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Chen-Xu M, Kassam C, Cameron E, Ryba S, Yiu V. Impact of electronic AKI alert/care bundle on AKI inpatient outcomes: a retrospective single-center cohort study. Ren Fail 2024; 46:2313177. [PMID: 38345055 PMCID: PMC10863540 DOI: 10.1080/0886022x.2024.2313177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/27/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Outcomes among acute kidney injury (AKI) patients are poor in United Kingdom (UK) hospitals, and electronic alerts and care bundles may improve them. We implemented such a system at West Suffolk Hospital (WSH) called the 'AKI order set'. We aimed to assess its impact on all-cause mortality, length of stay (LOS) and renal function among AKI patients, and its utilization. METHODS Retrospective, single-center cohort study of patients ≥ 18 years old with AKI at WSH, a 430-bed general hospital serving a rural UK population of approximately 280,000. 7243 unique AKI events representing 5728 patients with full data were identified automatically from our electronic health record (EHR) between 02 September 2018 and 1 July 2021 (median age 78 years, 51% male). All-cause mortality, LOS and improvement in AKI stage, demographic and comorbidity data, medications and AKI order set use were automatically collected from the EHR. RESULTS The AKI order set was used in 9.8% of AKI events and was associated with 28% lower odds of all-cause mortality (multivariable odds ratio [OR] 0.72, 95% confidence interval [CI] 0.57-0.91). Median LOS was longer when the AKI order set was utilized than when not (11.8 versus 8.8 days, p < .001), but was independently associated with improvement in the AKI stage (28.9% versus 8.7%, p < .001; univariable OR 4.25, 95% CI 3.53-5.10, multivariable OR 4.27, 95% CI 3.54-5.14). CONCLUSIONS AKI order set use led to improvements in all-cause mortality and renal function, but longer LOS, among AKI patients at WSH.
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Affiliation(s)
- Michael Chen-Xu
- West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Christopher Kassam
- West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Emma Cameron
- West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
| | - Szymon Ryba
- West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
| | - Vivian Yiu
- West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Azevedo FBD, Samaan F, Zanetta DMT, Yu L, Velasco IT, Burdmann EDA. Epidemiology of acute kidney injury in the clinical emergency: A prospective cohort study at a high-complexity public university hospital in São Paulo, Brazil. PLoS One 2024; 19:e0309949. [PMID: 39236044 PMCID: PMC11376543 DOI: 10.1371/journal.pone.0309949] [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: 06/18/2024] [Accepted: 08/22/2024] [Indexed: 09/07/2024] Open
Abstract
INTRODUCTION Southern Hemisphere countries have been underrepresented in epidemiological studies on acute kidney injury (AKI). The objectives of this study were to determine the frequency, risk factors, and outcomes of AKI in adult hospitalized patients from the emergency department of a public high-complexity teaching hospital in the city of São Paulo, Brazil. METHODS Observational and prospective study. AKI was defined by the KDIGO guidelines (Kidney Disease: Improving Global Outcomes) using only serum creatinine. RESULTS Among the 731 patients studied (age: median 61 years, IQR 47-72 years; 55% male), 48% had hypertension and 28% had diabetes as comorbidities. The frequency of AKI was 52.1% (25.9% community-based AKI [C-AKI] and 26.3% hospital-acquired AKI [H-AKI]). Dehydration, hypotension, and edema were found in 29%, 15%, and 15% of participants, respectively, at hospital admission. The in-hospital and 12-month mortality rates of patients with vs. without AKI were 25.2% vs. 11.1% (p<0.001) and 36.7% vs. 12.9% (p<0.001), respectively. The independent risk factors for C-AKI were chronic kidney disease (CKD), chronic liver disease, age, and hospitalization for cardiovascular disease. Those for H-AKI were CKD, heart failure as comorbidities, hypotension, and edema at hospital admission. H-AKI was an independent risk factor for death in the hospital, but not at 12 months. C-AKI was not a risk factor for death. CONCLUSIONS AKI occurred in more than half of the admissions to the clinical emergency department of the hospital and was equally distributed between C-AKI and H-AKI. Many patients had correctable risk factors for AKI, such as dehydration and arterial hypotension (44%) at admission. The only independent risk factor for both C-AKI and H-AKI was CKD as comorbidity.
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Affiliation(s)
- Flávia Barros de Azevedo
- Division of Clinical Emergencies, Hospital University of São Paulo, São Paulo, São Paulo, Brazil
- Mobile Emergency Care Service, Porangatu, Goias, Brazil
| | - Farid Samaan
- Planning and Evaluation Group, São Paulo State Department of Health, São Paulo, São Paulo, Brazil
- Research Division, Dante Pazzanese Institute of Cardiology, São Paulo, São Paulo, Brazil
| | | | - Luis Yu
- Laboratório de Investigação Médica (LIM) 12, Serviço de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Irineu Tadeu Velasco
- Division of Clinical Emergencies, Hospital University of São Paulo, São Paulo, São Paulo, Brazil
| | - Emmanuel de Almeida Burdmann
- Laboratório de Investigação Médica (LIM) 12, Serviço de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Horie R, Hayase N, Asada T, Yamamoto M, Matsubara T, Doi K. Trajectory pattern of serially measured acute kidney injury biomarkers in critically ill patients: a prospective observational study. Ann Intensive Care 2024; 14:84. [PMID: 38842613 PMCID: PMC11156822 DOI: 10.1186/s13613-024-01328-9] [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: 10/12/2023] [Accepted: 06/02/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND The clinical value of the trajectory of temporal changes in acute kidney injury (AKI) biomarkers has not been well established among intensive care unit (ICU) patients. METHODS This is a single-center, prospective observational study, performed at a mixed ICU in a teaching medical institute in Tokyo, Japan. Adult ICU patients with an arterial line and urethral catheter were enrolled from September 2014 to March 2015. Patients who stayed in the ICU for less than 48 h and patients with known end-stage renal disease were excluded from the study. Blood and urine samples were collected for measurement of AKI biomarkers at 0, 12, 24, and 48 h after ICU admission. The primary outcome was major adverse kidney events (MAKE) at discharge, defined as a composite of death, dialysis dependency, and persistent loss of kidney function (≥ 25% decline in eGFR). RESULTS The study included 156 patients. Serum creatinine-based estimated glomerular filtration rate (eGFR), plasma neutrophil gelatinase-associated lipocalin (NGAL), and urinary liver-type fatty acid-binding protein (uL-FABP) were serially measured and each variable was classified into three groups based on group-based trajectory modeling analysis. While the trajectory curves moved parallel to each other (i.e., "low," "middle," and "high") for eGFR and plasma NGAL, the uL-FABP curves showed distinct trajectory patterns and moved in different directions ("low and constant," "high and exponential decrease," and "high and exponential increase"). These trajectory patterns were significantly associated with MAKE. MAKE occurred in 16 (18%), 16 (40%), and 9 (100%) patients in the "low and constant," "high and exponential decrease," and "high and exponential increase" groups, respectively, based on uL-FABP levels (p-value < 0.001). The initial value and the 12-h change in uL-FABP were both significantly associated with MAKE, even after adjusting for eGFR [Odds ratio (95% confidence interval): 1.45 (1.17-1.83) and 1.43 (1.12-1.88) for increase of initial value and 12-h change of log-transformed uL-FABP by 1 point, respectively]. CONCLUSIONS Trajectory pattern of serially measured urinary L-FABP was significantly associated with MAKE in ICU patients.
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Affiliation(s)
- Ryohei Horie
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan.
| | - Naoki Hayase
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Toshifumi Asada
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Miyuki Yamamoto
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Takehiro Matsubara
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
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Bolt H, Suffel A, Matthewman J, Sandmann F, Tomlinson L, Eggo R. Seasonality of acute kidney injury phenotypes in England: an unsupervised machine learning classification study of electronic health records. BMC Nephrol 2023; 24:234. [PMID: 37558976 PMCID: PMC10413486 DOI: 10.1186/s12882-023-03269-0] [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: 05/05/2023] [Accepted: 07/14/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Acute Kidney Injury (AKI) is a multifactorial condition which presents a substantial burden to healthcare systems. There is limited evidence on whether it is seasonal. We sought to investigate the seasonality of AKI hospitalisations in England and use unsupervised machine learning to explore clustering of underlying comorbidities, to gain insights for future intervention. METHODS We used Hospital Episodes Statistics linked to the Clinical Practice Research Datalink to describe the overall incidence of AKI admissions between 2015 and 2019 weekly by demographic and admission characteristics. We carried out dimension reduction on 850 diagnosis codes using multiple correspondence analysis and applied k-means clustering to classify patients. We phenotype each group based on the dominant characteristics and describe the seasonality of AKI admissions by these different phenotypes. RESULTS Between 2015 and 2019, weekly AKI admissions peaked in winter, with additional summer peaks related to periods of extreme heat. Winter seasonality was more evident in those diagnosed with AKI on admission. From the cluster classification we describe six phenotypes of people admitted to hospital with AKI. Among these, seasonality of AKI admissions was observed among people who we described as having a multimorbid phenotype, established risk factor phenotype, and general AKI phenotype. CONCLUSION We demonstrate winter seasonality of AKI admissions in England, particularly among those with AKI diagnosed on admission, suggestive of community triggers. Differences in seasonality between phenotypes suggests some groups may be more likely to develop AKI as a result of these factors. This may be driven by underlying comorbidity profiles or reflect differences in uptake of seasonal interventions such as vaccines.
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Affiliation(s)
- Hikaru Bolt
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Anne Suffel
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Julian Matthewman
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Frank Sandmann
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Laurie Tomlinson
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Rosalind Eggo
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Wong E, Peracha J, Pitcher D, Casula A, Steenkamp R, Medcalf JF, Nitsch D. Seasonal mortality trends for hospitalised patients with acute kidney injury across England. BMC Nephrol 2023; 24:144. [PMID: 37226118 DOI: 10.1186/s12882-023-03094-5] [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: 09/14/2022] [Accepted: 02/22/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Incidence of acute kidney injury (AKI) is known to peak in winter months. This is likely influenced by seasonality of commonly associated acute illnesses. We set out to assess seasonal mortality trends for patients who develop AKI across the English National Health Service (NHS) and to better understand associations with patient 'case-mix'. METHODS The study cohort included all hospitalised adult patients in England who triggered a biochemical AKI alert in 2017. We modelled the impact of season on 30-day mortality using multivariable logistic regression; adjusting for age, sex, ethnicity, index of multiple deprivation (IMD), primary diagnosis, comorbidity (RCCI), elective/emergency admission, peak AKI stage and community/hospital acquired AKI. Seasonal odds ratios for AKI mortality were then calculated and compared across individual NHS hospital trusts. RESULTS The crude 30-day mortality for hospitalised AKI patients was 33% higher in winter compared to summer. Case-mix adjustment for a wide range of clinical and demographic factors did not fully explain excess winter mortality. The adjusted odds ratio of patients dying in winter vs. summer was 1.25 (1.22-1.29), this was higher than for Autumn and Spring vs. Summer, 1.09 (1.06-1.12) and 1.07 (1.04-1.11) respectively and varied across different NHS trusts (9 out of 90 centres outliers). CONCLUSION We have demonstrated an excess winter mortality risk for hospitalised patients with AKI across the English NHS, which could not be fully explained by seasonal variation in patient case-mix. Whilst the explanation for worse winter outcomes is not clear, unaccounted differences including 'winter-pressures' merit further investigation.
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Affiliation(s)
- Esther Wong
- Renal Registry, Kidney Association, Brandon House 20a1, Southmead Road, Bristol, BS34 7RR, UK.
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Javeria Peracha
- Department of Renal Medicine, Royal Wolverhampton NHS Trust, Wolverhampton, WV10 0QP, UK
| | - David Pitcher
- Renal Registry, Kidney Association, Brandon House 20a1, Southmead Road, Bristol, BS34 7RR, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Renal Medicine, University College London, London, UK
| | - Anna Casula
- Renal Registry, Kidney Association, Brandon House 20a1, Southmead Road, Bristol, BS34 7RR, UK
| | - Retha Steenkamp
- Renal Registry, Kidney Association, Brandon House 20a1, Southmead Road, Bristol, BS34 7RR, UK
| | - James F Medcalf
- Renal Registry, Kidney Association, Brandon House 20a1, Southmead Road, Bristol, BS34 7RR, UK
- Department of Health Sciences, University of Leicester, Leicester, LE1 7RH, UK
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, LE1 5WW, UK
| | - Dorothea Nitsch
- Renal Registry, Kidney Association, Brandon House 20a1, Southmead Road, Bristol, BS34 7RR, UK
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Department of Nephrology, Royal Free London NHS Foundation trust, London, NW3 2QG, UK
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Mirpanahi N, Nabovati E, Sharif R, Amirazodi S, Karami M. Effects and characteristics of clinical decision support systems on the outcomes of patients with kidney disease: a systematic review. Hosp Pract (1995) 2023:1-14. [PMID: 37068105 DOI: 10.1080/21548331.2023.2203051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
OBJECTIVES This systematic review was conducted to investigate the characteristics and effects of clinical decision support systems (CDSSs) on clinical and process-of-care outcomes of patients with kidney disease. METHODS A comprehensive systematic search was conducted in electronic databases to identify relevant studies published until November 2020. Randomized clinical trials evaluating the effects of using electronic CDSS on at least one clinical or process-of-care outcome in patients with kidney disease were included in this study. The characteristics of the included studies, features of CDSSs, and effects of the interventions on the outcomes were extracted. Studies were appraised for quality using the Cochrane risk-of-bias assessment tool. RESULTS Out of 8722 retrieved records, 11 eligible studies measured 32 outcomes, including 10 clinical outcomes and 22 process-of-care outcomes. The effects of CDSSs on 45.5% of the process-of-care outcomes were statistically significant, and all the clinical outcomes were not statistically significant. Medication-related process-of-care outcomes were the most frequently measured (54.5%), and CDSSs had the most effective and positive effect on medication appropriateness (18.2%). The characteristics of CDSSs investigated in the included studies comprised automatic data entry, real-time feedback, providing recommendations, and CDSS integration with the Computerized Provider Order Entry system. CONCLUSION Although CDSS may potentially be able to improve processes of care for patients with kidney disease, particularly with regard to medication appropriateness, no evidence was found that CDSS affects clinical outcomes in these patients. Further research is thus required to determine the effects of CDSSs on clinical outcomes in patients with kidney diseases.
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Affiliation(s)
- Nasim Mirpanahi
- Health Information Management Research Center, Department of Health Information Management & Technology, School of Allied Health Professions, Kashan University of Medical Sciences, Kashan, Iran
| | - Ehsan Nabovati
- Health Information Management Research Center, Department of Health Information Management & Technology, School of Allied Health Professions, Kashan University of Medical Sciences, Kashan, Iran
| | - Reihane Sharif
- Health Information Management Research Center, Department of Health Information Management & Technology, School of Allied Health Professions, Kashan University of Medical Sciences, Kashan, Iran
| | - Shahrzad Amirazodi
- Health Information Management Research Center, Department of Health Information Management & Technology, School of Allied Health Professions, Kashan University of Medical Sciences, Kashan, Iran
| | - Mahtab Karami
- Department of Health Information Management & Technology, School of Public Health, Shahid Sadoughi (Yazd) Kashan University of Medical Sciences, Kashan, Iran
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Cobussen M, Verhave JC, Buijs J, Stassen PM. The incidence and outcome of AKI in patients with sepsis in the emergency department applying different definitions of AKI and sepsis. Int Urol Nephrol 2023; 55:183-190. [PMID: 35859220 PMCID: PMC9807550 DOI: 10.1007/s11255-022-03267-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 05/16/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Sepsis is often accompanied with acute kidney injury (AKI). The incidence of AKI in patients visiting the emergency department (ED) with sepsis according to the new SOFA criteria is not exactly known, because the definition of sepsis has changed and many definitions of AKI exist. Given the important consequences of early recognition of AKI in sepsis, our aim was to assess the epidemiology of sepsis-associated AKI using different AKI definitions (RIFLE, AKIN, AKIB, delta check, and KDIGO) for the different sepsis classifications (SIRS, qSOFA, and SOFA). METHODS We retrospectively enrolled patients with sepsis in the ED in three hospitals and applied different AKI definitions to determine the incidence of sepsis-associated AKI. In addition, the association between the different AKI definitions and persistent kidney injury, hospital length of stay, and 30-day mortality were evaluated. RESULTS In total, 2065 patients were included. The incidence of AKI was 17.7-51.1%, depending on sepsis and AKI definition. The highest incidence of AKI was found in qSOFA patients when the AKIN and KDIGO definitions were applied (51.1%). Applying the AKIN and KDIGO definitions in patients with sepsis according to the SOFA criteria, AKI was present in 37.3% of patients, and using the SIRS criteria, AKI was present in 25.4% of patients. Crude 30-day mortality, prolonged length of stay, and persistent kidney injury were comparable for patients diagnosed with AKI, regardless of the definition used. CONCLUSION The incidence of AKI in patients with sepsis is highly dependent on how patients with sepsis are categorised and how AKI is defined. When AKI (any definition) was already present at the ED, 30-day mortality was high (22.2%). The diagnosis of AKI in sepsis can be considered as a sign of severe disease and helps to identify patients at high risk of adverse outcome at an early stage.
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Affiliation(s)
- Maarten Cobussen
- grid.412966.e0000 0004 0480 1382Department of Internal Medicine, Division of General Medicine, Section Acute Medicine, Maastricht University Medical Center, Maastricht, The Netherlands ,grid.415930.aDepartment of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jacobien C. Verhave
- grid.415930.aDepartment of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jacqueline Buijs
- grid.416905.fDepartment of Internal Medicine, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Patricia M. Stassen
- grid.412966.e0000 0004 0480 1382Department of Internal Medicine, Division of General Medicine, Section Acute Medicine, Maastricht University Medical Center, Maastricht, The Netherlands ,grid.5012.60000 0001 0481 6099CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Abbasi S, Nemati K, Alikiaii B, Saghaei M. The Value of Inferior Vena Cava Ultrasonography Administration for Hypovolemia Detection in Patients with Acute Kidney Injury Hospitalized in Intensive Care Unit. Adv Biomed Res 2023; 12:38. [PMID: 37057239 PMCID: PMC10086665 DOI: 10.4103/abr.abr_394_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/06/2022] [Accepted: 02/07/2022] [Indexed: 04/15/2023] Open
Abstract
Background The hypo-perfusion of the kidneys can lead to impairment in renal function and induce renal injury in case of delayed diagnosis and treatment. To date, laboratory markers are routinely used to determine the fluid volume status of the patients. The current study aims to evaluate the values of inferior vena cava (IVC) collapsibility index in hypovolemia diagnosis among critical patients admitted at the intensive care unit (ICU). Materials and Methods This is a cross-sectional study performed on 67 patients admitted to the ICU due to acute kidney injury from May 2018 to October 2019. Hypovolemia was assessed assessing IVC collapsibility using ultrasonography. Laboratory data, including urine osmolality, urine-plasma creatinine ratio, sodium excretion fraction and urinary sodium level were checked. Afterward, IVC collapsibility index was measured for each patient using ultrasonography and the values of this index in accordance with the mentioned criteria was evaluated. Accordingly, reciever operating curve was depicted. Results There was no significant asosociation between IVC collapsibility index with fractional excretion of sodium (P = 0.69), urine Na (P = 0.93) and urine osmolality ([P = 0.09]), while urine: Plasma creatinie ration revealed a significant association with IVC collapsibility index at cut point of 40.5% with sensitivity and specificity of 96% and 44% (P = 0.017, area under the curve: 0.67, 95% confidence interval: 0.551-0.804), respectively. Conclusion According to the findings of this study, IVC collapsibility detected via ultrasonography was not an appropriate index to figure out hypovolemia in ICU patients. Furthermore, detailed studies are recommended.
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Affiliation(s)
- Saeed Abbasi
- Department of Anesthesia and Critical Care, Anesthesiology and Critical Care Research Center, Nosocomial Infection Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Kourosh Nemati
- Department of Anesthesia and Critical Care, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Address for correspondence: Dr. Kourosh Nemati, Department of Anesthesia and Critical Care, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail:
| | - Babak Alikiaii
- Department of Anesthesia and Critical Care, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahmood Saghaei
- Department of Anesthesia and Critical Care, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Wang H, Liu T, Li Q, Cui R, Fan X, Tong Y, Ma S, Liu C, Zhang J. NSAID Treatment Before and on the Early Onset of Acute Kidney Injury Had an Opposite Effect on the Outcome of Patients With AKI. Front Pharmacol 2022; 13:843210. [PMID: 35656310 PMCID: PMC9152204 DOI: 10.3389/fphar.2022.843210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
Background: NSAIDs are one of the most frequently used medications and a risk factor for AKI. However, the optimal time of NSAIDs in patients with AKI is unknown. Methods: A secondary analysis of a multicenter, randomized clinical trial including adult inpatients with acute kidney injury was performed. Univariate, multivariate, and subgroup analyses were used to explore the impact of NSAIDs during the early onset of AKI on the outcome of patients with AKI. Results: A total of 6,030 patients with AKI were enrolled in the study. Following are the findings of the multi-factor analysis: NSAID treatments within 72 and 24 h before the onset of AKI were not associated with AKI progression, dialysis, or discharge from dialysis; only NSAID treatment within the 24-h onset of AKI was associated with these outcomes, and their OR values were independently 1.50 (95% CI: 1.02-2.19, p = 0.037), 4.20 (95% CI: 1.47-11.97, p = 0.007), and 0.71 (95% CI: 0.54-0.92, p = 0.011); only NSAID treatment within the 24-h onset of AKI would decrease the 14-day mortality, and the OR value was 0.52 (95% CI: 0.33-0.82, p = 0.005). The subgroup analysis revealed that in patients with age ≥65 years, CKD (chronic kidney disease), congestive heart failure, hypertension, and liver disease, NSAID treatments within the 24-h onset of AKI would deteriorate the outcome of patients with AKI. Conclusion: Before an early onset of AKI, NSAID treatment might be safe, but during the onset of AKI, even early NSAID treatment would deteriorate the outcome of patients with AKI.
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Affiliation(s)
- Hai Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Tong Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Qinglin Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Ruixia Cui
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Xueying Fan
- Department of Laboratory Medicine Center, Xi'an People's Hospital (The Fourth Hospital of Xi'an), Shaanxi, China
| | - Yingmu Tong
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Shuzhen Ma
- Health Management Department, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Chang Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Jingyao Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China.,Department of Surgical ICU (SICU), The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
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Hegarty H, Knight T, Atkin C, Kelly T, Subbe C, Lasserson D, Holland M. Nurse staffing levels within acute care: results of a national day of care survey. BMC Health Serv Res 2022; 22:493. [PMID: 35418056 PMCID: PMC9008904 DOI: 10.1186/s12913-022-07562-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 01/24/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction The relationship between nurse staffing levels and patient safety is well recognised. Inadequate provision of nursing staff is associated with increased medical error, as well as higher morbidity and mortality. Defining what constitutes safe nurse staffing levels is complex. A range of guidance and planning tools are available to inform staffing decisions. The Society for Acute Medicine (SAM) recommend a ‘nurse-to-bed‘ratio of greater than 1:6. Whether this standard accurately reflects the pattern and intensity of work on the Acute Medical Unit (AMU) is unclear. Methods Nurse staffing levels in AMUs were explored using the Society for Acute Medicine Benchmarking Audit 2019 (SAMBA19). Data from 122 acute hospitals were analysed. Nurse-to-bed ratios were calculated and compared. Estimates of the total nursing time available within the acute care system were compared to estimates of the time required to perform nursing activities. Results The total number of AMU beds across all 122 units was 4997. The mean daytime nurse-to-bed ratio was 1:4.3 and the mean night time nurse-to-bed ratio was 1:5.2. The SAM standard of a nurse to bed ratio of greater than 1:6 was achieved in 99 units (81.9%) during daytime hours and achieved by 74 units (60.6%) at night. The estimated time required to deliver direct clinical care was 35,698 h. A deficit of 4128 h (11.5% of time required) was estimated, representing the time difference between the total number of nursing hours available with current staffing and the estimated time needed for direct clinical care across all participating units. Conclusion This UK-wide study suggests a significant proportion of AMUs do not meet the recommenced SAM staffing levels, particularly at night. A difference was observed between the total number of nursing hours within the acute care system and the estimated time required to perform direct nursing activities. This suggests a workforce shortage of nurses within acute care at the system level.
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Affiliation(s)
- Hannah Hegarty
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University Hospital Birmingham NHS Foundation Trust, University of Birmingham, Edgbaston, Birmingham, B15 2GW, UK
| | - Thomas Knight
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University Hospital Birmingham NHS Foundation Trust, University of Birmingham, Edgbaston, Birmingham, B15 2GW, UK.,Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Catherine Atkin
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University Hospital Birmingham NHS Foundation Trust, University of Birmingham, Edgbaston, Birmingham, B15 2GW, UK
| | - Tash Kelly
- University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
| | - Chris Subbe
- School of Medical Sciences, Bangor University & Consultant Acute, Respiratory & Critical Care Medicine, Ysbyty Gwynedd, Bangor, LL57 2PW, UK
| | - Daniel Lasserson
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Mark Holland
- Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, Bolton, BL3 5AB, UK.
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11
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Hematological Ratios Are Associated with Acute Kidney Injury and Mortality in Patients That Present with Suspected Infection at the Emergency Department. J Clin Med 2022; 11:jcm11041017. [PMID: 35207289 PMCID: PMC8874958 DOI: 10.3390/jcm11041017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/03/2022] [Accepted: 02/10/2022] [Indexed: 01/27/2023] Open
Abstract
The early recognition of acute kidney injury (AKI) is essential to improve outcomes and prevent complications such as chronic kidney disease, the need for renal-replacement therapy, and an increased length of hospital stay. Increasing evidence shows that inflammation plays an important role in the pathophysiology of AKI and mortality. Several inflammatory hematological ratios can be used to measure systemic inflammation. Therefore, the association between these ratios and outcomes (AKI and mortality) in patients suspected of having an infection at the emergency department was investigated. Data from the SPACE cohort were used. Cox regression was performed to investigate the association between seven hematological ratios and outcomes. A total of 1889 patients were included, of which 160 (8.5%) patients developed AKI and 102 (5.4%) died in <30 days. The Cox proportional-hazards model revealed that the neutrophil-to-lymphocyte ratio (NLR), segmented-neutrophil-to-monocyte ratio (SMR), and neutrophil-lymphocyte-platelet ratio (NLPR) are independently associated with AKI <30 days after emergency-department presentation. Additionally, the NLR, SMR and NLPR were associated with 30-day all-cause mortality. These findings are an important step forward for the early recognition of AKI. The use of these markers might enable emergency-department physicians to recognize and treat AKI in an early phase to potentially prevent complications.
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12
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Niemantsverdriet MSA, Pieters TT, Hoefer IE, Verhaar MC, Joles JA, van Solinge WW, Tiel Groenestege WM, Haitjema S, Rookmaaker MB. GFR estimation is complicated by a high incidence of non-steady-state serum creatinine concentrations at the emergency department. PLoS One 2021; 16:e0261977. [PMID: 34965267 PMCID: PMC8716053 DOI: 10.1371/journal.pone.0261977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 12/14/2021] [Indexed: 11/29/2022] Open
Abstract
Background Acquiring a reliable estimate of glomerular filtration rate (eGFR) at the emergency department (ED) is important for clinical management and for dosing renally excreted drugs. However, renal function formulas such as CKD-EPI can give biased results when serum creatinine (SCr) is not in steady-state because the assumption that urinary creatinine excretion is constant is then invalid. We assessed the extent of this by analysing variability in SCr in patients who visited the ED of a tertiary care centre. Methods Data from ED visits at the University Medical Centre Utrecht, the Netherlands between 2012 and 2019 were extracted from the Utrecht Patient Oriented Database. Three measurement time points were defined for each visit: last SCr measurement before visit as baseline (SCr-BL), first measurement during visit (SCr-ED) and a subsequent measurement between 6 and 24 hours during admission (SCr-H1). Non-steady-state SCr was defined as exceeding the Reference Change Value (RCV), with 15% decrease or 18% increase between successive SCr measurements. Exceeding the RCV was deemed as a significant change. Results Of visits where SCr-BL and SCr-ED were measured (N = 47,540), 28.0% showed significant change in SCr. Of 17,928 visits admitted to the hospital with a SCr-H1 after SCr-ED, 27,7% showed significant change. More than half (55%) of the patients with SCr values available at all three timepoints (11,054) showed at least one significant change in SCr over time. Conclusion One third of ED visits preceded and/or followed by creatinine measurement show non-stable serum creatinine concentration. At the ED automatically calculated eGFR should therefore be interpreted with great caution when assessing kidney function.
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Affiliation(s)
- M S A Niemantsverdriet
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,SkylineDx, Rotterdam, The Netherlands
| | - T T Pieters
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - I E Hoefer
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - M C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - J A Joles
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - W W van Solinge
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - W M Tiel Groenestege
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - S Haitjema
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - M B Rookmaaker
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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13
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The incidence, mortality and renal outcomes of acute kidney injury in patients with suspected infection at the emergency department. PLoS One 2021; 16:e0260942. [PMID: 34879093 PMCID: PMC8654152 DOI: 10.1371/journal.pone.0260942] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 11/19/2021] [Indexed: 12/29/2022] Open
Abstract
Background Acute kidney injury (AKI) is a major health problem associated with considerable mortality and morbidity. Studies on clinical outcomes and mortality of AKI in the emergency department are scarce. The aim of this study is to assess incidence, mortality and renal outcomes after AKI in patients with suspected infection at the emergency department. Methods We used data from the SPACE-cohort (SePsis in the ACutely ill patients in the Emergency department), which included consecutive patients that presented to the emergency department of the internal medicine with suspected infection. Hazard ratios (HR) were assessed using Cox regression to investigate the association between AKI, 30-days mortality and renal function decline up to 1 year after AKI. Survival in patients with and without AKI was assessed using Kaplan-Meier analyses. Results Of the 3105 patients in the SPACE-cohort, we included 1716 patients who fulfilled the inclusion criteria. Of these patients, 10.8% had an AKI episode. Mortality was 12.4% for the AKI group and 4.2% for the non-AKI patients. The adjusted HR for all-cause mortality at 30-days in AKI patients was 2.8 (95% CI 1.7–4.8). Moreover, the cumulative incidence of renal function decline was 69.8% for AKI patients and 39.3% for non-AKI patients. Patients with an episode of AKI had higher risk of developing renal function decline (adjusted HR 3.3, 95% CI 2.4–4.5) at one year after initial AKI-episode at the emergency department. Conclusion Acute kidney injury is common in patients with suspected infection in the emergency department and is significantly associated with 30-days mortality and renal function decline one year after AKI.
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14
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Estimated glomerular filtration rate may be an independent predictor for clinical outcomes regardless of acute kidney injury complication in the emergency department. PLoS One 2021; 16:e0258665. [PMID: 34648576 PMCID: PMC8516290 DOI: 10.1371/journal.pone.0258665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/04/2021] [Indexed: 11/20/2022] Open
Abstract
Study objective Acute kidney injury (AKI), chronic kidney disease (CKD), and decreased estimated glomerular filtration rate (eGFR) are all associated with poor clinical outcomes among emergency department (ED) patients. This study aimed to evaluate the effect of different types of renal dysfunction and the degree of eGFR reduction on the clinical outcomes in a real-world ED setting. Methods Adult patients with an eGFR lower than 60 mL/min/1.73m2 in our ED, from October 1, 2016, to December 31, 2016, were enrolled in this retrospective observational study. Besides AKI and CKD, patients with unknown baseline renal function before an ED visit were categorized in the undetermined renal dysfunction (URD) category. Results Among 1495 patients who had eGFR evaluation at ED, this study finally enrolled 441 patients; 22 patients (5.0%) had AKI only, 32 (7.3%) had AKI on CKD, 196 (44.4%) had CKD only, 27 (6.1%) had subclinical kidney injury (those who met neither criteria for AKI nor CKD), and 164 (37.2%) had URD. There was a significant association between eGFR and critical illness defined as the composite outcome of death or intensive care unit (ICU) need, hospitalization, ICU need, death, and renal replacement therapy need (odds ratio [95% confidence interval]: 1.72 [1.45–2.05], 1.36 [1.16–1.59], 1.66 [1.39–2.00], 1.73 [1.32–2.28], and 2.71 [1.73–4.24] for every 10 mL/min/1.73m2 of reduction, respectively). Multivariate logistic regression analysis showed eGFR was an independent predictor of critical illness composite outcome (death or ICU need), hospitalization, and ICU need even after adjustment with AKI or URD. Conclusions Estimated GFR may be a sufficient predictor of clinical outcomes of ED patients regardless of AKI complication. Considerable ED patients were determined as URD, which might have a significant impact on the ED statistics regarding renal dysfunction.
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15
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Müller M, Traschitzger M, Nagler M, Arampatzis S, Exadaktylos AK, Sauter TC. Impaired kidney function at ED admission: a comparison of bleeding complications of patients with different oral anticoagulants. BMC Emerg Med 2021; 21:105. [PMID: 34536992 PMCID: PMC8449865 DOI: 10.1186/s12873-021-00497-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 08/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Up to a fourth of patients at emergency department (ED) presentation suffer from acute deterioration of renal function, which is an important risk factor for bleeding events in patients on oral anticoagulation therapy. We hypothesized that outcomes of patients, bleeding characteristics, therapy, and outcome differ between direct oral anticoagulants (DOACs) and vitamin-K antagonists (VKAs). METHODS All anticoagulated patients older than 17 years with an impaired kidney function treated for an acute haemorrhage in a large Swiss university ED from 01.06.2012 to 01.07.2017 were included in this retrospective cohort study. Patient, treatment, and bleeding characteristics as well as outcomes (length of stay ED, intensive care unit and in-hospital admission, ED resource consumption, in-hospital mortality) were compared between patients on DOAC or VKA anticoagulant. RESULTS In total, 158 patients on DOAC and 419 patients on VKA with acute bleeding and impaired renal function were included. The renal function in patients on VKA was significantly worse compared to patients on DOAC (VKA: median 141 μmol/L vs. DOAC 132 μmol/L, p = 0.002). Patients on DOAC presented with a smaller number of intracranial bleeding compared to VKA (14.6% DOAC vs. 22.4% VKA, p = 0.036). DOAC patients needed more emergency endoscopies (15.8% DOAC vs, 9.1% VKA, p = 0.020) but less interventional emergency therapies to stop the bleeding (13.9% DOAC vs. 22.2% VKA, p = 0.027). Investigated outcomes did not differ significantly between the two groups. CONCLUSIONS DOAC patients were found to have a smaller proportional incidence of intracranial bleedings, needed more emergency endoscopies but less often interventional therapy compared to patients on VKA. Adapted treatment algorithms are a potential target to improve care in patients with DOAC.
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Affiliation(s)
- Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Michaela Traschitzger
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Michael Nagler
- University Institute of Clinical Chemistry, Inselspital Bern University Hospital, and University of Bern, Bern University, Bern, Switzerland
| | - Spyridon Arampatzis
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Aristomenis K. Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Thomas C. Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
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16
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Chan KW, Yu KY, Lee PW, Lai KN, Tang SCW. Global REnal Involvement of CORonavirus Disease 2019 (RECORD): A Systematic Review and Meta-Analysis of Incidence, Risk Factors, and Clinical Outcomes. Front Med (Lausanne) 2021; 8:678200. [PMID: 34113640 PMCID: PMC8185046 DOI: 10.3389/fmed.2021.678200] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/09/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction: The quantitative effect of underlying non-communicable diseases on acute kidney injury (AKI) incidence and the factors affecting the odds of death among coronavirus disease 2019 (COVID-19) AKI patients were unclear at population level. This study aimed to assess the association between AKI, mortality, underlying non-communicable diseases, and clinical risk factors. Methods: A systematic search of six databases was performed from January 1, 2020, until October 5, 2020. Peer-reviewed observational studies containing quantitative data on risk factors and incidence of renal manifestations of COVID-19 were included. Location, institution, and time period were matched to avoid duplicated data source. Incidence, prevalence, and odds ratio of outcomes were extracted and pooled by random-effects meta-analysis. History of renal replacement therapy (RRT) and age group were stratified for analysis. Univariable meta-regression models were built using AKI incidence as dependent variable, with underlying comorbidities and clinical presentations at admission as independent variables. Results: Global incidence rates of AKI and RRT in COVID-19 patients were 20.40% [95% confidence interval (CI) = 12.07-28.74] and 2.97% (95% CI = 1.91-4.04), respectively, among patients without RRT history. Patients who developed AKI during hospitalization were associated with 8 times (pooled OR = 9.03, 95% CI = 5.45-14.94) and 16.6 times (pooled OR = 17.58, 95% CI = 10.51-29.38) increased odds of death or being critical. At population level, each percentage increase in the underlying prevalence of diabetes, hypertension, chronic kidney disease, and tumor history was associated with 0.82% (95% CI = 0.40-1.24), 0.48% (95% CI = 0.18-0.78), 0.99% (95% CI = 0.18-1.79), and 2.85% (95% CI = 0.93-4.76) increased incidence of AKI across different settings, respectively. Although patients who had a kidney transplant presented with a higher incidence of AKI and RRT, their odds of mortality was lower. A positive trend of increased odds of death among AKI patients against the interval between symptom onset and hospital admission was observed. Conclusion: Underlying prevalence of non-communicable diseases partly explained the heterogeneity in the AKI incidence at population level. Delay in admission after symptom onset could be associated with higher mortality among patients who developed AKI and warrants further research.
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Affiliation(s)
- Kam Wa Chan
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Kam Yan Yu
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Pak Wing Lee
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kar Neng Lai
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Sydney Chi-Wai Tang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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17
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Phillips T, Stammers M, Leggatt G, Bonfield B, Fraser S, Armstrong K, Veighey K. Acute kidney injury in COVID‐19: Identification of risk factors and potential biomarkers of disease in a large UK cohort. Nephrology (Carlton) 2021. [DOI: 10.1111/nep.13847] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Thomas Phillips
- Specialist Medicine University Hospital Southampton Southampton UK
| | - Matthew Stammers
- Specialist Medicine University Hospital Southampton Southampton UK
| | - Gary Leggatt
- Specialist Medicine University Hospital Southampton Southampton UK
| | - Becky Bonfield
- Specialist Medicine University Hospital Southampton Southampton UK
| | - Simon Fraser
- Specialist Medicine University Hospital Southampton Southampton UK
| | | | - Kristin Veighey
- Specialist Medicine University Hospital Southampton Southampton UK
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18
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Evans M, Morgan AR, Patel D, Dhatariya K, Greenwood S, Newland-Jones P, Hicks D, Yousef Z, Moore J, Kelly B, Davies S, Dashora U. Risk Prediction of the Diabetes Missing Million: Identifying Individuals at High Risk of Diabetes and Related Complications. Diabetes Ther 2021; 12:87-105. [PMID: 33190216 PMCID: PMC7843706 DOI: 10.1007/s13300-020-00963-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/28/2020] [Indexed: 01/08/2023] Open
Abstract
Early diagnosis and effective management of type 2 diabetes (T2D) are crucial in reducing the risk of developing life-changing complications such as heart failure, stroke, kidney disease, blindness and amputation, which are also associated with significant costs for healthcare providers. However, as T2D symptoms often develop slowly it is not uncommon for people to live with T2D for years without being aware of their condition-commonly known as the undiagnosed missing million. By the time a diagnosis is received, many individuals will have already developed serious complications. While the existence of undiagnosed diabetes has long been recognised, wide-reaching awareness among the general public, clinicians and policymakers is lacking, and there is uncertainty in how best to identify high-risk individuals. In this article we have used consensus expert opinion alongside the available evidence, to provide support for the diabetes healthcare community regarding risk prediction of the missing million. Its purpose is to provide awareness of the risk factors for identifying individuals at high, moderate and low risk of T2D and T2D-related complications. The awareness of risk predictors, particularly in primary care, is important, so that appropriate steps can be taken to reduce the clinical and economic burden of T2D and its complications.
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Affiliation(s)
- Marc Evans
- Diabetes Resource Centre, University Hospital Llandough, Cardiff, UK.
| | | | - Dipesh Patel
- Department of Diabetes, Division of Medicine, University College London, Royal Free NHS Trust, London, UK
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Sharlene Greenwood
- Renal Medicine, King's College Hospital, London, UK
- Renal Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | | | - Zaheer Yousef
- Wales Heart Research Institute, Cardiff University, Cardiff, UK
| | - Jim Moore
- Stoke Road Surgery, Bishop's Cleeve, Cheltenham, UK
| | | | | | - Umesh Dashora
- East Sussex Healthcare NHS Trust, St Leonards-on-Sea, UK
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19
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Hamilton P, Hanumapura P, Castelino L, Henney R, Parker K, Kumar M, Murphy M, Al-Sayed T, Pinnington S, Felton T, Challiner R, Ebah L. Characteristics and outcomes of hospitalised patients with acute kidney injury and COVID-19. PLoS One 2020; 15:e0241544. [PMID: 33141867 PMCID: PMC7608889 DOI: 10.1371/journal.pone.0241544] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/16/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION COVID-19 has spread globally to now be considered a pandemic by the World Health Organisation. Initially patients appeared to have a respiratory limited disease but there are now increasing reports of multiple organ involvement including renal disease in association with COVID-19. We studied the development and outcomes of acute kidney injury (AKI) in patients with COVID-19, in a large multicultural city hospital trust in the UK, to better understand the role renal disease has in the disease process. METHODS This was a retrospective review using electronic records and laboratory data of adult patients admitted to the four Manchester University Foundation Trust Hospitals between March 10 and April 30 2020 with a diagnosis of COVID-19. Records were reviewed for baseline characteristics, medications, comorbidities, social deprivation index, observations, biochemistry and outcomes including mortality, admission to critical care, mechanical ventilation and the need for renal replacement therapy. RESULTS There were 1032 patients included in the study of whom 210 (20.3%) had AKI in association with the diagnosis of COVID-19. The overall mortality with AKI was considerably higher at 52.4% compared to 26.3% without AKI (p-value <0.001). More patients with AKI required escalation to critical care (34.8% vs 11.2%, p-value <0.001). Following admission to critical care those with AKI were more likely to die (54.8% vs 25.0%, p-value <0.001) and more likely to require mechanical ventilation (86.3% vs 66.3%, p-value 0.006). DISCUSSION We have shown that the development of AKI is associated with dramatically worse outcomes for patients, in both mortality and the requirement for critical care. Patients with COVID-19 presenting with, or at risk of AKI should be closely monitored and appropriately managed to prevent any decline in renal function, given the significant risk of deterioration and death.
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Affiliation(s)
- Patrick Hamilton
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, United Kingdom
- Division of Cell Matrix Biology and Regenerative Medicine, Wellcome Centre for Cell-Matrix Research, School of Biological Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Prasanna Hanumapura
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, United Kingdom
| | - Laveena Castelino
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Robert Henney
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, United Kingdom
| | - Kathrine Parker
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, United Kingdom
| | - Mukesh Kumar
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Michelle Murphy
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Tamer Al-Sayed
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Sarah Pinnington
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Tim Felton
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- NIHR Manchester Biomedical Research Centre, Manchester, United Kingdom
| | - Rachael Challiner
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, United Kingdom
| | - Leonard Ebah
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, United Kingdom
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20
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Evaluation of patients receiving hemodialysis in an emergency service. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.747306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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21
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Martinez DA, Levin SR, Klein EY, Parikh CR, Menez S, Taylor RA, Hinson JS. Early Prediction of Acute Kidney Injury in the Emergency Department With Machine-Learning Methods Applied to Electronic Health Record Data. Ann Emerg Med 2020; 76:501-514. [DOI: 10.1016/j.annemergmed.2020.05.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 12/14/2022]
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22
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Pinheiro KHE, Azêdo FA, Areco KCN, Laranja SMR. Risk factors and mortality in patients with sepsis, septic and non septic acute kidney injury in ICU. ACTA ACUST UNITED AC 2020; 41:462-471. [PMID: 31528980 PMCID: PMC6979581 DOI: 10.1590/2175-8239-jbn-2018-0240] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 06/25/2019] [Indexed: 12/11/2022]
Abstract
Acute kidney injury (AKI) has an incidence rate of 5-6% among intensive care unit (ICU) patients and sepsis is the most frequent etiology.
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Affiliation(s)
- Kellen Hyde Elias Pinheiro
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Nefrologia, São Paulo, SP, Brazil
| | - Franciana Aguiar Azêdo
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Nefrologia, São Paulo, SP, Brazil
| | - Kelsy Catherina Nema Areco
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Nefrologia, São Paulo, SP, Brazil
| | - Sandra Maria Rodrigues Laranja
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Nefrologia, São Paulo, SP, Brazil.,Hospital do Servidor Público Estadual de São Paulo, Francisco Morato de Oliveira, São Paulo, SP, Brazil
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23
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Schanz M, Wasser C, Allgaeuer S, Schricker S, Dippon J, Alscher MD, Kimmel M. Urinary [TIMP-2]·[IGFBP7]-guided randomized controlled intervention trial to prevent acute kidney injury in the emergency department. Nephrol Dial Transplant 2020; 34:1902-1909. [PMID: 29961888 DOI: 10.1093/ndt/gfy186] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/15/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Early detection and prevention of acute kidney injury (AKI) is important to reduce morbidity and mortality. Discovery of early-detection biomarkers has enabled early preventive approaches. There are no data on early biomarker-guided intervention with nephrological consultation in emergency departments (EDs). METHODS In this prospective randomized controlled intervention trial, patients at high risk for AKI were screened with urinary [TIMP-2]·[IGFBP7] in the ED of Robert-Bosch-Hospital (Stuttgart, Germany). We screened 257 eligible patients of whom 100 met the inclusion criteria, with urinary [TIMP-2]·[IGFBP7] >0.3, and were included. The intervention group received immediate one-time nephrological consultation after randomization, implementing Kidney Disease: Improving Global Outcomes (KDIGO) 2012 recommendations on AKI. The primary outcome was the incidence of moderate to severe AKI within the first day after admission. Secondary outcomes were AKI occurrence within 3 days after admission, need for renal replacement therapy (RRT), length of hospital stay and death. RESULTS The primary outcome did not differ significantly (P = 0.9) between the groups, neither within the first day nor within the first 3 days after admission. The intervention group had significantly (P < 0.05) lower serum creatinine (SCr) on Day 2 and lower maximum SCr and tended (P = 0.08) to have higher urine output (UOP) at Day 3 than the non-intervention group. No patient in the intervention group needed RRT (0 versus 3) during the hospital stay (P = 0.09). CONCLUSIONS One-time routine nephrologist-guided application of the KDIGO bundle in ED patients with a risk for AKI cannot currently be recommended. However, due to the uniform trend of study endpoints in favour of intervention, further trials to investigate larger cohorts of more severely ill patients are warranted. TRIAL REGISTRATION www.ClinicalTrials.gov, study number NCT02730637.
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Affiliation(s)
- Moritz Schanz
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital Stuttgart, Stuttgart, Germany
| | - Christoph Wasser
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital Stuttgart, Stuttgart, Germany
| | - Sebastian Allgaeuer
- Division of Intensive Care Medicine, Robert-Bosch-Hospital Stuttgart, Germany
| | - Severin Schricker
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital Stuttgart, Stuttgart, Germany
| | - Juergen Dippon
- Department of Mathematics, University Stuttgart, Stuttgart, Germany
| | - Mark Dominik Alscher
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital Stuttgart, Stuttgart, Germany
| | - Martin Kimmel
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital Stuttgart, Stuttgart, Germany
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24
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Laszczyńska O, Severo M, Mascarenhas J, Paiva JA, Azevedo A. Serum creatinine trajectories in real-world hospitalized patients: clinical context and short-term mortality. J Investig Med 2020; 68:870-881. [DOI: 10.1136/jim-2019-001185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2020] [Indexed: 12/27/2022]
Abstract
Fluctuations in serum creatinine (SCr) during hospitalization may provide additional prognostic value beyond baseline renal function. This study aimed to identify groups of patients with distinct creatinine trajectories over hospital stay and assess them in terms of clinical characteristics and short-term mortality. This retrospective study included 35 853 unique adult admissions to a tertiary referral center between January 2012 and January 2016 with at least three SCr measurements within the first 9 days of stay. Individual SCr courses were determined using linear regression or linear-splines model and grouped into clusters. SCr trajectories were described as median SCr courses within clusters. Almost half of the patients presented with changing, mainly declining SCr concentration during hospitalization. In comparison to patients with an increase in SCr, those with a significant decline were younger, more often admitted via the emergency department, more often required a higher level of care, had fewer comorbidities and the more pronounced the fall in SCr, the greater the observed difference. Regardless of baseline renal function, an increase in SCr was related to the highest in-hospital mortality risk among compared clusters. Also, patients with normal renal function at admission followed by decreasing SCr were at higher risk of inpatient death, but lower 90-day postdischarge mortality than patients with a stable SCr. Acute changes in inpatient SCr convey important prognostic information and can only be interpreted by looking at their evolution over time. Recognizing underlying causes and providing adequate care is crucial for improving adverse prognosis.
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25
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Martin-Cleary C, Molinero-Casares LM, Ortiz A, Arce-Obieta JM. Development and internal validation of a prediction model for hospital-acquired acute kidney injury. Clin Kidney J 2019; 14:309-316. [PMID: 33564433 PMCID: PMC7857831 DOI: 10.1093/ckj/sfz139] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 09/06/2019] [Indexed: 12/16/2022] Open
Abstract
Background Predictive models and clinical risk scores for hospital-acquired acute kidney injury (AKI) are mainly focused on critical and surgical patients. We have used the electronic clinical records from a tertiary care general hospital to develop a risk score for new-onset AKI in general inpatients that can be estimated automatically from clinical records. Methods A total of 47 466 patients met inclusion criteria within a 2-year period. Of these, 2385 (5.0%) developed hospital-acquired AKI. Step-wise regression modelling and Bayesian model averaging were used to develop the Madrid Acute Kidney Injury Prediction Score (MAKIPS), which contains 23 variables, all obtainable automatically from electronic clinical records at admission. Bootstrap resampling was employed for internal validation. To optimize calibration, a penalized logistic regression model was estimated by the least absolute shrinkage and selection operator (lasso) method of coefficient shrinkage after estimation. Results The area under the curve of the receiver operating characteristic curve of the MAKIPS score to predict hospital-acquired AKI at admission was 0.811. Among individual variables, the highest odds ratios, all >2.5, for hospital-acquired AKI were conferred by abdominal, cardiovascular or urological surgery followed by congestive heart failure. An online tool (http://www.bioestadistica.net/MAKIPS.aspx) will facilitate validation in other hospital environments. Conclusions MAKIPS is a new risk score to predict the risk of hospital-acquired AKI, based on variables present at admission in the electronic clinical records. This may help to identify patients who require specific monitoring because of a high risk of AKI.
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Affiliation(s)
- Catalina Martin-Cleary
- Department of Nephrology and Hypertension, Investigación Sanitaria-Fundación Jimenez Diaz, Universidad Autónoma de Madrid, Madrid, Spain.,REDINREN, Madrid, Spain.,Fundación Renal Iñigo Alvarez de Toledo-IRSIN, Madrid, Spain
| | | | - Alberto Ortiz
- Department of Nephrology and Hypertension, Investigación Sanitaria-Fundación Jimenez Diaz, Universidad Autónoma de Madrid, Madrid, Spain.,REDINREN, Madrid, Spain.,Fundación Renal Iñigo Alvarez de Toledo-IRSIN, Madrid, Spain
| | - Jose Miguel Arce-Obieta
- Department of Health Information Management, University Hospital Fundación Jiménez Díaz, Madrid, Spain
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26
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Pedersen PB, Henriksen DP, Brabrand M, Lassen AT. Prevalence of organ failure and mortality among patients in the emergency department: a population-based cohort study. BMJ Open 2019; 9:e032692. [PMID: 31666275 PMCID: PMC6830583 DOI: 10.1136/bmjopen-2019-032692] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The aim was to describe population-based incidence and emergency department-based prevalence and 1-year all-cause mortality of patients with new organ failure present at arrival. DESIGN This was a population-based cohort study of all citizens in four municipalities (population of 230 000 adults). SETTING Emergency department at Odense University Hospital, Denmark. PARTICIPANTS We included all adult patients who arrived from 1 April 2012 to 31 March 2015. PRIMARY AND SECONDARY OUTCOME MEASURES Organ failure was defined as a modified Sequential Organ Failure Assessment score≥2 within six possible organ systems: cerebral, circulatory, renal, respiratory, hepatic and coagulation.The primary outcome was prevalence of organ failure, and secondary outcomes were 0-7 days, 8-30 days and 31-365 days all-cause mortality. RESULTS We identified in total 175 278 contacts, of which 70 399 contacts were further evaluated for organ failure. Fifty-two per cent of these were women, median age 62 (IQR 42-77) years. The incidence of new organ failure was 1342/100 000 person-years, corresponding to 5.2% of all emergency department contacts.The 0-7-day, 8-30-day and 31-365-day mortality was 11.0% (95% CI: 10.2% to 11.8%), 5.6% (95% CI: 5.1% to 6.2%) and 13.2% (95% CI: 12.3% to 14.1%), respectively, if the patient had one or more new organ failures at first contact in the observation period, compared with 1.4% (95% CI: 1.3% to 1.6%), 1.2% (95% CI: 1.1% to 1.3%) and 5.2% (95% CI: 5.0% to 5.4%) for patients without. Seven-day mortality ranged from hepatic failure, 6.5% (95% CI: 4.9% to 8.6%), to cerebral failure, 33.8% (95% CI: 31.0% to 36.8%), the 8-30-day mortality ranged from cerebral failure, 3.9% (95% CI: 2.8% to 5.3%), to hepatic failure, 8.6% (95% CI: 6.6% to 10.8%) and 31-365-day mortality ranged from cerebral failure, 9.3% (95% CI: 7.6% to 11.2%), to renal failure, 18.2% (95% CI: 15.5% to 21.1%). CONCLUSIONS The study revealed an incidence of new organ failure at 1342/100 000 person-years and a prevalence of 5.2% of all emergency department contacts. One-year all-cause mortality was 29.8% among organ failure patients.
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Affiliation(s)
- Peter Bank Pedersen
- Department of Emergency Medicine, Institute of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | | | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital & Hospital of South West Jutland, Odense & Esbjerg, Denmark
| | - Annmarie Touborg Lassen
- Department of Emergency Medicine, Institute of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
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27
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Wei J, Zhang J, Wang L, Jiang S, Fu L, Buggs J, Liu R. New mouse model of chronic kidney disease transitioned from ischemic acute kidney injury. Am J Physiol Renal Physiol 2019; 317:F286-F295. [PMID: 31116604 PMCID: PMC6732455 DOI: 10.1152/ajprenal.00021.2019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 12/28/2022] Open
Abstract
Acute kidney injury (AKI) significantly increases the risk of development of chronic kidney disease (CKD), which is closely associated with the severity of AKI. However, the underlying mechanisms for the AKI to CKD transition remain unclear. Several animal models with AKI to CKD transition have been generated and widely used in research; however, none of them exhibit the typical changes in glomerular filtration rate or plasma creatinine, the hallmarks of CKD. In the present study, we developed a novel model with a typical phenotype of AKI to CKD transition in C57BL/6 mice. In this model, life-threatening ischemia-reperfusion injury was performed in one kidney, whereas the contralateral kidney was kept intact to maintain animal survival; then, after 2 wk of recovery, when the renal function of the injured kidney restored above the survival threshold, the contralateral intact kidney was removed. Animals of this two-stage unilateral ischemia-reperfusion injury model with pedicle clamping of 21 and 24 min exhibited an incomplete recovery from AKI and subsequent progression of CKD with characteristics of a progressive decline in glomerular filtration rate, increase in plasma creatinine, worsening of proteinuria, and deleterious histopathological changes, including interstitial fibrosis and glomerulosclerosis. In conclusion, a new model of the AKI to CKD transition was generated in C57BL/6 mice.
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Affiliation(s)
- Jin Wei
- Department of Molecular Pharmacology and Physiology, University of South Florida College of Medicine , Tampa, Florida
| | - Jie Zhang
- Department of Molecular Pharmacology and Physiology, University of South Florida College of Medicine , Tampa, Florida
| | - Lei Wang
- Department of Molecular Pharmacology and Physiology, University of South Florida College of Medicine , Tampa, Florida
| | - Shan Jiang
- Department of Molecular Pharmacology and Physiology, University of South Florida College of Medicine , Tampa, Florida
| | - Liying Fu
- Tampa General Hospital , Tampa, Florida
| | | | - Ruisheng Liu
- Department of Molecular Pharmacology and Physiology, University of South Florida College of Medicine , Tampa, Florida
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28
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Affiliation(s)
- Indre K Semogas
- Department of Acute Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Amy Davis
- Department of Radiology, Epsom & St Helier Hospital NHS Trust, London, UK
| | - Imran Rafi
- Institute of Medical and Biomedical Education, St George's University of London, London, UK
| | - Christopher Anderson
- Institute of Medical and Biomedical Education, St George's University of London, London, UK
- Department of Urology, St George's University Hospitals NHS Foundation Trust, London
| | - Nicholas M P Annear
- Department of Acute Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
- Institute of Medical and Biomedical Education, St George's University of London, London, UK
- Department of Renal & Transplantation Medicine, St George's University Hospitals NHS Foundation Trust, London
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29
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Co I, Gunnerson K. Emergency Department Management of Acute Kidney Injury, Electrolyte Abnormalities, and Renal Replacement Therapy in the Critically Ill. Emerg Med Clin North Am 2019; 37:459-471. [PMID: 31262415 DOI: 10.1016/j.emc.2019.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Acute kidney injury (AKI) is a common sequela of critical illness. Clinical manifestation of AKI varies and can include electrolyte abnormalities, anion gap, or non-anion-gap metabolic acidosis. Treatment strategies require careful identification of the cause of the AKI, relying on both clinical history and laboratory data. Once the cause has been identified, treatment can then target the underlying cause and avoid further insults. Conservative management should first be attempted for patients with AKI. If conservative management fails, renal replacement therapy or hemodialysis can be used.
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Affiliation(s)
- Ivan Co
- Department of Emergency Medicine, University of Michigan Health System, 1500 East Medical Center Drive SPC 5301, Ann Arbor, MI 48109, USA; Department of Internal Medicine, Division of Pulmonary Critical Care, University of Michigan Health System, 1500 East Medical Center Drive SPC 5301, Ann Arbor, MI 48109, USA.
| | - Kyle Gunnerson
- Department of Emergency Medicine, Division of Emergency Critical Care, Massey Family Foundation Emergency Critical Center (EC3), University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5303, USA; Department of Anesthesiology, Division of Emergency Critical Care, Massey Family Foundation Emergency Critical Center (EC3), University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5303, USA; Department of Internal Medicine, Division of Emergency Critical Care, Massey Family Foundation Emergency Critical Center (EC3), University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5303, USA
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30
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Hall PS, Mitchell ED, Smith AF, Cairns DA, Messenger M, Hutchinson M, Wright J, Vinall-Collier K, Corps C, Hamilton P, Meads D, Lewington A. The future for diagnostic tests of acute kidney injury in critical care: evidence synthesis, care pathway analysis and research prioritisation. Health Technol Assess 2019; 22:1-274. [PMID: 29862965 DOI: 10.3310/hta22320] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is highly prevalent in hospital inpatient populations, leading to significant mortality and morbidity, reduced quality of life and high short- and long-term health-care costs for the NHS. New diagnostic tests may offer an earlier diagnosis or improved care, but evidence of benefit to patients and of value to the NHS is required before national adoption. OBJECTIVES To evaluate the potential for AKI in vitro diagnostic tests to enhance the NHS care of patients admitted to the intensive care unit (ICU) and identify an efficient supporting research strategy. DATA SOURCES We searched ClinicalTrials.gov, The Cochrane Library databases, Embase, Health Management Information Consortium, International Clinical Trials Registry Platform, MEDLINE, metaRegister of Current Controlled Trials, PubMed and Web of Science databases from their inception dates until September 2014 (review 1), November 2015 (review 2) and July 2015 (economic model). Details of databases used for each review and coverage dates are listed in the main report. REVIEW METHODS The AKI-Diagnostics project included horizon scanning, systematic reviewing, meta-analysis of sensitivity and specificity, appraisal of analytical validity, care pathway analysis, model-based lifetime economic evaluation from a UK NHS perspective and value of information (VOI) analysis. RESULTS The horizon-scanning search identified 152 potential tests and biomarkers. Three tests, Nephrocheck® (Astute Medical, Inc., San Diego, CA, USA), NGAL and cystatin C, were subjected to detailed review. The meta-analysis was limited by variable reporting standards, study quality and heterogeneity, but sensitivity was between 0.54 and 0.92 and specificity was between 0.49 and 0.95 depending on the test. A bespoke critical appraisal framework demonstrated that analytical validity was also poorly reported in many instances. In the economic model the incremental cost-effectiveness ratios ranged from £11,476 to £19,324 per quality-adjusted life-year (QALY), with a probability of cost-effectiveness between 48% and 54% when tests were compared with current standard care. LIMITATIONS The major limitation in the evidence on tests was the heterogeneity between studies in the definitions of AKI and the timing of testing. CONCLUSIONS Diagnostic tests for AKI in the ICU offer the potential to improve patient care and add value to the NHS, but cost-effectiveness remains highly uncertain. Further research should focus on the mechanisms by which a new test might change current care processes in the ICU and the subsequent cost and QALY implications. The VOI analysis suggested that further observational research to better define the prevalence of AKI developing in the ICU would be worthwhile. A formal randomised controlled trial of biomarker use linked to a standardised AKI care pathway is necessary to provide definitive evidence on whether or not adoption of tests by the NHS would be of value. STUDY REGISTRATION The systematic review within this study is registered as PROSPERO CRD42014013919. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Peter S Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | | | - Alison F Smith
- Academy of Primary Care, Hull York Medical School, Hull, UK.,National Institute for Health Research (NIHR) Diagnostic Evidence Co-operative Leeds, Leeds, UK
| | - David A Cairns
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Michael Messenger
- National Institute for Health Research (NIHR) Diagnostic Evidence Co-operative Leeds, Leeds, UK
| | | | - Judy Wright
- Academy of Primary Care, Hull York Medical School, Hull, UK
| | | | | | - Patrick Hamilton
- Manchester Institute of Nephrology and Transplantation, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - David Meads
- Academy of Primary Care, Hull York Medical School, Hull, UK
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31
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Pedersen PB, Hrobjartsson A, Nielsen DL, Henriksen DP, Brabrand M, Lassen AT. Prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital: A systematic review. PLoS One 2018; 13:e0206610. [PMID: 30383864 PMCID: PMC6211733 DOI: 10.1371/journal.pone.0206610] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 10/16/2018] [Indexed: 01/31/2023] Open
Abstract
Introduction Patients in an emergency department are diverse. Some are more seriously ill than others and some even arrive in multi-organ failure. Knowledge of the prevalence of organ failure and its prognosis in unselected patients is important from a diagnostic, hospital planning, and from a quality evaluation point of view, but is not reported systematically. Objectives To analyse the prevalence and prognosis of new onset organ failure in unselected acute patients at arrival to hospital. Methods A systematic review of studies of prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital. We searched PubMed, Cochrane Library, Embase and Cinahl, and read references in included studies. Two authors decided independently on study eligibility and extracted data. Results were summarised qualitatively. Results Four studies were included with a total of 678,960 patients. The number of different organ failures reported in the studies ranged from one to six, and the settings were emergency departments and wards. The definitions of organ failure varied between studies. The prevalence of organ failure was 7%, 14%, 14%, and 23%, and in-hospital mortality was 5%, 11% and 15% respectively. The relative risk of in-hospital mortality for patients with organ failure compared to patients without organ failure varied from 2.58 to 8.65. Numbers of organ failures per 1,000 visits varied from 71 to 256. Conclusion The results of this review indicate that clinicians have good reasons to be alert when a patient arrives to the emergency department; as a state of organ failure seems both frequent and highly severe. However, most studies identified were performed in patients after a diagnosis was established, and only very few studies were performed in unselected patients. Systematic review registration number PROSPERO: CRD42017060871.
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Affiliation(s)
- Peter Bank Pedersen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- * E-mail:
| | - Asbjørn Hrobjartsson
- Centre for Evidence-Based Medicine, University of Southern Denmark & Odense University Hospital, Odense, Denmark
| | | | - Daniel Pilsgaard Henriksen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - Annmarie Touborg Lassen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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32
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Mistry H, Abdelaziz TS, Thomas M. A Prospective Micro-costing Pilot Study of the Health Economic Costs of Acute Kidney Injury. Kidney Int Rep 2018; 3:1285-1293. [PMID: 30450455 PMCID: PMC6224786 DOI: 10.1016/j.ekir.2018.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/21/2018] [Accepted: 06/18/2018] [Indexed: 11/28/2022] Open
Abstract
Introduction Acute kidney injury (AKI) prevalence in the UK is estimated to be approximately 20% of all emergency admissions. Complications of AKI have a huge impact on health care costs. Most studies that have researched the economic costs of AKI have used macro-level costing using national tariffs and applying this to hospital episode statistics. Methods The Acute Kidney Outreach to Reduce Deterioration and Death (AKORDD) study was a pilot study that tested the provision of early specialist advice to improve outcomes for patients with AKI. As part of this prospective study, we undertook a health economics substudy that involved micro-costing to help more accurately define the total cost per patient. Results We found that the total cost of providing an AKI alert system and an outreach service (intervention group) was lower than current practice (control group) for patients with AKI. Overall, an episode of AKI that required inpatient care costs approximately £5000 over 12 months, which is somewhat higher than previous UK estimates. Although it was feasible to collect the required complex dataset needed to conduct a health economics analysis of an outreach service, significant amounts of time and resources needed to be dedicated to this endeavor. Conclusion We showed that it is possible to demonstrate a clearer, more detailed picture of the prolonged economic costs of AKI for a health care system, as part of a substudy of a larger trial. A larger scale, randomized controlled trial of AKI outreach is needed, with a prospective full economic evaluation conducted alongside the trial.
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Affiliation(s)
- Hema Mistry
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | - Tarek Samy Abdelaziz
- Department of Renal Medicine, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Mark Thomas
- Department of Renal Medicine, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
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33
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Wang D, Guo Y, Zhang Y, Li Z, Li A, Luo Y. Epidemiology of acute kidney injury in patients with stroke: a retrospective analysis from the neurology ICU. Intern Emerg Med 2018; 13:17-25. [PMID: 28656546 DOI: 10.1007/s11739-017-1703-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 06/19/2017] [Indexed: 01/20/2023]
Abstract
Acute kidney injury (AKI) is proven to be an independent risk factor for adverse clinical outcomes in patients with stroke, but data about the epidemiology of AKI in these patients are not well characterized. Therefore, we investigated the incidence, risk factors, and the impact of AKI on the clinical outcomes in a group of Chinese patients with stroke. We retrospectively recruited 647 stroke patients from the neurology ICU between 2012 and 2013. AKI was identified according to the 2012 KDIGO criteria. Baseline estimated glomerular filtration rate (eGFR) was calculated using modified Chronic Kidney Disease Epidemiology Collaboration equation for Chinese patients. National Institutes of Health Stroke Scale (NIHSS) score was assessed for the stroke severity. A total of 135 (20.9%) patients developed AKI. Patients with AKI stages from 1 to 3 were 84 (62.2%), 26 (19.3%), and 25 (18.5%), respectively. Logistic regression analysis showed that independent risk factors for AKI were higher NIHSS score (OR, 1.027; 95% CI 1.003-1.051), lower baseline eGFR (OR, 0.985; 95% CI 0.977-0.993), the presence of hypertension (OR, 1.592; 95% CI 1.003-2.529), and infectious complications (OR, 3.387; 95% CI 1.997-5.803) (P < 0.05 for all). AKI patients were also significantly associated with all-cause mortality in the neurology ICU [OR and 95% CI of AKI-stage 1, AKI-stage 2, and AKI-stage 3 were 4.961 (2.191-11.232), 19.722 (6.354-61.217), and 48.625 (17.616-134.222), respectively (P < 0.001 for all)]. AKI is common among patients with stroke and is associated with worse clinical outcomes after stroke. Prevention of AKI seems to be very important among these patients, because they are exposed to many risk factors for developing AKI.
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Affiliation(s)
- Dongxue Wang
- Department of Nephrology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yidan Guo
- Department of Nephrology, Beijing Shijitan Hospital, Capital Medical University, Haidian District, No 10, Tieyi Road, Beijing, People's Republic of China
| | - Yin Zhang
- Department of Nephrology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhaoxia Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ang Li
- Department of Intensive Care Unit, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yang Luo
- Department of Nephrology, Beijing Shijitan Hospital, Capital Medical University, Haidian District, No 10, Tieyi Road, Beijing, People's Republic of China.
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34
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Babar F, Singh G, Noor M, Sabath B. Retrospective analysis of inferior vena cava collapsibility with point of care ultrasound and urine sodium and FENa in patients with early stage acute kidney injury. J Community Hosp Intern Med Perspect 2017; 7:296-299. [PMID: 29147470 PMCID: PMC5676799 DOI: 10.1080/20009666.2017.1378048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 09/01/2017] [Indexed: 01/31/2023] Open
Abstract
Early stage acute kidney injury (AKI) is an independent risk factor for an increase in mortality. Accurate assessment of volume status is a major challenge during the early stages of acute renal injury. Determining volume status based on the history and physical exam lacks accuracy. Urine sodium and free excretion of sodium (FENa) provide objective evidence of intravascular volume status when interpreted carefully and is helpful to delineate prerenal from intrinsic renal failure. In recent years point of care ultrasound has been used to assess volume status. Our team conducted a retrospective chart review to assess the association of inferior vena cava collapsibility by point of care ultrasound (POCUS) and urine electrolytes (urine sodium, fractional excretion of sodium) during early stage AKI (Stage 1–2 of KDIGO guidelines). We reviewed 150 cases based on the provisional diagnosis. 36 patients met the criteria for further review. Using bivariate analysis, we found a strong association between >50% IVC collapsibility with FENa < 0.4% with an odds ratio 5.3 (CI 1.1–24.5, p = 0.04), and urine sodium <20 meq/dl with an odds ratio of 6.7 (Cl 1.5–30, p = 0.02). Subsequently, multivariate analysis and Spearman correlation showed an inverse relation between IVC collapsibility and fractional excretion of sodium FENa (β = −0.4, p = 0.001) and (r = −0.44, p = 0.01). These findings suggest the role of POCUS and urinary markers in determining the intravascular volume status in AKI. POCUS is also valuable to assess volume status in cases of renal failure where urine studies are difficult to interpret.
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Affiliation(s)
- Faizan Babar
- Department of Internal Medicine, Greater Baltimore Medical Center, MD, USA
| | - Gurkeerat Singh
- Department of Internal Medicine, Greater Baltimore Medical Center, MD, USA
| | - Mustafa Noor
- Department of Internal Medicine, Greater Baltimore Medical Center, MD, USA
| | - Bruce Sabath
- Department of Internal Medicine, Greater Baltimore Medical Center, MD, USA
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Chandrasekar T, Sharma A, Tennent L, Wong C, Chamberlain P, Abraham KA. A whole system approach to improving mortality associated with acute kidney injury. QJM 2017; 110:657-666. [PMID: 28521019 DOI: 10.1093/qjmed/hcx101] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is in the main managed by non-nephrologists, many who feel challenged by or lack awareness of the complexity that the renal element adds to their patients' care. National reports have raised major concerns about the quality of care and have predicted that mortality reductions of 30% are achievable with good medical practice. AIM This quality improvement project evaluated whether a whole system approach could improve outcomes for patients with AKI. DESIGN AND METHODS Quality improvement methodology was used to understand hospital patterns, processes and professional knowledge. Change concepts were developed which included management of patients at risk, staff education and awareness program, development of a patient specific electronic alert to prompt diagnosis, easy to remember care bundle (ABCDE-IT), dedicated outreach team and patient and family empowerment leaflet. RESULTS Statistical process control analysis was used to verify outcomes over time. A shift in the in-hospital mortality rate corresponded to a relative 23.2% reduction in mortality and was sustained over the next 33 months (P < 0.0001). The favourable shift in mortality was temporally distinct from the improved AKI detection rate. This timeframe corresponded to lying below the 99.8% lower confidence limit in comparison with all English acute trusts for comparative AKI specific SHMI/HSMR mortality rates. Length of stay also reduced shortly after onset of the project by 14.1% or 2.6 day reduction (P < 0.0001). CONCLUSION This project demonstrated that an integrated, whole-system approach is necessary to ensure sustained improvements in AKI mortality and length of stay.
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Affiliation(s)
- T Chandrasekar
- Nephrology Directorate, Aintree University Hospital, Liverpool L9 7AL, UK
| | - A Sharma
- Nephrology Directorate, Royal Liverpool University Hospital, Liverpool L7 8XP, UK
| | - L Tennent
- Administrative Services, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - C Wong
- Nephrology Directorate, Aintree University Hospital, Liverpool L9 7AL, UK
| | - P Chamberlain
- Innovation and Strategy, South Sefton CCG, Liverpool L20 3DL, UK
| | - K A Abraham
- Nephrology Directorate, Aintree University Hospital, Liverpool L9 7AL, UK
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Acute kidney injury is a risk factor for subsequent proteinuria. Kidney Int 2017; 93:460-469. [PMID: 28927644 DOI: 10.1016/j.kint.2017.07.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 06/20/2017] [Accepted: 07/13/2017] [Indexed: 12/31/2022]
Abstract
Acute kidney injury (AKI) is associated with subsequent chronic kidney disease (CKD), but the mechanism is unclear. To clarify this, we examined the association of AKI and new-onset or worsening proteinuria during the 12 months following hospitalization in a national retrospective cohort of United States Veterans hospitalized between 2004-2012. Patients with and without AKI were matched using baseline demographics, comorbidities, proteinuria, estimated glomerular filtration rate, blood pressure, angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (ACEI/ARB) use, and inpatient exposures linked to AKI. The distribution of proteinuria over one year post-discharge in the matched cohort was compared using inverse probability sampling weights. Subgroup analyses were based on diabetes, pre-admission ACEI/ARB use, and AKI severity. Among the 90,614 matched AKI and non-AKI pairs, the median estimated glomerular filtration rate was 62 mL/min/1.73m2. The prevalence of diabetes and hypertension were 48% and 78%, respectively. The odds of having one plus or greater dipstick proteinuria was significantly higher during each month of follow-up in patients with AKI than in patients without AKI (odds ratio range 1.20-1.39). Odds were higher in patients with Stage II or III AKI (odds ratios 1.32-1.81) than in Stage I AKI (odds ratios 1.18-1.32), using non-AKI as the reference group. Results were consistent regardless of diabetes status or baseline ACEI/ARB use. Thus, AKI is a risk factor for incident or worsening proteinuria, suggesting a possible mechanism linking AKI and future CKD. The type of proteinuria, physiology, and clinical significance warrant further study as a potentially modifiable risk factor in the pathway from AKI to CKD.
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Malachias MVB, Barbosa ECD, Martim JFV, Rosito GBA, Toledo JY, Passarelli O. 7th Brazilian Guideline of Arterial Hypertension: Chapter 14 - Hypertensive Crisis. Arq Bras Cardiol 2017; 107:79-83. [PMID: 27819393 PMCID: PMC5319471 DOI: 10.5935/abc.20160164] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Ebah L, Hanumapura P, Waring D, Challiner R, Hayden K, Alexander J, Henney R, Royston R, Butterworth C, Vincent M, Heatley S, Terriere G, Pearson R, Hutchison A. A Multifaceted Quality Improvement Programme to Improve Acute Kidney Injury Care and Outcomes in a Large Teaching Hospital. BMJ QUALITY IMPROVEMENT REPORTS 2017; 6:bmjqir.u219176.w7476. [PMID: 28607684 PMCID: PMC5457974 DOI: 10.1136/bmjquality.u219176.w7476] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 03/30/2017] [Indexed: 01/21/2023]
Abstract
Acute kidney injury (AKI) is now widely recognised as a serious health care issue, occurring in up to 25% of hospital in-patients, often with worsening of outcomes. There have been several reports of substandard care in AKI. This quality improvement (QI) programme aimed to improve AKI care and outcomes in a large teaching hospital. Areas of documented poor AKI care were identified and specific improvement activities implemented through sequential Plan-Do-Study-Act (PDSA) cycles. An electronic alert system (e-alert) for AKI was developed, a Priority Care Checklist (PCC) was tested with the aid of specialist nurses whilst targeted education activities were carried out and data on care processes and outcomes monitored. The e-alert had a sensitivity of 99% for the detection of new cases of AKI. Key aspects of the PCC saw significant improvements in their attainment: Detection of AKI within 24 hours from 53% to 100%, fluid assessment from 42% to 90%, drug review 48% to 95% and adherence to nine key aspects of care from 40% to 90%. There was a significant reduction in variability of delivered AKI care. AKI incidence reduced from 9% of all hospitalisations at baseline to 6.5% (28% reduction), AKI related length of stay reduced from 22.1 days to 17 days (23% reduction) and time to recovery (AKI days) 15.5 to 9.8 days (36% reduction). AKI related deaths also showed a trend towards reduction, from an average of 38 deaths to 34 (10.5%). The number of cases of hospital acquired AKI were reduced by 28% from 120 to 86 per month. This study demonstrates significant improvements related to a QI programme combining e-alerts, a checklist implemented by a nurse and education in improving key processes of care. This resulted in sustained improvement in key patient outcomes.
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Affiliation(s)
- Leonard Ebah
- Central Manchester University Hospitals NHS Foundation Trust
| | | | - Deryn Waring
- Central Manchester University Hospitals NHS Foundation Trust
| | | | | | - Jill Alexander
- Central Manchester University Hospitals NHS Foundation Trust
| | - Robert Henney
- Central Manchester University Hospitals NHS Foundation Trust
| | - Rachel Royston
- Central Manchester University Hospitals NHS Foundation Trust
| | | | - Marc Vincent
- Central Manchester University Hospitals NHS Foundation Trust
| | - Susan Heatley
- Central Manchester University Hospitals NHS Foundation Trust
| | - Ged Terriere
- Central Manchester University Hospitals NHS Foundation Trust
| | - Robert Pearson
- Central Manchester University Hospitals NHS Foundation Trust
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Manoeuvrier G, Bach-Ngohou K, Batard E, Masson D, Trewick D. Diagnostic performance of serum blood urea nitrogen to creatinine ratio for distinguishing prerenal from intrinsic acute kidney injury in the emergency department. BMC Nephrol 2017; 18:173. [PMID: 28545421 PMCID: PMC5445342 DOI: 10.1186/s12882-017-0591-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 05/17/2017] [Indexed: 11/11/2022] Open
Abstract
Background The blood urea nitrogen to creatinine ratio (BCR) has been used since the early 1940s to help clinicians differentiate between prerenal acute kidney injury (PR AKI) and intrinsic AKI (I AKI). This ratio is simple to use and often put forward as a reliable diagnostic tool even though little scientific evidence supports this. The aim of this study was to determine whether BCR is a reliable tool for distinguishing PR AKI from I AKI. Methods We conducted a retrospective observational study over a 13 months period, in the Emergency Department (ED) of Nantes University Hospital. Eligible for inclusion were all adult patients consecutively admitted to the ED with a creatinine >133 μmol/L (1.5 mg/dL). Results Sixty thousand one hundred sixty patients were consecutively admitted to the ED. 2756 patients had plasma creatinine levels in excess of 133 μmol/L, 1653 were excluded, leaving 1103 patients for definitive inclusion. Mean age was 75.7 ± 14.8 years old, 498 (45%) patients had PR AKI and 605 (55%) I AKI. BCR was 90.55 ± 39.32 and 91.29 ± 39.79 in PR AKI and I AKI groups respectively. There was no statistical difference between mean BCR of the PR AKI and I AKI groups, p = 0.758. The area under the ROC curve was 0.5 indicating that BCR had no capacity to discriminate between PR AKI and I AKI. Conclusions Our study is the largest to investigate the diagnostic performance of BCR. BCR is not a reliable parameter for distinguishing prerenal AKI from intrinsic AKI.
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Affiliation(s)
| | - Kalyane Bach-Ngohou
- Department of Biology, Laboratory of Clinical Biochemistry, CHU Nantes, Nantes, France
| | - Eric Batard
- Department of Emergency Medicine, CHU Nantes, Nantes, France.,Service des Urgences, CHU Hotel Dieu, 44000, Nantes, France
| | - Damien Masson
- Department of Biology, Laboratory of Clinical Biochemistry, CHU Nantes, Nantes, France
| | - David Trewick
- Department of Emergency Medicine, CHU Nantes, Nantes, France. .,Service des Urgences, CHU Hotel Dieu, 44000, Nantes, France.
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Scheuermeyer FX, Grafstein E, Rowe B, Cheyne J, Grunau B, Bradford A, Levin A. The Clinical Epidemiology and 30-Day Outcomes of Emergency Department Patients With Acute Kidney Injury. Can J Kidney Health Dis 2017; 4:2054358117703985. [PMID: 28491339 PMCID: PMC5406199 DOI: 10.1177/2054358117703985] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is associated with increased mortality and dialysis in hospitalized patients but has been little explored in the emergency department (ED) setting. OBJECTIVE The objective of this study was to describe the risk factors, prevalence, management, and outcomes in the ED population, and to identify the proportion of AKI patients who were discharged home with no renal-specific follow-up. DESIGN This is a retrospective cohort study using administrative and laboratory databases. SETTING Two urban EDs in Vancouver, British Columbia, Canada. PATIENTS We included all unique ED patients over a 1-week period. METHODS All patients had their described demographics, comorbidities, medications, laboratory values, and ED treatments collected. AKI was defined pragmatically, based upon accepted guidelines. The cohort was then probabilistically linked to the provincial renal database to ascertain renal replacement (transplant or dialysis) and the provincial vital statistics database to obtain mortality. The primary outcome was the prevalence of AKI; secondary outcomes included (1) the proportion of AKI patients who were discharged home with no renal-specific follow-up and (2) the combined 30-day rate of death or renal replacement among AKI patients. RESULTS There were 1651 ED unique patients, and 840 had at least one serum creatinine (SCr) obtained. Overall, 90 patients had AKI (10.7% of ED patients with at least one SCr, 95% confidence interval [CI], 8.7%-13.1%; 5.5% of all ED patients, 95% CI, 4.4%-6.7%) with a median age of 74 and 70% male. Of the 31 (34.4%) AKI patients discharged home, 4 (12.9%) had renal-specific follow-up arranged in the ED. Among the 90 AKI patients, 11 died and none required renal replacement at 30 days, for a combined outcome of 12.2% (95% CI, 6.5%-21.2%). LIMITATIONS Sample sizes may be small. Nearly half of ED patients did not obtain an SCr. Many patients did not have sequential SCr testing, and a modified definition of AKI was used.
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Affiliation(s)
- Frank Xavier Scheuermeyer
- Department of Emergency Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada.,The University of British Columbia, Vancouver, Canada
| | - Eric Grafstein
- The University of British Columbia, Vancouver, Canada.,Department of Emergency Medicine, Mount Saint Joseph Hospital, Vancouver, British Columbia, Canada
| | - Brian Rowe
- Department of Emergency Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada.,University of Alberta, Edmonton, Canada
| | - Jay Cheyne
- Department of Emergency Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada.,The University of British Columbia, Vancouver, Canada
| | - Brian Grunau
- Department of Emergency Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada.,The University of British Columbia, Vancouver, Canada
| | - Aaron Bradford
- Department of Emergency Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada.,The University of British Columbia, Vancouver, Canada
| | - Adeera Levin
- The University of British Columbia, Vancouver, Canada.,Division of Nephrology, Department of Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada
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Ahmed LI, Mansour HH, Hussen A, Zaki MS, Mohammed RR, Goda AT. Clinical evaluation of acute kidney injury in Al-Zahraa University Hospital, Cairo, Egypt. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2017. [DOI: 10.4103/ejim.ejim_3_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Sprenger-Mähr H, Zitt E, Lhotta K. Acute Kidney Injury Treated with Dialysis outside the Intensive Care Unit: A Retrospective Observational Single-Center Study. PLoS One 2016; 11:e0163512. [PMID: 27673681 PMCID: PMC5038962 DOI: 10.1371/journal.pone.0163512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 09/09/2016] [Indexed: 01/19/2023] Open
Abstract
Introduction The number of patients suffering from acute kidney injury requiring dialysis (AKI-D) is increasing. Whereas causes and outcome of AKI-D in the intensive care unit (ICU) are described extensively, few data exist about AKI-D patients treated outside the ICU. Aim of this study was to identify the causes of AKI-D, determine in-depth the comorbid conditions and outcome of this particular patient group and identify possibilities for its prevention. Methods We retrospectively studied all AKI-D patients treated outside the ICU in a single nephrology referral center between January 2010 and June 2015. Data on comorbid conditions, renal function and drug therapy prior to AKI-D, and possible causal events were collected. Patients were grouped into those with renal hypoperfusion as the predominant cause of AKI-D (hemodynamic group) and those with other causes (non-hemodynamic group). Results During 66 months 128 patients (57% male, mean age 69.3 years) were treated. AKI-D was community-acquired in 70.3%. The most frequent comorbidities were hypertension (62.5%), chronic kidney disease (CKD) (58.9%), coronary artery disease (CAD) (46.1%), diabetes (35.9%) and heart failure (34.1%). Most patients were prescribed diuretics (61.7%) and inhibitors of the renin-angiotensin-aldosterone system (RASI) (57.8%); 46.1% had a combination of both. In the 88 patients with hemodynamic AKI-D (68.8%) the most frequent initiating events were diarrhea (39.8%), infections (17.0%) and acute heart failure (13.6%). In the 40 patients with non-hemodynamic AKI-D (31.2%) interstitial nephritis (n = 15) was the prominent diagnosis. Patients with hemodynamic AKI-D were older (72.6 vs. 62.1 years, p = 0.001), suffered more often from CKD (68.2% vs. 33.3%, p = 0.003), CAD (54.5% vs. 27.5%, p = 0.004) and diabetes (42.0% vs. 22.5%, p = 0.033), and were more frequently on diuretics (75.0% vs. 32.5%, p<0.001), RASI (67.0% vs. 37.5%, p = 0.002) or their combination (58.0% vs. 20.0%, p<0.001). Twenty-two (17.2%) patients died and 27 (21.1%) patients died or developed end-stage renal disease. Conclusion AKI-D treated outside the ICU is most often caused by renal hypoperfusion. It predominantly afflicts elderly patients with one or more comorbid conditions, who are treated with diuretics and RASI and have an acute illness leading to volume depletion. Early discontinuation of these drugs may be a successful strategy to avoid AKI-D in vulnerable patients.
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Affiliation(s)
- Hannelore Sprenger-Mähr
- Department of Nephrology and Dialysis, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Emanuel Zitt
- Department of Nephrology and Dialysis, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Karl Lhotta
- Department of Nephrology and Dialysis, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Teaching Hospital Feldkirch, Feldkirch, Austria
- * E-mail:
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Fagugli RM, Patera F, Battistoni S, Tripepi G. Outcome in noncritically ill patients with acute kidney injury requiring dialysis: Effects of differing medical staffs and organizations. Medicine (Baltimore) 2016; 95:e4277. [PMID: 27472700 PMCID: PMC5265837 DOI: 10.1097/md.0000000000004277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Acute kidney injury requiring dialysis (AKI-D) treatment has significantly increased in incidence over the years, with more than 400 new cases per million population/y, 2/3 of which concern noncritically ill patients. In these patients, there are little data on mortality or on information of care organization and its impact on outcome. Specialty training and integrated teams, as well as a high volume of activity, seem to be linked to better hospital outcome. The study investigates mortality of patients admitted to and in-care of nephrology (NEPHROpts), a closed-staff organization, and to other medical wards (MEDpts), representing a model of open-staff organization.This is a single center, case-control cohort study derived from a prospective epidemiology investigation on patients with AKI-D admitted to or in-care of the Hospital of Perugia during the period 2007 to 2014. Noncritically ill AKI-D patients were analyzed: inclusion and exclusion criteria were defined to avoid possible bias on the cause of hospital admittance and comorbidities, and a propensity score (PS) matching was performed.Six hundred fifty-four noncritically ill patients were observed and 296 fulfilled inclusion/exclusion criteria. PS matching resulted in 2 groups: 100 NEPHROpts and 100 MEDpts. Characteristics, comorbidities, acute kidney injury causes, risk-injury-failure acute kidney injury criteria, and simplified acute physiology score (SAPS 2) were similar. Mortality was 36%, and a difference was reported between NEPHROpts and MEDpts (20% vs 52%, χ = 23.2, P < 0.001). Patients who died differed in age, serum creatinine, blood urea nitrogen/s.Creatinine ratio, dialysis urea reduction rate (URR), SAPS 2 and Charlson score; they presented a higher rate of heart disease, and a larger proportion required noradrenaline/dopamine for shock. After correction for mortality risk factors, multivariate Cox analysis revealed that site of treatment (medical vs nephrology wards) represents an independent risk factor of mortality (relative risk = 2.13, 95% confidence interval = 1.25, 3.63; P < 0.01). Other independent risk factors were age, URR, s.Creatinine at hemodialysis beginning, and SAPS 2 score.In our context, we have documented that noncritically ill AKI-D patients, who represented 2/3 of the population, had high in-hospital mortality (36%), and that a closed-staff specialty medical organization, such as a Nephrology team, seems to guarantee a better outcome than general medical organizations. The significance in healthcare system organization and resource allocation could be important.
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Affiliation(s)
- Riccardo Maria Fagugli
- Nephrology-Dialysis Unit, Azienda Ospedaliero-Universitaria Perugia, Perugia
- Correspondence: Dr Riccardo Maria Fagugli, S.C.Nefrologia e Dialisi, Azienda Ospedaliero-Universitaria di Perugia, S.Andrea delle Fratte, 06123 Perugia, Italy (e-mail: )
| | - Francesco Patera
- Nephrology-Dialysis Unit, Azienda Ospedaliero-Universitaria Perugia, Perugia
| | | | - Giovanni Tripepi
- CNR-IFC and Nephrology, Dialysis and Transplantation Unit of Reggio Calabria, Reggio Calabria, Italy
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Kimmel M, Shi J, Latus J, Wasser C, Kitterer D, Braun N, Alscher MD. Association of Renal Stress/Damage and Filtration Biomarkers with Subsequent AKI during Hospitalization among Patients Presenting to the Emergency Department. Clin J Am Soc Nephrol 2016; 11:938-946. [PMID: 27026519 PMCID: PMC4891754 DOI: 10.2215/cjn.10551015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 03/03/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Emergency departments (EDs) have a growing role in hospital admissions, but few studies address AKI biomarkers in the ED. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients admitted to the internal medicine service were enrolled during initial workup in the ED at Robert-Bosch-Hospital, Stuttgart, Germany. Daily serum creatinine (sCr) and urine output (UO) were recorded for AKI classification by Kidney Disease Improving Global Outcomes (KDIGO) criteria. Cystatin C, kidney injury molecule-1, liver-type fatty acid-binding protein, and neutrophil gelatinase-associated lipocalin were measured in blood and urine, and IL-18, insulin-like growth factor-binding protein 7 (IGFBP7), tissue inhibitor of metalloproteinases-2 (TIMP-2) and [TIMP-2]⋅[IGFBP7] were measured in urine collected at enrollment, after 6 hours, and the following morning. Association between these biomarkers and the end point of moderate-severe AKI (KDIGO stage 2-3) occurring within 12 hours of each sample collection was examined using generalized estimating equation logistic regression. Performance for prediction of the AKI end point using two previously validated [TIMP-2]-[IGFBP7] cutoffs was also tested. RESULTS Of 400 enrolled patients, 298 had sufficient sCr and UO data for classification by KDIGO AKI criteria: AKI stage 2 developed in 37 patients and AKI stage 3 in nine patients. All urinary biomarkers, sCr, and plasma cystatin C had statistically significant (P<0.05) odds ratios (ORs) for the AKI end point. In a multivariable model of the urine biomarkers and sCr, only [TIMP-2]⋅[IGFBP7] and sCr had statistically significant ORs. Compared with [TIMP-2]⋅[IGFBP7]<0.3 (ng/ml)(2)/1000, values between 0.3 and 2.0 (ng/ml)(2)/1000 indicated 2.5 (95% confidence interval [95% CI], 1.1 to 5.2) times the odds for the AKI end point and values >2.0 (ng/ml)(2)/1000 indicated 11.0 (95% CI, 4.4 to 26.9) times the odds. Addition of [TIMP-2]⋅[IGFBP7] to a clinical model significantly improved area under the receiver-operating characteristic curve from 0.67 (95% CI, 0.61 to 0.78) to 0.77 (95% CI, 0.72 to 0.86) (P<0.001); however, including both markers in the model was not significantly different from including either marker alone. CONCLUSIONS Urinary [TIMP-2]⋅[IGFBP7] with pre-established cutoffs provides valuable information about risk for imminent AKI in the ED that is complementary to sCr and clinical risk factors.
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Affiliation(s)
- Martin Kimmel
- Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany; and
| | - Jing Shi
- Walker Bioscience, Carlsbad, California
| | - Joerg Latus
- Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany; and
| | - Christoph Wasser
- Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany; and
| | - Daniel Kitterer
- Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany; and
| | - Niko Braun
- Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany; and
| | - Mark Dominik Alscher
- Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany; and
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Nascimento RAMD, Assunção MSC, Silva Junior JM, Amendola CP, Carvalho TMD, Lima EQ, Lobo SMA. Nurses' knowledge to identify early acute kidney injury. Rev Esc Enferm USP 2016; 50:399-404. [DOI: 10.1590/s0080-623420160000400004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 04/20/2016] [Indexed: 11/22/2022] Open
Abstract
Abstract OBJECTIVE To evaluate the knowledgeof nurses on early identification of acute kidney injury (AKI) in intensive care, emergency and hospitalization units. METHOD A prospective multi-center study was conducted with 216 nurses, using a questionnaire with 10 questions related to AKI prevention, diagnosis, and treatment. RESULTS 57.2% of nurses were unable to identify AKI clinical manifestations, 54.6% did not have knowledge of AKI incidence in patients admitted to the ICU, 87.0% of the nurses did not know how to answer as regards the AKI mortality rate in patients admitted to the ICU, 67.1% answered incorrectly that slight increases in serum creatinine do not have an impact on mortality, 66.8% answered incorrectly to the question on AKI prevention measures, 60.4% answered correctly that loop diuretics for preventing AKI is not recommended, 77.6% answered correctly that AKI does not characterize the need for hemodialysis, and 92.5% said they had no knowledge of the Acute Kidney Injury Networkclassification. CONCLUSION Nurses do not have enough knowledge to identify early AKI, demonstrating the importance of qualification programs in this field of knowledge.
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Parr SK, Siew ED. Delayed Consequences of Acute Kidney Injury. Adv Chronic Kidney Dis 2016; 23:186-94. [PMID: 27113695 PMCID: PMC4849427 DOI: 10.1053/j.ackd.2016.01.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 01/22/2016] [Indexed: 11/11/2022]
Abstract
Acute kidney injury (AKI) is an increasingly common complication of hospitalization and acute illness. Experimental data indicate that AKI may cause permanent kidney damage through tubulointerstitial fibrosis and progressive nephron loss, while also lowering the threshold for subsequent injury. Furthermore, preclinical data suggest that AKI may also cause distant organ dysfunction. The extension of these findings to human studies suggests long-term consequences of AKI including, but not limited to recurrent AKI, progressive kidney disease, elevated blood pressure, cardiovascular events, and mortality. As the number of AKI survivors increases, the need to better understand the mechanisms driving these processes becomes paramount. Optimizing care for AKI survivors will require understanding the short- and long-term risks associated with AKI, identifying patients at highest risk for poor outcomes, and testing interventions that target modifiable risk factors. In this review, we examine the literature describing the association between AKI and long-term outcomes and highlight opportunities for further research and potential intervention.
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Affiliation(s)
- Sharidan K Parr
- Tennessee Valley Healthcare System (TVHS), Geriatric Research Education and Clinical Centers (GRECC), Nashville, TN; TVHS, Veterans Administration (VA) Medical Center, Veterans Health Administration, Nashville, TN; Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; and Vanderbilt Center for Kidney Disease (VCKD), Nashville, TN
| | - Edward D Siew
- Tennessee Valley Healthcare System (TVHS), Geriatric Research Education and Clinical Centers (GRECC), Nashville, TN; TVHS, Veterans Administration (VA) Medical Center, Veterans Health Administration, Nashville, TN; Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; and Vanderbilt Center for Kidney Disease (VCKD), Nashville, TN.
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Awdishu L, Coates CR, Lyddane A, Tran K, Daniels CE, Lee J, El-Kareh R. The impact of real-time alerting on appropriate prescribing in kidney disease: a cluster randomized controlled trial. J Am Med Inform Assoc 2015; 23:609-16. [PMID: 26615182 DOI: 10.1093/jamia/ocv159] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 09/21/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with kidney disease are at risk for adverse events due to improper medication prescribing. Few randomized controlled trials of clinical decision support (CDS) utilizing dynamic assessment of patients' kidney function to improve prescribing for patients with kidney disease have been published. METHODS We developed a CDS tool for 20 medications within a commercial electronic health record. Our system detected scenarios in which drug discontinuation or dosage adjustment was recommended for adult patients with impaired renal function in the ambulatory and acute settings - both at the time of the initial prescription ("prospective" alerts) and by monitoring changes in renal function for patients already receiving one of the study medications ("look-back" alerts). We performed a prospective, cluster randomized controlled trial of physicians receiving clinical decision support for renal dosage adjustments versus those performing their usual workflow. The primary endpoint was the proportion of study prescriptions that were appropriately adjusted for patients' kidney function at the time that patients' conditions warranted a change according to the alert logic. We employed multivariable logistic regression modeling to adjust for glomerular filtration rate, gender, age, hospitalized status, length of stay, type of alert, time from start of study, and clustering within the prescribing physician on the primary endpoint. RESULTS A total of 4068 triggering conditions occurred in 1278 unique patients; 1579 of these triggering conditions generated alerts seen by physicians in the intervention arm and 2489 of these triggering conditions were captured but suppressed, so as not to generate alerts for physicians in the control arm. Prescribing orders were appropriate adjusted in 17% of the time vs 5.7% of the time in the intervention and control arms, respectively (odds ratio: 1.89, 95% confidence interval, 1.45-2.47, P < .0001). Prospective alerts had a greater impact than look-back alerts (55.6% vs 10.3%, in the intervention arm). CONCLUSIONS The rate of appropriate drug prescribing in kidney impairment is low and remains a patient safety concern. Our results suggest that CDS improves drug prescribing, particularly when providing guidance on new prescriptions.
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Affiliation(s)
- Linda Awdishu
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, CA, USA UC San Diego School of Medicine, San Diego, CA, USA
| | | | | | - Kim Tran
- Northeast Georgia Diagnostic Clinic, Gainsville, GA, USA
| | - Charles E Daniels
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, CA, USA UC San Diego Health System, San Diego, CA, USA
| | - Joshua Lee
- Keck Medicine, University of Southern California, Los Angeles, CA, USA
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Chao CT, Tsai HB, Wu CY, Lin YF, Hsu NC, Chen JS, Hung KY. The severity of initial acute kidney injury at admission of geriatric patients significantly correlates with subsequent in-hospital complications. Sci Rep 2015; 5:13925. [PMID: 26355041 PMCID: PMC4564739 DOI: 10.1038/srep13925] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 08/11/2015] [Indexed: 12/29/2022] Open
Abstract
Acute kidney injury (AKI) is associated with higher hospital mortality. However, the relationship between geriatric AKI and in-hospital complications is unclear. We prospectively enrolled elderly patients (≥65 years) from general medical wards of National Taiwan University Hospital, part of whom presented AKI at admission. We recorded subsequent in-hospital complications, including catastrophic events, incident gastrointestinal bleeding, hospital-associated infections, and new-onset electrolyte imbalances. Regression analyses were utilized to assess the associations between in-hospital complications and the initial AKI severity. A total of 163 elderly were recruited, with 39% presenting AKI (stage 1: 52%, stage 2: 23%, stage 3: 25%). The incidence of any in-hospital complication was significantly higher in the AKI group than in the non-AKI group (91% vs. 68%, p < 0.01). Multiple regression analyses indicated that elderly patients presenting with AKI had significantly higher risk of developing any complication (Odds ratio [OR] = 3.51, p = 0.01) and new-onset electrolyte imbalance (OR = 7.1, p < 0.01), and a trend toward more hospital-associated infections (OR = 1.99, p = 0.08). The risk of developing complications increased with higher AKI stage. In summary, our results indicate that initial AKI at admission in geriatric patients significantly increased the risk of in-hospital complications.
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Affiliation(s)
- Chia-Ter Chao
- Department of Medicine, National Taiwan University Hospital Jin-Shan branch, New Taipei City, Taiwan
- Graduate Institute of Toxicology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hung-Bin Tsai
- Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Yi Wu
- The Department of Nursing, National Taiwan University, Taipei, Taiwan
| | - Yu-Feng Lin
- Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Nin-Chieh Hsu
- Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jin-Shing Chen
- Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuan-Yu Hung
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Sepsis and AKI in Clinical Emergency Room Patients: The Role of Urinary NGAL. BIOMED RESEARCH INTERNATIONAL 2015; 2015:413751. [PMID: 26266256 PMCID: PMC4516828 DOI: 10.1155/2015/413751] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 05/19/2015] [Accepted: 05/21/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Few studies have investigated the predictive properties of urinary (u) NGAL as an AKI marker in septic population. OBJECTIVES This study evaluated the efficacy of uNGAL as predictor of AKI and death in septic patients admitted to the clinical emergency room (ER). METHODOLOGY We prospectively studied patients with sepsis admitted to the ER. Urine was analyzed for NGAL within the first 24 hours after admission (classified as NGAL1), between 24 and 48 h (NGAL2), and at moment of AKI diagnosis (NGAL3). RESULTS Among 168 septic patients admitted to ER, 72% developed AKI. The uNGAL and its relationship with creatinine (Cr) were high in septic patients but statistically higher in those with sepsis and AKI. The uNGAL1 and uNGAL2, as well as uNGAL1/uCr1 and uNGAL2/uCr2, were good predictors for AKI (AUC-ROC 0.73, 0.70, 0.77, and 0.84, resp.). The uNGAL1 and uNGAL1/uCr1 were poor predictors for death (AUC-ROC 0.66 and 0.68, resp.), whereas uNGAL2 and uNGAL2/uCr2 were better predictors (AUC-ROC 0.70 and 0.81, resp.). CONCLUSION The uNGAL is highly sensitive but nonspecific predictor of AKI and death in septic patients admitted into ER.
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Acute kidney injury in septic patients admitted to emergency clinical room: risk factors and outcome. Clin Exp Nephrol 2014; 19:859-66. [PMID: 25542518 DOI: 10.1007/s10157-014-1076-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 12/15/2014] [Indexed: 01/20/2023]
Abstract
PURPOSE Acute kidney injury (AKI) is a common source of morbidity in sepsis. We sought to determine risk factors for AKI, by acute kidney injury network (AKIN) criteria, in septic patients admitted in emergency clinical room (ER). MATERIALS AND METHODS Prospective cohort study of 200 patients admitted to the ER of a University Hospital, followed for development of AKI over 5 days. RESULTS AKI developed in 144/200 (72 %) patients. In multivariable regression analysis, independent risk factors for AKI included age over 65 years (OR 1.28; 95 % CI 1.12-1.89; p = 0.04), mean blood pressure (MBP) lower than 65 mmHg at moment of admission (OR 1.89; 95 % CI 1.43-2.64, p = 0.003) and diabetes mellitus (OR 1.66; 95 % CI 1.30-3.20; p = 0.012). Mortality rate was 51.4 % in AKI patients compared with 26.8 % for those without AKI (p = 0.002). Septic shock (OR = 1.83, 95 % CI 1.23-2.74, p = 0.007), AKIN 3 (OR = 1.64; 95 % CI 1.19-1.89, p = 0.02), APACHE 2 > 20 (OR 1.92, 95 % CI 1.34-2.02, p = 0.009) and need for dialysis (OR = 1.26, 95 % CI 1.13-1.75, p = 0.03) were identified as independent risk factors for death in multivariable regression analysis. CONCLUSIONS AKI severity in septic patients admitted in ER is associated with mortality. Diabetes, age over 65 years, and low MBP are independent risk factors for AKI and deserve further study to prevent AKI and, consequently, decreasing mortality.
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