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Ogurlu B, Hamelink TL, Lantinga VA, Leuvenink HGD, Pool MBF, Moers C. Furosemide attenuates tubulointerstitial injury and allows functional testing of porcine kidneys during normothermic machine perfusion. Artif Organs 2024; 48:595-605. [PMID: 38164041 DOI: 10.1111/aor.14705] [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: 08/16/2023] [Revised: 11/24/2023] [Accepted: 12/18/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Normothermic machine perfusion (NMP) is a promising pretransplant kidney quality assessment platform, but it remains crucial to increase its diagnostic potential while ensuring minimal additional injury to the already damaged kidney. Interventions that alter tubular transport can influence renal function and injury during perfusion. This study aimed to determine whether furosemide and desmopressin affect renal function and injury during NMP. METHODS Eighteen porcine kidneys (n = 6 per group) were subjected to 30 min of warm ischemia and 4 h of oxygenated hypothermic perfusion before being subjected to 6 h of NMP. Each organ was randomized to receive no drug, furosemide (750 mg), or desmopressin (16 μg) during NMP. RESULTS Compared with the other groups, the addition of furosemide resulted in significantly increased urine output, fractional excretion of sodium and potassium, and urea clearance during NMP. Urinary neutrophil gelatinase-associated lipocalin levels decreased significantly with furosemide supplementation compared with the other groups. The addition of desmopressin did not result in any significantly different outcome measurements compared with the control group. CONCLUSIONS This study showed that the addition of furosemide affected renal function while attenuating tubulointerstitial injury during NMP. Therefore, furosemide supplementation may provide renal protection and serve as a functional test for pretransplant kidney viability assessment during NMP.
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Affiliation(s)
- Baran Ogurlu
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Tim L Hamelink
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Veerle A Lantinga
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Henri G D Leuvenink
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Merel B F Pool
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cyril Moers
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Jiang J, Liu X, Cheng Z, Liu Q, Xing W. Interpretable machine learning models for early prediction of acute kidney injury after cardiac surgery. BMC Nephrol 2023; 24:326. [PMID: 37936067 PMCID: PMC10631004 DOI: 10.1186/s12882-023-03324-w] [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: 04/07/2023] [Accepted: 09/05/2023] [Indexed: 11/09/2023] Open
Abstract
OBJECTIVE Postoperative acute kidney injury (PO-AKI) is a common complication after cardiac surgery. We aimed to evaluate whether machine learning algorithms could significantly improve the risk prediction of PO-AKI. METHODS The retrospective cohort study included 2310 adult patients undergoing cardiac surgery in a tertiary teaching hospital, China. Postoperative AKI and severe AKI were identified by the modified KDIGO definition. The sample was randomly divided into a derivation set and a validation set based on a ratio of 4:1. Exploiting conventional logistic regression (LR) and five ML algorithms including decision tree, random forest, gradient boosting classifier (GBC), Gaussian Naive Bayes and multilayer perceptron, we developed and validated the prediction models of PO-AKI. We implemented the interpretation of models using SHapley Additive exPlanation (SHAP) analysis. RESULTS Postoperative AKI and severe AKI occurred in 1020 (44.2%) and 286 (12.4%) patients, respectively. Compared with the five ML models, LR model for PO-AKI exhibited the largest AUC (0.812, 95%CI: 0.756, 0.860, all P < 0.05), sensitivity (0.774, 95%CI: 0.719, 0.813), accuracy (0.753, 95%CI: 0.719, 0.781) and Youden index (0.513, 95%CI: 0.451, 0.573). Regarding severe AKI, GBC algorithm showed a significantly higher AUC than the other four ML models (all P < 0.05). Although no significant difference (P = 0.173) was observed in AUCs between GBC (0.86, 95%CI: 0.808, 0.902) and conventional logistic regression (0.803, 95%CI: 0.746, 0.852), GBC achieved greater sensitivity, accuracy and Youden index than conventional LR. Notably, SHAP analyses showed that preoperative serum creatinine, hyperlipidemia, lipid-lowering agents and assisted ventilation time were consistently among the top five important predictors for both postoperative AKI and severe AKI. CONCLUSION Logistic regression and GBC algorithm demonstrated moderate to good discrimination and superior performance in predicting PO-AKI and severe AKI, respectively. Interpretation of the models identified the key contributors to the predictions, which could potentially inform clinical interventions.
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Affiliation(s)
- Jicheng Jiang
- Department of Big Data Center for Cardiovascular Disease, Heart Center of Henan Provincial People's Hospital, Fuwai Central China Cardiovascular Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Xinyun Liu
- Department of Big Data Center for Cardiovascular Disease, Heart Center of Henan Provincial People's Hospital, Fuwai Central China Cardiovascular Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhaoyun Cheng
- Department of Cardiovascular Surgery, Heart Center of Henan Provincial People's Hospital, Fuwai Central China Cardiovascular Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China.
| | - Qianjin Liu
- Department of Cardiovascular Surgery, Heart Center of Henan Provincial People's Hospital, Fuwai Central China Cardiovascular Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Wenlu Xing
- Department of Big Data Center for Cardiovascular Disease, Heart Center of Henan Provincial People's Hospital, Fuwai Central China Cardiovascular Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
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3
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Sancho-Martínez SM, López-Hernández FJ. Pathophysiology of Acute Kidney Frailty. Physiology (Bethesda) 2023; 38:0. [PMID: 37738019 DOI: 10.1152/physiol.00011.2023] [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: 04/27/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 09/23/2023] Open
Abstract
Acute kidney frailty is a premorbid condition of diminished renal functional reserve that predisposes to acute kidney injury; this condition results from subclinical wear or distortion of renal homeostatic responses that protect the renal excretory function. Knowledge of its pathophysiological basis is critical for the development of diagnostic and therapeutic strategies that allow for prophylactic intervention and disease prevention.
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Affiliation(s)
- Sandra M Sancho-Martínez
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Departamento de Fisiología y Farmacología, Universidad de Salamanca, Salamanca, Spain
- Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain
- National Network for Kidney Research RICORS2040 RD21/0005/0004, Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco J López-Hernández
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Departamento de Fisiología y Farmacología, Universidad de Salamanca, Salamanca, Spain
- Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain
- National Network for Kidney Research RICORS2040 RD21/0005/0004, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Estudios de Ciencias de la Salud de Castilla y León (IECSCYL), Soria, Spain
- Group of Biomedical Research on Critical Care (BioCritic), Valladolid, Spain
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4
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Diagnosis of Cardiac Surgery-Associated Acute Kidney Injury: State of the Art and Perspectives. J Clin Med 2022; 11:jcm11154576. [PMID: 35956190 PMCID: PMC9370029 DOI: 10.3390/jcm11154576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/26/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022] Open
Abstract
Diagnosis of cardiac surgery-associated acute kidney injury (CSA-AKI), a syndrome of sudden renal dysfunction occurring in the immediate post-operative period, is still sub-optimal. Standard CSA-AKI diagnosis is performed according to the international criteria for AKI diagnosis, afflicted with insufficient sensitivity, specificity, and prognostic capacity. In this article, we describe the limitations of current diagnostic procedures and of the so-called injury biomarkers and analyze new strategies under development for a conceptually enhanced diagnosis of CSA-AKI. Specifically, early pathophysiological diagnosis and patient stratification based on the underlying mechanisms of disease are presented as ongoing developments. This new approach should be underpinned by process-specific biomarkers including, but not limited to, glomerular filtration rate (GFR) to other functions of renal excretion causing GFR-independent hydro-electrolytic and acid-based disorders. In addition, biomarker-based strategies for the assessment of AKI evolution and prognosis are also discussed. Finally, special focus is devoted to the novel concept of pre-emptive diagnosis of acquired risk of AKI, a premorbid condition of renal frailty providing interesting prophylactic opportunities to prevent disease through diagnosis-guided personalized patient handling. Indeed, a new strategy of risk assessment complementing the traditional scores based on the computing of risk factors is advanced. The new strategy pinpoints the assessment of the status of the primary mechanisms of renal function regulation on which the impact of risk factors converges, namely renal hemodynamics and tubular competence, to generate a composite and personalized estimation of individual risk.
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Changing serum creatinine in the detection of acute renal failure and recovery following radiocontrast studies among acutely ill inpatients: Reviewing insights regarding renal functional reserve gained by large-data analysis. Pract Lab Med 2022; 30:e00276. [PMID: 35509950 PMCID: PMC9059065 DOI: 10.1016/j.plabm.2022.e00276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/31/2022] [Accepted: 04/13/2022] [Indexed: 11/20/2022] Open
Abstract
A rise in serum creatinine (SCr) is widely used for the detection and definition of evolving acute kidney injury (AKI). Yet, it takes time for SCr to re-adjust in response to changes in glomerular filtration rate (GFR), and subtle transient changes in GFR may remain concealed. Additionally, it cannot differentiate altered glomerular hemodynamics and pre-renal failure from true renal tissue injury, necessitating additional clinical and laboratory diagnostic tools. While these features limit the usefulness of SCr and subsequently estimated GFR (eGFR) at a single time point for the individual patient, their overall pattern of changes along time in a large cohort of hospitalized patients may provide a powerful perspective regarding the detection and assessment of shifting kidney function in this population. Herein we review our experience running large data analyses, evaluating patterns of day-to-day changes in SCr among inpatients, occurring around the exposure to iodinated radiocontrast agents. These large data evaluations helped substantiating the existence of contrast-induced nephropathy in patients with advanced renal failure, underscoring the impact of predisposing and confounding factors. It also provides novel insights regarding a phenomenon of "acute kidney functional recovery” (AKR), and illustrate that the incidence of AKI and AKR along the scale of baseline kidney function co-associates and is inversely proportional to kidney function. This can be attributed to renal functional reserve, which serves as a buffer for up-and-down changes in GFR, forming the physiologic explanation for concealed subclinical AKI.
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6
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Grattan-Smith JD, Chow J, Kurugol S, Jones RA. Quantitative renal magnetic resonance imaging: magnetic resonance urography. Pediatr Radiol 2022; 52:228-248. [PMID: 35022851 PMCID: PMC9670866 DOI: 10.1007/s00247-021-05264-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/16/2021] [Accepted: 12/10/2021] [Indexed: 02/03/2023]
Abstract
The goal of functional renal imaging is to identify and quantitate irreversible renal damage and nephron loss, as well as potentially reversible hemodynamic changes. MR urography has evolved into a comprehensive evaluation of the urinary tract that combines anatomical imaging with functional evaluation in a single test without ionizing radiation. Quantitative functional MR imaging is based on dynamic contrast-enhanced MR acquisitions that provide progressive, visible enhancement of the renal parenchyma and urinary tract. The signal changes related to perfusion, concentration and excretion of the contrast agent can be evaluated using both quantitative and qualitative measures. Functional evaluation with MR has continued to improve as a result of significant technical advances allowing for faster image acquisition as well as the development of new tracer kinetic models of renal function. The most common indications for MR urography in children are the evaluation of congenital anomalies of the kidney and urinary tract including hydronephrosis and renal malformations, and the identification of ectopic ureters in children with incontinence. In this paper, we review the underlying acquisition schemes and techniques used to generate quantitative functional parameters including the differential renal function (DRF), asymmetry index, mean transit time (MTT), signal intensity versus time curves as well as the calculation of individual kidney glomerular filtration rate (GFR). Visual inspection and semi-quantitative assessment using the renal transit time (RTT) and calyceal transit times (CTT) are fundamental to accurate diagnosis and are used as a basis for the interpretation of the quantitative data. The importance of visual assessment of the images cannot be overstated when analyzing the quantitative measures of renal function.
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Affiliation(s)
| | - Jeanne Chow
- Department of Radiology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Sila Kurugol
- Department of Radiology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Richard A Jones
- Department of Radiology, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
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7
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Caravaca Pérez P, Nuche J, López-Azor JC, Salguero-Bodes R, Arribas Ynsaurriaga F, Delgado JF. Response by Caravaca Pérez et al to Letter Regarding Article, "Potential Role of Natriuretic Response to Furosemide Stress Test During Acute Heart Failure". Circ Heart Fail 2021; 15:e009258. [PMID: 34963307 DOI: 10.1161/circheartfailure.121.009258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Pedro Caravaca Pérez
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.).,Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares, Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.).,Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.)
| | - Jorge Nuche
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.).,Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares, Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.).,Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (J.N.).,Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.)
| | - Juan Carlos López-Azor
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.).,Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares, Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.).,Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.)
| | - Rafael Salguero-Bodes
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.).,Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares, Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.).,Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.).,Facultad de Medicina, Universidad Complutense de Madrid, Spain (R.S.-B., F.A.Y., J.F.D.)
| | - Fernando Arribas Ynsaurriaga
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.).,Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares, Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.).,Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.).,Facultad de Medicina, Universidad Complutense de Madrid, Spain (R.S.-B., F.A.Y., J.F.D.)
| | - Juan F Delgado
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.).,Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares, Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.).,Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain (P.C.P., J.N., J.C.L.-A., R.S.-B., F.A.Y., J.F.D.).,Facultad de Medicina, Universidad Complutense de Madrid, Spain (R.S.-B., F.A.Y., J.F.D.)
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8
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Gorelik Y, Khamaisi M, Abassi Z, Evans RG, Heyman SN. Renal functional recovery among inpatients: A plausible marker of reduced renal functional reserve. Clin Exp Pharmacol Physiol 2021; 48:1724-1727. [PMID: 34545593 DOI: 10.1111/1440-1681.13545] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/07/2021] [Accepted: 05/28/2021] [Indexed: 11/30/2022]
Abstract
Renal functional reserve (RFR) reflects the ability of the kidney to enhance glomerular filtration rate (GFR) in response to a protein load. Chronic kidney disease (CKD) leads to diminished RFR, since the capacity for whole-body GFR to increase through hyperfiltration of remaining nephrons is limited. Evaluating 41,456 inpatients following computerised tomography we reported many exhibiting acute kidney injury (AKI) but more patients with recovering kidney function (AKR), presumably reflecting resolution of their critical conditions. The incidences of AKI and AKR were closely co-associated and were both inversely correlated with baseline kidney function. We discuss this phenomenon, arguing that AKR among inpatients with an acute illness, like AKI, may often reflect underlying subtle CKD with diminished RFR.
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Affiliation(s)
- Yuri Gorelik
- Department of Medicine D, Rambam Health Care Campus and Ruth & Bruce Rappaport Faculty of Medicine, Technion-IIT, Haifa, Israel
| | - Mogher Khamaisi
- Department of Medicine D, Rambam Health Care Campus and Ruth & Bruce Rappaport Faculty of Medicine, Technion-IIT, Haifa, Israel
| | - Zaid Abassi
- Department of Physiology and Biophysics, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Vic, Australia
| | - Samuel N Heyman
- Department of Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
- Herzog Hospital, Jerusalem, Israel
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9
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Fuhrman D. The use of diagnostic tools for pediatric AKI: applying the current evidence to the bedside. Pediatr Nephrol 2021; 36:3529-3537. [PMID: 33492454 PMCID: PMC8813176 DOI: 10.1007/s00467-021-04940-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/08/2020] [Accepted: 01/08/2021] [Indexed: 12/17/2022]
Abstract
Given the known deleterious consequences of acute kidney injury (AKI), exciting recent research efforts have focused on developing strategies for the earlier recognition of AKI in the pediatric population. Recognizing the limitations of serum creatinine, investigators have focused on the study of novel biomarkers and practical bedside tools for identifying patients at risk for AKI prior to a rise in serum creatinine. In PubMed, there are presently over 30 original research papers exploring the use of pediatric AKI risk prediction tools in just the last 2 years. The following review highlights the most recent advances in the literature regarding opportunities to refine our ability to detect AKI early. Importantly, this review discusses how prediction tools including novel urine and serum biomarkers, practical risk stratification tests, renal functional reserve, and electronic medical record alerts may ultimately be applied to routine clinical practice.
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Affiliation(s)
- Dana Fuhrman
- Department of Critical Care Medicine, Department of Pediatrics, Division of Nephrology, The Center for Critical Care Nephrology, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
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10
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Luo Z, Liu Y, Tang Z, Liu J, Xu X, Li M, Dai Y. Quantitative Evaluation of Renal Cortex Perfusion Using Contrast-Enhanced Ultrasound Imaging Parameters in Ischemia-Reperfusion Injury in Rabbits. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:3253-3262. [PMID: 34400032 DOI: 10.1016/j.ultrasmedbio.2021.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/18/2021] [Accepted: 07/16/2021] [Indexed: 06/13/2023]
Abstract
The aim of this study was to evaluate blood perfusion of the renal cortex during ischemia-reperfusion (I/R) injury using quantitative contrast-enhanced ultrasound (CEUS) parameters. In this experiment, 24 rabbits were randomly divided into four groups (N = 6): sham-operated group, 24-h post-operation for I/R injury group (24-h I/R), 3-d post-operation for I/R injury group (3-d I/R) and 5 d post-operation for I/R injury group (5 d I/R). All quantitative CEUS parameters were monitored and included the gradient from the start frame to the peak frame (Grad), area under the curve (Area), time-to-peak (TTP), difference between B(intercept intensity at t=0) and A(the intensity attenuation t= 0) and arrival time (AT). Subsequently, we analyzed the changes in these parameters, as well as the correlation between changes in CEUS parameters and pathological parameters. AT and TTP values peaked 3 d after I/R surgery, which correlated with the most significant pathological changes at the same time point. These parameters (such as AT, TTP and Grad) may be useful in dynamically monitoring the severity of tissue damage at the early stage of I/R injury.
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Affiliation(s)
- Zhijian Luo
- Department of Ultrasound, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Yulu Liu
- Department of Medical Imaging, Southwest Medical University, Luzhou, Sichuan Province, China
| | - Ziyi Tang
- Department of Medical Imaging, Southwest Medical University, Luzhou, Sichuan Province, China
| | - Jialing Liu
- Department of Medical Imaging, Southwest Medical University, Luzhou, Sichuan Province, China
| | - Xuemei Xu
- Department of Medical Imaging, Southwest Medical University, Luzhou, Sichuan Province, China
| | - Mingxing Li
- Department of Ultrasound, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Yan Dai
- Department of Nuclear Medicine, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China; Department of Pharmacy, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China; Department of Ultrasound, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China.
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11
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Musiał K, Zwolińska D. Bone Morphogenetic Proteins (BMPs), Extracellular Matrix Metalloproteinases Inducer (EMMPRIN), and Macrophage Migration Inhibitory Factor (MIF): Usefulness in the Assessment of Tubular Dysfunction Related to Chronic Kidney Disease (CKD). J Clin Med 2021; 10:jcm10214893. [PMID: 34768412 PMCID: PMC8585016 DOI: 10.3390/jcm10214893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 11/28/2022] Open
Abstract
Bone morphogenetic proteins (BMP), extracellular matrix metalloproteinases inducer (EMMPRIN), and macrophage migration inhibitory factor (MIF) are known to be closely connected to renal tubule damage by experimental data; however, this has not been analyzed in children with chronic kidney disease (CKD). The aim of this study was to determine their usefulness in the assessment of CKD-related tubular dysfunction. The study group consisted of 61 children with CKD stages 1–5 and 23 controls. The serum and urine concentrations of BMP-2, BMP-6, EMMPRIN, and MIF were assessed by ELISA and their fractional excretion (FE) was calculated. The serum and urine concentrations of BMP-2, BMP-6, EMMPRIN, and MIF were significantly elevated in children with CKD vs. controls. The FE of BMP-2, FE BMP-6, and EMMPRIN increased significantly in CKD stages 1–2, but exceeded 1% in CKD stages 3–5. FE MIF became higher than in controls no sooner than in CKD 3–5, but remained below 1%. The FE values for BMP-2, BMP-6, and EMMPRIN of <1% may result from the tubular adaptive mechanisms, whereas those surpassing 1% suggest irreversible tubular damage. The analysis of serum/urinary concentrations and fractional excretion of examined parameters may allow the assessment of CKD-related tubular dysfunction.
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Yang SY, Chiou TTY, Shiao CC, Lin HYH, Chan MJ, Wu CH, Sun CY, Wang WJ, Huang YT, Wu VC, Chen YC, Fang JT, Hwang SJ, Pan HC. Nomenclature and diagnostic criteria for acute kidney injury - 2020 consensus of the Taiwan AKI-task force. J Formos Med Assoc 2021; 121:749-765. [PMID: 34446340 DOI: 10.1016/j.jfma.2021.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 06/23/2021] [Accepted: 08/06/2021] [Indexed: 12/31/2022] Open
Abstract
Acute kidney injury (AKI) is a common syndrome that has a significant impact on prognosis in various clinical settings. To evaluate whether new evidence supports changing the current definition/classification/staging systems for AKI suggested by the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline, the Taiwan AKI-TASK Force, composed of 64 experts in various disciplines, systematically reviewed the literature and proposed recommendations about the current nomenclature and diagnostic criteria for AKI. The Taiwan Acute Kidney Injury (TW-AKI) Consensus 2020 was established following the principles of evidence-based medicine to investigate topics covered in AKI guidelines. The Taiwan AKI-TASK Force determined that patients with AKI have a higher risk of developing chronic kidney disease, end-stage renal disease, and death. After a comprehensive review, the TASK Force recommended using novel biomarkers, imaging examinations, renal biopsy, and body fluid assessment in the diagnosis of AKI. Clinical issues with regards to the definitions of baseline serum creatinine (sCr) level and renal recovery, as well as the use of biomarkers to predict renal recovery are also discussed in this consensus. Although the present classification systems using sCr and urine output for the diagnosis of AKI are not perfect, there is not enough evidence to change the current criteria in clinical practice. Future research should investigate and clarify the roles of the aforementioned tools in clinical practice for AKI.
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Affiliation(s)
- Shao-Yu Yang
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Terry Ting-Yu Chiou
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan; Chung Shan Medical University School of Medicine, Taichung, Taiwan
| | - Chih-Chung Shiao
- Division of Nephrology, Department of Internal Medicine, Camillians Saint Mary's Hospital Luodong, Saint Mary's Junior College of Medicine, Nursing and Management, Luodong, Taiwan; Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan
| | - Hugo You-Hsien Lin
- Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan; Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Jen Chan
- Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Che-Hsiung Wu
- Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan
| | - Chiao-Yin Sun
- Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Wei-Jie Wang
- Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Division of Nephrology, Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Vin-Cent Wu
- Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yung-Chang Chen
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Ji-Tsung Fang
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Shang-Jyh Hwang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Heng-Chih Pan
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan.
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13
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Conceptual advances and evolving terminology in acute kidney disease. Nat Rev Nephrol 2021; 17:493-502. [PMID: 33712812 DOI: 10.1038/s41581-021-00410-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 01/31/2023]
Abstract
Over the past decade, new insights into epidemiology, pathophysiology and biomarkers have modified our understanding of acute kidney dysfunction and damage, and their association with subsequent chronic kidney disease. The concept of acute kidney injury (AKI), which has relied on established but nonetheless flawed biomarkers of solute clearance (serum creatinine levels and urinary output), has been challenged by the identification of novel biomarkers of tubular stress and/or damage. The expression of some of these novel biomarkers precedes changes in conventional biomarkers or can increase their predictive power, and might therefore enhance the clinical accuracy of the definition of AKI. In addition, the need to consider AKI recurrence, duration and progression to chronic kidney disease within the clinical and epidemiological framework of AKI led to the emergence of the concept of acute kidney disease. New definitions of acute syndromes of kidney impairment and injury are needed.
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14
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Samoni S, Villa G, De Rosa S, Husain-Syed F, Guglielmetti G, Tofani L, De Cal M, Nalesso F, Meola M, Ronco C. Ultrasonographic Intraparenchymal Renal Resistive Index Variation for Assessing Renal Functional Reserve in Patients Scheduled for Cardiac Surgery: A Pilot Study. Blood Purif 2021; 51:147-154. [PMID: 34044391 DOI: 10.1159/000516438] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/09/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication in patients undergoing cardiac surgery. Preoperative renal functional reserve (RFR) has been demonstrated to be highly predictive of CSA-AKI. We have previously demonstrated that intraparenchymal renal resistive index variation (IRRIV) measured by ultrasound (US) can identify the presence of RFR in healthy individuals. This study aimed (1) to examine the correlation between the US IRRIV test and RFR measured through the protein loading test in patients undergoing elective cardiac surgery and (2) to determine the value of the 2 methods for predicting occurrence of AKI or subclinical AKI after cardiac surgery. METHODS Consecutive patients scheduled for cardiac surgery were enrolled for this pilot study. The protein loading test and the IRRIV test were performed in all patients 2 days before cardiac surgery. Correlation between IRRIV and RFR was tested using Pearson correlation analysis. Association between presence of RFR and positive IRRIV test, presence of RFR and AKI and subclinical AKI, and positive IRRIV test and AKI and subclinical AKI was evaluated using logistic regression analysis. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the values of IRRIV for predicting RFR, RFR for predicting AKI and subclinical AKI, and IRRIV for predicting AKI and subclinical AKI. RESULTS Among the 31 patients enrolled, significant association was found between IRRIV and RFR (r = 0.81; 95% CI: 0.63-0.90; p < 0.01). The association between RFR and IRRIV was described in 27/31 (87.1%) patients. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the IRRIV test were 100, 84, 60, and 100%, respectively. In ROC curve analysis, the area under the curve (AUC) was 0.80 (95% CI: 0.64-0.96). After cardiac surgery, 1/31 (3.2%) patient had AKI and 12/31 (38.7%) had subclinical AKI. RFR predicted subclinical AKI (odds ratio [OR] = 0.93; 95% CI: 0.87-0.98; p = 0.02). The sensitivity, specificity, PPV, and NPV of the RFR were 61, 88.8, 80, and 76%, respectively; the AUC was 0.75 (95% CI: 0.59-0.91). IRRIV predicts subclinical AKI (OR = 0.79; 95% CI: 0.67-0.93; p = 0.005). The sensitivity, specificity, PPV, and NPV of the IRRIV test were 46.1, 100, 100, and 72%, respectively; the AUC was 0.73 (95% CI: 0.58-0.87). CONCLUSION This pilot study suggests that a positive IRRIV test can significantly predict the presence of RFR in patients scheduled for cardiac surgery. RFR measured by the protein loading test or by the US IRRIV test can predict the occurrence of subclinical postoperative AKI. The findings of this study need to be confirmed in large patient cohorts.
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Affiliation(s)
- Sara Samoni
- Department of Nephrology and Dialysis, ASST Lariana, S. Anna Hospital, Como, Italy
| | - Gianluca Villa
- Department of Anesthesia and Intensive Care, Section of Oncological Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Silvia De Rosa
- Department of Anesthesia and Intensive Care, San Bortolo Hospital, Vicenza, Italy
| | - Faeq Husain-Syed
- Department of Internal Medicine II, Division of Nephrology, Pulmonology and Critical Care Medicine, University Hospital Giessen and Marburg, Giessen, Germany
| | - Gabriele Guglielmetti
- Department of Translational Medicine, Nephrology and Kidney Transplantation Unit, University of Piemonte Orientale, "Maggiore della Carità" University Hospital, Novara, Italy
| | - Lorenzo Tofani
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Massimo De Cal
- Department of Nephrology, Dialysis and Transplantation and International Renal Research Institute Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - Federico Nalesso
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padua, Padua, Italy
| | - Mario Meola
- Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation and International Renal Research Institute Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy.,Department of Medicine (DIMED), University of Padua, Padua, Italy
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15
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Gorelik Y, Bloch-Isenberg N, Heyman SN, Khamaisi M. Renal Functional Recovery Confounding the Assessment of Contrast Nephropathy: Propensity Score Analysis. Am J Nephrol 2021; 52:76-83. [PMID: 33657555 DOI: 10.1159/000513914] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/17/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Large data analyses confirm the relative safety of contrast-enhanced computed tomography (CT), except for those with advanced renal failure. However, the prevalence of post-contrast acute kidney injury may be masked by acute kidney functional recovery (AKR) in unstable inpatients, irrespective of contrast-enhanced imaging. METHODS In this work we aimed to assess AKI and AKR along with need for dialysis and mortality, among inpatients undergoing contrast-enhanced or non-enhanced CT. We performed a large-scale retrospective data analysis using propensity score matching (PSM) that compared patients undergoing contrast-enhanced and non-enhanced imaging. We also performed a subgroup analysis of subjects stratified by baseline renal function. RESULTS A total of 41,456 patients were analyzed. PSM resulted in well-balanced groups. AKR occurred substantially more often than AKI among hospitalized patients following CT imaging, especially among those with low baseline renal function. Yet, in this population, whereas the rate of AKI significantly increased, the rate of AKR significantly decreased following contrast-enhanced studies as compared to patients that underwent non-enhanced CT. A significantly higher proportion of patients with baseline advanced renal failure that underwent contrast-enhanced imaging required dialysis. CONCLUSIONS The increased incidence of AKI and AKR as seen in patients with lower pre-imaging kidney function possibly suggests that both entities reflect impaired renal functional reserve. Unstable kidney function in inpatients, as demonstrated by rates of AKR and AKI, is an important confounder which requires attention in similar observational studies on the renal effects of contrast media and of various other renal injurious events.
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Affiliation(s)
- Yuri Gorelik
- Department of Medicine D, Rambam Health Care Campus and Ruth & Bruce Rappaport Faculty of Medicine, Technion-IIT, Haifa, Israel
| | - Natalie Bloch-Isenberg
- Department of Medicine D, Rambam Health Care Campus and Ruth & Bruce Rappaport Faculty of Medicine, Technion-IIT, Haifa, Israel
| | - Samuel N Heyman
- Department of Medicine, Hadassah Hebrew University Hospital, Mt. Scopus, Jerusalem, Israel
| | - Mogher Khamaisi
- Department of Medicine D, Rambam Health Care Campus and Ruth & Bruce Rappaport Faculty of Medicine, Technion-IIT, Haifa, Israel,
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16
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Cantaluppi V, Guglielmetti G, Dellepiane S, Marengo M, Mehta RL, Ronco C. A call to action to evaluate renal functional reserve in patients with COVID-19. Am J Physiol Renal Physiol 2020; 319:F792-F795. [PMID: 32969711 PMCID: PMC7641895 DOI: 10.1152/ajprenal.00245.2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/19/2020] [Accepted: 09/07/2020] [Indexed: 12/27/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) poses an unprecedented challenge to world health systems, substantially increasing hospitalization and mortality rates in all affected countries. Being primarily a respiratory disease, COVID-19 is mainly associated with pneumonia or minor upper respiratory tract symptoms; however, different organs can sustain considerable (if not terminal) damage because of coronavirus. Acute kidney injury is the most common complication of COVID-19-related pneumonia, and more than 20% of patients requiring ventilatory support develop renal failure. Additionally, chronic kidney disease is a major risk factor for COVID-19 severity and mortality. All these data demonstrate the relevance of renal function assessment in patients with COVID-19 and the need of early kidney-directed diagnostic and therapeutic approaches. However, the sole assessment of renal function could be not entirely indicative of kidney tissue status. In this viewpoint, we discuss the clinical significance and potential relevance of renal functional reserve evaluation in patients with COVID-19.
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Affiliation(s)
- Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale, "Maggiore della Carità" University Hospital, Novara, Italy
| | - Gabriele Guglielmetti
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale, "Maggiore della Carità" University Hospital, Novara, Italy
| | - Sergio Dellepiane
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale, "Maggiore della Carità" University Hospital, Novara, Italy
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Ravindra L Mehta
- Department of Medicine, University of California, San Diego, California
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padova, Italy
- Division of Nephrology, Dialysis and Kidney Transplantation Unit, International Renal Research Institute Vicenza, "San Bortolo" Hospital, Vicenza, Italy
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17
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Chapman CL, Johnson BD, Parker MD, Hostler D, Pryor RR, Schlader Z. Kidney physiology and pathophysiology during heat stress and the modification by exercise, dehydration, heat acclimation and aging. Temperature (Austin) 2020; 8:108-159. [PMID: 33997113 PMCID: PMC8098077 DOI: 10.1080/23328940.2020.1826841] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/17/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
The kidneys' integrative responses to heat stress aid thermoregulation, cardiovascular control, and water and electrolyte regulation. Recent evidence suggests the kidneys are at increased risk of pathological events during heat stress, namely acute kidney injury (AKI), and that this risk is compounded by dehydration and exercise. This heat stress related AKI is believed to contribute to the epidemic of chronic kidney disease (CKD) occurring in occupational settings. It is estimated that AKI and CKD affect upwards of 45 million individuals in the global workforce. Water and electrolyte disturbances and AKI, both of which are representative of kidney-related pathology, are the two leading causes of hospitalizations during heat waves in older adults. Structural and physiological alterations in aging kidneys likely contribute to this increased risk. With this background, this comprehensive narrative review will provide the first aggregation of research into the integrative physiological response of the kidneys to heat stress. While the focus of this review is on the human kidneys, we will utilize both human and animal data to describe these responses to passive and exercise heat stress, and how they are altered with heat acclimation. Additionally, we will discuss recent studies that indicate an increased risk of AKI due to exercise in the heat. Lastly, we will introduce the emerging public health crisis of older adults during extreme heat events and how the aging kidneys may be more susceptible to injury during heat stress.
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Affiliation(s)
- Christopher L. Chapman
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Human Physiology, University of Oregon, Eugene, OR, USA
| | - Blair D. Johnson
- Department of Kinesiology, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Mark D. Parker
- Department of Physiology and Biophysics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Ophthalmology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - David Hostler
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY, USA
| | - Riana R. Pryor
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY, USA
| | - Zachary Schlader
- Department of Kinesiology, School of Public Health, Indiana University, Bloomington, IN, USA
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18
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Damianaki K, Burnier M, Dimitriadis K, Tsioufis C, Petras D. Renal Functional Reserve Is Related to the Nondipping Phenotype and to the Exercise Heart Rate Response in Patients with Essential Hypertension and Preserved Renal Function. Kidney Blood Press Res 2020; 45:737-747. [PMID: 32784307 DOI: 10.1159/000508939] [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: 01/08/2020] [Accepted: 05/25/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Renal functional reserve (RFR), defined as the difference between stress and resting glomerular filtration rate (GFR), may constitute a diagnostic tool to identify patients at higher risk of developing acute kidney injury or chronic kidney disease. Blunted RFR has been demonstrated in early stages of hypertension and has been attributed to impaired vascular reactivity due to an overactive sympathetic nervous system (SNS). OBJECTIVE The purpose of this study was to investigate whether RFR correlates with other phenotypes expressing overactivity of the SNS in patients with essential hypertension and preserved renal function. METHODS Thirty-six patients with untreated essential hypertension and a GFR >60 mL/min/1.73 m2 were enrolled. The following parameters were measured: RFR, 24-h ambulatory blood pressure (BP) profile, a treadmill stress test, and an echocardiographic examination. Urine and venous samples were obtained at specific time points for the determination of clinical parameters, and both resting and stress GFR were calculated by using endogenous creatinine clearance for the measurement of RFR after an acute oral protein load (1 g/kg). RESULTS Twenty-one patients had a RFR <30 mL/min/1.73 m2 and 15 had a RFR above this cutoff. A nondipping pattern of 24-h BP was significantly more frequent in patients with low RFR (57.1 vs. 25.0%, p < 0.05 for systolic BP and 52.3 vs. 10.0%, p < 0.02 for diastolic BP). Moreover, patients with lower RFR values showed a blunted heart rate (HR) response to exercise during treadmill test (r = 0.439, p < 0.05). None of the echocardiographic parameters differed between the two groups of patients. CONCLUSIONS In hypertensive patients with preserved GFR, reduced RFR is related to nondipping BP phenotype as well as to attenuated exercise HR response. Overactivity of the SNS may be a common pathway. Since loss of RFR may represent a risk factor for acute or chronic kidney injury, hypertensive patients with blunted RFR might need a more careful renal follow-up.
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Affiliation(s)
- Katerina Damianaki
- Service of Nephrology, University Hospital of Athens, Hippokration Hospital, Athens, Greece,
| | - Michel Burnier
- Service of Nephrology and Hypertension, University Hospital of Lausanne, Lausanne, Switzerland
| | - Kyriakos Dimitriadis
- First Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
| | - Costas Tsioufis
- First Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
| | - Dimitrios Petras
- Service of Nephrology, University Hospital of Athens, Hippokration Hospital, Athens, Greece
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19
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The relationship between intra-parenchymal renal resistive index variation and renal functional reserve in healthy subjects. J Nephrol 2020; 34:403-409. [PMID: 32602005 DOI: 10.1007/s40620-020-00786-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 06/20/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Renal functional reserve can be used as a clinical tool for risk stratification of patients undergoing potentially nephrotoxic procedures. Ultrasound assessment of intra-parenchymal renal resistive index variation-IRRIV test-has been recently proposed as a safe, reproducible, inexpensive and easy to perform technique to identify the presence of renal functional reserve. The present study has been designed to externally validate the IRRIV test in a validation cohort of healthy subjects. METHODS We examined data from a group of 47 healthy subjects undergoing protein loading and IRRIV testing. The correlation between IRRIV and renal functional reserve was tested using Pearson correlation analysis. Concordance between presence of renal functional reserve (i.e. a value of renal functional reserve ≥ 15 ml/min/1.73 m2) and IRRIV was evaluated using logistic regression analysis. RESULTS We found a significant correlation between IRRIV and renal functional reserve (Pearson correlation coefficient = 0.83 [95% confidence interval (CI) 0.71-0.90; p < 0.01]). Concordance between the presence of renal functional reserve and the IRRIV test was described in 45 (95.7%) subjects. In particular, a negative IRRIV test correctly predicted the absence of renal functional reserve in 5 subjects, while a positive IRRIV test correctly predicted the presence of renal functional reserve in 40 subjects. Only two subjects were incorrectly classified by the IRRIV test. IRRIV predicts renal functional reserve with a ROC-AUC of 0.86 [CI 95% 0.68-1]. CONCLUSIONS The IRRIV test is an ultrasound technique that significantly predicts the presence and the degree of renal functional reserve in healthy subjects.
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20
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Lillås BS, Tøndel C, Gjerde A, Vikse BE. Measurement of renal functional response using iohexol clearance-a study of different outpatient procedures. Clin Kidney J 2019; 14:181-188. [PMID: 33564417 PMCID: PMC7857819 DOI: 10.1093/ckj/sfz167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 10/21/2019] [Indexed: 11/14/2022] Open
Abstract
Background Glomerular filtration rate (GFR) increases after a heavy protein load; an increase termed renal functional response (RFR). Decreased RFR could be a marker of early kidney damage, but published methods are cumbersome in the outpatient setting. The present study investigates the use of iohexol clearance to measure RFR in outpatients using both one- and two-sample methods. Methods Fourteen healthy volunteers with a mean ± SD age of 42 ± 12 years were included (six males and eight females). GFR was measured using plasma iohexol clearance with one- and two-sample methodologies. Four measurements in each individual were performed: one baseline test and three protein loading tests containing 80 g protein (commercially available protein supplementations from Myo Nutrition and Proteinfabrikken and 350 g chicken breast). RFR was calculated as percentage increase in GFR from the baseline test. Results Mean RFR was 11.4 ± 5.4% and 12.1 ± 6.4% using one- and two-sample methods, respectively. The three different protein loads resulted in similar mean RFR but there was considerable intra-individual variability. One- and two-sample methods for measurement of RFR showed similar results with near-identical means, but there was some intra-individual variation that was similar for different protein loads. The overall 95% limit of agreement between one- and two-sample methods for calculating RFR was -8.7 to 7.3. Conclusions RFR can be investigated using plasma iohexol clearance in an outpatient setting. Protocols using commercially available protein supplementation showed a mean RFR of about 12%. One- and two-sample methods for measuring RFR yield similar results.
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Affiliation(s)
- Bjørn Steinar Lillås
- Department of Medicine, Haugesund Hospital, Haugesund, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Camilla Tøndel
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Anna Gjerde
- Department of Medicine, Haugesund Hospital, Haugesund, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Bjørn Egil Vikse
- Department of Medicine, Haugesund Hospital, Haugesund, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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21
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Macedo E, Lima C. Comprehensive Assessment of Kidney Health in Acute Kidney Injury: Can It Be Achieved? Nephron Clin Pract 2019; 143:188-192. [PMID: 31533119 PMCID: PMC6821574 DOI: 10.1159/000502381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/25/2019] [Indexed: 12/27/2022] Open
Abstract
Acute kidney injury (AKI) is a frequent event in hospitalized patients, with an incidence that continues to rise, reaching as high as 70-80% in intensive care settings. The need for dialysis and progression to end-stage kidney disease (ESKD) after an episode of AKI is relatively low, from 5 to 20%. However, it is now recognized that patients with AKI may have very different kidney outcomes, varying from complete recovery, incipient chronic kidney disease (CKD), to progression to ESKD. Recent studies have shown that even mild AKI episodes can be associated with a 90% increased risk of developing CKD during long-term follow-up. There is a significant need to focus our efforts on factors that could mitigate the progression of kidney dysfunction and ultimately improve outcomes from AKI. The first step toward this goal encompasses a better understanding of tubular and glomerular alterations during and following an AKI episode. Our current approach, based solely on glomerular filtration rate (GFR), is flawed, since the loss of kidney function does not correspond to the degree of decline in estimated GFR (eGFR), and eGFR does not reflect tubular function. Changes in tubular concentration, reabsorptive and secretory capacity are recognized in AKI; however, they have not been incorporated in clinical assessments of overall kidney function. Here we review a few candidates to assess glomerular filtration/permeability, tubular dysfunction, and injury and how we expect these markers to alter during the development and recovery phase of AKI.
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Affiliation(s)
- Etienne Macedo
- Division of Nephrology, Department of Medicine, University of California San Diego, San Diego, California, USA,
- LIM 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil,
| | - Camila Lima
- LIM 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil
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22
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Kluger AY, Tecson KM, Lee AY, Lerma EV, Rangaswami J, Lepor NE, Cobble ME, McCullough PA. Class effects of SGLT2 inhibitors on cardiorenal outcomes. Cardiovasc Diabetol 2019; 18:99. [PMID: 31382965 PMCID: PMC6683461 DOI: 10.1186/s12933-019-0903-4] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 07/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To summarize the four recent sodium-glucose cotransporter 2 inhibitor (SGLT2i) trials: Dapagliflozin Effect on CardiovascuLAR Events (DECLARE-TIMI 58), CANagliflozin CardioVascular Assessment Study (CANVAS) Program, Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients-Removing Excess Glucose (EMPA-REG OUTCOME), Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE), and explore the potential determinants for their cardiovascular, renal, and safety outcomes. RESULTS The composite renal outcome event rates per 1000 patient-years for drug and placebo, as well as the corresponding relative risk reductions, were 3.7, 7.0, 47%; 5.5, 9.0, 40%; 6.3, 11.5, 46%; 43.2, 61.2, 30% for DECLARE-TIMI 58, CANVAS, EMPA-REG OUTCOME, and CREDENCE, respectively (event definitions varied across trials). The major adverse cardiovascular (CV) event rates per 1000 patient-years for drug and placebo, as well as the corresponding relative risk reductions, were 22.6, 24.2, 7%; 26.9, 31.5, 14%; 37.4, 43.9, 14%; 38.7, 48.7, 20% for DECLARE-TIMI 58, CANVAS, EMPA-REG OUTCOME, and CREDENCE, respectively. DECLARE-TIMI 58 had the fewest cardiorenal events and CREDENCE the most. These differences were presumably due to varying inclusion criteria resulting in DECLARE-TIMI 58 having the best baseline renal filtration function and CREDENCE the worst (mean estimated glomerular filtration rate 85.2, 76.5, 74, 56.2 mL/min/1.73 m2 for DECLARE-TIMI 58, CANVAS, EMPA-REG OUTCOME, and CREDENCE, respectively). Additionally, CREDENCE had considerably higher rates of albuminuria (median urinary albumin-creatinine ratios (UACR) were 927, 12.3, and 13.1 mg/g for CREDENCE, CANVAS, and DECLARE-TIMI 58, respectively; EMPA-REG OUTCOME had 59.4% UACR < 30, 28.6% UACR > 30-300, 11.0% UACR > 300 mg/g). CONCLUSIONS Dapagliflozin, empagliflozin, and canagliflozin have internally and externally consistent and biologically plausible class effects on cardiorenal outcomes. Baseline renal filtration function and degree of albuminuria are the most significant indicators of risk for both CV and renal events. Thus, these two factors also anticipate the greatest clinical benefit for SGLT2i.
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Affiliation(s)
- Aaron Y Kluger
- Baylor Heart and Vascular Institute, 621 N. Hall #H030, Dallas, TX, 75226, USA.
- Baylor Scott & White Research Institute, Dallas, TX, USA.
| | - Kristen M Tecson
- Baylor Heart and Vascular Institute, 621 N. Hall #H030, Dallas, TX, 75226, USA
- Baylor Scott & White Research Institute, Dallas, TX, USA
- Texas A&M College of Medicine Health Science Center, Dallas, TX, USA
| | - Andy Y Lee
- Baylor University Medical Center, Dallas, TX, USA
- Baylor Heart and Vascular Hospital, Dallas, TX, USA
| | - Edgar V Lerma
- UIC/Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Janani Rangaswami
- Einstein Medical Center, Philadelphia, PA, USA
- Sidney Kimmel College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Norman E Lepor
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Peter A McCullough
- Baylor Heart and Vascular Institute, 621 N. Hall #H030, Dallas, TX, 75226, USA
- Texas A&M College of Medicine Health Science Center, Dallas, TX, USA
- Baylor University Medical Center, Dallas, TX, USA
- Baylor Heart and Vascular Hospital, Dallas, TX, USA
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Husain-Syed F, Ferrari F, Sharma A, Hinna Danesi T, Bezerra P, Lopez-Giacoman S, Samoni S, de Cal M, Corradi V, Virzì GM, De Rosa S, Muciño Bermejo MJ, Estremadoyro C, Villa G, Zaragoza JJ, Caprara C, Brocca A, Birk HW, Walmrath HD, Seeger W, Nalesso F, Zanella M, Brendolan A, Giavarina D, Salvador L, Bellomo R, Rosner MH, Kellum JA, Ronco C. Persistent decrease of renal functional reserve in patients after cardiac surgery-associated acute kidney injury despite clinical recovery. Nephrol Dial Transplant 2019; 34:308-317. [DOI: 10.1093/ndt/gfy227] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
- Faeq Husain-Syed
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
- Department of Internal Medicine II, Division of Pulmonology, Nephrology and Critical Care Medicine, University Clinic Giessen and Marburg—Campus Giessen, Giessen, Germany
| | - Fiorenza Ferrari
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Aashish Sharma
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | | | - Pércia Bezerra
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | | | - Sara Samoni
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Massimo de Cal
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Valentina Corradi
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Grazia Maria Virzì
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Silvia De Rosa
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | | | - Carla Estremadoyro
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Gianluca Villa
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Jose J Zaragoza
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Carlotta Caprara
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Alessandra Brocca
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Horst-Walter Birk
- Department of Internal Medicine II, Division of Pulmonology, Nephrology and Critical Care Medicine, University Clinic Giessen and Marburg—Campus Giessen, Giessen, Germany
| | - Hans-Dieter Walmrath
- Department of Internal Medicine II, Division of Pulmonology, Nephrology and Critical Care Medicine, University Clinic Giessen and Marburg—Campus Giessen, Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine II, Division of Pulmonology, Nephrology and Critical Care Medicine, University Clinic Giessen and Marburg—Campus Giessen, Giessen, Germany
| | - Federico Nalesso
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Monica Zanella
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Alessandra Brendolan
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Davide Giavarina
- Department of Clinical Chemistry and Hematology Laboratory, San Bortolo Hospital, Vicenza, Italy
| | - Loris Salvador
- Department of Cardiac Surgery, San Bortolo Hospital, Vicenza, Italy
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Mitchell H Rosner
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, CRISMA, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
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De Moor B, Vanwalleghem JF, Swennen Q, Stas KJ, Meijers BKI. Haemodynamic or metabolic stimulation tests to reveal the renal functional response: requiem or revival? Clin Kidney J 2018; 11:623-654. [PMID: 30288259 PMCID: PMC6165749 DOI: 10.1093/ckj/sfy022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/26/2018] [Indexed: 12/24/2022] Open
Abstract
Renal stimulation tests document the dynamic response of the glomerular filtration rate (GFR) after a single or a combination of stimuli, such as an intravenous infusion of dopamine or amino acids or an oral protein meal. The increment of the GFR above the unstimulated state has formerly been called the renal functional reserve (RFR). Although the concept of a renal reserve capacity has not withstood scientific scrutiny, the literature documenting renal stimulation merits renewed interest. An absent or a blunted response of the GFR after a stimulus indicates lost or diseased nephrons. This information is valuable in preventing, diagnosing and prognosticating acute kidney injury and pregnancy-related renal events as well as chronic kidney disease. However, before renal function testing is universally practiced, some shortcomings must be addressed. First, a common nomenclature should be decided upon. The expression of RFR should be replaced by renal functional response. Second, a simple protocol must be developed and propagated. Third, we suggest designing prospective studies linking a defective stimulatory response to emergence of renal injury biomarkers, to histological or morphological renal abnormalities and to adverse renal outcomes in different renal syndromes.
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Affiliation(s)
- Bart De Moor
- Faculty of Medicine and Life Sciences, University of Hasselt, Diepenbeek, Belgium
- Department of Nephrology, Jessa Hospital of Hasselt, Hasselt, Belgium
| | | | - Quirine Swennen
- Faculty of Medicine and Life Sciences, University of Hasselt, Diepenbeek, Belgium
| | - Koen J Stas
- Department of Nephrology, Jessa Hospital of Hasselt, Hasselt, Belgium
| | - Björn K I Meijers
- Department of Nephrology, Universitair Ziekenhuis Leuven, Leuven, Belgium
- Department of Immunology and Microbiology, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
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Husain-Syed F, Ferrari F, Sharma A, Danesi TH, Bezerra P, Lopez-Giacoman S, Samoni S, de Cal M, Corradi V, Virzì GM, De Rosa S, Muciño Bermejo MJ, Estremadoyro C, Villa G, Zaragoza JJ, Caprara C, Brocca A, Birk HW, Walmrath HD, Seeger W, Nalesso F, Zanella M, Brendolan A, Giavarina D, Salvador L, Bellomo R, Rosner MH, Kellum JA, Ronco C. Preoperative Renal Functional Reserve Predicts Risk of Acute Kidney Injury After Cardiac Operation. Ann Thorac Surg 2018; 105:1094-1101. [PMID: 29382510 DOI: 10.1016/j.athoracsur.2017.12.034] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/30/2017] [Accepted: 12/12/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although acute kidney injury (AKI) frequently complicates cardiac operations, methods to determine AKI risk in patients without underlying kidney disease are lacking. Renal functional reserve (RFR) can be used to measure the capacity of the kidney to increase glomerular filtration rate under conditions of physiologic stress and may serve as a functional marker that assesses susceptibility to injury. We sought to determine whether preoperative RFR predicts postoperative AKI. METHODS We enrolled 110 patients with normal resting glomerular filtration rates undergoing elective cardiac operation. Preoperative RFR was measured by using a high oral protein load test. The primary end point was the ability of preoperative RFR to predict AKI within 7 days of operation. Secondary end points included the ability of a risk prediction model, including demographic and comorbidity covariates, RFR, and intraoperative variables to predict AKI, and the ability of postoperative cell cycle arrest markers at various times to predict AKI. RESULTS AKI occurred in 15 patients (13.6%). Preoperative RFR was lower in patients who experienced AKI (p < 0.001) and predicted AKI with an area under the receiver operating characteristic curve (AUC) of 0.83 (95% confidence interval [CI]: 0.70 to 0.96). Patients with preoperative RFRs not greater than 15 mL · min-1 · 1.73 m-2 were 11.8 times more likely to experience AKI (95% CI: 4.62 to 29.89 times, p < 0.001). In addition, immediate postoperative cell cycle arrest biomarkers predicted AKI with an AUC of 0.87. CONCLUSIONS Among elective cardiac surgical patients with normal resting glomerular filtration rates, preoperative RFR was highly predictive of AKI. A reduced RFR appears to be a novel risk factor for AKI, and measurement of RFR preoperatively can identify patients who are likely to benefit from preventive measures or to select for use of biomarkers for early detection. Larger prospective studies to validate the use of RFR in strategies to prevent AKI are warranted. ClinicalTrials.gov identifier: NCT03092947, ISRCTN Registry: ISRCTN16109759.
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Affiliation(s)
- Faeq Husain-Syed
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy; Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy; Department of Internal Medicine II, Division of Pulmonology, Nephrology and Critical Care Medicine, University Clinic Giessen and Marburg, Giessen, Germany
| | - Fiorenza Ferrari
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Aashish Sharma
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | | | - Pércia Bezerra
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | | | - Sara Samoni
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Massimo de Cal
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy; Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Valentina Corradi
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy; Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Grazia Maria Virzì
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy; Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Silvia De Rosa
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | | | - Carla Estremadoyro
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Gianluca Villa
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Jose J Zaragoza
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Carlotta Caprara
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Alessandra Brocca
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Horst-Walter Birk
- Department of Internal Medicine II, Division of Pulmonology, Nephrology and Critical Care Medicine, University Clinic Giessen and Marburg, Giessen, Germany
| | - Hans-Dieter Walmrath
- Department of Internal Medicine II, Division of Pulmonology, Nephrology and Critical Care Medicine, University Clinic Giessen and Marburg, Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine II, Division of Pulmonology, Nephrology and Critical Care Medicine, University Clinic Giessen and Marburg, Giessen, Germany
| | - Federico Nalesso
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Monica Zanella
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Alessandra Brendolan
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy; Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Davide Giavarina
- Department of Clinical Chemistry and Hematology Laboratory, San Bortolo Hospital, Vicenza, Italy
| | - Loris Salvador
- Department of Cardiac Surgery, San Bortolo Hospital, Vicenza, Italy
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mitchell H Rosner
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - John A Kellum
- Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy; Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy.
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[New kidney function tests: Renal functional reserve and furosemide stress test]. Med Klin Intensivmed Notfmed 2018; 115:37-42. [PMID: 29327197 DOI: 10.1007/s00063-017-0400-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/06/2017] [Accepted: 12/09/2017] [Indexed: 12/21/2022]
Abstract
Acute kidney injury (AKI) occurs in 30-50% of all intensive care patients. Renal replacement therapy (RRT) has to be initiated in 10-15%. The early in-hospital mortality is about 50%. Up to 20% of all survivors develop chronic kidney disease after intensive care discharge and progress to end-stage kidney disease within the next 10 years. For timely initiation of prophylactic or therapeutic interventions, it is crucial to exactly determine the actual kidney function, i. e., glomerular filtration rate (GFR), and to gain insight into the further development of kidney function. Traditionally, renal function has been estimated using serum levels of creatinine or urea. Unfortunately, both are notoriously unreliable and insensitive in intensive care patients. Cystatin C has fewer non-GFR determinants when compared to creatinine and is more sensitive and accurate to detect early decreases of GFR. At present, new functional tests are discussed, namely the furosemide stress test (FST) and renal functional reserve (RFR). The FST consists of an intravenous infusion of 1.0-1.5 mg/kgBW furosemide to critically ill patients with AKI. An increase in urine output to >100 ml/h is indicative of a GFR >20 ml/min and almost certainly excludes progression to AKI stage III and need for RRT. Estimation of RFR can be made by short-term oral or intravenous administration of a high protein load. A subsequent increase in GFR defines the presence and the magnitude of functional reserve which can be activated. Loss of RFR is an indicator of loss of functioning nephron mass and incomplete recovery following AKI. Both FST and RFR can help to improve diagnosis and care of high-risk patients with acute and chronic kidney disease.
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The role of renal response to amino acid infusion and oral protein load in normal kidneys and kidney with acute and chronic disease. Curr Opin Nephrol Hypertens 2018; 27:23-29. [DOI: 10.1097/mnh.0000000000000380] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Ronco C, Ferrari F, Ricci Z. Recovery after Acute Kidney Injury: A New Prognostic Dimension of the Syndrome. Am J Respir Crit Care Med 2017; 195:711-714. [PMID: 28294655 DOI: 10.1164/rccm.201610-1971ed] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Claudio Ronco
- 1 International Renal Research Institute of Vicenza San Bortolo Hospital Vicenza, Italy.,3 Department of Nephrology, Dialysis, and Transplantation San Bortolo Hospital AULSS8 Berica Vicenza, Italy
| | - Fiorenza Ferrari
- 1 International Renal Research Institute of Vicenza San Bortolo Hospital Vicenza, Italy
| | - Zaccaria Ricci
- 2 Pediatric Cardiac Intensive Care Unit Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico Rome, Italy and
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30
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Cardiac Surgery-Associated Acute Kidney Injury. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0224-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Göcze I, Wiesner C, Schlitt HJ, Bergler T. Renal recovery. Best Pract Res Clin Anaesthesiol 2017; 31:403-414. [PMID: 29248146 DOI: 10.1016/j.bpa.2017.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 08/17/2017] [Indexed: 10/19/2022]
Abstract
Recovery patterns after acute kidney injury (AKI) have increasingly become the focus of research, because currently available preventive measures and specific therapeutic intervention are limited. Moreover, changes in renal functional reserve are recognized as a "hidden" indicator of kidney susceptibility to either acute kidney injury or chronic kidney disease. Understanding these phenomena and their association with outcome may enable the initiation of strategies that facilitate fast and sustained recovery during the time course of AKI and limit AKI progression towards chronic kidney disease. Different interventions may be required during various phases of AKI continuum. Early recognition and prevention of second hit by kidney stress, treatment of cause and prevention of aggravation in the early phase of AKI and facilitation of recovery in the phase of acute kidney disease may together represent the key aspects of modern AKI management.
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Affiliation(s)
- Ivan Göcze
- Department of Surgery and Operative Intensive Care, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany.
| | - Christina Wiesner
- Department of Surgery and Operative Intensive Care, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
| | - Hans J Schlitt
- Department of Surgery and Operative Intensive Care, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
| | - Tobias Bergler
- Department of Nephrology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
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Rodenbach KE, Fuhrman DY, Maier PS, Schwartz GJ. Renal Response to a Protein Load in Healthy Young Adults as Determined by Iohexol Infusion Clearance, Cimetidine-Inhibited Creatinine Clearance, and Cystatin C Estimated Glomerular Filtration Rate. J Ren Nutr 2017; 27:275-281. [PMID: 28389059 DOI: 10.1053/j.jrn.2017.01.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 01/07/2017] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Renal reserve (RR) measures the increase in glomerular filtration rate (GFR) in response to a protein load; lack of RR could indicate subclinical kidney disease but such a test is not routinely used in clinical practice. The purpose of this study was to compare a meat versus liquid protein load in a cystatin C-based (Cys-C) RR test using cimetidine-inhibited creatinine clearance (Cr Cl) and iohexol infusion clearance (Io Cl) for validation. The design was cross-sectional analysis and the setting was a Clinical Research Center. SUBJECTS Participants (N = 16), mean (standard deviation [SD]) age 22 (2) years, had normal health and blood pressure without proteinuria. INTERVENTION Participants 1 to 8 received a beef burger (1 g/kg protein) and participants 9 to 16 received a ProCel shake (1-1.5 g/kg protein). MAIN OUTCOME MEASURE RR defined as the difference in stimulated versus baseline GFR. RESULTS Baseline GFR (SD) in mL/minute/1.73 m2 averaged 103.0 (15.6) for Cr Cl, 94.8 (7.9) for Io Cl, and 117.0 (6.0) for Cys-C estimated GFR (eGFR). Mean RR (SD) for the burger group (N = 8, mL/minute/1.73 m2) was 16.6 (12.3) for Cr Cl (P = .006); 7.2 (3.7) for Io Cl (P < .001), and 4.9 (2.6) for Cys-C eGFR (P = .001). Mean RR for the shake group (N = 8) was 15.8 (5.8) for Cr Cl (P < .001), 10.1 (7.8) for Io Cl (P = .008), and 2.4 (2.9) for Cys-C eGFR (P = .05). CONCLUSION Protein loading stimulates Io Cl and Cr Cl after a beef or milk-based protein load. The change in Cys-C eGFR is significant but smaller for the shake and burger group, which may be due to the dilutional effect of water loading or the length of Cys-C half-life in the blood.
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Affiliation(s)
- Kyle E Rodenbach
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Dana Y Fuhrman
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paula S Maier
- University of Rochester Medical Center, Rochester, New York
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Bellomo R, Kellum JA, Ronco C, Wald R, Martensson J, Maiden M, Bagshaw SM, Glassford NJ, Lankadeva Y, Vaara ST, Schneider A. Acute kidney injury in sepsis. Intensive Care Med 2017; 43:816-828. [PMID: 28364303 DOI: 10.1007/s00134-017-4755-7] [Citation(s) in RCA: 428] [Impact Index Per Article: 61.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 03/02/2017] [Indexed: 12/13/2022]
Abstract
Acute kidney injury (AKI) and sepsis carry consensus definitions. The simultaneous presence of both identifies septic AKI. Septic AKI is the most common AKI syndrome in ICU and accounts for approximately half of all such AKI. Its pathophysiology remains poorly understood, but animal models and lack of histological changes suggest that, at least initially, septic AKI may be a functional phenomenon with combined microvascular shunting and tubular cell stress. The diagnosis remains based on clinical assessment and measurement of urinary output and serum creatinine. However, multiple biomarkers and especially cell cycle arrest biomarkers are gaining acceptance. Prevention of septic AKI remains based on the treatment of sepsis and on early resuscitation. Such resuscitation relies on the judicious use of both fluids and vasoactive drugs. In particular, there is strong evidence that starch-containing fluids are nephrotoxic and decrease renal function and suggestive evidence that chloride-rich fluid may also adversely affect renal function. Vasoactive drugs have variable effects on renal function in septic AKI. At this time, norepinephrine is the dominant agent, but vasopressin may also have a role. Despite supportive therapies, renal function may be temporarily or completely lost. In such patients, renal replacement therapy (RRT) becomes necessary. The optimal intensity of this therapy has been established, while the timing of when to commence RRT is now a focus of investigation. If sepsis resolves, the majority of patients recover renal function. Yet, even a single episode of septic AKI is associated with increased subsequent risk of chronic kidney disease.
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Affiliation(s)
- Rinaldo Bellomo
- School of Medicine, The University of Melbourne, Melbourne, Australia.
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, 3084, Australia.
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, USA
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
- International Renal Research Institute of Vicenza (IRRIV) San Bortolo Hospital, Vicenza, Italy
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital and the University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada
| | - Johan Martensson
- Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Matthew Maiden
- Department of Intensive Care, Geelong University Hospital, Geelong, VIC, Australia
- Department of Intensive Care, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Neil J Glassford
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Yugeesh Lankadeva
- Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
| | - Suvi T Vaara
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antoine Schneider
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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Acute kidney disease and renal recovery: consensus report of the Acute Disease Quality Initiative (ADQI) 16 Workgroup. Nat Rev Nephrol 2017; 13:241-257. [PMID: 28239173 DOI: 10.1038/nrneph.2017.2] [Citation(s) in RCA: 883] [Impact Index Per Article: 126.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Consensus definitions have been reached for both acute kidney injury (AKI) and chronic kidney disease (CKD) and these definitions are now routinely used in research and clinical practice. The KDIGO guideline defines AKI as an abrupt decrease in kidney function occurring over 7 days or less, whereas CKD is defined by the persistence of kidney disease for a period of >90 days. AKI and CKD are increasingly recognized as related entities and in some instances probably represent a continuum of the disease process. For patients in whom pathophysiologic processes are ongoing, the term acute kidney disease (AKD) has been proposed to define the course of disease after AKI; however, definitions of AKD and strategies for the management of patients with AKD are not currently available. In this consensus statement, the Acute Disease Quality Initiative (ADQI) proposes definitions, staging criteria for AKD, and strategies for the management of affected patients. We also make recommendations for areas of future research, which aim to improve understanding of the underlying processes and improve outcomes for patients with AKD.
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Ronco C, Bellomo R, Kellum J. Understanding renal functional reserve. Intensive Care Med 2017; 43:917-920. [DOI: 10.1007/s00134-017-4691-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 01/18/2017] [Indexed: 12/27/2022]
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Mehta RL, Andringa KK, Sanders PW, Agarwal A. Changing Paradigms in Acute Kidney Injury: From Mechanisms to Management. Nephron Clin Pract 2016; 134:131-132. [DOI: 10.1159/000447676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 06/15/2016] [Indexed: 11/19/2022] Open
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