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Meersch M, Weiss R, Strauß C, Albert F, Booke H, Forni L, Pittet JF, Kellum JA, Rosner M, Mehta R, Bellomo R, Rosenberger P, Zarbock A. Acute kidney disease beyond day 7 after major surgery: a secondary analysis of the EPIS-AKI trial. Intensive Care Med 2024; 50:247-257. [PMID: 38285051 PMCID: PMC10907445 DOI: 10.1007/s00134-023-07314-2] [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: 09/04/2023] [Accepted: 12/19/2023] [Indexed: 01/30/2024]
Abstract
PURPOSE Acute kidney disease (AKD) is a significant health care burden worldwide. However, little is known about this complication after major surgery. METHODS We conducted an international prospective, observational, multi-center study among patients undergoing major surgery. The primary study endpoint was the incidence of AKD (defined as new onset of estimated glomerular filtration rate (eCFR) < 60 ml/min/1.73 m2 present on day 7 or later) among survivors. Secondary endpoints included the relationship between early postoperative acute kidney injury (AKI) (within 72 h after major surgery) and subsequent AKD, the identification of risk factors for AKD, and the rate of chronic kidney disease (CKD) progression in patients with pre-existing CKD. RESULTS We studied 9510 patients without pre-existing CKD. Of these, 940 (9.9%) developed AKD after 7 days of whom 34.1% experiencing an episode of early postoperative-AKI. Rates of AKD after 7 days significantly increased with the severity (19.1% Kidney Disease Improving Global Outcomes [KDIGO] 1, 24.5% KDIGO2, 34.3% KDIGO3; P < 0.001) and duration (15.5% transient vs 38.3% persistent AKI; P < 0.001) of early postoperative-AKI. Independent risk factors for AKD included early postoperative-AKI, exposure to perioperative nephrotoxic agents, and postoperative pneumonia. Early postoperative-AKI carried an independent odds ratio for AKD of 2.64 (95% confidence interval [CI] 2.21-3.15). Of 663 patients with pre-existing CKD, 42 (6.3%) had worsening CKD at day 90. In patients with CKD and an episode of early AKI, CKD progression occurred in 11.6%. CONCLUSION One in ten major surgery patients developed AKD beyond 7 days after surgery, in most cases without an episode of early postoperative-AKI. However, early postoperative-AKI severity and duration were associated with an increased rate of AKD and early postoperative-AKI was strongly associated with AKD independent of all other potential risk factors.
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Affiliation(s)
- Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Raphael Weiss
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Christian Strauß
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Felix Albert
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Hendrik Booke
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Lui Forni
- School of Medicine, University of Surrey, Kate Granger Building, Guildford, UK
- Intensive Care Unit, Royal Surrey Hospital, Guildford, UK
| | - Jean-Francois Pittet
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mitchell Rosner
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Ravindra Mehta
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Intensive Care, Austin Health, Heidelberg, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care, University Hospital Tübingen, Tübingen, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany.
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Sun R, Zhou Z, Li X, Xu Q, Zhou B, Yu H, Zhang W, Sun Q, Zhang X, Luo X, Li S, Luo A. Prognostic significance of preoperative nutritional status for postoperative acute kidney injury in older patients undergoing major abdominal surgery: a retrospective cohort study. Int J Surg 2024; 110:873-883. [PMID: 37921644 PMCID: PMC10871641 DOI: 10.1097/js9.0000000000000861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/22/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND The association between malnutrition and postoperative acute kidney injury (AKI) has not been well studied. In this study, the authors examined the association between preoperative nutritional status and postoperative AKI in older patients who underwent major abdominal surgery, as well as the predictive value of malnutrition for AKI. MATERIALS AND METHODS The authors retrospectively included patients aged 65 or older who underwent major elective abdominal surgery. The nutritional status of the patient was evaluated using three objective nutritional indices, such as the geriatric nutritional risk index (GNRI), the prognostic nutritional index (PNI), and the controlling nutritional status (CONUT). AKI was determined using the KDIGO criteria. The authors performed logistic regression analysis to investigate the association between preoperative nutritional status and postoperative AKI, as well as the predictive value of nutritional scores for postoperative AKI. RESULTS A total of 2775 patients were included in the study, of which 707 (25.5%), 291 (10.5%), and 517 (18.6%) had moderate to severe malnutrition according to GNRI, PNI, and CONUT calculations. After surgery, 144 (5.2%) patients developed AKI, 86.1% at stage 1, 11.1% at stage 2, and 2.8% at stage 3 as determined by KDIGO criteria. After adjustment for traditional risk factors, worse nutritional scores were associated with a higher AKI risk. In addition to traditional risk factors, these nutritional indices improved the predictive ability of AKI prediction models, as demonstrated by significant improvements in integrated discrimination and net reclassification. CONCLUSIONS Poor preoperative nutritional status, as assessed by GNRI, PNI, and CONUT scores, was associated with an increased risk of postoperative AKI. Incorporating these scores into AKI prediction models improved their performance. These findings emphasize the need for screening surgical patients for malnutrition risk. Further research is needed to determine whether preoperative malnutrition assessment and intervention can reduce postoperative AKI incidence.
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Affiliation(s)
- Rao Sun
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital
| | - Zhiqiang Zhou
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital
| | - Xinhua Li
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital
| | - Qiaoqiao Xu
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital
| | - Biyun Zhou
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital
| | - Honghui Yu
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital
| | - Wanjun Zhang
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital
| | - Qi Sun
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital
| | - Xiang Zhang
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital
| | - Xiaoxiao Luo
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Shiyong Li
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital
| | - Ailin Luo
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital
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Li S, Ren W, Ye X, Zhang L, Song B, Guo Z, Bian Q. An online-predictive model of acute kidney injury after pancreatic surgery. Am J Surg 2024; 228:151-158. [PMID: 37716826 DOI: 10.1016/j.amjsurg.2023.09.006] [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: 07/13/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 09/18/2023]
Abstract
OBJECTIVE Acute kidney injury(AKI) after pancreatic surgery is associated with increased mortality, longer hospital stays and poor prognosis. This study aims to identify the risk factors and establish an easy-to-use prediction calculator by the nomogram to predict the risk of AKI after pancreatic surgery. METHODS From January 2016 to June 2018, 1504 patients who underwent pancreatic surgery in our center were included in this retrospective analysis and randomly assigned to primary (1054 patients) and validation (450 patients) cohorts. The independent risk factors of AKI were identified using univariate and multivariate analyses. A risk-predicted nomogram for AKI was developed through multivariate logistic regression analysis in the primary cohort while the nomogram was evaluated in the validation cohort. Nomogram discrimination and calibration were assessed using C-index and calibration curves in the primary and validation cohorts. The clinical utility of the final nomogram was evaluated using decision curve analysis. RESULTS The overall incidence of AKI after pancreatic surgery was 5.3% (79/1504). Independent risk factors including smoking history, cardiovascular disease, ASA score, baseline eGFR, bilirubin>2 mg/dL, undergoing pancreaticoduodenectomy, and intraoperative blood loss>400 mL were identified by multivariate analysis. Nomogram revealed moderate discrimination and calibration in estimating the risk of AKI, with an unadjusted C-index of 0.79 (95 %CI, 0.73-0.85). Application of the nomogram in the validation cohort provided moderate discrimination (C-index,0.80 [95% CI, 0.72-0.88]) and good calibration. Besides, the decision curve analysis (DCA) confirmed the clinical usefulness of the nomogram. CONCLUSIONS An easy-to-use online prediction calculator comprised of preoperative and intraoperative factors was able to individually predict the occurrence risk of AKI among patients with pancreatic surgery, which may help identify reasonable risk judgments and develop proper treatment strategies to a certain extent.
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Affiliation(s)
- Siqian Li
- Department of Nephrology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Weifu Ren
- Department of Nephrology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Xiaofei Ye
- Department of Health Statistics, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Linyan Zhang
- Department of Nephrology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Bin Song
- Department of Hepatopancreatobiliary Surgery, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Zhiyong Guo
- Department of Nephrology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Qi Bian
- Department of Nephrology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China.
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Jiang W, Zhang C, Yu J, Shao J, Zheng R. Development and validation of a nomogram for predicting in-hospital mortality of elderly patients with persistent sepsis-associated acute kidney injury in intensive care units: a retrospective cohort study using the MIMIC-IV database. BMJ Open 2023; 13:e069824. [PMID: 36972970 PMCID: PMC10069590 DOI: 10.1136/bmjopen-2022-069824] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVES To identify the clinical risk factors that influence in-hospital mortality in elderly patients with persistent sepsis-associated acute kidney injury (S-AKI) and to establish and validate a nomogram to predict in-hospital mortality. DESIGN Retrospective cohort analysis. SETTING Data from critically ill patients at a US centre between 2008 and 2021 were extracted from the Medical Information Mart for Intensive Care (MIMIC)-IV database (V.1.0). PARTICIPANTS Data from 1519 patients with persistent S-AKI were extracted from the MIMIC-IV database. PRIMARY OUTCOME All-cause in-hospital death from persistent S-AKI. RESULTS Multiple logistic regression revealed that gender (OR 0.63, 95% CI 0.45-0.88), cancer (2.5, 1.69-3.71), respiratory rate (1.06, 1.01-1.12), AKI stage (2.01, 1.24-3.24), blood urea nitrogen (1.01, 1.01-1.02), Glasgow Coma Scale score (0.75, 0.70-0.81), mechanical ventilation (1.57, 1.01-2.46) and continuous renal replacement therapy within 48 hours (9.97, 3.39-33.9) were independent risk factors for mortality from persistent S-AKI. The consistency indices of the prediction and the validation cohorts were 0.780 (95% CI: 0.75-0.82) and 0.80 (95% CI: 0.75-0.85), respectively. The model's calibration plot suggested excellent consistency between the predicted and actual probabilities. CONCLUSIONS This study's prediction model demonstrated good discrimination and calibration abilities to predict in-hospital mortality of elderly patients with persistent S-AKI, although it warrants further external validation to verify its accuracy and applicability.
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Affiliation(s)
- Wei Jiang
- Medical College, Yangzhou University, Yangzhou, China
- Intensive Care Unit, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Chuanqing Zhang
- Medical College, Yangzhou University, Yangzhou, China
- Intensive Care Unit, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Jiangquan Yu
- Medical College, Yangzhou University, Yangzhou, China
- Intensive Care Unit, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Jun Shao
- Medical College, Yangzhou University, Yangzhou, China
- Intensive Care Unit, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Ruiqiang Zheng
- Medical College, Yangzhou University, Yangzhou, China
- Intensive Care Unit, Northern Jiangsu People's Hospital, Yangzhou, China
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Swartling O, Evans M, Larsson P, Gilg S, Holmberg M, Klevebro F, Löhr M, Sparrelid E, Ghorbani P. Risk factors for acute kidney injury after pancreatoduodenectomy, and association with postoperative complications and death. Pancreatology 2023; 23:227-233. [PMID: 36639282 DOI: 10.1016/j.pan.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/02/2023] [Accepted: 01/04/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is associated with increased morbidity and mortality after general surgery, although little is known among patients undergoing pancreatoduodenectomy. The objective was to investigate the association between AKI and postoperative complications and death after pancreatoduodenectomy. METHODS All patients ≥18 years who underwent a pancreatoduodenectomy 2008-2019 at the Karolinska University Hospital, Stockholm, Sweden, were included. Standardized criteria for AKI, including estimated glomerular filtration rate (eGFR) and urine volume measurements, were used to grade postoperative AKI. RESULTS In total, 970 patients were included with a median age of 68 years (IQR 61-74) of whom 517 (53.3%) were men. There were 137 (14.1%) patients who developed postoperative AKI. Risk factors for AKI included lower preoperative eGFR, cardiovascular disease and treatment with renin-angiotensin system inhibitors or diuretics. Those who developed AKI had a higher risk of severe postoperative complications, including Clavien-Dindo score ≥ IIIa (adjusted OR 3.35, 95% CI 2.24-5.01) and ICU admission (adjusted OR 7.83, 95% CI 4.39-13.99). In time-to-event analysis, AKI was associated with an increased risk for both 30-day mortality (adjusted HR 4.51, 95% CI 1.54-13.27) and 90-day mortality (adjusted HR 4.93, 95% CI 2.37-10.26). Patients with benign histology and AKI also had an increased 1-year mortality (HR 4.89, 95% CI 1.88-12.71). CONCLUSIONS Postoperative AKI was associated with major postoperative complications and an increased risk of postoperative mortality. Monitoring changes in serum creatinine levels and urine volume output could be important in the immediate perioperative period to improve outcomes after pancreatoduodenectomy.
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Affiliation(s)
- Oskar Swartling
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Marie Evans
- Renal Unit, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Patrik Larsson
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Gilg
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Holmberg
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Matthias Löhr
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
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Carlson WD, Keck PC, Bosukonda D, Carlson FR. A Process for the Design and Development of Novel Bone Morphogenetic Protein-7 (BMP-7) Mimetics With an Example: THR-184. Front Pharmacol 2022; 13:864509. [PMID: 35873578 PMCID: PMC9306349 DOI: 10.3389/fphar.2022.864509] [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: 01/28/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022] Open
Abstract
Growth Factors have been evaluated as therapeutic targets for the treatment of a broad spectrum of diseases. Because they are proteins with pleiotropic effects, the quest to harness their beneficial effects has presented challenges. Most Growth Factors operate at the extracellular-receptor level and have natural feedback mechanisms that modulate their effects. As proteins, they are difficult and expensive to manufacture. Frequently proteins must be administered parenterally, may invoke an immune response, and may be neutralized by naturally occurring inhibitors. To circumvent these limitations, we have undertaken an effort to develop mimetics for the Bone Morphogenetic Protein (BMP) signaling pathway effects that incorporate the beneficial effects, eliminate the deleterious effects, and thereby create effective drug-like compounds.To this end, we have designed and tested a family of small peptide BMP mimetics. The design used the three-dimensional structure of BMP-7 to identify likely active surface regions. Lead sequences were then optimized based on in vitro assays that examine the selective binding to BMP receptors, demonstrate the phosphorylation of Smad-1,5,8, detect anti-apoptosis and anti-inflammation, and block the epithelial to mesenchymal transition (EMT) in renal tubular epithelial cells. These sequences were further optimized using in vivo assays of the attenuation of acute kidney injury in a rat-model of unilateral clamp ischemic reperfusion. This process uses a Structure Variance Analysis algorithm (SVA) to identify structure/activity relationships. One member of this family, THR-184, is an agonist of BMP signaling and a potent antagonist of TGFβ signaling. This small peptide mimetic inhibits inflammation, apoptosis, fibrosis and reverses epithelial to mesenchymal transition (EMT) by regulating multiple signaling pathways involved in the cellular injury of multiple organs. Its effects have been shown to control Acute Kidney Injury (AKI). THR-184 has progressed through phase I and II clinical trials for the prevention of Cardio-Vascular Surgery (CVS) associated AKI. This work provides a roadmap for the development of other growth factor mimetics and demonstrates how we might harness their therapeutic potential.
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Affiliation(s)
- William D. Carlson
- Division of Cardiology, Mass General Hospital/Harvard, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Therapeutics By Design, Boston, MA, United States
- Thrasos Therapeutics, Hopkinton, MA, United States
- *Correspondence: William D. Carlson,
| | - Peter C. Keck
- Therapeutics By Design, Boston, MA, United States
- Thrasos Therapeutics, Hopkinton, MA, United States
| | - Dattatreyamurty Bosukonda
- Division of Cardiology, Mass General Hospital/Harvard, Boston, MA, United States
- Therapeutics By Design, Boston, MA, United States
- Thrasos Therapeutics, Hopkinton, MA, United States
| | - Frederic Roy Carlson
- Therapeutics By Design, Boston, MA, United States
- Thrasos Therapeutics, Hopkinton, MA, United States
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Role of Urinary Kidney Stress Biomarkers for Early Recognition of Subclinical Acute Kidney Injury in Critically Ill COVID-19 Patients. Biomolecules 2022; 12:biom12020275. [PMID: 35204776 PMCID: PMC8961647 DOI: 10.3390/biom12020275] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 02/06/2023] Open
Abstract
A high proportion of critically ill patients with COVID-19 develop acute kidney injury (AKI) and die. The early recognition of subclinical AKI could contribute to AKI prevention. Therefore, this study was aimed at exploring the role of the urinary biomarkers NGAL and [TIMP-2] × [IGFBP7] for the early detection of AKI in this population. This prospective, longitudinal cohort study included critically ill COVID-19 patients without AKI at study entry. Urine samples were collected on admission to critical care areas for determination of NGAL and [TIMP-2] × [IGFBP7] concentrations. The demographic information, comorbidities, clinical, and laboratory data were recorded. The study outcomes were the development of AKI and mortality during hospitalization. Of the 51 individuals that were studied, 25 developed AKI during hospitalization (49%). Of those, 12 had persistent AKI (23.5%). The risk factors for AKI were male gender (HR = 7.57, 95% CI: 1.28–44.8; p = 0.026) and [TIMP-2] × [IGFBP7] ≥ 0.2 (ng/mL)2/1000 (HR = 7.23, 95% CI: 0.99–52.4; p = 0.050). Mortality during hospitalization was significantly higher in the group with AKI than in the group without AKI (p = 0.004). Persistent AKI was a risk factor for mortality (HR = 7.42, 95% CI: 1.04–53.04; p = 0.046). AKI was frequent in critically ill COVID-19 patients. The combination of [TIMP-2] × [IGFBP7] together with clinical information, were useful for the identification of subclinical AKI in critically ill COVID-19 patients. The role of additional biomarkers and their possible combinations for detection of AKI in ritically ill COVID-19 patients remains to be explored in large clinical trials.
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Halmy L, Riedel J, Zeman F, Tege B, Linder V, Gnewuch C, Graf BM, Schlitt HJ, Bergler T, Göcze I. Renal Recovery after the Implementation of an Electronic Alert and Biomarker-Guided Kidney-Protection Strategy following Major Surgery. J Clin Med 2021; 10:jcm10215122. [PMID: 34768642 PMCID: PMC8584790 DOI: 10.3390/jcm10215122] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 12/29/2022] Open
Abstract
Background: The facilitation of early recovery of acute kidney injury (AKI) is an important step to improve outcome, particularly because of the limited therapeutic interventions currently available for AKI. The combination of an electronic alert and biomarker-guided kidney-protection strategy implemented in the routine care may have an impact on the incidence of early complete reversal of AKI after major non-cardiac surgery. Methods: We studied 294 patients in two cohorts before (n = 151) and after protocol implementation (n = 143). Data collection required 6 months for each cohort. The kidney-protection protocol included an electronic alert to detect patients who were eligible for urinary biomarker [TIMP2 × IGFBP7]-guided kidney-protection intervention. Intervention was stratified according to three levels of immediate AKI risk: low, moderate, and high. After intervention, postoperative changes in the glomerular filtration rate (eGFR) were identified with a tracking software that included an alert for nephrology consultation if the eGFR had declined by >25% from the preoperative reference value. Primary outcome was early AKI recovery, i.e., the complete reversal of any AKI stage to absence of AKI within the first 7 postoperative days. Results: Protocol implementation significantly increased the recovery of AKI (36/46, 78% compared to control 27/48, 56%, (p = 0.025)) and reduced the length of the ICU stay (p < 0.001). There was no significant difference in the overall incidence of all AKI and moderate and severe AKI in the first 7 postoperative days: 46/143 (32%) and 12/151 (8%) in the protocol implementation group compared to 48/151 (32%) and 18/151 (12%) in the historical control group. Patients with AKI reversal within the first 7 postoperative days had lower in-hospital mortality than patients without AKI reversal. Conclusions: Implementing a combined electronic alert and biomarker-guided kidney-protection strategy in routine care improved early recovery of AKI after major surgery.
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Affiliation(s)
- Laszlo Halmy
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (L.H.); (H.J.S.)
| | - Joshua Riedel
- Medical Faculty, University of Regensburg, Universitätsstraße 31, 93053 Regensburg, Germany;
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany;
| | - Birgit Tege
- Department IT, Information Technology and Clinical Applications, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (B.T.); (V.L.)
| | - Volker Linder
- Department IT, Information Technology and Clinical Applications, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (B.T.); (V.L.)
| | - Carsten Gnewuch
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany;
| | - Bernhard M. Graf
- Department of Anesthesiology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany;
| | - Hans J. Schlitt
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (L.H.); (H.J.S.)
| | - Tobias Bergler
- Department of Nephrology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany;
| | - Ivan Göcze
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (L.H.); (H.J.S.)
- Correspondence: ; Tel.: +49-941-9440; Fax: +49-941-944-6882
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Ding C, Hu T. Development and External Verification of a Nomogram for Patients with Persistent Acute Kidney Injury in the Intensive Care Unit. Int J Gen Med 2021; 14:5005-5015. [PMID: 34511984 PMCID: PMC8412828 DOI: 10.2147/ijgm.s325904] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/12/2021] [Indexed: 12/25/2022] Open
Abstract
Background We aimed to identify the affecting features of persistent acute kidney injury (pAKI) for patients in intensive care units (ICU). Methods The Medical Information Mart for Intensive Care IV (MIMIC-IV) database and eICU Collaborative Research Database (eICU-CRD) were used to identify AKI patients with and without duration of more than 48 hours. Least absolute shrinkage and selection operator (LASSO) regression and support vector machine (SVM-RFE) were utilized to screen for the significant clinical indexes associated with pAKI. Predictive nomogram was created based on the above informative parameters to predict the probability of pAKI. Results LASSO regression and SVM-RFE revealed that serum albumin, chronic kidney disease, AKI stage, sequential organ failure assessment score, lactate and renal replacement therapy during the first day were significantly associated with pAKI in the training cohort. The predictive nomogram based on the six predictors exhibited good predictive performance as calculated by C-index 0.730 (95% CI 0.710-0.749) in the training group, 0.702 (95% CI 0.672-0.722) in the internal validation set and 0.704 (0.677-0.731) in the external validation cohort for the prediction of pAKI. Moreover, the predictive nomogram exhibited not only encouraging calibration ability, but also great clinical utility in the training group, in the internal validation group as well as in the external validation cohort. Conclusion Serum albumin, CKD, AKI stage, SOFA score, lactate, RRT during the first day were closely associated with pAKI in patients in ICU. The predictive nomogram for pAKI manifested good predictive ability for the identification of ICU patients with pAKI.
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Affiliation(s)
- Chao Ding
- Department of Hematology, Suining Central Hospital, An Affiliated Hospital of Chongqing Medical University, Suining, Sichuan Province, People's Republic of China
| | - Tianyang Hu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
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Guangyu Y, Jingfeng L, Xing L, Hong Y, Yao L. Cardio- and Cerebrovascular Outcomes of Postoperative Acute Kidney Injury in Noncardiac Surgical Patients With Hypertension. Front Pharmacol 2021; 12:696456. [PMID: 34512331 PMCID: PMC8430207 DOI: 10.3389/fphar.2021.696456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/05/2021] [Indexed: 11/26/2022] Open
Abstract
Background: The cardiovascular and cerebrovascular risk of postoperative acute kidney injury (AKI) in surgical patients is poorly described, especially in the hypertensive population. Methods: We conducted a retrospective cohort study among all hypertensive patients who underwent elective noncardiac surgery from January 1st, 2012 to August 1st, 2017 at the Third Xiangya Hospital. The primary outcomes were fatal stroke and fatal myocardial infarction (MI). The secondary outcomes were all-cause mortality. Results: The postoperative cumulative mortality within 3 months, 6 months, 1 year, 2 years, and 5 years were 1.27, 1.48, 2.15, 2.15, and 5.36%, for fatal stroke, and 2.05, 2.27, 2.70, 3.37, and 5.61% for fatal MI, respectively, in patients with postoperative AKI. Compared with non-AKI patients, those with postoperative AKI had a significantly higher risk of fatal stroke and fatal MI within 3 months [hazard ratio (HR): 5.49 (95% CI: 1.88−16.00) and 11.82 (95% CI: 4.56−30.62), respectively], 6 months [HR: 3.58 (95% CI: 1.43−8.97) and 9.23 (95% CI: 3.89−21.90), respectively], 1 year [HR: 3.64 (95% CI: 1.63−8.10) and 5.14 (95% CI: 2.50−10.57), respectively], 2 years [HR: 2.21 (95% CI: 1.03−4.72) and 3.06 (95% CI: 1.66−5.64), respectively], and 5 years [HR: 2.27 (95% CI: 1.30−3.98) and 1.98 (95% CI: 1.16−3.20), respectively]. In subgroup analysis of perioperative blood pressure (BP) lowering administration, postoperative AKI was significantly associated with 1-year and 5-year risk of fatal stroke [HR: 9.46 (95% CI: 2.85−31.40) and 3.88 (95% CI: 1.67−9.01), respectively] in patients with ACEI/ARB, and MI [HR: 6.62 (95% CI: 2.23−19.62) and 2.44 (95% CI: 1.22−4.90), respectively] in patients with CCB. Conclusion: Hypertensive patients with postoperative AKI have a significantly higher risk of fatal stroke and fatal MI, as well as all-cause mortality, within 5 years after elective noncardiac surgery. In patients with perioperative administration of ACEI/ARB and CCB, postoperative AKI was significantly associated with higher risk of fatal stroke and MI, respectively.
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Affiliation(s)
- Yan Guangyu
- Center of Clinical Research, The Third Xiangya Hospital, Central South University, Changsha, China.,Department of General Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Lou Jingfeng
- Center of Clinical Research, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Liu Xing
- Department of Anesthesia, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yuan Hong
- Center of Clinical Research, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Lu Yao
- Center of Clinical Research, The Third Xiangya Hospital, Central South University, Changsha, China.,Department of Life Science and Medicine, King's College London, London, United Kingdom.,Key Laboratory of Medical Information Research(Central South University), College of Hunan Province, Changsha, China
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Gameiro J, Marques F, Lopes JA. Long-term consequences of acute kidney injury: a narrative review. Clin Kidney J 2021; 14:789-804. [PMID: 33777362 PMCID: PMC7986368 DOI: 10.1093/ckj/sfaa177] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/20/2020] [Indexed: 12/24/2022] Open
Abstract
The incidence of acute kidney injury (AKI) has increased in the past decades. AKI complicates up to 15% of hospitalizations and can reach up to 50-60% in critically ill patients. Besides the short-term impact of AKI in patient outcomes, several studies report the association between AKI and adverse long-term outcomes, such as recurrent AKI episodes in 25-30% of cases, hospital re-admissions in up to 40% of patients, an increased risk of cardiovascular events, an increased risk of progression of chronic kidney disease (CKD) after AKI and a significantly increased long-term mortality. Despite the long-term impact of AKI, there are neither established guidelines on the follow-up care of AKI patients, nor treatment strategies to reduce the incidence of sequelae after AKI. Only a minority of patients have been referred to nephrology post-discharge care, despite the evidence of improved outcomes associated with nephrology referral by addressing cardiovascular risk and risk of progression to CKD. Indeed, AKI survivors should have specialized nephrology follow-up to assess kidney function after AKI, perform medication reconciliation, educate patients on nephrotoxic avoidance and implement strategies to prevent CKD progression. The authors provide a comprehensive review of the transition from AKI to CKD, analyse the current evidence on the long-term outcomes of AKI and describe predisposing risk factors, highlight the importance of follow-up care in these patients and describe the current therapeutic strategies which are being investigated on their impact in improving patient outcomes.
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Affiliation(s)
- Joana Gameiro
- Department of Medicine, Division of Nephrology and Renal Transplantation, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal
| | - Filipe Marques
- Department of Medicine, Division of Nephrology and Renal Transplantation, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal
| | - José António Lopes
- Department of Medicine, Division of Nephrology and Renal Transplantation, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal
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