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Li G, Li B, Song B, Liu D, Sun Y, Ju H, Xu X, Mao J, Zhou F. Uplift modeling to predict individual treatment effects of renal replacement therapy in sepsis-associated acute kidney injury patients. Sci Rep 2024; 14:5833. [PMID: 38461349 PMCID: PMC10924888 DOI: 10.1038/s41598-024-55653-x] [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: 06/03/2023] [Accepted: 02/26/2024] [Indexed: 03/11/2024] Open
Abstract
Renal replacement therapy (RRT) is a crucial treatment for sepsis-associated acute kidney injury (S-AKI), but it is uncertain which S-AKI patients should receive immediate RRT. Identifying the characteristics of patients who may benefit the most from RRT is an important task. This retrospective study utilized a public database and enrolled S-AKI patients, who were divided into RRT and non-RRT groups. Uplift modeling was used to estimate the individual treatment effect (ITE) of RRT. The validity of different models was compared using a qini curve. After labeling the patients in the validation cohort, we characterized the patients who would benefit the most from RRT and created a nomogram. A total of 8289 patients were assessed, among whom 591 received RRT, and 7698 did not receive RRT. The RRT group had a higher severity of illness than the non-RRT group, with a Sequential Organ Failure Assessment (SOFA) score of 9 (IQR 6,11) vs. 5 (IQR 3,7). The 28-day mortality rate was higher in the RRT group than the non-RRT group (34.83% vs. 14.61%, p < 0.0001). Propensity score matching (PSM) was used to balance baseline characteristics, 458 RRT patients and an equal number of non-RRT patients were enrolled for further research. After PSM, 28-day mortality of RRT and non-RRT groups were 32.3% vs. 39.3%, P = 0.033. Using uplift modeling, we found that urine output, fluid input, mean blood pressure, body temperature, and lactate were the top 5 factors that had the most influence on RRT effect. The area under the uplift curve (AUUC) of the class transformation model was 0.068, the AUUC of SOFA was 0.018, and the AUUC of Kdigo-stage was 0.050. The class transformation model was more efficient in predicting individual treatment effect. A logistic regression model was developed, and a nomogram was drawn to predict whether an S-AKI patient can benefit from RRT. Six factors were taken into account (urine output, creatinine, lactate, white blood cell count, glucose, respiratory rate). Uplift modeling can better predict the ITE of RRT on S-AKI patients than conventional score systems such as Kdigo and SOFA. We also found that white blood cell count is related to the benefits of RRT, suggesting that changes in inflammation levels may be associated with the effects of RRT on S-AKI patients.
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Affiliation(s)
- Guanggang Li
- Medical School of Chinese PLA, Beijing, China
- Department of Critical Care Medicine, The Seventh Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Bo Li
- Department of Automation, Tianjin University of Technology, Tianjin, China
| | - Bin Song
- Department of Critical Care Medicine, The Seventh Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Dandan Liu
- Department of Critical Care Medicine, The Seventh Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yue Sun
- Department of Critical Care Medicine, The Seventh Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Hongyan Ju
- Department of Critical Care Medicine, The Seventh Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Xiuping Xu
- Department of Critical Care Medicine, The Seventh Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jingkun Mao
- Department of Automation, Tianjin University of Technology, Tianjin, China.
| | - Feihu Zhou
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China.
- Medical Engineering Laboratory, Chinese PLA General Hospital, Beijing, China.
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Balkrishna A, Sinha S, Kumar A, Arya V, Gautam AK, Valis M, Kuca K, Kumar D, Amarowicz R. Sepsis-mediated renal dysfunction: Pathophysiology, biomarkers and role of phytoconstituents in its management. Biomed Pharmacother 2023; 165:115183. [PMID: 37487442 DOI: 10.1016/j.biopha.2023.115183] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 07/08/2023] [Accepted: 07/18/2023] [Indexed: 07/26/2023] Open
Abstract
Sepsis has evolved as an enormous health issue amongst critically ill patients. It is a major risk factor that results in multiple organ failure and shock. Acute kidney injury (AKI) is one of the most frequent complications underlying sepsis, which portends a heavy burden of mortality and morbidity. Thus, the present review is aimed to provide an insight into the recent progression in the molecular mechanisms targeting dysregulated immune response and cellular dysfunction involved in the development of sepsis-associated AKI, accentuating the phytoconstituents as eligible candidates for attenuating the onset and progression of sepsis-associated AKI. The pathogenesis of sepsis-mediated AKI entails a complicated mechanism and is likely to involve a distinct constellation of hemodynamic, inflammatory, and immune mechanisms. Novel biomarkers like neutrophil gelatinase-associated lipocalin, soluble triggering receptor expressed on myeloid cells 1, procalcitonin, alpha-1-microglobulin, and presepsin can help in a more sensitive diagnosis of sepsis-associated AKI. Many bioactive compounds like curcumin, resveratrol, baicalin, quercetin, and polydatin are reported to play an important role in the prevention and management of sepsis-associated AKI by decreasing serum creatinine, blood urea nitrogen, cystatin C, lipid peroxidation, oxidative stress, IL-1β, TNF-α, NF-κB, and increasing the activity of antioxidant enzymes and level of PPARγ. The plant bioactive compounds could be developed into a drug-developing candidate in managing sepsis-mediated acute kidney injury after detailed follow-up studies. Lastly, the gut-kidney axis may be a more promising therapeutic target against the onset of septic AKI, but a deeper understanding of the molecular pathways is still required.
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Affiliation(s)
- Acharya Balkrishna
- Patanjali Herbal Research Department, Patanjali Research Institute, Haridwar, India
| | - Sugandh Sinha
- Patanjali Herbal Research Department, Patanjali Research Institute, Haridwar, India
| | - Ashwani Kumar
- Patanjali Herbal Research Department, Patanjali Research Institute, Haridwar, India.
| | - Vedpriya Arya
- Patanjali Herbal Research Department, Patanjali Research Institute, Haridwar, India
| | - Ajay Kumar Gautam
- Patanjali Herbal Research Department, Patanjali Research Institute, Haridwar, India
| | - Martin Valis
- Department of Neurology, Charles University in Prague, Faculty of Medicine in Hradec Králové and University Hospital, Hradec Králové, Czech Republic
| | - Kamil Kuca
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, Hradec Kralove, Czech Republic; Biomedical Research Center, University Hospital in Hradec Kralove, Sokolska 581, Hradec Kralove, Czech Republic.
| | - Dinesh Kumar
- School of Bioengineering and Food Technology, Shoolini University of Biotechnology and Management Sciences, Solan, India
| | - Ryszard Amarowicz
- Institute of Animal Reproduction and Food Research, Polish Academy of Sciences, Olsztyn, Poland
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Li Y, Zhang Y, Li R, Zhang M, Gao X. Timing of initiation of renal replacement therapy for patients with acute kidney injury: A meta-analysis of RCTs. Ther Apher Dial 2023; 27:207-221. [PMID: 36053938 DOI: 10.1111/1744-9987.13914] [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: 04/02/2022] [Revised: 07/21/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess the effects of delayed versus early renal replacement therapy (RRT) initiation for patients with AKI. METHODS Related RCTs of RRT initiated at different times published on PubMed, Web of Science, Embase, and Cochrane Library were searched. RESULTS Fifteen RCTs studies with 5395 patients were included. The results showed that the 28-day mortality (RR 1.01; 95% CI 0.94 ~ 1.08; p = 0.80), 60-day mortality (RR 1.00; 95% CI 0.91 ~ 1.11; p = 0.93), 90-day mortality (RR 1.01; 95% CI 0.94 ~ 1.08; p = 0.80), dialysis dependence among survivors (RR 0.67; 95% CI 0.40 ~ 1.13; p = 0.13), length of ICU stay (RR -1.32; 95% CI -3.26 ~ 0.62; p = 0.18) and length of hospital stay among survivors(RR -0.98; 95% CI -2.89 ~ 0.92; p = 0.31) were not significantly different between the two groups. In addition, early initiation of RRT increases the incidence of hypotension (RR 1.42, 95% CI 1.23 ~ 1.63; p < 0.00001) and infectious (RR 1.36; 95% CI 1.03 ~ 1.80; p = 0.03) events. CONCLUSION Early initiation of RRT cannot improve the prognosis and benefit patients.
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Affiliation(s)
- Yunjie Li
- School of Clinical Medicine, Weifang Medical University, Weifang, Shandong, China
| | - Yong Zhang
- Department of Critical Care Medicine, Affiliated Hospital of Weifang Medical University, Weifang, Shandong, China
| | - Rui Li
- Department of Critical Care Medicine, Chongqing Kaizhou District People's Hospital, Kaizhou, Chongqing, China
| | - Ming Zhang
- Department of Critical Care Medicine, Affiliated Hospital of Weifang Medical University, Weifang, Shandong, China
| | - Xiang Gao
- Department of Critical Care Medicine, Weifang People's Hospital, Weifang, Shandong, China
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Trakarnvanich T, Sirivongrangson P, Trongtrakul K, Srisawat N. The effect of citrate in cardiovascular system and clot circuit in critically ill patients requiring continuous renal replacement therapy. J Artif Organs 2023; 26:53-64. [PMID: 35412099 PMCID: PMC9968675 DOI: 10.1007/s10047-022-01329-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/23/2022] [Indexed: 11/25/2022]
Abstract
We aimed to evaluate the impact of citrate on hemodynamic responses and secondary outcomes, including the filter life span, metabolic complications, and levels of inflammatory cytokines, in critically ill patients who required CRRT compared with those who underwent the heparin-free method. This prospective, multicenter, open-label randomized trial compared regional citrate anticoagulation (RCA) with a heparin-free protocol in severe acute kidney injury (AKI) patients who received continuous venovenous hemodiafiltration (CVVHDF) in the postdilution mode. We measured hemodynamic changes using the FloTrac Sensor/EV1000™ Clinical Platform at certain time points after starting CRRT (0, 6, 12, 24, 48, and 72 h.). The levels of inflammatory cytokines (IL-1β, IL-6, IL-8, IL-10 and TNF-ɑ) were measured on days 1 and 3. Forty-one patients were recruited and randomized into the heparin (n = 20) and citrate groups (n = 21). The cardiac performances were not significantly different between the 2 groups at any time point. The inflammatory cytokines declined similarly in both treatment arms. The maximum filter survival time was insignificantly longer in the RCA group than in the heparin-free group (44.64 ± 26.56 h. vs p = 0.693 in citrate and heparin free group). No serious side effects were observed for either treatment arm, even in the group of liver dysfunction patients. RCA did not affect hemodynamic changes during CRRT. Inflammatory cytokines decreased similarly in both treatment arms.The filter life span was longer in the citrate group. RCA is a valid alternative to traditional anticoagulation and results in stable hemodynamic parameters.
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Affiliation(s)
- Thananda Trakarnvanich
- Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, 681 Samsen Road, Dusit, Bangkok, 10300, Thailand.
| | | | - Konlawij Trongtrakul
- Faculty of Medicine, Pulmonary, Critical Care, and Allergy Division, Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nattachai Srisawat
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Critical Care Nephrology Research Unit, Chulalongkorn University, Bangkok, Thailand
- Academy of Science, Royal Society of Thailand, Bangkok, Thailand
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Wang Z, Zhang L, Xu F, Han D, Lyu J. The association between continuous renal replacement therapy as treatment for sepsis-associated acute kidney injury and trend of lactate trajectory as risk factor of 28-day mortality in intensive care units. BMC Emerg Med 2022; 22:32. [PMID: 35227200 PMCID: PMC8886847 DOI: 10.1186/s12873-022-00589-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 02/21/2022] [Indexed: 12/03/2022] Open
Abstract
Background Sepsis has high incidence and fatality rates in intensive care units, often leading to renal failure. The effectiveness of continuous renal replacement therapy (CRRT) in sepsis-associated acute kidney injury (S-AKI) patients is currently uncertain. Aim Joint model was used to determine the association between CRRT and the lactate trajectory trend and how it correlated to 28-day mortality for S-AKI patient in ICU. Methods A retrospective study was applied to patients with sepsis and AKI, which were extracted from the MIMIC-III public database, with the endpoint being 28-day mortality. Every lactate level measurement within 28 days was observed and calculated using logarithms. Joint model combined the longitudinal analysis of the natural logarithm of the lactate level [log(lactate)] in longitudinal submodel and Cox regression by trajectory function, demonstrating the effects of CRRT on 28-day survival and log(lactate) changes, and its final relationship with the event status. Results Among the 717 S-AKI patients, 157 received CRRT. CRRT was not associated with 28-day mortality. After adjustments, the relationship between CRRT use and log(lactate) elevation was statistically significant. The parameter estimation of CRRT and log(lactate) indicated that using CRRT will increase log(lactate) by 0.041 in S-AKI patients. The joint model also instigated a fixed association between changes in the lactate level and the event result, revealing an exp value of (0.755) = 2.12, indicating that an increase of one unit in log(lactate) will increase the risk of 28-day mortality 2.12-times. Conclusion There was no significant association between CRRT use and 28-day survival in S-AKI patients, and JM showed that CRRT use might be associated with elevation of longitudinal lactate levels. Therefore, additional attention should be paid to other treatments to control lactate levels when providing renal support for patients with S-AKI. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00589-6.
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Affiliation(s)
- Zichen Wang
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China.,Department of Public Health, University of California, Irvine, USA
| | - Luming Zhang
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China.,Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Fengshuo Xu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, China
| | - Didi Han
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China.
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Cai X, Li J, Qin P, An P, Yang H, Zuo M, Wang J. Prognostic Prediction Using the Clinical Data and Ultrasomics-Based Model in Acute Respiratory Distress Syndrome (ARDS) Combined with Acute Kidney Injury (AKI). Int J Clin Pract 2022; 2022:4822337. [PMID: 35685598 PMCID: PMC9159198 DOI: 10.1155/2022/4822337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/04/2022] [Accepted: 04/12/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE A model was constructed based on clinical and ultrasomics features to predict the prognosis of patients in the respiratory intensive unit (RICU) who had acute respiratory distress syndrome (ARDS) combined with acute kidney injury (AKI). AKI ensues after ARDS in RICU ordinarily. The prognostic prediction tool was further developed on this basis. METHODS We collected clinical and ultrasonic data from 145 patients who had ARDS combined with AKI and received continuous renal replacement therapy (CRRT) in the RICU of Xiangyang Hospital of Traditional Chinese Medicine from March 2016 to November 2019. The patients were divided into the survival group (n = 51) and the death group (n = 94), depending on the treatment outcome. The training set (n = 102) and the testing set (n = 43) were established based on patient data. The clinical and ultrasomics features and the CRRT parameters were compared between the two groups. The influence factors of death were analyzed by logistic regression, and four predictive models were established. The predictive performance of 4 models was compared using the R Software 4.1.3. The decision curve analysis graphs were drawn using the R language to determine the net benefit of each. RESULT Univariate analysis was conducted in the training set. The following risk factors for poor prognosis were identified: age, concurrent cancers, sequential organ failure assessment score (SOFA), number of organ dysfunctions, positive cumulative fluid balance at 72 h, time from ICU admission to CRRT, mean arterial pressure, oxygenation index, and gray-level size zone matrix, GLSZM (SumEntropy.239/SmallDependenceHighGrayLevelEmphasis.314/Maximum.327/Variance.338) (P < 0.05). Four models were built based on the above factors: clinical model, CRRT model, ultrasomics-based model, and combination model. Comparison using the MedCalc software indicated that the best predictive performance achieved with the combination model. The decision curve analysis also suggested that the combination model had the highest net benefit. Similar results were reported after validation on the testing set. CONCLUSION The prognosis of ARDS patients combined with AKI is usually poor. The combination model based on clinical and ultrasomics features had the highest predictive performance. This model can be used to improve the clinical outcome and prognosis.
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Affiliation(s)
- Xing Cai
- Department of Respiratory Medicine, Xiangyang Hospital of Traditional Chinese Medicine, Xiangyang Central Hospital, Xiangyang, Hubei 441000, China
| | - Jing Li
- Department of Respiratory Medicine, Xiangyang Hospital of Traditional Chinese Medicine, Xiangyang Central Hospital, Xiangyang, Hubei 441000, China
| | - Ping Qin
- Department of Internal Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei 441000, China
| | - Peng An
- Department of Internal Medicine, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, China
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, The First Clinical Medical College, 155 Hanzhong Road, Nanjing 210029, Jiangsu, China
| | - Hao Yang
- Department of Ultrasound, Taizhou Hospital of Traditional Chinese Medicine, Taizhou, Jiangsu 225300, China
| | - MingYan Zuo
- Department of Respiratory Medicine, Xiangyang Hospital of Traditional Chinese Medicine, Xiangyang Central Hospital, Xiangyang, Hubei 441000, China
| | - Jinsong Wang
- Department of Respiratory Medicine, Xiangyang Hospital of Traditional Chinese Medicine, Xiangyang Central Hospital, Xiangyang, Hubei 441000, China
- Department of Internal Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei 441000, China
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The Effect of Long-Term Duration Renal Replacement Therapy on Outcomes of Critically Ill Patients with Acute Kidney Injury: A Retrospective Cohort Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:6623667. [PMID: 34504539 PMCID: PMC8423547 DOI: 10.1155/2021/6623667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 06/29/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022]
Abstract
Background Renal replacement therapy (RRT), as a cornerstone of supportive treatment, has long been performed in critically ill patients with acute kidney injury (AKI). However, the majority of studies may have neglected the effect of the duration of RRT on the outcome of AKI patients. This paper is aiming to explore the effect of the long duration of RRT on the outcome of critically ill patients with AKI. Methods This retrospective study was conducted by using the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC-II) database. The primary outcome measure of this study was the mortality at 28 days, 60 days, and 90 days in the long-duration RRT group and the non-long-duration RRT group. The secondary outcomes assessed the difference in clinical outcome in these two groups. Lastly, the effect of the duration of RRT on mortality in AKI patients was determined as the third outcome. Results We selected 1,020 patients in total who received RRT according to the MIMIC-II database. According to the inclusion and exclusion criteria, we finally selected 506 patients with AKI: 286 AKI patients in the non-long-duration RRT group and 220 in the long-duration RRT group. After 28 days, there was a significant difference in all-cause mortality between the long-duration RRT group and the non-long-duration RRT group (P=0.001). However, the difference disappeared after 60 days and 90 days (P=0.803 and P=0.925, respectively). The length of ICU stay, length of hospital stay, and duration of mechanical ventilation were significantly longer in the long-duration RRT group than those in the non-long-duration RRT group. Considering 28-day mortality, the longer duration of RRT was shown to be a protective factor (HR = 0.995, 95% CI 0.993-0.997, P < 0.0001), while 60-day and 90-day mortality were not correlated with improved protection. Conclusions The long duration of RRT can improve the short-term prognosis of AKI patients, but it does not affect the long-term prognosis of these patients. Prognosis is determined by the severity of the illness itself. This suggests that RRT can protect AKI patients through the most critical time; however, the final outcome cannot be altered.
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Schultz P, Schwier E, Eickmeyer C, Henzler D, Köhler T. High-dose CytoSorb hemoadsorption is associated with improved survival in patients with septic shock: A retrospective cohort study. J Crit Care 2021; 64:184-192. [PMID: 33962219 DOI: 10.1016/j.jcrc.2021.04.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 04/02/2021] [Accepted: 04/15/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND PURPOSE Hemoadsorption with CytoSorb® offers a possible therapeutic approach in septic shock, but modes of application and dosing are still undetermined. MATERIALS AND METHODS Data from surgical patients with septic shock, treated with hemoadsorption adjunctive to renal replacement therapy were analyzed retrospectively. The 28-day mortality was compared to predicted mortality. RESULTS In 70 patients (70.6 ± 13.3 years), hemoadsorption was applied for 85.6 ± 53.8 h. The APACHE ll (30.2 ± 6.3) calculated to a predicted mortality of 73.3%, while the observed mortality was significantly lower (50%, p < 0.05). The amount of blood purified was higher in survivors than in non-survivors (8.5 ± 4.4 vs. 6.1 ± 3.6 l/kgBW, p = 0.017). We identified three clusters of <6 l/kgBW, 6-13 l/kgBW and ≥ 13 l/kgBW with a linear dose-response relation between blood purification volume and survival, which was best in the highest volume cluster (83.3%; p = 0.045). CONCLUSIONS The application of CytoSorb® seems to be effective in various conditions of septic shock. In a cohort of most severely ill patients the observed mortality was lower than predicted and decreased linearly with blood purification volumes inadvertently exceeding 6 l/kg BW. These results suggest that hemoadsorption might improve survival provided that the applied dose is high enough.
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Affiliation(s)
- Philipp Schultz
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr-University Bochum, Klinikum Herford, Herford, Germany
| | - Elke Schwier
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr-University Bochum, Klinikum Herford, Herford, Germany
| | - Claas Eickmeyer
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr-University Bochum, Klinikum Herford, Herford, Germany
| | - Dietrich Henzler
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr-University Bochum, Klinikum Herford, Herford, Germany.
| | - Thomas Köhler
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr-University Bochum, Klinikum Herford, Herford, Germany
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Peng L, Gao Y, Zhang G, Tian X, Xu H, Yu Q, Cheng J, Li Y, Li Q, Chen Y, Zhao W, Luo Z. Effects of continuous venovenous hemofiltration on vancomycin trough concentrations in critically ill children. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:224. [PMID: 33708851 PMCID: PMC7940948 DOI: 10.21037/atm-20-4005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Vancomycin trough concentrations are associated with clinical outcomes and drug adverse effects. This study investigates the effects of continuous venovenous hemofiltration (CVVH) on vancomycin trough concentrations in critically ill children with a vancomycin dosage of 40–60 mg/kg/day. Methods Children with steady-state vancomycin trough concentrations admitted to the pediatric intensive care unit (PICU) between January 2016 and December 2019 were retrospectively enrolled. Patients were divided into CVVH and non-CVVH groups according to treatment differences and renal function. Vancomycin trough concentrations were then compared between the groups, and risk factors for supratherapeutic trough concentrations (>20 mg/L) were analyzed with logistic regression. Results Of the 119 patients included, 35 were enrolled in the CVVH group and 84 in the non-CVVH group. Median vancomycin trough concentrations were significantly higher in the CVVH group than those in the non-CVVH group [14.9 (IQR =9.6–19.6) vs. 9.3 (IQR =7.0–13.4), P<0.001] and the proportion of therapeutic trough concentrations (10–20 mg/L) was similar between CVVH and non-CVVH groups (54.3% vs. 39.3%, P=0.133). However, CVVH therapy patients had a significantly higher proportion of supratherapeutic trough concentrations (20.0% vs. 1.2%, P=0.001) compared to the non-CVVH group. Multivariate analysis demonstrated that the Pediatric Risk of Mortality (PRISM) III score ≥28 (OR =13.7; 95% CI, 1.4–137.0; P=0.026] was an independent risk factor for supratherapeutic trough concentrations in critically ill patients. Conclusions CVVH therapy affects vancomycin trough concentrations and is associated with supratherapeutic concentrations with a 40–60 mg/kg/day vancomycin dosage. PRISM III scores ≥28 may serve as an independent risk factor for supratherapeutic trough concentrations in children receiving CVVH therapy.
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Affiliation(s)
- Lengyue Peng
- Department of Respiratory Medicine Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yawen Gao
- Department of Respiratory Medicine Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Guangli Zhang
- Department of Respiratory Medicine Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xiaoyin Tian
- Department of Respiratory Medicine Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Huiting Xu
- Department of Respiratory Medicine Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Qinghong Yu
- Department of Respiratory Medicine Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jie Cheng
- Department of Respiratory Medicine Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yuanyuan Li
- Department of Respiratory Medicine Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Qinyuan Li
- Department of Respiratory Medicine Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yingfu Chen
- Department of Pediatric Intensive Care Unit Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Wei Zhao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Zhengxiu Luo
- Department of Respiratory Medicine Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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Wang X, Chen X, Tang F, Luo W, Fang J, Qi C, Sun H, Xiao H, Peng X, Shao J. Be aware of acute kidney injury in critically ill children with COVID-19. Pediatr Nephrol 2021; 36:163-169. [PMID: 32844290 PMCID: PMC7447530 DOI: 10.1007/s00467-020-04715-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/19/2020] [Accepted: 07/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication of critically ill adult patients with COVID-19. However, currently, no studies investigate kidney impairment in children with COVID-19. We investigated incidence and treatment of AKI in pediatric patients with COVID-19 in Wuhan Children's Hospital during the early stages of the COVID-19 pandemic and discuss possible mechanisms of AKI related to SARS-CoV-2 infection. METHODS By extracting data from electronic medical records, we conducted a retrospective observational study of kidney involvement in confirmed pediatric COVID-19 cases in Wuhan Children's Hospital during the coronavirus outbreak, from January 24 to March 20, 2020. Clinical presentations, clinical courses, laboratory findings, and medical interventions are described below. RESULTS Among 238 confirmed COVID-19 cases, only three were critically ill and needed intensive care unit (ICU) admission. All three developed AKI, but AKI was not detected in any non-critically ill patients outside the ICU. Two of the three patients with AKI had prodromal gastrointestinal symptoms. Significantly elevated interleukin-6 (IL-6) levels and complement activation were observed in these patients with AKI. The three patients with AKI were treated with plasma exchange (PE) and continuous kidney replacement therapy (CKRT), resulting in one complete recovery, one partial recovery, and one mortality due to critical illness. CONCLUSIONS Critically ill children with COVID-19 may develop AKI, especially following prodromal gastrointestinal symptoms. An inflammatory storm and complement-mediated injury may underlie AKI development in children with COVID-19. Our study supports implantation of PE and CKRT in management of critically ill patients with AKI.
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Affiliation(s)
- Xiaowen Wang
- Department of Nephrology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Xingfeng Chen
- Intensive Care Unit, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Feng Tang
- Department of Laboratory Medicine, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Wanjun Luo
- Hospital Acquired Infection Control Department, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Jian Fang
- Department of Nephrology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Chang Qi
- Department of Nephrology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Hua Sun
- Department of Nephrology, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Han Xiao
- Institute of Maternal and Child Health, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Xuehua Peng
- Medical Imaging Center, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Jianbo Shao
- Intensive Care Unit, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China.
- Medical Imaging Center, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China.
- Institute of Maternal and Child Health, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), 100# Hongkong Road, Wuhan, 430000, China.
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Raina R, Joshi H, Chakraborty R. Changing the terminology from kidney replacement therapy to kidney support therapy. Ther Apher Dial 2020; 25:437-457. [PMID: 32945598 DOI: 10.1111/1744-9987.13584] [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: 05/20/2020] [Revised: 08/16/2020] [Accepted: 09/12/2020] [Indexed: 11/28/2022]
Abstract
Kidney replacement therapy (KRT) is a common supportive treatment for renal dysfunction, especially acute kidney injury. However, critically ill or immunosuppressed patients with renal dysfunction often have dysfunction in other organs as well. To improve patient outcomes, clinicians began to initiate kidney replacement therapy in situations where nonrenal conditions may lead to acute kidney injury, such as septic shock, hematopoietic stem cell transplantation, veno-occlusive renal disease, cardiopulmonary bypass, chemotherapy, tumor lysis syndrome, hyperammonemia, and various others. In this review, we discuss the use of various modes of kidney replacement therapy in treating renal and nonrenal complications to illustrate why kidney support therapy is a more appropriate terminology than kidney replacement therapy.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Hirva Joshi
- Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Ronith Chakraborty
- Department of Nephrology, Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, Ohio, USA
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Abstract
Coronavirus disease 2019 (COVID-19) is spreading rapidly worldwide. Here, we review recently published studies on COVID-19-associated acute kidney injury (AKI) in China. The pooled incidence of AKI in all reported COVID-19 patients was 6.5%, with a much higher rate in patients from the intensive care unit (32.5%). AKI is associated with the severity of COVID-19 and mortality rates, which is similar to other kidney abnormalities including proteinuria and hematuria. The renal tubule is the main site of injury in COVID-19 patients, and the etiology of renal impairment in COVID-19 patients likely is diverse and multifactorial. Apart from direct viral attack via angiotensin-converting enzyme 2 and transmembrane serine proteases 2, hypoxia and hypercoagulability also may contribute to the occurrence of renal injury. To date, there is only randomized controlled trial evidence to support the use of dexamethasone in patients requiring oxygen therapy and remdesivir for shortening the time to recovery, with no specific treatment for COVID-19-associated AKI. Studies researching kidney pathologies or reporting renal outcome and prognosis are in urgent need. Further studies are urgently warranted to identify risk factors, to predict prognosis and renal outcome, to explore the exact mechanisms of renal injury, and to suggest targeted interventions.
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Affiliation(s)
- Xizi Zheng
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China; Peking University Institute of Nephrology, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Youlu Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China; Peking University Institute of Nephrology, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Li Yang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China; Peking University Institute of Nephrology, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.
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13
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Cai C, Qiu G, Hong W, Shen Y, Gong X. Clinical effect and safety of continuous renal replacement therapy in the treatment of neonatal sepsis-related acute kidney injury. BMC Nephrol 2020; 21:286. [PMID: 32682407 PMCID: PMC7368639 DOI: 10.1186/s12882-020-01945-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 07/12/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Sepsis is the leading cause of acute kidney injury (AKI) in the neonatal intensive care unit (NICU). The aim of the study is to explore the efficacy and security of continuous renal replacement therapy (CRRT) in the treatment of neonatal sepsis-related AKI. METHOD Totally12 sepsis-related AKI neonates treated with CRRT were hospitalized in the NICU of Shanghai Children's Hospital between November 2012 and November 2019, and the clinical data of these 12 cases were retrospectively analyzed. Renal function, acid-base balance, electrolytes, blood pressure and hemodynamics indexes were recorded before CRRT initiation, 12/24/48 h after CRRT initiation and at the end of CRRT respectively. The efficacy of CRRT was evaluated and the clinical outcome was observed in these 12 sepsis-related AKI neonates. Repeated measurement analysis of variance was used for statistical analysis of the data. RESULT (1) Continuous veno-venous hemodialysis filtration (CVVHDF) was used in 12 cases of sepsis-related AKI neonates. There were 6 cases with oliguria, 3 cases with fluid overload (FO), 3 cases with septic shock. The duration of CRRT was 49 ~ 110 h, average (76.2 ± 23.5) h. (2) The blood pressure (BP) of 12 sepsis -related AKI neonates could reach the normal level (40-60 mmHg) 12 h after CRRT initiation, and the normal BP level could be maintained during the CRRT treatment. After 12 h CRRT, the blood pH value increased to the normal range (7.35 ~ 7.45). After 12 h CRRT treatment, the oxygenation index of 12sepsis-related AKI neonates could reach 200 mmHg. After 24 h CRRT treatment, it could rise to more than 300 mmHg. Serum potassium, serum urea nitrogen and serum creatinine levels decreased significantly 12 h after CRRT initiation, and reached the normal range 24 h after CRRT initiation. The urine volume significantly increased 24 h after CRRT initiation. (3) Venous catheterization was performed successfully in all sepsis-related AKI neonates. We observed 2 cases of thrombocytopenia, 1 case of obstruction and 1 case of hypotension in the course of CRRT. There were no complications such as hypothermia, hemorrhage, thrombosis and infection.11 neonates were cured and discharged. One neonate was treated with CRRT and passed through the oliguria stage of AKI, but died after the parents gave up the treatment. CONCLUSIONS It is safe and effective to treat neonatal sepsis-related AKI with CRRT, which should be an effective measure for the treatment of sepsis-related AKI neonates.
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Affiliation(s)
- Cheng Cai
- Department of Neonatology, Shanghai Children’s Hospital, Shanghai Jiao Tong University, No.355, Luding Road, Shanghai, 200062 China
| | - Gang Qiu
- Department of Neonatology, Shanghai Children’s Hospital, Shanghai Jiao Tong University, No.355, Luding Road, Shanghai, 200062 China
| | - Wenchao Hong
- Department of Neonatology, Shanghai Children’s Hospital, Shanghai Jiao Tong University, No.355, Luding Road, Shanghai, 200062 China
| | - Yunlin Shen
- Department of Neonatology, Shanghai Children’s Hospital, Shanghai Jiao Tong University, No.355, Luding Road, Shanghai, 200062 China
| | - Xiaohui Gong
- Department of Neonatology, Shanghai Children’s Hospital, Shanghai Jiao Tong University, No.355, Luding Road, Shanghai, 200062 China
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Wu T, Zuo Z, Kang S, Jiang L, Luo X, Xia Z, Liu J, Xiao X, Ye M, Deng M. Multi-organ Dysfunction in Patients with COVID-19: A Systematic Review and Meta-analysis. Aging Dis 2020; 11:874-894. [PMID: 32765952 PMCID: PMC7390520 DOI: 10.14336/ad.2020.0520] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/20/2020] [Indexed: 02/05/2023] Open
Abstract
This study aimed to provide systematic evidence for the association between multiorgan dysfunction and COVID-19 development. Several online databases were searched for articles published until May 13, 2020. Two investigators independently selected trials, extracted data, and evaluated the quality of individual trials. Single-arm meta-analysis was performed to summarize the clinical features of confirmed COVID-19 patients. Fixed effects meta-analysis was performed for clinically relevant parameters that were closely related to the patients' various organ functions. A total of 73 studies, including 171,108 patients, were included in this analysis. The overall incidence of severe COVID-19 and mortality were 24% (95% confidence interval [CI], 20%-28%) and 2% (95% CI, 1%-3%), respectively. Patients with hypertension (odds ratio [OR] = 2.40; 95% CI, 2.08-2.78), cardiovascular disease (CVD) (OR = 3.54; 95% CI, 2.68-4.68), chronic obstructive pulmonary disease (COPD) (OR=3.70; 95% CI, 2.93-4.68), chronic liver disease (CLD) (OR=1.48; 95% CI, 1.09-2.01), chronic kidney disease (CKD) (OR = 1.84; 95% CI, 1.47-2.30), chronic cerebrovascular diseases (OR = 2.53; 95% CI, 1.84-3.49) and chronic gastrointestinal (GI) disease (OR = 2.13; 95% CI, 1.12-4.05) were more likely to develop severe COVID-19. Increased levels of lactate dehydrogenase (LDH), creatine kinase (CK), high-sensitivity cardiac troponin I (hs-cTnI), myoglobin, creatinine, urea, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin were highly associated with severe COVID-19. The incidence of acute organ injuries, including acute cardiac injury (ACI); (OR = 11.87; 95% CI, 7.64-18.46), acute kidney injury (AKI); (OR=10.25; 95% CI, 7.60-13.84), acute respiratory distress syndrome (ARDS); (OR=27.66; 95% CI, 18.58-41.18), and acute cerebrovascular diseases (OR=9.22; 95% CI, 1.61-52.72) was more common in patients with severe COVID-19 than in patients with non-severe COVID-19. Patients with a history of organ dysfunction are more susceptible to severe conditions. COVID-19 can aggravate an acute multiorgan injury.
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Affiliation(s)
- Ting Wu
- Department of Biochemistry and Molecular Biology & Hunan Province Key Laboratory of Basic and Applied Hematology, School of Life Sciences, Central South University, Hunan 410013, China.
- Department of Cardiovascular Medicine, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China.
| | - Zhihong Zuo
- Department of Biochemistry and Molecular Biology & Hunan Province Key Laboratory of Basic and Applied Hematology, School of Life Sciences, Central South University, Hunan 410013, China.
- Xiangya School of Medicine, Central South University, Hunan 410013, China.
| | - Shuntong Kang
- Department of Biochemistry and Molecular Biology & Hunan Province Key Laboratory of Basic and Applied Hematology, School of Life Sciences, Central South University, Hunan 410013, China.
- Xiangya School of Medicine, Central South University, Hunan 410013, China.
| | - Liping Jiang
- Xiangya School of Medicine, Central South University, Hunan 410013, China.
| | - Xuan Luo
- Hunan Yuanpin Cell Biotechnology Co., Ltd, Hunan 410129, China.
| | - Zanxian Xia
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha 410013, China.
- Hunan Key Laboratory of Animal Models for Human Diseases, Hunan Key Laboratory of Medical Genetics & Center for Medical Genetics, School of Life Sciences, Central South University, Changsha 410013, China.
| | - Jing Liu
- Department of Biochemistry and Molecular Biology & Hunan Province Key Laboratory of Basic and Applied Hematology, School of Life Sciences, Central South University, Hunan 410013, China.
| | - Xiaojuan Xiao
- Department of Biochemistry and Molecular Biology & Hunan Province Key Laboratory of Basic and Applied Hematology, School of Life Sciences, Central South University, Hunan 410013, China.
| | - Mao Ye
- Molecular Science and Biomedicine Laboratory, State Key Laboratory for Chemo/Biosensing and Chemometrics, College of Biology, College of Chemistry and Chemical Engineering, Collaborative Innovation Center for Molecular Engineering for Theranostics, Hunan University, Changsha, China
| | - Meichun Deng
- Department of Biochemistry and Molecular Biology & Hunan Province Key Laboratory of Basic and Applied Hematology, School of Life Sciences, Central South University, Hunan 410013, China.
- Xiangya School of Medicine, Central South University, Hunan 410013, China.
- Hunan Key Laboratory of Animal Models for Human Diseases, Hunan Key Laboratory of Medical Genetics & Center for Medical Genetics, School of Life Sciences, Central South University, Changsha 410013, China.
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