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Lievre L, Dupont V, Kanagaratnam L, Faroux L, Debrumetz A, Rieu P, Wynckel A. Urine-to-plasma creatinine ratio and fractional excretion of urea performance in acute-on-chronic kidney disease patients. J Nephrol 2023; 36:2661-2663. [PMID: 37402076 DOI: 10.1007/s40620-023-01700-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 06/09/2023] [Indexed: 07/05/2023]
Affiliation(s)
- Loïc Lievre
- Department of Nephrology, University Hospital of Reims, Reims, France.
- French Intensive Care Renal Network (FIRN), Reims, France.
| | - Vincent Dupont
- Department of Nephrology, University Hospital of Reims, Reims, France
- French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists (F-CRIN INI-CRCT), Reims, France
| | | | - Laurent Faroux
- Department of Cardiology, University Hospital of Reims, Reims, France
| | - Alexandre Debrumetz
- Department of Nephrology, University Hospital of Reims, Reims, France
- French Intensive Care Renal Network (FIRN), Reims, France
| | - Philippe Rieu
- Department of Nephrology, University Hospital of Reims, Reims, France
| | - Alain Wynckel
- Department of Nephrology, University Hospital of Reims, Reims, France
- French Intensive Care Renal Network (FIRN), Reims, France
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2
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Jiang W, Liao T, Yu J, Shao J, Zheng R. Predictability performance of urinary C-C motif chemokine ligand 14 and renal resistive index for persistent sepsis-associated acute kidney injury in ICU patients. Int Urol Nephrol 2023:10.1007/s11255-023-03511-6. [PMID: 36797554 DOI: 10.1007/s11255-023-03511-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/08/2023] [Indexed: 02/18/2023]
Abstract
OBJECTIVES The performance of renal resistance index (RRI) in predicting persistent sepsis-associated acute kidney injury (S-AKI) remains debatable, and the value of urinary C-C motif chemokine ligand 14 (CCL14) in predicting persistent S-AKI has not been validated yet. Therefore, we aimed to determine the applicability of a urinary biomarker CCL14 for the early detection of persistent S-AKI. Furthermore, the use of RRI obtained from renal Doppler ultrasonography was applied to differentiate transient from persistent S-AKI. Finally, we aimed to evaluate the use of these techniques in predicting different subtypes of S-AKI. METHODS This prospective observational study was conducted at the internal medicine intensive care unit (ICU) of a university hospital. The RRI was determined within 12 h of ICU admission and the urinary CCL14 was evaluated at T0, T6, T12, and T24. The reversibility of renal dysfunction was assessed within 48 h. The receiver operating characteristic curves were then plotted to assess the diagnostic efficacy of the RRI and urinary CCL14 in predicting persistent S-AKI. RESULTS Out of 48 patients, 23 developed persistent S-AKI upon admission. The RRI was higher in the persistent S-AKI group (P = 0.02) and the RRI ≥ 0.679 could predict persistent S-AKI with an area under the receiver operating characteristic curve of 0.79 (95% CI 0.65-0.93), a sensitivity of 91.30% (95% CI 70-98%), and a specificity of 65.20% (95% CI 43-83%). Urinary CCL14 was not significantly different between the two groups at the tested period, showing poor diagnostic performance at T0, T6, T12, and T24, with areas under the receiver operating characteristic curves of 0.56 (95% CI 0.38-0.73), 0.62 (95% CI 0.46-0.79), 0.52 (95% CI 0.35-0.68), and 0.60 (95% CI 0.43-0.77), respectively. CONCLUSIONS The RRI obtained from renal Doppler ultrasound is extremely effective in predicting persistent S-AKI in critically ill patients, and urinary CCL14 could not distinguish between transient and persistent S-AKIs.
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Affiliation(s)
- Wei Jiang
- Clinical Medical College, YangZhou University, Yangzhou, 225001, China.,Intensive Care Unit, Northern Jiangsu People's Hospital, Yangzhou, 225001, China
| | - Ting Liao
- Clinical Medical College, YangZhou University, Yangzhou, 225001, China.,Intensive Care Unit, Northern Jiangsu People's Hospital, Yangzhou, 225001, China
| | - Jiangquan Yu
- Clinical Medical College, YangZhou University, Yangzhou, 225001, China.,Intensive Care Unit, Northern Jiangsu People's Hospital, Yangzhou, 225001, China
| | - Jun Shao
- Clinical Medical College, YangZhou University, Yangzhou, 225001, China.,Intensive Care Unit, Northern Jiangsu People's Hospital, Yangzhou, 225001, China
| | - Ruiqiang Zheng
- Clinical Medical College, YangZhou University, Yangzhou, 225001, China. .,Intensive Care Unit, Northern Jiangsu People's Hospital, Yangzhou, 225001, China.
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3
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Fu Y, He C, Jia L, Ge C, Long L, Bai Y, Zhang N, Du Q, Shen L, Zhao H. Performance of the renal resistive index and usual clinical indicators in predicting persistent AKI. Ren Fail 2022; 44:2028-2038. [DOI: 10.1080/0886022x.2022.2147437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- You Fu
- Department of Critical Care Medicine, Hebei Medical University, Shijiazhuang City, China
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Cong He
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Lijing Jia
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Chen Ge
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Ling Long
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Yinxiang Bai
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Na Zhang
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Quansheng Du
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Limin Shen
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Heling Zhao
- Department of Critical Care Medicine, Hebei Medical University, Shijiazhuang City, China
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
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Urine volume as an estimator of residual renal clearance and urinary removal of solutes in patients undergoing peritoneal dialysis. Sci Rep 2022; 12:18755. [PMID: 36335200 PMCID: PMC9637165 DOI: 10.1038/s41598-022-23093-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 10/25/2022] [Indexed: 11/08/2022] Open
Abstract
In non-anuric patients undergoing peritoneal dialysis (PD), residual kidney function (RKF) is a main contributor to fluid and solute removal and an independent predictor of survival. We investigated if urine volume could be used to estimate renal clearances and removal of urea, creatinine, and phosphorus in PD patients. The observational, cross-sectional study included 93 non-anuric prevalent PD patients undergoing continuous ambulatory PD (CAPD; n = 34) or automated PD (APD; n = 59). Concentrations of urea, creatinine and phosphorus in serum and in 24-h collections of urine volume were measured to calculate weekly residual renal clearance (L/week) and removed solute mass (g/week). Median [interquartile range], 24-h urine output was 560 [330-950] mL and measured GFR (the mean of creatinine and urea clearances) was 3.24 [1.47-5.67] mL/min. For urea, creatinine and phosphorus, residual renal clearance was 20.60 [11.49-35.79], 43.02 [19.13-75.48] and 17.50 [8.34-33.58] L/week, respectively, with no significant differences between CAPD and APD. Urine volume correlated positively with removed solute masses (rho = 0.82, 0.67 and 0.74) and with weekly residual renal clearances (rho = 0.77, 0.62 and 0.72 for urea, creatinine, and phosphorus, respectively, all p < 0.001). Residual renal clearances and urinary mass removal rates for urea, creatinine, and phosphorus correlate strongly with 24-h urine volume suggesting that urine volume could serve as an estimator of typical values of residual solute removal indices in PD patients.
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Jiang X, Hu Y, Guo S, Du C, Cheng X. Prediction of persistent acute kidney injury in postoperative intensive care unit patients using integrated machine learning: a retrospective cohort study. Sci Rep 2022; 12:17134. [PMID: 36224308 PMCID: PMC9556643 DOI: 10.1038/s41598-022-21428-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/27/2022] [Indexed: 01/04/2023] Open
Abstract
Acute kidney injury (AKI) often occurs in patients in the intensive care unit (ICU). AKI duration is closely related to the prognosis of critically ill patients. Identifying the disease course length in AKI is critical for developing effective individualised treatment. To predict persistent AKI at an early stage based on a machine learning algorithm and integrated models. Overall, 955 patients admitted to the ICU after surgery complicated by AKI were retrospectively evaluated. The occurrence of persistent AKI was predicted using three machine learning methods: a support vector machine (SVM), decision tree, and extreme gradient boosting and with an integrated model. External validation was also performed. The incidence of persistent AKI was 39.4-45.1%. In the internal validation, SVM exhibited the highest area under the receiver operating characteristic curve (AUC) value, followed by the integrated model. In the external validation, the AUC values of the SVM and integrated models were 0.69 and 0.68, respectively, and the model calibration chart revealed that all models had good performance. Critically ill patients with AKI after surgery had high incidence of persistent AKI. Our machine learning model could effectively predict the occurrence of persistent AKI at an early stage.
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Affiliation(s)
- Xuandong Jiang
- grid.268099.c0000 0001 0348 3990Intensive Care Unit, Affiliated Dongyang Hospital of Wenzhou Medical University, No. 60 Wuning West Road, Jinhua, Dongyang, Zhejiang People’s Republic of China
| | - Yongxia Hu
- grid.268099.c0000 0001 0348 3990Intensive Care Unit, Affiliated Dongyang Hospital of Wenzhou Medical University, No. 60 Wuning West Road, Jinhua, Dongyang, Zhejiang People’s Republic of China
| | - Shan Guo
- grid.268099.c0000 0001 0348 3990Intensive Care Unit, Affiliated Dongyang Hospital of Wenzhou Medical University, No. 60 Wuning West Road, Jinhua, Dongyang, Zhejiang People’s Republic of China
| | - Chaojian Du
- grid.268099.c0000 0001 0348 3990Intensive Care Unit, Affiliated Dongyang Hospital of Wenzhou Medical University, No. 60 Wuning West Road, Jinhua, Dongyang, Zhejiang People’s Republic of China
| | - Xuping Cheng
- grid.268099.c0000 0001 0348 3990Intensive Care Unit, Affiliated Dongyang Hospital of Wenzhou Medical University, No. 60 Wuning West Road, Jinhua, Dongyang, Zhejiang People’s Republic of China
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6
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Hu J, Jin D, Fan R, Xie X, Zhou Z, Chen Y, Zhang Y, Zhang J, Gao L, Jiang J, Zhang Y, Liang P. The relationships of acute kidney injury duration and severity with long-term functional deterioration following partial nephrectomy. Int Urol Nephrol 2021; 54:1623-1628. [PMID: 34718932 DOI: 10.1007/s11255-021-03033-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 10/11/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate the effect of acute kidney injury (AKI) duration and severity on long-term renal functional outcomes in patients undergoing partial nephrectomy (PN). METHODS Altogether 292 consecutive patients undergoing laparoscopic PN from 2010 to 2018 were identified in two medical centers. In addition, the AKI duration {transient AK [≤ 3d] or persistent AKI [> 3d]} was combined with AKI severity (stages) to elucidate their relationships with long-term functional results. Kaplan-Meier (KM) analysis was also used to compare among patients with no AKI, transient AKI, and persistent AKI. Moreover, the Cox-proportional hazards regression model was utilized to assess the risk factors for renal function deterioration. RESULTS Altogether 67 patients (22.9%) experienced postoperative AKI. 75% eGFR preserve rate during the follow-up was compared among patients with no AKI, transient AKI and persistent AKI using KM analysis and log-rank test, which revealed significant difference. After adjusting for age and warm ischemia time by multivariate model proportional hazards analysis, AKI duration and severity were identified as the risk factors (Stage 1-transient AKI vs. non-AKI: adjusted hazard ratio (HR) 4.361, 95% confidential interval (CI) [2.062-9.233], p < 0.001; stage 1-persistent AKI vs. non-AKI: adjusted HR 6.706, 95% CI [2.405-18.699], p < 0.001; stage 2/3-transient AKI vs. non-AKI: adjusted HR 8.949, 95% CI [1.571-50.963], p = 0.014; stage 2/3-persistent AKI vs. non-AKI: adjusted HR 13.453, 95% CI [11.353-133.798], p = 0.027). CONCLUSIONS The AKI duration after PN is an important risk factor for long-term renal functional deterioration. Besides, AKI duration combined with AKI severity can be more comprehensive to understand the role of AKI on ultimately renal function. TRIAL REGISTRATION Chinese ClinicalTrials: ChiCTR2000034080.
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Affiliation(s)
- Jian Hu
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China
| | - Dachun Jin
- Department of Urology, Daping Hospital/Army Medical Center of PLA, Army Medical University, Chongqing, 400042, China
| | - Runze Fan
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China
| | - Xiaodu Xie
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China
| | - Zhihao Zhou
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China
| | - Yanlin Chen
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China
| | - Yao Zhang
- Department of Urology, Daping Hospital/Army Medical Center of PLA, Army Medical University, Chongqing, 400042, China
| | - Jun Zhang
- Department of Urology, Daping Hospital/Army Medical Center of PLA, Army Medical University, Chongqing, 400042, China
| | - Liang Gao
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China
| | - Jun Jiang
- Department of Urology, Daping Hospital/Army Medical Center of PLA, Army Medical University, Chongqing, 400042, China.
| | - Yuanfeng Zhang
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China.
| | - Peihe Liang
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China.
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7
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Luo XQ, Yan P, Zhang NY, Luo B, Wang M, Deng YH, Wu T, Wu X, Liu Q, Wang HS, Wang L, Kang YX, Duan SB. Machine learning for early discrimination between transient and persistent acute kidney injury in critically ill patients with sepsis. Sci Rep 2021; 11:20269. [PMID: 34642418 PMCID: PMC8511088 DOI: 10.1038/s41598-021-99840-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/30/2021] [Indexed: 12/29/2022] Open
Abstract
Acute kidney injury (AKI) is commonly present in critically ill patients with sepsis. Early prediction of short-term reversibility of AKI is beneficial to risk stratification and clinical treatment decision. The study sought to use machine learning methods to discriminate between transient and persistent sepsis-associated AKI. Septic patients who developed AKI within the first 48 h after ICU admission were identified from the Medical Information Mart for Intensive Care III database. AKI was classified as transient or persistent according to the Acute Disease Quality Initiative workgroup consensus. Five prediction models using logistic regression, random forest, support vector machine, artificial neural network and extreme gradient boosting were constructed, and their performance was evaluated by out-of-sample testing. A simplified risk prediction model was also derived based on logistic regression and features selected by machine learning algorithms. A total of 5984 septic patients with AKI were included, 3805 (63.6%) of whom developed persistent AKI. The artificial neural network and logistic regression models achieved the highest area under the receiver operating characteristic curve (AUC) among the five machine learning models (0.76, 95% confidence interval [CI] 0.74-0.78). The simplified 14-variable model showed adequate discrimination, with the AUC being 0.76 (95% CI 0.73-0.78). At the optimal cutoff of 0.63, the sensitivity and specificity of the simplified model were 63% and 76% respectively. In conclusion, a machine learning-based simplified prediction model including routine clinical variables could be used to differentiate between transient and persistent AKI in critically ill septic patients. An easy-to-use risk calculator can promote its widespread application in daily clinical practice.
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Affiliation(s)
- Xiao-Qin Luo
- Department of Nephrology, Hunan Key Laboratory of Kidney Disease and Blood Purification, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Ping Yan
- Department of Nephrology, Hunan Key Laboratory of Kidney Disease and Blood Purification, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Ning-Ya Zhang
- Information Center, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Bei Luo
- Department of Information Systems, City University of Hong Kong, Tat Chee Avenue, Kowloon, 999077, Hong Kong SAR, China
| | - Mei Wang
- Department of Nephrology, Hunan Key Laboratory of Kidney Disease and Blood Purification, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Ying-Hao Deng
- Department of Nephrology, Hunan Key Laboratory of Kidney Disease and Blood Purification, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Ting Wu
- Department of Nephrology, Hunan Key Laboratory of Kidney Disease and Blood Purification, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Xi Wu
- Department of Nephrology, Hunan Key Laboratory of Kidney Disease and Blood Purification, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Qian Liu
- Department of Nephrology, Hunan Key Laboratory of Kidney Disease and Blood Purification, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Hong-Shen Wang
- Department of Nephrology, Hunan Key Laboratory of Kidney Disease and Blood Purification, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Lin Wang
- Department of Nephrology, Hunan Key Laboratory of Kidney Disease and Blood Purification, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Yi-Xin Kang
- Department of Nephrology, Hunan Key Laboratory of Kidney Disease and Blood Purification, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Shao-Bin Duan
- Department of Nephrology, Hunan Key Laboratory of Kidney Disease and Blood Purification, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, 410011, Hunan, China.
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Acute kidney injury in the critically ill: an updated review on pathophysiology and management. Intensive Care Med 2021; 47:835-850. [PMID: 34213593 PMCID: PMC8249842 DOI: 10.1007/s00134-021-06454-7] [Citation(s) in RCA: 153] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/04/2021] [Indexed: 01/10/2023]
Abstract
Acute kidney injury (AKI) is now recognized as a heterogeneous syndrome that not only affects acute morbidity and mortality, but also a patient’s long-term prognosis. In this narrative review, an update on various aspects of AKI in critically ill patients will be provided. Focus will be on prediction and early detection of AKI (e.g., the role of biomarkers to identify high-risk patients and the use of machine learning to predict AKI), aspects of pathophysiology and progress in the recognition of different phenotypes of AKI, as well as an update on nephrotoxicity and organ cross-talk. In addition, prevention of AKI (focusing on fluid management, kidney perfusion pressure, and the choice of vasopressor) and supportive treatment of AKI is discussed. Finally, post-AKI risk of long-term sequelae including incident or progression of chronic kidney disease, cardiovascular events and mortality, will be addressed.
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Heida JE, Gansevoort RT, Messchendorp AL, Meijer E, Casteleijn NF, Boertien WE, Zittema D. Use of the Urine-to-Plasma Urea Ratio to Predict ADPKD Progression. Clin J Am Soc Nephrol 2021; 16:204-212. [PMID: 33504546 PMCID: PMC7863649 DOI: 10.2215/cjn.10470620] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 12/09/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Predicting disease progression in patients with autosomal dominant polycystic kidney disease (ADPKD) poses a challenge, especially in early-stage disease when kidney function is not yet affected. Ongoing growth of cysts causes maximal urine-concentrating capacity to decrease from early on. We therefore hypothesized that the urine-to-plasma urea ratio, as a reflection of the urine-concentrating capacity, can be used as a marker to predict ADPKD progression. DESIGN The urine-to-plasma urea ratio was calculated by dividing concentrations of early morning fasting spot urine urea by plasma urea. First, this ratio was validated as surrogate marker in 30 patients with ADPKD who underwent a prolonged water deprivation test. Thereafter, association with kidney outcome was evaluated in 583 patients with ADPKD with a broad range of kidney function. Multivariable mixed-model regression was used to assess association with eGFR slope, and logarithmic regression to identify patients with rapidly progressive disease, using a cutoff of -3.0 ml/min per 1.73 m2 per year. The urine-to-plasma urea ratio was compared with established predictors, namely, sex, age, baseline eGFR, Mayo Clinic height-adjusted total kidney volume class, and PKD gene mutation. RESULTS The maximal urine-concentrating capacity and urine-to-plasma urea ratio correlated strongly (R=0.90; P<0.001). Next, the urine-to-plasma urea ratio was significantly associated with rate of eGFR decline during a median follow-up of 4.0 (interquartile range, 2.6-5.0) years, both crude and after correction for established predictors (β=0.58; P=0.02). The odds ratio of rapidly progressive disease was 1.35 (95% confidence interval, 1.19 to 1.52; P<0.001) for every 10 units decrease in urine-to-plasma urea ratio, with adjustment for predictors. A combined risk score of the urine-to-plasma urea ratio, Mayo Clinic height-adjusted total kidney volume class, and PKD mutation predicted rapidly progressive disease better than each of the predictors separately. CONCLUSIONS The urine-to-plasma urea ratio, which is calculated from routine laboratory measurements, predicts disease progression in ADPKD in addition to other risk markers. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_01_27_CJN10470620_final.mp3.
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Affiliation(s)
- Judith E. Heida
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ron T. Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A. Lianne Messchendorp
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Esther Meijer
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Niek F. Casteleijn
- Department of Urology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wendy E. Boertien
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Debbie Zittema
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Felice VB, Lisboa TC, Souza LVD, Sell LC, Friedman G. Hemodynamically stable oliguric patients usually do not respond to fluid challenge. Rev Bras Ter Intensiva 2021; 32:564-570. [PMID: 33470358 PMCID: PMC7853676 DOI: 10.5935/0103-507x.20200094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 05/20/2020] [Indexed: 11/20/2022] Open
Abstract
Objective To evaluate renal responsiveness in oliguric critically ill patients after a fluid challenge. Methods We conducted a prospective observational study in one university intensive care unit. Patients with urine output < 0.5mL/kg/h for 3 hours with a mean arterial pressure > 60mmHg received a fluid challenge. We examined renal fluid responsiveness (defined as urine output > 0.5mL/kg/h for 3 hours) after fluid challenge. Results Forty-two patients (age 67 ± 13 years; APACHE II score 16 ± 6) were evaluated. Patient characteristics were similar between renal responders and renal nonresponders. Thirteen patients (31%) were renal responders. Hemodynamic or perfusion parameters were not different between those who did and those who did not increase urine output before the fluid challenge. The areas under the receiver operating characteristic curves were calculated for mean arterial pressure, heart rate, creatinine, urea, creatinine clearance, urea/creatinine ratio and lactate before the fluid challenge. None of these parameters were sensitive or specific enough to predict reversal of oliguria. Conclusion After achieving hemodynamic stability, oliguric patients did not increase urine output after a fluid challenge. Systemic hemodynamic, perfusion or renal parameters were weak predictors of urine responsiveness. Our results suggest that volume replacement to correct oliguria in patients without obvious hypovolemia should be done with caution.
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Affiliation(s)
- Vinicius Brenner Felice
- Unidade Central de Terapia Intensiva, Complexo Hospitalar Santa Casa de Porto Alegre - Porto Alegre (RS), Brasil.,Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Thiago Costa Lisboa
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Rede Institucional de Pesquisa e Inovação em Terapia Intensiva, Complexo Hospitalar Santa Casa de Porto Alegre - Porto Alegre (RS), Brasil
| | - Lucas Vieira de Souza
- Unidade Central de Terapia Intensiva, Complexo Hospitalar Santa Casa de Porto Alegre - Porto Alegre (RS), Brasil
| | - Luana Canevese Sell
- Unidade Central de Terapia Intensiva, Complexo Hospitalar Santa Casa de Porto Alegre - Porto Alegre (RS), Brasil
| | - Gilberto Friedman
- Unidade Central de Terapia Intensiva, Complexo Hospitalar Santa Casa de Porto Alegre - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
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Abosamak MF, Lippi G, Benoit SW, Henry BM, Shama AAA. Bladder urine oxygen partial pressure monitoring: Could it be a tool for early detection of acute kidney injury? EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1878686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Mohammed Fawzi Abosamak
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Giuseppe Lippi
- Department of Neuroscience, Section of Clinical Biochemistry, Biomedicine and Movement, University of Verona, Verona, Italy
| | - Stefanie W. Benoit
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Brandon Michael Henry
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Umbrello M, Formenti P, Chiumello D. Urine Electrolytes in the Intensive Care Unit: From Pathophysiology to Clinical Practice. Anesth Analg 2020; 131:1456-1470. [PMID: 33079869 DOI: 10.1213/ane.0000000000004994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Assessment of urine concentrations of sodium, chloride, and potassium is a widely available, rapid, and low-cost diagnostic option for the management of critically ill patients. Urine electrolytes have long been suggested in the diagnostic workup of hypovolemia, kidney injury, and acid-base and electrolyte disturbances. However, due to the wide range of normal reference values and challenges in interpretation, their use is controversial. To clarify their potential role in managing critical patients, we reviewed existing evidence on the use of urine electrolytes for diagnostic and therapeutic evaluation and assessment in critical illness. This review will describe the normal physiology of water and electrolyte excretion, summarize the use of urine electrolytes in hypovolemia, acute kidney injury, acid-base, and electrolyte disorders, and suggest some practical flowcharts for the potential use of urine electrolytes in daily critical care practice.
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Affiliation(s)
- Michele Umbrello
- From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
| | - Paolo Formenti
- From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
| | - Davide Chiumello
- From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
- Dipartimento di Scienze della Salute
- Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
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Plasma Renin Concentration is Associated With Hemodynamic Deficiency and Adverse Renal Outcome in Septic Shock. Shock 2020; 52:e22-e30. [PMID: 30407370 DOI: 10.1097/shk.0000000000001285] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND In septic shock, both systemic vasodilatation and glomerular arteriole dilatation are responsible for the drop in glomerular filtration observed in early acute kidney injury. Angiotensin II has been shown to act on both mechanisms. Our objective was to evaluate the impact of renin angiotensin system activation, on hemodynamic deficiency and renal outcome in patient with septic shock and to assess whether urinary sodium could be a reliable test for high plasma renin concentration screening. METHODS This was a prospective and observational study. Inclusion criteria were early septic shock (first episode), dose of norepinephrine ≥ 0.25 μg/kg/min, before the start of substitutive corticosteroids. Plasma renin concentration, plasma aldosterone concentration, and urinary sodium were measured at inclusion. Renal outcome, organ deficiency, and 28-day survival were followed. RESULTS Plasma renin concentration was associated with worse hemodynamic deficiency and adverse renal outcome. Natriuresis was associated with shock severity but was not associated with renal outcome. Low natriuresis (< 20 mM) was associated with higher renin concentration. Those two variables were only weakly correlated. CONCLUSION Plasma renin concentration is associated with adverse renal outcome, probably through shock severity and insufficient glomerular efferent arterioles vasoconstriction. An association was observed between low natriuresis and high plasma renin concentration.
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Titeca-Beauport D, Daubin D, Van Vong L, Belliard G, Bruel C, Alaya S, Chaoui K, Andrieu M, Rouquette-Vincenti I, Godde F, Pascal M, Diouf M, Vinsonneau C, Klouche K, Maizel J. Urine cell cycle arrest biomarkers distinguish poorly between transient and persistent AKI in early septic shock: a prospective, multicenter study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:280. [PMID: 32487237 PMCID: PMC7268340 DOI: 10.1186/s13054-020-02984-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/12/2020] [Indexed: 12/31/2022]
Abstract
Background The urine biomarkers tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) have been validated for predicting and stratifying AKI. In this study, we analyzed the utility of these biomarkers for distinguishing between transient and persistent AKI in the early phase of septic shock. Methods We performed a prospective, multicenter study in 11 French ICUs. Patients presenting septic shock, with the development of AKI within the first 6 h, were included. Urine [TIMP-2]*[IGFBP7] was determined at inclusion (0 h), 6 h, 12 h, and 24 h. AKI was considered transient if it resolved within 3 days. Discriminative power was evaluated by receiver operating characteristic (ROC) curve analysis. Results We included 184 patients, within a median [IQR] time of 1.0 [0.0–3.0] h after norepinephrine (NE) initiation; 100 (54%) patients presented transient and 84 (46%) presented persistent AKI. Median [IQR] baseline urine [TIMP-2]*[IGFBP7] was higher in the persistent AKI group (2.21 [0.81–4.90] (ng/ml)2/1000) than in the transient AKI group (0.75 [0.20–2.12] (ng/ml)2/1000; p < 0.001). Baseline urine [TIMP-2]*[IGFBP7] was poorly discriminant, with an AUROC [95% CI] of 0.67 [0.59–0.73]. The clinical prediction model combining baseline serum creatinine concentration, baseline urine output, baseline NE dose, and baseline extrarenal SOFA performed well for the prediction of persistent AKI, with an AUROC [95% CI] of 0.81 [0.74–0.86]. The addition of urine [TIMP-2]*[IGFBP7] to this model did not improve the predictive performance. Conclusions Urine [TIMP-2]*[IGFBP7] measurements in the early phase of septic shock discriminate poorly between transient and persistent AKI and do not improve clinical prediction over that achieved with the usual variables. Trial registration NCT02812784
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Affiliation(s)
- Dimitri Titeca-Beauport
- BoReal Study Group, Medical Intensive Care Unit and EA7517, Amiens University Hospital, F-80054, Amiens, France.
| | - Delphine Daubin
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Ly Van Vong
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Guillaume Belliard
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Bretagne Sud, Lorient, France
| | - Cédric Bruel
- Medical and Surgical Intensive Care Unit, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Sami Alaya
- Intensive Care Unit, Centre Hospitalier Général, 13300, Salon-de-Provence, France
| | - Karim Chaoui
- Intensive Care Unit, Jean Rougier Hospital, 335, rue du Président Wilson, 46000, Cahors, France
| | - Maud Andrieu
- Medical and Surgical Intensive Care Unit, Centre Hospitalier de Dax-Côte d'Argent, Dax, France
| | - Isabelle Rouquette-Vincenti
- Department of Anesthesia and Intensive Care, Princess Grace Hospital, Avenue Pasteur, Monaco (Principality), Monaco
| | - Frederic Godde
- Département de Réanimation Polyvalente, Centre Hospitalier Avranches-Granville, Granville, France
| | - Michel Pascal
- Intensive Care Unit, Centre Hospitalier de Mont De Marsan, 40000, Mont-de-Marsan, France
| | - Momar Diouf
- Clinical Research and Innovation Directorate, Amiens University Hospital, Amiens, France
| | | | - Kada Klouche
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Julien Maizel
- BoReal Study Group, Medical Intensive Care Unit and EA7517, Amiens University Hospital, F-80054, Amiens, France
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Darmon M, Truche AS, Abdel-Nabey M, Schnell D, Souweine B. Early Recognition of Persistent Acute Kidney Injury. Semin Nephrol 2020; 39:431-441. [PMID: 31514907 DOI: 10.1016/j.semnephrol.2019.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Despite the vast amount of literature dedicated to acute kidney injury (AKI) and its clinical consequences, short-term renal recovery has been relatively neglected. Recent studies have suggested that timing of renal recovery is associated with longer-term risk of death, residual renal function, and end-stage renal failure risk. In addition, longer AKI duration is associated with an increased requirement for renal replacement therapy. Comorbidities, especially renal and cardiovascular, severity of AKI, criteria to reach AKI diagnosis, as well as severity of critical illness have been associated with longer AKI duration, and, more specifically, risk of persistent renal dysfunction. Because predicting short-term renal recovery is clinically relevant, several tests, imaging, and biomarkers have been tested in a way to predict the course of AKI and chances for early renal recovery. In this review, the definition of recovery, consequences of persistent AKI, and tools proposed to predict recovery are described. The performance of these tools and their limits are discussed.
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Affiliation(s)
- Michaël Darmon
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, Paris, France; Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France; ECSTRA Team (Epidémiologie Clinique et Statistiques pour la Recherche en sAnté), Biostatistics and Clinical Epidemiology, UMR 1153, Center of Epidemiology and Biostatistic Sorbonne Paris Cité, INSERM, Paris, France.
| | - Anne-Sophie Truche
- Medical Intensive Care Unit, Grenoble University Hospital, La Tronche, France
| | | | - David Schnell
- Medical-Surgical Intensive Care Unit, Angoulême Hospital, Angoulême, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
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Abstract
Several biomarkers have been developed to detect acute kidney injury (AKI) and predict outcomes. Most AKI biomarkers have been shown to be expressed before serum creatinine and to be more sensitive and specific than urine output. Only a few studies have examined how implementation can change clinical outcomes. A second generation of AKI biomarkers have been developed. These markers, including tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulinlike growth factor-binding protein 7 (IGFBP7), have obtained regulatory approval in many countries based on large, rigorous clinical studies and small, single-centered trials and have begun to establish clinical utility.
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17
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Garnier F, Daubin D, Larcher R, Bargnoux AS, Platon L, Brunot V, Aarab Y, Besnard N, Dupuy AM, Jung B, Cristol JP, Klouche K. Reversibility of Acute Kidney Injury in Medical ICU Patients: Predictability Performance of Urinary Tissue Inhibitor of Metalloproteinase-2 x Insulin-Like Growth Factor-Binding Protein 7 and Renal Resistive Index. Crit Care Med 2020; 48:e277-e284. [PMID: 32205617 DOI: 10.1097/ccm.0000000000004218] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Urinary biomarkers and renal Doppler sonography remain considered as promising tools to distinguish transient from persistent acute kidney injury. The performance of the urinary biomarker, tissue inhibitor of metalloproteinase-2 x insulin-like growth factor-binding protein 7 and of renal resistive index to predict persistent acute kidney injury showed contradictory results. Our aim was to evaluate the performance of tissue inhibitor of metalloproteinase-2 x insulin-like growth factor-binding protein 7 and renal resistive index in predicting reversibility of acute kidney injury in critically ill patients. DESIGN Prospective observational study. SETTING Twenty-bed medical ICU in an university hospital. PATIENTS Consecutive patients with acute kidney injury. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Renal resistive index was measured within 12 hours after admission, and urinary tissue inhibitor of metalloproteinase-2 and insulin-like growth factor-binding protein 7 was measured at H0, H6, H12, and H24. Renal dysfunction reversibility was evaluated at day 3. Receiver operating characteristic curves were plotted to evaluate diagnostic performance of renal resistive index and tissue inhibitor of metalloproteinase-2 x insulin-like growth factor-binding protein 7 to predict a persistent acute kidney injury. Overall, 100 patients were included in whom 50 with persistent acute kidney injury. Renal resistive index was higher in persistent acute kidney injury group. Urinary tissue inhibitor of metalloproteinase-2 x insulin-like growth factor-binding protein 7 was not significantly different at each time between both groups. The performance of tissue inhibitor of metalloproteinase-2 x insulin-like growth factor-binding protein 7 was poor with respectively an area under the receiver operating characteristic curves of 0.57 (95% CI, 0.45-0.68), 0.58 (95% CI, 0.47-0.69), 0.61 (95% CI, 0.50-0.72), and 0.57 (95% CI, 0.46-0.68) at H0, H6, H12, and H24. The area under the receiver operating characteristic curve for renal resistive index was 0.93 (95% CI, 0.89-0.98). A renal resistive index greater than or equal to 0.685 predicting persistent acute kidney injury with 78% (95% CI, 64-88%) sensitivity and 90% (95% CI, 78-97%) specificity. CONCLUSIONS Renal resistive index had a good performance for predicting the reversibility of acute kidney injury in critically ill patients. Urinary tissue inhibitor of metalloproteinase-2 x insulin-like growth factor-binding protein 7 was unable to differentiate transient from persistent acute kidney injury.
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Affiliation(s)
- Fanny Garnier
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Delphine Daubin
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Romaric Larcher
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
- PhyMedExp, Centre National de la Recherche Scientifique (CNRS 9214) - Institut National de la Santé et de la Recherche Médicale (INSERM-U1046), Montpellier University, Montpellier, France
| | - Anne-Sophie Bargnoux
- PhyMedExp, Centre National de la Recherche Scientifique (CNRS 9214) - Institut National de la Santé et de la Recherche Médicale (INSERM-U1046), Montpellier University, Montpellier, France
- Department of Biochemistry, Lapeyronie University Hospital, Montpellier, France
| | - Laura Platon
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Vincent Brunot
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Yassir Aarab
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Noémie Besnard
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Anne-Marie Dupuy
- Department of Biochemistry, Lapeyronie University Hospital, Montpellier, France
| | - Boris Jung
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
- PhyMedExp, Centre National de la Recherche Scientifique (CNRS 9214) - Institut National de la Santé et de la Recherche Médicale (INSERM-U1046), Montpellier University, Montpellier, France
| | - Jean-Paul Cristol
- PhyMedExp, Centre National de la Recherche Scientifique (CNRS 9214) - Institut National de la Santé et de la Recherche Médicale (INSERM-U1046), Montpellier University, Montpellier, France
- Department of Biochemistry, Lapeyronie University Hospital, Montpellier, France
| | - Kada Klouche
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
- PhyMedExp, Centre National de la Recherche Scientifique (CNRS 9214) - Institut National de la Santé et de la Recherche Médicale (INSERM-U1046), Montpellier University, Montpellier, France
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Bagheri SM, Tajalli F, Shahrokh H, Nasiri Partovi M, Azadian N. Sonographic Indices in Patients with Severe Acute Tubular Necrosis during Early Post-Kidney Transplantation Period. Int J Organ Transplant Med 2019; 10:74-83. [PMID: 31285804 PMCID: PMC6604759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Kidney transplantation is the most effective and optimal treatment for end-stage renal disease. OBJECTIVE To investigate the association between serially measured ultrasound indices during the early post-operative period to determine severe acute tubular necrosis (ATN) in kidney allografts. METHODS In a prospective study, we assessed sonographic renal indices including interlobar arteries peak systolic velocity (PSV), end-diastolic velocity (EDV), resistance index (RI), pulsatility index (PI), power doppler grading (PDG), acceleration time (AT), and renal volume on the 3rd and 9th days after kidney transplantation in 46 adult recipients who had no other significant complications except ATN. Biopsies were performed in patients with prolonged delayed graft function (DGF) to exclude other pathologies, especially acute rejection. RESULTS 12 (20%) recipients experienced biopsy-proven severe ATN. The differences in the ultrasound indices and their measured discrepancies on the 1st and 2nd examinations between the groups were not statistically significant except for the 1st examined RI (p=0.029) and PI (p=0.04). No patient had PDG of >2. The first RI, with a cut-off value of 0.66, had a sensitivity of 91.7% and a specificity of 50% for predicting severe ATN (area under the ROC curve = 0.71). To compensate for the low specificity of this index, we suggest using the first PDG scale of equal to 2 with a specificity of 85.3%. Overall sensitivity, specificity, and positive and negative predictive values in established severe ATN throughout early post-operative days for a 3rd day RI >0.66 and PDG = 2, were 38%, 92.5%, 64.1%, and 80.9%, respectively. CONCLUSIONS The RI and the PDG measured on the 3rd day after renal transplantation are useful indices for the diagnosis of established severe ATN in kidney allografts. Furthermore, donor characteristics, post-harvesting organ preservation status, main renal vascular anastomosis, and early post-operative recipient's clinical situations may also influence the incidence of severe ATN. Although the 1st ultrasound examination on the 3rd day in early post-transplantation provides important diagnostic and prognostic information, repeated assessment about one week later provides no more valuable information.
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Affiliation(s)
- S. M. Bagheri
- Department of Radiology (Ultrasound Division), Shahid Hashemi Nejad Hospital, Iran Medical University of Sciences, Tehran, Islamic Republic of Iran
| | - F. Tajalli
- Department of Transplant Surgery, Shahid Hashemi Nejad Hospital, Iran Medical University of Sciences, Tehran, Islamic Republic of Iran
| | - H. Shahrokh
- Department of Transplant Surgery, Shahid Hashemi Nejad Hospital, Iran Medical University of Sciences, Tehran, Islamic Republic of Iran
| | - M. Nasiri Partovi
- Department of Radiology (Ultrasound Division), Shahid Hashemi Nejad Hospital, Iran Medical University of Sciences, Tehran, Islamic Republic of Iran
| | - N. Azadian
- Department of Radiology (Ultrasound Division), Shahid Hashemi Nejad Hospital, Iran Medical University of Sciences, Tehran, Islamic Republic of Iran
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Truche AS, Ragey SP, Souweine B, Bailly S, Zafrani L, Bouadma L, Clec'h C, Garrouste-Orgeas M, Lacave G, Schwebel C, Guebre-Egziabher F, Adrie C, Dumenil AS, Zaoui P, Argaud L, Jamali S, Goldran Toledano D, Marcotte G, Timsit JF, Darmon M. ICU survival and need of renal replacement therapy with respect to AKI duration in critically ill patients. Ann Intensive Care 2018; 8:127. [PMID: 30560526 PMCID: PMC6297118 DOI: 10.1186/s13613-018-0467-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 11/30/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Transient and persistent acute kidney injury (AKI) could share similar physiopathological mechanisms. The objective of our study was to assess prognostic impact of AKI duration on ICU mortality. DESIGN Retrospective analysis of a prospective database via cause-specific model, with 28-day ICU mortality as primary end point, considering discharge alive as a competing event and taking into account time-dependent nature of renal recovery. Renal recovery was defined as a decrease of at least one KDIGO class compared to the previous day. SETTING 23 French ICUs. PATIENTS Patients of a French multicentric observational cohort were included if they suffered from AKI at ICU admission between 1996 and 2015. INTERVENTION None. RESULTS A total of 5242 patients were included. Initial severity according to KDIGO creatinine definition was AKI stage 1 for 2458 patients (46.89%), AKI stage 2 for 1181 (22.53%) and AKI stage 3 for 1603 (30.58%). Crude 28-day ICU mortality according to AKI severity was 22.74% (n = 559), 27.69% (n = 327) and 26.26% (n = 421), respectively. Renal recovery was experienced by 3085 patients (58.85%), and its rate was significantly different between AKI severity stages (P < 0.01). Twenty-eight-day ICU mortality was independently lower in patients experiencing renal recovery [CSHR 0.54 (95% CI 0.46-0.63), P < 0.01]. Lastly, RRT requirement was strongly associated with persistent AKI whichever threshold was chosen between day 2 and 7 to delineate transient from persistent AKI. CONCLUSIONS Short-term renal recovery, according to several definitions, was independently associated with higher mortality and RRT requirement. Moreover, distinction between transient and persistent AKI is consequently a clinically relevant surrogate outcome variable for diagnostic testing in critically ill patients.
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Affiliation(s)
- A S Truche
- UMR 1137 - IAME Team 5 - DeSCID : Decision SCiences in Infectious Diseases, Control and Care, Inserm/Paris Diderot University, Sorbonne Paris Cité, Paris, France
- Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France
- Nephrology Dialysis Renal Transplantation, Grenoble University Hospital, La Tronche, France
| | - S Perinel Ragey
- Medical Intensive Care Unit, Croix Rousse Hospital, Lyon University Hospital, Lyon, France
| | - B Souweine
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - S Bailly
- UMR 1137 - IAME Team 5 - DeSCID : Decision SCiences in Infectious Diseases, Control and Care, Inserm/Paris Diderot University, Sorbonne Paris Cité, Paris, France
- Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France
| | - L Zafrani
- Medical Intensive Care Unit, AP-HP, Saint Louis Hospital, Paris, France
- Medicine University, Paris 7 University, Paris, France
| | - L Bouadma
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, 75018, Paris, France
| | - C Clec'h
- Intensive Care Unit, AP-HP, Avicenne Hospital, Paris, France
- Medicine University, Paris 13 University, Bobigny, France
| | - M Garrouste-Orgeas
- Intensive Care Unit, Saint Joseph Hospital Network, Paris, France
- Medicine University, Paris Descartes University, Sorbonne Cite, Paris, France
| | - G Lacave
- Medical Intensive Care Unit, André Mignot Hospital, Versailles, France
| | - C Schwebel
- Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France
| | - F Guebre-Egziabher
- Nephrology Dialysis Renal Transplantation, Grenoble University Hospital, La Tronche, France
| | - C Adrie
- Physiology Department, Cochin University Hospital, Assistance Publique, Hôpitaux de Paris (AP-HP), Paris Descartes University des, Sorbonne Cite, Paris, France
| | - A S Dumenil
- Medical-Surgical Intensive Care Unit, AP-HP, Antoine Béclère University Hospital, Clamart, France
| | - Ph Zaoui
- Nephrology Dialysis Renal Transplantation, Grenoble University Hospital, La Tronche, France
| | - L Argaud
- Medical Intensive Care Unit, Edouard Herriot University Hospital, Lyon, France
| | - S Jamali
- Critical Care Medicine Unit, Dourdan Hospital, Dourdan, France
| | | | - G Marcotte
- Surgical ICU, Edouard Herriot University Hospital, Lyon, France
| | - J F Timsit
- UMR 1137 - IAME Team 5 - DeSCID : Decision SCiences in Infectious Diseases, Control and Care, Inserm/Paris Diderot University, Sorbonne Paris Cité, Paris, France
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, 75018, Paris, France
| | - M Darmon
- Medical Intensive Care Unit, AP-HP, Saint Louis Hospital, Paris, France.
- Medicine University, Paris 7 University, Paris, France.
- ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Paris, France.
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Urinary potassium excretion and its association with acute kidney injury in the intensive care unit. J Crit Care 2018; 46:58-62. [DOI: 10.1016/j.jcrc.2018.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/13/2018] [Accepted: 04/13/2018] [Indexed: 11/18/2022]
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21
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Urinary Biochemistry in the Diagnosis of Acute Kidney Injury. DISEASE MARKERS 2018; 2018:4907024. [PMID: 30008975 PMCID: PMC6020498 DOI: 10.1155/2018/4907024] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/03/2018] [Accepted: 05/20/2018] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI) is a common complication, impacting short- and long-term patient outcomes. Although the application of the classification systems for AKI has improved diagnosis, early clinical recognition of AKI is still challenging, as increments in serum creatinine may be late and low urine output is not always present. The role of urinary biochemistry has remained unclear, especially in critically ill patients. Differentiating between a transient and persistent acute kidney injury is of great need in clinical practice, and despite studies questioning their application in clinical practice, biochemistry indices continue to be used while we wait for a novel early injury biomarker. An ideal marker would provide more detailed information about the type, intensity, and location of the injury. In this review, we will discuss factors affecting the fractional excretion of sodium (FeNa) and fractional excretion of urea (FeU). We believe that the frequent assessment of urinary biochemistry and microscopy can be useful in evaluating the likelihood of AKI reversibility. The availability of early injury biomarkers could help guide clinical interventions.
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Darmon M, Ostermann M, Cerda J, Dimopoulos MA, Forni L, Hoste E, Legrand M, Lerolle N, Rondeau E, Schneider A, Souweine B, Schetz M. Diagnostic work-up and specific causes of acute kidney injury. Intensive Care Med 2017; 43:829-840. [PMID: 28444409 DOI: 10.1007/s00134-017-4799-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/11/2017] [Indexed: 02/06/2023]
Abstract
Acute kidney injury (AKI) is common in critically ill patients and associated with grim short- and long-term outcome. Although in the vast majority of cases AKI is multifactorial, with sepsis, shock and nephrotoxicity accounting for most episodes, specific causes of AKI are not uncommon. Despite remaining uncertainties regarding their prevalence in the ICU, prompt recognition of specific aetiologies of AKI is likely to ensure timely management, limit worsening of renal dysfunction, and ultimately limit renal and systemic consequences of AKI. The ability to recognize conditions that may be associated with specific aetiologies and the appropriate use of clinical imaging, biological and immunological tests, along with optimal assessment of the need for renal biopsies, should be part of routine ICU care. In this review, we summarize uncertainties, current knowledge and recent advances regarding specific types of AKI. We describe the most common specific causes as well as rare aetiologies requiring urgent management, and outline available tools that may be used during the diagnostic work-up along with their limitations.
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Affiliation(s)
- Michael Darmon
- Medical-Surgical Intensive Care Unit, Hopital NordSaint-Etienne University Hospital, Avenue Albert Raimond, Saint-Priest-en-Jarez, EA3065, 42270, Saint-Etienne, France.
| | - Marlies Ostermann
- Department of Critical Care and Nephrology, Guy's and St. Thomas Hospital, London, SE19RT, UK
| | - Jorge Cerda
- Division of Nephrology, Department of Medicine, Albany Medical College, Albany, NY, USA
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Lui Forni
- Intensive Care Unit, Surrey Perioperative Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, UK
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Eric Hoste
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Matthieu Legrand
- Department of Anaesthesiology and Critical Care and Burn Unit, AP-HP, St-Louis Hospital, 75475, Paris, France
- INSERM UMR 942, Hôpital Lariboisière, 75475, Paris, France
- University Paris Diderot, Paris, France
| | - Nicolas Lerolle
- Angers University, Angers, France
- Department of Medical Intensive Care and Hyperbaric Medicine, Angers University Hospital, Angers, France
| | - Eric Rondeau
- APHP, Intensive Care and Renal Transplant Unit, Tenon University Hospital, 75571, Paris Cedex 20, France
- Inserm UMR S 1155, Paris, France
- Sorbonne University, UPMC University, Paris, France
| | - Antoine Schneider
- Adult Intensive Care Unit, Centre Hospitalier et Universitaire Vaudois, Lausanne, Switzerland
| | - Bertrand Souweine
- Medical ICU, Hôpital Gabriel Montpied, CHU de Clermont-Ferrand, Université d'Auvergne, 63003, Clermont-Ferrand, France
| | - Miet Schetz
- Division of Cellular and Molecular Medicine, Clinical Department and Laboratory of Intensive Care Medicine, KU Leuven University, Herestraat 49, B3000, Louvain, Belgium
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Daubin D, Cristol JP, Dupuy AM, Kuster N, Besnard N, Platon L, Buzançais A, Brunot V, Garnier F, Jonquet O, Klouche K. Urinary Biomarkers IGFBP7 and TIMP-2 for the Diagnostic Assessment of Transient and Persistent Acute Kidney Injury in Critically Ill Patients. PLoS One 2017; 12:e0169674. [PMID: 28085896 PMCID: PMC5234791 DOI: 10.1371/journal.pone.0169674] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 12/20/2016] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The capability of urinary TIMP-2 (tissue inhibitor of metalloproteinase) and IGFBP7 (insulin-like growth factor binding protein)-NephroCheck Test (NC) = ([TIMP-2] x [IGFBP7]) / 1000)-to predict renal recovery from acute kidney injury (AKI) has been poorly studied. The aim of this study was to assess the performance of measurements of ([TIMP-2] x [IGFBP7]) / 1000) over 24 hours to differentiate transient from persistent AKI. METHODS Of 460 consecutive adult patients admitted to the ICU, 101 were prospectively studied: 56 men, 62 (52-71) years old. A fresh urine sample was collected at H0, H4, H12 and H24 to determine ([TIMP-2] x [IGFBP7]) / 1000) levels. Areas under the curves of Delta NC H4-Ho and H12-H4 and serum creatinine (sCr) for detection of AKI recovery were compared. RESULTS Forty-one (40.6%) patient were diagnosed with AKI: 27 transient and 14 persistent AKI. At admission (H0), AKI patients had a significantly higher NC score than patients without AKI (0.43 [0.07-2.06] vs 0.15 [0.07-0.35], p = 0.027). In AKI groups, transient AKI have a higher NC, at H0 and H4, than persistent AKI (0.87 [0.09-2.82] vs 0.13 [0.05-0.66] p = 0.035 and 0.13 [0.07-0.61] vs 0.05 [0.02-0.13] p = 0.013). Thereafter, NC level decreased in both AKI groups with a Delta NC score H4-H0 and H12-H4 significantly more important in transient AKI. Roc curves showed however that delta NC scores did not discriminate between transient and persistent AKI. CONCLUSION In our population, absolute urinary levels of NC score were higher at early hours after ICU admission (H0 and H4) in transient AKI as compared to persistent AKI patients. NC variations (Delta NC scores) over the first 12 hours may indicate the AKI's evolving nature with a more significant decrease in case of transient AKI but were not able to differentiate transient from persistent AKI.
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Affiliation(s)
- Delphine Daubin
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Jean Paul Cristol
- Department of Biochemistry, Lapeyronie University Hospital, Montpellier, France
- PhyMedExp, Centre National de la Recherche Scientifique (CNRS 9214) - Institut National de la Santé et de la Recherche Médicale (INSERM U-1046), Montpellier University, Montpellier, France
| | - Anne Marie Dupuy
- Department of Biochemistry, Lapeyronie University Hospital, Montpellier, France
| | - Nils Kuster
- Department of Biochemistry, Lapeyronie University Hospital, Montpellier, France
| | - Noémie Besnard
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Laura Platon
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Aurèle Buzançais
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Vincent Brunot
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Fanny Garnier
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Olivier Jonquet
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Kada Klouche
- Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
- PhyMedExp, Centre National de la Recherche Scientifique (CNRS 9214) - Institut National de la Santé et de la Recherche Médicale (INSERM U-1046), Montpellier University, Montpellier, France
- * E-mail:
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Askenazi DJ, Heung M, Connor MJ, Basu RK, Cerdá J, Doi K, Koyner JL, Bihorac A, Golestaneh L, Vijayan A, Okusa M, Faubel S. Optimal Role of the Nephrologist in the Intensive Care Unit. Blood Purif 2016; 43:68-77. [PMID: 27923227 PMCID: PMC5340591 DOI: 10.1159/000452317] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
As advances in Critical Care Medicine continue, critically ill patients are surviving despite the severity of their illness. The incidence of acute kidney injury (AKI) has increased, and its impact on clinical outcomes as well as medical expenditures has been established. The role, indications and technological advancements of renal replacement therapy (RRT) have evolved, allowing more effective therapies with less complications. With these changes, Critical Care Nephrology has become an established specialty, and ongoing collaborations between critical care physicians and nephrologist have improved education of multi-disciplinary team members and patient care in the ICU. Multidisciplinary programs to support these changes have been stablished in some hospitals to maximize the delivery of care, while other programs have continue to struggle in their ability to acquire the necessary resources to maximize outcomes, educate their staff, and develop quality initiatives to evaluate and drive improvements. Clearly, the role of the nephrologist in the ICU has evolved, and varies widely among institutions. This special article will provide insights that will hopefully optimize the role of the nephrologist as the leader of the acute care nephrology program, as clinician for critically ill patients, and as teacher for all members of the health care team.
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Affiliation(s)
- David J. Askenazi
- Department of Pediatrics—Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, USA
| | - Michael Heung
- Department of Medicine—Division of Nephrology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael J. Connor
- Department of Medicine—Division of Renal Medicine, Emory University, Atlanta, Georgia, USA
| | - Rajit K. Basu
- Center for Acute Care Nephrology, Cincinnati Children’s Hospital Center, Cincinnati, Ohio, USA
| | - Jorge Cerdá
- Department of Medicine, Albany Medical College, Albany, New York, USA
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Bunkyo, Tokyo, Japan
| | - Jay L. Koyner
- Department of Medicine—Section of Nephrology, University of Chicago, Chicago, Illinois, USA
| | - Azra Bihorac
- Department of Anesthesiology—University of Florida, Gainesville, Florida, USA
| | | | - Anitha Vijayan
- Division of Nephrology, Washington University, St Louis, Missouri, USA
| | - Mark Okusa
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Sarah Faubel
- Department of Medicine—University of Colorado, and Denver VA Medical Center, Denver, Colorado, USA
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Makris K, Spanou L. Acute Kidney Injury: Diagnostic Approaches and Controversies. Clin Biochem Rev 2016; 37:153-175. [PMID: 28167845 PMCID: PMC5242479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Acute kidney injury (AKI) is a significant independent risk factor for morbidity and mortality. In the last ten years a large number of publications have highlighted the limitations of traditional approaches and the inadequacies of conventional biomarkers to diagnose and monitor renal insufficiency in the acute setting. A great effort was directed not only to the discovery and validation of new biomarkers aimed to detect AKI more accurately but also to standardise the definition of AKI. Despite the advances in both areas, biomarkers have not yet entered into routine clinical practice and the definition of this syndrome has many areas of uncertainty. This review will discuss the controversies in diagnosis and the potential of novel biomarkers to improve the definition of the syndrome.
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Affiliation(s)
- Konstantinos Makris
- Clinical Biochemistry Department, KAT General Hospital, Kifissia, Athens, 14561, Greece
| | - Loukia Spanou
- Clinical Biochemistry Department, KAT General Hospital, Kifissia, Athens, 14561, Greece
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26
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Cohen JF, Korevaar DA, Altman DG, Bruns DE, Gatsonis CA, Hooft L, Irwig L, Levine D, Reitsma JB, de Vet HCW, Bossuyt PMM. STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration. BMJ Open 2016; 6:e012799. [PMID: 28137831 PMCID: PMC5128957 DOI: 10.1136/bmjopen-2016-012799] [Citation(s) in RCA: 1270] [Impact Index Per Article: 158.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/03/2016] [Accepted: 08/25/2016] [Indexed: 12/11/2022] Open
Abstract
Diagnostic accuracy studies are, like other clinical studies, at risk of bias due to shortcomings in design and conduct, and the results of a diagnostic accuracy study may not apply to other patient groups and settings. Readers of study reports need to be informed about study design and conduct, in sufficient detail to judge the trustworthiness and applicability of the study findings. The STARD statement (Standards for Reporting of Diagnostic Accuracy Studies) was developed to improve the completeness and transparency of reports of diagnostic accuracy studies. STARD contains a list of essential items that can be used as a checklist, by authors, reviewers and other readers, to ensure that a report of a diagnostic accuracy study contains the necessary information. STARD was recently updated. All updated STARD materials, including the checklist, are available at http://www.equator-network.org/reporting-guidelines/stard Here, we present the STARD 2015 explanation and elaboration document. Through commented examples of appropriate reporting, we clarify the rationale for each of the 30 items on the STARD 2015 checklist, and describe what is expected from authors in developing sufficiently informative study reports.
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Affiliation(s)
- Jérémie F Cohen
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pediatrics, INSERM UMR 1153, Necker Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Daniël A Korevaar
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Douglas G Altman
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - David E Bruns
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Constantine A Gatsonis
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Lotty Hooft
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Les Irwig
- Screening and Diagnostic Test Evaluation Program, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Deborah Levine
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Radiology Editorial Office, Boston, Massachusetts, USA
| | - Johannes B Reitsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Henrica C W de Vet
- Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Patrick M M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Schnell D, Darmon M. Quelle est la place du Doppler rénal dans la prise en charge de l’insuffisance rénale aiguë ? MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1233-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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28
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Lehner GF, Forni LG, Joannidis M. Oliguria and Biomarkers of Acute Kidney Injury: Star Struck Lovers or Strangers in the Night? Nephron Clin Pract 2016; 134:183-190. [PMID: 27505252 DOI: 10.1159/000447979] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/23/2016] [Indexed: 11/19/2022] Open
Abstract
Oliguria is a common phenomenon that is found in hospitalized patients . Although a rapid reduction in urine excretion rate may reflect a precipitous fall in the glomerular filtration rate, in many cases it may not. Given the common physiological finding of oliguria, we explore the relationship between the functional biomarker of renal injury (oliguria) with the increasing number of markers of renal injury to see if this combination may aid in risk stratification. © 2016 S. Karger AG, Basel.
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Affiliation(s)
- Georg F Lehner
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
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29
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Urine sodium concentration to predict fluid responsiveness in oliguric ICU patients: a prospective multicenter observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:165. [PMID: 27236480 PMCID: PMC4884621 DOI: 10.1186/s13054-016-1343-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 05/12/2016] [Indexed: 12/21/2022]
Abstract
Background Oliguria is one of the leading triggers of fluid loading in patients in the intensive care unit (ICU). The purpose of this study was to assess the predictive value of urine Na+ (uNa+) and other routine urine biomarkers for cardiac fluid responsiveness in oliguric ICU patients. Methods We conducted a prospective multicenter observational study in five university ICUs. Patients with urine output (UO) <0.5 ml/kg/h for 3 consecutive hours with a mean arterial pressure >65 mmHg received a fluid challenge. Cardiac fluid responsiveness was defined by an increase in stroke volume >15 % after fluid challenge. Urine and plasma biochemistry samples were examined before fluid challenge. We examined renal fluid responsiveness (defined as UO >0.5 ml/kg/h for 3 consecutive hours) after fluid challenge as a secondary endpoint. Results Fifty-four patients (age 51 ± 37 years, Simplified Acute Physiology Score II score 40 ± 20) were included. Most patients (72 %) were not cardiac responders (CRs), and 50 % were renal responders (RRs) to fluid challenge. Patient characteristics were similar between CRs and cardiac nonresponders. uNa+ (37 ± 38 mmol/L vs 25 ± 75 mmol/L, p = 0.44) and fractional excretion of sodium (FENa+) (2.27 ± 2.5 % vs 2.15 ± 5.0 %, p = 0.94) were not statistically different between those who did and those who did not respond to the fluid challenge. Areas under the receiver operating characteristic (AUROC) curves were 0.51 (95 % CI 0.35–0.68) and 0.56 (95 % CI 0.39–0.73) for uNa+ and FENa+, respectively. Fractional excretion of urea had an AUROC curve of 0.70 (95 % CI 0.54–0.86, p = 0.03) for CRs. Baseline UO was higher in RRs than in renal nonresponders (1.07 ± 0.78 ml/kg/3 h vs 0.65 ± 0.53 ml/kg/3 h, p = 0.01). The AUROC curve for RRs was 0.65 (95 % CI 0.53–0.78) for uNa+. Conclusions In the present study, most oliguric patients were not CRs and half were not renal responders to fluid challenge. Routine urinary biomarkers were not predictive of fluid responsiveness in oliguric normotensive ICU patients.
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Nayak NM, Madhumitha S, Annigeri RA, Venkataraman R, Balasubramaian S, Seshadri R, Vadamalai V, Rao BS, Kowdle PC, Ramakrishnan N, Mani MK. Clinical utility of urine neutrophil gelatinase-associated lipocalin measured at admission to predict outcomes in heterogeneous population of critically ill patients. Indian J Nephrol 2016; 26:119-24. [PMID: 27051136 PMCID: PMC4795427 DOI: 10.4103/0971-4065.157800] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Urine neutrophil gelatinase-associated lipocalin (uNGAL) is a reliable early biomarker of acute kidney injury (AKI) in a homogeneous patient population. However, its utility in a heterogeneous population of critically ill, in whom the time of onset of renal insult is often unclear, is not clearly established. We evaluated the ability of a single measurement of uNGAL in a heterogeneous adult population, on admission to intensive care unit (ICU), to predict the occurrence of AKI and hospital mortality. One hundred and two consecutive adult patients had uNGAL measured within 8 h of admission to ICU. The demographic and laboratory data were collected at admission. The diagnosis of AKI was based on AKI Network (AKIN) criteria. The primary outcome was the development of AKI, and the secondary outcome was hospital mortality. The mean age was 54 ± 16.4 years and 65% were males. Urine NGAL (ng/ml) was 69 ± 42 in patients with AKI (n = 42) and 30.4 ± 41.7 in those without AKI (P < 0.001). The area under the receiver operating characteristic (ROC) curve for prediction of AKI was 0.79 and for serum creatinine (SCr) was 0.88. The sensitivity and specificity for a cut-off value of uNGAL of 75 ng/ml to predict AKI were 0.5 and 0.85 respectively. uNGAL > 75 ng/ml was a strong (odd ratio = 5.17, 95% confidence interval: 1.39–19.3) and independent predictor of hospital mortality. A single measurement of uNGAL at admission to ICU exhibited good predictive ability for AKI though the sensitivity was low. The predictive ability of uNGAL was inferior to simultaneously measured SCr at admission, hence limited its clinical utility to predict AKI. However, admission uNGAL was a strong, independent predictor of hospital mortality.
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Affiliation(s)
- N M Nayak
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - S Madhumitha
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - R A Annigeri
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - R Venkataraman
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - S Balasubramaian
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - R Seshadri
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - V Vadamalai
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - B S Rao
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - P C Kowdle
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - N Ramakrishnan
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - M K Mani
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
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Urine biochemistry assessment in critically ill patients: controversies and future perspectives. J Clin Monit Comput 2016; 31:539-546. [PMID: 27038161 DOI: 10.1007/s10877-016-9871-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 03/30/2016] [Indexed: 12/17/2022]
Abstract
In the past, urine biochemistry was a major tool in acute kidney injury (AKI) management. Classic papers published some decades ago established the values of the urine indices which were thought to distinguish "pre-renal" (functional) AKI attributed to low renal perfusion and "renal" (structural) AKI attributed to acute tubular necrosis (ATN). However, there were a lot of drawbacks and limitations in these studies and some recent articles have questioned the utility of measuring urine electrolytes especially because they do not seem to adequately inform about renal perfusion nor AKI duration (transient vs. persistent). At the same time, the "pre-renal" paradigm has been consistently criticized because hypoperfusion followed by ischemia and ATN does not seem to explain most of the AKI developing in critically ill patients and distinct AKI durations do not seem to be clearly related to different pathophysiological mechanisms or histopathological findings. In this new context, other possible roles for urine biochemistry have emerged. Some studies have suggested standardized changes in the urine electrolyte composition preceding increases in serum creatinine independently of AKI subsequent duration, which might actually be due to intra-renal microcirculatory changes and activation of sodium-retaining mechanisms even in the absence of impaired global renal blood flow. In the present review, the points of controversy regarding urine biochemistry assessment were evaluated as well as future perspectives for its role in AKI monitoring. An alternative approach for the interpretation of measured urine electrolytes is proposed which needs further larger studies to be validated and incorporated in daily ICU practice.
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Honore PM, Jacobs R, Hendrickx I, Bagshaw SM, Joannes-Boyau O, Boer W, De Waele E, Van Gorp V, Spapen HD. Prevention and treatment of sepsis-induced acute kidney injury: an update. Ann Intensive Care 2015; 5:51. [PMID: 26690796 PMCID: PMC4686459 DOI: 10.1186/s13613-015-0095-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 12/01/2015] [Indexed: 12/14/2022] Open
Abstract
Sepsis-induced acute kidney injury (SAKI) remains an important challenge in critical care medicine. We reviewed current available evidence on prevention and treatment of SAKI with focus on some recent advances and developments. Prevention of SAKI starts with early and ample fluid resuscitation preferentially with crystalloid solutions. Balanced crystalloids have no proven superior benefit. Renal function can be evaluated by measuring lactate clearance rate, renal Doppler, or central venous oxygenation monitoring. Assuring sufficiently high central venous oxygenation most optimally prevents SAKI, especially in the post-operative setting, whereas lactate clearance better assesses mortality risk when SAKI is present. Although the adverse effects of an excessive “kidney afterload” are increasingly recognized, there is actually no consensus regarding an optimal central venous pressure. Noradrenaline is the vasopressor of choice for preventing SAKI. Intra-abdominal hypertension, a potent trigger of AKI in post-operative and trauma patients, should not be neglected in sepsis. Early renal replacement therapy (RRT) is recommended in fluid-overloaded patients’ refractory to diuretics but compelling evidence about its usefulness is still lacking. Continuous RRT (CRRT) is advocated, though not sustained by convincing data, as the preferred modality in hemodynamically unstable SAKI. Diuretics should be avoided in the absence of hypervolemia. Antimicrobial dosing during CRRT needs to be thoroughly reconsidered to assure adequate infection control.
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Affiliation(s)
- Patrick M Honore
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Rita Jacobs
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Inne Hendrickx
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
| | - Olivier Joannes-Boyau
- Haut Leveque University Hospital of Bordeaux, University of Bordeaux 2, Pessac, France.
| | - Willem Boer
- Department of Anaesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium.
| | - Elisabeth De Waele
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Viola Van Gorp
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Herbert D Spapen
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
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Insuffisances rénales aiguës : pertinence d’une classification fondée sur le délai de récupération. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1112-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Chang CH, Yang CH, Yang HY, Chen TH, Lin CY, Chang SW, Chen YT, Hung CC, Fang JT, Yang CW, Chen YC. Urinary Biomarkers Improve the Diagnosis of Intrinsic Acute Kidney Injury in Coronary Care Units. Medicine (Baltimore) 2015; 94:e1703. [PMID: 26448023 PMCID: PMC4616771 DOI: 10.1097/md.0000000000001703] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Acute kidney injury (AKI) is associated with increased morbidity and mortality and is frequently encountered in coronary care units (CCUs). Its clinical presentation differs considerably from that of prerenal or intrinsic AKI. We used the biomarkers calprotectin and neutrophil gelatinase-associated lipocalin (NGAL) and compared their utility in predicting and differentiating intrinsic AKI. This was a prospective observational study conducted in a CCU of a tertiary care university hospital. Patients who exhibited any comorbidity and a kidney stressor were enrolled. Urinary samples of the enrolled patients collected between September 2012 and August 2013 were tested for calprotectin and NGAL. The definition of AKI was based on Kidney Disease Improving Global Outcomes classification. All prospective demographic, clinical, and laboratory data were evaluated as predictors of AKI. A total of 147 adult patients with a mean age of 67 years were investigated. AKI was diagnosed in 71 (50.3%) patients, whereas intrinsic AKI was diagnosed in 43 (60.5%) of them. Multivariate logistic regression analysis revealed urinary calprotectin and serum albumin as independent risk factors for intrinsic AKI. For predicting intrinsic AKI, both urinary NGAL and calprotectin displayed excellent areas under the receiver operating characteristic curve (AUROC) (0.918 and 0.946, respectively). A combination of these markers revealed an AUROC of 0.946. Our result revealed that calprotectin and NGAL had considerable discriminative powers for predicting intrinsic AKI in CCU patients. Accordingly, careful inspection for medication, choice of therapy, and early intervention in patients exhibiting increased biomarker levels might improve the outcomes of kidney injury.
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Affiliation(s)
- Chih-Hsiang Chang
- From the Department of Nephrology, Kidney Research Center, Taipei, Taiwan (C-HC, H-YY, C-YL, C-CH, J-TF, C-WY, Y-CC); Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan (C-HY, T-HC); Clinical Informatics and Medical Statistics Research Center, Taipei, Taiwan (S-WC); Department of Biomedical Sciences, Chang Gung University, Taoyuan, Taiwan (Y-TC); and College of Medicine, Chang Gung University, Taoyuan, Taiwan (C-HC, H-YY, C-YL, C-CH, J-TF, C-WY, Y-CC)
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Varela CF, Greloni G, Schreck C, Bratti G, Medina A, Marenchino R, Pizarro R, Belziti C, Rosa-Diez G. Assessment of fractional excretion of urea for early diagnosis of cardiac surgery associated acute kidney injury. Ren Fail 2015; 37:327-31. [PMID: 26398357 DOI: 10.3109/0886022x.2015.1087800] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication after cardiac surgery (CS). Recently, neutrophil gelatinase-associated lipocalin (NGAL) was shown to predict AKI development earlier than serum creatinine, but it is not widely used in clinical practice. Fractional excretion of urea (FeU) has been referred to as a useful tool to discriminate between prerenal and established AKI. The aim of our study is to evaluate the sensitivity and specificity of FeU, in the early diagnosis of AKI in patients undergoing CS. METHODS We performed a prospective study on adults undergoing CS. AKI was defined by AKIN criteria. Individuals suffering from CKD, were excluded. Sensitivity and specificity of FeU, fractional excretion of sodium (FeNa) and urine NGAL, measured at 1, 6 and 24 h following CS, were assessed. RESULTS We included 66 patients (26% female) aging 68 ± 11 years. AKI prevalence was 24% and mortality was 3.28%. Patients with AKI had a significantly lower FeU compared to those without AKI (23.89 ± 0.67% vs. 34.22 ± 0.58%; p < 0.05) 6 h after CS, but not at the 1- and 24-h time points. NGAL was also statistically significant between both groups. FeU showed a 75% sensitivity and 79.5% specificity; the AUC was 0.786. ROC analysis of FeU and NGAL yielded similar values (p = NS). CONCLUSION FeU is useful as an early biomarker to predict AKI after CS and it is comparable to the new biomarker NGAL.
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Affiliation(s)
- Carlos Federico Varela
- a Servicio de Nefrología del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Gustavo Greloni
- a Servicio de Nefrología del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Carlos Schreck
- a Servicio de Nefrología del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Griselda Bratti
- a Servicio de Nefrología del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Angel Medina
- a Servicio de Nefrología del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Ricardo Marenchino
- b Servicio de Cirugía Cardiovascular del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina , and
| | - Rodolfo Pizarro
- c Servicio de Cardiología del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Cesar Belziti
- c Servicio de Cardiología del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Guillermo Rosa-Diez
- a Servicio de Nefrología del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
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Dewitte A, Joannès-Boyau O, Sidobre C, Fleureau C, Bats ML, Derache P, Leuillet S, Ripoche J, Combe C, Ouattara A. Kinetic eGFR and Novel AKI Biomarkers to Predict Renal Recovery. Clin J Am Soc Nephrol 2015; 10:1900-10. [PMID: 26342047 DOI: 10.2215/cjn.12651214] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 01/27/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Prompt recognition of severe renal impairment could improve the early management of critically ill patients. We compared the value of kinetic eGFR, plasma neutrophil gelatinase-associated lipocalin (NGAL), and urine tissue inhibitor of metalloproteinase-2 and urine insulin-like growth factor-binding protein 7 ([TIMP-2]*[IGFBP7]) in predicting short-term recovery from AKI and major adverse kidney events. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS During the 6-month study period, 245 patients were admitted to our intensive care unit. This study included 57 consecutive patients presenting with AKI within the first 24 hours after admission. AKI markers were evaluated at inclusion (day 0) and 24 hours later (day 1). Kinetic eGFR was calculated on day 1 according to serum creatinine evolution. Renal recovery was defined as normalization of serum creatinine with reversal of oliguria within 48 hours. Major adverse kidney events included death, need for RRT, or persistence of renal dysfunction at hospital discharge. RESULTS Plasma NGAL and [TIMP-2]*[IGFBP7] predicted renal recovery, with area under the receiver-operating characteristic curve (AUC-ROC) values between 0.70 and 0.79 at inclusion. Although plasma NGAL values frequently reached the maximal measurement range, their decrease on day 1 predicted recovery. The kinetic eGFR calculation after initial resuscitation provided the best AUC-ROC value for renal recovery, at 0.87. The best predictions for major adverse kidney events were provided by [TIMP-2]*[IGFBP7] and kinetic eGFR (equal AUC-ROCs of 0.81). Combining AKI markers in addition to clinical prediction models improved the discrimination and reclassification of patients who will recover from AKI or suffer from major adverse kidney events. CONCLUSIONS Biomarkers of kidney damage predicted short-term renal recovery and major adverse kidney events for an unselected cohort of critically ill patients. Calculating the kinetic eGFR imposed a delay after initial resuscitation but provided a good diagnostic and prognostic approach. The utility of functional and damage AKI marker combinations in addition to clinical information requires validation in larger prospective studies.
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Affiliation(s)
- Antoine Dewitte
- Departments of Anesthesia and Intensive Care II, French Institute of Health and Medical Research (INSERM) U1026, Tissue Bioengineering (BioTis), University of Bordeaux, Bordeaux, France;
| | | | | | | | | | | | | | - Jean Ripoche
- French Institute of Health and Medical Research (INSERM) U1026, Tissue Bioengineering (BioTis), University of Bordeaux, Bordeaux, France
| | - Christian Combe
- French Institute of Health and Medical Research (INSERM) U1026, Tissue Bioengineering (BioTis), University of Bordeaux, Bordeaux, France; Nephrology, Transplantation, Dialysis, University Hospital, Bordeaux, France
| | - Alexandre Ouattara
- Departments of Anesthesia and Intensive Care II, INSERM U1034, Cardiovascular Adaptation to Ischemia, University of Bordeaux, Pessac, France
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Maciel AT, Park M, Macedo E. Fractional excretion of potassium in the course of acute kidney injury in critically ill patients: potential monitoring tool? Rev Bras Ter Intensiva 2015; 26:143-7. [PMID: 25028948 PMCID: PMC4103940 DOI: 10.5935/0103-507x.20140021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Accepted: 04/07/2014] [Indexed: 11/26/2022] Open
Abstract
Objective To evaluate the behavior of fractional excretion of potassium in the course of
acute kidney injury in critically ill patients. Methods As part of a larger study in which we have evaluated blood and urinary parameters
in the course of acute kidney injury, 168 patients were included. Blood and urine
samples were collected daily until the removal of the urinary catheter or the
initiation of renal replacement therapy. We describe the evolution of fractional
excretion of potassium based on whether acute kidney injury was diagnosed, its
duration (transient or persistent) and its severity (creatinine-based Acute Kidney
Injury Network - AKIN stage). The diagnostic performance of fractional excretion
of potassium in predicting the duration of acute kidney injury and the need for
renal replacement therapy on the day of acute kidney injury diagnosis was also
evaluated. Results Fractional excretion of potassium was significantly higher in persistent acute
kidney injury compared to transient acute kidney injury on the day of acute kidney
injury diagnosis (24.8 vs. 13.8%, p<0.001). Both groups had the median
fractional excretion of potassium increasing in the two days preceding the acute
kidney injury diagnosis. Patients without acute kidney injury had stable low
fractional excretion of potassium values. The fractional excretion of potassium
was fairly accurate in predicting persistent acute kidney injury (area under the
curve: 0.712; 95% confidence interval: 0.614-0.811; p<0.001) on the day of
acute kidney injury diagnosis. The area under the curve was 0.663 (95% confidence
interval: 0.523-0.803; p=0.03) for renal replacement therapy. The fractional
excretion of potassium increased with maximum AKIN stage reached, in both
transient and persistent acute kidney injury. Conclusion Sequential fractional excretion of potassium assessment appears to be useful in
critically ill patients at risk for acute kidney injury.
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Affiliation(s)
- Alexandre Toledo Maciel
- Unidade de Terapia Intensiva, Departamento de Emergências Clínicas, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Marcelo Park
- Unidade de Terapia Intensiva, Departamento de Emergências Clínicas, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Etienne Macedo
- Departamento de Nefrologia, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
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Transient and Persistent Acute Kidney Injury and the Risk of Hospital Mortality in Critically Ill Patients. Crit Care Med 2015; 43:e269-75. [DOI: 10.1097/ccm.0000000000001077] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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The authors reply. Crit Care Med 2015; 43:e264. [PMID: 26079247 DOI: 10.1097/ccm.0000000000000988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Doppler-based renal resistive index for prediction of renal dysfunction reversibility: A systematic review and meta-analysis. J Crit Care 2015; 30:629-35. [PMID: 25746587 DOI: 10.1016/j.jcrc.2015.02.008] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 01/30/2015] [Accepted: 02/08/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Doppler-based renal resistive index (RI) might help in distinguishing transient from persistent acute kidney injury (AKI). The main objective of these systematic review and meta-analysis was to investigate the diagnostic performance of RI in predicting short-term reversibility of AKI. STUDY DESIGN A systematic review of the literature was performed. Relevant studies were identified in Pubmed and Cochrane databases covering the years 1985 to 2013 and reviewed independently by 3 authors. Renal transplant recipients were excluded from this analysis. The summary estimates were computed using a random-effects model based on the DerSimonian and Lair meta-analytic method. RESULTS Among the 154 unique articles identified, 9 studies were included. Of the 176 patients in these studies with elevated RI or pulsatility index, 146 (83%) had a persistent AKI vs 44 (16%) of the 273 patients with normal values. Elevated RI or pulsatility index was associated with an increased risk of persistent AKI (odds ratio, 29.85; 95% confidence interval [CI], 8.73-102.16; P < .00001) with significant heterogeneity (I(2) = 75.0%, P < .0001). The pooled sensitivity and specificity were 0.83 (95% CI, 0.77-0.88) and 0.84 (95% CI, 0.79-0.88). The summary positive and negative likelihood ratios were 4.9 (95% CI, 2.44-9.87) and 0.21 (95% CI, 0.11-0.41). CONCLUSION These results suggest that an elevated RI may be a predictor of persistent AKI in critically ill patients. Further studies are warranted, however, to clarify the exact test performance given the marked heterogeneity among the included studies.
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Ricci Z, Di Nardo M, Ronco C. Year in review 2013: Critical Care - nephrology. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:574. [PMID: 25426759 PMCID: PMC4281925 DOI: 10.1186/s13054-014-0574-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
We review original research in the field of critical care nephrology accepted or published in 2013 in Critical Care and, when considered relevant or linked to these studies, in other journals. Three main topics have been identified and are discussed for a rapid overview: acute kidney injury (diagnosis, risk factors and outcome); timing and modality of renal replacement therapy; and extracorporeal membrane oxygenation and renal dysfunction.
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Barreto R, Elia C, Solà E, Moreira R, Ariza X, Rodríguez E, Graupera I, Alfaro I, Morales-Ruiz M, Poch E, Guevara M, Fernández J, Jiménez W, Arroyo V, Ginès P. Urinary neutrophil gelatinase-associated lipocalin predicts kidney outcome and death in patients with cirrhosis and bacterial infections. J Hepatol 2014; 61:35-42. [PMID: 24613364 DOI: 10.1016/j.jhep.2014.02.023] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 02/04/2014] [Accepted: 02/25/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Infections in cirrhosis are frequently complicated by kidney dysfunction that entails a poor prognosis. Urinary biomarkers may be of potential clinical usefulness in this setting. We aimed at assessing the value of urinary neutrophil gelatinase-associated lipocalin (uNGAL), a biomarker overexpressed in kidney tubules during kidney injury, in predicting clinical outcomes in cirrhosis with infections. METHODS One-hundred and thirty-two consecutive patients hospitalized with infections were evaluated prospectively. Acute kidney injury (AKI) was defined according to AKIN criteria. uNGAL was measured at infection diagnosis and at days 3 and 7 (ELISA, Bioporto, DK). RESULTS Patients with AKI (n=65) had significantly higher levels of uNGAL compared to patients without AKI (203 ± 390 vs. 79 ± 126 μg/g creatinine, p<0.001). Moreover, uNGAL levels were significantly higher in patients who developed persistent AKI (n=40), compared to those with transient AKI (n=25) (281 ± 477 vs. 85 ± 79 μg/g creatinine, p<0.001). Among patients with persistent AKI, uNGAL was able to discriminate type-1 HRS from other causes of AKI (59 ± 46 vs. 429 ± 572 μg/g creatinine, respectively; p<0.001). Moreover, the time course of uNGAL was markedly different between the two groups. Interestingly, baseline uNGAL levels also predicted the development of a second infection during hospitalization. Overall, 3-month mortality was 34%. Independent predictive factors of 3-month mortality were MELD score, serum sodium, and uNGAL levels at diagnosis, but not presence or stage of AKI. CONCLUSIONS In patients with cirrhosis and infections, measurement of urinary NGAL at infection diagnosis is useful in predicting important clinical outcomes, specifically persistency and type of AKI, development of a second infection, and 3-month mortality.
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Affiliation(s)
- Rogelio Barreto
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; Instituto Reina Sofía de Investigación Nefrológica (IRSIN), Spain
| | - Chiara Elia
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; Instituto Reina Sofía de Investigación Nefrológica (IRSIN), Spain
| | - Elsa Solà
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; Instituto Reina Sofía de Investigación Nefrológica (IRSIN), Spain
| | - Rebeca Moreira
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; Instituto Reina Sofía de Investigación Nefrológica (IRSIN), Spain
| | - Xavier Ariza
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; Instituto Reina Sofía de Investigación Nefrológica (IRSIN), Spain
| | - Ezequiel Rodríguez
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; Instituto Reina Sofía de Investigación Nefrológica (IRSIN), Spain
| | - Isabel Graupera
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; Instituto Reina Sofía de Investigación Nefrológica (IRSIN), Spain
| | - Ignacio Alfaro
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; Instituto Reina Sofía de Investigación Nefrológica (IRSIN), Spain
| | - Manuel Morales-Ruiz
- Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; Biochemistry and Molecular Genetics Department, University of Barcelona, Barcelona, Catalonia, Spain
| | - Estaban Poch
- Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Hospital Clínic, Nephrology Unit, University of Barcelona, Barcelona, Catalonia, Spain
| | - Mónica Guevara
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; Instituto Reina Sofía de Investigación Nefrológica (IRSIN), Spain
| | - Javier Fernández
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; Instituto Reina Sofía de Investigación Nefrológica (IRSIN), Spain
| | - Wladimiro Jiménez
- Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; Biochemistry and Molecular Genetics Department, University of Barcelona, Barcelona, Catalonia, Spain
| | - Vicente Arroyo
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; Instituto Reina Sofía de Investigación Nefrológica (IRSIN), Spain
| | - Pere Ginès
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; Instituto Reina Sofía de Investigación Nefrológica (IRSIN), Spain.
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Abstract
PURPOSE OF REVIEW The purpose of the present work was to review the literature on the role of biomarkers for the diagnosis, the risk stratification, and the management of circulatory failure. RECENT FINDINGS Recent research has highlighted how biomarkers could guide physicians in making proper diagnosis of the cause of the circulatory failure, assessing the consequence in terms of organ injury and function, refining prognosis prediction and stratification of patients, and guiding treatments, in patients with cardiovascular failure. SUMMARY Because of the tight association between circulatory and renal failure, we put a special emphasis on cardiovascular [B-type natriuretic peptide (BNP), Nt-proBNP, troponin, QSOX-1, sST-2, mid-regional pro-atrial natriuretic peptide] and renal biomarkers (neutrophil gelatinase-associated lipocalin, cystatin C, liver-type fatty acid-binding protein, kidney injury molecule-1, insulin-like growth factor-binding protein-7, tissue inhibitor of metalloproteinase-2). We also discuss nonspecific biomarkers (pro-ADM, glycemia, MicroRNA, chromogramin A) in this setting. We discuss the potential interest and limits, from diagnosis to prognosis reclassification, of cutting-edge new biomarkers, but also widely available and inexpensive biomarkers, in the particular setting of circulatory failure.
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Biomarqueurs et physiopathologie. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-013-0735-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Maciel AT, Vitorio D. Urine biochemistry in acute kidney injury: are we moving in the right direction? Crit Care 2013; 17:459. [PMID: 24229438 PMCID: PMC4057450 DOI: 10.1186/cc13112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Schneider AG, Bellomo R. Urinalysis and pre-renal acute kidney injury: time to move on. Crit Care 2013; 17:141. [PMID: 23659200 PMCID: PMC3672654 DOI: 10.1186/cc12676] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Urinary indices are classically believed to allow differentiation of transient (or pre-renal) acute kidney injury (AKI) from persistent (or acute tubular necrosis) AKI. However, the data validating urinalysis in critically ill patients are weak. In the previous issue of Critical Care, Pons and colleagues demonstrate in a multicenter observational study that sodium and urea excretion fractions as well as urinary over plasma ratios performed poorly as diagnostic tests to separate such entities. This study confirms the limited diagnostic and prognostic ability of urine testing. Together with other studies, this study raises more fundamental questions about the value, meaning and pathophysiologic validity of the pre-renal AKI paradigm and suggests that AKI (like all other forms of organ injury) is a continuum of injury that cannot be neatly divided into functional (pre-renal or transient) or structural (acute tubular necrosis or persistent).
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