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Malbrain MLNG, Tantakoun K, Zara AT, Ferko NC, Kelly T, Dabrowski W. Urine output is an early and strong predictor of acute kidney injury and associated mortality: a systematic literature review of 50 clinical studies. Ann Intensive Care 2024; 14:110. [PMID: 38980557 PMCID: PMC11233478 DOI: 10.1186/s13613-024-01342-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 06/22/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND Although the present diagnosis of acute kidney injury (AKI) involves measurement of acute increases in serum creatinine (SC) and reduced urine output (UO), measurement of UO is underutilized for diagnosis of AKI in clinical practice. The purpose of this investigation was to conduct a systematic literature review of published studies that evaluate both UO and SC in the detection of AKI to better understand incidence, healthcare resource use, and mortality in relation to these diagnostic measures and how these outcomes may vary by population subtype. METHODS The systematic literature review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Data were extracted from comparative studies focused on the diagnostic accuracy of UO and SC, relevant clinical outcomes, and resource usage. Quality and validity were assessed using the National Institute for Health and Care Excellence (NICE) single technology appraisal quality checklist for randomized controlled trials and the Newcastle-Ottawa Quality Assessment Scale for observational studies. RESULTS A total of 1729 publications were screened, with 50 studies eligible for inclusion. A majority of studies (76%) used the Kidney Disease: Improving Global Outcomes (KDIGO) criteria to classify AKI and focused on the comparison of UO alone versus SC alone, while few studies analyzed a diagnosis of AKI based on the presence of both UO and SC, or the presence of at least one of UO or SC indicators. Of the included studies, 33% analyzed patients treated for cardiovascular diseases and 30% analyzed patients treated in a general intensive care unit. The use of UO criteria was more often associated with increased incidence of AKI (36%), than was the application of SC criteria (21%), which was consistent across the subgroup analyses performed. Furthermore, the use of UO criteria was associated with an earlier diagnosis of AKI (2.4-46.0 h). Both diagnostic modalities accurately predicted risk of AKI-related mortality. CONCLUSIONS Evidence suggests that the inclusion of UO criteria provides substantial diagnostic and prognostic value to the detection of AKI.
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Affiliation(s)
- Manu L N G Malbrain
- First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland.
- International Fluid Academy, Lovenjoel, Belgium.
- Medical Data Management, Medaman, Geel, Belgium.
| | - Krista Tantakoun
- Value & Evidence Division, Marketing and Market Access, EVERSANA™, Burlington, ON, Canada
| | - Anthony T Zara
- Value & Evidence Division, Marketing and Market Access, EVERSANA™, Burlington, ON, Canada
| | - Nicole C Ferko
- Value & Evidence Division, Marketing and Market Access, EVERSANA™, Burlington, ON, Canada
| | - Timothy Kelly
- Becton, Dickinson and Company, Franklin Lakes, NJ, USA
| | - Wojciech Dabrowski
- First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
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2
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Baggot H, Hodgson L, Forni L, Venn R, Koulouglioti C. Feasibility of an electronic fluid balance chart to detect and understand the significance of oliguric acute kidney injury in a general ward setting: a prospective observational cohort study. Future Healthc J 2023; 10:21-26. [PMID: 37786499 PMCID: PMC10538676 DOI: 10.7861/fhj.2022-0041] [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: 04/03/2023]
Abstract
Background Outside critical care environments, few studies have assessed the significance of oliguric acute kidney injury (AKI). This study investigated the feasibility of an electronic fluid balance chart to diagnose oliguric AKI. Data were used to determine if oliguric AKI was met earlier than creatinine AKI and to establish outcomes of those who developed AKI. Methods A single-centre prospective cohort study investigated Kidney Disease Improving Global Outcomes oliguric and creatinine AKI criteria on general surgical wards. Results 2,149 cases were included in the analysis. Incidence of oliguric AKI was significantly higher than creatinine criteria (73 versus 10.1%) and detection occurred earlier (2.1 versus 6.1 days, p<0.05). In cases with oliguric AKI, 8.1% also developed AKI by creatinine criteria. In cases not meeting oliguric AKI criteria, fewer cases developed creatinine AKI, as compared to those meeting oliguric AKI criteria (7.9% versus 11%, p=0.043). There was a high incidence of missing data. Conclusions Oliguric AKI was met in a high proportion of cases and occurred earlier than by changes in creatinine. Barriers to consistency of recording must be addressed before oliguric criteria could be implemented in clinical practice.
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Affiliation(s)
- Hannah Baggot
- University Hospitals Sussex NHS Foundation Trust, Chichester, UK
| | - Luke Hodgson
- University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Lui Forni
- Royal Surrey County Hospital NHS Foundation Trust, Surrey, UK
| | - Richard Venn
- University Hospitals Sussex NHS Foundation Trust, Worthing, UK
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Sakai T, Ko JS, Crouch CE, Kumar S, Little MB, Chae MS, Ganoza A, Gómez-Salinas L, Humar A, Kim SH, Koo BN, Rodriguez G, Sirianni J, Smith NK, Song JG, Ullah A, Hendrickse A. Perioperative management of adult living donor liver transplantation: Part 1 - recipients. Clin Transplant 2022; 36:e14667. [PMID: 35435293 DOI: 10.1111/ctr.14667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/06/2022] [Accepted: 03/31/2022] [Indexed: 11/29/2022]
Abstract
Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation option has become an established and widely practiced transplantation method for adult patients suffering from end-stage liver disease. It has successfully addressed the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplant Anesthesia jointly reviewed published studies on the perioperative management of live donor liver transplant recipients. The review aims to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live liver transplantation recipients. We feature the status, outcomes, surgical procedure, portal venous decompression, anesthetic management, prevention of acute kidney injury, avoidance of blood transfusion, monitoring and therapeutic strategies of hemodynamic derangements, and Enhanced Recovery After Surgery protocols for liver transplant recipients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Clinical and Translational Science Institute, University of Pittsburgh, PA, USA.,McGowan Institute for Regenerative Medicine, University of Pittsburgh, PA, USA
| | - Justin Sangwook Ko
- Department of Anesthesiology & Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Cara E Crouch
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sathish Kumar
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Michael B Little
- Department of Anesthesiology, UT Health San Antonio, San Antonio, TX, USA
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Armando Ganoza
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Luis Gómez-Salinas
- Department of Anesthesiology and Pain Medicine, Hospital General Universitario de Alicante, Alicante, Spain
| | - Abhi Humar
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sang Hyun Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Gyeonggi-do, Republic of Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gonzalo Rodriguez
- Department of Surgery, Hospital General Universitario de Alicante, Alicante, Spain
| | - Joel Sirianni
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Natalie K Smith
- Department of Anesthesiology, Perioperative & Pain Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Aisha Ullah
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Adrian Hendrickse
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Weiss R, Saadat-Gilani K, Kerschke L, Wempe C, Meersch M, Zarbock A. EPIdemiology of Surgery-Associated Acute Kidney Injury (EPIS-AKI): study protocol for a multicentre, observational trial. BMJ Open 2021; 11:e055705. [PMID: 35588372 PMCID: PMC8718477 DOI: 10.1136/bmjopen-2021-055705] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION More than 300 million surgical procedures are performed each year. Acute kidney injury (AKI) is a common complication after major surgery and is associated with adverse short-term and long-term outcomes. However, there is a large variation in the incidence of reported AKI rates. The establishment of an accurate epidemiology of surgery-associated AKI is important for healthcare policy, quality initiatives, clinical trials, as well as for improving guidelines. The objective of the Epidemiology of Surgery-associated Acute Kidney Injury (EPIS-AKI) trial is to prospectively evaluate the epidemiology of AKI after major surgery using the latest Kidney Disease: Improving Global Outcomes (KDIGO) consensus definition of AKI. METHODS AND ANALYSIS EPIS-AKI is an international prospective, observational, multicentre cohort study including 10 000 patients undergoing major surgery who are subsequently admitted to the ICU or a similar high dependency unit. The primary endpoint is the incidence of AKI within 72 hours after surgery according to the KDIGO criteria. Secondary endpoints include use of renal replacement therapy (RRT), mortality during ICU and hospital stay, length of ICU and hospital stay and major adverse kidney events (combined endpoint consisting of persistent renal dysfunction, RRT and mortality) at day 90. Further, we will evaluate preoperative and intraoperative risk factors affecting the incidence of postoperative AKI. In an add-on analysis, we will assess urinary biomarkers for early detection of AKI. ETHICS AND DISSEMINATION EPIS-AKI has been approved by the leading Ethics Committee of the Medical Council North Rhine-Westphalia, of the Westphalian Wilhelms-University Münster and the corresponding Ethics Committee at each participating site. Results will be disseminated widely and published in peer-reviewed journals, presented at conferences and used to design further AKI-related trials. TRIAL REGISTRATION NUMBER NCT04165369.
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Affiliation(s)
- Raphael Weiss
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Universitätsklinikum Münster, Münster, Germany
| | - Khaschayar Saadat-Gilani
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Universitätsklinikum Münster, Münster, Germany
| | - Laura Kerschke
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Carola Wempe
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Universitätsklinikum Münster, Münster, Germany
| | - Melanie Meersch
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Universitätsklinikum Münster, Münster, Germany
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Universitätsklinikum Münster, Münster, Germany
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Park J, Jeong J, Choi HJ, Shim JW, Lee HM, Hong SH, Park CS, Choi JH, Chae MS. Role of thrombocytopenia in risk stratification for acute kidney injury after living donor liver transplantation. Platelets 2020; 32:453-462. [PMID: 32299264 DOI: 10.1080/09537104.2020.1754377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The aim of our study was to investigate pre and intraoperative clinical factors, including platelet count, which could inform risk stratification of early acute kidney injury (AKI) after living donor liver transplantation (LDLT). Additionally, the impact of severe thrombocytopenia on AKI risk was assessed using a propensity score (PS)-matched analysis. In total, 591 adult patients who underwent LDLT between January 2009 and December 2018 at our hospital were retrospectively analyzed. Early postoperative AKI was determined based on the KDIGO criteria, and 149 patients (25.2%) developed AKI immediately after surgery. In a multivariate analysis, a lower preoperative platelet count was significantly associated with early postoperative AKI, together with diabetes mellitus, lower hourly urine output, and longer graft ischemic time; furthermore, a decrease in platelet count was correlated with AKI severity. After adjusting for the PS, the probability of AKI was significantly (1.9-fold) higher in patients with severe thrombocytopenia than in those without severe thrombocytopenia. Patients with thrombocytopenia showed a higher postoperative incidence of AKI and a higher requirement for dialysis than those without thrombocytopenia. The platelet count can easily be obtained via regular blood analysis of patients scheduled for LDLT and can be used to identify patients at risk for AKI.
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Affiliation(s)
- Jaesik Park
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Anesthesiology and Pain Medicine, Seocho-gu, Seoul, Korea (The Republic Of)
| | - Jangsu Jeong
- Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Anesthesiology and Pain Medicine, Seocho-gu, Seoul, Korea (The Republic Of)
| | - Ho Joong Choi
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Surgery, Seocho-gu, Seoul, Korea (The Republic Of)
| | - Jung-Woo Shim
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Anesthesiology and Pain Medicine, Seocho-gu, Seoul, Korea (The Republic Of)
| | - Hyung Mook Lee
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Anesthesiology and Pain Medicine, Seocho-gu, Seoul, Korea (The Republic Of)
| | - Sang Hyun Hong
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Anesthesiology and Pain Medicine, Seocho-gu, Seoul, Korea (The Republic Of)
| | - Chul Soo Park
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Anesthesiology and Pain Medicine, Seocho-gu, Seoul, Korea (The Republic Of)
| | - Jong Ho Choi
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Anesthesiology and Pain Medicine, Seocho-gu, Seoul, Korea (The Republic Of)
| | - Min Suk Chae
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Anesthesiology and Pain Medicine, Seocho-gu, Seoul, Korea (The Republic Of)
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The impact of acute kidney injury by serum creatinine or urine output criteria on major adverse kidney events in cardiac surgery patients. J Thorac Cardiovasc Surg 2020; 162:143-151.e7. [PMID: 32033818 DOI: 10.1016/j.jtcvs.2019.11.137] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 11/05/2019] [Accepted: 11/28/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Oliguria after cardiac surgery remains of uncertain clinical significance. Therefore, we investigated the relationship of acute kidney injury severity across urine output and creatinine domains with the risk for major adverse kidney events at 180 days. We aimed to determine the impact of acute kidney injury after cardiac surgery. METHODS In a retrospective multicenter study, we investigated the relationship of acute kidney injury severity across urine output and creatinine categories with the risk for major adverse kidney events at 180 days-the composite of death, dialysis, and persistent renal dysfunction-using a large database of patients undergoing cardiac surgery at 1 of 5 hospitals within the regional medical system. We analyzed electronic records from 6637 patients treated between 2008 and 2014, of whom 5389 (81.2%) developed any acute kidney injury within 72 hours of surgery. We stratified patients by levels of urine output or serum creatinine according to Kidney Disease Improving Global Outcomes criteria for acute kidney injury. RESULTS Major adverse kidney events at 180 days increased from 4.5% for no acute kidney injury to 61.3% for stage 3 acute kidney injury (P < .001). Death or dialysis by day 180 was 2.4% for those with no acute kidney injury and 46.7% for those with acute kidney injury stage 3 (P < .001). Isolated oliguria was common (42.6%), and isolated azotemia was rare (6.1%). Even stage 1 acute kidney injury by oliguria alone was associated with an increased risk of major adverse kidney events at 180 days (odds ratio, 1.76; 1.20-2.57; P = .004), mainly driven by persistent renal dysfunction (odds ratio, 2.01; 1.26-3.18; P = .003). CONCLUSIONS Acute kidney injury is common in patients undergoing cardiac surgery, and even milder forms of acute kidney injury, including isolated stage 1 oliguria, are associated with adverse long-term consequences.
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Lin PC, Huang HC, Komorowski M, Lin WK, Chang CM, Chen KT, Li YC, Lin MC. A machine learning approach for predicting urine output after fluid administration. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 177:155-159. [PMID: 31319943 DOI: 10.1016/j.cmpb.2019.05.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/21/2019] [Accepted: 05/13/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE To develop a machine learning model to predict urine output (UO) in sepsis patients after fluid resuscitation. METHODS We identified sepsis patients in the Multiparameter Intelligent Monitoring in Intensive Care-III v1.4 database according to the Sepsis-3 criteria. We focused on two outcomes: whether the UO decreased after fluid administration and whether oliguria (defined as UO less than the threshold of 0.5 mL/kg/h) developed. A gradient tree-based machine learning model implemented with an eXtreme Gradient Boosting algorithm was used to integrate relevant physiological parameters for predicting the aforementioned outcomes. A confusion matrix was computed. RESULTS A total of 232,929 events in 19,275 patients were included. Using decreased UO as the outcome measure, the optimal model achieved an area under the curve (AUC) of 0.86; for predicting oliguria, most models achieved an AUC greater than 0.86, and the highest sensitivity was 92.2% when the model was applied to patients with baseline oliguria. CONCLUSIONS Machine learning could help clinicians evaluate fluid status in sepsis patients after fluid administration, thus preventing fluid overload-related complications.
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Affiliation(s)
- Pei-Chen Lin
- Graduate Institute of Biomedical Informatics, College of Medicine Science and Technology, Taipei Medical University, Taipei, Taiwan; Emergency Department, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Hsu-Cheng Huang
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Radiology, Taipei City Hospital, Yangming Branch, Taipei, Taiwan
| | - Matthieu Komorowski
- Department of Surgery and Cancer, Imperial College London, London, UK; Department of Bioengineering, Imperial College London, London, UK; Laboratory of Computational Physiology, Harvard-MIT Division of Health Sciences & Technology, Cambridge, MA, USA
| | - Wei-Kai Lin
- Institute of Information Science, Academia Sinica, Taipei, Taiwan
| | - Chun-Min Chang
- Institute of Information Science, Academia Sinica, Taipei, Taiwan
| | - Kuan-Ta Chen
- Institute of Information Science, Academia Sinica, Taipei, Taiwan
| | - Yu-Chuan Li
- International Center for Health Information Technology, Taipei Medical University, Taipei, Taiwan; Department of Dermatology, Wan Fang Hospital, Taipei, Taiwan
| | - Ming-Chin Lin
- Graduate Institute of Biomedical Informatics, College of Medicine Science and Technology, Taipei Medical University, Taipei, Taiwan; Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan.
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Bonavia A, Javaherian M, Skojec AJ, Chinchilli VM, Mets B, Karamchandani K. Angiotensin axis blockade, acute kidney injury, and perioperative morbidity in patients undergoing colorectal surgery: A retrospective cohort study. Medicine (Baltimore) 2019; 98:e16872. [PMID: 31415426 PMCID: PMC6831354 DOI: 10.1097/md.0000000000016872] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients undergoing surgery and taking angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) are susceptible to complications related to intraoperative hypotension. Perioperative continuation of such medications in patients undergoing colorectal surgery may be associated with more harm than benefit, as these patients are often exposed to other risk factors which may contribute to intraoperative hypotension. Our objectives were to assess the incidence and severity of postinduction hypotension as well as the rates of acute kidney injury (AKI), 30-day all-cause mortality, 30-day readmission, and hospital length of stay in adult patients undergoing colorectal surgery who take ACEi/ARB.We performed a retrospective chart review of patients undergoing colorectal surgery of ≥4 hour duration at a tertiary care academic medical center between January 2011 and November 2016. The preoperative and intraoperative characteristics as well as postoperative outcomes were compared between patients taking ACEi/ARB and patients not taking these medications.Of the 1020 patients meeting inclusion criteria, 174 (17%) were taking either ACEi or ARB before surgery. Patients taking these medications were more likely to receive both postinduction and intraoperative phenylephrine and ephedrine. The incidences of postoperative AKI (P = .35), 30-day all-cause mortality (P = .36), 30-day hospital readmission (P = .45), and hospital length of stay (P = .25), were not significantly different between the 2 groups.Our results support the current recommendation that ACEi/ARB use is probably safe within the colorectal surgery population during the perioperative period. Intraoperative hypotension should be expected and treated with vasopressors.
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Affiliation(s)
- Anthony Bonavia
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | - Milad Javaherian
- Department of Anesthesiology, Harbor-UCLA Medical Center, Torrance, CA
| | - Alexander J. Skojec
- Department of Anesthesiology, School of Medicine, University of Virginia, Charlottesville, VA
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Berend Mets
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | - Kunal Karamchandani
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
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Incidence and Impact of Acute Kidney Injury after Liver Transplantation: A Meta-Analysis. J Clin Med 2019; 8:jcm8030372. [PMID: 30884912 PMCID: PMC6463182 DOI: 10.3390/jcm8030372] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/05/2019] [Accepted: 03/14/2019] [Indexed: 02/06/2023] Open
Abstract
Background: The study’s aim was to summarize the incidence and impacts of post-liver transplant (LTx) acute kidney injury (AKI) on outcomes after LTx. Methods: A literature search was performed using the MEDLINE, EMBASE and Cochrane Databases from inception until December 2018 to identify studies assessing the incidence of AKI (using a standard AKI definition) in adult patients undergoing LTx. Effect estimates from the individual studies were derived and consolidated utilizing random-effect, the generic inverse variance approach of DerSimonian and Laird. The protocol for this systematic review is registered with PROSPERO (no. CRD42018100664). Results: Thirty-eight cohort studies, with a total of 13,422 LTx patients, were enrolled. Overall, the pooled estimated incidence rates of post-LTx AKI and severe AKI requiring renal replacement therapy (RRT) were 40.7% (95% CI: 35.4%–46.2%) and 7.7% (95% CI: 5.1%–11.4%), respectively. Meta-regression showed that the year of study did not significantly affect the incidence of post-LTx AKI (p = 0.81). The pooled estimated in-hospital or 30-day mortality, and 1-year mortality rates of patients with post-LTx AKI were 16.5% (95% CI: 10.8%–24.3%) and 31.1% (95% CI: 22.4%–41.5%), respectively. Post-LTx AKI and severe AKI requiring RRT were associated with significantly higher mortality with pooled ORs of 2.96 (95% CI: 2.32–3.77) and 8.15 (95%CI: 4.52–14.69), respectively. Compared to those without post-LTx AKI, recipients with post-LTx AKI had significantly increased risk of liver graft failure and chronic kidney disease with pooled ORs of 3.76 (95% CI: 1.56–9.03) and 2.35 (95% CI: 1.53–3.61), respectively. Conclusion: The overall estimated incidence rates of post-LTx AKI and severe AKI requiring RRT are 40.8% and 7.0%, respectively. There are significant associations of post-LTx AKI with increased mortality and graft failure after transplantation. Furthermore, the incidence of post-LTx AKI has remained stable over the ten years of the study.
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Zarbock A, Koyner JL, Hoste EAJ, Kellum JA. Update on Perioperative Acute Kidney Injury. Anesth Analg 2018; 127:1236-1245. [DOI: 10.1213/ane.0000000000003741] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Lemon K, Al-Khafaji A, Humar A. Critical Care Management of Living Donor Liver Transplants. Crit Care Clin 2018; 35:107-116. [PMID: 30447773 DOI: 10.1016/j.ccc.2018.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This article represents a review of the postoperative management of donors and recipients after living donor liver transplant, including monitoring, liberation from mechanical ventilation, nutritional support, and pain control. Vascular complications, such as biliary and sepsis, and bleeding are also discussed. Finally, commonly used immunosuppression and antimicrobial prophylaxes are reviewed.
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Affiliation(s)
- Kristina Lemon
- Department of Surgery, University of Pittsburgh Medical Center, Thomas E. Starzl Transplantation Institute, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, 3550 Terrace Street, Scaife 613, Pittsburgh, PA 15261, USA.
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh Medical Center, Thomas E. Starzl Transplantation Institute, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA
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Abstract
The development of acute kidney injury in the setting of liver disease is a significant event both before and after liver transplant. Whether acute kidney injury is the cause of or merely associated with worse outcomes, the development of renal failure is significant from a prognostic as well as from a diagnostic and therapeutic standpoint. Although not every etiology is reversible, there are number of etiologies that are correctable, to include hypovolemia, nephrotoxic medications, and acute tubular necrosis. In the post-liver transplant period, renal failure is associated with graft failure as well as worse outcomes overall. Prompt recognition, workup, and intervention can significantly impact outcomes and survival both before and after liver transplant.
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Affiliation(s)
| | - Ali Al-Khafaji
- 2 Department of Critical Care Medicine, The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
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13
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Amathieu R, Al-Khafaji A, Sileanu FE, Foldes E, DeSensi R, Hilmi I, Kellum JA. Significance of oliguria in critically ill patients with chronic liver disease. Hepatology 2017; 66:1592-1600. [PMID: 28586126 DOI: 10.1002/hep.29303] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 04/28/2017] [Accepted: 06/01/2017] [Indexed: 01/16/2023]
Abstract
UNLABELLED Clinical guidelines recommend using Kidney Disease Improving Global Outcomes (KDIGO) criteria for the diagnosis and classification of acute kidney injury (AKI) in patients with chronic liver disease (CLD). Concerns have been raised about the use of urine output (UO) criteria in CLD. We examined the significance of oliguria meeting the urine output criteria for AKI (AKI-UO) and examined its association with clinical outcomes in CLD patients. Using an 8-year clinical database from a large university medical center, 3458 patients with CLD were identified. AKI occurred in 2854 (82.5%) patients when they fulfilled any KDIGO criteria. When serum creatinine (SC) and UO criteria were used, 604 patients (17.5%) had no evidence of AKI and had the lowest hospital mortality rate (5%). Using AKI-UO criteria alone, 2103 patients (60.8%) were classified as stage 2-3 AKI. When only SC criteria were applied, 1281 (61%) of those patients with stage 2-3 AKI-UO were misclassified as either no AKI or AKI stage 1. Patients reclassified with AKI according to UO criteria (AKI-UO) had nearly a 3-fold increased rate of hospital mortality compared with patients without any AKI (14.6% versus 5%; P < 0.001) and more than a 50% increased mortality compared with stage 1 AKI-SC (14.6% versus 9%; P < 0.001). Patients with transient oliguria (AKI-UO stage 1) had increased mortality rates compared with patients without oliguria (14.9% versus 6.9%; P < 0.001). CONCLUSION CLD patients have a high incidence of AKI. Compared with creatinine criteria alone, incorporating UO into the diagnostic criteria increased the measured incidence of AKI. Stage 2-3 AKI-UO has a high negative impact on hospital mortality. (Hepatology 2017;66:1592-1600).
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Affiliation(s)
- Roland Amathieu
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.,The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Department of Critical Care Medicine and Anesthesiology, University Paris 13 School of Medicine and Jean Verdier Hospital, Bondy, France
| | - Ali Al-Khafaji
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.,The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Florentina E Sileanu
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.,The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Emily Foldes
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.,The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Rebecca DeSensi
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.,The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ibtesam Hilmi
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.,The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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14
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Acute kidney injury after pediatric liver transplantation: incidence, risk factors, and association with outcome. J Anesth 2017; 31:758-763. [DOI: 10.1007/s00540-017-2395-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/25/2017] [Indexed: 02/07/2023]
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15
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Targeting urine output and 30-day mortality in goal-directed therapy: a systematic review with meta-analysis and meta-regression. BMC Anesthesiol 2017; 17:22. [PMID: 28187752 PMCID: PMC5303289 DOI: 10.1186/s12871-017-0316-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 02/06/2017] [Indexed: 02/07/2023] Open
Abstract
Background Oliguria is associated with a decreased kidney- and organ perfusion, leading to organ damage and increased mortality. While the effects of correcting oliguria on renal outcome have been investigated frequently, whether urine output is a modifiable risk factor for mortality or simply an epiphenomenon remains unclear. We investigated whether targeting urine output, defined as achieving and maintaining urine output above a predefined threshold, in hemodynamic management protocols affects 30-day mortality in perioperative and critical care. Methods We performed a systematic review with a random-effects meta-analyses and meta-regression based on search strategy through MEDLINE, EMBASE and references in relevant articles. We included studies comparing conventional fluid management with goal-directed therapy and reporting whether urine output was used as target or not, and reporting 30-day mortality data in perioperative and critical care. Results We found 36 studies in which goal-directed therapy reduced 30-day mortality (OR 0.825; 95% CI 0.684-0.995; P = 0.045). Targeting urine output within goal-directed therapy increased 30-day mortality (OR 2.66; 95% CI 1.06-6.67; P = 0.037), but not in conventional fluid management (OR 1.77; 95% CI 0.59-5.34; P = 0.305). After adjusting for operative setting, hemodynamic monitoring device, underlying etiology, use of vasoactive medication and year of publication, we found insufficient evidence to associate targeting urine output with a change in 30-day mortality (goal-directed therapy: OR 1.17; 95% CI 0.54-2.56; P = 0.685; conventional fluid management: OR 0.74; 95% CI 0.39-1.38; P = 0.334). Conclusions The principal finding of this meta-analysis is that after adjusting for confounders, there is insufficient evidence to associate targeting urine output with an effect on 30-day mortality. The paucity of direct data illustrates the need for further research on whether permissive oliguria should be a key component of fluid management protocols. Electronic supplementary material The online version of this article (doi:10.1186/s12871-017-0316-4) contains supplementary material, which is available to authorized users.
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16
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Mizota T, Hamada M, Matsukawa S, Seo H, Tanaka T, Segawa H. Relationship Between Intraoperative Hypotension and Acute Kidney Injury After Living Donor Liver Transplantation: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2016; 31:582-589. [PMID: 28216198 DOI: 10.1053/j.jvca.2016.12.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Acute kidney injury (AKI) is common after liver transplantation (LT) and has a significant impact on outcomes. Although several risk factors for post-LT AKI have been identified, the effect of intraoperative hemodynamic status on post-LT AKI remains unknown. Therefore, the authors aimed to investigate the relationship between hemodynamic parameters during LT and postoperative AKI. DESIGN A retrospective observational study. SETTING University hospital. PARTICIPANTS Patients who underwent living donor LT (n = 231). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Severe AKI (stages 2-3 according to recent guidelines) was the primary outcome. Multivariable logistic regression analysis was used to control for confounding variables to obtain the independent relationship between intraoperative hemodynamic parameters (mean arterial pressure [MAP] and cardiac index) and severe AKI. The prevalence of severe AKI was 30.7%. Nadir MAP during the surgery was independently predictive of severe AKI (adjusted odds ratio, 2.11 [95% confidence interval, 1.32-3.47] per 10-mmHg decrease; p = 0.002). Subgroup analyses based on various patient or operative variables and extensive sensitivity analyses showed substantially similar results. Severe hypotension (MAP<40 mmHg), even for fewer than 10 minutes, was related significantly to severe AKI (adjusted odds ratio, 3.80 [95% confidence interval, 1.17-12.30]; p = 0.026). In contrast, nadir cardiac index was not related significantly to severe AKI. CONCLUSIONS The authors found an independent relationship between degree of intraoperative hypotension and risk of severe AKI in living donor LT recipients. Severe hypotension, even for a short duration, was related significantly to severe AKI.
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Affiliation(s)
- Toshiyuki Mizota
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan.
| | - Miho Hamada
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Shino Matsukawa
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Hideya Seo
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Tomoharu Tanaka
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Hajime Segawa
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
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17
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Xue FS, Yang GZ, Sun C. Association of acute kidney injury with adverse post-operative outcomes after living donor liver transplantation. Acta Anaesthesiol Scand 2016; 60:1337-8. [PMID: 27468949 DOI: 10.1111/aas.12772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- F. S. Xue
- Department of Anaesthesiology; Plastic Surgery Hospital; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - G.-Z. Yang
- Department of Anaesthesiology; Plastic Surgery Hospital; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - C. Sun
- Department of Anaesthesiology; Plastic Surgery Hospital; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
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18
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Mizota T, Minamisawa S. Reply to: Xue FS, et al. Association of acute kidney injury with adverse postoperative outcomes after living donor liver transplantation. Acta Anaesthesiol Scand 2016; 60:1339-40. [PMID: 27469038 DOI: 10.1111/aas.12774] [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]
Affiliation(s)
- T. Mizota
- Department of Anaesthesia; Kyoto University Hospital; Sakyo-ku, Kyoto Japan
| | - S. Minamisawa
- Department of Healthcare Economics and Quality Management; Graduate School of Medicine; Kyoto University; Sakyo-ku, Kyoto Japan
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