association between knowledge of AKI and specialty (p=0.593) or year of practice (p=0.312). CONCLUSION There were significant deficiencies in the knowledge of AKI amongst most non-nephrology doctors in Ondo city. We therefore recommend regular in-service training on AKI for practicing doctors.
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Affiliation(s)
- Oluseyi Adejumo
- Kidney Care Centre, University of Medical Sciences Ondo, Ondo State, Nigeria
| | - Ayodeji Akinbodewa
- Kidney Care Centre, University of Medical Sciences Ondo, Ondo State, Nigeria
| | - Oladimeji Alli
- Kidney Care Centre, University of Medical Sciences Ondo, Ondo State, Nigeria
| | - Pirisola Olufemi
- Kidney Care Centre, University of Medical Sciences Ondo, Ondo State, Nigeria
| | - Abolarin Olatunji
- Kidney Care Centre, University of Medical Sciences Ondo, Ondo State, Nigeria
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Abstract
Acute kidney injury (AKI) is a growing problem with untoward economic and medical consequences. Anticancer drug toxicity remains an important and increasing cause of AKI. Importantly, drug-induced AKI affects all nephron segments—vasculature, glomerulus, tubules, and interstitium. Recent studies have increased insight into the subcellular mechanisms of drug-induced AKI that include direct cellular toxicity and immune-mediated effects. Identification of patients with high-risk cancer before drug exposure may allow prevention or at least a reduction in the development and severity of nephrotoxicity. Recognition of drug-induced AKI and rapid discontinuation (or dose reduction) of the offending agents, when appropriate, are critical to maximizing kidney function recovery. Preventive measures require understanding patient and drug-related risk factors coupled with correcting risk factors, assessing baseline kidney function before initiation of therapy, adjusting the drug dosage and avoiding use of nephrotoxic drug combinations.
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Andres-Hernando A, Okamura K, Bhargava R, Kiekhaefer CM, Soranno D, Kirkbride-Romeo LA, Gil HW, Altmann C, Faubel S. Circulating IL-6 upregulates IL-10 production in splenic CD4 + T cells and limits acute kidney injury-induced lung inflammation. Kidney Int 2017; 91:1057-1069. [PMID: 28214022 DOI: 10.1016/j.kint.2016.12.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 11/21/2016] [Accepted: 12/01/2016] [Indexed: 12/16/2022]
Abstract
Although it is well established that acute kidney injury (AKI) is a proinflammatory state, little is known about the endogenous counter-inflammatory response. IL-6 is traditionally considered a pro-inflammatory cytokine that is elevated in the serum in both human and murine AKI. However, IL-6 is known to have anti-inflammatory effects. Here we sought to investigate the role of IL-6 in the counter-inflammatory response after AKI, particularly in regard to the anti-inflammatory cytokine IL-10. Ischemic AKI was induced by bilateral renal pedicle clamping. IL-10-deficient mice had increased systemic and lung inflammation after AKI, demonstrating the role of IL-10 in limiting inflammation after AKI. We then sought to determine whether IL-6 mediates IL-10 production. Wild-type mice with AKI had a marked upregulation of splenic IL-10 that was absent in IL-6-deficient mice with AKI. In vitro, addition of IL-6 to splenocytes increased IL-10 production in CD4+ T cells, B cells, and macrophages. In vivo, CD4-deficient mice with AKI had reduced splenic IL-10 and increased lung myeloperoxidase activity. Thus, IL-6 directly increases IL-10 production and participates in the counter-inflammatory response after AKI.
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Affiliation(s)
- Ana Andres-Hernando
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA
| | - Kayo Okamura
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA
| | - Rhea Bhargava
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA
| | - Carol M Kiekhaefer
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA
| | - Danielle Soranno
- Department of Pediatrics and Bioengineering, University of Colorado, Aurora, Colorado, USA
| | - Lara A Kirkbride-Romeo
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA
| | - Hyo-Wook Gil
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA; Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Chris Altmann
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA
| | - Sarah Faubel
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA.
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Tsujimoto H, Tsujimoto Y, Nakata Y, Fujii T, Akazawa M, Kataoka Y. Pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2016. [DOI: 10.1002/14651858.cd012467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Hiraku Tsujimoto
- Hyogo Prefectural Amagasaki General Medical Center; Hospital Care Research Unit; Higashi-Naniwa-Cho 2-17-77 Amagasaki Hyogo Japan 606-8550
| | - Yasushi Tsujimoto
- School of Public Health in the Graduate School of Medicine, Kyoto University; Department of Healthcare Epidemiology; Yoshida Konoe-cho, Sakyo-ku Kyoto Japan 606-8501
| | - Yukihiko Nakata
- Shimane University; Department of Mathematics; 1060 Nishikawatsu cho Matsue 690-8504 Japan
| | - Tomoko Fujii
- Graduate School of Medicine, Kyoto University; Department of Epidemiology and Preventive Medicine; Kyoto Japan
| | - Mai Akazawa
- Shiga University of Medical Science Hospital; Department of Anesthesia; Seta-Tsukinowa-cho Otsu Shiga Japan 520-2192
| | - Yuki Kataoka
- School of Public Health in the Graduate School of Medicine, Kyoto University; Department of Healthcare Epidemiology; Yoshida Konoe-cho, Sakyo-ku Kyoto Japan 606-8501
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Koyner JL, Adhikari R, Edelson DP, Churpek MM. Development of a Multicenter Ward-Based AKI Prediction Model. Clin J Am Soc Nephrol 2016; 11:1935-1943. [PMID: 27633727 PMCID: PMC5108182 DOI: 10.2215/cjn.00280116] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 07/22/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Identification of patients at risk for AKI on the general wards before increases in serum creatinine would enable preemptive evaluation and intervention to minimize risk and AKI severity. We developed an AKI risk prediction algorithm using electronic health record data on ward patients (Electronic Signal to Prevent AKI). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS All hospitalized ward patients from November of 2008 to January of 2013 who had serum creatinine measured in five hospitals were included. Patients with an initial ward serum creatinine >3.0 mg/dl or who developed AKI before ward admission were excluded. Using a discrete time survival model, demographics, vital signs, and routine laboratory data were used to predict the development of serum creatinine-based Kidney Disease Improving Global Outcomes AKI. The final model, which contained all variables, was derived in 60% of the cohort and prospectively validated in the remaining 40%. Areas under the receiver operating characteristic curves were calculated for the prediction of AKI within 24 hours for each unique observation for all patients across their inpatient admission. We performed time to AKI analyses for specific predicted probability cutoffs from the developed score. RESULTS Among 202,961 patients, 17,541 (8.6%) developed AKI, with 1242 (0.6%) progressing to stage 3. The areas under the receiver operating characteristic curve of the final model in the validation cohort were 0.74 (95% confidence interval, 0.74 to 0.74) for stage 1 and 0.83 (95% confidence interval, 0.83 to 0.84) for stage 3. Patients who reached a cutoff of ≥0.010 did so a median of 42 (interquartile range, 14-107) hours before developing stage 1 AKI. This same cutoff provided sensitivity and specificity of 82% and 65%, respectively, for stage 3 and was reached a median of 35 (interquartile range, 14-97) hours before AKI. CONCLUSIONS Readily available electronic health record data can be used to improve AKI risk stratification with good to excellent accuracy. Real time use of Electronic Signal to Prevent AKI would allow early interventions before changes in serum creatinine and may improve costs and outcomes.
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Affiliation(s)
- Jay L Koyner
- Department of Medicine, University of Chicago, Chicago, Illinois
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Faubel S, Shah PB. Immediate Consequences of Acute Kidney Injury: The Impact of Traditional and Nontraditional Complications on Mortality in Acute Kidney Injury. Adv Chronic Kidney Dis 2016; 23:179-85. [PMID: 27113694 DOI: 10.1053/j.ackd.2016.02.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 02/20/2016] [Accepted: 02/23/2016] [Indexed: 01/20/2023]
Abstract
Acute kidney injury (AKI) that requires renal replacement therapy is associated with a mortality rate that exceeds 50% in the intensive care unit, which is greater than other serious illnesses such as acute lung injury and myocardial infarction. Much information is now available regarding the complications of AKI that contribute to mortality and may be usefully categorized as "traditional" and "nontraditional". Traditional complications are the long-recognized complications of AKI such as hyperkalemia, acidosis, and volume overload, which may be typically corrected with renal replacement therapy. "Nontraditional" complications include complications such as sepsis, lung injury, and heart failure that may arise due to the effects of AKI on inflammatory cytokines, immune function, and cell death pathways such as apoptosis. In this review, we discuss both traditional and nontraditional complications of AKI with a focus on factors that contribute to mortality, considering both pathophysiology and potential remedies. Because AKI is the most common inpatient consult to nephrologists, it is essential to be aware of the complications of AKI that contribute to mortality to devise appropriate treatment strategies to prevent and manage AKI complications with the ultimate goal of reducing the unacceptably high mortality rate of AKI.
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Vijayan A, Faubel S, Askenazi DJ, Cerda J, Fissell WH, Heung M, Humphreys BD, Koyner JL, Liu KD, Mour G, Nolin TD, Bihorac A. Clinical Use of the Urine Biomarker [TIMP-2] × [IGFBP7] for Acute Kidney Injury Risk Assessment. Am J Kidney Dis 2016; 68:19-28. [PMID: 26948834 DOI: 10.1053/j.ajkd.2015.12.033] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 12/26/2015] [Indexed: 12/13/2022]
Abstract
Acute kidney injury (AKI) is a serious complication, commonly occurring in the critically ill population, with devastating short- and long-term consequences. Despite standardization of the definition and staging of AKI, early recognition remains challenging given that serum creatinine level is a marker, albeit imperfect, of kidney function and not kidney injury. Furthermore, the delay in increase in serum creatinine level after loss of glomerular filtration also prevents timely detection of decreased kidney function in patients with AKI. During the past decade, numerous clinical investigations have evaluated the utility of several biomarkers in the early diagnosis and risk stratification of AKI. In 2014, the US Food and Drug Administration approved the marketing of a test based on the combination of urine concentrations of tissue inhibitor of metalloproteinase 2 and insulin-like growth factor binding protein 7 ([TIMP-2] × [IGFBP7]) to determine whether certain critically ill patients are at risk for developing moderate to severe AKI. The optimal role of this biomarker in the diagnosis, management, and prognosis of AKI in different clinical settings requires further clarification. In this perspective, we summarize the biological actions of these 2 cell-cycle arrest biomarkers and present important considerations regarding the clinical application, interpretation, and limitations of this novel test for the early detection of AKI.
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Affiliation(s)
- Anitha Vijayan
- Renal Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO.
| | - Sarah Faubel
- Renal Division, University of Colorado Denver and Denver VA Medical Center, Denver, CO
| | - David J Askenazi
- Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL
| | | | - William H Fissell
- Division of Nephrology, Department of Medicine, Vanderbilt University, Nashville, TN
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Benjamin D Humphreys
- Renal Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL
| | - Kathleen D Liu
- Department of Medicine, University of California, San Francisco, San Francisco, CA; Department of Anesthesia, University of California, San Francisco, San Francisco, CA
| | - Girish Mour
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL; Department of Anesthesiology, University of Florida, Gainesville, FL; Department of Surgery, University of Florida, Gainesville, FL
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Torres da Costa e Silva V, Costalonga EC, Oliveira APL, Hung J, Caires RA, Hajjar LA, Fukushima JT, Soares CM, Bezerra JS, Oikawa L, Yu L, Burdmann EA. Evaluation of Intermittent Hemodialysis in Critically Ill Cancer Patients with Acute Kidney Injury Using Single-Pass Batch Equipment. PLoS One 2016; 11:e0149706. [PMID: 26938932 PMCID: PMC4777515 DOI: 10.1371/journal.pone.0149706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 02/04/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Data on renal replacement therapy (RRT) in cancer patients with acute kidney injury (AKI) in the intensive care unit (ICU) is scarce. The aim of this study was to assess the safety and the adequacy of intermittent hemodialysis (IHD) in critically ill cancer patients with AKI. METHODS AND FINDINGS In this observational prospective cohort study, 149 ICU cancer patients with AKI were treated with 448 single-pass batch IHD procedures and evaluated from June 2010 to June 2012. Primary outcomes were IHD complications (hypotension and clotting) and adequacy. A multiple logistic regression was performed in order to identify factors associated with IHD complications (hypotension and clotting). Patients were 62.2 ± 14.3 years old, 86.6% had a solid cancer, sepsis was the main AKI cause (51%) and in-hospital mortality was 59.7%. RRT session time was 240 (180-300) min, blood/dialysate flow was 250 (200-300) mL/min and UF was 1000 (0-2000) ml. Hypotension occurred in 25% of the sessions. Independent risk factors (RF) for hypotension were dialysate conductivity (each ms/cm, OR 0.81, CI 0.69-0.95), initial mean arterial pressure (each 10 mmHg, OR 0.49, CI 0.40-0.61) and SOFA score (OR 1.16, CI 1.03-1.30). Clotting and malfunctioning catheters (MC) occurred in 23.8% and 29.2% of the procedures, respectively. Independent RF for clotting were heparin use (OR 0.57, CI 0.33-0.99), MC (OR 3.59, CI 2.24-5.77) and RRT system pressure increase over 25% (OR 2.15, CI 1.61-4.17). Post RRT blood tests were urea 71 (49-104) mg/dL, creatinine 2.71 (2.10-3.8) mg/dL, bicarbonate 24.1 (22.5-25.5) mEq/L and K 3.8 (3.5-4.1) mEq/L. CONCLUSION IHD for critically ill patients with cancer and AKI offered acceptable hemodynamic stability and provided adequate metabolic control.
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Affiliation(s)
| | - Elerson C. Costalonga
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Ana Paula Leandro Oliveira
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - James Hung
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Renato Antunes Caires
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Ludhmila Abrahão Hajjar
- Intensive Care Unit Department, Sao Paulo State Cancer Institute, University of Sao Paulo School Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Julia T. Fukushima
- Intensive Care Unit Department, Sao Paulo State Cancer Institute, University of Sao Paulo School Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Cilene Muniz Soares
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Juliana Silva Bezerra
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Luciane Oikawa
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Luis Yu
- LIM 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Emmanuel A. Burdmann
- LIM 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil
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Wells CC. ABCs of the Intensive Care Unit. PHYSICIAN ASSISTANT CLINICS 2016. [DOI: 10.1016/j.cpha.2015.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Koyner JL, Coca SG, Thiessen-Philbrook H, Patel UD, Shlipak MG, Garg AX, Parikh CR. Urine Biomarkers and Perioperative Acute Kidney Injury: The Impact of Preoperative Estimated GFR. Am J Kidney Dis 2015; 66:1006-14. [PMID: 26386737 PMCID: PMC4658239 DOI: 10.1053/j.ajkd.2015.07.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 07/18/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND The interaction between baseline kidney function and the performance of biomarkers of acute kidney injury (AKI) on the development of AKI is unclear. STUDY DESIGN Post hoc analysis of prospective cohort study. SETTING & PARTICIPANTS The 1,219 TRIBE-AKI Consortium adult cardiac surgery cohort participants. PREDICTOR Unadjusted postoperative urinary biomarkers of AKI measured within 6 hours of surgery. OUTCOME AKI was defined as AKI Network stage 1 (any AKI) or higher, as well as a doubling of serum creatinine level from the preoperative value or the need for post-operative dialysis (severe AKI). MEASUREMENTS Stratified analyses by preoperative estimated glomerular filtration rate (eGFR) ≤ 60 versus > 60mL/min/1.73m(2). RESULTS 180 (42%) patients with preoperative eGFRs≤60mL/min/1.73m(2) developed clinical AKI compared with 246 (31%) of those with eGFRs>60mL/min/1.73m(2) (P<0.001). For log2-transformed biomarker concentrations, there was a significant interaction between any AKI and baseline eGFR for interleukin 18 (P=0.007) and borderline significance for liver-type fatty acid binding protein (P=0.06). For all biomarkers, the adjusted relative risk (RR) point estimates for the risk for any AKI were higher in those with elevated baseline eGFRs compared with those with eGFRs≤60mL/min/1.73m(2). However, the difference in magnitude of these risks was low (adjusted RRs were 1.04 [95% CI, 0.99-1.09] and 1.11 [95% CI, 1.07-1.15] for those with preoperative eGFRs≤60mL/min/1.73m(2) and those with higher eGFRs, respectively). Although no biomarker displayed an interaction for baseline eGFR and severe AKI, log2-transformed interleukin 18 and kidney injury molecule 1 had significant adjusted RRs for severe AKI in those with and without baseline eGFRs≤60mL/min/1.73m(2). LIMITATIONS Limited numbers of patients with severe AKI and post-operative dialysis. CONCLUSIONS The association between early postoperative AKI urinary biomarkers and AKI is modified by preoperative eGFR. The degree of this modification and its impact on the biomarker-AKI association is small across biomarkers. Our findings suggest that distinct biomarker cutoffs for those with and without a preoperative eGFR≤60mL/min/1.73m(2) is not necessary.
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Affiliation(s)
- Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - Steven G Coca
- Department of Internal Medicine, Clinical Epidemiology Research Center, Yale University School of Medicine, New Haven, CT
| | | | | | - Michael G Shlipak
- Division of General Internal Medicine, San Francisco VA Medical Center, University of California, San Francisco, CA
| | - Amit X Garg
- Division of Nephrology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Chirag R Parikh
- Department of Internal Medicine, Clinical Epidemiology Research Center, Yale University School of Medicine, New Haven, CT.
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Morrison W, Womer J, Nathanson P, Kersun L, Hester DM, Walsh C, Feudtner C. Pediatricians' Experience with Clinical Ethics Consultation: A National Survey. J Pediatr 2015. [PMID: 26210945 DOI: 10.1016/j.jpeds.2015.06.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To conduct a national survey of pediatricians' access to and experience with clinical ethics consultation. STUDY DESIGN We surveyed a randomly selected sample of 3687 physician members of the American Academy of Pediatrics. We asked about their experiences with ethics consultation, the helpfulness of and barriers to consultation, and ethics education. Using a discrete choice experiment with maximum difference scaling, we evaluated which traits of ethics consultants were most valuable. RESULTS Of the total sample of 3687 physicians, 659 (18%) responded to the survey. One-third of the respondents had no experience with clinical ethics consultation, and 16% reported no access to consultation. General pediatricians were less likely to have access. The vast majority (90%) who had experience with consultation had found it helpful. Those with fewer years in practice were more likely to have training in ethics. The most frequently reported issues leading to consultation concerned end-of-life care and conflicts with patients/families or among the team. Intensive care unit physicians were more likely to have requested consultation. Mediation skills and ethics knowledge were the most highly valued consultant characteristics, and representing the official position of the hospital was the least-valued characteristic. CONCLUSION There is variability in pediatricians' access to ethics consultation. Most respondents reported that consultation had been helpful in the past. Determining ethically appropriate end-of-life care and mediation of disagreements are common reasons that pediatricians request consultation.
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Affiliation(s)
- Wynne Morrison
- Pediatric Advanced Care Team, Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - James Womer
- Pediatric Advanced Care Team, Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, PA; Temple University School of Medicine, Philadelphia, PA
| | - Pamela Nathanson
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Leslie Kersun
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - D Micah Hester
- Division of Medical Humanities, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Corbett Walsh
- New York University School of Medicine, New York, NY
| | - Chris Feudtner
- Pediatric Advanced Care Team, Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Mallappallil MC, Mehta R, Yoshiuchi E, Briefel G, Lerma E, Salifu M. Parameters used to discontinue dialysis in acute kidney injury recovery: a survey of United States nephrologists. Nephron Clin Pract 2015; 130:41-7. [PMID: 25999063 DOI: 10.1159/000381924] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 03/25/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite advances in the approach to cure acute kidney injury (AKI), including definition, classification and treatment methods, there are no standard criteria to withdraw dialysis in the setting of improving AKI. We conducted this survey to elucidate parameters that United States (US) nephrologists used to determine when to stop dialysis with improving renal function in AKI. We hypothesized that there would be a difference in approach to weaning a patient off dialysis based on years in practice or the number of cases of AKI treated per year. METHODS This was an anonymous electronic survey of practicing nephrologists who treated AKI. Data was de-identified and analyzed using descriptive statistics. RESULTS The commonest criteria used to stop dialysis when renal function improved was, in decreasing order of importance, resolution in oliguria (51%), resolution of volume overload (29%), improvement in serum creatinine (26.7%) and resolution of hyperkalemia (21%). The most common reasons for re-starting dialysis within 28 days did not show a specific trend but respondents (20%) reported re-starting if estimated glomerular filtration rates (eGFR) declined. There was no significant pattern in approach to withdrawing dialysis or resuming dialysis based on the number of years in nephrology practice. However, responses of nephrologists who saw more than 20 AKI patients/year were significantly different in stopping dialysis with clinical stabilization of blood pressure (p < 0.001), improvement in respiratory parameters (p = 0.005), improvement in pre-dialysis blood urea nitrogen (BUN) levels despite the same dose of dialysis (p = 0.05) and resolution of oliguria (p = 0.025) compared to those who saw fewer cases. CONCLUSION Resolution of oliguria was the commonest factor used to help deciding to stop dialysis in improving AKI. However, considerable variation was noted among US nephrologists who participated in this survey, regarding what criteria they used to withdraw dialysis in the setting of improving AKI. These results call for more studies in withdrawing dialysis in the setting of AKI that could lead to guideline formulation.
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Affiliation(s)
- Mary C Mallappallil
- Department of Internal Medicine, Renal Division, State University of New York at Brooklyn, Downstate Medical Center, Brooklyn and Kings County Hospital Center, Brooklyn, N.Y., USA
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Nasri H, Rafieian-Kopaei M. On the occasion of world kidney day 2016; work together to better protect the kidney. J Nephropathol 2015; 5:15-8. [PMID: 27047805 PMCID: PMC4790182 DOI: 10.15171/jnp.2016.03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 04/14/2015] [Indexed: 11/09/2022] Open
Abstract
Context: World kidney day is a yearly global alertness and education ceremony, held on the second Thursday in March.
Evidence Acquisition: Directory of open access journals (DOAJ), EMBASE, Google Scholar, PubMed, EBSCO, and Web of Science have been searched.
Results: Once again we reached to March 14, the world kidney day of 2016. This is the 10th anniversary of world kidney day, a program of the International Society of Nephrology (ISN) and the International Federation of Kidney Foundations (IFKF). World kidney day first began in 2006 and the worldwide campaign highlights a specific theme each year. The theme for 2015 was to invite everybody to drink a glass of water and give one, too, to celebrate their kidneys. This is a symbolic action to memorize that kidneys are vital organs and that they might be cared.
Conclusions: It is a manner to make individuals more conscious about their lifestyle choices. In this year, world kidney day will be celebrated on Thursday March 10, 2016. The theme for 2016 will highlight on renal disease and children.
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Affiliation(s)
- Hamid Nasri
- Department of Nephrology, Isfahan University of Medical Sciences, Isfahan, Iran
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McCulloch MI. Acute Kidney Injury (AKI): Current Thoughts and Controversies in Pediatrics. CURRENT PEDIATRICS REPORTS 2015. [DOI: 10.1007/s40124-014-0073-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Koyner JL, Davison DL, Brasha-Mitchell E, Chalikonda DM, Arthur JM, Shaw AD, Tumlin JA, Trevino SA, Bennett MR, Kimmel PL, Seneff MG, Chawla LS. Furosemide Stress Test and Biomarkers for the Prediction of AKI Severity. J Am Soc Nephrol 2015; 26:2023-31. [PMID: 25655065 DOI: 10.1681/asn.2014060535] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/19/2014] [Indexed: 01/22/2023] Open
Abstract
Clinicians have access to limited tools that predict which patients with early AKI will progress to more severe stages. In early AKI, urine output after a furosemide stress test (FST), which involves intravenous administration of furosemide (1.0 or 1.5 mg/kg), can predict the development of stage 3 AKI. We measured several AKI biomarkers in our previously published cohort of 77 patients with early AKI who received an FST and evaluated the ability of FST urine output and biomarkers to predict the development of stage 3 AKI (n=25 [32.5%]), receipt of RRT (n=11 [14.2%]), or inpatient mortality (n=16 [20.7%]). With an area under the curve (AUC)±SEM of 0.87±0.09 (P<0.0001), 2-hour urine output after FST was significantly better than each urinary biomarker tested in predicting progression to stage 3 (P<0.05). FST urine output was the only biomarker to significantly predict RRT (0.86±0.08; P=0.001). Regardless of the end point, combining FST urine output with individual biomarkers using logistic regression did not significantly improve risk stratification (ΔAUC, P>0.10 for all). When FST urine output was assessed in patients with increased biomarker levels, the AUC for progression to stage 3 improved to 0.90±0.06 and the AUC for receipt of RRT improved to 0.91±0.08. Overall, in the setting of early AKI, FST urine output outperformed biochemical biomarkers for prediction of progressive AKI, need for RRT, and inpatient mortality. Using a FST in patients with increased biomarker levels improves risk stratification, although further research is needed.
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Affiliation(s)
- Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
| | | | | | | | - John M Arthur
- Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James A Tumlin
- Renal Division, University of Tennessee College of Medicine at Chattanooga, Chattanooga, Tennessee
| | - Sharon A Trevino
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Michael R Bennett
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital, Cincinnati, Ohio; and
| | - Paul L Kimmel
- Department of Medicine, George Washington University Medical Center, Washington DC
| | | | - Lakhmir S Chawla
- Department of Medicine, Division of Intensive Care Medicine and Division of Nephrology, Washington DC Veterans Affairs Medical Center, Washington, DC
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