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Moll V, Zhao M, Minear S, Swaminathan M, Kurz A, Huang J, Parr KG, Stanton K, Khanna AK. Continuous Urine Output-Based Alert Identifies Cardiac Surgery-associated Acute Kidney Injury Earlier Than Serum Creatinine: A Prospective and Retrospective Observational Study. J Cardiothorac Vasc Anesth 2024; 38:2238-2246. [PMID: 39019742 DOI: 10.1053/j.jvca.2024.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 06/15/2024] [Indexed: 07/19/2024]
Abstract
OBJECTIVE(S) Acute kidney injury (AKI) is defined and staged by reduced urine output (UO) and increased serum creatinine (SCr). UO is typically measured manually and documented in the electronic health record, making early and reliable detection of oliguria-based AKI and electronic data extraction challenging. The authors investigated the diagnostic performance of continuous UO, enabled by active drain line clearance-based alerts (Accuryn AKI Alert), compared with AKI stage 2 SCr criteria and their associations with length of stay, need for continuous renal replacement therapy, and 30-day mortality. DESIGN This study was a prospective and retrospective observational study. SETTING Nine tertiary centers participated. PARTICIPANTS Cardiac surgery patients were enrolled. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 522 patients were analyzed. AKI stages 1, 2, and 3 were diagnosed in 32.18%, 30.46%, and 3.64% of patients based on UO, compared with 33.72%, 4.60%, and 3.26% of patients using SCr, respectively. Continuous UO-based alerts diagnosed stage ≥1 AKI 33.6 (IQR =15.43, 95.68) hours before stage ≥2 identified by SCr criteria. A SCr-based diagnosis of AKI stage ≥2 has been designated a Hospital Harm by the Centers for Medicare & Medicaid Services. Using this criterion as a benchmark, AKI alerts had a discriminative power of 0.78. The AKI Alert for stage 1 was significantly associated with increased intensive care unit and hospital length of stay and continuous renal replacement therapy, and stage ≥2 alerts were associated with mortality. CONCLUSIONS AKI Alert, based on continuous UO and enabled by active drain line clearance, detected AKI stages 1 and 2 before SCr criteria. Early AKI detection allows for early kidney optimization, potentially improving patient outcomes.
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Affiliation(s)
- Vanessa Moll
- Department of Anesthesiology, Division of Critical Care Medicine, University of Minnesota, Minneapolis, MN; Department of Anesthesiology, Division of Critical Care Medicine, Emory School of Medicine, Atlanta, GA.
| | - Manxu Zhao
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Steven Minear
- Department of Anesthesiology, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Madhav Swaminathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Andrea Kurz
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH; Department of General Anesthesiology, Emergency and Intensive Care Medicine, University of Graz, 8036 Graz, Austria
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY
| | - K Gage Parr
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Ashish K Khanna
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC; Outcomes Research Consortium, Cleveland, OH
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2
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Villegas CV, Gorman E, Liu FM, Winchell RJ. Acute kidney injury in the acute care surgery patient: What you need to know. J Trauma Acute Care Surg 2024:01586154-990000000-00800. [PMID: 39238092 DOI: 10.1097/ta.0000000000004401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2024]
Abstract
ABSTRACT Acute kidney injury is associated with poor outcomes in the trauma and emergency general surgery population, and recent consensus definitions have allowed for significant advances in defining the burden of disease. The current definitions rely on overall functional measures (i.e., serum creatinine and urine output), which can be confounded by a variety of clinical factors. Biomarkers are increasingly being investigated as more direct diagnostic assays for the diagnosis of acute kidney injury and may allow earlier detection and more timely therapeutic intervention. Etiologies fall into two general categories: disorders of renal perfusion and exposure to nephrotoxic agents. Therapy is largely supportive, and prevention offers the best chance to decrease clinical impact.
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Affiliation(s)
- Cassandra V Villegas
- From the Department of Surgery (C.V.V., E.G., R.J.W.), and Department of Nephrology (F.M.L.), Weill Cornell Medicine, New York, New York
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Wang J, Luo C, Luo M, Zhou S, Kuang G. Targets and Mechanisms of Xuebijing in the Treatment of Acute Kidney Injury Associated with Sepsis: A Network Pharmacology-based Study. Curr Comput Aided Drug Des 2024; 20:752-763. [PMID: 37211841 DOI: 10.2174/1573409919666230519121138] [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: 09/01/2022] [Revised: 03/05/2023] [Accepted: 04/12/2023] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Sepsis is a state of the systemic inflammatory response of the host induced by infection, frequently affecting numerous organs and producing varied degrees of damage. The most typical consequence of sepsis is sepsis-associated acute kidney injury(SA-AKI). Xuebijing is developed based on XueFuZhuYu Decoction. Five Chinese herbal extracts, including Carthami Flos, Radix Paeoniae Rubra, Chuanxiong Rhizoma, Radix Salviae, and Angelicae Sinensis Radix, make up the majority of the mixture. It has properties that are anti-inflammatory and anti-oxidative stress. Xuebijing is an effective medication for the treatment of SA-AKI, according to clinical research. But its pharmacological mechanism is still not completely understood. METHODS First, the composition and target information of Carthami Flos, Radix Paeoniae Rubra, Chuanxiong Rhizoma, Radix Salviae, and Angelicae Sinensis Radix were collected from the TCMSP database, while the therapeutic targets of SA-AKI were exported from the gene card database. To do a GO and KEGG enrichment analysis, we first screened the key targets using a Venn diagram and Cytoscape 3.9.1. To assess the binding activity between the active component and the target, we lastly used molecular docking. RESULTS For Xuebijing, a total of 59 active components and 267 corresponding targets were discovered, while for SA-AKI, a total of 1,276 targets were connected. There were 117 targets in all that was shared by goals for active ingredients and objectives for diseases. The TNF signaling pathway and the AGE-RAGE pathway were later found to be significant pathways for the therapeutic effects of Xuebijing by GO analysis and KEGG pathway analysis. Quercetin, luteolin, and kaempferol were shown to target and modulate CXCL8, CASP3, and TNF, respectively, according to molecular docking results. CONCLUSION This study predicts the mechanism of action of the active ingredients of Xuebijing in the treatment of SA-AKI, which provides a basis for future applications of Xuebijing and studies targeting the mechanism.
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Affiliation(s)
- Jing Wang
- Department of Blood Transfusion, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Chengyu Luo
- Department of Clinical Medicine, Faculty of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Mengling Luo
- Department of Clinical Medicine, Faculty of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Siwen Zhou
- Department of Clinical Medicine, Faculty of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Guicheng Kuang
- Department of Clinical Medicine, Faculty of Clinical Medicine, Southwest Medical University, Luzhou, China
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4
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Kashani KB, Koyner JL. Digital health utilities in acute kidney injury management. Curr Opin Crit Care 2023; 29:542-550. [PMID: 37861196 PMCID: PMC11285742 DOI: 10.1097/mcc.0000000000001105] [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] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) is a highly prevalent clinical syndrome that substantially impacts patient outcomes. It is accepted by the clinical communities that the management of AKI is time-sensitive. Unfortunately, despite growing proof of its preventability, AKI management remains suboptimal in community, acute care, and postacute care settings. Digital health solutions comprise various tools and models to improve care processes and patient outcomes in multiple medical fields. AKI development, progression, recovery, or lack thereof, offers tremendous opportunities for developing, validating, and implementing digital health solutions in multiple settings. This article will review the definitions and components of digital health, the characteristics of AKI that allow digital health solutions to be considered, and the opportunities and threats in implementing these solutions. RECENT FINDINGS Over the past two decades, the academic output related to the use of digital health solutions in AKI has exponentially grown. While this indicates the growing interest in the topic, most topics are primarily related to clinical decision support by detecting AKI within hospitals or using artificial intelligence or machine learning technologies to predict AKI within acute care settings. However, recently, projects to assess the impact of digital health solutions in more complex scenarios, for example, managing nephrotoxins among adults of pediatric patients who already have AKI, is increasing. Depending on the type of patients, chosen digital health solution intervention, comparator groups, and selected outcomes, some of these studies showed benefits, while some did not indicate additional gain in care processes or clinical outcomes. SUMMARY Careful needs assessment, selection of the correct digital health solution, and appropriate clinical validation of the benefits while avoiding additional health disparities are moral, professional, and ethical obligations for all individuals using these healthcare tools, including clinicians, data scientists, and administrators.
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Affiliation(s)
- Kianoush B. Kashani
- Division of Nephrology and Hypertension, University of Chicago, Chicago, Illinois, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, University of Chicago, Chicago, Illinois, USA
| | - Jay L. Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
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5
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Martin-Cleary C, Sanz AB, Avello A, Sanchez-Niño MD, Ortiz A. NephroCheck at 10: addressing unmet needs in AKI diagnosis and risk stratification. Clin Kidney J 2023; 16:1359-1366. [PMID: 37664563 PMCID: PMC10468756 DOI: 10.1093/ckj/sfad146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Indexed: 09/05/2023] Open
Abstract
Despite its name, the current diagnosis of acute kidney injury (AKI) still depends on markers of decreased kidney function and not on markers of injury. This results in a delayed diagnosis: AKI is diagnosed based on serum creatinine criteria only when the severity of injury is enough to decrease glomerular filtration rate. Moreover, by the time AKI is diagnosed, the insult may have already ceased, and even appropriate therapy targeted at the specific insult and its associated pathogenic pathways may no longer be effective. Biomarkers of injury are needed that allow the diagnosis of AKI based on injury criteria. At least three commercially available immunoassays assessing urinary or plasma neutrophil gelatinase-associated lipocalin and urinary tissue inhibitor of metalloproteinases-2 × insulin-like growth factor-binding protein-7 ([TIMP2]*[IGFBP7]) (NephroCheck®) have generated promising data regarding prediction and early diagnosis of AKI, although their relative performance may depend on clinical context. Recently, a urinary peptidomics classifier (PeptAKI) was reported to predict AKI better than current biomarkers. Focusing on [TIMP2]*[IGFBP7], the cellular origin of urinary TIMP2 and IGFBP7 remains unclear, especially under the most common predisposing condition for AKI, i.e. chronic kidney disease. We now discuss novel data on the kidney cell expression of TIMP2 and IGFBP7 and its clinical implications.
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Affiliation(s)
- Catalina Martin-Cleary
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
- RICORS2040, Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ana Belen Sanz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
- RICORS2040, Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
| | - Alejandro Avello
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
- RICORS2040, Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
| | - Maria Dolores Sanchez-Niño
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
- RICORS2040, Madrid, Spain
- Departamento de Farmacología, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
| | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
- RICORS2040, Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
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6
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Lofgren L, Silverton N, Kuck K. Combining Machine Learning and Urine Oximetry: Towards an Intraoperative AKI Risk Prediction Algorithm. J Clin Med 2023; 12:5567. [PMID: 37685632 PMCID: PMC10488092 DOI: 10.3390/jcm12175567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
Acute kidney injury (AKI) affects up to 50% of cardiac surgery patients. The definition of AKI is based on changes in serum creatinine relative to a baseline measurement or a decrease in urine output. These monitoring methods lead to a delayed diagnosis. Monitoring the partial pressure of oxygen in urine (PuO2) may provide a method to assess the patient's AKI risk status dynamically. This study aimed to assess the predictive capability of two machine learning algorithms for AKI in cardiac surgery patients. One algorithm incorporated a feature derived from PuO2 monitoring, while the other algorithm solely relied on preoperative risk factors. The hypothesis was that the model incorporating PuO2 information would exhibit a higher area under the receiver operator characteristic curve (AUROC). An automated forward variable selection method was used to identify the best preoperative features. The AUROC for individual features derived from the PuO2 monitor was used to pick the single best PuO2-based feature. The AUROC for the preoperative plus PuO2 model vs. the preoperative-only model was 0.78 vs. 0.66 (p-value < 0.01). In summary, a model that includes an intraoperative PuO2 feature better predicts AKI than one that only includes preoperative patient data.
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Affiliation(s)
- Lars Lofgren
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA;
| | - Natalie Silverton
- Department of Anesthesiology, University of Utah, Salt Lake City, UT 84112, USA;
- Geriatric Research, Education and Clinical Centre, Veteran Affairs Medical Center, Salt Lake City, UT 84112, USA
| | - Kai Kuck
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA;
- Department of Anesthesiology, University of Utah, Salt Lake City, UT 84112, USA;
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7
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Hahn RG, Weinberg L, Li Y, Bahlmann H, Bellomo R, Wuethrich PY. Concentrated urine, low urine flow, and postoperative elevation of plasma creatinine: A retrospective analysis of pooled data. PLoS One 2023; 18:e0290071. [PMID: 37590224 PMCID: PMC10434918 DOI: 10.1371/journal.pone.0290071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 08/01/2023] [Indexed: 08/19/2023] Open
Abstract
Elevations of plasma creatinine are common after major surgery, but their pathophysiology is poorly understood. To identify possible contributing mechanisms, we pooled data from eight prospective studies performed in four different countries to study circumstances during which elevation of plasma creatinine occurs. We included 642 patients undergoing mixed major surgeries, mostly open gastrointestinal. Plasma and urinary creatinine and a composite index for renal fluid conservation (Fluid Retention Index, FRI) were measured just before surgery and on the first postoperative morning. Urine flow was measured during the surgery. The results show that patients with a postoperative increase in plasma creatinine by >25% had a high urinary creatinine concentration (11.0±5.9 vs. 8.3±5.6 mmol/L; P< 0001) and higher FRI value (3.2±1.0 vs. 2.9±1.1; P< 0.04) already before surgery was initiated. Progressive increase of plasma creatinine was associated with a gradually lower urine flow and larger blood loss during the surgery (Kruskal-Wallis test, P< 0.001). The patients with an elevation > 25% also showed higher creatinine and a higher FRI value on the first postoperative morning (P< 0.001). Elevations to > 50% of baseline were associated with slightly lower mean arterial pressure (73 ± 10 vs. 80 ± 12 mmHg; P< 0.005). We conclude that elevation of plasma creatinine in the perioperative period was associated with low urine flow and greater blood loss during surgery and with concentrated urine both before and after the surgery. Renal water conservation-related mechanisms seem to contribute to the development of increased plasma creatinine after surgery.
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Affiliation(s)
- Robert G. Hahn
- Karolinska Institutet at Danderyds Hospital (KIDS), Stockholm, Sweden
| | - Laurence Weinberg
- Department of Anesthesia, Austin Hospital; Melbourne, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
| | - Yuhong Li
- Department of Anesthesiology, Shulan International Hospital, Shuren University, Hangzhou, 3100004, Zhejiang Province, PR of China
| | - Hans Bahlmann
- Department of Anesthesiology and Intensive Care in Linköping, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Department of Critical Care, The University of Melbourne; Melbourne, Australia
| | - Patrick Y. Wuethrich
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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8
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Lacquaniti A, Ceresa F, Campo S, Barbera G, Caruso D, Palazzo E, Patanè F, Monardo P. Acute Kidney Injury and Sepsis after Cardiac Surgery: The Roles of Tissue Inhibitor Metalloproteinase-2, Insulin-like Growth Factor Binding Protein-7, and Mid-Regional Pro-Adrenomedullin. J Clin Med 2023; 12:5193. [PMID: 37629236 PMCID: PMC10455441 DOI: 10.3390/jcm12165193] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Identifying a panel of markers detecting kidney injury before the glomerular filtration rate reduction is a challenge to improving the diagnosis and management of acute kidney injury (AKI) in septic patients. This study evaluated the roles of tissue inhibitor metal proteinase-2, insulin growth factor binding protein-7 (TIMP2*IGFBP7), and mid-regional pro-adrenomedullin (MR-proADM) in patients with AKI. PATIENTS AND METHODS This study was prospectively conducted in an intensive care unit (ICU) enrolling 230 patients who underwent cardiac surgery. Biomarkers were evaluated before and after 4 h of the cardiac surgery. RESULTS Whereas urine and creatinine alterations appeared at 23.2 (12.7-36.5) hours after cardiac surgery, urinary TIMP2*IGBP7 levels were higher at 4 h in AKI patients (1.1 ± 0.4 mg/L vs. 0.08 ± 0.02 mg/L; p < 0.001). Its concentration > 2 mg/L increases AKI risk within the following 24 h, clearly identifying the population at high risk of renal replacement therapy (RRT). In patients with sepsis, MR-proADM levels were 2.3 nmol/L (0.7-7.8 nmol/L), with the highest values observed in septic shock patients (5.6 nmol/L (3.2-18 nmol/L)) and a better diagnostic profile than procalcitonin and C-reactive protein to identify septic patients. MR-proADM values > 5.1 nmol/L and urine TIMP2*IGBP7 levels > 2 mg/L showed a significantly faster progression to RRT, with a mean follow-up time of 1.1 days. CONCLUSIONS TIMP2*IGBP7 and MR-proADM precociously diagnose AKI in septic patients after cardiac surgery, giving prognostic information for RRT requirement.
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Affiliation(s)
| | - Fabrizio Ceresa
- Cardiac Surgery Unit, Papardo Hospital, 98158 Messina, Italy
| | - Susanna Campo
- Nephrology and Dialysis Unit, Papardo Hospital, 98158 Messina, Italy
| | - Giovanna Barbera
- Clinical Pathology Unit, Papardo Hospital, 98158 Messina, Italy (D.C.)
| | - Daniele Caruso
- Clinical Pathology Unit, Papardo Hospital, 98158 Messina, Italy (D.C.)
| | - Elenia Palazzo
- Clinical Pathology Unit, Papardo Hospital, 98158 Messina, Italy (D.C.)
| | | | - Paolo Monardo
- Nephrology and Dialysis Unit, Papardo Hospital, 98158 Messina, Italy
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9
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Williams VL, Groetzinger LM, Smithburger PL, Imhoff A, Culley CM, Murugan R, Kellum JA, Kane-Gill SL. Case presentations of medication management for patients at risk for drug-associated acute kidney injury identified with a CDS system and a novel biomarker. Am J Health Syst Pharm 2023; 80:423-429. [PMID: 36308452 DOI: 10.1093/ajhp/zxac322] [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: 10/27/2022] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Traditional methods used to evaluate changes in kidney function to identify acute kidney injury (AKI) have significant limitations. Damage biomarkers can identify patients at risk for AKI prior to changes in kidney function. While clinical trials have shown that biomarker-guided treatment can improve outcomes, whether these biomarkers can influence providers' choice of treatment strategy for risk prediction, surveillance, or diagnostic evaluation in clinical practice is uncertain. SUMMARY This case series describes 4 patients at an academic medical center whose care was informed by kidney biomarker utilization in conjunction with a clinical decision support system (CDSS). Though each patient's clinical presentation was unique, kidney biomarkers were successfully employed as clinical tools in evaluating the risks and benefits of nephrotoxic medications. CONCLUSION This case series demonstrates 4 scenarios in which a kidney injury biomarker used in conjunction with CDSS and consideration of the patients' clinical presentation informed treatment strategies with the intent to prevent AKI.
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Affiliation(s)
| | | | - Pamela L Smithburger
- UPMC Presbyterian, Pittsburgh, PA, and University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | | | - Colleen M Culley
- University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Raghavan Murugan
- UPMC Presbyterian, Pittsburgh, PA, and Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sandra L Kane-Gill
- UPMC Presbyterian, Pittsburgh, PA, and University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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10
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Sůva M, Kala P, Poloczek M, Kaňovský J, Štípal R, Radvan M, Hlasensky J, Hudec M, Brázdil V, Řehořová J. Contrast-induced acute kidney injury and its contemporary prevention. Front Cardiovasc Med 2022; 9:1073072. [PMID: 36561776 PMCID: PMC9763312 DOI: 10.3389/fcvm.2022.1073072] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
Abstract
The complexity and application range of interventional and diagnostic procedures using contrast media (CM) have recently increased. This allows more patients to undergo procedures that involve CM administration. However, the intrinsic CM toxicity leads to the risk of contrast-induced acute kidney injury (CI-AKI). At present, effective therapy of CI-AKI is rather limited. Effective prevention of CI-AKI therefore becomes crucially important. This review presents an in-depth discussion of CI-AKI incidence, pathogenesis, risk prediction, current preventive strategies, and novel treatment possibilities. The review also discusses the difference between CI-AKI incidence following intraarterial and intravenous CM administration. Factors contributing to the development of CI-AKI are considered in conjunction with the mechanism of acute kidney damage. The need for ultimate risk estimation and the prediction of CI-AKI is stressed. Possibilities of CI-AKI prevention is evaluated within the spectrum of existing preventive measures aimed at reducing kidney injury. In particular, the review discusses intravenous hydration regimes and pre-treatment with statins and N-acetylcysteine. The review further focuses on emerging alternative imaging technologies, alternative intravascular diagnostic and interventional procedures, and new methods for intravenous hydration guidance; it discusses the applicability of those techniques in complex procedures and their feasibility in current practise. We put emphasis on contemporary interventional cardiology imaging methods, with a brief discussion of CI-AKI in non-vascular and non-cardiologic imaging and interventional studies.
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Affiliation(s)
- Marek Sůva
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Petr Kala
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia,*Correspondence: Petr Kala,
| | - Martin Poloczek
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jan Kaňovský
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Roman Štípal
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Martin Radvan
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jiří Hlasensky
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Martin Hudec
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Vojtěch Brázdil
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jitka Řehořová
- Department of Internal Medicine and Gastroenterology, University Hospital, Brno, Czechia
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11
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Yang HS, Hur M, Lee KR, Kim H, Kim HY, Kim JW, Chua MT, Kuan WS, Chua HR, Kitiyakara C, Phattharapornjaroen P, Chittamma A, Werayachankul T, Anandh U, Herath S, Endre Z, Horvath AR, Antonini P, Di Somma S. Biomarker Rule-in or Rule-out in Patients With Acute Diseases for Validation of Acute Kidney Injury in the Emergency Department (BRAVA): A Multicenter Study Evaluating Urinary TIMP-2/IGFBP7. Ann Lab Med 2022; 42:178-187. [PMID: 34635611 PMCID: PMC8548247 DOI: 10.3343/alm.2022.42.2.178] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/07/2021] [Accepted: 09/13/2021] [Indexed: 02/06/2023] Open
Abstract
Background Urine tissue inhibitor of metalloproteinases-2/insulin-like growth factor-binding protein 7 (TIMP-2/IGFBP7) (NephroCheck, Ortho Clinical Diagnostics, Raritan, NJ, USA) is a US Food and Drug Administration-approved biomarker for risk assessment of acute kidney injury (AKI) in critically ill adult patients in intensive care units; however, its clinical impact in the emergency department (ED) remains unproven. We evaluated the utility of NephroCheck for predicting AKI development and short-term mortality in the ED. Methods This was a prospective, observational, five-center international study. We consecutively enrolled ED patients admitted with ≥30% risk of AKI development (assessed by ED physician: ED score) or acute diseases. Serum creatinine was tested on ED arrival (T0), day 1, and day 2 (T48); urine for NephroCheck was collected at T0 and T48. We performed ROC curve and reclassification analyses. Results Among the 529 patients enrolled (213 females; median age, 65 years), AKI developed in 59 (11.2%) patients. The T0 NephroCheck value was higher in the AKI group than in the non-AKI group (median 0.77 vs. 0.29 (ng/m)2/1,000, P=0.001), and better predicted AKI development than the ED score (area under the curve [AUC], 0.64 vs. 0.53; P=0.04). In reclassification analyses, adding NephroCheck to the ED score improved the prediction of AKI development (P<0.05). The T0 NephroCheck value predicted 30-day mortality (AUC, 0.68; P<0.001). Conclusions NephroCheck can predict both AKI development and short-term mortality in at-risk ED patients. NephroCheck would be a useful biomarker for early ruling-in or ruling-out of AKI in the ED.
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Affiliation(s)
- Hyun Suk Yang
- Departments of Cardiovascular Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Mina Hur
- Departments of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Kyeong Ryong Lee
- Departments of Emergency Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Hanah Kim
- Departments of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Hahn Young Kim
- Departments of Neurology, Konkuk University School of Medicine, Seoul, Korea
| | - Jong Won Kim
- Departments of Emergency Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Mui Teng Chua
- Department of Emergency Medicine, Division of Nephrology, National University Hospital, National University Health System, Singapore
| | - Win Sen Kuan
- Department of Emergency Medicine, Division of Nephrology, National University Hospital, National University Health System, Singapore
| | - Horng Ruey Chua
- Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Chagriya Kitiyakara
- Departments of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Anchalee Chittamma
- Departments of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thiyapha Werayachankul
- Section of Translational Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Section of Pharmaceutical Care, Faculty of Pharmaceutical Sciences, Burapha University, Chonburi, Thailand
| | - Urmila Anandh
- Department of Nephrology, Yashoda Hospital, Secunderabad, India
| | - Sanjeeva Herath
- Department of Nephrology, Prince of Wales Hospital, Sydney, Australia
| | - Zoltan Endre
- Department of Nephrology, Prince of Wales Hospital, Sydney, Australia
| | - Andrea Rita Horvath
- New South Wales Health Pathology, Department of Chemical Pathology, Prince of Wales Hospital, Sydney, Australia
| | - Paola Antonini
- GREAT Network Italy, University of Rome La Sapienza, Rome, Italy
| | - Salvatore Di Somma
- GREAT Network Italy, University of Rome La Sapienza, Rome, Italy
- Department of Medical-Surgery Sciences and Translational Medicine, University of Rome La Sapienza, Rome, Italy
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Hahn RG, Yanase F, Zdolsek JH, Tosif SH, Bellomo R, Weinberg L. Serum Creatinine Levels and Nephrocheck® Values With and Without Correction for Urine Dilution-A Multicenter Observational Study. Front Med (Lausanne) 2022; 9:847129. [PMID: 35252280 PMCID: PMC8894808 DOI: 10.3389/fmed.2022.847129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 01/25/2022] [Indexed: 11/21/2022] Open
Abstract
Background The Nephrocheck® test is a single-use cartridge designed to measure the concentrations of two novel cell-cycle arrest biomarkers of acute kidney injury, namely tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7). Correlations of serum creatine values and TIMP-2 and IGFBP7 with and without correction for urine dilution have not been previously undertaken in patients undergoing major abdominal surgery. We hypothesized that the Nephrocheck® values would be significantly different with and without correction for urine dilution in patients with elevated creatinine values post major abdominal surgery. Methods We performed a post hoc analysis of serum and urine specimens sampled preoperatively and postoperatively in 72 patients undergoing major abdominal surgery. Thirty samples were measured from patients with the greatest decrease and the greatest increase in postoperative serum creatinine values. Urine was analyzed with the Nephrocheck to predict the risk of acute kidney injury (AKIRisk™). We then examined the relationship between serum creatinine and the urinary excretion of TIMP-2 and IGFBP7 as measured by the Nephrocheck test. The AKIRisk between the groups with and without correction for urine dilution was assessed. Results The median perioperative change in serum creatinine in the two groups was −19% and +57%, respectively. The uncorrected median baseline AKIRisk decreased from 0.70 (25th−75th percentiles, 0.09–1.98) to 0.35 (0.19–0.57) (mg/L)2 in the first group and rose from 0.57 (0.22–1.53) to 0.85 (0.67–2.20) (mg/L)2 in the second group. However, when corrected for the squared urine dilution, the AKIRisk™ in patients with postoperative increases in serum creatinine was not indicative of kidney injury; the corrected AKIRisk was 8.0 (3.2–11.7) μg2/mmol2 before surgery vs.6.9 (5.3–11.0) μg2/mmol2 after the surgery (P = 0.69). Conclusion In the setting of major abdominal surgery, after correction of TIMP-2 and IGFBP7 for urine dilution, the Nephrocheck AKIRisk scores were significantly different from the uncorrected values. These finding imply that the AKIRisk index is a function of urine flow in addition to an increased release of the biomarkers.
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Affiliation(s)
- Robert G. Hahn
- Karolinska Institute at Danderyd's Hospital (KIDS), Stockholm, Sweden
- Department of Research, Sodertalje Hospital, Sodertalje, Sweden
| | - Fumitaka Yanase
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Joachim H. Zdolsek
- Department of Biomedical and Clinical Sciences (BKV), Linköping University, Linköping, Sweden
| | - Shervin H. Tosif
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- *Correspondence: Laurence Weinberg
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Irqsusi M, Beckers J, Wiesmann T, Talipov I, Ramzan R, Rastan AJ, Vogt S. Urinary TIMP-2 and IGFBP-7 protein levels as early predictors of acute kidney injury after cardiac surgery. J Card Surg 2022; 37:717-724. [PMID: 35001430 DOI: 10.1111/jocs.16200] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/18/2021] [Accepted: 11/26/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a frequent complication associated with on-pump cardiac surgery. Early recognition may alter their prognosis. Therefore, the urinary concentrations of TIMP-2 (tissue inhibitor of metalloproteinases-2) and IGFBP7 (insulin-like growth factor-binding protein) as predictors for AKI were studied. METHODS Repetitive blood and urine samples were collected consecutively from 50 patients. Demographic, intra-, and postoperative data were recorded prospectively. To calculate the production of the TIMP-2 and IGFBP-7 protein concentrations, urinary samples were taken preoperatively, intraoperatively at 30 and 60 min after aortic clamping and at 0, 6, 12, and 24 h after admission to the intensive care unit (ICU). RESULTS AKI occurred in 14 patients (28%), all of them at Kidney Disease: Improving Global Outcomes stage 1. Predictive value for [TIMP-2] × [IGFBP7] was shown at 0 and 24 h after admission to ICU. At 0 h, the sensitivity was 84.6% and the specificity 55.6% for an ideal calculated cutoff at 0.07. After 24 h, the ideal cutoff amounted to 0.35 with a sensitivity of 53.8% and a specificity of 88.2%. The receiver operating characteristic curves demonstrated areas under the curve of 0.725 and 0.718. The suggested cutoffs of 0.3 and 2.0 could not be confirmed. The serum creatinine was reached to the peak median within 48 h after admission to ICU. CONCLUSION Postoperative risk assessment for the development of AKI can be established by [ TIMP - 2 ] × [ IGFBP 7 ] . Previously suggested cutoff values could not be confirmed. A correlation with urinary dilution parameters may enable the identification of more universal cutoffs.
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Affiliation(s)
- Marc Irqsusi
- Department of Cardiothoracic Surgery, University Hospital of Giessen and Marburg, Marburg, Germany
| | - Julius Beckers
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Thomas Wiesmann
- Department of Anesthesiology and Intensive Care, University Hospital of Giessen and Marburg, Marburg, Germany
| | - Ildar Talipov
- Department of Cardiothoracic Surgery, University Hospital of Giessen and Marburg, Marburg, Germany
| | - Rabia Ramzan
- Department of Cardiothoracic Surgery, University Hospital of Giessen and Marburg, Marburg, Germany
| | - Ardawan J Rastan
- Department of Cardiothoracic Surgery, University Hospital of Giessen and Marburg, Marburg, Germany
| | - Sebastian Vogt
- Department of Cardiothoracic Surgery, University Hospital of Giessen and Marburg, Marburg, Germany
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Diagnosis of Cardiac Surgery-Associated Acute Kidney Injury. J Clin Med 2021; 10:jcm10163664. [PMID: 34441960 PMCID: PMC8397056 DOI: 10.3390/jcm10163664] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 01/22/2023] Open
Abstract
Acute kidney injury after cardiac surgery is characterized by specific patterns of damage and recovery that are important to consider for management and outcome. The Kidney Disease: Improving Global Outcomes (KDIGO) classification covers only part of the conceptual framework and is thus insufficient for a comprehensive diagnosis. This review highlights the strengths and limitations of the recent criteria and provides an overview of biomarkers of cardiac surgery-associated acute kidney injury (CSA-AKI). The evolving understanding of CSA-AKI as a time-sensitive condition has increased the demand to enhance the diagnostic criteria and translate biomarkers into clinical practice.
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15
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Lee TH, Lee CC, Chen JJ, Fan PC, Tu YR, Yen CL, Kuo G, Chen SW, Tsai FC, Chang CH. Assessment of Cardiopulmonary Bypass Duration Improves Novel Biomarker Detection for Predicting Postoperative Acute Kidney Injury after Cardiovascular Surgery. J Clin Med 2021; 10:jcm10132741. [PMID: 34206256 PMCID: PMC8268369 DOI: 10.3390/jcm10132741] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/15/2021] [Accepted: 06/17/2021] [Indexed: 12/20/2022] Open
Abstract
Urinary liver-type fatty acid binding protein (L-FABP) is a novel biomarker with promising performance in detecting kidney injury. Previous studies reported that L-FABP showed moderate discrimination in patients that underwent cardiac surgery, and other studies revealed that longer duration of cardiopulmonary bypass (CPB) was associated with a higher risk of postoperative acute kidney injury (AKI). This study aims to examine assessing CPB duration first, then examining L-FABP can improve the discriminatory ability of L-FABP in postoperative AKI. A total of 144 patients who received cardiovascular surgery were enrolled. Urinary L-FABP levels were examined at 4 to 6 and 16 to 18 h postoperatively. In the whole study population, the AUROC of urinary L-FABP in predicting postoperative AKI within 7 days was 0.720 at 16 to 18 h postoperatively. By assessing patients according to CPB duration, the urinary L-FABP at 16 to 18 h showed more favorable discriminating ability with AUROC of 0.742. Urinary L-FABP exhibited good performance in discriminating the onset of AKI within 7 days after cardiovascular surgery. Assessing postoperative risk of AKI through CPB duration first and then using urinary L-FABP examination can provide more accurate and satisfactory performance in predicting postoperative AKI.
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Affiliation(s)
- Tao Han Lee
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (T.H.L.); (C.-C.L.); (J.-J.C.); (P.-C.F.); (Y.-R.T.); (C.-L.Y.); (G.K.)
| | - Cheng-Chia Lee
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (T.H.L.); (C.-C.L.); (J.-J.C.); (P.-C.F.); (Y.-R.T.); (C.-L.Y.); (G.K.)
- Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Jia-Jin Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (T.H.L.); (C.-C.L.); (J.-J.C.); (P.-C.F.); (Y.-R.T.); (C.-L.Y.); (G.K.)
| | - Pei-Chun Fan
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (T.H.L.); (C.-C.L.); (J.-J.C.); (P.-C.F.); (Y.-R.T.); (C.-L.Y.); (G.K.)
- Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Yi-Ran Tu
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (T.H.L.); (C.-C.L.); (J.-J.C.); (P.-C.F.); (Y.-R.T.); (C.-L.Y.); (G.K.)
| | - Chieh-Li Yen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (T.H.L.); (C.-C.L.); (J.-J.C.); (P.-C.F.); (Y.-R.T.); (C.-L.Y.); (G.K.)
| | - George Kuo
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (T.H.L.); (C.-C.L.); (J.-J.C.); (P.-C.F.); (Y.-R.T.); (C.-L.Y.); (G.K.)
| | - Shao-Wei Chen
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (S.-W.C.); (F.-C.T.)
| | - Feng-Chun Tsai
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (S.-W.C.); (F.-C.T.)
| | - Chih-Hsiang Chang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (T.H.L.); (C.-C.L.); (J.-J.C.); (P.-C.F.); (Y.-R.T.); (C.-L.Y.); (G.K.)
- Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Correspondence: ; Tel.: +886-3-328-1200
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