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Strauß C, Booke H, Forni L, Zarbock A. Biomarkers of acute kidney injury: From discovery to the future of clinical practice. J Clin Anesth 2024; 95:111458. [PMID: 38581927 DOI: 10.1016/j.jclinane.2024.111458] [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: 02/07/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 04/08/2024]
Abstract
Purpose of this review Acute kidney injury (AKI) is a complex syndrome whose development is associated with an increased morbidity and mortality. Recent studies show that this syndrome is a common complication in critically ill and surgical patients the trajectory of which may differ. As AKI can be induced by different triggers, it is complex and therefore challenging to manage patients with AKI. This review strives to provide a brief historical perspective on AKI, elucidate recent developments in diagnosing and managing AKI, and show the current usage of novel biomarkers in both clinical routine and research. In addition, we provide a perspective on potential future developments and their impact of AKI understanding and management. Recent findings/developments Recent studies show the merits of stress and damage biomarkers, highlighting limitations of the current KDIGO definition that only uses the functional biomarkers serum creatinine and urine output. The use of novel biomarkers led to the introduction of the concept of "subclinical AKI". This new classification may allow a more distinct management of affected or at risk patients. Ongoing studies, such as BigpAK-2 and PrevProgAKI, investigate the implementation of biomarker-guided interventions in clinical practice and may demonstrate an improvement in patients' outcome. Summary The ongoing scientific efforts surrounding AKI have deepened our understanding of the syndrome prompting an expansion of existing concepts. A future integration of stress and damage biomarkers in AKI management, may lead to an individualized therapy in this area.
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Affiliation(s)
- Christian Strauß
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Germany
| | - Hendrik Booke
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Germany
| | - Lui Forni
- School of Medicine, Kate Granger Building, Manor Park, University of Surrey, GU2 7YH, UK
| | - Alexander Zarbock
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
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Yoshida T, Matsuura R, Komaru Y, Miyamoto Y, Yoshimoto K, Hamasaki Y, Noiri E, Nangaku M, Doi K. Different Roles of Functional and Structural Renal Markers Measured at Discontinuation of Renal Replacement Therapy for Acute Kidney Injury. Blood Purif 2023; 52:786-792. [PMID: 37757763 PMCID: PMC10777711 DOI: 10.1159/000532034] [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: 12/24/2022] [Accepted: 07/03/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Severe acute kidney injury (AKI) requiring renal replacement therapy (RRT) has been associated with an unacceptably high mortality of 50% or more. Successful discontinuation of RRT is thought to be linked to better outcomes. Although functional and structural renal markers have been evaluated in AKI, little is known about their roles in predicting outcomes at the time of RRT discontinuation. METHODS In this prospective single-center cohort study, we analyzed patients who received continuous RRT (CRRT) for AKI between August 2016 and March 2018 in the intensive care unit of the University of Tokyo Hospital (Tokyo, Japan). Clinical parameters and urine samples were obtained at CRRT discontinuation. Successful CRRT discontinuation was defined as neither resuming CRRT for 48 h nor receiving intermittent hemodialysis for 7 days from the CRRT termination. Major adverse kidney events (MAKEs) were defined as death, requirement for dialysis, or a decrease in the estimated glomerular filtration rate (eGFR) of more than 25% from the baseline at day 90. RESULTS Of 73 patients, who received CRRT for AKI, 59 successfully discontinued CRRT and 14 could not. Kinetic eGFR, urine volume, urinary neutrophil gelatinase-associated lipocalin (NGAL), and urinary L-type fatty acid binding protein were predictive for CRRT discontinuation. Of these factors, urine volume had the highest area under the curve (AUC) 0.91 with 95% confidence interval [0.80-0.96] for successful CRRT discontinuation. For predicting MAKEs at day 90, the urinary NGAL showed the highest AUC 0.76 [0.62-0.86], whereas kinetic eGFR and urine volume failed to show statistical significance (AUC 0.49 [0.35-0.63] and AUC 0.59 [0.44-0.73], respectively). CONCLUSIONS Our prospective study confirmed that urine volume, a functional renal marker, predicted successful discontinuation of RRT and that urinary NGAL, a structural renal marker, predicted long-term renal outcomes. These observations suggest that the functional and structural renal makers play different roles in predicting the outcomes of severe AKI requiring RRT.
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Affiliation(s)
- Teruhiko Yoshida
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan,
| | - Ryo Matsuura
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yohei Komaru
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshihisa Miyamoto
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kohei Yoshimoto
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshifumi Hamasaki
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Eisei Noiri
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
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Muiru A, Hsu J, Zhang X, Appel L, Chen J, Cohen DL, Drawz PE, Freedman BI, Go AS, He J, Horwitz E, Hsu RK, Lash JP, Liu KD, McCoy IE, Porter A, Rao P, Ricardo AC, Rincon-Choles H, Sondheimer J, Taliercio J, Unruh M, Hsu CY. Risk for Chronic Kidney Disease Progression After Acute Kidney Injury: Findings From the Chronic Renal Insufficiency Cohort Study. Ann Intern Med 2023; 176:961-968. [PMID: 37429030 PMCID: PMC10829039 DOI: 10.7326/m22-3617] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Prior studies associating acute kidney injury (AKI) with more rapid subsequent loss of kidney function had methodological limitations, including inadequate control for differences between patients who had AKI and those who did not. OBJECTIVE To determine whether AKI is independently associated with subsequent kidney function trajectory among patients with chronic kidney disease (CKD). DESIGN Multicenter prospective cohort study. SETTING United States. PARTICIPANTS Patients with CKD (n = 3150). MEASUREMENTS Hospitalized AKI was defined by a 50% or greater increase in inpatient serum creatinine (SCr) level from nadir to peak. Kidney function trajectory was assessed using estimated glomerular filtration rate (eGFR) based on SCr level (eGFRcr) or cystatin C level (eGFRcys) measured at annual study visits. RESULTS During a median follow-up of 3.9 years, 433 participants had at least 1 AKI episode. Most episodes (92%) had stage 1 or 2 severity. There were decreases in eGFRcr (-2.30 [95% CI, -3.70 to -0.86] mL/min/1.73 m2) and eGFRcys (-3.61 [CI, -6.39 to -0.82] mL/min/1.73 m2) after AKI. However, in fully adjusted models, the decreases were attenuated to -0.38 (CI, -1.35 to 0.59) mL/min/1.73 m2 for eGFRcr and -0.15 (CI, -2.16 to 1.86) mL/min/1.73 m2 for eGFRcys, and the CI bounds included the possibility of no effect. Estimates of changes in eGFR slope after AKI determined by either SCr level (0.04 [CI, -0.30 to 0.38] mL/min/1.73 m2 per year) or cystatin C level (-0.56 [CI, -1.28 to 0.17] mL/min/1.73 m2 per year) also had CI bounds that included the possibility of no effect. LIMITATIONS Few cases of severe AKI, no adjudication of AKI cause, and lack of information about nephrotoxic exposures after hospital discharge. CONCLUSION After pre-AKI eGFR, proteinuria, and other covariables were accounted for, the association between mild to moderate AKI and worsening subsequent kidney function in patients with CKD was small. PRIMARY FUNDING SOURCE National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.
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Affiliation(s)
- Anthony Muiru
- Division of Nephrology, University of California, San Francisco School of Medicine, San Francisco, CA
| | - Jesse Hsu
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Xiaoming Zhang
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Larry Appel
- Division of General Internal Medicine, The Johns Hopkins University, Baltimore, MD
| | - Jing Chen
- Section of Nephrology & Hypertension, Tulane University School of Medicine, New Orleans, LA
| | - Debbie L. Cohen
- Division of Nephrology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Paul E. Drawz
- Division of Nephrology and Hypertension, University of Minnesota Medical School, Minneapolis, MN
| | - Barry I. Freedman
- Section on Nephrology, Wake Forest University, Winston-Salem, North Carolina
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Jiang He
- Tulane University School of Public Health & Tropical Medicine, New Orleans, LA
| | - Ed Horwitz
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Raymond K. Hsu
- Division of Nephrology, University of California, San Francisco School of Medicine, San Francisco, CA
| | - James P. Lash
- Division of Nephrology, University of Illinois Health, Chicago, IL
| | - Kathleen D. Liu
- Division of Nephrology, University of California, San Francisco School of Medicine, San Francisco, CA
| | - Ian E. McCoy
- Division of Nephrology, University of California, San Francisco School of Medicine, San Francisco, CA
| | - Anna Porter
- Division of Nephrology, University of Illinois Health, Chicago, IL
| | - Panduranga Rao
- Division of Nephrology, University of Michigan Health, Ann Arbor, MI
| | - Ana C. Ricardo
- Division of Nephrology, University of Illinois Health, Chicago, IL
| | | | - James Sondheimer
- Division of Nephrology and Hypertension, Wayne State University School of Medicine, Detroit, MI
| | | | - Mark Unruh
- University of New Mexico Health Sciences, Albuquerque, NM
| | - Chi-yuan Hsu
- Division of Nephrology, University of California, San Francisco School of Medicine, San Francisco, CA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Loane SC, Thomson JM, Williams TL, McCallum KE. Evaluation of symmetric dimethylarginine in cats with acute kidney injury and chronic kidney disease. J Vet Intern Med 2022; 36:1669-1676. [PMID: 35903963 PMCID: PMC9511064 DOI: 10.1111/jvim.16497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 07/07/2022] [Indexed: 11/26/2022] Open
Abstract
Background Serum symmetric dimethylarginine (SDMA) concentrations are considered a biomarker for renal dysfunction in dogs and humans with acute kidney injury (AKI). No studies have assessed SDMA in cats with AKI. Hypothesis/Objectives SDMA correctly identifies cats with azotemic AKI. Animals Fifteen control cats, 22 with novel AKI, 13 with acute on chronic‐AKI (AoC) and 19 with chronic kidney disease (CKD). Methods Retrospective study. Cats with azotemia (serum creatinine concentrations >1.7 mg/dL) were defined as having AKI or CKD based on history, clinical signs, clinicopathological findings and diagnostic imaging, and classified using the International Renal Interest Society (IRIS) grading/staging systems. Serum SDMA concentrations were compared between groups with nonparametric methods, and correlations assessed using Spearman's correlation coefficient. Data are presented as median [range]. Results SDMA concentrations were 11 (8‐21) μg/dL, 36 (9‐170)μg/dL, 33 (22‐75) μg/dL and 25 (12‐69) μg/dL in control, novel AKI, AoC and CKD cats. SDMA concentrations were significantly higher in cats with novel AKI (P < .001), AoC (P < .001) and CKD (P < .01) compared to controls. SDMA concentrations were significantly higher in cats with more advanced AKI (IRIS grade IV‐V) compared to less severe AKI (IRIS grade II). Serum creatinine and SDMA concentrations had a significant correlation in cats with novel AKI (rs = 0.826, n = 22; P < .001) and a significant correlation when all cats across all 4 groups were considered together (rs = 0.837, n = 69; P < .001). Conclusions and Clinical Importance Serum SDMA concentrations are elevated in cats with established AKI (novel and AoC) and CKD, providing evidence for use of SDMA as a biomarker for AKI in cats.
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Affiliation(s)
- Samantha C Loane
- Department of Veterinary Medicine, University of Cambridge, Cambridge, United Kingdom
| | - James M Thomson
- Department of Veterinary Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Timothy L Williams
- Department of Veterinary Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Katie E McCallum
- Department of Veterinary Medicine, University of Cambridge, Cambridge, United Kingdom
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Creatinine generation rate can detect sarcopenia in patients with hemodialysis. Clin Exp Nephrol 2021; 26:272-277. [PMID: 34591238 DOI: 10.1007/s10157-021-02142-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Sarcopenia is strongly associated with long-term mortality in patients undergoing hemodialysis. The diagnostic modalities used to assess muscle mass, such as bioimpedance analysis and dual-energy X-ray absorption measurement, have limitations for application in patients on hemodialysis. Therefore, there is a need to establish a simple index for assessing muscle mass that can be universally performed in patients on hemodialysis. METHODS Patients on maintenance hemodialysis were included in this study. Laboratory tests, skeletal muscle mass measured by bioimpedance analysis, and clinical records were obtained retrospectively. The creatinine generation rate (CGR) was calculated from the pre- and postdialysis blood tests using a kinetic model as the index for whole-body muscle mass. Correlations between the CGR and skeletal muscle mass were investigated, and the cut-off value for muscle wasting was determined. Kaplan-Meier survival analysis was performed to investigate the feasibility of the CGR for predicting long-term survival. RESULTS Among the 130 patients included, eight were diagnosed with sarcopenia by bioimpedance analysis. The CGR was positively correlated with skeletal muscle mass (r = 0.454, p < 0.001). Multiple linear regression analysis revealed that age and sex independently influenced the CGR. The patients were classified into two groups according to age- and sex-adjusted CGRs. During a median follow-up period of 32 months, the Kaplan-Meier survival analysis showed that patients with low CGR showed significantly poor long-term prognosis (p = 0.002). CONCLUSION The CGR is a simple index for muscle mass and can predict long-term mortality in patients on hemodialysis.
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Ullah S, Zoller M, Jaehde U, Huseyn-Zada M, Weig T, Fuhr U, Arshad U, Zander J, Taubert M. A Model-Based Approach to Assess Unstable Creatinine Clearance in Critically Ill Patients. Clin Pharmacol Ther 2021; 110:1240-1249. [PMID: 34137456 DOI: 10.1002/cpt.2341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/01/2021] [Indexed: 11/07/2022]
Abstract
Creatinine clearance is an important tool to describe the renal elimination of drugs in pharmacokinetic (PK) evaluations and clinical practice. In critically ill patients, unstable kidney function invalidates the steady-state assumption underlying equations, such as Cockcroft-Gault. Although measured creatinine clearance (mCrCL) is often used in nonsteady-state situations, it assumes that observed data are error-free, neglecting frequently occurring errors in urine collection. In contrast, compartmental nonlinear mixed effects models of creatinine allow to describe dynamic changes in kidney function while explicitly accounting for a residual error associated with observations. Based on 530 serum and 373 urine creatinine observations from 138 critically ill patients, a one-compartment creatinine model with zero-order creatinine generation rate (CGR) and first-order CrCL was evaluated. An autoregressive approach for interoccasion variability provided a distinct model improvement compared to a classical approach (Δ Akaike information criterion (AIC) -49.0). Fat-free mass, plasma urea concentration, age, and liver transplantation were significantly related to CrCL, whereas weight and sex were linked to CGR. The model-based CrCL estimates were superior to standard approaches to estimate CrCL (or glomerular filtration rate) including Cockcroft-Gault, mCrCL, four-variable modification of diet in renal disease (MDRD), six-variable MDRD, and chronic kidney disease epidemiology collaboration as a covariate to describe cefepime and meropenem PKs in terms of objective function value. In conclusion, a dynamic model of creatinine kinetics provides the means to estimate actual CrCL despite dynamic changes in kidney function, and it can easily be incorporated into population PK evaluations.
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Affiliation(s)
- Sami Ullah
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany.,Institute of Pharmacy, Clinical Pharmacy, University of Bonn, Bonn, Germany
| | - Michael Zoller
- Department of Anaesthesiology, Hospital of the Ludwig Maximilians University of Munich, Munich, Germany
| | - Ulrich Jaehde
- Institute of Pharmacy, Clinical Pharmacy, University of Bonn, Bonn, Germany
| | - Mikayil Huseyn-Zada
- Department of Anaesthesiology, Hospital of the Ludwig Maximilians University of Munich, Munich, Germany
| | - Thomas Weig
- Department of Anaesthesiology, Hospital of the Ludwig Maximilians University of Munich, Munich, Germany
| | - Uwe Fuhr
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Usman Arshad
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany.,Institute of Pharmacy, Clinical Pharmacy, University of Bonn, Bonn, Germany
| | - Johannes Zander
- Institute of Laboratory Medicine, Hospital of the Ludwig Maximilians University of Munich, Munich, Germany
| | - Max Taubert
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
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7
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Nix DE, Erstad BL. Creatinine Assessment in Non-Steady-State Conditions: A Critical Review. Ann Pharmacother 2021; 55:1536-1544. [PMID: 33678030 DOI: 10.1177/1060028021999644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To discuss methods for the assessment of creatinine clearance (Clcr) when serum creatinine (SCr) is not at steady state in order to estimate kidney function and apply the estimate to kidney function staging for clinical assessment or drug dosing. DATA SOURCES A PubMed search was conducted from 1976 to mid-January 2021 with other articles identified through review of bibliographies of retrieved articles and citations in Scopus. STUDY SELECTION AND DATA EXTRACTION Articles assessing Clcr under non-steady-state conditions and studies evaluating predictive equations were selected. DATA SYNTHESIS When SCr is systematically changing (ie, trending up or down), kinetic methods to estimate Clcr are appropriate. Estimates from kinetic methods should be individual based and not indexed to body surface area, and careful monitoring is required to confirm predictions as the situation evolves. Standard methods intended for steady-state conditions should not be used to estimate Clcr in patients with unstable SCr. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Creatinine continues to be a monitoring parameter of choice and is an important variable in all the commonly used equations for estimating Clcr and most important for estimating glomerular filtration rate. However, standard methods of estimating Clcr for medication dosing are not accurate under non-steady-state conditions. CONCLUSION The methods for kinetic clearance estimation and standards methods for clearance estimation, such as the Cockcroft-Gault equation, are mutually exclusive. There are no benefits of using the kinetic method in patients with stable SCr concentrations, and standard equations are not appropriate with unstable SCr concentrations.
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Defauw P, Schoeman JP, Leisewitz AL, Goddard A, Duchateau L, Aresu L, Meyer E, Daminet S. Evaluation of acute kidney injury in dogs with complicated or uncomplicated Babesia rossi infection. Ticks Tick Borne Dis 2020; 11:101406. [PMID: 32107174 DOI: 10.1016/j.ttbdis.2020.101406] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 01/25/2020] [Accepted: 02/03/2020] [Indexed: 11/26/2022]
Abstract
Dogs with babesiosis can present with multiple complications, including acute kidney injury (AKI). The objective of this study was to characterize AKI in dogs with babesiosis caused by Babesia rossi at presentation and after treatment. Thirty-five client-owned dogs with B. rossi infection and 10 control dogs were included in this prospective observational study. Blood and urine were collected in Babesia-infected dogs at presentation (T0, n = 35), after 24 h (T24h, n = 11), and after 1 month (T1m, n = 9). The following urinary kidney injury biomarkers were assessed: urinary protein to creatinine ratio (UPC), urinary glomerular injury biomarkers (immunoglobulin G (uIgG) and C-reactive protein (uCRP)), and urinary tubular injury biomarkers (retinol-binding protein (uRBP) and neutrophil gelatinase-associated lipocalin (uNGAL)). Serum functional renal biomarkers were creatinine (sCr) and symmetric dimethylarginine (sSDMA). Post-mortem kidney biopsies were analyzed by light and transmission electron microscopy. At T0, all kidney injury biomarkers were significantly higher in Babesia-infected dogs compared to healthy controls (P < 0.001), while functional renal biomarkers were not significantly different (P > 0.05). At T24h, all urinary tubular injury biomarkers and UPC decreased significantly (P < 0.01), while glomerular injury biomarkers did not (P = 0.084). At T1m, all urinary kidney injury biomarkers decreased to values not significantly different from healthy controls (P > 0.5). Significant changes in functional renal biomarkers were not seen after treatment (P > 0.05). Dogs with complicated babesiosis had significantly higher glomerular injury biomarkers, UPC, and sSDMA compared to uncomplicated cases (P < 0.05), while all tubular injury biomarkers and sCr were not significantly different (P > 0.1). Dogs with babesiosis caused by B. rossi showed transient kidney injury, which was detected by all kidney injury biomarkers, but remained undetected by functional biomarkers. All infected dogs, irrespective of disease severity, suffered comparable kidney injury based on tubular injury biomarker concentrations, while loss of function was seen more often in dogs with complicated babesiosis based on sSDMA results.
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Affiliation(s)
- P Defauw
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium.
| | - J P Schoeman
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Pretoria, Onderstepoort 0110, South Africa.
| | - A L Leisewitz
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Pretoria, Onderstepoort 0110, South Africa.
| | - A Goddard
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Pretoria, Onderstepoort 0110, South Africa.
| | - L Duchateau
- Biometrics Research Group, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium.
| | - L Aresu
- Department of Veterinary Science, University of Turin, Largo Braccini 2, 10095 Grugliasco, Torino, Italy.
| | - E Meyer
- Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium.
| | - S Daminet
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium.
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Desanti De Oliveira B, Xu K, Shen TH, Callahan M, Kiryluk K, D'Agati VD, Tatonetti NP, Barasch J, Devarajan P. Molecular nephrology: types of acute tubular injury. Nat Rev Nephrol 2019; 15:599-612. [PMID: 31439924 PMCID: PMC7303545 DOI: 10.1038/s41581-019-0184-x] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2019] [Indexed: 12/29/2022]
Abstract
The acute loss of kidney function has been diagnosed for many decades using the serum concentration of creatinine - a muscle metabolite that is an insensitive and non-specific marker of kidney function, but is now used for the very definition of acute kidney injury (AKI). Fortunately, myriad new tools have now been developed to better understand the relationship between acute tubular injury and elevation in serum creatinine (SCr). These tools include unbiased gene and protein expression analyses in kidney, urine and blood, the localization of specific gene transcripts in pathological biopsy samples by rapid in-situ RNA technology and single-cell RNA-sequencing analyses. However, this molecular approach to AKI has produced a series of unexpected problems, because the expression of specific kidney-derived molecules that are indicative of injury often do not correlate with SCr levels. This discrepancy between kidney injury markers and SCr level can be reconciled by the recognition that many separate subtypes of AKI exist, each with distinct patterning of molecular markers of tubular injury and SCr data. In this Review, we describe the weaknesses of isolated SCr-based diagnoses, the clinical and molecular subtyping of acute tubular injury, and the role of non-invasive biomarkers in clinical phenotyping. We propose a conceptual model that synthesizes molecular and physiological data along a time course spanning from acute cellular injury to organ failure.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Prasad Devarajan
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Continuous Infusion of Low-Dose Iohexol Measures Changing Glomerular Filtration Rate in Critically Ill Patients. Crit Care Med 2019; 46:e190-e197. [PMID: 29194145 DOI: 10.1097/ccm.0000000000002870] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Measurement of changing glomerular filtration rate in acute kidney injury remains problematic. We have previously used a continuous infusion of low-dose Iohexol to measure glomerular filtration rate in stable subjects and postulate that changes greater than 10.3% in critically ill patients indicate acute kidney injury. Our objective is to explore the extent to which continuous infusion of low-dose Iohexol can be a measure of changing glomerular filtration rate during acute kidney injury. DESIGN Clinical observational exploratory study. SETTING Adult ICU. PATIENTS Three patient groups were recruited: nephrectomy group: predictable onset of acute kidney injury and outcome (n = 10); surgery group: predictable onset of acute kidney injury, unpredictable outcome (n = 11); and acute kidney injury group: unpredictable onset of acute kidney injury and outcome (n = 13). INTERVENTIONS Continuous infusion of low-dose Iohexol was administered for 24-80 hours. Plasma (ClP) and renal (ClR) Iohexol clearances were measured at timed intervals. MEASUREMENTS AND MAIN RESULTS Kidney Disease: Improved Global Outcomes acute kidney injury criteria were fulfilled in 22 patients (nephrectomy = 5, surgery = 4, and acute kidney injury = 13); continuous infusion of low-dose Iohexol demonstrated acute kidney injury in 29 patients (nephrectomy = 10, surgery = 8, acute kidney injury = 11). Dynamic changes in glomerular filtration rate were tracked in all patients. In the nephrectomy group, ClR decreased by an expected 50% (50.8% ± 11.0%). Agreement between ClP and ClR improved with increasing duration of infusion: bias of ClP versus ClR at 48 hours was -0.1 ± 3.6 mL/min/1.73 m (limits of agreement: -7.2 to 7.1 mL/min/1.73 m). Coefficient of variation of laboratory sample analysis was 2.4%. CONCLUSIONS Continuous infusion of low-dose Iohexol is accurate and precise when measuring glomerular filtration rate and tracks changes in patients with differing risks of acute kidney injury. Continuous infusion of low-dose Iohexol may provide a useful standard against which to test novel biomarkers for the diagnosis of acute kidney injury.
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Hsu RK, Hsu CY, McCulloch CE, Yang J, Anderson AH, Chen J, Feldman HI, He J, Liu KD, Navaneethan SD, Porter AC, Rahman M, Tan TC, Wilson FP, Xie D, Zhang X, Go AS. Research-based versus clinical serum creatinine measurements and the association of acute kidney injury with subsequent kidney function: findings from the Chronic Renal Insufficiency Cohort study. Clin Kidney J 2019; 13:55-62. [PMID: 32082553 PMCID: PMC7025351 DOI: 10.1093/ckj/sfz057] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/08/2019] [Indexed: 12/21/2022] Open
Abstract
Background Observational studies relying on clinically obtained data have shown that acute kidney injury (AKI) is linked to accelerated chronic kidney disease (CKD) progression. However, prior reports lacked uniform collection of important confounders such as proteinuria and pre-AKI kidney function trajectory, and may be susceptible to ascertainment bias, as patients may be more likely to undergo kidney function testing after AKI. Methods We studied 444 adults with CKD who participated in the prospective Chronic Renal Insufficiency Cohort (CRIC) Study and were concurrent members of a large integrated healthcare delivery system. We estimated glomerular filtration rate (eGFR) trajectories using serum creatinine measurements from (i) the CRIC research protocol (yearly) and (ii) routine clinical care. We used linear mixed effects models to evaluate the associations of AKI with acute absolute change in eGFR and post-AKI eGFR slope, and explored whether these varied by source of creatinine results. Models were adjusted for demographic characteristics, diabetes status and albuminuria. Results During median follow-up of 8.5 years, mean rate of eGFR loss was −0.31 mL/min/1.73 m2/year overall, and 73 individuals experienced AKI (55% Stage 1). A significant interaction existed between AKI and source of serum creatinine for acute absolute change in eGFR level after discharge; in contrast, AKI was independently associated with a faster rate of eGFR decline (mean additional loss of −0.67 mL/min/1.73 m2/year), which was not impacted by source of serum creatinine. Conclusions AKI is independently associated with subsequent steeper eGFR decline regardless of the serum creatinine source used, but the strength of association is smaller than observed in prior studies after taking into account key confounders such as pre-AKI eGFR slope and albuminuria.
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Affiliation(s)
- Raymond K Hsu
- Department of Medicine, School of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Chi-Yuan Hsu
- Department of Medicine, School of Medicine, University of California-San Francisco, San Francisco, CA, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, School of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Jingrong Yang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Amanda H Anderson
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Jing Chen
- Department of Medicine, School of Medicine, Tulane University, New Orleans, LA, USA
| | - Harold I Feldman
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jiang He
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Kathleen D Liu
- Department of Medicine, School of Medicine, University of California-San Francisco, San Francisco, CA, USA.,Department of Anesthesia, University of California-San Francisco, San Francisco, CA, USA
| | | | - Anna C Porter
- Department of Medicine, College of Medicine, University of Illinois-Chicago, Chicago, IL, USA
| | - Mahboob Rahman
- Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Thida C Tan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - F Perry Wilson
- Program of Applied Translational Research and Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Xiaoming Zhang
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alan S Go
- Department of Medicine, School of Medicine, University of California-San Francisco, San Francisco, CA, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.,Department of Epidemiology and Biostatistics, School of Medicine, University of California-San Francisco, San Francisco, CA, USA
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12
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Stads S, Schilder L, Nurmohamed SA, Bosch FH, Purmer IM, den Boer SS, Kleppe CG, Vervloet MG, Beishuizen A, Girbes ARJ, ter Wee PM, Gommers D, Groeneveld ABJ, Oudemans-van Straaten HM. Fluid balance-adjusted creatinine at initiation of continuous venovenous hemofiltration and mortality. A post-hoc analysis of a multicenter randomized controlled trial. PLoS One 2018; 13:e0197301. [PMID: 29874271 PMCID: PMC5991340 DOI: 10.1371/journal.pone.0197301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/27/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) requiring renal replacement therapy (RRT) is associated with high mortality. The creatinine-based stage of AKI is considered when deciding to start or delay RRT. However, creatinine is not only determined by renal function (excretion), but also by dilution (fluid balance) and creatinine generation (muscle mass). The aim of this study was to explore whether fluid balance-adjusted creatinine at initiation of RRT is related to 28-day mortality independent of other markers of AKI, surrogates of muscle mass and severity of disease. METHODS We performed a post-hoc analysis on data from the multicentre CASH trial comparing citrate to heparin anticoagulation during continuous venovenous hemofiltration (CVVH). To determine whether fluid balance-adjusted creatinine was associated with 28-day mortality, we performed a logistic regression analysis adjusting for confounders of creatinine generation (age, gender, body weight), other markers of AKI (creatinine, urine output) and severity of disease. RESULTS Of the 139 patients, 32 patients were excluded. Of the 107 included patients, 36 died at 28 days (34%). Non-survivors were older, had higher APACHE II and inclusion SOFA scores, lower pH and bicarbonate, lower creatinine and fluid balance-adjusted creatinine at CVVH initiation. In multivariate analysis lower fluid balance-adjusted creatinine (OR 0.996, 95% CI 0.993-0.999, p = 0.019), but not unadjusted creatinine, remained associated with 28-day mortality together with bicarbonate (OR 0.869, 95% CI 0.769-0.982, P = 0.024), while the APACHE II score non-significantly contributed to the model. CONCLUSION In this post-hoc analysis of a multicentre trial, low fluid balance-adjusted creatinine at CVVH initiation was associated with 28-day mortality, independent of other markers of AKI, organ failure, and surrogates of muscle mass, while unadjusted creatinine was not. More tools are needed for better understanding of the complex determinants of "AKI classification", "CVVH initiation" and their relation with mortality, fluid balance is only one.
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Affiliation(s)
- Susanne Stads
- Department of Intensive care, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Intensive care, Ikazia Hospital, Rotterdam, the Netherlands
| | - Louise Schilder
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
| | - S. Azam Nurmohamed
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
| | - Frank H. Bosch
- Department of Intensive Care, Rijnstate Hospital, Arnhem, the Netherlands
| | - Ilse M. Purmer
- Department of Intensive care, Haga hospital, den Haag, the Netherlands
| | - Sylvia S. den Boer
- Department of Intensive care, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Cynthia G. Kleppe
- Department of Intensive care, Noordwest Ziekenhuis groep, Alkmaar, the Netherlands
| | - Marc G. Vervloet
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
| | - Albertus Beishuizen
- Department of Intensive care, VU University Medical Center, Amsterdam, the Netherlands
- Department of Intensive care, Medical Spectrum, Twente, the Netherlands
| | - Armand R. J. Girbes
- Department of Intensive care, VU University Medical Center, Amsterdam, the Netherlands
| | - Pieter M. ter Wee
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
| | - Diederik Gommers
- Department of Intensive care, Erasmus Medical Center, Rotterdam, the Netherlands
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13
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Chen S. Kinetic Glomerular Filtration Rate in Routine Clinical Practice-Applications and Possibilities. Adv Chronic Kidney Dis 2018; 25:105-114. [PMID: 29499881 DOI: 10.1053/j.ackd.2017.10.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 10/23/2017] [Accepted: 10/29/2017] [Indexed: 01/23/2023]
Abstract
When the [creatinine] is changing, the kidney function can still be tracked with a quantitative technique called kinetic glomerular filtration rate (GFR). The equation yields useful information on the severity of acute kidney injury, the clinical course of kidney and dialysis clearances, and the timing of kidney recovery. It has been validated in at least 3 independent studies, where it performed sufficiently well in intensive care unit and kidney transplant settings, and in head-to-head comparisons with biomarkers. Because it is based on a mathematical model, the kinetic GFR faces limitations depending on the accuracy of its assumptions. As the assumptions more accurately reflect the complexities of biology, some of these limitations can be overcome in a more sophisticated model. Kinetic GFR is an easy-to-use, low-cost tool that should be more widely incorporated into medical practice.
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14
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Liu KD, Hsu CY, Yang J, Tan TC, Zheng S, Ordonez JD, Go AS. Acute Kidney Injury Ascertainment Is Affected by the Use of First Inpatient Versus Outpatient Baseline Serum Creatinine. Kidney Int Rep 2017; 3:211-215. [PMID: 29340333 PMCID: PMC5762956 DOI: 10.1016/j.ekir.2017.08.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 07/31/2017] [Accepted: 08/21/2017] [Indexed: 11/29/2022] Open
Affiliation(s)
- Kathleen D Liu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, California, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Jingrong Yang
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Thida C Tan
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Sijie Zheng
- Division of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - Juan D Ordonez
- Division of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - Alan S Go
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, California, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.,Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California, USA
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15
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Abstract
In the general hospital setting, approximately 15% of inpatients sustain an episode of acute kidney injury (AKI) but in the critical care environment this can increase to over 25%. An episode of AKI increases the risk for both future chronic kidney disease and associated cardiovascular complications. Discharge of patients who have suffered a renal insult resulting in AKI should include consideration of longer-term follow-up, which may require nephrology input. This increase in health care burden and economic costs may be quantified and justifies the need to develop robust quality-improvement projects aimed at AKI prevention, identification, and improved management.
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Affiliation(s)
- James F Doyle
- Intensive Care Unit, Department of Intensive Care Medicine, Surrey Peri-Operative Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey County Hospital, NHS Foundation Trust, Egerton Road, Guildford, Surrey GU2 7XX, UK
| | - Lui G Forni
- Intensive Care Unit, Department of Intensive Care Medicine, Surrey Peri-Operative Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey County Hospital, NHS Foundation Trust, Egerton Road, Guildford, Surrey GU2 7XX, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK.
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16
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Golden D, Corbett J, Forni LG. Peri-operative renal dysfunction: prevention and management. Anaesthesia 2016; 71 Suppl 1:51-7. [PMID: 26620147 DOI: 10.1111/anae.13313] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2015] [Indexed: 01/05/2023]
Abstract
Postoperative increases in serum creatinine concentration, by amounts historically viewed as trivial, are associated with increased morbidity and mortality. Acute kidney injury is common, affecting one in five patients admitted with acute medical disease and up to four in five patients admitted to intensive care, of whom one in two have had operations. This review is focused principally on the identification of patients at risk of acute kidney injury and the prevention of injury. In the main, there are no interventions that directly treat the damaged kidney. The management of acute kidney injury is based on correction of dehydration, hypotension, and urinary tract obstruction, stopping nephrotoxic drugs, giving antibiotics for bacterial infection, and commencing renal replacement therapy if necessary.
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Affiliation(s)
- D Golden
- Department of Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - J Corbett
- Department of Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - L G Forni
- Department of Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK.,Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group and Faculty of Health Care Sciences, University of Surrey, Guildford, Surrey, UK
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17
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Kao SS, Kim SW, Horwood CM, Hakendorf P, Li JY, Thompson CH. Variability in inpatient serum creatinine: its impact upon short- and long-term mortality. QJM 2015; 108:781-7. [PMID: 25636343 DOI: 10.1093/qjmed/hcv020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Long-staying medical inpatients carry a significant burden of acute and chronic illness. Prediction of their in-hospital and longer-term mortality risk is important. AIM The aim of this study was to determine to what extent creatinine variability predicts in-hospital and 1-year mortality in inpatients. DESIGN Retrospective cohort analysis. METHODS Patients were included if aged 18 years or older and if admitted for 7 days or longer. The main outcome variables were mortality in hospital and after discharge. RESULTS Increasing age, the presence of heart failure and a reduced estimated glomerular filtration rate (eGFR) on admission (<60 ml/min/1.73 m(2)) all associated with death risk (both in hospital and within a year of discharge). The creatinine change was related to mortality risk for the patient whilst in hospital and within 1 year after discharge independently of these other factors. The threshold of creatinine change, above which the in-hospital mortality rose significantly was 25 µmol/l (P < 0.001). A creatinine change of >10 µmol/l predicted significantly higher mortality within a year of discharge (P < 0.001). Every 5 µmol/l change in creatinine was associated with an in-hospital mortality increase of 3% (P < 0.001) and a 1-year mortality increase of 1% (P < 0.007). CONCLUSIONS Patients with a creatinine rise or fall of >10 µmol/l during admission are at higher risk of death after discharge than those with more stable creatinine. These patients therefore merit further attention that might include more focused nutritional assessment, cardiovascular risk factor management or advance care planning.
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Affiliation(s)
- S S Kao
- From the Royal Adelaide Hospital, Adelaide, South Australia
| | - S W Kim
- Flinders Centre for Epidemiology and Biostatistics, School of Medicine, Flinders University, Adelaide, South Australia
| | | | | | - J Y Li
- Department of General Medicine, Flinders Medical Centre, Adelaide, South Australia and
| | - C H Thompson
- School of Medicine, University of Adelaide, Adelaide, South Australia
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18
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Lin J, Fernandez H, Shashaty MGS, Negoianu D, Testani JM, Berns JS, Parikh CR, Wilson FP. False-Positive Rate of AKI Using Consensus Creatinine-Based Criteria. Clin J Am Soc Nephrol 2015; 10:1723-31. [PMID: 26336912 DOI: 10.2215/cjn.02430315] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 07/22/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES Use of small changes in serum creatinine to diagnose AKI allows for earlier detection but may increase diagnostic false-positive rates because of inherent laboratory and biologic variabilities of creatinine. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined serum creatinine measurement characteristics in a prospective observational clinical reference cohort of 2267 adult patients with AKI by Kidney Disease Improving Global Outcomes creatinine criteria and used these data to create a simulation cohort to model AKI false-positive rates. We simulated up to seven successive blood draws on an equal population of hypothetical patients with unchanging true serum creatinine values. Error terms generated from laboratory and biologic variabilities were added to each simulated patient's true serum creatinine value to obtain the simulated measured serum creatinine for each blood draw. We determined the proportion of patients who would be erroneously diagnosed with AKI by Kidney Disease Improving Global Outcomes creatinine criteria. RESULTS Within the clinical cohort, 75.0% of patients received four serum creatinine draws within at least one 48-hour period during hospitalization. After four simulated creatinine measurements that accounted for laboratory variability calculated from assay characteristics and 4.4% of biologic variability determined from the clinical cohort and publicly available data, the overall false-positive rate for AKI diagnosis was 8.0% (interquartile range =7.9%-8.1%), whereas patients with true serum creatinine ≥1.5 mg/dl (representing 21% of the clinical cohort) had a false-positive AKI diagnosis rate of 30.5% (interquartile range =30.1%-30.9%) versus 2.0% (interquartile range =1.9%-2.1%) in patients with true serum creatinine values <1.5 mg/dl (P<0.001). CONCLUSIONS Use of small serum creatinine changes to diagnose AKI is limited by high false-positive rates caused by inherent variability of serum creatinine at higher baseline values, potentially misclassifying patients with CKD in AKI studies.
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Affiliation(s)
- Jennie Lin
- Renal Electrolyte and Hypertension Division, Department of Medicine and
| | - Hilda Fernandez
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York; and
| | - Michael G S Shashaty
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dan Negoianu
- Renal Electrolyte and Hypertension Division, Department of Medicine and
| | | | - Jeffrey S Berns
- Renal Electrolyte and Hypertension Division, Department of Medicine and
| | - Chirag R Parikh
- Nephrology and Program of Applied Translational Research, Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - F Perry Wilson
- Nephrology and Program of Applied Translational Research, Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
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19
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Kirwan CJ, Blunden MJ, Dobbie H, James A, Nedungadi A, Prowle JR. Critically ill patients requiring acute renal replacement therapy are at an increased risk of long-term renal dysfunction, but rarely receive specialist nephrology follow-up. Nephron Clin Pract 2015; 129:164-70. [PMID: 25765730 DOI: 10.1159/000371448] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 12/09/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Episodes of acute kidney injury (AKI) have been associated with the development of chronic kidney disease (CKD). However, follow-up pathways for patients who have survived AKI complicating critical illness are not well established. We hypothesised that patients who had AKI requiring renal replacement therapy (RRT) in intensive care are at risk of CKD, but are rarely referred for nephrology follow-up at hospital discharge. METHODS We performed a retrospective analysis of all patients who survived AKI requiring renal replacement therapy in intensive care units (ICUs) in the East London region, examining renal function at baseline, hospital discharge and 3-6 months follow-up. We excluded patients who were known to renal services prior to index admission. RESULTS From 5,544 critical care admissions, we identified 219 patients who survived to be discharged, having undergone RRT for AKI, that were not previously known to renal services. Of these, 124 (57%) had creatinine measured within 3-6 months after discharge, 104 having a pre-morbid baseline for comparison. Only 26 patients (12%) received specialist nephrology follow-up. At 3-6 months follow-up, the estimated glomerular filtration rate was significantly lower than baseline (48 vs. 60 ml/min/1.73 m(2); p < 0.001), with the prevalence of CKD stage III-V rising from 49 to 70% (p < 0.001). CONCLUSIONS Follow-up of patients who required RRT for AKI in ICU is inconsistent despite evidence of a significant increase in the prevalence of CKD. There is strong justification for the development of robust pathways to identify survivors of AKI in order to detect and manage CKD and its complications.
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Affiliation(s)
- Christopher J Kirwan
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
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20
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Dixon JJ, Lane K, Dalton RN, Turner C, Grounds RM, MacPhee IAM, Philips BJ. Validation of a continuous infusion of low dose Iohexol to measure glomerular filtration rate: randomised clinical trial. J Transl Med 2015; 13:58. [PMID: 25885409 PMCID: PMC4336474 DOI: 10.1186/s12967-015-0414-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 01/20/2015] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION There is currently no accurate method of measuring glomerular filtration rate (GFR) during acute kidney injury (AKI). Knowledge of how much GFR varies in stable subjects is necessary before changes in GFR can be attributed to AKI. We have designed a method of continuous measurement of GFR intended as a research tool to time effects of AKI. The aims of this crossover trial were to establish accuracy and precision of a continuous infusion of low dose Iohexol (CILDI) and variation in GFR in stable volunteers over a range of estimated GFR (23-138 mL/min/1.73 m(2)). METHODS We randomised 17 volunteers to GFR measurement by plasma clearance (PC) and renal clearance (RC) of either a single bolus of Iohexol (SBI; routine method), or of a continuous infusion of low dose Iohexol (CILDI; experimental method) at 0.5 mL/h for 12 h. GFR was measured by the alternative method after a washout period (4-28 days). Iohexol concentration was measured by high performance liquid chromatography/electrospray tandem mass spectrometry and time to steady state concentration (Css) determined. RESULTS Mean PC was 76.7 ± 28.5 mL/min/1.73 m(2) (SBI), and 78.9 ± 28.6 mL/min/1.73 m(2) (CILDI), p = 0.82. No crossover effects occurred (p = 0.85). Correlation (r) between the methods was 0.98 (p < 0.0001). Bias was 2.2 mL/min/1.73 m(2) (limits of agreement -8.2 to 12.6 mL/min/1.73 m(2)) for CILDI. PC overestimated RC by 7.1 ± 7.3 mL/min/1.73 m(2). Mean intra-individual variation in GFR (CILDI) was 10.3% (p < 0.003). Mean ± SD Css was 172 ± 185 min. CONCLUSION We hypothesise that changes in GFR >10.3% depict evolving AKI. If this were applicable to AKI, this is less than the 50% change in serum creatinine currently required to define AKI. CILDI is now ready for testing in patients with AKI. TRIAL REGISTRATION This trial was registered with the European Union Clinical Trials Register ( https://www.clinicaltrialsregister.eu/ ), registration number: 2010-019933-89 .
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Affiliation(s)
- John J Dixon
- General Intensive Care Unit, St. George's Hospital, London, UK. .,Acute Kidney Injury Research Group, Division of Clinical Sciences, St. George's, University of London, London, UK. .,Renal Medicine, St. George's Hospital, London, UK.
| | - Katie Lane
- General Intensive Care Unit, St. George's Hospital, London, UK. .,Acute Kidney Injury Research Group, Division of Clinical Sciences, St. George's, University of London, London, UK.
| | - R Neil Dalton
- WellChild Laboratory, King's College London, Evelina Children's Hospital, London, UK.
| | - Charles Turner
- WellChild Laboratory, King's College London, Evelina Children's Hospital, London, UK.
| | | | - Iain A M MacPhee
- Acute Kidney Injury Research Group, Division of Clinical Sciences, St. George's, University of London, London, UK. .,Renal Medicine, St. George's Hospital, London, UK.
| | - Barbara J Philips
- General Intensive Care Unit, St. George's Hospital, London, UK. .,Acute Kidney Injury Research Group, Division of Clinical Sciences, St. George's, University of London, London, UK.
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21
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Wilson FP, Xie D, Anderson AH, Leonard MB, Reese PP, Delafontaine P, Horwitz E, Kallem R, Navaneethan S, Ojo A, Porter AC, Sondheimer JH, Sweeney HL, Townsend RR, Feldman HI. Urinary creatinine excretion, bioelectrical impedance analysis, and clinical outcomes in patients with CKD: the CRIC study. Clin J Am Soc Nephrol 2014; 9:2095-103. [PMID: 25381342 DOI: 10.2215/cjn.03790414] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Previous studies in chronic disease states have demonstrated an association between lower urinary creatinine excretion (UCr) and increased mortality, a finding presumed to reflect the effect of low muscle mass on clinical outcomes. Little is known about the relationship between UCr and other measures of body composition in terms of the ability to predict outcomes of interest. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using data from the Chronic Renal Insufficiency Cohort (CRIC), the relationship between UCr, fat free mass (FFM) as estimated by bioelectrical impedance analysis, and (in a subpopulation) whole-body dual-energy x-ray absorptiometry assessment of appendicular lean mass were characterized. The associations of UCr and FFM with mortality and ESRD were compared using Cox proportional hazards models. RESULTS A total of 3604 CRIC participants (91% of the full CRIC cohort) with both a baseline UCr and FFM measurement were included; of these, 232 had contemporaneous dual-energy x-ray absorptiometry measurements. Participants were recruited between July 2003 and March 2007. UCr and FFM were modestly correlated (rho=0.50; P<0.001), while FFM and appendicular lean mass were highly correlated (rho=0.91; P<0.001). Higher urinary urea nitrogen, black race, younger age, and lower serum cystatin C level were all significantly associated with higher UCr. Over a median (interquartile range) of 4.2 (3.1-5.0) years of follow-up, 336 (9.3%) participants died and 510 (14.2%) reached ESRD. Lower UCr was associated with death and ESRD even after adjustment for FFM (adjusted hazard ratio for death per 1 SD higher level of UCr, 0.63 [95% confidence interval, 0.56 to 0.72]; adjusted hazard ratio for ESRD per 1 SD higher level of UCr, 0.70 [95% confidence interval, 0.63 to 0.75]). CONCLUSIONS Among a cohort of individuals with CKD, lower UCr is associated with death and ESRD independent of FFM as assessed by bioelectrical impedance analysis.
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Affiliation(s)
- F Perry Wilson
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
| | - Dawei Xie
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Amanda H Anderson
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Mary B Leonard
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Peter P Reese
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Patrice Delafontaine
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Edward Horwitz
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Radhakrishna Kallem
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Sankar Navaneethan
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Akinlolu Ojo
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Anna C Porter
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - James H Sondheimer
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - H Lee Sweeney
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Raymond R Townsend
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Harold I Feldman
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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22
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Schetz M, Gunst J, Van den Berghe G. The impact of using estimated GFR versus creatinine clearance on the evaluation of recovery from acute kidney injury in the ICU. Intensive Care Med 2014; 40:1709-17. [PMID: 25266132 DOI: 10.1007/s00134-014-3487-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 09/04/2014] [Indexed: 12/14/2022]
Abstract
PURPOSE To quantify the error in evaluating recovery from acute kidney injury (AKI) with estimated GFR (eGFR) in relation to ICU stay. METHODS Secondary analysis performed on the database of the EPaNIC trial. In a cohort of patients who developed AKI during ICU stay we compared eGFR with measured creatinine clearance (Clcr) at ICU discharge. Recovery of kidney function was assessed by comparison with baseline eGFR and the accuracy of eGFR to detect "potential CKD status" defined by Clcr was quantified. The same analysis was performed in subgroups with different ICU stay. Multivariate regression was performed to determine independent predictors of the eGFR-Clcr difference. RESULTS A total of 757 patients were included. The bias (limits of agreement (LOA)) between eGFR and Clcr at ICU discharge related to ICU stay, increasing from +1.3 (-37.4/+40) ml/min/1.73 m(2) in patients with short stay to +34.7 (-54.4/+123.8) ml/min/1.73 m(2) in patients with ICU stay of more than 14 days. This resulted in a significantly different incidence of complete recovery with the two evaluation methods and reduced sensitivity to detect "potential CKD status" with eGFR in patients with prolonged ICU stay. Independent predictors of the bias included creatinine excretion on the last day in ICU, baseline eGFR, ICU stay, gender, and age. CONCLUSION Compared to Clcr, discharge eGFR results in overestimation of renal recovery in patients with prolonged ICU stay and in reduced accuracy of "CKD staging". Since age, gender and race do not change during ICU stay the same conclusion can be drawn with regard to plasma creatinine.
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Affiliation(s)
- M Schetz
- Division of Cellular and Molecular Medicine, Clinical Department and Laboratory of Intensive Care Medicine, KU Leuven University, Herestraat 49, 3000, Leuven, Belgium,
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23
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Wilson FP, Reese PP, Shashaty MG, Ellenberg SS, Gitelman Y, Bansal AD, Urbani R, Feldman HI, Fuchs B. A trial of in-hospital, electronic alerts for acute kidney injury: design and rationale. Clin Trials 2014; 11:521-9. [PMID: 25023200 DOI: 10.1177/1740774514542619] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Acute kidney injury is common in hospitalized patients, increases morbidity and mortality, and is under-recognized. To improve provider recognition, we previously developed an electronic alert system for acute kidney injury. To test the hypothesis that this electronic acute kidney injury alert could improve patient outcome, we designed a randomized controlled trial to test the effectiveness of this alert in hospitalized patients. The study design presented several methodologic, ethical, and statistical challenges. PURPOSE To highlight the challenges faced and the solutions employed in the design and implementation of a clinical trial to determine whether the provision of an early electronic alert for acute kidney injury would improve outcomes in hospitalized patients. Challenges included how to randomize the delivery of the alert system and the ethical framework for waiving informed consent. Other methodologic challenges included the selection and statistical evaluation of our study outcome, a ranked-composite of a continuous covariate (creatinine) and two dichotomous outcomes (dialysis and death), and the use of the medical record as a source of trial data. METHODS We have designed a randomized trial to assess the effectiveness of an electronic alert system for acute kidney injury. With broad inclusion criteria, and a waiver of informed consent, we enroll and randomize virtually every patient with acute kidney injury in our hospital. RESULTS As of 31 March 2014, we have enrolled 2373 patients of 2400 targeted. Pre-alert data demonstrated a strong association between severity of acute kidney injury and inpatient mortality with a range of 6.4% in those with mild, stage 1 acute kidney injury, to 29% among those with stage 3 acute kidney injury (p < 0.001). We judged that informed consent would undermine the scientific validity of the study and present harms that are out of proportion to the very low risk intervention. CONCLUSION Our study demonstrates the feasibility of designing an ethical randomized controlled trial of an early electronic alert for acute kidney injury without obtaining informed consent from individual participants. Our study outcome may serve as a model for other studies of acute kidney injury, insofar as our paradigm accounts for the effect that early death and dialysis have on assessment of acute kidney injury severity as defined by maximum achieved serum creatinine.
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Affiliation(s)
- Francis Perry Wilson
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter P Reese
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Gs Shashaty
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Susan S Ellenberg
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Yevgeniy Gitelman
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Amar D Bansal
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Richard Urbani
- Department of Information Services, University of Pennsylvania, Philadelphia PA, USA
| | - Harold I Feldman
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Barry Fuchs
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Luo X, Jiang L, Du B, Wen Y, Wang M, Xi X. A comparison of different diagnostic criteria of acute kidney injury in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R144. [PMID: 25005361 PMCID: PMC4227114 DOI: 10.1186/cc13977] [Citation(s) in RCA: 187] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 06/18/2014] [Indexed: 12/25/2022]
Abstract
Introduction Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) proposed a new definition and classification of acute kidney injury (AKI) on the basis of the RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage renal failure) and AKIN (Acute Kidney Injury Network) criteria, but comparisons of the three criteria in critically ill patients are rare. Methods We prospectively analyzed a clinical database of 3,107 adult patients who were consecutively admitted to one of 30 intensive care units of 28 tertiary hospitals in Beijing from 1 March to 31 August 2012. AKI was defined by the RIFLE, AKIN, and KDIGO criteria. Receiver operating curves were used to compare the predictive ability for mortality, and logistic regression analysis was used for the calculation of odds ratios and 95% confidence intervals. Results The rates of incidence of AKI using the RIFLE, AKIN, and KDIGO criteria were 46.9%, 38.4%, and 51%, respectively. KDIGO identified more patients than did RIFLE (51% versus 46.9%, P = 0.001) and AKIN (51% versus 38.4%, P <0.001). Compared with patients without AKI, in-hospital mortality was significantly higher for those diagnosed as AKI by using the RIFLE (27.8% versus 7%, P <0.001), AKIN (32.2% versus 7.1%, P <0.001), and KDIGO (27.4% versus 5.6%, P <0.001) criteria, respectively. There was no difference in AKI-related mortality between RIFLE and KDIGO (27.8% versus 27.4%, P = 0.815), but there was significant difference between AKIN and KDIGO (32.2% versus 27.4%, P = 0.006). The areas under the receiver operator characteristic curve for in-hospital mortality were 0.738 (P <0.001) for RIFLE, 0.746 (P <0.001) for AKIN, and 0.757 (P <0.001) for KDIGO. KDIGO was more predictive than RIFLE for in-hospital mortality (P <0.001), but there was no difference between KDIGO and AKIN (P = 0.12). Conclusions A higher incidence of AKI was diagnosed according to KDIGO criteria. Patients diagnosed as AKI had a significantly higher in-hospital mortality than non-AKI patients, no matter which criteria were used. Compared with the RIFLE criteria, KDIGO was more predictive for in-hospital mortality, but there was no significant difference between AKIN and KDIGO.
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Prowle JR, Kolic I, Purdell-Lewis J, Taylor R, Pearse RM, Kirwan CJ. Serum creatinine changes associated with critical illness and detection of persistent renal dysfunction after AKI. Clin J Am Soc Nephrol 2014; 9:1015-23. [PMID: 24742481 DOI: 10.2215/cjn.11141113] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVES AKI is a risk factor for development or worsening of CKD. However, diagnosis of renal dysfunction by serum creatinine could be confounded by loss of muscle mass and creatinine generation after critical illness. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A retrospective, single center analysis of serum in patients surviving to hospital discharge with an intensive care unit admission of 5 or more days between 2009 and 2011 was performed. RESULTS In total, 700 cases were identified, with a 66% incidence of AKI. In 241 patients without AKI, creatinine was significantly lower (P<0.001) at hospital discharge than admission (median, 0.61 versus 0.88 mg/dl; median decrease, 33%). In 160 patients with known baseline, discharge creatinine was significantly lower than baseline in all patients except those patients with severe AKI (Kidney Disease Improving Global Outcomes category 3), who had no significant difference. In a multivariable regression model, median duration of hospitalization was associated with a predicted 30% decrease (95% confidence interval, 8% to 45%) in creatinine from baseline in the absence of AKI; after allowing for this effect, AKI was associated with a 29% (95% confidence interval, 10% to 51%) increase in predicted hospital discharge creatinine. Using a similar model to exclude the confounding effect of prolonged major illness on creatinine, 148 of 700 patients (95% confidence interval, 143 to 161) would have eGFR<60 ml/min per 1.73 m(2) at hospital discharge compared with only 63 of 700 patients using eGFR based on unadjusted hospital creatinine (a 135% increase in potential CKD diagnoses; P<0.001). CONCLUSION Critical illness is associated with significant falls in serum creatinine that persist to hospital discharge, potentially causing inaccurate assessment of renal function at discharge, particularly in survivors of AKI. Prospective measurements of GFR and creatinine generation are required to confirm the significance of these findings.
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Affiliation(s)
- John R Prowle
- Adult Critical Care Unit and Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; and William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | | | | | | | - Rupert M Pearse
- Adult Critical Care Unit and William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Christopher J Kirwan
- Adult Critical Care Unit and Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; and William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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Wilson FP, Yang W, Machado CA, Mariani LH, Borovskiy Y, Berns JS, Feldman HI. Dialysis versus nondialysis in patients with AKI: a propensity-matched cohort study. Clin J Am Soc Nephrol 2014; 9:673-81. [PMID: 24651073 PMCID: PMC3974360 DOI: 10.2215/cjn.07630713] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 11/05/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The benefit of the initiation of dialysis for AKI may differ depending on patient factors, but, because of a lack of robust evidence, the decision to initiate dialysis for AKI remains subjective in many cases. Prior studies examining dialysis initiation for AKI have examined outcomes of dialyzed patients compared with other dialyzed patients with different characteristics. Without an adequate nondialyzed control group, these studies cannot provide information on the benefit of dialysis initiation. To determine which patients would benefit from initiation of dialysis for AKI, a propensity-matched cohort study was performed among a large population of patients with severe AKI. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Adults admitted to one of three acute care hospitals within the University of Pennsylvania Health System from January 1, 2004, to August 31, 2010, who subsequently developed severe AKI were included (n=6119). Of these, 602 received dialysis. Demographic, clinical, and laboratory variables were used to generate a time-varying propensity score representing the daily probability of initiation of dialysis for AKI. Not-yet-dialyzed patients were matched to each dialyzed patient according to day of AKI and propensity score. Proportional hazards analysis was used to compare time to all-cause mortality among dialyzed versus nondialyzed patients across a spectrum of prespecified variables. RESULTS After propensity score matching, covariates were well balanced between the groups, and the overall hazard ratio for death in dialyzed versus nondialyzed patients was 1.01 (95% confidence interval, 0.85 to 1.21; P=0.89). Serum creatinine concentration modified the association between dialysis and survival, with a 20% (95% confidence interval, 9% to 30%) greater survival benefit from dialysis for each 1-mg/dl increase in serum creatinine concentration (P=0.001). This finding persisted after adjustment for markers of disease severity. Dialysis initiation was associated with more benefit than harm at a creatinine concentration ≥ 3.8 mg/dl. CONCLUSIONS Dialysis was associated with increased survival when initiated in patients with AKI who have a more elevated creatinine level but was associated with increased mortality when initiated in patients with lower creatinine concentrations.
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Affiliation(s)
- F Perry Wilson
- Renal, Electrolyte, and Hypertension Division,, †Center for Clinical Epidemiology and Biostatistics, and, ‡Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania;, §Division of Nephrology, University of Michigan, Ann Arbor, Michigan, ‖Penn Data Store Team, Information Services at the University of Pennsylvania, Philadelphia, Pennsylvania
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Dixon J, Lane K, Macphee I, Philips B. Xenobiotic metabolism: the effect of acute kidney injury on non-renal drug clearance and hepatic drug metabolism. Int J Mol Sci 2014; 15:2538-53. [PMID: 24531139 PMCID: PMC3958866 DOI: 10.3390/ijms15022538] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 12/12/2013] [Accepted: 12/27/2013] [Indexed: 01/20/2023] Open
Abstract
Acute kidney injury (AKI) is a common complication of critical illness, and evidence is emerging that suggests AKI disrupts the function of other organs. It is a recognized phenomenon that patients with chronic kidney disease (CKD) have reduced hepatic metabolism of drugs, via the cytochrome P450 (CYP) enzyme group, and drug dosing guidelines in AKI are often extrapolated from data obtained from patients with CKD. This approach, however, is flawed because several confounding factors exist in AKI. The data from animal studies investigating the effects of AKI on CYP activity are conflicting, although the results of the majority do suggest that AKI impairs hepatic CYP activity. More recently, human study data have also demonstrated decreased CYP activity associated with AKI, in particular the CYP3A subtypes. Furthermore, preliminary data suggest that patients expressing the functional allele variant CYP3A5*1 may be protected from the deleterious effects of AKI when compared with patients homozygous for the variant CYP3A5*3, which codes for a non-functional protein. In conclusion, there is a need to individualize drug prescribing, particularly for the more sick and vulnerable patients, but this needs to be explored in greater depth.
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Affiliation(s)
- John Dixon
- General Intensive Care Unit, St. George's Hospital, London SW17 0QT, UK.
| | - Katie Lane
- General Intensive Care Unit, St. George's Hospital, London SW17 0QT, UK.
| | - Iain Macphee
- Division of Clinical Sciences, St. George's, University of London, London SW17 0RE, UK.
| | - Barbara Philips
- General Intensive Care Unit, St. George's Hospital, London SW17 0QT, UK.
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Prowle JR. Acute kidney injury: an intensivist's perspective. Pediatr Nephrol 2014; 29:13-21. [PMID: 23361310 DOI: 10.1007/s00467-013-2411-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 12/28/2012] [Accepted: 01/03/2013] [Indexed: 01/05/2023]
Abstract
The changing epidemiology of acute kidney injury (AKI) in adults and children has resulted in more patients being treated for kidney injury occurring in the context of multi-organ failure requiring treatment in the intensive care unit (ICU). AKI complicating critical illness has complex, multi-factorial etiology, and supportive care, including organ support, remains the mainstay of therapy. In the day-to-day management of AKI in the ICU two of the major challenges are the inadequacy of current diagnostics for the early identification of AKI and the relationship between hemodynamic resuscitation strategies and the development of AKI. This review focuses on these areas from the intensivist's perspective. Given that the diagnosis of AKI is often delayed, the prevention of complications and limitation of secondary renal injury are of particular importance. Fluid overload is increasingly being associated with adverse patient outcomes in critical illness and may contribute to persistent renal dysfunction. Thus, hemodynamic management strategies in AKI should be tailored to limit fluid overload as much as possible.
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Affiliation(s)
- John R Prowle
- Adult Critical Care Unit and Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, UK, E1 1BB,
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29
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Pickering JW, Endre ZH. The definition and detection of acute kidney injury. J Renal Inj Prev 2013; 3:21-5. [PMID: 25340159 PMCID: PMC4206042 DOI: 10.12861/jrip.2014.08] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 11/26/2013] [Indexed: 01/23/2023] Open
Abstract
The first consensus definition of Acute Kidney Injury (AKI) was published a decade ago. In this mini narrative review we look at the history of the changes in the definition of AKI and consider how it may change again in the near future. The epidemiology of small changes in creatinine and the difficulties with determining baseline creatinine have driven the changes. Recent evidence on urinary output and the application of structural injury biomarkers are likely to change the definition once more.
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Affiliation(s)
- John W Pickering
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Zoltán H Endre
- Department of Nephrology, Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
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Abstract
In patients with acute kidney injury (AKI), optimization of systemic haemodynamics is central to the clinical management. However, considerable debate exists regarding the efficacy, nature, extent and duration of fluid resuscitation, particularly when the patient has undergone major surgery or is in septic shock. Crucially, volume resuscitation might be required to maintain or restore cardiac output. However, resultant fluid accumulation and tissue oedema can substantially contribute to ongoing organ dysfunction and, particularly in patients developing AKI, serious clinical consequences. In this Review, we discuss the conflict between the desire to achieve adequate resuscitation of shock and the need to mitigate the harmful effects of fluid overload. In patients with AKI, limiting and resolving fluid overload might prompt earlier use of renal replacement therapy. However, rapid or early excessive fluid removal with diuretics or extracorporeal therapy might lead to hypovolaemia and recurrent renal injury. Optimal management might involve a period of guided fluid resuscitation, followed by management of an even fluid balance and, finally, an appropriate rate of fluid removal. To obtain best clinical outcomes, serial fluid status assessment and careful definition of cardiovascular and renal targets will be required during fluid resuscitation and removal.
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Philips BJ, Lane K, Dixon J, MacPhee I. The effects of acute renal failure on drug metabolism. Expert Opin Drug Metab Toxicol 2013; 10:11-23. [DOI: 10.1517/17425255.2013.835802] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Sherman RA. Briefly Noted. Semin Dial 2013. [DOI: 10.1111/sdi.12050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Heimburger O, Stenvinkel P, Barany P. The enigma of decreased creatinine generation in acute kidney injury. Nephrol Dial Transplant 2012; 27:3973-4. [DOI: 10.1093/ndt/gfs459] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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