Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

Timing of Chest Tube Removal Following Adult Cardiac Surgery: A Cluster Randomized Controlled Trial

OBJECTIVES

Early chest tube removal following cardiac surgery may be associated with an increased risk of pleural or pericardial effusions following cardiac surgery. This study compares the effects of two fast-track chest tube removal protocols regarding the risk of pleural or pericardial effusions, requirement of opioids, respiratory function, and postoperative complications.

DESIGN

Prospective non-blinded cluster-randomized study with alternating chest tube removal protocol in adult patients undergoing elective cardiac surgery. Monthly changing allocation to scheduled chest tube removal on the day of surgery (Day 0) versus removal on the 1st postoperative day (Day 1) provided no air leakage and output < 200 mL within the last four hours.

RESULTS

A total of 527 patients were included in the study from September 1st 2020 until October 29th 2021 and randomly allocated to chest tube removal at day 0 (n = 255), and day 1 (n = 272). More than every fourth patient required drainage for pleural effusion with no significant difference between the groups. Earlier removal of chest tubes did not reduce requirement of analgesics, improve early respiratory function, or reduce postoperative complications. The study was halted for futility after halfway interim analysis showed insufficient promise of any treatment benefit.

CONCLUSION

Fast-track protocols with chest tube removal within the first 24 h after cardiac surgery may be associated a high rate of pleural effusions.

Association between normal saline infusion volume in the emergency department and acute kidney injury in heat stroke patients: a multicenter retrospective study

BACKGROUND

Previous studies have shown that intravenous normal saline (NS) may be associated with the incidence of acute kidney injury (AKI). This study aimed to evaluate the association between the volume of NS infusion and AKI in heat stroke (HS) patients.

METHODS

This multicenter retrospective cohort study included 138 patients with HS. The primary outcome was the incidence of AKI. Secondary outcomes included the need for continuous renal replacement therapy (CRRT), admission to the intensive care unit (ICU), length of stay in the ICU and hospital, and in-hospital mortality. Multivariate regression models, random forest imputation, and genetic and propensity score matching were used to explore the relationship between NS infusion and outcomes.

RESULTS

The mean volume of NS infusion in the emergency department (ED) was 3.02 ± 1.45 L. During hospitalization, 33 patients (23.91%) suffered from AKI. In the multivariate model, as a continuous variable (per 1 L), the volume of NS infusion was associated with the incidence of AKI (OR, 2.51; 95% CI, 1.43-4.40; p = .001), admission to the ICU (OR, 3.46; 95% CI 1.58-7.54; p = .002), and length of stay in the ICU (β, 1.00 days; 95% CI, 0.44-1.56; p < .001) and hospital (β, 1.41 days; 95% CI, 0.37-2.45; p = .008). These relationships also existed in the forest imputation cohort and matching cohort. There were no differences in the use of CRRT or in-hospital mortality.

CONCLUSIONS

The volume of NS infusion was associated with a significant increase in the incidence of AKI, admission to the ICU, and length of stay in the ICU and hospital among patients with HS.

Association of Geriatric Nutritional Risk Index with short-term mortality in patients with severe acute kidney injury: a retrospective cohort study

OBJECTIVES

Geriatric Nutritional Risk Index (GNRI) is a new and simple index recently introduced to assess nutritional status, and its predictive value for clinical outcomes has been demonstrated in patients with chronic kidney disease. However, the association between the GNRI and prognosis has not been evaluated so far in patients with acute kidney injury (AKI), especially in those receiving continuous renal replacement therapy (CRRT).

METHODS

A total of 1096 patients with severe AKI initiating CRRT were identified for inclusion in this retrospective observational study. Patients were divided into three groups according to GNRI tertiles, with tertile 1 as the reference. The outcomes of interest were the 28- and 90-days of all-cause mortality. The associations between GNRI and clinical outcomes were estimated using multivariate Cox proportional hazards model analysis.

RESULTS

The overall mortality rates at 28- and 90-days were 61.6% (675/1096) and 71.5% (784/1096), respectively. After adjusting for multiple confounding factors, GNRI was identified as an independent prognostic factor for 28-days all-cause mortality (HR, 0.582; 95% CI, 0.467-0.727; p < .001 for tertile 3 vs. tertile 1) as well as 90-days all-cause mortality (HR, 0.540; 95% CI, 0.440-0.661; p < .001 for tertile 3 vs. tertile 1). The observed inverse associations were robust across subgroup analysis, and were more pronounced in elderly patients over 65 years of age. Finally, incorporating GNRI in a model with established risk factors might significantly improve its predictive power for the short-term death.

CONCLUSIONS

GNRI is considered to be a useful prognostic factor in patients with severe AKI initiating CRRT, especially in elderly patients.

Factors associated with post-hospitalization dialysis dependence in ECMO patients who required continuous renal replacement therapy

OBJECTIVE

This single center retrospective study aimed to describe the variables associated with outpatient dialysis dependence in extracorporeal membrane oxygenation (ECMO) patients who needed continuous renal replacement therapy (CRRT) for acute kidney injury (AKI) during their hospitalization.

METHODS

Retrospective study of patients who required ECMO-CRRT.

RESULTS

Between the years of 2016 and 2022, 202 patients required ECMO-CRRT. One hundred and six patients (52.5%) survived their hospitalization and were followed up for a median of 391 [133, 1005] days. Eighty-one patients (76.5%) recovered kidney function and were dialysis-free before hospital discharge. Twenty-five patients (23.5%) were hemodialysis-dependent after hospitalization. On multivariate regression analysis, hyperlipidemia (odds ratio, OR 6.08 [1.67-22]) and CRRT duration (OR 1.09 [1.03-1.15]) were associated with the need for dialysis post-hospitalization. In this group, 16 patients eventually became dialysis-free, after a median of 49 [34.7, 78.5] days. These patients had a higher median baseline glomerular filtration rate (GFR) compared to those who never recovered renal function (93 mL/min/1.73 m2 [82.4, 104.3] vs. 63.8 mL/min/1.73 m2 [37.9, 83], p = .009). Their follow-up GFR was lower compared to those who recovered renal function before hospital discharge; (87 mL/min/1.73 m2 [68.2, 98.9] vs. 99 mL/min/1.73 m2 [79, 118], p = .07).

CONCLUSIONS

AKI requiring CRRT was associated with high mortality in patients receiving ECMO. Nonetheless, most ECMO survivors became dialysis-free before hospital discharge. Variables associated with the need for outpatient dialysis included hyperlipidemia and prolonged need for CRRT during hospitalization.

Safety and effectiveness of remdesivir in hospitalized patients with COVID-19 and severe renal impairment: experience at a large medical center

BACKGROUND

Literature on the safety of remdesivir in hospitalized COVID-19 patients with severe renal impairment is limited. We aimed to investigate the safety and effectiveness of remdesivir in this population.

METHODS

We conducted a retrospective cohort study of adult hospitalized COVID-19 patients who received remdesivir between April 2022 and October 2022. Outcomes were compared between estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 and ≥30 mL/min/1.73 m2 groups. The primary safety outcomes were acute kidney injury (AKI) and bradycardia, while the primary effectiveness outcomes included mortality in COVID-19-dedicated wards and hospital mortality. Secondary outcomes included laboratory changes, disease progression, and recovery time.

RESULTS

A total of 1,343 patients were recruited, with 307 (22.9%) in the eGFR <30 group and 1,036 (77.1%) in the eGFR ≥30 group. Patients with an eGFR <30 had higher risks of AKI (adjusted hazard ratio [aHR] 2.92, 95% CI 1.93-4.44) and hospital mortality (aHR 1.47, 95% CI 1.06-2.05) but had comparable risks of bradycardia (aHR 1.15, 95% CI 0.85-1.56) and mortality in dedicated wards (aHR 1.43, 95% CI 0.90-2.28) than patients with an eGFR ≥30. Risk of disease progression was higher in the eGFR <30 group (adjusted odds ratio 1.62, 95% CI 1.16-2.26). No difference between the two groups in laboratory changes and recovery time.

CONCLUSIONS

Hospitalized COVID-19 patients receiving remdesivir with severe renal impairment had an increased risk of AKI, hospital mortality, and COVID-19 disease progression compared to patients without severe renal impairment.

Development of acute kidney injury following repair of Stanford type A aortic dissection is associated with increased mortality and complications: a systematic review, meta-analysis, and meta-regression analysis

Acute kidney injury (AKI) frequently complicates the repair of Stanford type A aortic dissection (TAAD). This systematic review, meta-analysis, and meta-regression analysis aimed to elucidate the prognostic impact of AKI in these patients. A literature search in PubMed, EMBASE, and Google Scholar identified relevant studies on the predictors and outcomes of AKI following TAAD repair. The primary endpoint was 30-day mortality; secondary endpoints included stroke, dialysis/continuous renal replacement therapy (CRRT), and other complications. Random-effects meta-analyses were used, with significance set at P < 0.05. Twenty-one studies (10 396 patients) were analyzed. AKI was associated with higher risks of 30-day mortality (risk ratio = 3.98), stroke (risk ratio = 2.05), dialysis/CRRT (risk ratio = 32.91), cardiovascular (risk ratio = 2.85) and respiratory complications (risk ratio = 2.13), sepsis (risk ratio = 4.92), and re-exploration for bleeding (risk ratio = 2.46). No significant differences were noted in sternal wound infection, tracheostomy, paraplegia, or hepatic failure. AKI significantly increases mortality, morbidity, hospital, and ICU stay duration in TAAD repair patients.

Longitudinal analysis of ARDS variability and biomarker predictive power in burn patients

Acute Respiratory Distress Syndrome (ARDS) is a severe complication in burn patients, characterized by rapid lung inflammation and hypoxemia. Managing ARDS is challenging due to its high mortality rates and the complex interplay of various pathophysiological factors. This study aims to investigate the heterogeneity of ARDS in burn patients admitted to the Intensive Care Unit (ICU) and evaluate the predictive efficacy of biomarkers in comparison to the PaO2/FiO2 (PF) ratio. A retrospective cohort study was conducted at the Burn Intensive Care Unit of Hangang Sacred Heart Hospital in Seoul, Korea, from July 2010 to December 2022, involving 2,318 patients. Longitudinal k-means clustering was employed to identify patient subgroups based on PF ratio trajectories. Biomarkers, including albumin, white blood cell (WBC) count, and lactate, were assessed for their predictive accuracy using multivariable logistic regression, area under the curve (AUC) analysis, net reclassification improvement (NRI), and integrated discrimination improvement (IDI). Four distinct patient clusters were identified. Cluster A exhibited the highest mortality rate at 54.9%, while Cluster D showed the lowest at 7.9%. Albumin demonstrated significantly higher predictive accuracy in Cluster A (AUC: 0.905, NRI: 0.421) and Cluster C (AUC: 0.915, NRI: 0.845), outperforming the PF ratio in both groups. However, in Clusters B and D, biomarkers did not significantly improve upon the predictive power of the PF ratio. Across all clusters, the integration of biomarkers with the PF ratio led to modest improvements but did not consistently outperform the PF ratio as a standalone predictor. This study reveals substantial heterogeneity in ARDS progression among burn patients, with varying mortality rates and biomarker efficacy across clusters. While biomarkers such as albumin showed potential in specific subgroups, their overall contribution to predictive accuracy was limited. Further multicenter, prospective studies are required to validate these findings and develop more refined predictive models. Personalized treatment strategies, based on biomarker profiles and traditional clinical metrics, could enhance ARDS management in burn patients.

Cardiac surgery-Associated acute kidney injury - A narrative review

Cardiac Surgery-Associated Acute Kidney Injury (CSA-AKI) is a serious complication seen in approximately 20-30% of cardiac surgery patients. The underlying pathophysiology is complex, often involving both patient- and procedure related risk factors. In contrast to AKI occurring after other types of major surgery, the use of cardiopulmonary bypass comprises both additional advantages and challenges, including non-pulsatile flow, targeted blood flow and pressure as well as the ability to manipulate central venous pressure (congestion). With an increasing focus on the impact of CSA-AKI on both short and long-term mortality, early identification and management of high-risk patients for CSA-AKI has evolved. The present narrative review gives an up-to-date summary on definition, diagnosis, underlying pathophysiology, monitoring and implications of CSA-AKI, including potential preventive interventions. The review will provide the reader with an in-depth understanding of how to identify, support and provide a more personalized and tailored perioperative management to avoid development of CSA-AKI.

Fine-grained subphenotypes in acute kidney injury populations based on deep clustering: Derivation and interpretation

BACKGROUND

Acute kidney injury (AKI) is associated with increased mortality in critically ill patients. Due to differences in the etiology and pathophysiological mechanism, the current AKI criteria put it an embarrassment to evaluate clinical therapy and prognosis.

OBJECTIVE

We aimed to identify subphenotypes based on routinely collected clinical data to expose the unique pathophysiologic patterns.

METHODS

A retrospective study was conducted based on the Medical Information Mart for Intensive Care IV (MIMIC-IV) and the eICU Collaborative Research Database (eICU-CRD), and a deep clustering approach was conducted to derive subphenotypes. We conducted further analysis to uncover the underlying clinical patterns and interpret the subphenotype derivation.

RESULTS

We studied 14,189 and 19,382 patients with AKI within 48 h of ICU admission in the two datasets, respectively. Through our approach, we identified seven distinct AKI subphenotypes with mortality heterogeneity in each cohort. These subphenotypes displayed significant variations in demographics, comorbidities, levels of laboratory measurements, and survival patterns. Notably, the subphenotypes could not be effectively characterized using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria alone. Therefore, we uncovered the unique underlying characteristics of each subphenotype through model-based interpretation. To assess the usability of the subphenotypes, we conducted an evaluation, which yielded a micro-Area Under the Receiver Operating Characteristic (AUROC) of 0.81 in the single-center cohort and 0.83 in the multi-center cohort within 48-hour of admission.

CONCLUSION

We derived highly characteristic, interpretable, and usable AKI subphenotypes that exhibited superior prognostic values.

Individualized heparin monitoring and management reduces protamine requirements in cardiac surgery on minimal invasive extracorporeal circulation; A prospective randomized study

INTRODUCTION

Individualized heparin and protamine management is increasingly used as a strategy to reduce coagulation activation and bleeding complications. While it is associated with increased heparin requirements during Cardiopulmonary Bypass (CPB), the impact on protamine administration remains controversial. We aim to investigate the effect of heparin level-guided monitoring on protamine dosing during cardiac surgery where low-anticoagulation protocols are implemented.

METHODS

This is a prospective, randomized, controlled trial. A total of 132 patients undergoing elective full-spectrum cardiac surgery with Minimal Invasive Extracorporeal Circulation (MiECC) were recruited. All patients were managed by the same anaesthetic, surgical and perfusion team. Patients were randomly allocated in two groups; the individualized heparin-protamine titration (IHPT) group and the conventional heparinization and reversal group by using ACT (cACT) with a 0.75:1, protamine: heparin ratio. Titration was accomplished with the Hepcon HMS Plus (Medtronic, Minneapolis, MN) system. The primary outcome of the study was the total protamine dose used. Secondary outcomes comprised of the total heparin dose, the percentage of patients achieving target ACT, 24-h transfusion requirements, postoperative bleeding, duration of mechanical ventilation, major morbidity and length of hospital stay. Patients in each group were divided in two subgroups according to the target ACT; those operated for coronary artery bypass grafting (CABG) using a target ACT >300 s and the rest (non-CABG) patients operated with a target ACT >400 s, respectively.

RESULTS

Protamine requirements were significantly reduced when IHPT was implemented; CABG (118 ± 24 mg vs 163 ± 61 mg; p < 0.001) and non-CABG cases (151 ± 46 mg vs 197 ± 45 mg; p < 0.001). Moreover, heparin requirements were significantly higher in the non-CABG subgroup managed with IHPT (34,539 ± 7658 IU vs 29,893 ± 9037 IU; p = 0.02). In overall, no significant differences were detected with respect to postoperative bleeding, transfusion of RBC or other blood products.

CONCLUSIONS

Individualized heparin monitoring and management reduces protamine requirements in cardiac surgery with MiECC implementing reduced anticoagulation strategy.

TRIAL REGISTRATION

clinicaltrials.gov; NCT04215588.

Driving pressure during general anesthesia for minimally invasive abdominal surgery (GENERATOR)-study protocol of a randomized clinical trial

BACKGROUND

Intraoperative driving pressure (ΔP) has an independent association with the development of postoperative pulmonary complications (PPCs) in patients receiving ventilation during general anesthesia for major surgery. Ventilation with high intraoperative positive end-expiratory pressure (PEEP) with recruitment maneuvers (RMs) that result in a low ΔP has the potential to prevent PPCs. This trial tests the hypothesis that compared to standard low PEEP without RMs, an individualized high PEEP strategy, titrated to the lowest ΔP, with RMs prevents PPCs in patients receiving intraoperative protective ventilation during anesthesia for minimally invasive abdominal surgery.

METHODS

"DrivinG prEssure duriNg gEneRal AnesThesia fOr minimally invasive abdominal suRgery (GENERATOR)" is an international, multicenter, two-group, patient and outcome-assessor blinded randomized clinical trial. In total, 1806 adult patients scheduled for minimally invasive abdominal surgery and with an increased risk of PPCs based on (i) the ARISCAT risk score for PPCs (≥ 26 points) and/or (ii) a combination of age > 40 years and scheduled surgery lasting > 2 h and planned to receive an intra-arterial catheter for blood pressure monitoring during the surgery will be included. Patients are assigned to either an intraoperative ventilation strategy with individualized high PEEP, titrated to the lowest ΔP, with RMs or one with a standard low PEEP of 5 cm H2O without RMs. The primary outcome is a collapsed composite endpoint of PPCs until postoperative day 5.

DISCUSSION

GENERATOR will be the first adequately powered randomized clinical trial to compare the effects of individualized high PEEP with RMs versus standard low PEEP without RMs on the occurrence of PPCs after minimally invasive abdominal surgery. The results of the GENERATOR trial will support anesthesiologists in their decisions regarding PEEP settings during minimally invasive abdominal surgery.

TRIAL REGISTRATION

GENERATOR is registered at ClinicalTrials.gov (study identifier: NCT06101511) on 26 October 2023.

Diagnostic accuracy of NT-proBNP to predict the incidence of CSA-AKI: A systematic review and meta-analysis

BACKGROUND

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a severe complication following cardiac surgery. Early identification and diagnosis are critical. In this study, we aim to systematically assess the diagnostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) for CSA-AKI.

METHODS

The PubMed, Embase, Web of Science, and Cochrane Library databases were searched from January 1971 to October 2023 to identify prospective observational and retrospective observational studies. Data extraction and study screening were carried out independently by 2 authors. The methodological quality of the included studies was evaluated by the Quality Assessment of Diagnostic Accuracy Studies 2 standards, and all statistical analyses were conducted by Stata 15.0.

RESULTS

Seven studies including 37,200 patients were identified. The pooled sensitivity of 0.67 (95% credible interval [CI] = 0.56-0.77), specificity of 0.55 (95% CI = 0.45-0.64), area under the summary receiver operating characteristic curve of 0.65 (95% CI = 0.60-0.69), positive likelihood ratio of 1.5 (95% CI = 1.2-1.8), negative likelihood ratio of 0.60 (95% CI = 0.46-0.79), and diagnostic odds ratio of 2 (95% CI = 2-4) suggested that patients with higher preoperative NT-proBNP levels (pg/mL) are at higher risk of developing acute kidney injury after cardiac surgery. However, NT-proBNP lacks sufficient sensitivity and specificity to reliably predict CSA-AKI.

CONCLUSION

Our findings suggest that the diagnostic accuracy of NT-proBNP to predict the incidence of CSA-AKI is limited. However, we provide novel perspectives on the early detection of CSA-AKI biomarkers, and it is urgent to identify more precise and practical biomarkers for the early diagnosis of CSA-AKI.

Serum uromodulin associates with kidney function and outcome in a cohort of hospitalised COVID-19 patients

This study investigates the prevalence and evaluates the prognostic implications of acute kidney injury (AKI) in COVID-19 patients, with a novel emphasis on the evaluation of serum uromodulin (sUmod) as a potential kidney-specific biomarker. A cohort of hospitalised COVID-19 patients (n = 378) was examined for AKI using standard criteria. In addition to traditional urinary biomarkers, sUmod levels were analysed. Univariable and multivariable regression models were employed to evaluate the association of sUmod and AKI and in-hospital mortality. Levels of sUmod were significantly lower in patients with CKD (91.8 ± 60.7 ng/ml) compared to patients with normal kidney function (204.7 ± 91.7 ng/ml; p < 0.001). 151 patients (40.0%) presented with AKI at the time of hospital admission or developed an AKI during hospitalization. 116 patients (76.8%) had an AKI already at the time of hospital admission. COVID-19 patients with AKI had significantly lower levels of sUmod compared to patients without AKI during hospitalisation (124.8 ± 79.5 ng/ml) vs 214.6 ± 92.3 ng/ml; p < 0.001). The in-hospital mortality rate in this cohort of COVID-19 patients was 15.3%. Patients with AKI had a higher probability for in-hospital death (OR 5.6, CI 1.76 to 17.881, p = 0.004). Patients who died during hospital stay, had significantly lower sUmod levels (129.14 ± 89.56 ng/ml) compared to patients surviving hospitalisation (187.71 ± 96,64 ng/ml; p < 0.001). AKI is frequently associated with COVID-19 in hospitalized patients. Serum uromodulin may emerge as a promising biomarker for AKI in COVID-19 patients. Further research is warranted to explore its clinical application and refine risk stratification in this patient population.

The Addition of a Non-Steroidal Anti-Inflammatory Drug (NSAID) in Local Infiltration Analgesia During Total Knee Arthroplasty Increases the Risk of Acute Kidney Injury in Patients Who Have Renal Impairment: A Propensity-Matched Retrospective Cohort Study

BACKGROUND

Local infiltration analgesia (LIA) is a crucial component of pain management during total knee arthroplasty (TKA). Various formulations of the LIA drug cocktail have been described, with non-steroidal anti-inflammatory drugs (NSAIDs) commonly included. Although NSAIDs are highly effective in improving postoperative pain, they are associated with adverse renal, gastrointestinal, and cardiovascular effects. This study aimed to investigate whether the addition of an NSAID in LIA affects the incidence of acute kidney injury (AKI) in TKA patients, especially those who have pre-existing renal impairment. The secondary aim was to determine overall AKI incidence.

METHODS

A retrospective cohort study was conducted on elective, primary TKA patients in a single tertiary institution between January 2020 and April 2024. Data was obtained from a prospectively collected institutional knee arthroplasty registry. Patients were administered LIA intraoperatively, with or without an NSAID (30 mg of ketorolac). The study population was divided into two subpopulations, patients who did or did not have chronic kidney disease (CKD), and analyzed separately. Propensity matching was performed on the CKD group, correcting for age, sex, BMI, ASA score, and presence of diabetes mellitus/hypertension. The outcome of interest was the incidence of AKI. A t-test or Chi-square test was used, where appropriate, to determine the statistical significance of the results.

RESULTS

In patients who had CKD (n = 114), the presence of ketorolac in LIA was associated with a higher AKI incidence (12.7 versus 2.0%, P = 0.041). In patients who did not have CKD (n = 870), the presence of ketorolac in LIA was not associated with a higher AKI incidence (2.0 versus 1.9%, P = 1.0). Overall AKI incidence was 2.6%.

CONCLUSION

In patients who have CKD, orthopaedic surgeons should be highly cautious of administering ketorolac in LIA during TKA, as it is associated with a higher risk of AKI. Patients who have normal renal function can be safely given ketorolac in LIA without an elevated risk of AKI. Further studies are needed to examine AKI incidence when other NSAIDs are used in LIA.

Early prediction of acute pancreatitis with acute kidney injury using abdominal contrast-enhanced CT features

Early prediction of acute pancreatitis (AP) with acute kidney injury (AKI) using abdominal contrast-enhanced CT could effectively reduce the mortality and the economic burden on patients and society. However, this challenge is limited by the imaging manifestations of early-stage AP that are not clearly visible to the naked eye. To address this, we developed a machine learning model using imperceptible variations in the structural changes of pancreas and peripancreatic region, extracted by radiomics and artificial intelligence technology, to screen and stratify the high-risk AP patients at the early stage of AP. The results demonstrate that the machine learning model could screen the high-risk AP with AKI patients with an area under the curve (AUC) of 0.82 for the external cohort, superior to the human radiologists. This finding confirms the significant potential of machine learning in the screening of acute pancreatitis and contributes to personalized treatment and management for AP patients.

Sex-related differences in clinical characteristics and in-hospital outcomes of patients in acute type A aortic dissection

OBJECTIVE

The aim of this study was to investigate sex-related differences in the clinical characteristics and hospital outcomes of patients undergoing surgery for acute type A aortic dissection (AAAD).

METHODS

This study was a retrospective study. Patients who underwent surgery for AAAD at the Department of Cardiac Surgery, Fujian Medical University Union Hospital, from January 2014 to March 2023 were consecutively included. Data was extracted from electronic medical records. The primary outcome measure was in-hospital mortality, and secondary outcome measures included new-onset postoperative arrhythmia (POA), acute kidney injury (AKI), hepatic dysfunction, neurological complications, gastrointestinal hemorrhage, ICU length of stay, and hospital length of stay. Patients were divided into two groups based on sex, and data analysis was performed using SPSS 25.0 software.

RESULTS

A total of 1137 subjects were included, with 863 males (75.9%) and 274 females (24.1%). There were statistically significant differences in age and BMI between the two groups (P < 0.05). There was no statistically significant difference in the incidence of pain at the onset between the two groups, but chest tightness in females was higher than in males (22.6% vs. 13.8%). Regarding primary outcomes, the in-hospital mortality rate was 11.1% for males and 10.6% for females (P = 0.803). There were no statistically significant differences between the groups in ICU days, length of hospitalization, neurological complications, or liver dysfunction (P > 0.05). The rate of POA in females was 4.7%, higher than in males (2.2%), but AKI and gastrointestinal hemorrhage were both higher in males than in females (P < 0.05). Multivariate analysis showed that age, white blood cell (WBC) counts, lactic acid, operation duration and prolonged mechanical ventilation (PMV) increased the risk of in-hospital mortality in male patients. Hypertension, WBC counts, lactic acid, and PMV increased the risk of in-hospital mortality in female patients.

CONCLUSION

Despite significant baseline characteristic differences between male and female AAAD patients, there were no significant differences in onset symptoms. The in-hospital mortality rates were similar between male and female patients, but the risk factors for in-hospital mortality differed.

Desmopressin use in major cardiac surgery is associated with renal impairment: a retrospective single-center analysis

BACKGROUND

Desmopressin acetate (1-deamino-8-d-arginine vasopressin-DDAVP) is a analogue of the antidiuretic hormone vasopressin. DDAVP is suggested to reduce bleeding after cardiac surgery using cardiopulmonary bypass. The aim of this study was to determine if DDAVP has any negative impact on renal function leading to acute kidney injury (AKI) and therefore increases the need for renal replacement therapy (RRT).

METHODS

We performed a retrospective single institutional cohort analysis of 2,179 patients undergoing elective and urgent cardiac surgery with CPB from 2017 to 2021. Logistic regression analysis was used to investigate any association between DDAVP, the incidence of AKI KDIGO class 3 and the need for RRT, respectively. The model was adjusted for relevant covariates, including preexisting renal impairment, pharmacological hemodynamic support with vasopressors, complexity of the surgery and postoperative lactate. Secondary outcomes included, in hospital mortality and the need for allogenic blood transfusion.

RESULTS

A total of 992 (45.5%) patients received DDAVP intraoperatively during surgery or shortly thereafter. The use of DDAVP was associated with a significant increase in in AKI KDIGO class 3 (OR 2.27; 95% CI 1.46-3.55; p < 0,001) and the need for RRT (OR 2.19; 95%CI 1.48-3.24; p < 0,001). Both findings persisted after covariate adjusting. No increased in-hospital mortality was associated with DDAVP.

CONCLUSION

In cardiac surgery, the use of DDAVP was associated with an increased rate of server AKI and the requirement for RRT. Given the severity of the potential harm associated with DDAVP, an evidence-based reevaluation is needed to enable an accurate risk and benefit assessment.

Cytomegalovirus (CMV) Prophylaxis in Pediatric Liver Transplantation (PLT): A Comparison of Strategies Across the SPLIT Consortium

Although cytomegalovirus (CMV) is a common complication after pediatric liver transplantation (PLT), the optimal method for CMV prevention is uncertain and lacks multi-centered investigation. We compared the effectiveness of short (<120d) versus long (>180d) CMV primary antiviral prophylaxis to prevent CMV disease in PLT, through a prospective cohort study of primary PLT (<18 yrs of age) recipients enrolled in the Society of Pediatric Liver Transplantation (SPLIT) registry from 2015 to 2019 with either donor or recipient CMV seropositivity. Participants were grouped into short or long prophylaxis based on their center's practice and intended duration. 199 PLT recipients were enrolled including 112 (56.3%) short and 87 (43.7%) long prophylaxis. End-organ disease was rare and similar between groups (2.7% and 1.1%; p=0.45). CMV DNAemia and syndrome were more common in the short compared to long (26.8% v. 13.8%; p=0.03 and 18.8% v. 6.9%; p=0.02). Neutropenia occurred more commonly with long prophylaxis (55.2% vs. 16.1%; p<0.001). Graft and patient survival were similar. Consideration of a short prophylaxis must weigh increased risk of CMV syndrome/DNAemia against medication burden and neutropenia of longer prophylaxis.

Monocentric Evaluation of Physician-Modified Fenestrations or Parallel Endografts for Complex Aortic Diseases

PURPOSE

This study aimed to investigate the demographic and anatomic characteristics, as well as perioperative and follow-up results of fenestration and parallel techniques for the endovascular repair of complex aortic diseases.

MATERIALS AND METHODS

A retrospective study was conducted on 67 consecutive patients underwent endovascular treatment for complex aortic diseases including abdominal aortic aneurysm (AAA), thoracoabdominal aneurysm (TAAA), aortic dissection, or prior endovascular repair with either fenestrated and parallel endovascular aortic repair (f-EVAR or ch-EVAR) at a single institute from 2013 to 2021. Choices of intervention were made by the disease' emergency, patients' general condition, the anatomic characteristics, as well as following the recommendation from the devices' guidelines. Patients' clinical demographics, aortic disease characteristics, perioperative details, and disease courses were discussed. Short- and mid-term follow-up results were obtained and analyzed. Endpoints were aneurysm-related and unrelated mortality, branch instability, and renal function deterioration.

RESULTS

Totally, 34 and 27 patients received f-EVAR and ch-EVAR, while 6 patients received a combination of both. Fenestrated endovascular aortic repair was conducted mainly in AAA affecting visceral branches and TAAA, whereas ch-EVAR was normally utilized for infrarenal AAA. Regarding the average number of reconstructed arteries per patient, there was a significant difference among f-EVAR, ch-EVAR, and the combination group (mean = 2.3 ± 0.9, 1.4 ± 0.6, 3.5 ± 0.5, p<0.001). Primary technical success was achieved in 28 (82.4%), 22 (81.5%), and 3 (50.0%) patients for each group. Besides operational time (5.77 ± 2.58, 4.47 ± 1.44, p=0.033), no significant difference was observed for blood transfusion, intensive care unit (ICU) or hospital stay, blood creatinine level, 30-day complications, or follow-up complications between patients undergoing f-EVAR or ch-EVAR. Patients receiving combination of both techniques had a higher rate of blood transfusion (p=0.044), longer operational time (p=0.008) or hospital stay (p=0.017), as well as more stent occlusion (p=0.001), endoleak (p=0.004) at short-term and a higher rate of endoleak (p=0.023) at mid-term follow-up.

CONCLUSION

In conclusion, this study demonstrated that f-EVAR and ch-EVAR techniques had acceptable perioperative and follow-up results and should be considered viable alternatives when encountering complex aortic diseases.

CLINICAL IMPACT

This study sought to investigate the baseline and pathological characteristics, as well as perioperative and follow-up results of f-EVAR and ch-EVAR at a single Chinese institution. F-EVAR (mostly physician-modified f-EVAR) was applied in patients with a wide range of etiologies and disease types, while ch-EVAR was preferred for AAA in older patients with an average higher ASA grade. Our experience suggested acceptable safety and efficacy both for techniques, and no significant difference was observed between the two groups regarding any short or mid-term adverse events.

Trifecta outcomes of robotic partial nephrectomy in obese patients: A comparison of body mass index <25, 25 to <30, and ≥30

OBJECTIVE

We analyzed robotic partial nephrectomy (RPN) outcomes in obese patients based on body mass index (BMI) and trifecta achievement.

METHODS

We retrospectively reviewed 296 patients who underwent RPN at Kansai Medical University Hospital between 2014 and 2022. The preoperative clinical data and perioperative outcomes were evaluated. Trifecta achievement (negative surgical margin, no major complications, and no acute kidney injury on postoperative day three) and its relationship to three BMI groups (<25, 25 to <30, and ≥30) were the primary outcome. The correlation between factors in achieving trifecta and BMI was evaluated. Univariate and multivariate analyses assessed variables for achieving the trifecta with logistic regression analysis. C-statistics quantitatively evaluated the prediction accuracy.

RESULTS

Among 296 patients, 264 (89.2%) achieved trifecta (BMI categories were <25 [89.9%], 25 to <30 [89.4%], and ≥30 [82.6%]). There was no significant BMI-related difference (p = 0.566). Intraoperative blood loss increased with the BMI (p = 0.034). Multivariate analyses showed preoperative aspects and dimensions used for anatomic (PADUA) score independently predicted trifecta failure (odds ratio 1.71; 95% confidence interval 1.32-2.20; p < 0.001). The C-statistics of the PADUA score increased with increasing BMI.

CONCLUSIONS

Higher BMI patients had more intraoperative blood loss during RPN. However, RPN remains safe and has acceptable quality and functional outcomes. Since patients with high PADUA scores combined with a high BMI may be at risk of trifecta failure, this should be explained before RPN.

Advanced biomarker clustering analysis reveals mortality predictors in burn patients with sepsis

This study addresses the challenge of predicting mortality in sepsis among burn patients. Given the heterogeneity of sepsis, especially in the context of burn injuries, this study aims to identify reliable biomarkers for mortality prediction. The study is a retrospective review, focusing on the evaluation of various biomarkers and their changes over time in a burn patient cohort. Conducted in the Burn Intensive Care Unit of Hangang Sacred Heart Hospital, the study involved a retrospective review of 1,659 adult burn patients from January 2010 to December 2022. Key biomarkers analyzed include lactate levels, pH, platelets, procalcitonin, and others. Advanced clustering methodologies, such as dynamic time warping and hierarchical clustering, were utilized to classify patients into distinct groups based on their biomarker profiles and clinical outcomes. The study identified four patient clusters with unique lactate level trajectories. Significant findings include the identification of procalcitonin, pH, and platelets as key predictors of mortality, with varying degrees of efficacy across different clusters. For instance, in the "Persistent Rise" cluster, pH and platelet count showed Area Under the Curve (AUC) values of 0.756 and 0.753, respectively, indicating their strong predictive power. The study concludes that a combination of biomarkers, especially lactate dynamics, can effectively predict mortality in burn-induced sepsis. The results advocate for a more personalized approach in managing sepsis in burn patients, considering the specific biomarker trajectories. These findings are crucial for enhancing treatment strategies and improving patient outcomes in burn care.

Contrast‑associated acute kidney injury in myocardial infarction patients undergoing elective percutaneous coronary intervention: insight from the Iodixanol-AKI Registry

Previous studies have reported a high occurrence of contrast-associated acute kidney injury (CA-AKI) in myocardial infarction (MI) patients undergoing primary percutaneous coronary intervention (PCI). However, the data on CA-AKI in MI patients who underwent elective PCI are limited. To evaluate the incidence of CA-AKI in MI patients undergoing elective PCI. The data were sourced from the Iodixanol-AKI Registry of MI patients scheduled to undergo elective PCI in 8 medical centers from May 2020 to November 2021. The participants were divided into three groups: acute, prior, and multiple MI. The outcomes measured were CA-AKI and the composite endpoint of major adverse renal and cardiovascular events (MARCE). The incidence of CA-AKI was 4.46% (37/830) in the MI patients, 4.40% (7/159) in the acute MI patients, 4.41% (22/499) in the prior MI patients, and 4.65% (8/172) in the multiple MI patients. Of note, 36 patients (97.30%) at AKI stage 1, and only 1 patient at AKI stage 2. There was no difference in the incidence of CA-AKI (P = 0.991) among the three groups. Multivariate regression analysis revealed that the independent risk factors for CA-AKI were diabetes and an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2. MARCE occurred in 3.4% (28/830) of the total patients and was not associated with either any subgroup of patients with MI or AKI. The incidence of CA-AKI was low and mainly limited to mildly impaired renal function in MI patients undergoing elective PCI.

Early Acute Kidney Injury Recovery in Elderly Patients Undergoing Valve Replacement Surgery

OBJECTIVES

This study was designed to determine the incidence, contributing factors, and prognostic implications of acute kidney injury (AKI) recovery patterns in patients who experienced AKI after valve replacement surgery (VRS).

DESIGN

A retrospective cohort study was conducted.

SETTING

The work took place in a postoperative care center in a single large-volume cardiovascular center.

PARTICIPANTS

Patients undergoing VRS between January 2010 and December 2019 were enrolled.

INTERVENTION

Patients were categorized into three groups based on their postoperative AKI status: non-AKI, AKI with early recovery (less than 48 hours), and persistent AKI.

MEASUREMENT AND MAIN RESULTS

The primary outcome was in-hospital major adverse clinical events. The secondary outcomes included in-hospital and 1-year mortality. A total of 4,161 patients who developed AKI following VRS were included. Of these, 1,513 (36.4%) did not develop postoperative AKI, 1,875 (45.1%) experienced AKI with early recovery, and 773 (18.6%) had persistent AKI. Advanced age, diabetes, New York Heart Association III-IV heart failure, moderate-to-severe renal dysfunction, anemia, and AKI stages 2 and 3 were identified as independent risk factors for persistent AKI. In-hospital major adverse clinical events occurred in 59 (3.9%) patients without AKI, 88 (4.7%) with early AKI recovery, and 159 (20.6%) with persistent AKI (p < 0.001). Persistent AKI was independently associated with an increased risk of in-hospital adverse events and 1-year mortality. In contrast, AKI with early recovery did not pose additional risk compared with non-AKI patients.

CONCLUSIONS

In patients who develop AKI following VRS, early AKI recovery does not pose additional risk compared with non-AKI. However, AKI lasting more than 48 hours is associated with an increased risk of in-hospital and long-term adverse outcomes.

Impacts of age, type 2 diabetes, and hypertension on circulating neutrophil gelatinase-associated lipocalin and kidney injury molecule-1 after prolonged work in the heat in men

PURPOSE

Prolonged work in the heat increases the risk of acute kidney injury (AKI) in young men. Whether aging and age-associated chronic disease may exacerbate the risk of AKI remains unclear.

METHODS

We evaluated plasma neutrophil gelatinase-associated lipocalin (NGAL) and serum kidney injury molecule-1 (KIM1) before and after 180 min of moderate-intensity work (200 W/m2) in temperate (wet-bulb globe temperature [WBGT] 16 °C) and hot (32 °C) environments in healthy young (n = 13, 22 years) and older men (n = 12, 59 years), and older men with type 2 diabetes (T2D; n = 9, 60 years) or hypertension (HTN; n = 9, 60 years).

RESULTS

There were no changes in NGAL or KIM1 concentrations following prolonged work in temperate conditions in any group. Despite a similar work tolerance, the relative change in NGAL was greater in the older group when compared to the young group following exercise in the hot condition (mean difference + 82 ng/mL; p < 0.001). Baseline concentrations of KIM1 were ~ 22 pg/mL higher in the older relative to young group, increasing by ~ 10 pg/mL in each group after exercise in the heat (both p ≤ 0.03). Despite a reduced work tolerance in the heat in older men with T2D (120 ± 40 min) and HTN (108 ± 42 min), elevations in NGAL and KIM1 were similar to their healthy counterparts.

CONCLUSION

Age may be associated with greater renal stress following prolonged work in the heat. The similar biomarker responses in T2D and HTN compared to healthy older men, alongside reduced exercise tolerance in the heat, suggest these individuals may exhibit greater vulnerability to heat-induced AKI if work is prolonged.

Reexamining Transplant Outcomes in Acute Kidney Injury Kidneys Through Machine Learning

BACKGROUND

Despite many people awaiting kidney transplant, kidney allografts from acute kidney injury (AKI) donors continue to be underutilized. We aimed to cluster kidney transplant recipients of AKI kidney allografts using an unsupervised machine learning (ML) approach.

METHODS

Using Organ Procurement and Transplantation Network-United Network for Organ Sharing (OPTN/UNOS) data, a consensus clustering cohort analysis was performed in 12 356 deceased donor kidney transplant recipients between 2015 and 2019 in whom donors had a terminal serum creatinine ≥1.5 mg/dL. Significant cluster characteristics were determined, and outcomes were compared.

RESULTS

The median donor terminal creatinine was 2.2 (interquartile range [IQR] 1.7-3.3) mg/dL. Cluster analysis was performed on 12 356 AKI kidney recipients, and three clinically distinct clusters were identified. Young, sensitized kidney re-transplant patients characterized Cluster 1. Cluster 2 was characterized by first-time kidney transplant patients with hypertensive and diabetic kidney diseases. Older diabetic recipients characterized Cluster 3. Clusters 1 and 2 donors were young and met standard kidney donor profile index (KDPI) criteria; Cluster 3 donors were older, more likely to have hypertension or diabetes, and meet high KDPI criteria. Cluster 1 had a higher risk of acute rejection, 3-year patient death, and graft failure. Cluster 3 had a higher risk of death-censored graft failure, patient death, and graft failure at 1 and 3 years. Cluster 2 had the best patient-, graft-, and death-censored graft survival at 1 and 3 years. Compared to non-AKI kidney recipients, the AKI clusters showed a higher incidence of delayed graft function (DGF, AKI: 43.2%, 41.7%, 45.3% vs. non-AKI: 25.5%); however, there were comparable long-term outcomes specific to death-censored graft survival (AKI: 93.6%, 93.4%, 90.4% vs. non-AKI: 92.3%), patient survival (AKI: 89.1%, 93.2%, 84.2% vs. non-AKI: 91.2%), and overall graft survival (AKI: 84.7%, 88.2%, 79.0% vs. non-AKI: 86.0%).

CONCLUSIONS

In this unsupervised ML approach study, AKI recipient clusters demonstrated differing, but good clinical outcomes, suggesting opportunities for transplant centers to incrementally increase kidney utilization from AKI donors.

Acute kidney injury in coronavirus disease: a comparative study of the two waves in Brazil

BACKGROUND

Magalhães et al. demonstrated that the incidence of acute kidney injury was high in hospitalized patients with COVID-19 and that the second wave was associated with greater severity; however, the mortality rates were similar between the two periods. This may reflect both the effectiveness of vaccines and the constant learning that frontline professionals gained throughout the pandemic to provide greater support to their patients.

BACKGROUND

◼ Renal involvement was frequent in patients with COVID-19 and related to worse outcomes.

BACKGROUND

◼ Diuretic use, mechanical ventilation, proteinuria, hematuria, age, and creatine phosphokinase and D-dimer levels were risk factors for acute kidney injury.

BACKGROUND

◼ Acute kidney injury, mechanical ventilation, elevated SOFA Score, and elevated ATN-ISS were associated with mortality.

BACKGROUND

◼ The second wave was associated with greater severity; however, the mortality rates were similar between the two periods.

BACKGROUND

◼ This may reflect the effectiveness of vaccines and the constant learning that frontline professionals gained throughout the pandemic.

OBJECTIVE

This study aimed to evaluate the incidence of acute kidney injury in hospitalized Brazilian patients with COVID-19 and identify the risk factors associated with its development and prognosis during the two waves of the disease.

METHODS

We performed a prospective cohort study of hospitalized patients with COVID-19 at a public university hospital in São Paulo from March 2020 to May 2021.

RESULTS

Of 887 patients hospitalized with COVID-19, 54.6% were admitted to the intensive care unit. The incidence of acute kidney injury was 48.1%, and the overall mortality rate was 38.9%. Acute kidney replacement therapy was indicated for 58.8% of the patients. The factors associated with acute kidney injury were diuretic use (odds ratio [OR] 2.2, 95%CI= 1.2-4.1, p=0.01), mechanical ventilation (OR= 12.9, 95%CI= 4.3-38.2, p<0.0001), hematuria(OR= 2.02, 95%CI= 1.1-3.5, p<0.0001), chronic kidney disease (OR= 2.6, 95%CI= 1.2-5.5, p=0.009), age (OR= 1.03, 95%CI= 1.01-1.07, p=0.02), and elevated creatine phosphokinase (OR= 1.02, 95%CI= 1.01-1.07, p=0.02) and D-dimer levels (OR= 1.01, 95%CI= 1.01-1.09, p<0.0001). Mortality was higher among those with acute kidney injury (OR= 1.12, 95%CI= 1.02-2.05, p=0.01), elevated Sequential Organ Failure Assessment Scores (OR= 1.35, 95%CI= 1.1-1.6, p=0.007), elevated Acute Tubular Necrosis-Injury Severity Score (ATN-ISS; (OR= 96.4, 95%CI= 4.8-203.1, p<0.0001), and who received mechanical ventilation (OR= 12.9, 95%CI= 4.3-38.2, p<0.0001). During the second wave, the number of cases requiring mechanical ventilation (OR= 1.57, 95%CI= 1.01-2.3, p=0.026), with proteinuria (OR= 1.44, 95%CI= 1.01-2.1, p=0.04), and with higher ATN-ISS Scores (OR= 40.9, 95%CI= 1.7-48.1, p=0.04) was higher than that during the first wave.

CONCLUSION

Acute kidney injury was frequent in hospitalized patients with COVID-19, and the second wave was associated with greater severity. However, mortality rates were similar between the two periods, which may reflect both the effectiveness of vaccines and the constant learning that frontline professionals gained throughout the pandemic to provide greater support to their patients.

REGISTRY OF CLINICAL TRIALS

RBR-62y3h7.

Urinary Complement C3 and Vitamin D-Binding Protein Predict Adverse Outcomes in Patients with Acute Kidney Injury after Cardiac Surgery

INTRODUCTION

Acute kidney injury (AKI) is associated with adverse outcomes, including death and dialysis. The goal of this study was to identify prognostic biomarkers of AKI that could be used across multiple phenotypes of AKI and across different species.

METHODS

Liquid chromatography/tandem mass spectrometry analysis of urine samples from three species (human, rat, and mouse) and four etiologies of AKI identified five potential biomarkers, of which two were validated, complement C3 and vitamin D-binding protein, in a cohort of 157 patients that developed AKI following cardiothoracic surgery. We studied the relationship between the biomarker's concentration in the urine and the development of a composite primary endpoint (stage 3 AKI within 10 days or death within 30 days).

RESULTS

Of the 153 patients who developed AKI following cardiovascular surgery, 17 met the combined primary outcome. The median concentration of urine complement C3 adjusted to urine creatinine had the best predictive value and was significantly higher in the primary outcome group than in the controls. Similarly, the median concentration of vitamin D-binding protein was higher in the primary outcome group.

CONCLUSIONS

The studies provide proof in principle that cross-species discovery analyses could be a valuable tool for identifying novel prognostic biomarkers in AKI. Urine complement C3 and vitamin D-binding protein could be promising early predictors of adverse outcomes in patients who develop AKI after cardiac surgery.

Impact of obesity on clinical outcomes of methicillin-susceptible Staphylococcus aureus bloodstream infections

Obesity affects over one-third of U.S. adults and complicates the treatment of methicillin-susceptible Staphylococcus aureus (MSSA) bloodstream infections (BSI). A study at the University of Florida Health Centers compared clinical outcomes between 233 obese and non-obese patients receiving cefazolin for MSSA BSI. No significant differences were found in clinical success (81.9% vs 82.7%), mortality (7.2% vs 5.3%), or adverse events (3.6% vs 3.3%). However, obese patients took longer to clear blood cultures (4.62 vs 4.01 days, P = 0.017).

Erythropoiesis-stimulating agents for preventing acute kidney injury

BACKGROUND

Acute kidney injury (AKI) is characterised by a rapid decline in kidney function and is caused by a variety of clinical conditions. The incidence of AKI in hospitalised adults is high. In animal studies, erythropoiesis-stimulating agents (ESA) have been shown to act as a novel nephroprotective agent against ischaemic, toxic, and septic AKI by inhibiting apoptosis, promoting cell proliferation, and inducing antioxidant and anti-inflammatory responses. As a result, ESAs may reduce the incidence of AKI in humans. Randomised controlled trials (RCTs) have been conducted on the efficacy and safety of ESAs, but no prior systematic reviews exist that comprehensively examine ESAs with respect to AKI prevention, although the effectiveness of these agents has been examined for a range of other diseases and clinical situations.

OBJECTIVES

This review aimed to look at the benefits and harms of ESAs for preventing AKI in the context of any health condition.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 30 August 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included RCTs and quasi-RCTs (in which allocation to treatment was based on alternate assignment or order of medical records, admission dates, date of birth or other non-random methods) that compared ESAs with placebo or standard care in people at risk of AKI.

DATA COLLECTION AND ANALYSIS

Three authors independently extracted data and assessed the risk of bias for included studies. We used random-effects model meta-analyses to perform quantitative synthesis of the data. We used the I2 statistic to measure heterogeneity amongst the studies in each analysis. We indicated summary estimates as a risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with their 95% confidence interval (CI). We assessed the certainty of the evidence for each main outcome using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach.

MAIN RESULTS

A total of 20 studies (36 records, 5348 participants) were included. The number of participants ranged from 10 to 1302, and most studies were carried out in single centres (13/20). All the included studies compared ESAs to placebo or usual care. Many of the studies were judged to have unclear or high risk of reporting bias, but were at low risk for other types of bias. ESAs, when compared to control interventions, probably makes little or no difference to the risk of AKI (18 studies, 5314 participants: RR 0.97, 95% CI 0.85 to 1.10; I² = 19%; moderate-certainty evidence), or death (18 studies, 5263 participants: RR 0.92, 95% CI 0.80 to 1.06; I² = 0%; moderate-certainty evidence), and may make little or no difference to the initiation of dialysis (14 studies, 2059 participants: RR 1.16, 95% CI 0.90 to 1.51; I² = 0%; low-certainty evidence). Even with standardised measurement of AKI, the studies showed no difference in results between different routes of administration (subcutaneous or intravenous), background diseases (cardiac surgeries, children or neonates, other adults at risk of AKI), or duration or dose of ESA. ESAs may make little or no difference to the risk of thrombosis when compared to control interventions (8 studies, 3484 participants: RR 0.92, 95% CI 0.68 to 1.24; I² = 0%). Similarly, ESAs may have little or no effect on kidney function measures and adverse events such as myocardial infarction, stroke or hypertension. However, this may be due to the low incidence of these adverse events.

AUTHORS' CONCLUSIONS

In patients at risk of AKI, ESAs probably do not reduce the risk of AKI or death and may not reduce the need for starting dialysis. Similarly, there may be no differences in kidney function measures and adverse events such as thrombosis, myocardial infarction, stroke or hypertension. There are currently two ongoing studies that have either not been completed or published, and it is unclear whether they will change the results. Caution should be exercised when using ESAs to prevent AKI.

Comparative study of acute kidney injury in pararenal aortic aneurysm: open surgical versus endovascular repair

Background

Pararenal abdominal aortic aneurysms (PR-AAA), constituting around 15%-20% of AAA patients, are defined as having no neck between the aneurysm and the renal arteries. Due to an insufficient sealing zone, open surgical repair (OSR) is the gold standard, while EVAR is reserved for those unfit for surgery. Renal outcomes disturb long-term survival, and they have massive socioeconomic and quality of life implications, especially if patients require dialysis.

Methods

This study aims to elucidate any difference between EVAR and OSR of PR-AAA, excluding suprarenal aneurysms, with specific emphasis on renal dysfunction over the short and long term. An existing database of PR-AAA between 2002 and 2023 was used to glean information regarding the therapeutic option used. Renal events were defined by the RIFLE criteria. Out of 1,563 aortic interventions, we identified 179 PR-AAA, of which 99 high-risk patients had an aortic neck of less than 10 mm with complete follow-up. We excluded patients with fenestrated EVAR (FEVAR), branched EVAR (BEVAR), or chimney EVAR (Ch-EVAR) and any patients requiring visceral artery reimplantation.

Results

In total, 63 patients underwent EVAR, and 36 required OSR. 17.46% of patients who underwent EVAR experienced acute kidney injury (AKI) compared with 36.11% of the OSR group (P = 0.037). The mean post-op creatinine for OSR was 109.88 µmol/L, and for EVAR was 127.06 µmol/L (P = 0.192). The mean difference between long-term (9-12 years) creatinine values in OSR was 14.29 µmol/L (P = 0.191), and the mean difference for EVAR was 25.05 µmol/L (P = 0.024). Furthermore, 27.8% of OSR patients who underwent Left Renal Vein Division and Ligation (LRVDL) experienced an AKI, while 50% who did not undergo LRVDL experienced an AKI (P = 0.382). Thirty-day morbidity in the EVAR group (20.97%) was significantly lower than in the OSR group (42.62%) (P = 0.022). Moreover, 3.17% in EVAR group and 7.14% in OSR group had aneurysm-related mortality (P = 0.584).

Conclusion

The rate of renal events for OSR is higher, while the rate of endovascular renal events was lower. Our study shows that PR-AAA undergoing OSR may benefit from endovascular repair.

Efficacy and safety of colistin plus beta-lactams for bone and joint infection caused by fluoroquinolone-resistant gram-negative bacilli: a prospective multicenter study

OBJECTIVES

The prognosis of bone and joint infections (BJI) caused by Gram-negative bacilli (GNB) worsens significantly in the face of fluoroquinolone-resistance. In this setting, scarce pre-clinical and clinical reports suggest that intravenous beta-lactams plus colistin may improve outcome. Our aim was to assess the efficacy and safety of this treatment in a well-characterized prospective cohort.

METHODS

Observational, prospective, non-comparative, multicenter (14 hospitals) study of adults with BJI caused by fluoroquinolone-resistant GNB treated with surgery and intravenous beta-lactams plus colistin for ≥ 21 days. The primary endpoint was the cure rate.

RESULTS

Of the 44 cases included (median age 72 years [IQR 50-81], 22 [50%] women), 32 (73%) had an orthopedic device-related infection, including 17 (39%) prosthetic joints. Enterobacterales were responsible for 27 (61%) episodes, and Pseudomonas spp for 17 (39%), with an overall rate of MDR/XDR GNB infections of 27/44 (61%). Patients were treated with colistin plus intravenous beta-lactam for 28 days (IQR 22-37), followed by intravenous beta-lactam alone for 19 days (IQR 5-35). The cure rate (intention-to-treat analysis; median follow-up = 24 months, IQR 19-30) was 82% (95% CI 68%-90%) and particularly, 80% (95% CI 55%-93%) among patients managed with implant retention. Adverse events (AEs) leading to antimicrobial withdrawal occurred in 10 (23%) cases, all of which were reversible. Colistin AEs were associated with higher plasma drug concentrations (2.8 mg/L vs. 0.9 mg/L, p = 0.0001).

CONCLUSIONS

Combination therapy with intravenous beta-lactams plus colistin is an effective regimen for BJI caused by fluoroquinolone-resistant GNB. AEs were reversible and potentially preventable by close therapeutic drug monitoring.

Past, Present, and Future Biomarkers of Kidney Function and Injury: The Relationship With Antibiotics

Routinely used kidney biomarkers of injury and function such as serum creatinine and urine albumin to creatinine ratio, are neither sensitive nor specific. Future biomarkers are being developed for clinical use and have already been included in guidance from groups such as the U.S. Food and Drug Administration and the Predictive Safety Testing Consortium. These biomarkers have important implications for early identification of kidney injury and more accurate measurement of kidney function. Many antibiotics are either eliminated by the kidney or can cause clinically significant nephrotoxicity. As a result, clinicians should be familiar with new biomarkers of kidney function and injury, their place in clinical practice, and applications for antibiotic dosing.

Acute kidney injury in the acute care surgery patient: What you need to know

ABSTRACT

Acute kidney injury is associated with poor outcomes in the trauma and emergency general surgery population, and recent consensus definitions have allowed for significant advances in defining the burden of disease. The current definitions rely on overall functional measures (i.e., serum creatinine and urine output), which can be confounded by a variety of clinical factors. Biomarkers are increasingly being investigated as more direct diagnostic assays for the diagnosis of acute kidney injury and may allow earlier detection and more timely therapeutic intervention. Etiologies fall into two general categories: disorders of renal perfusion and exposure to nephrotoxic agents. Therapy is largely supportive, and prevention offers the best chance to decrease clinical impact.

Effect of Change in Sodium after Slow Low-Efficiency Dialysis in Critically Ill Patients with Acute Kidney Injury

INTRODUCTION

The effect of sodium (Na) correction by slow low-efficiency dialysis (SLED) in dysnatremic (135 mEq/L <Na >145 mEq/L) critically ill patients is unclear.

METHODS

Prospective observational study enrolled dysnatremic critically ill adult patients with acute kidney injury undergoing the first SLED as cases and normonatremic patients as controls. Baseline and SLED-related parameters and 30-day mortality were noted.

RESULTS

100 dysnatremic and 51 normonatremic patients were included, with a median age of 31 (25-52) years and median admission SOFA scores of 10 (9-12). Patients with dysnatremia at study inclusion had a mortality of 53%, with the highest mortality in severe hypernatremia (Na >160 mEq/L) (75%), followed by those with severe hyponatremia (Na <120 mEq/L) (68.6%). SLED-associated natremia change >10 mEq/L was significantly associated with mortality, in patients with mild dysnatremia and normonatremia (Na: 130-150) (p < 0.001), and not in those with moderate to severe dysnatremia (Na <130 and Na >150) (p = 0.72). Upon multivariate logistic regression analysis, a model with pre-SLED pH, dialyzate-pre-SLED Na difference, and duration of SLED significantly predicted SLED-associated natremia change (R2 0.18, p = 0.001).

CONCLUSIONS

SLED can be safely and effectively performed in critically ill adults with dysnatremia requiring renal replacement therapy with mortality comparable to normonatremic controls.

Early therapeutic drug monitoring of methotrexate and its association with acute kidney injury: A retrospective cohort study

INTRODUCTION

High-dose methotrexate (HDMTX) use can be limited by the development of acute kidney injury (AKI). Early AKI detection is paramount to prevent further renal injury and irreversible toxicities. This study sought to determine whether early elimination patterns of MTX would be useful as a biomarker of AKI in HDMTX treatment.

METHODS

This retrospective cohort study included two sites that collected ≥2 MTX levels within 16 h from completion of MTX infusion. Early levels were tagged and MTX elimination half-life (t½) were calculated from combinations of two of three different early time periods. Receiver operating characteristic (ROC) curves were synthesized for each elimination t½ (biomarker) with respect to AKI and delayed methotrexate elimination (DME); the biomarker with the highest area under the ROC curve (AUC) was tested in a multiple variable logistic regression model.

RESULTS

Data from 169 patients who received a total of 556 courses of HDMTX were analyzed. ROC analysis revealed MTX elimination t½ calculated from the second and third time periods had the highest AUC for AKI at 0.62 (interquartile range [IQR] 0.56-0.69) and DME at 0.86 (IQR 0.73-1.00). After adjusting for age, sex, dose (mg/m2), infusion duration, HDMTX course, and baseline estimated glomerular filtration rate, it remained significant for AKI with an OR of 1.29 and 95% confidence interval of 1.03-1.65.

CONCLUSION

Early MTX elimination t½ measured within 16 h of infusion completion was significantly associated with the development of AKI and serves as an early clearance biomarker that may identify patients who benefit from increased hydration, augmented leucovorin rescue, and glucarpidase administration.

Night-time surgery for type a aortic dissection: Immediate or delaying?

OBJECTIVES

This study aims to investigate whether surgery performed during night compared with daytime were associated with an increased risk of operative mortality of type A aortic dissection (TAAD) patients.

METHODS

A total of 2015 TAAD patients who underwent surgical repair were collected from two cardiovascular centers from Jan 2015 to Jan 2021. According to the start time of surgery, patients were divided into daytime group (06:01 a.m. to 06:00 p.m.) and night-time group (06:01 p.m. to 06:00 a.m.), and retrospective analyses were performed between them.

RESULTS

The operative mortality of night-time group (12.2%, 43/352) was dramatically higher than daytime group (6.9%, 115/1663; p = 0.001). There was significant difference between night-time and daytime groups in terms of 30-days mortality (5.8% vs 10.8%; p = 0.001) and in-hospital mortality (3.5% vs 6.0%; p = 0.03). The night-time group had a longer duration of intensive care unit stay (4 vs two; days; p < 0.001) and ventilation support (34 vs 19; hours; p < 0.001), compared with daytime group. The risk factors for operative mortality were night-time surgery (odds ratio [OR], 1.545; p = 0.027), age (odds ratio, 1.152; p < 0.001), total arch replacement (OR, 2.265; p < 0.001) and previous aortic surgery (OR, 2.376; p = 0.003).

CONCLUSION

Night-time surgical repair may be associated with higher operative mortality of patients with TAAD. Nevertheless, it is reasonable to offer emergency surgery at night-time for such patients who were more likely to present disastrous complications with delayed surgical intervention, as outcomes indicate acceptable operative mortality.

The association of withholding or continuing angiotensin-converting enzyme inhibitors or angiotensin 2 receptor blockers on acute kidney injury after non-cardiac surgery

BACKGROUND

Withholding or continuing angiotensin-converting enzyme inhibitors or angiotensin 2 receptor blockers peri-operatively in non-cardiac surgery remains controversial as they may result in intra-operative hypotension and postoperative organ damage.

METHODS

We included patients prescribed angiotensin-converting enzyme inhibitors or angiotensin 2 receptor blockers who underwent surgical procedures > 1 h duration under general or spinal anaesthesia from January 2012 to June 2022 in a single centre. We categorised patients by whether these drugs were withheld for 24 h before surgery. We evaluated the association of withholding these drugs before non-cardiac surgery with creatinine concentrations that increased ≥ 26.4 μmol.l-1 in the first 48 postoperative hours (acute kidney injury). We also analysed changes in creatinine concentrations and estimated glomerular filtration rates.

RESULTS

Angiotensin-converting enzyme inhibitors or angiotensin 2 receptor blockers were withheld in 24,285 of 32,933 (74%) patients and continued in 8648 (26%) patients. We used propensity scores for drug discontinuation to match 8631 patient pairs who did or did not continue these drugs: acute kidney injury was recorded for 1791 (21%) patients who continued these drugs vs. 1587 (18%) who did not (OR (95%CI) 1.16 (1.08-1.25), p < 0.001). Intra-operative hypotension was recorded for 3892 (45%) patients who continued drugs vs. 3373 (39%) patients who did not (OR (95%CI) 1.28 (1.21-1.36), p < 0.001). Continuing drugs was independently associated with a mean increase in creatinine of 2.2 μmol.l-1 (p < 0.001) and a mean decrease in estimated glomerular filtration rate of 1.4 ml.min.1.73 m-2 (p < 0.001).

CONCLUSIONS

Continuing angiotensin-converting enzyme inhibitors or angiotensin 2 receptor blockers 24 h before non-cardiac surgery was associated with intra-operative hypotension and postoperative acute kidney injury.

Epidemiology and Long-term Outcomes of Acute Kidney Injury in Adult Patients with Perforation Peritonitis Undergoing Emergency Laparotomy

Background

Reported incidence of acute kidney injury (AKI) is around 5.0-7.5% of all hospitalized patients, and 40% of them are postoperative patients. Major abdominal surgeries account for 3.1-35% of cases of postoperative AKI in various series. The aim of the study was to identify the incidence and risk factors of AKI in peritonitis patients undergoing emergency laparotomy.

Materials and methods

Adult patients aged 18-65 years undergoing emergency laparotomy for perforation peritonitis were included in this prospective observational study. Baseline clinical and laboratory data, intraoperative details and postoperative outcome data (AKI at day 7, length of intensive care unit and hospital stay, and mortality) were recorded. Logistic regression model was constructed to predict AKI at day 7.

Results

N = 140 patients were included in this study and 69 patients (49.3%) developed AKI within day 7. Larger volume of crystalloid [OR (95% CI) 1.00 (1.00-1.00); p = 0.012], intraoperative vasopressor use (OR 7.42 (2.41-22.83); p < 0.001), intraoperative blood loss [OR 1.004(1.00-1.01); p = 0.003] and the presence of chronic liver disease (CLD) [OR 22.44 (1.68-299.26); p = 0.019] were risk factors for the development of AKI. Acute kidney injury patients had increased mortality at day 90 (24.6% vs 1.4%; p < 0.001), length of ICU stay (3 days vs 0 days, p < 0.001), and length of hospital stay (11 days vs 7 days; p < 0.001).

Conclusion

In peritonitis patients undergoing emergency laparotomy, as many as 49% of patients develop AKI within 1 week. The presence of CLD, intraoperative blood loss, and the use of crystalloids and vasopressor increase the odds of developing AKI.

How to cite this article

Priya P, Baidya DK, Anand RK, Ray BR, Khanna P, Krishna A, et al. Epidemiology and Long-term Outcomes of Acute Kidney Injury in Adult Patients with Perforation Peritonitis Undergoing Emergency Laparotomy. Indian J Crit Care Med 2024;28(9):854-858.

Effect of acute kidney injury and overall survival in patients with postoperative head and neck cancer who received chemoradiotherapy with cisplatin: A supplementary analysis of the phase II/III trial of JCOG1008

BACKGROUND

In a randomized phase II/III trial (JCOG1008), weekly cisplatin (40 mg/m2) was non-inferior to 3-weekly cisplatin (100 mg/m2) for postoperative high-risk head and neck cancer. We investigated how acute kidney injury (AKI), a major dose-limiting toxicity effect of cisplatin, affects overall survival (OS).

METHODS

We analyzed 251 patients from JCOG1008 receiving chemoradiotherapy. AKI was defined based on AKI Network criteria (serum creatinine increase of ≥0.3 mg/dL or ≥1.5-fold [≥ stage I]) within 30 days after completing chemoradiotherapy. OS in the two arms was compared according to AKI development using the log-rank test.

RESULTS

The total incidence of AKI was lower in the weekly arm than in the 3-weekly arm (38/122 [31.1%] vs. 56/129 [43.4%]). Additionally, stage II/III AKI occurred less frequently in the weekly arm than in the 3-weekly arm (8/122 [6.6%] vs. 19/129 [14.7%]). Cisplatin doses were similar in the weekly arm for patients with and without AKI (median, 238.6 mg/m2 vs. 239.2 mg/m2; p = 0.94), but lower in the 3-weekly arm for those who developed AKI (median, 276.3 mg/m2 vs. 297.4 mg/m2; p = 0.007). In the weekly arm, there was no difference in OS between patients with and without AKI (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.53 to 2.10). However, in the 3-weekly arm, patients with AKI had poorer OS than those without AKI (HR, 1.83; 95% CI, 1.04 to 3.21).

CONCLUSIONS

In this supplementary analysis of JCOG1008 data, AKI impacted the OS of patients with head and neck cancer undergoing postoperative chemoradiotherapy in the 3-weekly arm but not in the weekly arm. Our results further endorse the utilization of weekly cisplatin at 40 mg/m2 in this setting.

A clinical comparative study on carbamylated haemoglobin as a surrogate marker to differentiate acute kidney injury from chronic kidney disease

Introduction

Carbamylated haemoglobin is the result of reaction of isocyanate with N-terminal valine residues of the α and β chains of haemoglobin. Carbamylated haemoglobin concentration is dependent on the degree and duration of uraemia and thus may potentially serve as a marker to differentiate acute kidney injury (AKI) and chronic kidney disease (CKD).

Methods

A hospital-based prospective clinical comparative study was conducted in an urban tertiary medical care centre. Carbamylated haemoglobin was estimated in a total of 60 patients, 30 each of chronic kidney disease and acute kidney injury. The comparison of the carbamylated haemoglobin levels among the CKD and AKI groups was done using Mann-Whitney test. The mean value of carbamylated haemoglobin among the CKD group was 240.71 ± 75.64 μgVH/g, whereas among the AKI group, it was 67.15 ± 17.05 μgVH/g. These values are statistically significant with P < 0.001.

Results

Carbamylated haemoglobin values were elevated in relation to renal dysfunction, and it significantly correlated with chronicity of kidney disease. Mean CarHb among the CKD group was significantly high in comparison to the AKI group with statistical significance, with a P value of <0.001.

Conclusion

It was significantly attributed in this study that carbamylated haemoglobin >100 μgVH/g is diagnostic of CKD and a value <100 μgVH/g is diagnostic of AKI. Thus, in this study, it can be concluded that carbamylated haemoglobin is a useful marker to differentiate AKI from CKD.

Development and validation of a nomogram to predict the risk of vancomycin-related acute kidney injury in critical care patients

Background

Vancomycin-associated acute kidney injury (AKI) leads to underestimated morbidity in the intensive care unit (ICU). It is significantly important to predict its occurrence in advance. However, risk factors and nomograms to predict this AKI are limited.

Methods

This was a retrospective analysis of two databases. A total of 1,959 patients diagnosed with AKI and treated with vancomycin were enrolled from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. According to the 7:3 ratio, the training set (n = 1,372) and the internal validation set (n = 587) were randomly allocated. The external validation set included 211 patients from the eICU Collaborative Research Database (eICU). Next, to screen potential variables, the least absolute shrinkage and selection operator (LASSO) regression was utilized. Subsequently, the nomogram was developed by the variables of the selected results in the multivariable logistic regression. Finally, discrimination, calibration, and clinical utility were evaluated to validate the nomogram.

Results

The constructed nomogram showed fine discrimination in the training set (area under the receiver operator characteristic curve [AUC] = 0.791; 95% confidence interval [CI]: 0.758-0.823), internal validation set (AUC = 0.793; 95% CI: 0.742-0.844), and external validation set (AUC = 0.755; 95% CI: 0.663-0.847). Moreover, it also well demonstrated calibration and clinical utility. The significant improvement (P < 0.001) in net reclassification improvement (NRI) and integrated differentiation improvement (IDI) confirmed that the predictive model outperformed others.

Conclusion

This established nomogram indicated promising performance in determining individual AKI risk of vancomycin-treated critical care patients, which will be beneficial in making clinical decisions.

Prediction models for acute kidney injury following liver transplantation: A systematic review and critical appraisal

OBJECTIVE

This study aims to systematically review and critical evaluation of the risk of bias and the applicability of existing prediction models for acute kidney injury post liver transplantation.

DATA SOURCE

A comprehensive literature search up until February 7, 2024, was conducted across nine databases: PubMed, Web of Science, EBSCO CINAHL Plus, Embase, Cochrane Library, CNKI, Wanfang, CBM, and VIP.

STUDY DESIGN

Systematic review of observational studies.

EXTRACTION METHODS

Literature screening and data extraction were independently conducted by two researchers using a standardized checklist designed for the critical appraisal of prediction modelling studies in systematic reviews. The prediction model risk of bias assessment tool was utilized to assess both the risk of bias and the models' applicability.

PRINCIPAL FINDINGS

Thirty studies were included, identifying 34 prediction models. External validation was conducted in seven studies, while internal validation exclusively took place in eight studies. Three models were subjected to both internal and external validation, the area under the curve ranging from 0.610 to 0.921. A meta-analysis of high-frequency predictors identified several statistically significant factors, including recipient body mass index, Model for End-stage Liver Disease score, preoperative albumin levels, international normalized ratio, and surgical-related factors such as cold ischemia time. All studies were demonstrated a high risk of bias, mainly due to the use of unsuitable data sources and inadequate detail in the analysis reporting.

CONCLUSIONS

The evaluation with prediction model risk of bias assessment tool indicated a considerable bias risk in current predictive models for acute kidney injury post liver transplantation.

IMPLICATIONS FOR CLINICAL PRACTICE

The recognition of high bias in existing models calls for future research to employ rigorous methodologies and robust data sources, aiming to develop and validate more accurate and clinically applicable predictive models for acute kidney injury post liver transplantation.

Tumour lysis syndrome

Tumour lysis syndrome (TLS) represents a critical oncological emergency characterized by extensive tumour cell breakdown, leading to the swift release of intracellular contents into the systemic circulation, outpacing homeostatic mechanisms. This process results in hyperuricaemia (a by-product of intracellular DNA release), hyperkalaemia, hyperphosphataemia, hypocalcaemia and the accumulation of xanthine. These electrolyte and metabolic imbalances pose a significant risk of acute kidney injury, cardiac arrhythmias, seizures, multiorgan failure and, rarely, death. While TLS can occur spontaneously, it usually arises shortly after the initiation of effective treatment, particularly in patients with a large cancer cell mass (defined as ≥500 g or ≥300 g/m2 of body surface area in children). To prevent TLS, close monitoring and hydration to improve renal perfusion and urine output and to minimize uric acid or calcium phosphate precipitation in renal tubules are essential. Intervention is based on the risk of a patient of having TLS and can include rasburicase and allopurinol. Xanthine, typically enzymatically converted to uric acid, can accumulate when xanthine oxidases, such as allopurinol, are administered during TLS management. Whether measurement of xanthine is clinically useful to optimize the use of allopurinol or rasburicase remains to be determined.

Acute Kidney Injury in Relation to Nephrotoxic Medication Use Among Critically Ill Children in the Paediatric Intensive Care Unit

Background: Critically ill children are vulnerable to acute kidney injury (AKI) and are often exposed to nephrotoxic medications. Objectives: We aimed to investigate the association between nephrotoxic medications and the risk of AKI in critically ill children admitted to our paediatric intensive care unit (PICU). Methods: Patients aged > 1 month to ≤18 years old were prospectively recruited from 6/2020 to 6/2021. The medication records from 14 days prior to PICU admission to PICU discharge were reviewed. Medication-exposure intensity was defined as the number of concomitant nephrotoxic medications. The relative risk (RR) of nephrotoxic medication exposure indices and other potential predictors for AKI development were determined. Results: Altogether 253 episodes of admissions (median [IQR] age of 4.9 [9.6] years) were enrolled. The AKI incidence was 41.9% and 69.2% of the patients were exposed to ≥1 of the 47 nephrotoxic medications. The total nephrotoxic medication dose (RR: 1.01 [1.00, 1.02]) and medication-exposure intensity (RR: 1.381 [1.101, 1.732]) were significantly associated with AKI development. The risk of AKI increased when the medication-exposure intensity was ≥4 (RR: 3.687 (1.320, 10.301)). During their PICU stay, children with AKI received a higher number (P < .01), total dose (P < .01) and medication exposure intensity (P < .01) of nephrotoxic medications. Children with AKI who received nephrotoxic medications were more likely to have a persistently higher peak-to-baseline ratio (P = .046). Conclusion: Nephrotoxic medication exposure significantly increased the risk of AKI development among critically ill children. The use of nephrotoxic medications among critically ill children at risk for AKI should be monitored frequently.

Predictors of length of hospital stay after pediatric Ebstein anomaly corrective surgery: a retrospective cohort study

BACKGROUND

The remarkable advancements in surgical techniques over recent years have shifted the clinical focus from merely reducing mortality to enhancing the quality of postoperative recovery. The duration of a patient's hospital stay serves as a crucial indicator in evaluating postoperative recovery and surgical outcomes. This study aims to identify predictors of the length of hospital stay for children who have undergone corrective surgery for Ebstein Anomaly (EA).

METHODS

We conducted a retrospective cohort study on children (under 18 years of age) diagnosed with EA who were admitted for corrective surgery between January 2009 and November 2021 at Fuwai Hospital. The primary outcome was the Time to Hospital Discharge (THD). Cox proportional hazard models were utilized to identify predictors of THD. In the context of time-to-event analysis, discharge was considered an event. In cases where death occurred before discharge, it was defined as an extended THD, input as 100 days (exceeding the longest observed THD), and considered as a non-event.

RESULTS

A total of 270 children were included in this study, out of which three died in the hospital. Following the Cox proportional hazard analysis, six predictors of THD were identified. The hazard ratios and corresponding 95% confidence intervals were as follows: age, 1.030(1.005,1.055); C/R > 0.65, 0.507(0.364,0.707); Carpentier type C or D, 0.578(0.429,0.779); CPB time, 0.995(0.991,0.998); dexamethasone, 1.373(1.051,1.795); and transfusion, 0.680(0.529,0.875). The children were categorized into three groups based on the quartile of THD. Compared to children in the ≤ 6 days group, those in the ≥ 11 days group were associated with a higher incidence of adverse outcomes. Additionally, the duration of mechanical ventilation and ICU stay, as well as hospital costs, were significantly higher in this group.

CONCLUSION

We identified six predictors of THD for children undergoing corrective surgery for EA. Clinicians can utilize these variables to optimize perioperative management strategies, reduce adverse complications, improve postoperative recovery, and reduce unnecessary medical expenses.

Leveraging Electronic Health Records to Predict the Risk of Acute Kidney Injury after Allogeneic Hematopoietic Cell Transplantation

BACKGROUND

The objective of this study is to assess the electronic health records (EHRs), which are potential risk factors for acute kidney injury (AKI) after allogenic hematopoietic cell transplantation (allo-HCT), and to propose a basic dataset and score for the calculation of HCT-acute kidney injury risk (HCT-AKIR).

METHODS

We undertook a retrospective analysis of the EHRs of 312 patients. Pre- and post-transplant factors were assessed, recognizing the following structured entries: laboratory data, encounters, medication, imaging studies, diagnoses, and procedures. Composite variables were used to create patient groups by combining two or more multivariate significant risk factors for AKI. The EHRs dataset and HCT-AKIR score were created based on the multivariate analysis of the composite variables.

RESULTS

A multivariate analysis showed that previous CKD and once-impaired pre-transplant kidney function, sepsis, imaging procedures with contrast media, and cumulative length of intensive care unit stay after transplantation were significant risk factors. A new unit-weighted composite score based on the combination of significant risk factors contained in common EHR resources was proposed.

CONCLUSIONS

Using our novel HCT-AKIR score calculated from the basic EHR dataset could be an easy way to increase awareness of post-transplant AKI and provide risk stratification.

Electronic Glycemic Management System Improved Glycemic Control and Reduced Complications in Patients With Diabetes Undergoing Coronary Artery Bypass Surgery: A Randomized Controlled Trial

BACKGROUND

In-hospital hyperglycemia poses significant risks for patients with diabetes mellitus undergoing coronary artery bypass graft (CABG) surgery. Electronic glycemic management systems (eGMSs) like InsulinAPP offer promise in standardizing and improving glycemic control (GC) in these settings. This study evaluated the efficacy of the InsulinAPP protocol in optimizing GC and reducing adverse outcomes post-CABG.

METHODS

This prospective, randomized, open-label study was conducted with 100 adult type 2 diabetes mellitus (T2DM) patients post-CABG surgery, who were randomized into two groups: conventional care (gCONV) and eGMS protocol (gAPP). The gAPP used InsulinAPP for insulin therapy management, whereas the gCONV received standard clinical care. The primary outcome was a composite of hospital-acquired infections, renal function deterioration, and symptomatic atrial arrhythmia. Secondary outcomes included GC, hypoglycemia incidence, hospital stay length, and costs.

RESULTS

The gAPP achieved lower mean glucose levels (167.2 ± 42.5 mg/dL vs 188.7 ± 54.4 mg/dL; P = .040) and fewer patients-day with BG above 180 mg/dL (51.3% vs 74.8%, P = .011). The gAPP received an insulin regimen that included more prandial bolus and correction insulin (either bolus-correction or basal-bolus regimens) than the gCONV (90.3% vs 16.7%). The primary composite outcome occurred in 16% of gAPP patients compared with 58% in gCONV (P < .010). Hypoglycemia incidence was lower in the gAPP (4% vs 16%, P = .046). The gAPP protocol also resulted in shorter hospital stays and reduced costs.

CONCLUSIONS

The InsulinAPP protocol effectively optimizes GC and reduces adverse outcomes in T2DM patients' post-CABG surgery, offering a cost-effective solution for inpatient diabetes management.

Risk factors for acute kidney injury in very-low birth weight newborns: a systematic review with meta-analysis

This study aims to analyze the main risk factors for acute kidney injury in the subgroup of very-low birth weight newborns, using the diagnosing criteria of the Kidney Disease Improving Global Outcomes (KDIGO) or the Acute Kidney Injury Network (AKIN). A systematic review of the literature was performed on the EMBASE® and PubMed® platforms. Studies that evaluated the risk factors for developing AKI in VLBW newborns were included. For the meta-analysis, we only included the risk factors that were associated with AKI in the univariate analysis of at least two studies. After an initial screening, abstract readings, and full-text readings, 10 articles were included in the systematic review and 9 in the meta-analysis. The incidence of AKI varied from 11.6 to 55.8%. All the studies have performed multivariate analysis, and the risk factors that appeared most were PDA and hemodynamic instability (use of inotropes or hypotension), sepsis, and invasive mechanical ventilation. After the meta-analysis, only cesarian delivery did not show an increased risk of AKI, all the other variables remained as important risk factors. Moreover, in our meta-analysis, we found a pooled increased risk of death in newborns with AKI almost 7 times.  Conclusion: AKI in VLBW has several risk factors and must be seen as a multifactorial disease. The most common risk factors were PDA, hemodynamic instability, sepsis, and invasive mechanical ventilation. What is known: • Acute kidney injury is associated with worst outcomes in all ages. It´s prevention can help diminish mortality. What is new: • A synthesis of the main risk factors associated with AKI in very low birth weight newborns.