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Jeong R, Haines R, Ostermann M. Outcomes after acute kidney injury and critical illness. Curr Opin Crit Care 2024; 30:502-509. [PMID: 39092636 DOI: 10.1097/mcc.0000000000001183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) in critical illness is common, and survivors are faced with a host of adverse outcomes. In this article, we review the current landscape of outcomes and care in survivors of AKI and critical illness. RECENT FINDINGS Follow-up care of survivors of AKI and critical illness is prudent to monitor for and mitigate the risk of adverse outcomes. Observational data have suggested improvement in outcomes with nephrology-based follow-up care, and recent interventional studies demonstrate similar findings. However, current post-AKI care is suboptimal with various challenges, such as breakdowns in the transition of care during hospital episodes and into the community, barriers for patients in follow-up, and lack of identification of high-risk patients for nephrology-based follow-up. Tools predictive of renal nonrecovery and long-term outcomes may help to identify high-risk patients who may benefit the most from nephrology-based care post-AKI. SUMMARY Follow-up care of survivors of AKI and critical illness may improve outcomes and there is a need to prioritize transitions of care into the community. Further research is needed to elucidate the best ways to risk-stratify and manage post-AKI survivors to improve outcomes.
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Affiliation(s)
- Rachel Jeong
- Division of Nephrology, Department of Medicine
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Ryan Haines
- Department of Critical Care, King's College London, Guy's & St. Thomas' Hospital, King's College London, London, UK
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St. Thomas' Hospital, King's College London, London, UK
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2
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Booke H, Zarbock A, Meersch M. Renal dysfunction in surgical patients. Curr Opin Crit Care 2024:00075198-990000000-00204. [PMID: 39248076 DOI: 10.1097/mcc.0000000000001203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
PURPOSE OF REVIEW To provide an overview of the current diagnostic criteria for acute kidney injury (AKI) including their limitations and to discuss prevention and treatment approaches in the perioperative setting. RECENT FINDINGS AKI is common in the perioperative period and is associated with worse short- and long-term outcomes. Current definitions of AKI have several limitations and lead to delayed recognition of kidney dysfunction which is why novel diagnostic approaches by using renal biomarkers may be helpful. In general, prevention of the development and progression of AKI is vital as a causal treatment for AKI is currently not available. Optimization of kidney perfusion and avoidance of nephrotoxic drugs reduce the occurrence of AKI in surgical patients. Angiotensin II as a new vasopressor, the use of remote ischemic preconditioning, and amino acids may be approaches with a positive effect on the kidneys. SUMMARY Evidence suggests that the implementation of supportive measures in patients at high risk for AKI might reduce the occurrence of AKI. Novel biomarkers can help allocating resources by detecting patients at high risk for AKI.
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Affiliation(s)
- Hendrik Booke
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, University of Muenster, Muenster, Germany
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3
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Pan SY, Huang TTM, Jiang ZH, Lin LC, Tsai IJ, Wu TL, Hsu CY, Wang T, Chen HC, Lin YF, Wu VC. Unveiling the enigma of acute kidney disease: predicting prognosis, exploring interventions, and embracing a multidisciplinary approach. Kidney Res Clin Pract 2024; 43:406-416. [PMID: 38934037 PMCID: PMC11237330 DOI: 10.23876/j.krcp.23.289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/08/2024] [Accepted: 02/27/2024] [Indexed: 06/28/2024] Open
Abstract
Acute kidney disease (AKD) is a critical transitional period between acute kidney injury and chronic kidney disease. The incidence of AKD following acute kidney injury is approximately 33.6%, and it can occur without identifiable preceding acute kidney injury. The development of AKD is associated with increased risks of chronic kidney disease, dialysis, and mortality. Biomarkers and subphenotypes are promising tools to predict prognosis in AKD. The complex clinical situations in patients with AKD necessitate a comprehensive and structured approach, termed "KAMPS" (kidney function check, advocacy, medications, pressure, sick day protocols). We introduce "MAND-MASS," an acronym devised to summarize the reconciliation of medications during episodes of acute illness, as a critical component of the sick day protocols at AKD. A multidisciplinary team care, consisting of nephrologists, pharmacists, dietitians, health educators, and nurses, is an optimal model to achieve the care bundle in KAMPS. Although the evidence for patients with AKD is still lacking, several potential pharmacological agents may improve outcomes, including but not limited to angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists, sodium-glucose cotransporter 2 inhibitors, and glucagon-like peptide 1 receptor agonists. In conclusion, accurate prognosis prediction and effective treatment for AKD are critical yet unmet clinical needs. Future studies are urgently needed to improve patient care in this complex and rapidly evolving field.
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Affiliation(s)
- Szu-Yu Pan
- Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Thomas Tao-Min Huang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- NSARF (National Taiwan University Hospital Study Group on Acute Renal Failure), Taipei, Taiwan
| | - Zheng-Hong Jiang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Chun Lin
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - I-Jung Tsai
- Division of Nephrology, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsung-Lin Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Yi Hsu
- Department of Dietetics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ting Wang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Hui-Chuen Chen
- Department of Dietetics, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Feng Lin
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- NSARF (National Taiwan University Hospital Study Group on Acute Renal Failure), Taipei, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- NSARF (National Taiwan University Hospital Study Group on Acute Renal Failure), Taipei, Taiwan
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Zhang M, Yang Y, Zhu L, Cui K, Zhang S, Xu Y, Jiang Y. Plasma proenkephalin and neutrophil gelatinase-associated lipocalin predict mortality in ICU patients with acute kidney injury. BMC Nephrol 2024; 25:181. [PMID: 38778257 PMCID: PMC11112877 DOI: 10.1186/s12882-024-03611-0] [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: 03/31/2023] [Accepted: 05/14/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication in patients admitted to intensive care unit (ICU) and mortality rates for this condition are high. To reduce the high incidence of short-term mortality, reliable prognostic indicators are required to facilitate early diagnosis and treatment of AKI. We assessed the ability of plasma proenkephalin (p‑PENK) and plasma neutrophil gelatinase-associated lipocalin (p‑NGAL) to predict 28-day mortality in AKI patients in intensive care. METHODS This prospective study, carried out between January 2019 and December 2019, comprised 150 patients (100 male) diagnosed with AKI after excluding 20 patients discharged within 24 h and those with missing hospitalization data. Blood samples were collected to determine admission p-PENK and p-NGAL levels. The study outcome was 28‑day mortality. RESULTS The mean patient age was 68 years (female, 33%). The average P‑PENK and p‑NGAL levels were 0.24 ng/µL and 223.70 ng/mL, respectively. P‑PENK levels >0.36 ng/µL and p‑NGAL levels >230.30 ng/mL were used as critical values to reliably indicate 28‑day mortality for patients with AKI (adjusted hazard ratios 0.785 [95% confidence interval 0.706-0.865, P<0.001] and 0.700 [95% confidence interval 0.611-0.789, P<0.001], respectively). This association was significant for mortality in patients in intensive care with AKI. Baseline p-PENK (0.36 ng/µL) and p-NGAL (230.30 ng/mL) levels and their respective cut-off values showed clinical value in predicting 28-day mortality. CONCLUSION Serum PENK and NGAL levels, when used in conjunction, improved the accuracy of predicting 28-day mortality in patients with AKI while retaining sensitivity and specificity.
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Affiliation(s)
- Mengqin Zhang
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, No. 150, XiMen Street, Taizhou, China
| | - Yang Yang
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Luqi Zhu
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, No. 150, XiMen Street, Taizhou, China
| | - Ke Cui
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, No. 150, XiMen Street, Taizhou, China
| | - Sheng Zhang
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, No. 150, XiMen Street, Taizhou, China
| | - Yinghe Xu
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, No. 150, XiMen Street, Taizhou, China.
| | - Yongpo Jiang
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, No. 150, XiMen Street, Taizhou, China.
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Slim MA, van Amstel RBE, Bos LDJ, Cremer OL, Wiersinga WJ, van der Poll T, van Vught LA. Inflammatory subphenotypes previously identified in ARDS are associated with mortality at intensive care unit discharge: a secondary analysis of a prospective observational study. Crit Care 2024; 28:151. [PMID: 38715131 PMCID: PMC11077885 DOI: 10.1186/s13054-024-04929-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/21/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Intensive care unit (ICU)-survivors have an increased risk of mortality after discharge compared to the general population. On ICU admission subphenotypes based on the plasma biomarker levels of interleukin-8, protein C and bicarbonate have been identified in patients admitted with acute respiratory distress syndrome (ARDS) that are prognostic of outcome and predictive of treatment response. We hypothesized that if these inflammatory subphenotypes previously identified among ARDS patients are assigned at ICU discharge in a more general critically ill population, they are associated with short- and long-term outcome. METHODS A secondary analysis of a prospective observational cohort study conducted in two Dutch ICUs between 2011 and 2014 was performed. All patients discharged alive from the ICU were at ICU discharge adjudicated to the previously identified inflammatory subphenotypes applying a validated parsimonious model using variables measured median 10.6 h [IQR, 8.0-31.4] prior to ICU discharge. Subphenotype distribution at ICU discharge, clinical characteristics and outcomes were analyzed. As a sensitivity analysis, a latent class analysis (LCA) was executed for subphenotype identification based on plasma protein biomarkers at ICU discharge reflective of coagulation activation, endothelial cell activation and inflammation. Concordance between the subphenotyping strategies was studied. RESULTS Of the 8332 patients included in the original cohort, 1483 ICU-survivors had plasma biomarkers available and could be assigned to the inflammatory subphenotypes. At ICU discharge 6% (n = 86) was assigned to the hyperinflammatory and 94% (n = 1397) to the hypoinflammatory subphenotype. Patients assigned to the hyperinflammatory subphenotype were discharged with signs of more severe organ dysfunction (SOFA scores 7 [IQR 5-9] vs. 4 [IQR 2-6], p < 0.001). Mortality was higher in patients assigned to the hyperinflammatory subphenotype (30-day mortality 21% vs. 11%, p = 0.005; one-year mortality 48% vs. 28%, p < 0.001). LCA deemed 2 subphenotypes most suitable. ICU-survivors from class 1 had significantly higher mortality compared to class 2. Patients belonging to the hyperinflammatory subphenotype were mainly in class 1. CONCLUSIONS Patients assigned to the hyperinflammatory subphenotype at ICU discharge showed significantly stronger anomalies in coagulation activation, endothelial cell activation and inflammation pathways implicated in the pathogenesis of critical disease and increased mortality until one-year follow up.
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Affiliation(s)
- Marleen A Slim
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Amsterdam, The Netherlands.
| | - Rombout B E van Amstel
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Amsterdam, The Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Amsterdam, The Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Medicine, Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Medicine, Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Lonneke A van Vught
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Amsterdam, The Netherlands
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Yeh TH, Tu KC, Wang HY, Chen JY. From Acute to Chronic: Unraveling the Pathophysiological Mechanisms of the Progression from Acute Kidney Injury to Acute Kidney Disease to Chronic Kidney Disease. Int J Mol Sci 2024; 25:1755. [PMID: 38339031 PMCID: PMC10855633 DOI: 10.3390/ijms25031755] [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: 01/05/2024] [Revised: 01/28/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
This article provides a thorough overview of the biomarkers, pathophysiology, and molecular pathways involved in the transition from acute kidney injury (AKI) and acute kidney disease (AKD) to chronic kidney disease (CKD). It categorizes the biomarkers of AKI into stress, damage, and functional markers, highlighting their importance in early detection, prognosis, and clinical applications. This review also highlights the links between renal injury and the pathophysiological mechanisms underlying AKI and AKD, including renal hypoperfusion, sepsis, nephrotoxicity, and immune responses. In addition, various molecules play pivotal roles in inflammation and hypoxia, triggering maladaptive repair, mitochondrial dysfunction, immune system reactions, and the cellular senescence of renal cells. Key signaling pathways, such as Wnt/β-catenin, TGF-β/SMAD, and Hippo/YAP/TAZ, promote fibrosis and impact renal function. The renin-angiotensin-aldosterone system (RAAS) triggers a cascade leading to renal fibrosis, with aldosterone exacerbating the oxidative stress and cellular changes that promote fibrosis. The clinical evidence suggests that RAS inhibitors may protect against CKD progression, especially post-AKI, though more extensive trials are needed to confirm their full impact.
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Affiliation(s)
- Tzu-Hsuan Yeh
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan 71004, Taiwan; (T.-H.Y.); (H.-Y.W.)
| | - Kuan-Chieh Tu
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan 71004, Taiwan;
| | - Hsien-Yi Wang
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan 71004, Taiwan; (T.-H.Y.); (H.-Y.W.)
- Department of Sport Management, College of Leisure and Recreation Management, Chia Nan University of Pharmacy and Science, Tainan 71710, Taiwan
| | - Jui-Yi Chen
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan 71004, Taiwan; (T.-H.Y.); (H.-Y.W.)
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan 71710, Taiwan
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7
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Schiefer J, Bernardi MH, Lichtenegger P, Schak G, Atallah L, Ristl R, Ramazanova D, Faybik P. Incidence and outcomes of AKI in postoperative patients admitted to ICU using full KDIGO criteria - a cohort study. J Clin Anesth 2023; 89:111156. [PMID: 37356195 DOI: 10.1016/j.jclinane.2023.111156] [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: 01/16/2023] [Revised: 05/02/2023] [Accepted: 05/21/2023] [Indexed: 06/27/2023]
Abstract
STUDY OBJECTIVE Acute kidney injury (AKI) is a serious complication in postoperative ICU patients. The incidence of AKI varies substantially based on the type of surgery and definition used. This study focuses on the incidence of AKI in postoperative ICU patients using full KDIGO criteria and related outcomes regarding to different types of surgery. DESIGN Retrospective cohort study. SETTING Tertiary level university hospital, eight anaesthesiological/surgical ICUs, between 2016 and 2018. PATIENTS 6261 adult patients. MEASUREMENTS Primary outcome was 28-day all-cause mortality in different stages of AKI according to complete KDIGO criteria. MAIN RESULTS We found 3497 (55.9%) postoperative ICU patients with AKI. The severity distribution of AKI stage 1 to 3 was 19.7%, 28.4% and 7.8%, respectively, and 235 (4%) patients received RRT. The 28-day mortality was 3% (n = 205). Increasing AKI severity was associated with increased 28-day mortality when adjusted for other variables (AKI 2°: OR 2.81; 95% CI 1.55 to 5.24; p < 0.001 and AKI 3°: OR 11.37.; 95% CI 5.91 to 22.55; p < 0.001). Besides AKI stages 2 and 3, age (OR 1.02; 95% CI 1.01 to 1.04, p < 0.001), NYHA IV (OR 2.23; 95% CI 1.03 to 4.43, p = 0.042), need for surgical reintervention within 48 h (OR 2.92; 95% CI 1.76 to 4.72, p = 0.001), urgent surgery (OR 1.78; 95% CI 1.15 to 2.71, p = 0.01), emergency surgery (OR 2.63; 95% CI 1.58 to 4.31, p = 0.001), vascular surgery (OR 2.01; 95% CI 1.06 to 3.98, p = 0.033), and orthopedic and trauma surgery (OR 3.79; 95% CI 1.98 to 7.09, p < 0.001) versus cardiac surgery was significantly associated with increased risk for 28-days mortality in multivariate analysis. CONCLUSION AKI based on full KDIGO criteria is very common in postoperative ICU patients and it is associated with stepwise increase in 28-days mortality.
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Affiliation(s)
- Judith Schiefer
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Vienna, Austria
| | - Martin H Bernardi
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Vienna, Austria; Division of Cardiac Thoracic Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria.
| | - Paul Lichtenegger
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Vienna, Austria
| | - Gerhard Schak
- Software Customer Services International, Patient Care & Monitoring Solutions, Philips Healthcare, Austria
| | - Louis Atallah
- Philips EMR & Care Management, Philips Healthcare, United States of America
| | - Robin Ristl
- Center for Medical Statistics, Informatics and intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Dariga Ramazanova
- Center for Medical Statistics, Informatics and intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Peter Faybik
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Vienna, Austria
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Chaudhary S, Kashani KB. Acute Kidney Injury Management Strategies Peri-Cardiovascular Interventions. Interv Cardiol Clin 2023; 12:555-572. [PMID: 37673499 DOI: 10.1016/j.iccl.2023.06.008] [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] [Indexed: 09/08/2023]
Abstract
In many countries, the aging population and the higher incidence of comorbid conditions have resulted in an ever-growing need for cardiac interventions. Acute kidney injury (AKI) is a common complication of these interventions, associated with higher mortalities, chronic or end-stage kidney disease, readmission rates, and hospital and post-discharge costs. The AKI pathophysiology includes contrast-associated AKI, hemodynamic changes, cardiorenal syndrome, and atheroembolism. Preventive measures include limiting contrast media dose, optimizing hemodynamic conditions, and limiting exposure to other nephrotoxins. This review article outlines the current state-of-art knowledge regarding AKI pathophysiology, risk factors, preventive measures, and management strategies in the peri-interventional period.
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Affiliation(s)
- Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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9
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Charlton JR, Li T, Wu T, deRonde K, Xu Y, Baldelomar EJ, Bennett KM. Use of novel structural features to identify urinary biomarkers during acute kidney injury that predict progression to chronic kidney disease. BMC Nephrol 2023; 24:178. [PMID: 37331957 DOI: 10.1186/s12882-023-03196-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/09/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND A significant barrier to biomarker development in the field of acute kidney injury (AKI) is the use of kidney function to identify candidates. Progress in imaging technology makes it possible to detect early structural changes prior to a decline in kidney function. Early identification of those who will advance to chronic kidney disease (CKD) would allow for the initiation of interventions to halt progression. The goal of this study was to use a structural phenotype defined by magnetic resonance imaging and histology to advance biomarker discovery during the transition from AKI to CKD. METHODS Urine was collected and analyzed from adult C57Bl/6 male mice at four days and 12 weeks after folic acid-induced AKI. Mice were euthanized 12 weeks after AKI and structural metrics were obtained from cationic ferritin-enhanced-MRI (CFE-MRI) and histologic assessment. The fraction of proximal tubules, number of atubular glomeruli (ATG), and area of scarring were measured histologically. The correlation between the urinary biomarkers at the AKI or CKD and CFE-MRI derived features was determined, alone or in combination with the histologic features, using principal components. RESULTS Using principal components derived from structural features, twelve urinary proteins were identified at the time of AKI that predicted structural changes 12 weeks after injury. The raw and normalized urinary concentrations of IGFBP-3 and TNFRII strongly correlated to the structural findings from histology and CFE-MRI. Urinary fractalkine concentration at the time of CKD correlated with structural findings of CKD. CONCLUSIONS We have used structural features to identify several candidate urinary proteins that predict whole kidney pathologic features during the transition from AKI to CKD, including IGFBP-3, TNFRII, and fractalkine. In future work, these biomarkers must be corroborated in patient cohorts to determine their suitability to predict CKD after AKI.
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Affiliation(s)
- Jennifer R Charlton
- School of Medicine, Department of Pediatrics, Division Nephrology, University of Virginia, Box 800386, Charlottesville, VA, 22903, USA.
| | - Teng Li
- Department of Computer Science, School of Computing and Augmented Intelligence, Arizona State University, Tempe, AZ, USA
| | - Teresa Wu
- Department of Industrial Engineering, School of Computing and Augmented Intelligence, Arizona State University, Tempe, AZ, USA
| | - Kimberly deRonde
- School of Medicine, Department of Pediatrics, Division Nephrology, University of Virginia, Box 800386, Charlottesville, VA, 22903, USA
| | - Yanzhe Xu
- Department of Industrial Engineering, School of Computing and Augmented Intelligence, Arizona State University, Tempe, AZ, USA
| | - Edwin J Baldelomar
- Washington University in St. Louis, Mallinckrodt Institute of Radiology, St. Louis MO, USA
| | - Kevin M Bennett
- Washington University in St. Louis, Mallinckrodt Institute of Radiology, St. Louis MO, USA
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10
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Lazzareschi D, Mehta RL, Dember LM, Bernholz J, Turan A, Sharma A, Kheterpal S, Parikh CR, Ali O, Schulman IH, Ryan A, Feng J, Simon N, Pirracchio R, Rossignol P, Legrand M. Overcoming barriers in the design and implementation of clinical trials for acute kidney injury: a report from the 2020 Kidney Disease Clinical Trialists meeting. Nephrol Dial Transplant 2023; 38:834-844. [PMID: 35022767 PMCID: PMC10064977 DOI: 10.1093/ndt/gfac003] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Indexed: 12/15/2022] Open
Abstract
Acute kidney injury (AKI) is a growing epidemic and is independently associated with increased risk of death, chronic kidney disease (CKD) and cardiovascular events. Randomized-controlled trials (RCTs) in this domain are notoriously challenging and many clinical studies in AKI have yielded inconclusive findings. Underlying this conundrum is the inherent heterogeneity of AKI in its etiology, presentation and course. AKI is best understood as a syndrome and identification of AKI subphenotypes is needed to elucidate the disease's myriad etiologies and to tailor effective prevention and treatment strategies. Conventional RCTs are logistically cumbersome and often feature highly selected patient populations that limit external generalizability and thus alternative trial designs should be considered when appropriate. In this narrative review of recent developments in AKI trials based on the Kidney Disease Clinical Trialists (KDCT) 2020 meeting, we discuss barriers to and strategies for improved design and implementation of clinical trials for AKI patients, including predictive and prognostic enrichment techniques, the use of pragmatic trials and adaptive trials.
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Affiliation(s)
- Daniel Lazzareschi
- Department of Anesthesia & Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Ravindra L Mehta
- Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Laura M Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
| | | | - Alparslan Turan
- Department of Anesthesiology, Lerner College of Medicine of Case Western University, Cleveland, OH, USA
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | | | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Chirag R Parikh
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Omar Ali
- Verpora Ltd, Nottingham, UK
- University of Portsmouth, UK
| | - Ivonne H Schulman
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Abigail Ryan
- Division of Chronic Care Management, Centers for Medicare & Medicaid Services, Woodlawn, MD, USA
| | - Jean Feng
- Department of Epidemiology and Biostatistics, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Noah Simon
- Department of Biostatistics, University of Washington (UW), Seattle, WA, USA
| | - Romain Pirracchio
- Department of Anesthesia & Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Patrick Rossignol
- INI-CRCT Network, Nancy, France
- University of Lorraine, Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116, Nancy, France
| | - Matthieu Legrand
- Department of Anesthesia & Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
- INI-CRCT Network, Nancy, France
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11
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Burn-Induced Acute Kidney Injury-Two-Lane Road: From Molecular to Clinical Aspects. Int J Mol Sci 2022; 23:ijms23158712. [PMID: 35955846 PMCID: PMC9368898 DOI: 10.3390/ijms23158712] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/19/2022] [Accepted: 08/02/2022] [Indexed: 12/29/2022] Open
Abstract
Severe burn injuries lead to acute kidney injury (AKI) development, increasing the mortality risk up to 28-100%. In addition, there is an increase in hospitalization days and complications appearance. Various factors are responsible for acute or late AKI debut, like hypovolemia, important inflammatory response, excessive load of denatured proteins, sepsis, and severe organic dysfunction. The main measure to improve the prognosis of these patients is rapidly recognizing this condition and reversing the underlying events. For this reason, different renal biomarkers have been studied over the years for early identification of burn-induced AKI, like neutrophil gelatinase-associated lipocalin (NGAL), cystatin C, kidney injury molecule-1 (KIM-1), tissue inhibitor of metalloproteinase-2 (TIMP-2), interleukin-18 (IL-18), and insulin-like growth factor-binding protein 7 (IGFBP7). The fundamental purpose of these studies is to find a way to recognize and prevent acute renal injury progression early in order to decrease the risk of mortality and chronic kidney disease (CKD) onset.
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12
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Kakkanattu TJ, Kaur J, Nagesh V, Kundu M, Kamboj K, Kaur P, Sethi J, Kohli HS, Gupta KL, Ghosh A, Kumar V, Yadav AK, Jha V. Serum myo-inositol oxygenase levels at hospital discharge predict progression to chronic kidney disease in community-acquired acute kidney injury. Sci Rep 2022; 12:13225. [PMID: 35918463 PMCID: PMC9345942 DOI: 10.1038/s41598-022-17599-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/27/2022] [Indexed: 11/17/2022] Open
Abstract
Acute kidney injury (AKI) increases the risk of morbidity, mortality, and progression to chronic kidney disease (CKD). There are few data on the risk of CKD following community-acquired AKI (CA-AKI) and its predictors from developing countries. We evaluated the association of a panel of serum and urine biomarkers at the time of hospital discharge with 4-month renal outcome in CA-AKI. Patients of either sex, aged between 18 and 70 years, with no underlying CKD, and with CA-AKI were recruited at the time of discharge from hospital in this prospective observational study. Levels of serum and urine biomarkers were analyzed and association between these markers and development of CKD, defined as eGFR < 60 ml/min/1.73 m2 or dialysis dependence at 4 month after discharge, were analyzed using multivariate logistic regression analysis and penalized least absolute shrinkage and selection operator logistic regression. Out of a total 126 patients followed up for 4 months, 25 developed CKD. Those who developed CKD were older (p = 0.008), had higher serum creatinine (p < 0.001) and lower serum albumin (p = 0.001) at discharge. Adjusted logistic regression showed that each 10% increase in standardized serum myo-inositol oxygenase (MIOX) level increased the odds of progression to CKD by 13.5%. With 10% increase in standardized urine Neutrophil gelatinase-associated lipocalin (NGAL), serum creatinine and urine protein creatinine ratio (uPCR), increase in the odds of progression to CKD was 10.5%, 9.6% and 8%, respectively. Multivariable logistic model including serum MIOX, discharge serum creatinine and discharge uPCR, was able to predict the progression of CKD [AUC ROC 0.88; (95% CI 0.81, 0.95)]. High level serum MIOX levels at the time of discharge from hospital are associated with progression to CKD in patients with CA-AKI.
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Affiliation(s)
- Tom Jose Kakkanattu
- Department of Nephrology, Postgraduate Institute of Medical Institute Education and Research, Chandigarh, 160012, India
| | - Jaskiran Kaur
- Department of Experimental Medicine and Biotechnology, Postgraduate Institute of Medical Institute Education and Research, Chandigarh, 160012, India
| | - Vinod Nagesh
- Department of Nephrology, Postgraduate Institute of Medical Institute Education and Research, Chandigarh, 160012, India
| | - Monica Kundu
- George Institute for Global Health, UNSW, New Delhi, India
| | - Kajal Kamboj
- Department of Nephrology, Postgraduate Institute of Medical Institute Education and Research, Chandigarh, 160012, India
| | - Prabhjot Kaur
- Department of Nephrology, Postgraduate Institute of Medical Institute Education and Research, Chandigarh, 160012, India
| | - Jasmine Sethi
- Department of Nephrology, Postgraduate Institute of Medical Institute Education and Research, Chandigarh, 160012, India
| | - Harbir Singh Kohli
- Department of Nephrology, Postgraduate Institute of Medical Institute Education and Research, Chandigarh, 160012, India
| | - Kishan Lal Gupta
- Department of Nephrology, Postgraduate Institute of Medical Institute Education and Research, Chandigarh, 160012, India
| | - Arpita Ghosh
- George Institute for Global Health, UNSW, New Delhi, India
| | - Vivek Kumar
- Department of Nephrology, Postgraduate Institute of Medical Institute Education and Research, Chandigarh, 160012, India
| | - Ashok Kumar Yadav
- Department of Experimental Medicine and Biotechnology, Postgraduate Institute of Medical Institute Education and Research, Chandigarh, 160012, India.
| | - Vivekanand Jha
- George Institute for Global Health, UNSW, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Manipal Academy of Higher Education, Manipal, India
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13
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Birkelo BC, Pannu N, Siew ED. Overview of Diagnostic Criteria and Epidemiology of Acute Kidney Injury and Acute Kidney Disease in the Critically Ill Patient. Clin J Am Soc Nephrol 2022; 17:717-735. [PMID: 35292532 PMCID: PMC9269585 DOI: 10.2215/cjn.14181021] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Since the description ischuria renalis by William Heberden (1), AKI has remained a prominent complication of critical illness. Beyond KRT, treatment has been limited by the capacity to phenotype this condition. Here, we chronicle the evolution of attempts to classify AKI, including the adoption of consensus definitions, the expansion of diagnosis and prognosis with novel biomarkers, and emerging tools such as artificial intelligence (AI).
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Affiliation(s)
- Bethany C. Birkelo
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neesh Pannu
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Edward D. Siew
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
- Health Services Research and Development, Veterans Affairs Tennessee Valley, Nashville, Tennessee
- Veterans Affairs Geriatrics Research Education and Clinical Center (GRECC), Tennessee Valley Health System (THVS), Veteran’s Health Administration, Nashville, Tennessee
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14
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Soussi S, Sharma D, Jüni P, Lebovic G, Brochard L, Marshall JC, Lawler PR, Herridge M, Ferguson N, Del Sorbo L, Feliot E, Mebazaa A, Acton E, Kennedy JN, Xu W, Gayat E, Dos Santos CC. Identifying clinical subtypes in sepsis-survivors with different one-year outcomes: a secondary latent class analysis of the FROG-ICU cohort. Crit Care 2022; 26:114. [PMID: 35449071 PMCID: PMC9022336 DOI: 10.1186/s13054-022-03972-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Late mortality risk in sepsis-survivors persists for years with high readmission rates and low quality of life. The present study seeks to link the clinical sepsis-survivors heterogeneity with distinct biological profiles at ICU discharge and late adverse events using an unsupervised analysis. METHODS In the original FROG-ICU prospective, observational, multicenter study, intensive care unit (ICU) patients with sepsis on admission (Sepsis-3) were identified (N = 655). Among them, 467 were discharged alive from the ICU and included in the current study. Latent class analysis was applied to identify distinct sepsis-survivors clinical classes using readily available data at ICU discharge. The primary endpoint was one-year mortality after ICU discharge. RESULTS At ICU discharge, two distinct subtypes were identified (A and B) using 15 readily available clinical and biological variables. Patients assigned to subtype B (48% of the studied population) had more impaired cardiovascular and kidney functions, hematological disorders and inflammation at ICU discharge than subtype A. Sepsis-survivors in subtype B had significantly higher one-year mortality compared to subtype A (respectively, 34% vs 16%, p < 0.001). When adjusted for standard long-term risk factors (e.g., age, comorbidities, severity of illness, renal function and duration of ICU stay), subtype B was independently associated with increased one-year mortality (adjusted hazard ratio (HR) = 1.74 (95% CI 1.16-2.60); p = 0.006). CONCLUSIONS A subtype with sustained organ failure and inflammation at ICU discharge can be identified from routine clinical and laboratory data and is independently associated with poor long-term outcome in sepsis-survivors. Trial registration NCT01367093; https://clinicaltrials.gov/ct2/show/NCT01367093 .
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Affiliation(s)
- Sabri Soussi
- Interdepartmental Division of Critical Care, Faculty of Medicine, St Michael's Hospital, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, University of Toronto, 209 Victoria St 7th Floor, Toronto, ON, M5B 1T8, Canada.
| | - Divya Sharma
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, M5B 1W8, Canada.,Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Gerald Lebovic
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, M5B 1W8, Canada.,Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care, Faculty of Medicine, St Michael's Hospital, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, University of Toronto, 209 Victoria St 7th Floor, Toronto, ON, M5B 1T8, Canada
| | - John C Marshall
- Interdepartmental Division of Critical Care, Faculty of Medicine, St Michael's Hospital, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, University of Toronto, 209 Victoria St 7th Floor, Toronto, ON, M5B 1T8, Canada
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, University Health Network, and Heart and Stroke Richard Lewar Centre of Excellence in Cardiovascular Research, University of Toronto, Toronto, ON, Canada
| | - Margaret Herridge
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto General Research Institute, Institute of Medical Science, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Niall Ferguson
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto General Research Institute, Institute of Medical Science, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Lorenzo Del Sorbo
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto General Research Institute, Institute of Medical Science, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Elodie Feliot
- Department of Anesthesiology, Critical Care, Lariboisière - Saint-Louis Hospitals, DMU Parabol, AP-HP Nord; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesiology, Critical Care, Lariboisière - Saint-Louis Hospitals, DMU Parabol, AP-HP Nord; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
| | - Erica Acton
- Interdepartmental Division of Critical Care, Faculty of Medicine, St Michael's Hospital, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, University of Toronto, 209 Victoria St 7th Floor, Toronto, ON, M5B 1T8, Canada
| | - Jason N Kennedy
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Etienne Gayat
- Department of Anesthesiology, Critical Care, Lariboisière - Saint-Louis Hospitals, DMU Parabol, AP-HP Nord; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
| | - Claudia C Dos Santos
- Interdepartmental Division of Critical Care, Faculty of Medicine, St Michael's Hospital, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, University of Toronto, 209 Victoria St 7th Floor, Toronto, ON, M5B 1T8, Canada
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15
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Acute Kidney Injury: Biomarker-Guided Diagnosis and Management. Medicina (B Aires) 2022; 58:medicina58030340. [PMID: 35334515 PMCID: PMC8953384 DOI: 10.3390/medicina58030340] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 12/23/2022] Open
Abstract
Acute kidney injury (AKI) is a common clinical syndrome that is characterized by abnormal renal function and structure. The Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference in 2019 reviewed the stages of AKI and the definitions of AKI-related terminologies, and discussed the advances in the last decade. Along with serum creatinine level and urine output, more accurate novel biomarkers for predicting AKI are being applied for the early detection of renal dysfunction. A literature search was conducted in PubMed, Scopus, Medline, and ClinicalTrials.gov using the terms AKI and biomarker, combined with diagnosis, management, or prognosis. Because of the large volume of data (160 articles) published between 2005 and 2022, representative literature was chosen. A number of studies have demonstrated that new biomarkers are more sensitive in detecting AKI in certain populations than serum creatinine and urine output according to the recommendations from the Acute Disease Quality Initiative Consensus Conference. To be specific, there is a persistently unresolved need for earlier detection of patients with AKI before AKI progresses to a need for renal replacement therapy. Biomarker-guided management may help to identify a high-risk group of patients in progression to severe AKI, and decide the initiation time to renal replacement therapy and optimal follow-up period. However, limitations such as biased data to certain studied populations and absence of cutoff values need to be solved for worldwide clinical use of biomarkers in the future. Here, we provide a comprehensive review of biomarker-based AKI diagnosis and management and highlight recent developments.
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16
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Estimated glomerular filtration rate may be an independent predictor for clinical outcomes regardless of acute kidney injury complication in the emergency department. PLoS One 2021; 16:e0258665. [PMID: 34648576 PMCID: PMC8516290 DOI: 10.1371/journal.pone.0258665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/04/2021] [Indexed: 11/20/2022] Open
Abstract
Study objective Acute kidney injury (AKI), chronic kidney disease (CKD), and decreased estimated glomerular filtration rate (eGFR) are all associated with poor clinical outcomes among emergency department (ED) patients. This study aimed to evaluate the effect of different types of renal dysfunction and the degree of eGFR reduction on the clinical outcomes in a real-world ED setting. Methods Adult patients with an eGFR lower than 60 mL/min/1.73m2 in our ED, from October 1, 2016, to December 31, 2016, were enrolled in this retrospective observational study. Besides AKI and CKD, patients with unknown baseline renal function before an ED visit were categorized in the undetermined renal dysfunction (URD) category. Results Among 1495 patients who had eGFR evaluation at ED, this study finally enrolled 441 patients; 22 patients (5.0%) had AKI only, 32 (7.3%) had AKI on CKD, 196 (44.4%) had CKD only, 27 (6.1%) had subclinical kidney injury (those who met neither criteria for AKI nor CKD), and 164 (37.2%) had URD. There was a significant association between eGFR and critical illness defined as the composite outcome of death or intensive care unit (ICU) need, hospitalization, ICU need, death, and renal replacement therapy need (odds ratio [95% confidence interval]: 1.72 [1.45–2.05], 1.36 [1.16–1.59], 1.66 [1.39–2.00], 1.73 [1.32–2.28], and 2.71 [1.73–4.24] for every 10 mL/min/1.73m2 of reduction, respectively). Multivariate logistic regression analysis showed eGFR was an independent predictor of critical illness composite outcome (death or ICU need), hospitalization, and ICU need even after adjustment with AKI or URD. Conclusions Estimated GFR may be a sufficient predictor of clinical outcomes of ED patients regardless of AKI complication. Considerable ED patients were determined as URD, which might have a significant impact on the ED statistics regarding renal dysfunction.
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17
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Ostermann M, Karsten E, Lumlertgul N. Biomarker-Based Management of AKI: Fact or Fantasy? Nephron Clin Pract 2021; 146:295-301. [PMID: 34515152 PMCID: PMC9216309 DOI: 10.1159/000518365] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/15/2021] [Indexed: 11/19/2022] Open
Abstract
New biomarkers for acute kidney injury (AKI) have improved our understanding of the etiology and pathogenesis of AKI. Depending on their origin, function, and kinetic profile, biomarkers have a role in screening, diagnosis, prognostication, and monitoring of AKI. This offers opportunities to improve the management of AKI, but concerns and limitations remain. In this review, we summarize the current role of new AKI biomarkers in the management of AKI and outline some of the ongoing limitations and challenges.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Emma Karsten
- Emergency Department, Guy's & St Thomas' Foundation Trust, London, United Kingdom
| | - Nuttha Lumlertgul
- Department of Critical Care, King's College London, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
- Division of Nephrology, Department of Internal Medicine and Excellence Center in Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Research Unit in Critical Care Nephrology, Chulalongkorn University, Bangkok, Thailand
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18
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Angiotensin-Converting Enzyme Inhibitors and or Receptor Blockers After Acute Kidney Injury: Rehabilitation of the Supervillains. Crit Care Med 2021; 48:1922-1923. [PMID: 33255118 DOI: 10.1097/ccm.0000000000004641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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19
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See EJ, Polkinghorne KR, Toussaint ND, Bailey M, Johnson DW, Bellomo R. Epidemiology and Outcomes of Acute Kidney Diseases: A Comparative Analysis. Am J Nephrol 2021; 52:342-350. [PMID: 33906191 DOI: 10.1159/000515231] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/10/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Acute kidney diseases and disorders (AKD) encompass acute kidney injury (AKI) and subacute or persistent alterations in kidney function that occur after an initiating event. Unlike AKI, accurate estimates of the incidence and prognosis of AKD are not available and its clinical significance is uncertain. METHODS We studied the epidemiology and long-term outcome of AKD (as defined by the KDIGO criteria), with or without AKI, in a retrospective cohort of adults hospitalized at a single centre for >24 h between 2012 and 2016 who had a baseline eGFR ≥60 mL/min/1.73 m2 and were alive at 30 days. In patients for whom follow-up data were available, the risks of major adverse kidney events (MAKEs), CKD, kidney failure, and death were examined by Cox and competing risk regression analyses. RESULTS Among 62,977 patients, 906 (1%) had AKD with AKI and 485 (1%) had AKD without AKI. Follow-up data were available for 36,118 patients. In this cohort, compared to no kidney disease, AKD with AKI was associated with a higher risk of MAKEs (40.25 per 100 person-years; hazard ratio [HR] 2.51, 95% confidence interval [CI] 2.16-2.91), CKD (27.84 per 100 person-years); subhazard ratio [SHR] 3.18, 95% CI 2.60-3.89), kidney failure (0.56 per 100 person-years; SHR 24.84, 95% CI 5.93-104.03), and death (14.86 per 100 person-years; HR 1.52, 95% CI 1.20-1.92). Patients who had AKD without AKI also had a higher risk of MAKEs (36.21 per 100 person-years; HR 2.26, 95% CI 1.89-2.70), CKD (22.94 per 100 person-years; SHR 2.69, 95% CI 2.11-3.43), kidney failure (0.28 per 100 person-years; SHR 12.63, 95% CI 1.48-107.64), and death (14.86 per 100 person-years; HR 1.57, 95% CI 1.19-2.07). MAKEs after AKD were driven by CKD, especially in the first 3 months. CONCLUSIONS These findings establish the burden and poor prognosis of AKD and support prioritisation of clinical initiatives and research strategies to mitigate such risk.
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Affiliation(s)
- Emily J See
- School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Centre for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia
| | - Kevan R Polkinghorne
- School of Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia
- Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Nigel D Toussaint
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Michael Bailey
- School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, Brisbane, Queensland, Australia
- Translational Research Institute, Brisbane, Queensland, Australia
| | - Rinaldo Bellomo
- School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia
- Data Analytics Research and Evaluation, The University of Melbourne and Austin Hospital, Melbourne, Victoria, Australia
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20
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Chen JJ, Lee TH, Lee CC, Chang CH. Using lipocalin as a prognostic biomarker in acute kidney injury. Expert Rev Mol Diagn 2021; 21:455-464. [PMID: 33874823 DOI: 10.1080/14737159.2021.1917384] [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] [Indexed: 02/07/2023]
Abstract
Introduction: Human lipocalin-2, known as neutrophil gelatinase-associated lipocalin (NGAL), is a widely studied biomarker of acute kidney injury (AKI).Areas covered: NGAL can serve as a predictor of AKI, disease progression, and mortality and can help in differentiating between AKI etiologies. We conducted a systematic review in the PubMed and Medline databases involving the clinical application of NGAL in patients with AKI.Expert opinion: In this review, we explored the usefulness of NGAL for AKI or clinical outcome prediction. The use of urine or blood NGAL levels alone or in combination with a clinical prediction model may facilitate AKI prediction, severity prediction, AKI etiological differentiation, and mortality prediction. For AKI prediction, urine and plasma NGAL levels have an area under the curve (AUC) ranging from 0.71 to 0.90 and from 0.71 to 0.89, respectively, in different populations. The diagnostic performance of NGAL alone for renal replacement therapy or successful discontinuation prediction is suboptimal (AUC range: 0.65-0.81). Sepsis limits the application of NGAL as a clinical predictor, and the prediction performance of NGAL is affected by baseline renal function, timing of sample collection, and underlying comorbidities. The lack of internationally approved reference material also limits the usefulness of NGAL.
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Affiliation(s)
- Jia-Jin Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Tao-Han Lee
- Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Cheng-Chia Lee
- Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan.,Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan.,Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
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21
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Jamme M, Legrand M, Geri G. Outcome of acute kidney injury: how to make a difference? Ann Intensive Care 2021; 11:60. [PMID: 33856581 PMCID: PMC8050180 DOI: 10.1186/s13613-021-00849-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 04/03/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is one of the most frequent organ failure encountered among intensive care unit patients. In addition to the well-known immediate complications (hydroelectrolytic disorders, hypervolemia, drug overdose), the occurrence of long-term complications and/or chronic comorbidities related to AKI has long been underestimated. The aim of this manuscript is to briefly review the short- and long-term consequences of AKI and discuss strategies likely to improve outcome of AKI. MAIN BODY We reviewed the literature, focusing on the consequences of AKI in all its aspects and the management of AKI. We addressed the importance of clinical management for improving outcomes AKI. Finally, we have also proposed candidate future strategies and management perspectives. CONCLUSION AKI must be considered as a systemic disease. Due to its short- and long-term impact, measures to prevent AKI and limit the consequences of AKI are expected to improve global outcomes of patients suffering from critical illnesses.
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Affiliation(s)
- Matthieu Jamme
- Service de Réanimation, Hôpital de Poissy, CHI Poissy Saint Germain, 10 rue du champ Gaillard, 78300, Poissy, France.
- INSERM UMR 1018, Equipe Epidémiologie clinique, CESP, Villejuif, France.
- Université Paris Saclay, UFR Simone Veil - Santé, Montigny-Le-Bretonneux, France.
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, USA
| | - Guillaume Geri
- INSERM UMR 1018, Equipe Epidémiologie clinique, CESP, Villejuif, France
- Université Paris Saclay, UFR Simone Veil - Santé, Montigny-Le-Bretonneux, France
- Service de Médecine Intensive Réanimation, Hôpital Ambroise Paré, AP-HP, Boulogne Billancourt, France
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22
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Abstract
PURPOSE OF REVIEW The aim of this study was to summarize the current evidence around the impact of individualizing patient care following an episode of acute kidney injury (AKI) in the ICU. RECENT FINDINGS Over the last years, evidence has demonstrated that the follow-up care after episodes of AKI is lacking and standardization of this process is likely needed. Although this is informed largely by large retrospective cohort studies, a few prospective observational trials have been performed. Medication reconciliation and patient/caregiver education are important tenants of follow-up care, regardless of the severity of AKI. There is evidence the initiation and/or reinstitution of renin-angiotensin-aldosterone agents may improve patient's outcomes following AKI, although they may increase the risk for adverse events, especially when reinitiated early. In addition, 3 months after an episode of AKI, serum creatinine and proteinuria evaluation may help identify patients who are likely to develop progressive chronic kidney disease over the ensuing 5 years. Lastly, there are emerging differences between those who do and do not require renal replacement therapy (RRT) for their AKI, which may require more frequent and intense follow-up in those needing RRT. SUMMARY Although large scale evidence-based guidelines are lacking, standardization of post-ICU-AKI is needed.
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23
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Kim H, Hur M, Struck J, Bergmann A, Di Somma S. Proenkephalin Predicts Organ Failure, Renal Replacement Therapy, and Mortality in Patients With Sepsis. Ann Lab Med 2020; 40:466-473. [PMID: 32539302 PMCID: PMC7295958 DOI: 10.3343/alm.2020.40.6.466] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 04/09/2020] [Accepted: 05/11/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Kidney failure occurs frequently and is associated with high mortality during sepsis. Proenkephalin (PENK) is an emerging biomarker of kidney function. We explored whether PENK levels could predict severity, organ failure, and mortality in septic patients. METHODS We measured the PENK level in the plasma of 215 septic patients using the sphingotest penKid assay (Sphingotec GmbH, Hennigsdorf, Germany). This was analyzed in terms of sepsis severity, vasopressor use, 30-day mortality, sequential organ failure assessment (SOFA) renal subscore, the Chronic Kidney Disease Epidemiology Collaboration estimated glomerular filtration rate (CKD-EPI eGFR) categories, and renal replacement therapy (RRT) requirement. RESULTS The PENK levels were significantly higher in patients with septic shock, vasopressor use, and non-survivors than in patients with solitary sepsis, no vasopressor use, and survivors, respectively (P=0.02, P=0.007, P<0.001, respectively). The PENK levels were significantly associated with SOFA renal subscore and CKD-EPI eGFR categories (both P<0.001). The distribution of lower eGFR (<60 mL/min/1.73 m2), RRT requirement, SOFA renal subscore, and the number of organ failures differed significantly according to the PENK quartile (P for trend<0.001 or 0.017). The 30-day mortality rate also differed significantly according to the PENK quartile (P for trend<0.001). CONCLUSIONS PENK could be an objective and reliable marker to predict severity, organ failure, and 30-day mortality in septic patients.
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Affiliation(s)
- Hanah Kim
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul,
Korea
| | - Mina Hur
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul,
Korea
| | | | | | - Salvatore Di Somma
- Department of Medical-Surgery Sciences and Translational Medicine, School of Medicine and Psychology, Sapienza–University, Sant’ Andrea Hospital, Rome,
Italy
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Ostermann M, Zarbock A, Goldstein S, Kashani K, Macedo E, Murugan R, Bell M, Forni L, Guzzi L, Joannidis M, Kane-Gill SL, Legrand M, Mehta R, Murray PT, Pickkers P, Plebani M, Prowle J, Ricci Z, Rimmelé T, Rosner M, Shaw AD, Kellum JA, Ronco C. Recommendations on Acute Kidney Injury Biomarkers From the Acute Disease Quality Initiative Consensus Conference: A Consensus Statement. JAMA Netw Open 2020; 3:e2019209. [PMID: 33021646 DOI: 10.1001/jamanetworkopen.2020.19209] [Citation(s) in RCA: 332] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE In the last decade, new biomarkers for acute kidney injury (AKI) have been identified and studied in clinical trials. Guidance is needed regarding how best to incorporate them into clinical practice. OBJECTIVE To develop recommendations on AKI biomarkers based on existing data and expert consensus for practicing clinicians and researchers. EVIDENCE REVIEW At the 23rd Acute Disease Quality Initiative meeting, a meeting of 23 international experts in critical care, nephrology, and related specialties, the panel focused on 4 broad areas, as follows: (1) AKI risk assessment; (2) AKI prediction and prevention; (3) AKI diagnosis, etiology, and management; and (4) AKI progression and kidney recovery. A literature search revealed more than 65 000 articles published between 1965 and May 2019. In a modified Delphi process, recommendations and consensus statements were developed based on existing data, with 90% agreement among panel members required for final adoption. Recommendations were graded using the Grading of Recommendations, Assessment, Development and Evaluations system. FINDINGS The panel developed 11 consensus statements for biomarker use and 14 research recommendations. The key suggestions were that a combination of damage and functional biomarkers, along with clinical information, be used to identify high-risk patient groups, improve the diagnostic accuracy of AKI, improve processes of care, and assist the management of AKI. CONCLUSIONS AND RELEVANCE Current evidence from clinical studies supports the use of new biomarkers in prevention and management of AKI. Substantial gaps in knowledge remain, and more research is necessary.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care and Nephrology, King's College London, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care Medicine, and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Stuart Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Nephrology Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Etienne Macedo
- Division of Nephrology, Department of Medicine, University of California, San Diego
| | - Raghavan Murugan
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Max Bell
- Department of Perioperative Medicine and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Lui Forni
- Intensive Care Unit, Royal Surrey Hospital NHS Foundation Trust, Surrey, United Kingdom
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Surrey, United Kingdom
| | - Louis Guzzi
- Department of Critical Care Medicine, AdventHealth Waterman, Orlando, Florida
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Mathieu Legrand
- Department of Anesthesia and Perioperative Care, University of California, San Francisco
| | - Ravindra Mehta
- Department of Medicine, UCSD Medical Center, University of California, San Diego
| | | | - Peter Pickkers
- Department of Intensive Care Medicine, Nijmegen Medical Center, Radboud University, Nijmegen, the Netherlands
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
- Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - John Prowle
- William Harvey Research Institute, Royal London Hospital, Queen Mary University of London, London, United Kingdom
| | - Zaccaria Ricci
- Pediatric Cardiac Intensive Care Unit, Bambino Gesu Children's Hospital, Istituto Di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Thomas Rimmelé
- Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France
| | - Mitchell Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padova, Italy
- Department of Nephrology, Dialysis, and Transplantation, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
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25
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Khorashadi M, Beunders R, Pickkers P, Legrand M. Proenkephalin: A New Biomarker for Glomerular Filtration Rate and Acute Kidney Injury. Nephron Clin Pract 2020; 144:655-661. [PMID: 32739920 DOI: 10.1159/000509352] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/10/2020] [Indexed: 12/15/2022] Open
Abstract
Assessment of kidney function is primarily based on urine output and Creatinine (Cr)-based methods to estimate glomerular filtration rate (GFR). The latter is confounded as Cr is not exclusively filtered by the kidney and rises relatively late after the onset of acute kidney injury (AKI). This leads to delays in recognition of reduced kidney function and diagnosis of AKI, particularly in critically ill patients where kidney function can change rapidly. The gold standard methods of GFR determination, such as inulin or iohexol clearance, are labor intensive and unfeasible in acute clinical settings. Proenkephalin A 119-159 (PENK) has been intensively studied as a novel biomarker of kidney function. PENK belongs to the enkephalin peptide family and is freely filtrated in the glomerulus. Plasma PENK concentration appears to correlate strongly with GFR. Moreover, increased plasma PENK concentrations are found to be associated with long-term kidney outcomes and mortality. In this review, we summarize the role of PENK in assessment of kidney function and its capacity to predict various clinical outcomes.
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Affiliation(s)
- Mina Khorashadi
- Department of Anesthesiology and Peri-Operative Medicine, University of California, San Francisco, California, USA
| | - Remi Beunders
- Department of Intensive Care Medicine, Radboud University Medical Hospital, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Hospital, Nijmegen, The Netherlands,
| | - Matthieu Legrand
- Department of Anesthesiology and Peri-Operative Medicine, University of California, San Francisco, California, USA
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26
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Affiliation(s)
- Matthieu Legrand
- From the Department of Anesthesiology and Perioperative Care, University of California, San Francisco, San Francisco (M.L.); and INSERM 942, Lariboisière Hospital, and French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists (F-CRIN INI-CRCT), Paris (M.L.), and Université de Lorraine, INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM Unité 1116, Centre Hospitalier Régional Universitaire (CHRU) de Nancy, and F-CRIN INI-CRCT, Nancy (P.R.) - all in France
| | - Patrick Rossignol
- From the Department of Anesthesiology and Perioperative Care, University of California, San Francisco, San Francisco (M.L.); and INSERM 942, Lariboisière Hospital, and French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists (F-CRIN INI-CRCT), Paris (M.L.), and Université de Lorraine, INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM Unité 1116, Centre Hospitalier Régional Universitaire (CHRU) de Nancy, and F-CRIN INI-CRCT, Nancy (P.R.) - all in France
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