1
|
Contrera Rolón N, Cantos J, Huespe I, Prado E, Bratti GI, Schreck C, Giannasi S, Rosa Diez G, Varela CF. Fractional excretion of sodium and potassium and urinary strong ion difference in the evaluation of persistent AKI in sepsis. Med Intensiva 2024:S2173-5727(24)00027-4. [PMID: 38403531 DOI: 10.1016/j.medine.2024.02.003] [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: 10/05/2023] [Accepted: 01/18/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE To evaluate the diagnostic performance of FENa (Fractional excretion of sodium), FEK (fractional excretion of potassium) and uSID (urinary strong ion difference) in predicting pAKI in sepsis and septic shock. DESIGN Retrospective cohort study. SETTING Two intensive care units in Argentina. PATIENTS Adult patients with a confirmed diagnosis of sepsis or septic shock and AKI, and had a urinary biochemistry within 24h of the AKI diagnosis. INTERVENTIONS None. MAIN VARIABLES OF INTEREST We evaluated the diagnostic accuracy of FENa, FEK and uSID through a ROC (Receiver Operating Characteristic) curve analysis. RESULTS 80 patients were included. 40 patients presented pAKI. pAKI group had higher APACHE, SOFA score, and mortality rate. In the ROC curve analysis, uSID had no diagnostic utility (AUC=0.52, p=0.69). FENa presented moderate accuracy showing an AUC of 0.71 (95% CI 0.60-0.83; p=0.001), while FEK presented low accuracy with an AUC of 0.69 (95% CI 0.57-0.80; p=0.04). The optimal Youden point for identifying pAKI was at a FENa higher than 0.51 % with a specificity of 72.5% and a sensitivity of 65.0%. In the case of FEK, a value higher than 21.9 % presented the best relation, with a specificity of 67.5% and a sensitivity of 65.0%. CONCLUSIONS urine biochemistry interpretation in septic patients must be revised. FENa and FEK are related to the severity of AKI and could be helpful complementary tools for diagnosing pAKI.
Collapse
Affiliation(s)
- Nicolás Contrera Rolón
- Critical Care Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Nephrology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - Joaquín Cantos
- Critical Care Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Iván Huespe
- Critical Care Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Eduardo Prado
- Critical Care Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Griselda I Bratti
- Nephrology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Carlos Schreck
- Nephrology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Sergio Giannasi
- Critical Care Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Guillermo Rosa Diez
- Nephrology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Carlos F Varela
- Nephrology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| |
Collapse
|
2
|
Takano K, Monna-Oiwa M, Isobe M, Kato S, Takahashi S, Nannya Y, Konuma T. Low urinary sodium-to-potassium ratio in the early phase following single-unit cord blood transplantation is a predictive factor for poor non-relapse mortality in adults. Sci Rep 2024; 14:1413. [PMID: 38228718 DOI: 10.1038/s41598-024-51748-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 01/09/2024] [Indexed: 01/18/2024] Open
Abstract
Although daily higher urinary sodium (Na) and potassium (K) excretion ratio is associated with the risk of cardiovascular disease in the general population, a low Na/K ratio is associated with renal dysfunction in critically ill patients. Thus, we retrospectively analyzed the impact of daily urinary Na and K excretion and their ratio on non-relapse mortality (NRM) and overall mortality in 172 adult single-unit cord blood transplantation (CBT) patients treated at our institution between 2007 and 2020. Multivariate analysis showed that a low urinary Na/K ratio at both 14 days (hazard ratio [HR], 4.82; 95% confidence interval [CI], 1.81-12.83; P = 0.001) and 28 days (HR, 4.47; 95% CI 1.32-15.12; P = 0.015) was significantly associated with higher NRM. Furthermore, a low urinary Na/K ratio at 28 days was significantly associated with higher overall mortality (HR, 2.38; 95% CI 1.15-4.91; P = 0.018). Patients with a low urinary Na/K ratio had decreased urine volume, more weight gain, experienced more grade III-IV acute graft-versus-host disease, and required corticosteroids by 28 days after CBT. These findings indicate that a low urinary Na/K ratio early after single-unit CBT is associated with poor NRM and survival in adults.
Collapse
Affiliation(s)
- Kosuke Takano
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan
| | - Maki Monna-Oiwa
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan
| | - Masamichi Isobe
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan
| | - Seiko Kato
- Division of Clinical Precision Research Platform, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Satoshi Takahashi
- Division of Clinical Precision Research Platform, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Yasuhito Nannya
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan
| | - Takaaki Konuma
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan.
| |
Collapse
|
3
|
Cantos J, Huespe IA, Sinner JF, Prado EM, Roman ES, Rolón NC, Musso CG. Alactic base excess is an independent predictor of death in sepsis: A propensity score analysis. J Crit Care 2023; 74:154248. [PMID: 36640477 DOI: 10.1016/j.jcrc.2022.154248] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 11/13/2022] [Accepted: 12/24/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE Alactic base excess (ABE) is a novel biomarker defined as the sum of lactate and standard base excess and estimates the renal capability of handling acid-base disturbances in sepsis. The objective of this study is to see if ABE is an independent predictor of mortality in septic patients with and without renal dysfunction. MATERIALS AND METHODS We retrospectively studied 1178 patients with sepsis and septic shock. Patients were divided according to ABE values: 1) negative ABE (<-3 mmol/L); 2) neutral ABE (≥ - 3 and < 4 mmol/L); and 3) positive ABE (≥4 mmol/L). The effect of ABE on mortality was evaluated using Cox regression weight by inverse probability weighting (IPWT) analysis after propensity score assessment. Additionally, we performed a stratified analysis in patients with GFR > 60 mL/min/1.73 m2. RESULTS Negative ABE patients had higher mortality than patients with neutral ABE (adjusted HR 1.43; 95%CI 1.02-2.01). Also, in patients with GFR > 60 mL/min/1.73 m2 (n = 493), we observed higher mortality in patients with negative ABE (adjusted HR 2.43; 95%CI 1.07-5.53). CONCLUSIONS Negative ABE is an independent predictor of in-hospital mortality in septic patients with and without renal dysfunction.
Collapse
Affiliation(s)
- Joaquín Cantos
- Critical Care Department, Hospital Italiano de Buenos Aires, Argentina.
| | - Iván A Huespe
- Critical Care Department, Hospital Italiano de Buenos Aires, Argentina; Internal Clinical Research Area, Hospital Italiano de Buenos Aires, Argentina; Institute of Translational Medicine and Biomedical Engineering, IUHI, CONICET, HIBA, Argentina
| | - Jorge F Sinner
- Critical Care Department, Hospital Italiano de Buenos Aires, Argentina
| | - Eduardo M Prado
- Critical Care Department, Hospital Italiano de Buenos Aires, Argentina
| | - Eduardo San Roman
- Critical Care Department, Hospital Italiano de Buenos Aires, Argentina
| | - Nicolás Contrera Rolón
- Critical Care Department, Hospital Italiano de Buenos Aires, Argentina; Nephrology Department, Hospital Italiano de Buenos Aires, Argentina
| | - Carlos G Musso
- Research Department, Hospital Italiano de Buenos Aires, Argentina; Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
| |
Collapse
|
4
|
de Morais DG, Sanches TRC, Santinho MAR, Yada EY, Segura GC, Lowe D, Navarro G, Seabra VF, Taniguchi LU, Malbouisson LMS, de André CDS, Andrade L, Rodrigues CE. Urinary sodium excretion is low prior to acute kidney injury in patients in the intensive care unit. FRONTIERS IN NEPHROLOGY 2022; 2:929743. [PMID: 37675036 PMCID: PMC10479577 DOI: 10.3389/fneph.2022.929743] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/31/2022] [Indexed: 09/08/2023]
Abstract
Background The incidence of acute kidney injury (AKI) is high in intensive care units (ICUs), and a better understanding of AKI is needed. Early chronic kidney disease is associated with urinary concentration inability and AKI recovery with increased urinary solutes in humans. Whether the inability of the kidneys to concentrate urine and excrete solutes at appropriate levels could occur prior to the diagnosis of AKI is still uncertain, and the associated mechanisms have not been studied. Methods In this single-center prospective observational study, high AKI risk in ICU patients was followed up for 7 days or until ICU discharge. They were grouped as "AKI" or "No AKI" according to their AKI status throughout admission. We collected daily urine samples to measure solute concentrations and osmolality. Data were analyzed 1 day before AKI, or from the first to the fifth day of admission in the "No AKI" group. We used logistic regression models to evaluate the influence of the variables on future AKI diagnosis. The expression of kidney transporters in urine was evaluated by Western blotting. Results We identified 29 patients as "No AKI" and 23 patients as "AKI," the latter being mostly low severity AKI. Urinary sodium excretion was lower in "AKI" patients prior to AKI diagnosis, particularly in septic patients. The expression of Na+/H+ exchanger (NHE3), a urinary sodium transporter, was higher in "AKI" patients. Conclusions Urinary sodium excretion is low before an AKI episode in ICU patients, and high expressions of proximal tubule sodium transporters might contribute to this.
Collapse
Affiliation(s)
- David Gomes de Morais
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Talita Rojas Cunha Sanches
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Mirela Aparecida Rodrigues Santinho
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo Yuki Yada
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Gabriela Cardoso Segura
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Diogo Lowe
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Guilherme Navarro
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Victor Faria Seabra
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Leandro Utino Taniguchi
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Carmen Diva Saldiva de André
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Lúcia Andrade
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Camila Eleuterio Rodrigues
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
5
|
Maciel AT, Vitorio D, Osawa EA. Urine biochemistry assessment in the sequential evaluation of renal function: Time to think outside the box. Front Med (Lausanne) 2022; 9:912877. [PMID: 35957852 PMCID: PMC9360530 DOI: 10.3389/fmed.2022.912877] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/05/2022] [Indexed: 12/12/2022] Open
Abstract
Urine biochemistry (UB) remains a controversial tool in acute kidney injury (AKI) monitoring, being considered to be of limited value both in terms of AKI diagnosis and prognosis. However, many criticisms can be made to the studies that have established the so called “pre-renal paradigm” (used for decades as the essential physiological basis for UB assessment in AKI) as well as to more recent studies suggesting that UB has no utility in daily clinical practice. The aim of this article is to describe our hypothesis on how to interpret simple and widely recognized urine biochemical parameters from a novel perspective, propose the rationale for their sequential assessment and demonstrate their usefulness in AKI monitoring, especially in the critical care setting.
Collapse
Affiliation(s)
- Alexandre T. Maciel
- Research Department, Imed Group, São Paulo, Brazil
- Adult Intensive Care Unit, São Camilo Hospital–Pompéia Unit, São Paulo, Brazil
- *Correspondence: Alexandre T. Maciel,
| | - Daniel Vitorio
- Research Department, Imed Group, São Paulo, Brazil
- Adult Intensive Care Unit, São Camilo Hospital–Pompéia Unit, São Paulo, Brazil
| | - Eduardo A. Osawa
- Research Department, Imed Group, São Paulo, Brazil
- Adult Intensive Care Unit, São Camilo Hospital–Pompéia Unit, São Paulo, Brazil
| |
Collapse
|
6
|
Shahsavarinia K, Bahramian M, Shadvar K, Saghaleini SH, Sabzevari T, Mahmoodpoor A. Correlation of urinary potassium and acute kidney injury in patients admitted to the intensive care unit. J Clin Anesth 2021; 74:110429. [PMID: 34166862 DOI: 10.1016/j.jclinane.2021.110429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/02/2021] [Accepted: 06/09/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Kavous Shahsavarinia
- Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran; Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Maria Bahramian
- Department of Anesthesiology and intensive care medicine, faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kamran Shadvar
- Department of Anesthesiology and intensive care medicine, faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seied Hadi Saghaleini
- Department of Anesthesiology and intensive care medicine, faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Tara Sabzevari
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Mahmoodpoor
- Department of Anesthesiology and intensive care medicine, faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
| |
Collapse
|
7
|
Kumar NS, Kumar GN, Misra KC, Rao M, Chitithoti S, Prakash SY. Association between Urinary Potassium Excretion and Acute Kidney Injury in Critically Ill Patients. Indian J Crit Care Med 2021; 25:768-772. [PMID: 34316170 PMCID: PMC8286379 DOI: 10.5005/jp-journals-10071-23914] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Introduction Acute kidney injury (AKI) is defined in terms of serum creatinine (SrCrt) and urine output (UO). AKI occurs in 25% of critically ill patients, which increases the risk of morbidity and mortality. Early diagnosis of AKI is challenging, as utility of biomarkers is limited. This study is the first of its kind to estimate urinary potassium (UrK) excretion and its association with AKI in an Indian intensive care unit (ICU). Aims and objectives To study the association between UrK excretion and its ability to predict AKI in ICU patients. Material and methods During this prospective observational study, the patient's urinary indices and renal function tests were measured on day 1 of the ICU admission. UrK excretion and creatinine clearance (CrCl) were calculated from a 2-hour morning urine sample. Association between 2-hour UrK excretion and calculated CrCl and their ability to predict AKI in the subsequent 7 days was evaluated by Kidney Disease Improving Global Outcome (KDIGO)-AKI grading. Results Hundred patients admitted to ICU with a mean age of 53.59 ± 15.8 years were studied. The mean UrK excretion of 4.39 ± 2.52 was correlated linearly with CrCl and has a better prediction to AKI with the area under the receiver-operating characteristic curve value of 0.809 (CI 0.719-0.899), with a significant p-value (p <0.05). UrK excretion value of 3.49 on day 1 of ICU admission had 87% sensitivity and 74% specificity in predicting AKI. Thirty-one (31%) developed AKI, of which seven (22.58%) required renal replacement therapy (RRT), with 19% of all-cause mortality. Conclusion Diagnosis of AKI with traditional methods is not promising. UrK excretion correlates well with CrCl, which can be considered as the simplest accessible marker for predicting AKI in ICUs. How to cite this article Kumar NS, Kumar GN, Misra KC, Rao M, Chitithoti S, Prakash SY. Association between Urinary Potassium Excretion and Acute Kidney Injury in Critically Ill Patients. Indian J Crit Care Med 2021;25(7):768-772.
Collapse
Affiliation(s)
- Nadikuda Sunil Kumar
- Department of Critical Care Medicine, Yashoda Hospital, Hyderabad, Telangana, India
| | | | - Krushna C Misra
- Department of Critical Care Medicine, Yashoda Hospital, Hyderabad, Telangana, India
| | - Manimala Rao
- Department of Critical Care Medicine, Yashoda Hospital, Hyderabad, Telangana, India
| | - Suneetha Chitithoti
- Department of Critical Care Medicine, Yashoda Hospital, Hyderabad, Telangana, India
| | - Surya Y Prakash
- Department of Critical Care Medicine, Yashoda Hospital, Hyderabad, Telangana, India
| |
Collapse
|
8
|
Umbrello M, Formenti P, Chiumello D. Urine Electrolytes in the Intensive Care Unit: From Pathophysiology to Clinical Practice. Anesth Analg 2020; 131:1456-1470. [PMID: 33079869 DOI: 10.1213/ane.0000000000004994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Assessment of urine concentrations of sodium, chloride, and potassium is a widely available, rapid, and low-cost diagnostic option for the management of critically ill patients. Urine electrolytes have long been suggested in the diagnostic workup of hypovolemia, kidney injury, and acid-base and electrolyte disturbances. However, due to the wide range of normal reference values and challenges in interpretation, their use is controversial. To clarify their potential role in managing critical patients, we reviewed existing evidence on the use of urine electrolytes for diagnostic and therapeutic evaluation and assessment in critical illness. This review will describe the normal physiology of water and electrolyte excretion, summarize the use of urine electrolytes in hypovolemia, acute kidney injury, acid-base, and electrolyte disorders, and suggest some practical flowcharts for the potential use of urine electrolytes in daily critical care practice.
Collapse
Affiliation(s)
- Michele Umbrello
- From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
| | - Paolo Formenti
- From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
| | - Davide Chiumello
- From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
- Dipartimento di Scienze della Salute
- Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
| |
Collapse
|
9
|
Gomez DE, Buczinski S, Darby S, Palmisano M, Beatty SSK, Mackay RJ. Agreement of 2 electrolyte analyzers for identifying electrolyte and acid-base disorders in sick horses. J Vet Intern Med 2020; 34:2758-2766. [PMID: 32965055 PMCID: PMC7694849 DOI: 10.1111/jvim.15889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/11/2020] [Accepted: 08/19/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Use of different analyzers to measure electrolytes in the same horse can lead to different interpretation of acid-base balance when using the simplified strong ion difference (sSID) approach. OBJECTIVE Investigate the level of agreement between 2 analyzers in determining electrolytes concentrations, sSID variables, and acid-base disorders in sick horses. ANIMALS One hundred twenty-four hospitalized horses. METHODS Retrospective study using paired samples. Electrolytes were measured using a Beckman Coulter AU480 Chemistry analyzer (PBMA) and a Nova Biomedical Stat Profile (WBGA), respectively. Calculated sSID variables included strong ion difference, SID4 ; unmeasured strong ions, USI; and total nonvolatile buffer ion concentration in plasma (Atot ). Agreement between analyzers was explored using Passing-Bablok regression and Bland-Altman analysis. Kappa (κ) test evaluated the level of agreement between analyzers in detecting acid-base disorders. RESULTS Methodologic differences were identified in measured Na+ and Cl- and calculated values of SID4 and USI. Mean bias (95% limits of agreement) for Na+ , Cl- , SID4 , and USI were: -1.2 mmol/L (-9.2 to 6.8), 4.4 mmol/L (-4.4 to 13), -5.4 mmol/L (-13 to 2), and -6.2 mmol/L (-14 to 1.7), respectively. The intraclass correlation coefficient for SID4 and USI was .55 (95%CI: -0.2 to 0.8) and .2 (95%CI: -0.15 to 0.48), respectively. There was a poor agreement between analyzers for detection of SID4 (κ = 0.20, 95%CI, 0.1 to 0.31) or USI abnormalities (κ = -0.04, 95%CI, -0.11 to 0.02). CONCLUSIONS AND CLINICAL IMPORTANCE Differences between analyzer methodology in measuring electrolytes led to a poor agreement between the diagnosis of acid-base disorders in sick horses when using the sSID approach.
Collapse
Affiliation(s)
- Diego E Gomez
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada.,Department of Clinical Studies, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | - Sébastien Buczinski
- Département de Sciences Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal, Montréal, Quebec, Canada
| | - Shannon Darby
- Department of Clinical Studies, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | - Megan Palmisano
- Department of Clinical Studies, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | - Sarah S K Beatty
- Department of Comparative, Diagnostic & Population Medicine, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | - Robert J Mackay
- Department of Clinical Studies, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| |
Collapse
|
10
|
Maciel AT. Urine electrolyte measurement as a "window" into renal microcirculatory stress assessment in critically ill patients. J Crit Care 2018; 48:90-96. [PMID: 30176529 DOI: 10.1016/j.jcrc.2018.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/07/2018] [Accepted: 08/14/2018] [Indexed: 12/20/2022]
Abstract
Urine electrolyte assessment has long been used in order to understand electrolyte concentration disturbances in blood and as an easy tool for monitoring renal perfusion and structural tubular damage. In the last few years, great improvement in the pathophysiology of acute kidney injury (AKI) has occurred, and the correlation between urine biochemistry (UB) behavior and renal perfusion was frequently questioned. Many authors have suggested abandoning UB monitoring due to its unclear role in AKI monitoring. Our group has been working in this field in the critically ill population, and we believe that, although UB is indeed very useful, a different point of view regarding the interpretation of the data should be used. The aim of this review is to explain the rationale of these new concepts and make suggestions for their adequate use in daily ICU practice, especially in low-income countries where more sophisticated and expensive AKI biomarker assessments are not available.
Collapse
Affiliation(s)
- Alexandre T Maciel
- Imed Research Group, Adult Intensive Care Unit, São Camilo Hospital, São Paulo, Brazil.
| |
Collapse
|
11
|
Urinary potassium excretion and its association with acute kidney injury in the intensive care unit. J Crit Care 2018; 46:58-62. [DOI: 10.1016/j.jcrc.2018.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/13/2018] [Accepted: 04/13/2018] [Indexed: 11/18/2022]
|
12
|
Srisawat N, Sintawichai N, Kulvichit W, Lumlertgul N, Sitticharoenchai P, Thamrongsat N, Peerapornratana S. Current practice of diagnosis and management of acute kidney injury in intensive care unit in resource limited settings. J Crit Care 2018; 46:44-49. [PMID: 29669237 DOI: 10.1016/j.jcrc.2018.04.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/28/2018] [Accepted: 04/09/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE In a resource limited settings, there is sparse information about the management of acute kidney injury (AKI) based on systemic data collection. This survey aimed to described the current management of AKI in intensive care units (ICUs) across Thailand. MATERIALS AND METHODS Questionnaires were distributed to 160 physicians involved in the intensive care between January and December 2014 across Thailand. Distribution was done through an online survey platform or telephone interview. RESULTS The response rate was 80.6% (129 physicians). AKI diagnosis was mostly made by using KDIGO criteria (36.7%). A common diagnostic investigation of AKI was urinalysis (86%). Nephrologists had a major role (86.4%) in deciding the initiation and selection of renal replacement therapy (RRT) modality. Intermittent hemodialysis is the preferable mode of RRT (72.0%), followed by continuous renal replacement therapy (CRRT, 12%), sustained low efficiency dialysis (10.0%) and peritoneal dialysis (6.0%). Catheter insertion was predominantly performed by nephrologist (51.1%) with ultrasound guidance. The right internal jugular vein was the most common site of insertion (70.4%). The most common indication for CRRT was hemodynamic instability. CONCLUSIONS Amid increasing concern of AKI in the ICU, our study provides the insight into the management of AKI in resource limited settings.
Collapse
Affiliation(s)
- Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
| | - Nattaya Sintawichai
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Win Kulvichit
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Nuttha Lumlertgul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Patita Sitticharoenchai
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nicha Thamrongsat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Sadudee Peerapornratana
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| |
Collapse
|
13
|
Abstract
The use of fluid bolus infusion is the cornerstone for hemodynamic resuscitation of critically ill patients. Recently, the clinical use of colloids has lost strength with the publication of several trials suggesting no benefit, and possible harm of its use.On the other hand, the so-called balanced solutions, with low chloride concentrations, have emerged as an alternative with potential physiological benefits over traditional saline solution. Normal saline carries a high amount of chloride which has been associated with an increased incidence of metabolic acidosis, renal vasoconstriction, and reduced urine output. Recent observational studies associated the use of saline with acute kidney injury, which was not observed in a single prospective randomized controlled trial.The present review summarizes available literature regarding the potential clinical and laboratorial benefits of balanced solutions in septic patients.
Collapse
Affiliation(s)
- Pedro Vitale Mendes
- Intensive Care Unit , Emergency Department, Hospital das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | | | | |
Collapse
|
14
|
Abstract
Acute kidney injury (AKI) occurs frequently in the surgical intensive care unit and results in significant morbidity and mortality. AKI needs to be identified early and underlying causes treated or eliminated. Sepsis, major surgery such as coronary artery bypass, and hypovolemia are the most common causes and patients with underlying comorbidities have increased susceptibility. Treatment should begin by ensuring that patients are adequately resuscitated and all contributing causes are replaced or eliminated. After stabilization of hemodynamic status and elimination of contributing causes, treatment becomes largely supportive and may require the use of a renal replacement therapy.
Collapse
Affiliation(s)
- Robert A Maxwell
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, TN, USA.
| | - Christopher Michael Bell
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, TN, USA
| |
Collapse
|
15
|
Romano TG, Correia MDT, Mendes PV, Zampieri FG, Maciel AT, Park M. Metabolic acid-base adaptation triggered by acute persistent hypercapnia in mechanically ventilated patients with acute respiratory distress syndrome. Rev Bras Ter Intensiva 2017; 28:19-26. [PMID: 27096672 PMCID: PMC4828087 DOI: 10.5935/0103-507x.20160009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 01/22/2016] [Indexed: 01/23/2023] Open
Abstract
Objective Hypercapnia resulting from protective ventilation in acute respiratory
distress syndrome triggers metabolic pH compensation, which is not entirely
characterized. We aimed to describe this metabolic compensation. Methods The data were retrieved from a prospective collected database. Variables
from patients' admission and from hypercapnia installation until the third
day after installation were gathered. Forty-one patients with acute
respiratory distress syndrome were analyzed, including twenty-six with
persistent hypercapnia (PaCO2 > 50mmHg > 24 hours) and 15
non-hypercapnic (control group). An acid-base quantitative physicochemical
approach was used for the analysis. Results The mean ages in the hypercapnic and control groups were 48 ± 18
years and 44 ± 14 years, respectively. After the induction of
hypercapnia, pH markedly decreased and gradually improved in the ensuing 72
hours, consistent with increases in the standard base excess. The metabolic
acid-base adaptation occurred because of decreases in the serum lactate and
strong ion gap and increases in the inorganic apparent strong ion
difference. Furthermore, the elevation in the inorganic apparent strong ion
difference occurred due to slight increases in serum sodium, magnesium,
potassium and calcium. Serum chloride did not decrease for up to 72 hours
after the initiation of hypercapnia. Conclusion In this explanatory study, the results indicate that metabolic acid-base
adaptation, which is triggered by acute persistent hypercapnia in patients
with acute respiratory distress syndrome, is complex. Furthermore, further
rapid increases in the standard base excess of hypercapnic patients involve
decreases in serum lactate and unmeasured anions and increases in the
inorganic apparent strong ion difference by means of slight increases in
serum sodium, magnesium, calcium, and potassium. Serum chloride is not
reduced.
Collapse
Affiliation(s)
- Thiago Gomes Romano
- Departamento de Nefrologia, Faculdade de Medicina do ABC, Santo André, SP, Brazil
| | - Mario Diego Teles Correia
- Unidade de Terapia Intensiva, Disciplina de Emergências Clínicas, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Fernando Godinho Zampieri
- Unidade de Terapia Intensiva, Disciplina de Emergências Clínicas, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Marcelo Park
- Unidade de Terapia Intensiva, Disciplina de Emergências Clínicas, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| |
Collapse
|
16
|
Ostermann M, Joannidis M. Acute kidney injury 2016: diagnosis and diagnostic workup. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:299. [PMID: 27670788 PMCID: PMC5037640 DOI: 10.1186/s13054-016-1478-z] [Citation(s) in RCA: 211] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute kidney injury (AKI) is common and is associated with serious short- and long-term complications. Early diagnosis and identification of the underlying aetiology are essential to guide management. In this review, we outline the current definition of AKI and the potential pitfalls, and summarise the existing and future tools to investigate AKI in critically ill patients.
Collapse
Affiliation(s)
- Marlies Ostermann
- Department of Critical Care Medicine, King's College London, Guy's & St Thomas' Foundation Hospital, Westminster Bridge Road, London, UK.
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Medical University of Innsbruck, Anichstr. 35, Innsbruck, Austria.
| |
Collapse
|
17
|
Maciel AT. Back to Basics: Is There a Good Reason to Not Systematically Measure Urine Creatinine in Acute Kidney Injury Monitoring? Nephron Clin Pract 2016; 133:111-5. [DOI: 10.1159/000446666] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/04/2016] [Indexed: 11/19/2022] Open
|
18
|
Urinary Strong Ion Difference as a Marker of Renal Dysfunction. A Retrospective Analysis. PLoS One 2016; 11:e0156941. [PMID: 27258049 PMCID: PMC4892615 DOI: 10.1371/journal.pone.0156941] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 05/23/2016] [Indexed: 12/21/2022] Open
Abstract
Introduction The kidneys play a crucial role in the regulation of electrolytes and acid-base homeostasis. Urinary Strong Ion Difference (SIDu = NaU + KU—ClU) represents an important aspect of renal acid-base regulation. We evaluated the role of SIDu as a marker of renal dysfunction in critically ill patients. Materials and Methods Patients admitted to the Medical Intensive Care Unit with a diagnosis of AKI for whom concomitant urinary samples available for SIDu calculation were retrospectively reviewed and staged according to KDIGO criteria for 3 days from inclusion. Patients were classified as Recovered (R-AKI) or Persistent-AKI (P-AKI) whether they exited KDIGO criteria within the 3-day observation period or not. A control group with normal renal function and normal serum acid-base and electrolytes was prospectively recruited in order to identify reference SIDu values. Results One-hundred-and-forty-three patients with a diagnosis of AKI were included: 77 with R-AKI, and 66 with P-AKI. Thirty-six controls were recruited. Patients with P-AKI had more severe renal dysfunction and higher mortality than patients with R-AKI (SCr 2.23(IQR:1.68–3.45) and 1.81(IQR1.5–2.5) mg/dl respectively, p<0.001; 24-h UO 1297(950) and 2100(1094) ml respectively, p = 0.003); 30-d mortality, 39% and 13% respectively; p<0.001). SIDu significantly differed between groups, with rising values from controls to P-AKI groups (16.4(12), 30(24) and 47.3(21.5) mEq/l respectively, p<0.001). Discussion SIDu may be a simple and inexpensive tool in AKI patients’ evaluation. Further research is needed to evaluate the ability of SIDu to identify patients with renal dysfunction before derangements in serum creatinine or urine output are observed.
Collapse
|
19
|
Maciel AT, Delphino Salles L, Vitorio D. Simple blood and urinary parameters measured at ICU admission may sign for AKI development in the early postoperative period: a retrospective, exploratory study. Ren Fail 2016; 38:1607-1615. [PMID: 27101843 DOI: 10.3109/0886022x.2016.1144162] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Recent studies have suggested that some blood physicochemical and urinary biochemical parameters have a standardized behavior during acute kidney injury (AKI) development. The changes in these parameters frequently begin to occur before significant rises in serum creatinine (sCr) and may help in identifying patients with more subtle decreases in glomerular filtration rate (GFR). Surgical patients have an increased risk of AKI but renal impairment is usually not evident at ICU admission. We hypothesized that the surgical patients who have AKI diagnosed in the early postoperative period have an impaired GFR since ICU admission, indirectly inferred by alterations in these blood physicochemical and urinary biochemical parameters even in the presence of a still normal sCr. We retrospectively evaluated 112 surgical patients who were categorized according to AKI development during the first 3 ICU days. Twenty-eight patients developed AKI, most of them in the first day (D1) after ICU admission (D0). AKI patients had, at D0, lower serum pH and albumin, higher C - reactive protein (CRP), lower urine sodium (NaU) and fractional excretion of urea (FEUr). Fractional excretion of potassium (FEK) was high in both groups at D0 but remained high in the subsequent days only in AKI patients. Very low CRP and high serum albumin, high NaU and FEUr values at ICU admission had a significant negative predictive value for AKI. We concluded that some easily assessed parameters in blood and urine may help to identify patients with indirect signs of increased inflammatory response and decreased GFR at ICU admission, which could help to predict the risk of postoperative AKI development.
Collapse
Affiliation(s)
- Alexandre Toledo Maciel
- a Imed Research Group , Intensive Care Unit, Hospital São Camilo Pompéia , São Paulo , Brazil
| | - Lia Delphino Salles
- a Imed Research Group , Intensive Care Unit, Hospital São Camilo Pompéia , São Paulo , Brazil
| | - Daniel Vitorio
- a Imed Research Group , Intensive Care Unit, Hospital São Camilo Pompéia , São Paulo , Brazil
| | -
- a Imed Research Group , Intensive Care Unit, Hospital São Camilo Pompéia , São Paulo , Brazil
| |
Collapse
|
20
|
Urine biochemistry assessment in critically ill patients: controversies and future perspectives. J Clin Monit Comput 2016; 31:539-546. [PMID: 27038161 DOI: 10.1007/s10877-016-9871-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 03/30/2016] [Indexed: 12/17/2022]
Abstract
In the past, urine biochemistry was a major tool in acute kidney injury (AKI) management. Classic papers published some decades ago established the values of the urine indices which were thought to distinguish "pre-renal" (functional) AKI attributed to low renal perfusion and "renal" (structural) AKI attributed to acute tubular necrosis (ATN). However, there were a lot of drawbacks and limitations in these studies and some recent articles have questioned the utility of measuring urine electrolytes especially because they do not seem to adequately inform about renal perfusion nor AKI duration (transient vs. persistent). At the same time, the "pre-renal" paradigm has been consistently criticized because hypoperfusion followed by ischemia and ATN does not seem to explain most of the AKI developing in critically ill patients and distinct AKI durations do not seem to be clearly related to different pathophysiological mechanisms or histopathological findings. In this new context, other possible roles for urine biochemistry have emerged. Some studies have suggested standardized changes in the urine electrolyte composition preceding increases in serum creatinine independently of AKI subsequent duration, which might actually be due to intra-renal microcirculatory changes and activation of sodium-retaining mechanisms even in the absence of impaired global renal blood flow. In the present review, the points of controversy regarding urine biochemistry assessment were evaluated as well as future perspectives for its role in AKI monitoring. An alternative approach for the interpretation of measured urine electrolytes is proposed which needs further larger studies to be validated and incorporated in daily ICU practice.
Collapse
|
21
|
Maciel AT. New concepts for bringing urine biochemistry back to clinical practice in the intensive care unit. Rev Bras Ter Intensiva 2016; 26:330-2. [PMID: 25607258 PMCID: PMC4304457 DOI: 10.5935/0103-507x.20140049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 07/18/2014] [Indexed: 11/20/2022] Open
Affiliation(s)
- Alexandre Toledo Maciel
- Grupo de Pesquisa Imed, Unidade de Terapia Intensiva, Hospital São Camilo, São Paulo, SP, Brasil
| | | |
Collapse
|
22
|
Maciel AT, Nassar AP, Vitorio D. Very Transient Cases of Acute Kidney Injury in the Early Postoperative Period After Cardiac Surgery: The Relevance of More Frequent Serum Creatinine Assessment and Concomitant Urinary Biochemistry Evaluation. J Cardiothorac Vasc Anesth 2016; 30:56-63. [DOI: 10.1053/j.jvca.2015.04.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Indexed: 11/11/2022]
|
23
|
Maciel AT, Park M, Macedo E. Fractional excretion of potassium in the course of acute kidney injury in critically ill patients: potential monitoring tool? Rev Bras Ter Intensiva 2015; 26:143-7. [PMID: 25028948 PMCID: PMC4103940 DOI: 10.5935/0103-507x.20140021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Accepted: 04/07/2014] [Indexed: 11/26/2022] Open
Abstract
Objective To evaluate the behavior of fractional excretion of potassium in the course of
acute kidney injury in critically ill patients. Methods As part of a larger study in which we have evaluated blood and urinary parameters
in the course of acute kidney injury, 168 patients were included. Blood and urine
samples were collected daily until the removal of the urinary catheter or the
initiation of renal replacement therapy. We describe the evolution of fractional
excretion of potassium based on whether acute kidney injury was diagnosed, its
duration (transient or persistent) and its severity (creatinine-based Acute Kidney
Injury Network - AKIN stage). The diagnostic performance of fractional excretion
of potassium in predicting the duration of acute kidney injury and the need for
renal replacement therapy on the day of acute kidney injury diagnosis was also
evaluated. Results Fractional excretion of potassium was significantly higher in persistent acute
kidney injury compared to transient acute kidney injury on the day of acute kidney
injury diagnosis (24.8 vs. 13.8%, p<0.001). Both groups had the median
fractional excretion of potassium increasing in the two days preceding the acute
kidney injury diagnosis. Patients without acute kidney injury had stable low
fractional excretion of potassium values. The fractional excretion of potassium
was fairly accurate in predicting persistent acute kidney injury (area under the
curve: 0.712; 95% confidence interval: 0.614-0.811; p<0.001) on the day of
acute kidney injury diagnosis. The area under the curve was 0.663 (95% confidence
interval: 0.523-0.803; p=0.03) for renal replacement therapy. The fractional
excretion of potassium increased with maximum AKIN stage reached, in both
transient and persistent acute kidney injury. Conclusion Sequential fractional excretion of potassium assessment appears to be useful in
critically ill patients at risk for acute kidney injury.
Collapse
Affiliation(s)
- Alexandre Toledo Maciel
- Unidade de Terapia Intensiva, Departamento de Emergências Clínicas, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Marcelo Park
- Unidade de Terapia Intensiva, Departamento de Emergências Clínicas, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Etienne Macedo
- Departamento de Nefrologia, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| |
Collapse
|
24
|
Besen BAMP, Gobatto ALN, Melro LMG, Maciel AT, Park M. Fluid and electrolyte overload in critically ill patients: An overview. World J Crit Care Med 2015; 4:116-129. [PMID: 25938027 PMCID: PMC4411563 DOI: 10.5492/wjccm.v4.i2.116] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 12/24/2014] [Accepted: 03/05/2015] [Indexed: 02/06/2023] Open
Abstract
Fluids are considered the cornerstone of therapy for many shock states, particularly states that are associated with relative or absolute hypovolemia. Fluids are also commonly used for many other purposes, such as renal protection from endogenous and exogenous substances, for the safe dilution of medications and as “maintenance” fluids. However, a large amount of evidence from the last decade has shown that fluids can have deleterious effects on several organ functions, both from excessive amounts of fluids and from their non-physiological electrolyte composition. Additionally, fluid prescription is more common in patients with systemic inflammatory response syndrome whose kidneys may have impaired mechanisms of electrolyte and free water excretion. These processes have been studied as separate entities (hypernatremia, hyperchloremic acidosis and progressive fluid accumulation) leading to worse outcomes in many clinical scenarios, including but not limited to acute kidney injury, worsening respiratory function, higher mortality and higher hospital and intensive care unit length-of-stays. In this review, we synthesize this evidence and describe this phenomenon as fluid and electrolyte overload with potentially deleterious effects. Finally, we propose a strategy to safely use fluids and thereafter wean patients from fluids, along with other caveats to be considered when dealing with fluids in the intensive care unit.
Collapse
|
25
|
Maciel AT, Vitorio D, Salles LD, Park M. Sodium concentration in urine greater than in the plasma: possible biomarker of normal renal function and better outcome in critically ill patients. Anaesth Intensive Care 2014; 42:584-91. [PMID: 25233171 DOI: 10.1177/0310057x1404200507] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Correct interpretation of the urinary sodium concentration (NaU) and its relation to renal function in critically ill patients is lacking. Our aim was to evaluate the relationship between simultaneous NaU value and serum creatinine (sCr). The hypothesis is that a NaU value greater than 140 mmol/l (normal equivalent value in plasma) is only found in patients with normal sCr. We made a retrospective analysis of 1153 simultaneous samples of NaU and sCr, divided according to diuretic use in the previous 24 hours and grouped in five distinct NaU ranges (< 20, 20 to 39, 40 to 139, 140 to 169, ≥ 170 mmol/l). NaU values below 140 mmol/l were found simultaneously with both normal and increased sCr. NaU values above 140 mmol/l were almost always found in patients with normal sCr, even if diuretics were used. Median sCr values in the NaU ranges above 140 mmol/l were significantly lower than in the other NaU ranges. Estimated glomerular filtration rates were lower and intensive care unit and hospital mortalities were higher in patients with NaU values lower than 140 mmol/l compared to patients with a NaU higher than 140 mmol/l. We concluded that a high natriuretic capacity reflects significant residual renal function in the critically ill. NaU greater than normal plasma sodium is a possible biomarker of normal/improving renal function and also of better outcome. Sole NaU values below 140 mmol/l are difficult to interpret but it is possible that very low NaU values may signify some threat to normal kidney function and worse prognosis even in the presence of normal sCr. Our way to interpret NaU values in critically ill patients needs further careful evaluation.
Collapse
Affiliation(s)
- A T Maciel
- Intensive Care Unit, Hospital São Camilo Pompéia, São Paulo, Brazil
| | | | | | | |
Collapse
|
26
|
Acute Kidney Injury Induced by Systemic Inflammatory Response Syndrome is an Avid and Persistent Sodium-Retaining State. Case Rep Crit Care 2014; 2014:471658. [PMID: 25309760 PMCID: PMC4189521 DOI: 10.1155/2014/471658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 08/27/2014] [Accepted: 08/29/2014] [Indexed: 12/27/2022] Open
Abstract
Acute kidney injury (AKI) is a frequent complication of the systemic inflammatory response syndrome (SIRS), which is triggered by many conditions in the intensive care unit, including different types of circulatory shock. One under-recognized characteristic of the SIRS-induced AKI is its avidity for sodium retention, with progressive decreases in urinary sodium concentration (NaU) and its fractional excretion (FENa). This phenomenon occurs in parallel with increases in serum creatinine, being only transitorily mitigated by diuretic use. In the present case, we report a situation of two consecutive shocks: the first shock is hemorrhagic in origin and then the second shock is a septic one in the same patient. The SIRS and AKI triggered by the first shock were not completely solved when the second shock occurred. This could be viewed as a persistent avid sodium-retaining state, which may be appreciated even during renal replacement therapy (in the absence of complete anuria) and that usually solves only after complete AKI and SIRS resolution. We suggest that decreases in NaU and FENa are major characteristics of SIRS-induced AKI, irrespective of the primary cause, and may serve as additional monitoring tools in its development and resolution.
Collapse
|