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Tao Y, Heskia F, Zhang M, Qin R, Kang B, Chen L, Wu F, Huang J, Brengel-Pesce K, Chen H, Mo X, Liang J, Wang W, Xu Z. Evaluation of acute kidney injury by urinary tissue inhibitor metalloproteinases-2 and insulin-like growth factor-binding protein 7 after pediatric cardiac surgery. Pediatr Nephrol 2022; 37:2743-2753. [PMID: 35211796 DOI: 10.1007/s00467-022-05477-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND With adult patients, the measurement of [TIMP-2]*[IGFBP7] can predict the risk of moderate to severe AKI within 12 h of testing. In pediatrics, however, the performance of [TIMP-2]*[IGFBP7] as a predictor of AKI was less studied and yet to be widely utilized in clinical practice. This study was conducted to validate the utility of [TIMP-2]*[IGFBP7] as an earlier biomarker for AKI prediction in Chinese infants and small children. METHODS We measured urinary [TIMP-2]*[IGFBP7] using NEPHROCHECK® at eight perioperative time points in 230 patients undergoing complex cardiac surgery and evaluated the performance of [TIMP-2]*[IGFBP7] for predicting severe AKI within 72 h of surgery. RESULTS A total of 50 (22%) of 230 developed AKI stages 2-3 within 72 h after CPB initiation. In the AKI stage 2-3 patients, two patterns of serum creatinine (SCr) elevations were observed. The patients with only a transient increase in SCr within 24 h (< 24 h, early AKI 2-3) did not experience a worse outcome than patients in AKI stage 0-1. AKI stage 2-3 patients with SCr elevation after 24 h (24-72 h, late AKI 2-3), as well as AKI dialysis patients (together designated severe AKI), did experience worse outcomes. Compared to AKI stages 0-1, significant elevations of [TIMP-2]*[IGFBP7] values were observed in severe AKI patients at hours T2, T4, T12, and T24 following CPB initiation. The AUC for predicting severe AKI with [TIMP-2]*[IGFBP7] at T2 (AUC = 0.76) and maximum T2/T24 (AUC = 0.80) are higher than other time points. The addition of the NEPHROCHECK® test to the postoperative parameters improved the risk assessment of severe AKI. CONCLUSIONS Multiple AKI phenotypes (early versus late AKI) were identified after pediatric complex cardiac surgery according to SCr-based AKI definition. Urinary [TIMP-2]*[IGFBP7] predicts late severe AKI (but not early AKI) as early as 2 h following CPB initiation. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Yue Tao
- Shanghai Children's Medical Center-bioMérieux Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,The Laboratory of Pediatric Infectious Diseases, Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fabienne Heskia
- Global Medical Affairs Department, bioMérieux SA, Marcy l'Etoile, France
| | - Mingjie Zhang
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Rong Qin
- Global Medical Affairs Department, bioMérieux SA, Marcy l'Etoile, France
| | - Bin Kang
- Shanghai Children's Medical Center-bioMérieux Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,bioMérieux (Shanghai) Company Limited, Shanghai, China
| | - Luoquan Chen
- Shanghai Children's Medical Center-bioMérieux Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,bioMérieux (Shanghai) Company Limited, Shanghai, China
| | - Fei Wu
- Shanghai Children's Medical Center-bioMérieux Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,bioMérieux (Shanghai) Company Limited, Shanghai, China
| | - Jihong Huang
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Karen Brengel-Pesce
- Open Innovation & Partnerships Department, bioMérieux SA, Marcy l'Etoile, France
| | - Huiwen Chen
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xi Mo
- Shanghai Children's Medical Center-bioMérieux Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,The Laboratory of Pediatric Infectious Diseases, Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ji Liang
- Shanghai Children's Medical Center-bioMérieux Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,bioMérieux (Shanghai) Company Limited, Shanghai, China
| | - Wei Wang
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhuoming Xu
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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Maciel AT, Vitorio D, Osawa EA. Urine biochemistry assessment in the sequential evaluation of renal function: Time to think outside the box. Front Med (Lausanne) 2022; 9:912877. [PMID: 35957852 PMCID: PMC9360530 DOI: 10.3389/fmed.2022.912877] [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: 04/05/2022] [Accepted: 07/05/2022] [Indexed: 12/12/2022] Open
Abstract
Urine biochemistry (UB) remains a controversial tool in acute kidney injury (AKI) monitoring, being considered to be of limited value both in terms of AKI diagnosis and prognosis. However, many criticisms can be made to the studies that have established the so called “pre-renal paradigm” (used for decades as the essential physiological basis for UB assessment in AKI) as well as to more recent studies suggesting that UB has no utility in daily clinical practice. The aim of this article is to describe our hypothesis on how to interpret simple and widely recognized urine biochemical parameters from a novel perspective, propose the rationale for their sequential assessment and demonstrate their usefulness in AKI monitoring, especially in the critical care setting.
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Affiliation(s)
- Alexandre T. Maciel
- Research Department, Imed Group, São Paulo, Brazil
- Adult Intensive Care Unit, São Camilo Hospital–Pompéia Unit, São Paulo, Brazil
- *Correspondence: Alexandre T. Maciel,
| | - Daniel Vitorio
- Research Department, Imed Group, São Paulo, Brazil
- Adult Intensive Care Unit, São Camilo Hospital–Pompéia Unit, São Paulo, Brazil
| | - Eduardo A. Osawa
- Research Department, Imed Group, São Paulo, Brazil
- Adult Intensive Care Unit, São Camilo Hospital–Pompéia Unit, São Paulo, Brazil
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Umbrello M, Formenti P, Chiumello D. Urine Electrolytes in the Intensive Care Unit: From Pathophysiology to Clinical Practice. Anesth Analg 2020; 131:1456-1470. [PMID: 33079869 DOI: 10.1213/ane.0000000000004994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Assessment of urine concentrations of sodium, chloride, and potassium is a widely available, rapid, and low-cost diagnostic option for the management of critically ill patients. Urine electrolytes have long been suggested in the diagnostic workup of hypovolemia, kidney injury, and acid-base and electrolyte disturbances. However, due to the wide range of normal reference values and challenges in interpretation, their use is controversial. To clarify their potential role in managing critical patients, we reviewed existing evidence on the use of urine electrolytes for diagnostic and therapeutic evaluation and assessment in critical illness. This review will describe the normal physiology of water and electrolyte excretion, summarize the use of urine electrolytes in hypovolemia, acute kidney injury, acid-base, and electrolyte disorders, and suggest some practical flowcharts for the potential use of urine electrolytes in daily critical care practice.
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Affiliation(s)
- Michele Umbrello
- From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
| | - Paolo Formenti
- From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
| | - Davide Chiumello
- From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
- Dipartimento di Scienze della Salute
- Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
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Borracci RA, Macias Miranda J, Ingino CA. Transient acute kidney injury after cardiac surgery does not independently affect postoperative outcomes. J Card Surg 2018; 33:727-733. [PMID: 30353571 DOI: 10.1111/jocs.13935] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The objective of this study was to assess the incidence of in-hospital acute kidney injury (AKI) after cardiac surgery by comparing preoperative baseline renal function with renal function during the postoperative period and at discharge, and to relate these indices with in-hospital postoperative outcomes. METHODS A retrospective analysis was performed over a 4-year period from a series of 426 adult patients. Kidney function was based on serum creatinine (SCr), Cockroft-Gault estimated creatinine clearance (eCrCl), and glomerular filtration rate estimated with the Modification of Diet in Renal Disease formula (eGFR). Baseline values were compared with "peak" values of altered kidney function postoperatively, and "discharge" values. In-hospital mortality and complication rates were compared between patients with transient and persistent AKI, and those without postoperative AKI. RESULTS After surgery, AKI (Risk-Injury-Failure-Loss-Endstage [RIFLE] classes Injury and Failure) was diagnosed in 14.6-17.5% of patients based on peak values. AKI diagnosis was reduced to 3.6-4.5% when SCr, eCrCl, and eGFR were measured at discharge. In-hospital mortality of patients with transient AKI was 4% versus 26% in patients with AKI at discharge (odds ratio = 0.11, 95% confidence interval 0.02-0.62, P = 0.011). CONCLUSIONS A diagnosis of AKI based on measurements of eGFR during the postoperative period was nearly four times more frequent than the same diagnosis at discharge. Transient AKI was the predominate presentation of postoperative kidney dysfunction in this study. Transient AKI did not affect in-hospital outcomes compared with patients without AKI. Patients with persistent AKI at discharge had the highest mortality.
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Affiliation(s)
- Raul A Borracci
- Biostatistics, School of Medicine, Austral University, Buenos Aires, Argentina.,Department of Cardiology and Cardiac Surgery, ENERI-Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Julio Macias Miranda
- Department of Cardiology and Cardiac Surgery, ENERI-Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Carlos A Ingino
- Department of Cardiology and Cardiac Surgery, ENERI-Sagrada Familia Clinic, Buenos Aires, Argentina
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Maciel AT. Urine electrolyte measurement as a "window" into renal microcirculatory stress assessment in critically ill patients. J Crit Care 2018; 48:90-96. [PMID: 30176529 DOI: 10.1016/j.jcrc.2018.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/07/2018] [Accepted: 08/14/2018] [Indexed: 12/20/2022]
Abstract
Urine electrolyte assessment has long been used in order to understand electrolyte concentration disturbances in blood and as an easy tool for monitoring renal perfusion and structural tubular damage. In the last few years, great improvement in the pathophysiology of acute kidney injury (AKI) has occurred, and the correlation between urine biochemistry (UB) behavior and renal perfusion was frequently questioned. Many authors have suggested abandoning UB monitoring due to its unclear role in AKI monitoring. Our group has been working in this field in the critically ill population, and we believe that, although UB is indeed very useful, a different point of view regarding the interpretation of the data should be used. The aim of this review is to explain the rationale of these new concepts and make suggestions for their adequate use in daily ICU practice, especially in low-income countries where more sophisticated and expensive AKI biomarker assessments are not available.
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Affiliation(s)
- Alexandre T Maciel
- Imed Research Group, Adult Intensive Care Unit, São Camilo Hospital, São Paulo, Brazil.
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Abstract
PURPOSE OF REVIEW In this review, we discuss the latest updates on perioperative acute kidney injury (AKI) and the specific considerations that are relevant to different surgeries and patient populations. RECENT FINDINGS AKI diagnosis is constantly evolving. New biomarkers detect AKI early and shed a light on the possible cause of AKI. Hypotension, even for a short duration, is associated with perioperative AKI. The debate on the deleterious effects of chloride-rich solutions is still far from conclusion. Remote ischemic preconditioning is showing promising results in the possible prevention of perioperative AKI. No definite data show a beneficiary effect of statins, fenoldepam, or sodium bicarbonate in preventing AKI. SUMMARY Perioperative AKI is prevalent and associated with significant morbidity and mortality. Considering the lack of effective preventive or therapeutic interventions, this review focuses on perioperative AKI: measures for early diagnosis, defining risks and possible mechanisms, and summarizing current knowledge for intraoperative fluid and hemodynamic management to reduce risk of AKI.
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Bolliger D, Fassl J. Avoiding Acute Kidney Injury After Cardiac Surgery: Simple and Easy? J Cardiothorac Vasc Anesth 2017; 32:223-224. [PMID: 29249579 DOI: 10.1053/j.jvca.2017.09.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel Bolliger
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine, and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Jens Fassl
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine, and Pain Therapy, University Hospital Basel, Basel, Switzerland
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De Loor J, Herck I, Francois K, Van Wesemael A, Nuytinck L, Meyer E, Hoste EAJ. Diagnosis of cardiac surgery-associated acute kidney injury: differential roles of creatinine, chitinase 3-like protein 1 and neutrophil gelatinase-associated lipocalin: a prospective cohort study. Ann Intensive Care 2017; 7:24. [PMID: 28251598 PMCID: PMC5332341 DOI: 10.1186/s13613-017-0251-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 02/24/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND A common and serious complication of cardiac surgery prompting early detection and intervention is cardiac surgery-associated acute kidney injury (CSA-AKI). Urinary chitinase 3-like protein 1 (UCHI3L1) was found to predict AKI associated with critical illness in adults. Our aims were therefore to evaluate whether UCHI3L1 can also be used to predict AKI associated with elective cardiac surgery in adults, and to compare this predictive ability with that of urinary neutrophil gelatinase-associated lipocalin (UNGAL), more frequently assessed early serum creatinine (SCr) measurements, and various two-biomarker panels. METHODS This was a single-centre prospective cohort study at the eight-bed cardiac surgery ICU of Ghent University Hospital. AKI was diagnosed and classified according to the Kidney Disease|Improving Global Outcomes definitions for the diagnosis and staging of AKI, which are based on SCr and urine output (UO). Of the 211 enrolled elective cardiac surgery patients, we included 203 patients who had no AKI pre-operatively and at time of post-operative ICU admission (t1) in the primary endpoint analysis (i.e. AKI stage ≥1 within 48 h after t1), while 210 patients without AKI stage ≥2 pre-operatively and at t1 were included in the secondary endpoint analysis (i.e. AKI stage ≥2 within 12 h after t1). Systemic and/or urine concentrations of Cr, CHI3L1 and NGAL were measured more frequently than SCr in routine early post-operative ICU practice. UO was monitored hourly in the ICU. RESULTS Within 48 h after t1, 46.8% of the patients had developed AKI (70.5% stage 1, 20.0% stage 2 and 9.5% stage 3). In the early post-operative period, only SCr was a good predictor of AKI within 48 h after t1 (primary endpoint). SCHI3L1 combined with either UCHI3L1 or UNGAL was a good predictor of AKI stage ≥2 within 12 h after t1 (secondary endpoint). However, SCr and its absolute difference from pre-operative to early measures after surgery outperformed these combinations. CONCLUSIONS We found that more frequent assessment of the functional biomarker SCr in the early post-operative ICU period (first 4 h) after elective cardiac surgery in adult patients had good to excellent predictive value for CSA-AKI, indicating that routine SCr assessment must become more frequent in order to detect AKI more early. This performance was in contrast with the inadequate predictive value of the urinary renal stress or damage biomarkers UCHI3L1 and UNGAL.
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Affiliation(s)
- Jorien De Loor
- Laboratory of Biochemistry, Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium
| | - Ingrid Herck
- Division of Intensive Care, Department of Internal Medicine, Ghent University Hospital, Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Katrien Francois
- Division of Cardiac Surgery, Department of Surgery, Ghent University Hospital, Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Astrid Van Wesemael
- Department of Anaesthesiology, General Hospital Sint-Lucas Ghent, Groenebriel 1, 9000 Ghent, Belgium
| | - Lieve Nuytinck
- Bimetra – Clinical Research Centre Ghent, Ghent University Hospital, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Evelyne Meyer
- Laboratory of Biochemistry, Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium
| | - Eric A. J. Hoste
- Division of Intensive Care, Department of Internal Medicine, Ghent University Hospital, Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
- Research Foundation – Flanders, Egmontstraat 5, 1000 Brussels, Belgium
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Mayer T, Bolliger D, Scholz M, Reuthebuch O, Gregor M, Meier P, Grapow M, Seeberger MD, Fassl J. Urine Biomarkers of Tubular Renal Cell Damage for the Prediction of Acute Kidney Injury After Cardiac Surgery—A Pilot Study. J Cardiothorac Vasc Anesth 2017; 31:2072-2079. [DOI: 10.1053/j.jvca.2017.04.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Indexed: 12/11/2022]
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Maciel AT. Back to Basics: Is There a Good Reason to Not Systematically Measure Urine Creatinine in Acute Kidney Injury Monitoring? Nephron Clin Pract 2016; 133:111-5. [DOI: 10.1159/000446666] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/04/2016] [Indexed: 11/19/2022] Open
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Maciel AT, Delphino Salles L, Vitorio D. Simple blood and urinary parameters measured at ICU admission may sign for AKI development in the early postoperative period: a retrospective, exploratory study. Ren Fail 2016; 38:1607-1615. [PMID: 27101843 DOI: 10.3109/0886022x.2016.1144162] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Recent studies have suggested that some blood physicochemical and urinary biochemical parameters have a standardized behavior during acute kidney injury (AKI) development. The changes in these parameters frequently begin to occur before significant rises in serum creatinine (sCr) and may help in identifying patients with more subtle decreases in glomerular filtration rate (GFR). Surgical patients have an increased risk of AKI but renal impairment is usually not evident at ICU admission. We hypothesized that the surgical patients who have AKI diagnosed in the early postoperative period have an impaired GFR since ICU admission, indirectly inferred by alterations in these blood physicochemical and urinary biochemical parameters even in the presence of a still normal sCr. We retrospectively evaluated 112 surgical patients who were categorized according to AKI development during the first 3 ICU days. Twenty-eight patients developed AKI, most of them in the first day (D1) after ICU admission (D0). AKI patients had, at D0, lower serum pH and albumin, higher C - reactive protein (CRP), lower urine sodium (NaU) and fractional excretion of urea (FEUr). Fractional excretion of potassium (FEK) was high in both groups at D0 but remained high in the subsequent days only in AKI patients. Very low CRP and high serum albumin, high NaU and FEUr values at ICU admission had a significant negative predictive value for AKI. We concluded that some easily assessed parameters in blood and urine may help to identify patients with indirect signs of increased inflammatory response and decreased GFR at ICU admission, which could help to predict the risk of postoperative AKI development.
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Affiliation(s)
- Alexandre Toledo Maciel
- a Imed Research Group , Intensive Care Unit, Hospital São Camilo Pompéia , São Paulo , Brazil
| | - Lia Delphino Salles
- a Imed Research Group , Intensive Care Unit, Hospital São Camilo Pompéia , São Paulo , Brazil
| | - Daniel Vitorio
- a Imed Research Group , Intensive Care Unit, Hospital São Camilo Pompéia , São Paulo , Brazil
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- a Imed Research Group , Intensive Care Unit, Hospital São Camilo Pompéia , São Paulo , Brazil
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Urine biochemistry assessment in critically ill patients: controversies and future perspectives. J Clin Monit Comput 2016; 31:539-546. [PMID: 27038161 DOI: 10.1007/s10877-016-9871-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 03/30/2016] [Indexed: 12/17/2022]
Abstract
In the past, urine biochemistry was a major tool in acute kidney injury (AKI) management. Classic papers published some decades ago established the values of the urine indices which were thought to distinguish "pre-renal" (functional) AKI attributed to low renal perfusion and "renal" (structural) AKI attributed to acute tubular necrosis (ATN). However, there were a lot of drawbacks and limitations in these studies and some recent articles have questioned the utility of measuring urine electrolytes especially because they do not seem to adequately inform about renal perfusion nor AKI duration (transient vs. persistent). At the same time, the "pre-renal" paradigm has been consistently criticized because hypoperfusion followed by ischemia and ATN does not seem to explain most of the AKI developing in critically ill patients and distinct AKI durations do not seem to be clearly related to different pathophysiological mechanisms or histopathological findings. In this new context, other possible roles for urine biochemistry have emerged. Some studies have suggested standardized changes in the urine electrolyte composition preceding increases in serum creatinine independently of AKI subsequent duration, which might actually be due to intra-renal microcirculatory changes and activation of sodium-retaining mechanisms even in the absence of impaired global renal blood flow. In the present review, the points of controversy regarding urine biochemistry assessment were evaluated as well as future perspectives for its role in AKI monitoring. An alternative approach for the interpretation of measured urine electrolytes is proposed which needs further larger studies to be validated and incorporated in daily ICU practice.
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