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Borucki JP, Woods R, Fielding A, Webb LA, Hernon JM, Lines SW, Stearns AT. Postoperative decline in renal function after rectal resection and all-cause mortality: a retrospective cohort study. Colorectal Dis 2023; 25:2225-2232. [PMID: 37803491 DOI: 10.1111/codi.16768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/20/2023] [Accepted: 08/14/2023] [Indexed: 10/08/2023]
Abstract
AIM Fluid loss, dehydration and resultant kidney injury are common when a diverting ileostomy is formed during rectal cancer surgery, the consequences of which are unknown. The aim of this retrospective single-site cohort study is to evaluate the impact of sustained postoperative renal dysfunction after rectal resection on long-term renal impairment and survival. METHOD All patients with rectal adenocarcinoma undergoing resection between January 2003 and March 2017 were included, with follow-up to June 2020. The primary outcome was impact on long-term mortality attributed to a 25% or greater drop in estimated glomerular filtration rate (eGFR) following rectal resection. Secondary outcomes were the long-term effect on renal function resulting from the same drop in eGFR and the effect on long-term mortality and renal function of a 50% drop in eGFR. We also calculated the effect on mortality of a 1% drop in eGFR. RESULTS A total of 1159 patients were identified. Postoperative reductions in eGFR of 25% and 50% were associated with long-term overall mortality with adjusted hazard ratios of 1.84 (1.22-2.77) (p = 0.004) and 2.88 (1.45-5.71) (p = 0.002). The median survival of these groups was 86.0 (64.0-108.0) months and 53.3 (7.8-98.8) months compared with 144.5 (128.1-160.9) months for controls. Long-term effects on renal function were demonstrated, with those who sustained a >25% drop in renal function having a 38.8% mean decline in eGFR at 10 years compared with 10.2% in controls. CONCLUSION Persistent postoperative declines in renal function may be linked to long-term mortality. Further research is needed to assess causal relationships and prevention.
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Affiliation(s)
- Joseph P Borucki
- Department of General Surgery, James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, UK
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
- Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - Rebecca Woods
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - Alexandra Fielding
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - Lucy-Ann Webb
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - James M Hernon
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
- Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - Simon W Lines
- Department of Nephrology, St Bernard's Hospital, Gibraltar, Gibraltar
| | - Adam T Stearns
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
- Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
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Yan YT, Liu HM, Kong YF, Liu JM, Li C, Zhao BC, Liu KX. Association of preoperative neutrophil-lymphocyte ratio with acute kidney injury in patients with non-cardiac surgery: difference among surgical types. Int Urol Nephrol 2023; 55:2647-2656. [PMID: 36964822 DOI: 10.1007/s11255-023-03567-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 03/18/2023] [Indexed: 03/26/2023]
Abstract
PURPOSE To examine the relationship between Neutrophil-Lymphocyte Ratio (NLR) and Acute Kidney Injury (AKI) in patients undergoing noncardiac surgery, and subgroup analysis was performed for different types of non-cardiac surgery. METHODS The present retrospective cohort study included 10,159 adult patients who underwent major noncardiac surgery at Nanfang Hospital, Southern Medical University, between 2008 and 2018. Postoperative AKI was defined as an increase in serum creatinine level of at least 0.3 mg/dl within 48 h, or 1.5 times higher than baseline within 7 days postoperatively according to the Kidney Disease Improving Global Outcome. The correlation between preoperative NLR and postoperative AKI was determined by stepwise multivariate logistic regression analysis, and the predictive value of NLR was evaluated by the receiver operating characteristics curve (ROC) analysis. RESULTS Four hundred and eighty-five (4.77%) patients developed AKI postoperatively. Preoperative NLR was independently associated with postoperative AKI in all patients undergoing non-cardiac surgery (Odds ratio [OR], 1.03; 95% confidence interval [CI], 1.00-1.06). The optimal cut-off value of NLR was 2.12 according ROC analysis. The OR and 95% CI of AKI for NLR > 2.12 was 1.48 (1.21-1.81) compared with NLR ≤ 2.12. In addition, the positive association was mainly shown in patients undergone digestive system surgery with a cut-off value of 2.12 but not in neurological and musculoskeletal system surgeries. CONCLUSION The present study confirmed the association of preoperative NLR with postoperative AKI in digestive system surgical patients. A NLR value of 2.12 may be a useful cut-off to evaluate the risk of AKI.
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Affiliation(s)
- Yang-Tian Yan
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Hua-Min Liu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yi-Fan Kong
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Jia-Ming Liu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Cai Li
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Bing-Cheng Zhao
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.
| | - Ke-Xuan Liu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.
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Pichler A, Kurz A, Eichlseder M, Graf A, Eichinger M, Taschner A, Kabon B, Fleischmann E, Reiterer C. PerIoperative iNflammatory reSponse assessment In hiGH-risk patienTs undergoing non-cardiac surgery (INSIGHT): study protocol of a prospective non-interventional observational study. BMJ Open 2023; 13:e065469. [PMID: 37474184 PMCID: PMC10357807 DOI: 10.1136/bmjopen-2022-065469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Abstract
INTRODUCTION Increased inflammatory processes after non-cardiac surgery are very common. The association between postoperative inflammation and the occurrence of cardiovascular complications after non-cardiac surgery are still not entirely clear. Therefore, we will evaluate the association between postoperative inflammation and the occurrence of major cardiovascular complications in patients at-risk for cardiovascular complications undergoing non-cardiac surgery. We will further evaluate the association of postoperative inflammation and days-at-home within 30 days after surgery (DAH30), the incidence of acute kidney injury, postoperative N-terminal probrain natriuretic peptide (NT-proBNP) concentrations and neurocognitive decline. METHODS AND ANALYSIS In this multicentre study, we will include 1400 patients at-risk for cardiovascular complications undergoing non-cardiac surgery. Our primary aim is to evaluate the association of postoperative maximum C-reactive protein concentration and the occurrence of a composite of five major cardiovascular complications (myocardial infarction, myocardial injury after non-cardiac surgery, new onset of atrial fibrillation, stroke and death) within 30 days after surgery using a Mann-Whitney-U test as well as a logistic regression model. As our secondary aim, we will evaluate the association of a composite of three inflammatory biomarkers (interleukin 6, procalcitonin and copeptin) on the occurrence of our composite of five cardiovascular complications within 30 days and 1 year after surgery, acute kidney injury, DAH30 and NT-proBNP concentrations using linear or logistic regression models. We will measure inflammatory biomarkers before surgery, and on the first, second, third and fifth postoperative day. We will check medical records and conduct a telephone survey 30 days and 1 year after surgery. We evaluate neurocognitive function, using a Montreal Cognitive Assessment, before and 1 year after surgery. ETHICS AND DISSEMINATION This study was approved by the ethics committees at the Medical University of Vienna (2458/2020) and at the Medical University of Graz (33-274 ex 20/21). TRIAL REGISTRATION NUMBER NCT04753307.
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Affiliation(s)
- Alexander Pichler
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
- Outcome Research Consortium, Cleveland, Ohio, USA
| | - Andrea Kurz
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
- Outcome Research Consortium, Cleveland, Ohio, USA
| | - Michael Eichlseder
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
- Outcome Research Consortium, Cleveland, Ohio, USA
| | - Alexandra Graf
- Center for Medical Data Science, Medical University of Vienna, Vienna, Austria
| | - Michael Eichinger
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
- Outcome Research Consortium, Cleveland, Ohio, USA
| | - Alexander Taschner
- Outcome Research Consortium, Cleveland, Ohio, USA
- Department of Anaesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Barbara Kabon
- Outcome Research Consortium, Cleveland, Ohio, USA
- Department of Anaesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Edith Fleischmann
- Outcome Research Consortium, Cleveland, Ohio, USA
- Department of Anaesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Christian Reiterer
- Outcome Research Consortium, Cleveland, Ohio, USA
- Department of Anaesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
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Agreement of somatic and renal near-infrared spectroscopy with reference blood samples during a controlled hypoxia sequence: a healthy volunteer study. J Clin Monit Comput 2022; 37:805-814. [PMID: 36463540 PMCID: PMC10175462 DOI: 10.1007/s10877-022-00944-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 10/17/2022] [Accepted: 10/29/2022] [Indexed: 12/05/2022]
Abstract
AbstractPurpose: O3® Regional Oximetry (Masimo Corporation, California, USA) is validated for cerebral oximetry. We aimed to assess agreement of somatic and renal near-infrared spectroscopy with reference blood samples. Methods: O3 sensors were placed bilaterally on the quadriceps and flank of 26 healthy volunteers. A stepped, controlled hypoxia sequence was performed by adding a mixture of nitrogen and room air to the breathing circuit. O3-derived oxygen saturation values were obtained at baseline and at six decremental saturation levels (5% steps). Blood samples (radial artery, iliac vein (somatic reference) and renal vein) were obtained at each step. Reference values were calculated as: 0.7 × venous saturation + 0.3 × arterial saturation. The agreement between O3-derived values with blood reference values was assessed by calculating root-mean-square error accuracy and Bland-Altman plots. Results: The root-mean-square error accuracy was 6.0% between quadriceps oxygen saturation and somatic reference values. The mean bias was 0.8%, with limits of agreement from -7.7 to 9.3%. These were 5.1% and 0.6% (-8.3 to 9.5%) for flank oxygen saturation and somatic reference values, respectively, and 7.7% and -4.9% (-15.0 to 5.2%) for flank oxygen saturation and renal reference values. The kidney depth was 3.1 ± 0.9 cm below the skin. Conclusion: O3 regional oximetry can be used on the quadriceps and flank to monitor somatic saturation, yet has a saturation-level dependent bias. O3-derived values obtained at the flank underestimated renal reference values. Additionally, it is unlikely that the flank sensors did directly measure renal tissue. Trial registration: Clinicaltrials.gov (NCT04584788): registered October 6th, 2020.
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Mortality and costs associated with acute kidney injury following major elective, non-cardiac surgery. J Clin Anesth 2022; 82:110933. [PMID: 35933842 DOI: 10.1016/j.jclinane.2022.110933] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/15/2022] [Accepted: 07/08/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study evaluated postoperative AKI severity and its relation to short- and long-term patient outcomes. DESIGN A retrospective, single-center cohort study of patients undergoing surgery from January 2015 to May 2020. SETTING An urban, academic medical center. PATIENTS Adult patients undergoing elective, non-cardiac surgery at our institution with a postoperative length of stay (LOS) of at least 24 h were included. Patients were included in 1-year mortality analysis if their procedure occurred prior to June 2019. INTERVENTIONS None. MEASUREMENTS Postoperative AKI was identified and staged using the Kidney Disease Improving Global Outcomes definitions. The outcomes analyzed were in-hospital mortality, LOS, total cost of the surgical hospitalization, and 1-year mortality. MAIN RESULTS Of the 8887 patients studied, 648 (7.3%) had postoperative AKI. AKI was associated with severity-dependent increases in all outcomes studied. Patients with AKI had rates of in-hospital mortality of 2.0%, 3.8%, and 12.5% for stage 1, 2, and 3 AKI compared to 0.3% for patients without AKI. Mean total costs of the surgical hospitalization were $23,896 (SD $23,736) for patients without AKI compared to $33,042 (SD $27,115), $39,133 (SD $34,006), and $73,216 ($82,290) for patients with stage 1, 2, and 3 AKI, respectively. In the 6729 patients who met inclusion for 1-year mortality analysis, AKI was also associated with 1-year mortality rates of 13.9%, 19.4%, and 22.7% compared to 5.2% for patients without AKI. In multivariate models, stage 1 AKI patients still had a higher probability of 1-year mortality (OR 1.9, 95% CI 1.3-2.6, p < 0.001) in addition to $4391 of additional costs when compared to patients without AKI (95% CI $2498-$6285, p < 0.001). CONCLUSIONS All stages of postoperative AKI were associated with increased LOS, surgical hospitalization costs, in-hospital mortality, and 1-year mortality. These findings suggest that patients with even a low-grade or stage 1 AKI are at higher risk for short- and long-term complications.
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Wu LP, Pang K, Li B, Le Y, Tang YZ. Predictive Value of Glycosylated Hemoglobin for Post-operative Acute Kidney Injury in Non-cardiac Surgery Patients. Front Med (Lausanne) 2022; 9:886210. [PMID: 35899215 PMCID: PMC9309303 DOI: 10.3389/fmed.2022.886210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/22/2022] [Indexed: 11/18/2022] Open
Abstract
Objective Recent studies have indicated that patients (both with and without diabetes) with elevated hemoglobin A1c (HbA1c) have a higher rate of acute kidney injury (AKI) following cardiac surgery. However, whether HbA1c could help to predict post-operative AKI in patients after non-cardiac surgery is less clear. This study aims to explore the predictive value of pre-operative HbA1c for post-operative AKI in non-cardiac surgery. Methods We reviewed the medical records of patients (≥ 18 years old) who underwent non-cardiac surgery between 2011 and 2020. Patient-related variables, including demographic and laboratory and procedure-related information, were collected, and univariable and multivariable logistic regression analyses were performed to determine the association of HbA1c with AKI. The area under the receiver operating curve (AUC), net reclassification improvement index (NRI), and integrated discriminant improvement index (IDI) were used to evaluate the predictive ability of the model, and decision curve analysis was used to evaluate the clinical utility of the HbA1c-added predictive model. Results A total of 3.3% of patients (94 of 2,785) developed AKI within 1 week after surgery. Pre-operative HbA1c was an independent predictor of AKI after adjustment for some clinical variables (OR comparing top to bottom quintiles 5.02, 95% CI, 1.90 to 13.24, P < 0.001 for trend; OR per percentage point increment in HbA1c 1.20, 95% CI, 1.07 to 1.33). Compared to the model with only clinical variables, the incorporation of HbA1c increased the model fit, modestly improved the discrimination (change in area under the curve from 0.7387 to 0.7543) and reclassification (continuous net reclassification improvement 0.2767, 95% CI, 0.0715 to 0.4818, improved integrated discrimination 0.0048, 95% CI, -5e-04 to 0.0101) of AKI and non-AKI cases, NRI for non-AKI improvement 0.3222, 95% CI, 0.2864 to 0.3580 and achieved a higher net benefit in decision curve analysis. Conclusion Elevated pre-operative HbA1c was independently associated with post-operative AKI risk and provided predictive value in patients after non-cardiac surgery. HbA1c improved the predictive power of a logistic regression model based on traditional clinical risk factors for AKI. Further prospective studies are needed to demonstrate the results and clinical application.
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Affiliation(s)
- Lan-Ping Wu
- Department of Anesthesiology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Ke Pang
- Department of Anesthesiology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Bo Li
- Surgery Center, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yuan Le
- Department of Anesthesiology, The Third Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Yuan Le,
| | - Yong-Zhong Tang
- Department of Anesthesiology, The Third Xiangya Hospital, Central South University, Changsha, China
- Yong-Zhong Tang,
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Goeddel LA, Erlinger S, Murphy Z, Tang O, Bergmann J, Moeller S, Hattab M, Hebbar S, Slowey C, Esfandiary T, Fine D, Faraday N. Association Between Left Ventricular Relative Wall Thickness and Acute Kidney Injury After Noncardiac Surgery. Anesth Analg 2022; 135:605-616. [PMID: 35467553 DOI: 10.1213/ane.0000000000006055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) after major noncardiac surgery is commonly attributed to cardiovascular dysfunction. Identifying novel associations between preoperative cardiovascular markers and kidney injury may guide risk stratification and perioperative intervention. Increased left ventricular relative wall thickness (RWT), routinely measured on echocardiography, is associated with myocardial dysfunction and long-term risk of heart failure in patients with preserved left ventricular ejection fraction (LVEF); however, its relationship to postoperative complications has not been studied. We evaluated the association between preoperative RWT and AKI in high-risk noncardiac surgical patients with preserved LVEF. METHODS Patients ≥18 years of age having major noncardiac surgery (high-risk elective intra-abdominal or noncardiac intrathoracic surgery) between July 1, 2016, and June 30, 2018, who had transthoracic echocardiography in the previous 12 months were eligible. Patients with preoperative creatinine ≥2 mg/dL or reduced LVEF (<50%) were excluded. The association between RWT and AKI, defined as an increase in serum creatinine by 0.3 mg/dL from baseline within 48 hours or by 50% within 7 days after surgery, was assessed using multivariable logistic regression adjusted for preoperative covariates. An additional model adjusted for intraoperative covariates, which are strongly associated with AKI, especially hypotension. RWT was modeled continuously, associating the change in odds of AKI for each 0.1 increase in RWT. RESULTS The study included 1041 patients (mean ± standard deviation [SD] age 62 ± 15 years; 59% female). A total of 145 subjects (13.9%) developed AKI within 7 days. For RWT quartiles 1 through 4, respectively, 20 of 262 (7.6%), 40 of 259 (15.4%), 39 of 263 (14.8%), and 46 of 257 (17.9%) developed AKI. Log-odds and proportion with AKI increased across the observed RWT values. After adjusting for confounders (demographics, American Society of Anesthesiologists [ASA] physical status, comorbidities, baseline creatinine, antihypertensive medications, and left ventricular mass index), each RWT increase of 0.1 was associated with an estimated 26% increased odds of developing AKI (odds ratio [OR]; 95% confidence interval [CI]) of 1.26 (1.09-1.46; P = .002). After adjusting for intraoperative covariates (length of surgery, presence of an arterial line, intraoperative hypotension, crystalloid administration, transfusion, and urine output), RWT remained independently associated with the odds of AKI (OR; 95% CI) of 1.28 (1.13-1.47; P = .001). Increased RWT was also independently associated with hospital length of stay and adjusted hazard ratio (HR [95% CI]) of 0.94 (0.89-0.99; P = .018). CONCLUSIONS Left ventricular RWT is a novel cardiovascular factor associated with AKI within 7 days after high-risk noncardiac surgery among patients with preserved LVEF. Application of this commonly available measurement of risk stratification or perioperative intervention warrants further investigation.
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Affiliation(s)
- Lee A Goeddel
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Samuel Erlinger
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, St Louis, Missouri
| | - Zachary Murphy
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Olive Tang
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jules Bergmann
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shaun Moeller
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mohammad Hattab
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sachinand Hebbar
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charles Slowey
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tina Esfandiary
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Derek Fine
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nauder Faraday
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Surgery Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department ofMedicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Ariyarathna D, Bhonsle A, Nim J, Huang CKL, Wong GH, Sim N, Hong J, Nan K, Lim AKH. Intraoperative vasopressor use and early postoperative acute kidney injury in elderly patients undergoing elective noncardiac surgery. Ren Fail 2022; 44:648-659. [PMID: 35403562 PMCID: PMC9009951 DOI: 10.1080/0886022x.2022.2061997] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
| | - Ajinkya Bhonsle
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Joseph Nim
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Colin K. L. Huang
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Gabriella H. Wong
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Nicholle Sim
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Joy Hong
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Kirrolos Nan
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Andy K. H. Lim
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
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Pre-Operative Factors Associated with the Occurrence of Acute Kidney Injury in Patients Aged 65 Years and Over Undergoing Non-Ambulatory Non-Cardiac Surgery. Healthcare (Basel) 2022; 10:healthcare10030558. [PMID: 35327036 PMCID: PMC8955534 DOI: 10.3390/healthcare10030558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/02/2022] [Accepted: 03/10/2022] [Indexed: 12/04/2022] Open
Abstract
This study sought to identify risk factors for acute kidney injury (AKI) from pre-operative variables in a population of subjects aged over 65. Eligible patients were aged 65 years or over who underwent scheduled non-cardiac, non-ambulatory surgery. Patients with a diagnosis of AKI recorded in the hospital’s databases were considered since cases, from which 300 patients with no diagnosis of AKI, were drawn at random as controls. In total, 81 cases of post-operative AKI and 239 controls were identified. The incidence of post-operative AKI was 2.87%. Pre-operative creatinine level (p = 0.0001), a history of respiratory insufficiency (p = 0.04), prior vascular surgery (p = 0.0001) and abdominal surgery (p = 0.03) were associated with an increased risk of AKI after surgery. These four variables calculated a score and developed a nomogram for predicting occurrence of post-operative AKI. A history of renal disease was associated with increased risk of post-operative AKI, predominantly in cases of vascular or abdominal surgery.
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Pilarczyk K, Huenges K, Bewig B, Balke L, Cremer J, Haneya A, Panholzer B. Acute Kidney Injury in Patients with Severe ARDS Requiring Extracorporeal Membrane Oxygenation: Incidence, Prognostic Impact and Risk Factors. J Clin Med 2022; 11:1079. [PMID: 35207357 PMCID: PMC8874829 DOI: 10.3390/jcm11041079] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/03/2022] [Accepted: 02/11/2022] [Indexed: 01/27/2023] Open
Abstract
(1) Background: Acute kidney injury (AKI) is a common but under-investigated complication in patients receiving extracorporeal membrane oxygenation (ECMO). We aimed to define the incidence and clinical course, as well as the predictors of AKI in adults receiving ECMO support. (2) Materials and Methods: This is a retrospective analysis of all patients undergoing veno-venous ECMO treatment in a tertiary care center between December 2008 and December 2017. The primary endpoint was the new occurrence of an AKI of stage 2 or 3 according to the Kidney Disease: Improving Global Outcomes (KDIGO) classification after ECMO implantation. (3) Results: During the observation period, 103 patients underwent veno-venous ECMO implantation. In total, 59 patients (57.3%) met the primary endpoint with an AKI of stage 2 or 3 and 55 patients (53.4%) required renal replacement therapy. Patients with an AKI of 2 or 3 suffered from more bleeding and infectious complications. Whereas weaning failure from ECMO (30/59 (50.8%) vs. 15/44 (34.1%), p = 0.08) and 30-day mortality (35/59 (59.3%) vs. 17/44 (38.6%), p = 0.06) only tended to be higher in the group with an AKI of stage 2 or 3, long-term survival of up to five years was significantly lower in the group with an AKI of stage 2 or 3 (p = 0.015). High lactate, serum creatinine, and ECMO pump-speed levels, and low platelets, a low base excess, and a low hematocrit level before ECMO were independent predictors of moderate to severe AKI. Primary hypercapnic acidosis was more common in AKI non-survivors (12 (32.4%) vs. 0 (0.0%), p < 0.01). Accordingly, pCO2-levels prior to ECMO implantation tended to be higher in AKI non-survivors (76.12 ± 27.90 mmHg vs. 64.44 ± 44.31 mmHg, p = 0.08). In addition, the duration of mechanical ventilation prior to ECMO-implantation tended to be longer (91.14 ± 108.16 h vs. 75.90 ± 86.81 h, p = 0.078), while serum creatinine (180.92 ± 115.72 mmol/L vs. 124.95 ± 77.77 mmol/L, p = 0.03) and bicarbonate levels were significantly higher in non-survivors (28.22 ± 8.44 mmol/L vs. 23.36 ± 4.19 mmol/L, p = 0.04). (4) Conclusion: Two-thirds of adult patients receiving ECMO suffered from moderate to severe AKI, with a significantly increased morbidity and long-term mortality.
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Affiliation(s)
- Kevin Pilarczyk
- Department of Intensive Care Medicine, Imland Klinik Rendsburg, 24768 Rendsburg, Germany
| | - Katharina Huenges
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, 24105 Kiel, Germany; (K.H.); (J.C.); (A.H.); (B.P.)
| | - Burkhard Bewig
- Department of Pneumology, Städtisches Krankenhaus Kiel, 24116 Kiel, Germany; (B.B.); (L.B.)
| | - Lorenz Balke
- Department of Pneumology, Städtisches Krankenhaus Kiel, 24116 Kiel, Germany; (B.B.); (L.B.)
| | - Jochen Cremer
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, 24105 Kiel, Germany; (K.H.); (J.C.); (A.H.); (B.P.)
| | - Assad Haneya
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, 24105 Kiel, Germany; (K.H.); (J.C.); (A.H.); (B.P.)
| | - Bernd Panholzer
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, 24105 Kiel, Germany; (K.H.); (J.C.); (A.H.); (B.P.)
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11
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Health system perspectives in acute kidney injury: commitment to kidney health and planning implementation interventions. Curr Opin Crit Care 2021; 27:593-603. [PMID: 34757995 DOI: 10.1097/mcc.0000000000000878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To discuss a deliberate commitment by health systems to optimize kidney health and outcomes of patients who are at risk for or develop acute kidney injury (AKI) during hospitalization. RECENT FINDINGS In 2019, the US Department of Health and Human Services set national goals targeted at improving the care and outcomes of patients with kidney disease including prevention by reducing the number of Americans who develop end-stage kidney disease (ESKD) by 25% by 2030. In response to this call to action, there is a need to focus on education to identify patients at high-risk for kidney disease development and progression, active surveillance methods to ensure timely identification, offering better follow-up care after an episode of AKI. A strategic approach to determining the health systems level of commitment and developing a plan for organizational change is discussed in this commentary. Items for consideration are structuring sound implementation projects and selecting implementation interventions. Clinical interventions to consider for implementation include the use of clinical decision support for detecting patients with AKI, novel biomarkers to determine patients at high-risk for AKI and nephrotoxin stewardship to prevent medication safety complications and drug-associated AKI. SUMMARY There is a national call to action to improve the care and outcomes of patients with kidney disease. Health systems have an opportunity to respond by providing a high level of commitment towards ensuring the best kidney health for all patients equally. Deliberate change that is sustainable and scalable should be considered by all health systems.
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12
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Zhong J, Gao J, Luo JC, Zheng JL, Tu GW, Xue Y. Serum creatinine as a predictor of mortality in patients readmitted to the intensive care unit after cardiac surgery: a retrospective cohort study in China. J Thorac Dis 2021; 13:1728-1736. [PMID: 33841963 PMCID: PMC8024843 DOI: 10.21037/jtd-20-3205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients readmitted to the intensive care unit (ICU) after cardiac surgery have a high mortality rate. The relationship between renal function and in-hospital mortality in readmitted patients has not been well demonstrated. METHODS We retrospectively evaluated cardiac surgery patients who were readmitted to the ICU at least once. Data on serum creatinine levels before surgery and on the day of ICU readmission were collected. The estimated glomerular filtration rate (eGFR) was calculated according to the creatinine-based Chronic Kidney Disease-Epidemiology Collaboration equation. We used logistic regression models and restricted cubic spline curves with four knots (5%, 35%, 65%, 95%) to investigate the relationship between renal function indicators and mortality. RESULTS Of the 184 patients evaluated, 30 patients died during hospitalization, yielding a mortality rate of 16.30%. Cardiac dysfunction (n=84, 45.65%) and respiration disorder (n=51, 27.72%) were the most common reasons for ICU readmission. Creatinine [odds ratio (OR): 1.14, 95% confidence interval (CI): 1.07-1.25] and eGFR (OR: 0.95, 95% CI: 0.93-0.98) were independently associated with in-hospital mortality after adjusting for various confounders. Both creatinine level and eGFR had a linear association with in-hospital mortality (P for non-linearity ˃0.05). CONCLUSION Renal function is significantly associated with the in-hospital mortality of patients readmitted to the ICU after cardiac surgery, as evidenced by the independent correlation of both creatinine and eGFR with in-hospital mortality.
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Affiliation(s)
- Jun Zhong
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian Gao
- Department of Biostatistics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ji-Li Zheng
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yan Xue
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
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13
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Gameiro J, Marques F, Lopes JA. Long-term consequences of acute kidney injury: a narrative review. Clin Kidney J 2021; 14:789-804. [PMID: 33777362 PMCID: PMC7986368 DOI: 10.1093/ckj/sfaa177] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/20/2020] [Indexed: 12/24/2022] Open
Abstract
The incidence of acute kidney injury (AKI) has increased in the past decades. AKI complicates up to 15% of hospitalizations and can reach up to 50-60% in critically ill patients. Besides the short-term impact of AKI in patient outcomes, several studies report the association between AKI and adverse long-term outcomes, such as recurrent AKI episodes in 25-30% of cases, hospital re-admissions in up to 40% of patients, an increased risk of cardiovascular events, an increased risk of progression of chronic kidney disease (CKD) after AKI and a significantly increased long-term mortality. Despite the long-term impact of AKI, there are neither established guidelines on the follow-up care of AKI patients, nor treatment strategies to reduce the incidence of sequelae after AKI. Only a minority of patients have been referred to nephrology post-discharge care, despite the evidence of improved outcomes associated with nephrology referral by addressing cardiovascular risk and risk of progression to CKD. Indeed, AKI survivors should have specialized nephrology follow-up to assess kidney function after AKI, perform medication reconciliation, educate patients on nephrotoxic avoidance and implement strategies to prevent CKD progression. The authors provide a comprehensive review of the transition from AKI to CKD, analyse the current evidence on the long-term outcomes of AKI and describe predisposing risk factors, highlight the importance of follow-up care in these patients and describe the current therapeutic strategies which are being investigated on their impact in improving patient outcomes.
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Affiliation(s)
- Joana Gameiro
- Department of Medicine, Division of Nephrology and Renal Transplantation, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal
| | - Filipe Marques
- Department of Medicine, Division of Nephrology and Renal Transplantation, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal
| | - José António Lopes
- Department of Medicine, Division of Nephrology and Renal Transplantation, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal
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Nishimoto M, Murashima M, Kokubu M, Matsui M, Eriguchi M, Samejima KI, Akai Y, Tsuruya K. Anemia following acute kidney injury after noncardiac surgery and long-term outcomes: the NARA-AKI cohort study. Clin Kidney J 2020; 14:673-680. [PMID: 35261759 PMCID: PMC8894936 DOI: 10.1093/ckj/sfaa184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Indexed: 02/01/2023] Open
Abstract
Abstract
Background
This study was conducted to investigate whether acute kidney injury (AKI) is an independent predictor of anemia and whether anemia following AKI is a mediator of mortality after AKI.
Methods
This is a retrospective cohort study. Adults with noncardiac surgery from 2007 to 2011 were included. Obstetric or urological surgery, missing data or preoperative dialysis were excluded. Subjects were followed until the end of 2015 or lost to follow-up. Exposures of interest were postoperative AKI. Outcome variables were hematocrit values at 3, 6 and 12 months postoperatively and mortality. Associations between AKI and hematocrit or association between AKI and mortality were examined by multivariable linear regression or Cox regression, respectively.
Results
Among 6692 subjects, 445 (6.6%) developed AKI. Among those with postoperative data, AKI was independently associated with lower hematocrit at 3, 6 and 12 months postoperatively, with coefficients of −0.79 [95% confidence interval (CI) −1.47 to −0.11; n = 1750], −1.35 (−2.11 to −0.60; n = 1558) and −0.91 (−1.59 to −0.22; n = 2463), respectively. Higher stages or longer duration of AKI were associated with more severe anemia. AKI was associated with higher mortality after 3 months postoperatively with a hazard ratio of 1.54 (95% CI 1.12–2.12). Further adjustment with hematocrit at 3 months attenuated the association. The mediation effect was significant (P = 0.02) by mediation analysis.
Conclusions
AKI was an independent predictor of anemia following AKI. Higher mortality associated with AKI was at least partially mediated by anemia following AKI. Whether correction of anemia following AKI improves mortality requires further research.
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Affiliation(s)
| | - Miho Murashima
- Department of Nephrology, Nara Medical University, Nara, Japan
- Department of Nephrology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Maiko Kokubu
- Department of Nephrology, Nara Prefecture General Medical Center, Nara, Japan
| | - Masaru Matsui
- Department of Nephrology, Nara Medical University, Nara, Japan
- Department of Nephrology, Nara Prefecture General Medical Center, Nara, Japan
| | | | | | - Yasuhiro Akai
- Department of Nephrology, Nara Medical University, Nara, Japan
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15
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Kimura S, Iwasaki T, Shimizu K, Kanazawa T, Kawase H, Shioji N, Kuroe Y, Isoyama S, Morimatsu H. Evaluation of a point-of-care serum creatinine measurement device and the impact on diagnosis of acute kidney injury in pediatric cardiac patients: A retrospective, single center study. Health Sci Rep 2020; 3:e143. [PMID: 32166189 PMCID: PMC7060889 DOI: 10.1002/hsr2.143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/24/2019] [Accepted: 10/24/2019] [Indexed: 01/09/2023] Open
Abstract
Background and aims Agreement between measurements of creatinine concentrations using point‐of‐care (POC) devices and measurements conducted in a standard central laboratory is unclear for pediatric patients. Our objectives were (a) to assess the agreement for pediatric patients and (b) to compare the incidence of postoperative acute kidney injury (AKI) according to the two methods. Methods This retrospective, single‐center study included patients under 18 years of age who underwent cardiac surgery and who were admitted into the pediatric intensive care unit of a tertiary teaching hospital (Okayama University Hospital, Japan) from 2013 to 2017. The primary objective was to assess the correlation and the agreement between measurements of creatinine concentrations by a Radiometer blood gas analyzer (Cregas) and those conducted in a central laboratory (Crelab). The secondary objective was to compare the incidence of postoperative AKI between the two methods based on Kidney Disease Improving Global Outcomes (KDIGO) criteria. Results We analyzed the results of 1404 paired creatinine measurements from 498 patients, whose median age was 14 months old (interquartile range [IQR] 3, 49). The Pearson correlation coefficient of Cregas vs Crelab was 0.968 (95% confidence interval [CI], 0.965‐0.972, P < 0.001). The median bias between Cregas and Crelab was 0.02 (IQR ‐0.02, 0.05) mg/dL. While 199 patients (40.0%) were diagnosed as having postoperative AKI based on Crelab, 357 patients (71.7%) were diagnosed as having postoperative AKI based on Cregas (Kappa = 0.39, 95% CI, 0.33‐0.46). In a subgroup analysis of patients whose Cregas and Crelab were measured within 1 hour, similar percentage of patients were diagnosed as having postoperative AKI based on Cregas and Crelab (42.8% vs 46.0%; Kappa = 0.76, 95% CI, 0.68‐0.84). Conclusion There was an excellent correlation between Cregas and Crelab in pediatric patients. Although more patients were diagnosed as having postoperative AKI based on Cregas than based on Crelab, paired measurements with a short time gap showed good agreement on AKI diagnosis.
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Affiliation(s)
- Satoshi Kimura
- Department of Anesthesiology and Resuscitation Okayama University Hospital Okayama Japan
| | - Tatsuo Iwasaki
- Department of Anesthesiology and Resuscitation Okayama University Hospital Okayama Japan
| | - Kazuyoshi Shimizu
- Department of Anesthesiology and Resuscitation Okayama University Hospital Okayama Japan
| | - Tomoyuki Kanazawa
- Department of Anesthesiology and Resuscitation Okayama University Hospital Okayama Japan
| | - Hirokazu Kawase
- Department of Anesthesiology and Resuscitation Okayama University Hospital Okayama Japan
| | - Naohiro Shioji
- Department of Anesthesiology and Resuscitation Okayama University Hospital Okayama Japan
| | - Yasutoshi Kuroe
- Department of Anesthesiology and Resuscitation Okayama University Hospital Okayama Japan
| | - Satoshi Isoyama
- Department of Anesthesiology and Resuscitation Okayama University Hospital Okayama Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitation Okayama University Hospital Okayama Japan
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16
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Branch-Elliman W, O'Brien W, Gupta K. Ideal Total Joint Arthroplasty Antibiotic Prophylaxis Unknown-Reply. JAMA Surg 2019; 154:1169. [PMID: 31461137 DOI: 10.1001/jamasurg.2019.2908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Westyn Branch-Elliman
- Section of Infectious Diseases, Department of Medicine, Virginia Boston Healthcare System, West Roxbury, Massachusetts.,VA Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - William O'Brien
- VA Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
| | - Kalpana Gupta
- Section of Infectious Diseases, Department of Medicine, Virginia Boston Healthcare System, West Roxbury, Massachusetts.,VA Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
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17
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Rahamimov R, van Dijk TY, Molcho M, Lahav I, Mor E, Ben Dor N, Goldman S, Rozen-Zvi B. Acute Kidney Injury and Long-Term Risk for Cardiovascular Events in Patients after Kidney Transplantation. Kidney Blood Press Res 2019; 44:1149-1157. [PMID: 31537005 DOI: 10.1159/000502523] [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: 02/15/2019] [Accepted: 08/02/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) was found to be associated with an increased risk of major adverse cardiovascular events (MACE) in the general population. Patients after kidney transplantation are prone to AKI events and are also at an increased risk of cardiovascular (CV) disease. The association between AKI and MACE in kidney transplant patients is yet to be studied. METHODS This retrospective single-center cohort study reviewed 416 adult renal allograft recipients transplanted between 2005 and 2010. AKI events were recorded starting 2 weeks after transplantation, or following discharge with a functioning graft. AKI was defined, according to the KDIGO criteria. The primary outcome was the composite of MACE starting 6 months after transplantation and all-cause mortality. For survival analysis, we used univariate and multivariate time varying Cox proportional hazard model. RESULTS One hundred and twenty-four patients (29.8%) had at least one episode of AKI. During the median follow-up time of 7.2 years (interquartile range 4.3-9.1), 144 outcome events occurred. By time varying Cox regression analysis, AKI was associated with an increased rate of CV outcomes or death (hazard ratio [HR] 1.96, 95% CI 1.36-2.81, p < 0.001), and the association remained significant by multivariate adjusted model (HR 1.76, 95% CI 1.18-2.63, p = 0.005). As for the different components of MACE, all-cause mortality and CV mortality were the only outcomes that were significantly associated with AKI. No interaction between AKI timing and MACE was found. CONCLUSION AKI in kidney transplant recipient is associated with an increased risk of CV disease.
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Affiliation(s)
- Ruth Rahamimov
- Department of Nephrology and Hypertension, Rabin Medical Center, Beilinson Campus, Petah-Tikva, Israel, .,Department of Transplantation, Rabin Medical Center, Beilinson Campus, Petah-Tikva, Israel, .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Tuvia Y van Dijk
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Emergency Medicine, Rabin Medical Center, Beilinson Campus, Petah-Tikva, Israel
| | - Maya Molcho
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Itay Lahav
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eytan Mor
- Department of Transplantation, Rabin Medical Center, Beilinson Campus, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naomy Ben Dor
- Department of Nephrology and Hypertension, Rabin Medical Center, Beilinson Campus, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shira Goldman
- Department of Nephrology and Hypertension, Rabin Medical Center, Beilinson Campus, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Benaya Rozen-Zvi
- Department of Nephrology and Hypertension, Rabin Medical Center, Beilinson Campus, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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Branch-Elliman W, O’Brien W, Strymish J, Itani K, Wyatt C, Gupta K. Association of Duration and Type of Surgical Prophylaxis With Antimicrobial-Associated Adverse Events. JAMA Surg 2019; 154:590-598. [PMID: 31017647 PMCID: PMC6487902 DOI: 10.1001/jamasurg.2019.0569] [Citation(s) in RCA: 189] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/21/2019] [Indexed: 12/20/2022]
Abstract
Importance The benefits of antimicrobial prophylaxis are limited to the first 24 hours postoperatively. Little is known about the harms associated with continuing antimicrobial prophylaxis after skin closure. Objective To characterize the association of type and duration of prophylaxis with surgical site infection (SSI), acute kidney injury (AKI), and Clostridium difficile infection. Design, Setting, and Participants In this multicenter, national retrospective cohort study, all patients within the national Veterans Affairs health care system who underwent cardiac, orthopedic total joint replacement, colorectal, and vascular procedures and who received planned manual review by a trained nurse reviewer for type and duration of surgical prophylaxis and for SSI from October 1, 2008, to September 30, 2013, were included. Data were analyzed using multivariable logistic regression, with adjustments for covariates determined a priori to be associated with the outcomes of interest. Data were analyzed from December 2016 to December 2018. Exposures Duration of postoperative antimicrobial prophylaxis (<24 hours, 24-<48 hours, 48-<72 hours, and ≥72 hours). Main Outcomes and Measures Surgical site infection, AKI, and C difficile infection. Results Of the 79 058 included patients, 76 109 (96.3%) were men, and the mean (SD) age was 64.8 (9.4) years. Among 79 058 surgical procedures in the cohort, all had SSI and C difficile outcome data available; 71 344 (90.2%) had AKI outcome data. After stratification by type of surgery and adjustment for age, sex, race, diabetes, smoking, American Society of Anesthesiologists score greater than 2, methicillin-resistant Staphylococcus aureus colonization, mupirocin, type of prophylaxis, and facility factors, SSI was not associated with duration of prophylaxis. Adjusted odds of AKI increased with each additional day of prophylaxis (cardiac procedure: 24-<48 hours: adjusted odds ratio [aOR], 1.03; 95% CI, 0.95-1.12; 48-<72 hours: aOR, 1.22; 95% CI, 1.08-1.39; ≥72 hours: aOR, 1.82; 95% CI, 1.54-2.16; noncardiac procedure: 24-<48 hours: aOR, 1.31; 95% CI, 1.21-1.42; 48-<72 hours: aOR, 1.72; 95% CI, 1.47-2.01; ≥72 hours: aOR, 1.79; 95% CI, 1.27-2.53). The risk of postoperative C difficile infection demonstrated a similar duration-dependent association (24-<48 hours: aOR 1.08; 95% CI, 0.89-1.31; 48-<72 hours: aOR, 2.43; 95% CI, 1.80-3.27; ≥72 hours: aOR, 3.65; 95% CI, 2.40-5.53). The unadjusted numbers needed to harm for AKI after 24 to less than 48 hours, 48 to less than 72 hours, and 72 hours or more of postoperative prophylaxis were 9, 6, and 4, respectively; and 2000, 90, and 50 for C difficile infection, respectively. Vancomycin receipt was also a significant risk factor for AKI (cardiac procedure: aOR, 1.17; 95% CI, 1.10-1.25; noncardiac procedure: aOR, 1.21; 95% CI, 1.13-1.30). Conclusions and Relevance Increasing duration of antimicrobial prophylaxis was associated with higher odds of AKI and C difficile infection in a duration-dependent fashion; extended duration did not lead to additional SSI reduction. These findings highlight the notion that every day matters and suggest that stewardship efforts to limit duration of prophylaxis have the potential to reduce adverse events without increasing SSI.
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Affiliation(s)
- Westyn Branch-Elliman
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
- VA Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - William O’Brien
- VA Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
- Department of Surgery, VA Boston Healthcare System, Boston, Massachusetts
| | - Judith Strymish
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
- VA Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Kamal Itani
- VA Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Surgery, VA Boston Healthcare System, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Christina Wyatt
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute (DCRI), Durham, North Carolina
| | - Kalpana Gupta
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
- VA Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
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Kim NY, Hong JH, Koh DH, Lee J, Nam HJ, Kim SY. Effect of Diabetes Mellitus on Acute Kidney Injury after Minimally Invasive Partial Nephrectomy: A Case-Matched Retrospective Analysis. J Clin Med 2019; 8:jcm8040468. [PMID: 30959851 PMCID: PMC6518027 DOI: 10.3390/jcm8040468] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 12/11/2022] Open
Abstract
Postoperative acute kidney injury (AKI) is still a concern in partial nephrectomy (PN), even with the development of minimally invasive technique. We aimed to compare AKI incidence between patients with and without diabetes mellitus (DM) and to determine the predictive factors for postoperative AKI. This case-matched retrospective study included 884 patients with preoperative creatinine levels ≤1.4 mg/dL who underwent laparoscopic or robot-assisted laparoscopic PN between December 2005 and May 2018. Propensity score matching was employed to match patients with and without DM in a 1:3 ratio (101 and 303 patients, respectively). Of 884 patients, 20.4% had postoperative AKI. After propensity score matching, the incidence of postoperative AKI in DM and non-DM patients was 30.7% and 14.9%, respectively (P < 0.001). In multivariate analysis, male sex and warm ischemia time (WIT) >25 min were significantly associated with postoperative AKI in patients with and without DM. In patients with DM, hemoglobin A1c (HbA1c) >7% was a predictive factor for AKI, odds ratio (OR) = 4.59 (95% CI, 1.47⁻14.36). In conclusion, DM increased the risk of AKI after minimally invasive PN; male sex, longer WIT, and elevated HbA1c were independent risk factors for AKI in patients with DM.
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Affiliation(s)
- Na Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea.
| | - Jung Hwa Hong
- Department of Policy Research Affairs National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro, Ilsandong-gu, Goyang, Gyeonggi-do 10444, Korea.
| | - Dong Hoon Koh
- Department of Urology, Konyang University College of Medicine, 158 Gwanjeodong-ro, Daejeon 35365, Korea.
| | - Jongsoo Lee
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea.
| | - Hoon Jae Nam
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea.
| | - So Yeon Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea.
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