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Glir JRZ, Bernardelli RS, Kozesinski-Nakatani AC, Deucher RADO, de Oliveira MC, Réa-Neto Á. Accuracy of the persistent AKI risk index in predicting acute kidney injury in patients admitted to the intensive care unit for acute respiratory failure. CRITICAL CARE SCIENCE 2023; 35:302-310. [PMID: 38133160 PMCID: PMC10734811 DOI: 10.5935/2965-2774.20230141-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/11/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To evaluate the accuracy of the persistent AKI risk index (PARI) in predicting acute kidney injury within 72 hours after admission to the intensive care unit, persistent acute kidney injury, renal replacement therapy, and death within 7 days in patients hospitalized due to acute respiratory failure. METHODS This study was done in a cohort of diagnoses of consecutive adult patients admitted to the intensive care unit of eight hospitals in Curitiba, Brazil, between March and September 2020 due to acute respiratory failure secondary to suspected COVID-19. The COVID-19 diagnosis was confirmed or refuted by RT-PCR for the detection of SARS-CoV-2. The ability of PARI to predict acute kidney injury at 72 hours, persistent acute kidney injury, renal replacement therapy, and death within 7 days was analyzed by ROC curves in comparison to delta creatinine, SOFA, and APACHE II. RESULTS Of the 1,001 patients in the cohort, 538 were included in the analysis. The mean age was 62 ± 17 years, 54.8% were men, and the median APACHE II score was 12. At admission, the median SOFA score was 3, and 83.3% had no renal dysfunction. After admission to the intensive care unit, 17.1% had acute kidney injury within 72 hours, and through 7 days, 19.5% had persistent acute kidney injury, 5% underwent renal replacement therapy, and 17.1% died. The PARI had an area under the ROC curve of 0.75 (0.696 - 0.807) for the prediction of acute kidney injury at 72 hours, 0.71 (0.613 - 0.807) for renal replacement therapy, and 0.64 (0.565 - 0.710) for death. CONCLUSION The PARI has acceptable accuracy in predicting acute kidney injury within 72 hours and renal replacement therapy within 7 days of admission to the intensive care unit, but it is not significantly better than the other scores.
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Affiliation(s)
| | | | | | | | | | - Álvaro Réa-Neto
- Centro de Estudos e Pesquisa em Terapia Intensiva - Curitiba (PR),
Brazil
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2
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Fishman G, Ram E, Gorfil D, Kassif Y, David R, Hershko T, Malbrain MLNG, Singer P, Sessler DI. Early detection of oliguric events in critically ill patients in the ICU with a novel continuous urine flow measurement device: results of an initial validation study. J Clin Monit Comput 2023; 37:1341-1349. [PMID: 37027058 PMCID: PMC10080177 DOI: 10.1007/s10877-023-00991-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/26/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVES Urine output is used to evaluate fluid status and is an important marker for acute kidney injury (AKI). Our primary aim was to validate a new automatic urine output monitoring device by comparison to the current practice - the standard urometer. METHODS We conducted a prospective observational study in three ICUs. Urine flow measurements by Serenno Medical Automatic urine output measuring device (Serenno Medical, Yokneam, Israel) were compared to standard urometer readings taken automatically at 5-minutes intervals by a camera, and to hourly urometer readings by the nurses, both over 1 to 7 days. Our primary outcome was the difference between urine flow assessed by the Serenno device and reference camera-derived measurements (Camera). Our secondary outcome was the difference between urine flow assessed by the Serenno device and hourly nursing assessments (Nurse), and detection of oliguria. RESULTS Thirty-seven patients completed the study, with 1,306 h of recording and a median of 25 measurement hours per patient. Bland and Altman analysis comparing the study device to camera measurements demonstrated good agreement, with a bias of -0.4 ml/h and 95% confidence intervals ranging from - 28 to 27ml/h. Concordance was 92%. The correlation between Camera and hourly nursing assessment of urine output was distinctly worse with a bias of 7.2 ml and limits of agreement extending from - 75 to + 107 ml. Severe oliguria (urine output < 0.3 ml/kg/h) lasting 2 h or more was common and observed in 8 (21%) of patients. Among the severe oliguric events lasting more than 3 consecutive hours, 6 (41%) were not detected or documented by the nursing staff. There were no device-related complications. CONCLUSION The Serenno Medical Automatic urine output measuring device required minimal supervision, little ICU nursing staff attention, and is sufficiently accurate and precise. In addition to providing continuous assessments of urine output, it was considerably more accurate than hourly nursing assessments.
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Affiliation(s)
- Guy Fishman
- Department of General Intensive Care, Rabin Medical Center, campus Beilinson, Petah, Tikva, Israel
| | - Eilon Ram
- Department of Cardiac Surgery, Leviev cardiothoracic and vascular center, Sackler School of Medicine, Sheba Medical Center at Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Dan Gorfil
- Cardiothoracic Surgery Department, Rabin Medical Center, campus Beilinson, Petah, Tikva, Israel
| | - Yigal Kassif
- Department of Cardiac Surgery, Leviev cardiothoracic and vascular center, Sackler School of Medicine, Sheba Medical Center at Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Rachel David
- Department of General Intensive Care, Rabin Medical Center, campus Beilinson, Petah, Tikva, Israel
| | - Tzlil Hershko
- Adelson School of Medicine at Ariel University, Samaria, Israel
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Jaczewskiego street 8, Lublin, 20-954, Poland
- International Fluid Academy, Dreef 3, Lovenjoel, 3360, Belgium
| | - Pierre Singer
- Department of General Intensive Care, Rabin Medical Center, campus Beilinson, Petah, Tikva, Israel
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, 9500 Euclid Ave L1-407, Cleveland, OH, 44195, USA
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3
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Claure-Del Granado R, Neyra JA, Basu RK. Acute Kidney Injury: Gaps and Opportunities for Knowledge and Growth. Semin Nephrol 2023; 43:151439. [PMID: 37968179 DOI: 10.1016/j.semnephrol.2023.151439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Acute kidney injury (AKI) occurs frequently in hospitalized patients, regardless of age or prior medical history. Increasing awareness of the epidemiologic problem of AKI has directly led to increased study of global recognition, diagnostic tools, both reactive and proactive management, and analysis of long-term sequelae. Many gaps remain, however, and in this article we highlight opportunities to add significantly to the increasing bodies of evidence surrounding AKI. Practical considerations related to initiation, prescription, anticoagulation, and monitoring are discussed. In addition, the importance of AKI follow-up evaluation, particularly for those surviving the receipt of renal replacement therapy, is highlighted as a push for global equity in the realm of critical care nephrology is broached. Addressing these gaps presents an opportunity to impact patient care directly and improve patient outcomes.
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Affiliation(s)
- Rolando Claure-Del Granado
- Department of Medicine, Division of Nephrology, Hospital Obrero No 2-Caja Nacional de Salud, Cochabamba, Bolivia; Biomedical Research Institute, Facultad de Medicina, Universidad Mayor de San Simon, Cochabamba, Bolivia
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Rajit K Basu
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University, Ann and Robert Lurie Children's Hospital of Chicago, Chicago, IL.
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4
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Rodrigues CE, Endre ZH. Definitions, phenotypes, and subphenotypes in acute kidney injury-Moving towards precision medicine. Nephrology (Carlton) 2023; 28:83-96. [PMID: 36370326 PMCID: PMC10100386 DOI: 10.1111/nep.14132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/23/2022] [Accepted: 10/31/2022] [Indexed: 11/13/2022]
Abstract
The current definition of acute kidney injury (AKI) is generic and, based only on markers of function, is unsuitable for guiding individualized treatment. AKI is a complex syndrome with multiple presentations and causes. Targeted AKI management will only be possible if different phenotypes and subphenotypes of AKI are recognised, based on causation and related pathophysiology. Molecular signatures to identify subphenotypes are being recognised, as specific biomarkers reveal activated pathways. Assessment of individual clinical risk needs wider dissemination to allow identification of patients at high risk of AKI. New and more timely markers for glomerular filtration rate (GFR) are available. However, AKI diagnosis and classification should not be limited to GFR, but include tubular function and damage. Combining damage and stress biomarkers with functional markers enhances risk prediction, and identifies a population enriched for clinical trials targeting AKI. We review novel developments and aim to encourage implementation of these new techniques into clinical practice as a strategy for individualizing AKI treatment akin to a precision medicine-based approach.
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Affiliation(s)
- Camila Eleuterio Rodrigues
- Nephrology Department, Prince of Wales Clinical School - UNSW Medicine, Sydney, New South Wales, Australia.,Nephrology Department, Hospital das Clínicas - University of São Paulo School of Medicine, São Paulo, Brazil
| | - Zoltán H Endre
- Nephrology Department, Prince of Wales Clinical School - UNSW Medicine, Sydney, New South Wales, Australia
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5
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Hu J, Ananth D, Sethi SK, Taliwal N, Govindan S, Raina R. Neonatal AKI: An update. J Neonatal Perinatal Med 2023; 16:361-373. [PMID: 37718869 DOI: 10.3233/npm-230120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Neonatal acute kidney injury (AKI) is a common complication, especially in the neonatal intensive care unit, that is associated with long term consequences and poor outcomes. Early detection and treatment is critical. Currently, neonatal AKI is defined with urinary markers and serum creatinine, with limitations on early detection and individual treatment. There have been numerous biomarkers and risk factor scores that have been studied for their ability to predict neonatal AKI. To move towards personalized medicine, neonatal AKI must be categorized into phenotypes and subphenotypes that fully encapsulate the diverse causes and specific treatments. This review aims to advance our understanding of neonatal AKI detection through the use of biomarkers, subphenotypes, and phenotypes to move towards personalized treatment strategies.
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Affiliation(s)
- J Hu
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - D Ananth
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - S K Sethi
- Pediatric Nephrology & Pediatric Kidney Transplantation, Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - N Taliwal
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - S Govindan
- Department of Pediatric Nephrology, Dr. Mehta's Hospitals, Chetpet and Vellapanchavadi, Chennai, India
| | - R Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
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6
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Fu Y, He C, Jia L, Ge C, Long L, Bai Y, Zhang N, Du Q, Shen L, Zhao H. Performance of the renal resistive index and usual clinical indicators in predicting persistent AKI. Ren Fail 2022; 44:2028-2038. [DOI: 10.1080/0886022x.2022.2147437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- You Fu
- Department of Critical Care Medicine, Hebei Medical University, Shijiazhuang City, China
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Cong He
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Lijing Jia
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Chen Ge
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Ling Long
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Yinxiang Bai
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Na Zhang
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Quansheng Du
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Limin Shen
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
| | - Heling Zhao
- Department of Critical Care Medicine, Hebei Medical University, Shijiazhuang City, China
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, China
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Singh T, Mahajan V, Kaur J, D'Cruz S, Randev S, Guglani V, Singla S. Early diagnosis of kidney injury in a paediatric population: a prospective cohort study (E-DRIP STUDY). Pediatr Nephrol 2022; 37:2771-2779. [PMID: 35262799 DOI: 10.1007/s00467-022-05442-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/07/2021] [Accepted: 12/22/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Renal Angina Index (RAI) is a bedside tool for risk stratification of patients to predict acute kidney injury (AKI). Kidney biomarkers are better indicators of real-time injury and give us lead time for diagnosing impending AKI. METHODS We enrolled consecutive children aged 2 months-14 years admitted to a tertiary hospital in northern India over 2 years. RAI was calculated on day 0 (D0) and urinary (u) and plasma (p) neutrophil gelatinase-associated lipocalin (NGAL) were measured within 6 h of admission. Children were followed for the development of severe AKI on day 3 (D3) using Kidney Disease Improving Global Outcomes criteria to define and stage AKI. RESULTS Of the 253 children enrolled and analysed, 44 (17.4%) developed D3-AKI (stage 1 in 52.2%, stage 2 in 20.5% and stage 3 in 27.3%). Renal angina (RAI ≥ 8) on D0 was present in 66.7% children who developed stage 2/3 D3-AKI vs. 43.5% in children who did not develop D3-AKI /stage 1 AKI (p = 0.065). Area under ROC (AUROC) curve for D0-RAI to predict D3-severe-AKI was 0.66 (95% CI, 0.55-0.77). AUROC curve for uNGAL and pNGAL to predict D3-severe-AKI was 0.62 (95% CI, 0.50-0.74) and 0.48 (95% CI, 0.35-0.61), respectively. The severe AKI group had greater requirement of ventilation and inotropic support with mortality being thrice higher compared to the non-AKI group. CONCLUSION RAI ≥ 8 and uNGAL had a high negative predictive value but low sensitivity for predicting D3-severe-AKI. pNGAL had a poor predictive value for D3-severe-AKI. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Tanvi Singh
- Department of Pediatrics, Government Medical College and Hospital, Sector 32, Chandigarh, 160030, India
| | - Vidushi Mahajan
- Department of Pediatrics, Government Medical College and Hospital, Sector 32, Chandigarh, 160030, India.
| | - Jasbinder Kaur
- Department of Biochemistry, Government Medical College and Hospital, Sector 32, Chandigarh, India
| | - Sanjay D'Cruz
- Department of General Medicine (Nephrology), Government Medical College and Hospital, Sector 32, Chandigarh, India
| | - Shivani Randev
- Department of Pediatrics, Government Medical College and Hospital, Sector 32, Chandigarh, 160030, India
| | - Vishal Guglani
- Department of Pediatrics, Government Medical College and Hospital, Sector 32, Chandigarh, 160030, India
| | - Seema Singla
- Department of Biochemistry, Government Medical College and Hospital, Sector 32, Chandigarh, India
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8
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Webb TN. Detection of Acute Kidney Injury in Neonates after Cardiopulmonary Bypass. Nephron Clin Pract 2022; 146:282-285. [DOI: 10.1159/000522316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 01/24/2022] [Indexed: 11/19/2022] Open
Abstract
Cardiac surgery-associated acute kidney injury (CS-AKI) in neonates has been associated with poor outcomes. Early detection and intervention of acute kidney injury (AKI) are needed in order to mitigate some of these sequalae. Currently, serum creatinine (SCr) remains the gold standard for AKI diagnosis; however, changes are not seen until days after injury thus delaying the diagnosis. Serum creatinine in neonates varies based on multiple factors such as prematurity, the presence of maternal SCr and renal tubule immaturity. Acute kidney injury biomarkers, such as neutrophil gelatinase-associated lipocalin (NGAL), are useful for early AKI diagnosis. In addition to SCr and AKI biomarkers, a risk-based assessment of neonates at risk for CS-AKI could prove useful for early AKI diagnosis and intervention.
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9
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Advances in pediatric acute kidney injury. Pediatr Res 2022; 91:44-55. [PMID: 33731820 DOI: 10.1038/s41390-021-01452-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/26/2021] [Accepted: 02/16/2021] [Indexed: 01/10/2023]
Abstract
The objective of this study was to inform the pediatric nephrologists of recent advances in acute kidney injury (AKI) epidemiology, pathophysiology, novel biomarkers, diagnostic tools, and management modalities. Studies were identified from PubMed, EMBASE, and Google Scholar for topics relevant to AKI. The bibliographies of relevant studies were also reviewed for potential articles. Pediatric (0-18 years) articles from 2000 to May 2020 in the English language were included. For epidemiological outcomes analysis, a meta-analysis on data regarding AKI incidence, mortality, and proportion of kidney replacement therapy was performed and an overall pooled estimate was calculated using the random-effects model. Other sections were created highlighting pathophysiology, novel biomarkers, changing definitions of AKI, evolving tools for AKI diagnosis, and various management modalities. AKI is a common condition seen in hospitalized children and the diagnosis and management have shown to be quite a challenge. However, new standardized definitions, advancements in diagnostic tools, and the development of novel management modalities have led to increased survival benefits in children with AKI. IMPACT: This review highlights the recent innovations in the field of AKI, especially in regard to epidemiology, pathophysiology, novel biomarkers, diagnostic tools, and management modalities.
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10
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Sethi SK, Bunchman T, Chakraborty R, Raina R. Pediatric acute kidney injury: new advances in the last decade. Kidney Res Clin Pract 2021; 40:40-51. [PMID: 33663033 PMCID: PMC8041642 DOI: 10.23876/j.krcp.20.074] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/19/2020] [Accepted: 08/28/2020] [Indexed: 12/25/2022] Open
Abstract
Pediatric acute kidney injury (AKI) is a frequently missed complication. AKI has a significant impact on both short- and long-term outcomes in children. Within the last decade, there have been major landmark developments in this field of critical care pediatric nephrology. The topic was searched by two independent researchers using Google Scholar and PubMed and related studies published in the last 10 years. The terms used for the search were 'pediatric acute kidney injury,' 'pediatric acute renal failure,' 'pediatric dialysis,' 'biomarkers,' 'nephrotoxins,' 'nephrotoxicity in children,' and 'pediatric critical care nephrology.' We found that AKI is common in critically ill neonates and children. Among the various definitions, the Kidney Disease: Improving Global Outcomes (KDIGO) definition is most commonly used. In addition, it is imperative to risk stratify sick children at admission in the hospital to predict AKI and worse outcomes as this aids in early management. There are now major landmark trials that describe the epidemiology, prevention, and management guidelines in this field and health care professionals need to be aware they should diagnose AKI early. Overall, this review highlights the landmark studies in the last decade and shows that early diagnosis and management of AKI in 'at risk' children can improve outcomes.
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Affiliation(s)
- Sidharth K. Sethi
- Department of Pediatric Nephrology, Kidney Institute, Medanta-The Medicity Hospital, Gurgaon, India
| | - Timothy Bunchman
- Departments of Pediatric Nephrology and Transplantation, Children’s Hospital of Richmond at VCU, Richmond, VA, USA
| | - Ronith Chakraborty
- Akron Nephrology Associates and Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Rupesh Raina
- Akron Nephrology Associates and Cleveland Clinic Akron General Medical Center, Akron, OH, USA
- Department of Nephrology, Akron Children’s Hospital, Akron, OH, USA
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11
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Ahmad AH, Mahadeo KM. Perspective: A Framework to Screen Pediatric and Adolescent Hematopoietic Cellular Therapy Patients for Organ Dysfunction: Time for a Multi-Disciplinary and Longitudinal Approach. Front Oncol 2021; 11:622630. [PMID: 33718184 PMCID: PMC7943835 DOI: 10.3389/fonc.2021.622630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/05/2021] [Indexed: 12/23/2022] Open
Abstract
Hematopoietic Cell Transplantation (HCT) is a potentially curative therapy for children and adolescent/young adults (AYA) with high-risk malignancies as well as some non-malignant genetic diseases. However, HCT may be associated with endotheliopathies and/or organ dysfunction that may progress to pediatric multi-organ dysfunction syndrome (pMODS) and require critical care intervention. Discipline specific scoring systems may be used to characterize individual organ dysfunction, but the extent to which they are used to prospectively monitor HCT patients with mild dysfunction is unknown. Further, separate scoring systems may be used to define risk of mortality and inform prognostication among those who require critical care support. Our understanding of the epidemiology, risk factors, morbidity, mortality, required monitoring, optimal prevention strategies and appropriate management of children undergoing HCT who develop organ dysfunction, endotheliopathies and/or progress to pMODS is poor. Discipline-specific registries and clinical studies have described improving outcomes for children undergoing HCT, including those who require critical care support; however, longitudinal studies/prospective registries that capture common data elements among HCT patients with and without organ dysfunction, endotheliopathies and pMODS are needed to facilitate inter-disciplinary collaboration and optimally characterize the risk profiles, define screening and prophylaxis regimens and mitigate toxicity.
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Affiliation(s)
- Ali H Ahmad
- Pediatric Critical Care Medicine, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Kris M Mahadeo
- Pediatric Stem Cell Transplantation and Cellular Therapy and CARTOX Program, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
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Shawwa K, Ghosh E, Lanius S, Schwager E, Eshelman L, Kashani KB. Predicting acute kidney injury in critically ill patients using comorbid conditions utilizing machine learning. Clin Kidney J 2020; 14:1428-1435. [PMID: 33959271 PMCID: PMC8087133 DOI: 10.1093/ckj/sfaa145] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Indexed: 01/20/2023] Open
Abstract
Background Acute kidney injury (AKI) carries a poor prognosis. Its incidence is increasing in the intensive care unit (ICU). Our purpose in this study is to develop and externally validate a model for predicting AKI in the ICU using patient data present prior to ICU admission. Methods We used data of 98 472 adult ICU admissions at Mayo Clinic between 1 January 2005 and 31 December 2017 and 51 801 encounters from Medical Information Mart for Intensive Care III (MIMIC-III) cohort. A gradient-boosting model was trained on 80% of the Mayo Clinic cohort using a set of features to predict AKI acquired in the ICU. Results AKI was identified in 39 307 (39.9%) encounters in the Mayo Clinic cohort. Patients who developed AKI in the ICU were older and had higher ICU and in-hospital mortality compared to patients without AKI. A 30-feature model yielded an area under the receiver operating curve of 0.690 [95% confidence interval (CI) 0.682–0.697] in the Mayo Clinic cohort set and 0.656 (95% CI 0.648–0.664) in the MIMIC-III cohort. Conclusions Using machine learning, AKI among ICU patients can be predicted using information available prior to admission. This model is independent of ICU information, making it valuable for stratifying patients at admission.
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Affiliation(s)
- Khaled Shawwa
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Erina Ghosh
- Philips Research North America, Cambridge, MA, USA
| | | | | | | | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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13
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Cell-Cycle Arrest Biomarkers: Usefulness for Cardiac Surgery-Related Acute Kidney Injury in Neonates and Infants. Pediatr Crit Care Med 2020; 21:563-570. [PMID: 32195906 DOI: 10.1097/pcc.0000000000002270] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Cell cycle arrest urine biomarkers have recently been shown to be early indicators of acute kidney injury in various clinical settings in critically ill adults and children. The product of tissue inhibitor metalloproteinase -1 and insulin-like growth factor binding protein-7 concentrations/1,000 (TIMP-1) × (IGFBP-7) provides stratification of acute kidney injury-risk in adults with critical illness. The present study explores the predictive accuracy of (TIMP-1) × (IGFBP-7) measured early after cardiopulmonary bypass for cardiac surgery-related acute kidney injury in neonates and infants, a population in whom such data are not yet available. DESIGN Prospective, observational. SETTING A tertiary referral pediatric cardiac ICU. PATIENTS Fifty-seven neonates and 110 infants undergoing surgery with cardiopulmonary bypass. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS (TIMP-1) × (IGFBP-7) was measured on the NephroCheck (Astute Medical, San Diego, CA) platform preoperatively, less than 1 hour of cardiopulmonary bypass and 1-3 hours of cardiopulmonary bypass. The incidence of postoperative acute kidney injury, dialysis, and/or death were compared among quintiles of postoperative (TIMP-1) × (IGFBP-7). Multivariable regression was used to assess the added predictive value for renal events of (TIMP-1) × (IGFBP-7) over clinical models. Basal (TIMP-1) × (IGFBP-7) increased with age at surgery (regression coefficient = 0.004 ± 0.001; p = 0.005). (TIMP-1) × (IGFBP-7) increased after cardiopulmonary bypass. Neonates had lower postoperative (TIMP-1) × (IGFBP-7) compared with older infants, despite undergoing longer surgeries and experiencing a higher incidence of postoperative renal events. (TIMP-1) × (IGFBP-7) was not associated with acute kidney injury, dialysis, and/or death and was not a predictor of the aforementioned events when added to a clinical acute kidney injury model including age, duration of cardiopulmonary bypass, and mechanical ventilation prior to surgery. CONCLUSIONS These findings question the usefulness of (TIMP-1) × (IGFBP-7) for the prediction of cardiac surgery-related acute kidney injury in neonates and infants when measured within 3 hours of cardiopulmonary bypass.
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14
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Darmon M, Truche AS, Abdel-Nabey M, Schnell D, Souweine B. Early Recognition of Persistent Acute Kidney Injury. Semin Nephrol 2020; 39:431-441. [PMID: 31514907 DOI: 10.1016/j.semnephrol.2019.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Despite the vast amount of literature dedicated to acute kidney injury (AKI) and its clinical consequences, short-term renal recovery has been relatively neglected. Recent studies have suggested that timing of renal recovery is associated with longer-term risk of death, residual renal function, and end-stage renal failure risk. In addition, longer AKI duration is associated with an increased requirement for renal replacement therapy. Comorbidities, especially renal and cardiovascular, severity of AKI, criteria to reach AKI diagnosis, as well as severity of critical illness have been associated with longer AKI duration, and, more specifically, risk of persistent renal dysfunction. Because predicting short-term renal recovery is clinically relevant, several tests, imaging, and biomarkers have been tested in a way to predict the course of AKI and chances for early renal recovery. In this review, the definition of recovery, consequences of persistent AKI, and tools proposed to predict recovery are described. The performance of these tools and their limits are discussed.
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Affiliation(s)
- Michaël Darmon
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, Paris, France; Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France; ECSTRA Team (Epidémiologie Clinique et Statistiques pour la Recherche en sAnté), Biostatistics and Clinical Epidemiology, UMR 1153, Center of Epidemiology and Biostatistic Sorbonne Paris Cité, INSERM, Paris, France.
| | - Anne-Sophie Truche
- Medical Intensive Care Unit, Grenoble University Hospital, La Tronche, France
| | | | - David Schnell
- Medical-Surgical Intensive Care Unit, Angoulême Hospital, Angoulême, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
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Massoth C, Zarbock A, Meersch M. Risk Stratification for Targeted AKI Prevention After Surgery: Biomarkers and Bundled Interventions. Semin Nephrol 2020; 39:454-461. [PMID: 31514909 DOI: 10.1016/j.semnephrol.2019.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Perioperative acute kidney injury (AKI) is a surgery-associated complication with increasing incidence, not only because of enhanced awareness for the diagnosis, but also as a result of the aging society with a growing number of severe comorbidities undergoing major surgical procedures. The dilemma of AKI as a global health burden lies in the discrepancy between its importance as a significant risk factor for morbidity and mortality, and the unavailability of specific therapies to modify these adverse outcomes. Thus, it is all the more important to focus management on AKI prevention, and when AKI occurs to focus on early recognition and immediate adaption of individualized care. AKI is the result of an inter-relationship between patient susceptibility and determinants of perioperative exposures. Screening for constellations of risk factors along with measurement of novel biomarkers allows for early identification of patients who are susceptible to AKI and to initiate early targeted care. Targeted care involves implementation of a bundle of interventions adapted from a consensus management guideline, and is a strategy with growing evidence of a beneficial effect on patients' short- and long-term outcomes.
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Affiliation(s)
- Christina Massoth
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
| | - Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany.
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17
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Early Sequential Risk Stratification Assessment to Optimize Fluid Dosing, CRRT Initiation and Discontinuation in Critically Ill Children with Acute Kidney Injury: Taking Focus 2 Process Article. JOURNAL OF CLINICAL TRIALS 2020; 10:435. [PMID: 34476130 PMCID: PMC8409431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Acute Kidney Injury (AKI) is common in critically ill children and is associated with increased morbidity and mortality. Recognition and management of AKI is often delayed, predisposing patients to risk of clinically significant fluid accumulation (Fluid Overload (FO)). Early recognition and intervention in high risk patients could decrease fluid associated morbidity. We aim to assess an AKI Clinical Decision Algorithm (CDA) using a sequential risk stratification strategy integrating the Renal Angina Index (RAI), urine Neutrophil Gelatinase-Associated Lipocalin (NGAL) and the Furosemide Stress Test (FST) to optimize AKI and FO prediction and management in critically ill children. METHODS/DESIGN This single center prospective observational cohort study evaluates the AKI CDA in a Pediatric Intensive Care Unit (PICU). Every patient ≥ 3 months old has the risk score RAI calculated automatically at 12 hours of admission. Patients with a RAI ≥ 8 (fulfilling renal angina) have risk further stratified with a urine NGAL and, if positive (NGAL ≥ 150ng/mL), subsequently by their response to a standardized dose of furosemide (namely FST). RAI negative or NGAL negative patients are treated per usual care. FST-responders are managed conservatively, while non-responders receive fluid restrictive strategy and/or continuous renal replacement therapy (CRRT) at 10%-15% of FO. 2100 patients over 3 years will be evaluated to capture 210 patients with severe AKI (KDIGO Stage 2 or 3 AKI), 100 patients with >10% FO, and 50 requiring CRRT. Primary analyses: Standardizing a pediatric FST and assessing prediction accuracy of CDA for severe AKI, FO>10% and CRRT requirement in children. Secondary analyses in patients with AKI: Renal function return to baseline, RRT and mortality within 28 days. DISCUSSION This will be the first prospective evaluation of feasibility of AKI CDA, integrating individual prediction tools in one cohesive and comprehensive approach, and its prediction of FO>10% and AKI, as well as the first to standardize the FST in the pediatric population. This will increase knowledge on current AKI prediction tools and provide actionable insight for early interventions in critically ill children based on their level of risk.
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18
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Roy JP, Johnson C, Towne B, Menke F, Kiger S, Young W, Basu R, Chima R, Fei L, Krallman K, Goldstein SL. Use of height-independent baseline creatinine imputation method with renal angina index. Pediatr Nephrol 2019; 34:1777-1784. [PMID: 31286243 PMCID: PMC6776697 DOI: 10.1007/s00467-019-04294-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/06/2019] [Accepted: 06/11/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Renal Angina Index (RAI) is a validated screening tool used at 12 h of pediatric intensive care unit (PICU) admission to predict severe acute kidney injury (AKI) on day 3 of PICU stay. A measured or height-imputed baseline serum creatinine (SCr) is required for AKI diagnosis and RAI calculation, yet these are often lacking. We assessed an age-based, height-independent baseline SCr calculation and compared the RAI values employing this method to their historical counterpart. METHODS An electronic algorithm was implemented to generate RAI score for patients admitted to our PICU. We reviewed 157 consecutive patient records from May 2017, until we cumulated 100 with a valid RAI calculation. We compared RAI scores using the age-based SCr imputation method of Pottel to the historical RAI. Our primary outcome was a difference in the rate of RAI fulfillment (≥ 8) reclassification between methods. RESULTS Of the first 100 patients, 27 had measured baseline SCr and 73 used height imputation. Only two patients had RAI reclassified with the Pottel method (one in each direction). Being small for age or older were associated with ≥ 25% overestimation of the baseline SCr in 20 patients with the Pottel method compared with height imputation. 15/157 patients had a falsely positive RAI due to lack of measured baseline SCr and height. CONCLUSION The age-based method to estimate baseline SCr offers a viable height-independent alternative for RAI calculation. While less precise than a height-based approach, this lack of precision rarely leads to reclassification of patient RAI status.
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Affiliation(s)
- Jean-Philippe Roy
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Room T6.243, Cincinnati, OH, 45229-3039, USA.
| | - Catherine Johnson
- Department of Information Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bryan Towne
- Department of Information Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Frank Menke
- Department of Information Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Samuel Kiger
- Department of Information Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - William Young
- Department of Information Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rajit Basu
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Ranjit Chima
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lin Fei
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kelli Krallman
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Room T6.243, Cincinnati, OH, 45229-3039, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Room T6.243, Cincinnati, OH, 45229-3039, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Roy JP, Forster CS. Clinical Progress Note: Pediatric Acute Kidney Injury. J Hosp Med 2019; 14:552-554. [PMID: 31433778 DOI: 10.12788/jhm.3280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/25/2019] [Accepted: 06/28/2019] [Indexed: 01/24/2023]
Affiliation(s)
- Jean-Philippe Roy
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Catherine S Forster
- Division of Hospitalist Medicine, Children's National Medical Center, Washington, DC
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20
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Suzuki G, Ichibayashi R, Yamamoto S, Nakamichi Y, Watanabe M, Honda M. Clinical significance of urinary L-FABP in the emergency department. Int J Emerg Med 2019; 12:24. [PMID: 31470789 PMCID: PMC6716847 DOI: 10.1186/s12245-019-0244-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 08/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study's aim is to measure liver-type fatty acid-binding protein (L-FABP) levels in urine using a rapid semiquantitative assay kit in the emergency department and to investigate whether the onset of acute kidney injury (AKI) after hospitalization can be predicted. METHODS This was a prospective observation study. Patients transferred to the emergency and critical care center were divided into two groups: urinary L-FABP negative and positive groups. The status and severity of AKI were evaluated for the respective patients based on the Kidney Disease: Improving Global Outcome (KDIGO) classification. We compared the proportion of AKI patients in the two groups. RESULTS In the urine L-FABP-positive group, many patients had a significant onset of AKI (p < 0.001). After excluding patients who were diagnosed as AKI for creatinine level at admission, urinary L-FABP could predict the onset of AKI after admission (p < 0.001). CONCLUSION By measuring urinary L-FABP concentration using a rapid semiquantitative assay kit, there is the possibility that the onset of AKI after admission can be predicted from immediately after a patient is transported by ambulance.
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Affiliation(s)
- Ginga Suzuki
- Emergency and Critical Care Center, Toho University Omori Medical Center, 6-11-1 Omori-Nishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Ryo Ichibayashi
- Emergency and Critical Care Center, Toho University Omori Medical Center, 6-11-1 Omori-Nishi, Ota-ku, Tokyo, 143-8541, Japan
| | - Saki Yamamoto
- Emergency and Critical Care Center, Toho University Omori Medical Center, 6-11-1 Omori-Nishi, Ota-ku, Tokyo, 143-8541, Japan
| | - Yoshimi Nakamichi
- Emergency and Critical Care Center, Toho University Omori Medical Center, 6-11-1 Omori-Nishi, Ota-ku, Tokyo, 143-8541, Japan
| | - Masayuki Watanabe
- Emergency and Critical Care Center, Toho University Omori Medical Center, 6-11-1 Omori-Nishi, Ota-ku, Tokyo, 143-8541, Japan
| | - Mitsuru Honda
- Emergency and Critical Care Center, Toho University Omori Medical Center, 6-11-1 Omori-Nishi, Ota-ku, Tokyo, 143-8541, Japan
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21
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Griffin BR, Gist KM, Faubel S. Current Status of Novel Biomarkers for the Diagnosis of Acute Kidney Injury: A Historical Perspective. J Intensive Care Med 2019; 35:415-424. [PMID: 30654681 DOI: 10.1177/0885066618824531] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) is a common and serious medical condition associated with significant increases in morbidity, mortality, and cost of care. Because of the high incidence and poor outcomes associated with AKI, there has been significant interest in the development of new therapies for the prevention and treatment of the disease. A lack of efficacy in drug trials led to the concern that AKI was not being diagnosed early enough for an effective intervention and that a rise in serum creatinine itself is not a sensitive-enough marker. Researchers have been searching for novel biomarkers that can not only assess a decline in kidney function but also demonstrate structural damage to the kidney and at time points earlier than increases in serum creatinine measurements allow. Over the past 10 years, there have been 3300 new publications and hundreds of new biomarkers investigated, yet concern still remains regarding AKI biomarker performance. The AKI biomarkers are yet to be widely utilized in clinical practice, leading some to question whether AKI biomarkers will ever reach their initial promise. However, we believe that biomarkers are an important part of current and future AKI research and clinical management. In this review, we compare the historical contexts of acute myocardial ischemia and AKI biomarker development to illustrate the progress that has been made within AKI biomarker research in a relatively short period of time and also to point out key differences between the disease processes that have been barriers to widespread AKI biomarker adoption. Finally, we discuss potential paths by which biomarkers can lead to appropriate AKI treatment responses that lower morbidity and mortality.
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Affiliation(s)
- Benjamin R Griffin
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Katja M Gist
- Department of Pediatrics, The Heart Institute, University of Colorado, Aurora, CO, USA
| | - Sarah Faubel
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Renal Section, Veterans Affairs Eastern Colorado Health Care System, Denver, CO, USA
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Cleto-Yamane TL, Gomes CLR, Suassuna JHR, Nogueira PK. Acute Kidney Injury Epidemiology in pediatrics. J Bras Nefrol 2018; 41:275-283. [PMID: 30465591 PMCID: PMC6699449 DOI: 10.1590/2175-8239-jbn-2018-0127] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 09/05/2018] [Indexed: 03/19/2023] Open
Abstract
We performed a search in the MEDLINE database using the MeSH term: "Acute Kidney
Injury", selecting the subtopic "Epidemiology", and applying age and year of
publication filters. We also searched for the terms: "acute renal failure" and
"epidemiology" "acute tubular necrosis" and "epidemiology" in the title and
summary fields with the same filters. In a second search, we searched in the
LILACS database, with the terms: "acute renal injury", or "acute renal failure"
or "acute kidney injury" and the age filter. All abstracts were evaluated by the
authors and the articles considered most relevant, were examined in their
entirety. Acute Kidney Injury (AKI) -related mortality ranged from 3-63% in the
studies included in this review. AKI etiology has marked regional differences,
with sepsis being the main cause in developed countries. In developing
countries, primary renal diseases and hypovolemia are still a common cause of
AKI.
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23
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Bolliger D, Mauermann E. Renal Angina: A New Paradigm for the Prevention of Acute Kidney Injury After Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 33:365-367. [PMID: 30409534 DOI: 10.1053/j.jvca.2018.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel Bolliger
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Eckhard Mauermann
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
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Cho MH, Kang HG. Acute kidney injury and continuous renal replacement therapy in children; what pediatricians need to know. KOREAN JOURNAL OF PEDIATRICS 2018; 61:339-347. [PMID: 30360040 PMCID: PMC6258966 DOI: 10.3345/kjp.2018.06996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/22/2018] [Indexed: 12/15/2022]
Abstract
Acute kidney injury (AKI) is characterized by abrupt deterioration of renal function, and its diagnosis relies on creatinine measurements and urine output. AKI is associated with higher morbidity and mortality, and is a risk factor for development of chronic kidney disease. There is no proven medication for AKI. Therefore, prevention and early detection are important. Physicians should be aware of the risk factors for AKI and should monitor renal function in high-risk patients. Management of AKI includes optimization of volume status and renal perfusion, avoidance of nephrotoxic agents, and sufficient nutritional support. Continuous renal replacement therapy is widely available for critically ill children, and this review provides basic information regarding this therapy. Long-term follow-up of patients with AKI for renal function, blood pressure, and proteinuria is recommended.
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Affiliation(s)
- Myung Hyun Cho
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
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25
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Lin YF, Huang TM, Lin SL, Wu VC, Wu KD. Short- and long-term outcomes after postsurgical acute kidney injury requiring dialysis. Clin Epidemiol 2018; 10:1583-1598. [PMID: 30464638 PMCID: PMC6208534 DOI: 10.2147/clep.s169302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective Prompt assessment of perioperative complications is critical for the comprehensive care of surgical patients. Acute kidney injury requiring dialysis (AKI-D) is associated with high mortality, yet little is known about how long-term outcomes of patients have evolved. The association of AKI-D with postsurgical outcomes has not been well studied. Methods We investigated patients from the National Health Insurance Research Database and validated by the multicenter Clinical Trial Consortium for Renal Diseases cohort. All patients with AKI-D 18 years or older undergoing four major surgeries (cardiothoracic, esophagus, intestine, and liver) were retrospectively investigated (N=106,573). Patient demographics, surgery type, comorbidities before admission, and postsurgical outcomes, including the in-hospital, 30-day, and long-term mortality together with dialysis dependence were collected. Results AKI-D is the top risk factor for 30-day and long-term mortality after major surgery. Of 1,664 individuals with AKI-D and 6,656 matched controls, AKI-D during the hospital stay was associated with in-hospital (adjusted hazard ratio [aHR]=3.04, 95% CI 2.79–3.31), 30-day (aHR=3.65, 95% CI 3.37–3.94), and long-term (aHR=3.22, 95% CI 3.01–3.44) mortality. Patients undergoing cardiothoracic surgery (CTS) showed less in-hospital (aHR=0.85, 95% CI 0.75–0.97), 30-day (aHR=0.79, 95% CI 0.70–0.89), and long-term (aHR=0.80, 95% CI 0.72–0.90) mortality compared with non-CTS patients with AKI-D. CTS patients had a high risk of 30-day dialysis dependence (subhazard ratio [sHR]=1.67, 95% CI 1.18–2.38), but the risk of long-term dialysis dependence was similar (sHR=1.38, 95% CI 0.96–2.00) after AKI-D by taking mortality as a competing risk. Non-CTS patients had more comorbidities of sepsis, azotemia, hypoalbuminemia, and metabolic acidosis compared with CTS patients. Conclusion AKI exhibits paramount effects on postsurgical outcomes that extend well beyond discharge from the hospital. The goal of the perioperative assessment should include the reassurance of enhancing renal function recovery among different surgeries, and optimized follow-up is warranted in attenuating the complications after postsurgical AKI has occurred.
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Affiliation(s)
- Yu-Feng Lin
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan,
| | - Tao-Min Huang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, .,Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Shuei-Liong Lin
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, .,Graduate Institute of Physiology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan,
| | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan,
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Fierro MA, Ehieli EI, Cooter M, Traylor A, Stafford-Smith M, Swaminathan M. Renal Angina Is a Sensitive, but Nonspecific Identifier of Postcardiac Surgery Acute Kidney Injury. J Cardiothorac Vasc Anesth 2018; 33:357-364. [PMID: 30243866 DOI: 10.1053/j.jvca.2018.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Acute kidney injury (AKI) is a common complication of cardiac surgery, and early detection is difficult. This study was performed to determine the sensitivity, specificity, positive predictive value, negative predictive value, and statistical performance of renal angina (RA) as an early predictor of AKI in an adult cardiac surgical patient population. DESIGN Retrospective, nonrandomized, observational study. SETTING A single, university-affiliated, quaternary medical center. PARTICIPANTS The study comprised 324 consecutive patients undergoing coronary artery bypass grafting or cardiac valvular surgery from February 1 through July 30, 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred-seven patients at moderate or high risk of developing postoperative renal injury were identified, 82 of whom met criteria for RA. The occurrence of RA was found to have an 80.9% sensitivity and 30.8% specificity for the prediction of AKI using Acute Kidney Injury Network criteria and 89.3% sensitivity and 27.8% specificity when paired with the Risk, Injury, Failure, Loss, End Stage Renal Disease criteria. A receiver operating characteristic area under the curve analysis revealed a nonsignificant predictive ability of 55.8% (95% confidence interval 0.47-0.65) when RA was paired with Acute Kidney Injury Network criteria; however, the receiver operating characteristic area under the curve was significant when paired with Risk, Injury, Failure, Loss, End Stage Renal Disease criteria, with a predictive ability of 0.586 (0.509-0.662). CONCLUSIONS RA is a sensitive, but nonspecific, predictor of postcardiac surgery AKI, with clinical utility most suited as a screening tool.
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Affiliation(s)
- Michael A Fierro
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Eric I Ehieli
- Community Division, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Mary Cooter
- Division of Critical Care, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Austin Traylor
- Division of Critical Care, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Mark Stafford-Smith
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Madhav Swaminathan
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | -
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Abstract
PURPOSE OF REVIEW In this review, we discuss the latest updates on perioperative acute kidney injury (AKI) and the specific considerations that are relevant to different surgeries and patient populations. RECENT FINDINGS AKI diagnosis is constantly evolving. New biomarkers detect AKI early and shed a light on the possible cause of AKI. Hypotension, even for a short duration, is associated with perioperative AKI. The debate on the deleterious effects of chloride-rich solutions is still far from conclusion. Remote ischemic preconditioning is showing promising results in the possible prevention of perioperative AKI. No definite data show a beneficiary effect of statins, fenoldepam, or sodium bicarbonate in preventing AKI. SUMMARY Perioperative AKI is prevalent and associated with significant morbidity and mortality. Considering the lack of effective preventive or therapeutic interventions, this review focuses on perioperative AKI: measures for early diagnosis, defining risks and possible mechanisms, and summarizing current knowledge for intraoperative fluid and hemodynamic management to reduce risk of AKI.
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Acute Kidney Injury in Trauma Patients Admitted to Critical Care: Development and Validation of a Diagnostic Prediction Model. Sci Rep 2018; 8:3665. [PMID: 29483607 PMCID: PMC5827665 DOI: 10.1038/s41598-018-21929-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 02/07/2018] [Indexed: 12/17/2022] Open
Abstract
Acute Kidney Injury (AKI) complicating major trauma is associated with increased mortality and morbidity. Traumatic AKI has specific risk factors and predictable time-course facilitating diagnostic modelling. In a single centre, retrospective observational study we developed risk prediction models for AKI after trauma based on data around intensive care admission. Models predicting AKI were developed using data from 830 patients, using data reduction followed by logistic regression, and were independently validated in a further 564 patients. AKI occurred in 163/830 (19.6%) with 42 (5.1%) receiving renal replacement therapy (RRT). First serum creatinine and phosphate, units of blood transfused in first 24 h, age and Charlson score discriminated need for RRT and AKI early after trauma. For RRT c-statistics were good to excellent: development: 0.92 (0.88–0.96), validation: 0.91 (0.86–0.97). Modelling AKI stage 2–3, c-statistics were also good, development: 0.81 (0.75–0.88) and validation: 0.83 (0.74–0.92). The model predicting AKI stage 1–3 performed moderately, development: c-statistic 0.77 (0.72–0.81), validation: 0.70 (0.64–0.77). Despite good discrimination of need for RRT, positive predictive values (PPV) at the optimal cut-off were only 23.0% (13.7–42.7) in development. However, PPV for the alternative endpoint of RRT and/or death improved to 41.2% (34.8–48.1) highlighting death as a clinically relevant endpoint to RRT.
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Matsuura R, Srisawat N, Claure-Del Granado R, Doi K, Yoshida T, Nangaku M, Noiri E. Use of the Renal Angina Index in Determining Acute Kidney Injury. Kidney Int Rep 2018; 3:677-683. [PMID: 29854976 PMCID: PMC5976819 DOI: 10.1016/j.ekir.2018.01.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/12/2018] [Accepted: 01/30/2018] [Indexed: 12/12/2022] Open
Abstract
Introduction The renal angina index (RAI) is determined based on changes in the creatinine and condition scores of patients. The aim of this study is to evaluate the efficacy of the RAI in predicting persistent acute kidney injury (AKI) in Asian intensive care unit (ICU) patients. Methods This is a subanalysis of 3 prospective studies conducted in Japan and Thailand. The RAI was calculated for all enrolled patients using the method of Goldstein and colleagues, with a minor modification for adults on day 2. To determine the accuracy of RAI further, we evaluated a subgroup of patients for whom baseline serum creatinine values were available at ICU admission (i.e., those with hospital-acquired AKI). AKI biomarkers were evaluated for their efficacy in improving the performance of RAI. The outcome was defined as AKI stage 2 or 3 over 48 hours. Results Of the 263 patients analyzed, a total of 22 progressed to stage 2 or 3 AKI over 48 hours. The RAI was associated with an area under the curve (AUC) of 0.63 in receiver-operating characteristics analysis, with a cutoff of 10. In those admitted from general wards, the RAI had good performance, with an AUC of 0.73 and a cutoff of 6. A combination of L-type fatty acid–binding protein with the RAI improved the predictive performance for assessing persistent AKI with an AUC of 0.79. Conclusion The RAI may be effective in predicting persistent AKI in adult patients admitted from general wards. Incorporation of AKI biomarkers into the RAI may potentially improve prediction.
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Affiliation(s)
- Ryo Matsuura
- Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Japan
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Chulalongkorn University, Thailand
| | | | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Japan
| | - Teruhiko Yoshida
- Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Japan
| | - Masaomi Nangaku
- Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Japan
| | - Eisei Noiri
- Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Japan
- Correspondence: Eisei Noiri, Department of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan.
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Basu RK, Kaddourah A, Goldstein SL. Assessment of a renal angina index for prediction of severe acute kidney injury in critically ill children: a multicentre, multinational, prospective observational study. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:112-120. [PMID: 30035208 DOI: 10.1016/s2352-4642(17)30181-5] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Acute kidney injury (AKI) occurs in one in four children admitted to the intensive care unit (ICU) and AKI severity is independently associated with increased patient morbidity and mortality. Early prediction of AKI has the potential to improve outcomes. In smaller, single center populations, we have previously derived and validated the performance of the renal angina index (RAI), a context driven risk stratification system, to predict severe AKI. Methods A prospective, observational study (AWARE1, January-December 2014) was conducted in intensive care units from 32 centers in 9 countries. The primary outcome was the presence of severe AKI ("AKIS"; Stage 2-3 AKI KDIGO guidelines) on the third day after ICU admission (). We compared the performance of the RAI to changes in serum creatinine relative to baseline (SCr/Base) for prediction of the primary outcome and secondary outcomes of interest. A RAI ≥ 8 defined fulfillment of renal angina (RA+); RA+ was compared to SCr increased relative to baseline ("SCr>Base"; using maximum SCr in first 12 hours of ICU admission). Findings The 1590 patients studied were 55% male and had median age of 54.5 months. 286 patients (17.9%) were RA+. AKIS occurred in 121 (42.3%) RA+ vs. 247 (18.9%) RA-patients (relative risk (RR) 2.23; 95% confidence interval (CI): 1.87-2.66, p<0.001). 368 (23.1%) patients with AKIS had increased renal replacement therapy utilization (10.9% vs. 1.5%, p<0.001) and increased mortality (7.6% vs. 4.3%, p=0.01) compared to patients without AKIS. RA+ demonstrated better prediction for AKIS than SCr>Base (RR: 1.61; (1.33-1.93), p<0.001) which was maintained on multivariate regression (independent odds ratio (OR): RA+ 3.21; 95% CI (2.20-4.67) vs. SCr>Base 0.68; 95% CI (0.49-4.94)). Interpretation Earlier, better prediction of severe AKI has the potential to improve AKI associated patient outcomes. Compared to isolated, context-free changes in SCr, renal angina risk assessment improved accuracy for prediction of severe AKI in critically ill children and young adults.
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Affiliation(s)
- Rajit K Basu
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Atlanta, GA 30322
| | - Ahmad Kaddourah
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Atlanta, GA 30322.,Center for Acute Care Nephrology, Cincinnati Children's Hospital and Medical Center, University of Cincinnati, Department of Pediatrics, Cincinnati, Ohio 45229
| | - Stuart L Goldstein
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Atlanta, GA 30322
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31
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Gist KM, Goldstein SL, Wrona J, Alten JA, Basu RK, Cooper DS, Soranno DE, Duplantis J, Altmann C, Gao Z, Faubel S. Kinetics of the cell cycle arrest biomarkers (TIMP-2*IGFBP-7) for prediction of acute kidney injury in infants after cardiac surgery. Pediatr Nephrol 2017; 32:1611-1619. [PMID: 28382566 DOI: 10.1007/s00467-017-3655-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/22/2017] [Accepted: 03/14/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Tissue inhibitor metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein-7 (IGFBP-7) are cell-cycle arrest biomarkers that have been shown to be predictive of acute kidney injury (AKI) in critically ill adults. AKI affects a large proportion (40%) of children following cardiac surgery. The aim of this study was to describe the kinetics of TIMP-2*IGFBP-7 and test its ability to predict AKI in infants following cardiac surgery. METHODS A multicenter prospective study was performed in infants undergoing cardiac surgery with cardiopulmonary bypass (CPB) from October 2013 to January 2015. Urine samples were obtained at baseline and at 2, 6, 12, 24, 48 and 72 h after CPB initiation. TIMP-2*IGFBP-7 concentration was measured in urine samples using the Astute 140® meter to determine a risk score for AKI. This risk score is the product of TIMP-2 (ng/mL) and IGFBP-7 (ng/mL) divided by 1000. RESULTS A total of 94 infants with a mean age of 154.2 ± 85.7 days were enrolled in the study, of whom 31 (33%) subsequently developed AKI. The mean time to AKI diagnosis was 25 ± 7 h after CPB initiation. The concentration of TIMP-2*IGFBP-7 was significantly higher in patients with AKI at 12 h after CPB initiation relative to baseline (p = 0.006). At 12 h after CPB initiation patients with a TIMP-2*IGFBP-7 concentration of ≥0.78 had a threefold higher odds of developing AKI than those with a TIMP-2*IGFBP-7 concentration of < 0.78 (95% confidence interval 1.47-6.11, p = 0.001). CONCLUSION These results demonstration that TIMP-2*IGFBP-7 concentration can be used in infants to predict subsequent serum creatinine-defined AKI following CPB.
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Affiliation(s)
- Katja M Gist
- Children's Hospital Colorado-The University of Colorado, 13123 E 16th Ave, Aurora, CO, 80045, USA. .,The Heart Institute, Children's Hospital Colorado, 13123 E 16th Ave, B100, Aurora, CO, 80045, USA.
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7022, Cincinnati, OH, 45229, USA
| | - Julia Wrona
- The Heart Institute, Children's Hospital Colorado, 13123 E 16th Ave, B100, Aurora, CO, 80045, USA
| | - Jeffrey A Alten
- Pediatric Critical Care Medicine, Children's of Alabama-University of Alabama, WIC 1799 6th Ave S, Suite 9100 176 F, Birmingham, AL, 35233, USA
| | - Rajit K Basu
- Pediatric Critical Care Medicine, Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2005, Cincinnati, OH, 45229, USA
| | - David S Cooper
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA
| | - Danielle E Soranno
- Children's Hospital Colorado-The University of Colorado, 13123 E 16th Ave, Aurora, CO, 80045, USA.,The Kidney Center, Children's Hospital Colorado-The University of Colorado, 13123 E 16th Ave, Aurora, CO, 80045, USA
| | - Jane Duplantis
- Children's Hospital Colorado-The University of Colorado, 13123 E 16th Ave, Aurora, CO, 80045, USA.,The Kidney Center, Children's Hospital Colorado-The University of Colorado, 13123 E 16th Ave, Aurora, CO, 80045, USA
| | - Christopher Altmann
- Department of Internal Medicine, Division of Renal Disease and Hypertension, University of Colorado Anschutz Medical Campus, 12700 E 19th Ave, Box C281, Aurora, CO, 80045, USA
| | - Zhiqian Gao
- Heart Institute Research Core, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC, Cincinnati, OH, 45229, USA
| | - Sarah Faubel
- Department of Internal Medicine, Division of Renal Disease and Hypertension, University of Colorado Anschutz Medical Campus, 12700 E 19th Ave, Box C281, Aurora, CO, 80045, USA
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Abstract
Acute kidney injury (AKI) is characterized by an acute decline in renal function and is associated to increased mortality rate, hospitalization time, and total health-related costs. The severity of this ‘fearsome’ clinical complication might depend on, or even be worsened by, the late detection of AKI, when the diagnosis is based on the elevation of serum creatinine (SCr). For these reasons, in recent years a great number of new tools, biomarkers and predictive models have been proposed to clinicians in order to improve diagnosis and prevent the development of AKI. The purpose of this narrative paper is to review the current state of the art in prediction and early detection of AKI and outline future challenges.
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Affiliation(s)
- Simona Pozzoli
- Chair of Nephrology - IRCCS San Raffaele Scientific Institute, Genomics of Renal Diseases and Hypertension Unit, Università Vita Salute San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Marco Simonini
- Chair of Nephrology - IRCCS San Raffaele Scientific Institute, Genomics of Renal Diseases and Hypertension Unit, Università Vita Salute San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
| | - Paolo Manunta
- Chair of Nephrology - IRCCS San Raffaele Scientific Institute, Genomics of Renal Diseases and Hypertension Unit, Università Vita Salute San Raffaele, Via Olgettina 60, 20132, Milan, Italy
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Jia HM, Huang LF, Zheng Y, Li WX. Diagnostic value of urinary tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 for acute kidney injury: a meta-analysis. Crit Care 2017; 21:77. [PMID: 28340605 PMCID: PMC5366112 DOI: 10.1186/s13054-017-1660-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 02/28/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7), inducers of G1 cell cycle arrest, are two recently discovered good biomarkers for early diagnosis of acute kidney injury (AKI). To obtain a more robust performance measurement, the present meta-analysis was performed, pooling existing studies. METHODS Literature in the MEDLINE (via PubMed), Ovid, Embase, and Cochrane Library databases was systematically searched from inception to 12 October 2016. Studies that met the set inclusion and exclusion criteria were identified by two independent investigators. The diagnostic value of urinary [TIMP-2] × [IGFBP7] for AKI was evaluated by pooled sensitivity, specificity, likelihood ratio (LR), diagnostic odds ratio (DOR), and summary receiver operating characteristic (SROC) curve analyses. The causes of heterogeneity were explored by sensitivity and subgroup analyses. RESULTS A total of nine published and eligible studies assessing 1886 cases were included in this meta-analysis. Early diagnostic value of urinary [TIMP-2] × [IGFBP7] for AKI was assessed using a random-effects model. Pooled sensitivity and specificity with corresponding 95% CIs were 0.83 (95% CI 0.79-0.87, heterogeneity I 2 = 68.8%) and 0.55 (95% CI 0.52-0.57, I 2 = 92.9%), respectively. Pooled positive LR, negative LR, and DOR were 2.37 (95% CI 1.87-2.99, I 2 = 82.6%), 0.30 (95% CI 0.21-0.41, I 2 = 43.4%), and 9.92 (95% CI 6.09-16.18, I 2 = 38.5%), respectively. The AUC estimated by SROC was 0.846 (SE 0.027) with a Q* value of 0.777 (SE 0.026). Sensitivity analysis indicated that one study significantly affected the stability of pooled results. Subgroup analysis showed that population setting and AKI threshold were the key factors causing heterogeneity in pooled sensitivity and specificity. CONCLUSIONS On the basis of recent evidence, urinary [TIMP-2] × [IGFBP7] is an effective predictive factor of AKI. TRIAL REGISTRATION PROSPERO registration number: CRD42016051186 . Registered on 10 November 2016.
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Affiliation(s)
- Hui-Miao Jia
- Department of Surgical Intensive Care Unit, Beijing Chao-yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020 China
| | - Li-Feng Huang
- Department of Surgical Intensive Care Unit, Beijing Chao-yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020 China
| | - Yue Zheng
- Department of Surgical Intensive Care Unit, Beijing Chao-yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020 China
| | - Wen-Xiong Li
- Department of Surgical Intensive Care Unit, Beijing Chao-yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020 China
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Brocca A, Virzì GM, de Cal M, Giavarina D, Carta M, Ronco C. Elevated Levels of Procalcitonin and Interleukin-6 are Linked with Postoperative Complications in Cardiac Surgery. Scand J Surg 2017; 106:318-324. [PMID: 28737097 DOI: 10.1177/1457496916683096] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury is a frequent and serious postoperative complication of cardiac surgery and is associated with an increased risk of morbidity, mortality, and length stay. In this study, we hypothesized that persistent elevation in inflammation in the first 48 h might be a powerful predictor of clinical outcome. Our aim was to elucidate the usefulness of interleukin-6 and procalcitonin postoperative levels in predicting mortality and renal complications in cardiac surgery patients. METHODS A total of 122 cardiac surgery patients were enrolled. Procalcitonin and interleukin-6 concentrations were measured on the second postoperative day, and their levels were evaluated versus a number of conditions and endpoints. RESULTS Procalcitonin has a good predictive value for adverse renal outcome (p < 0.05). Interleukin-6 has a good predictive value for 30 days and overall mortality in cardiac surgery population (p < 0.05). We did not observe a significant difference in procalcitonin and interleukin-6 levels among patients with different types of surgery and different extracorporeal circulation time, but the levels of both the molecules increase significantly depending on number of transfusions received by patients (p < 0.01). CONCLUSION We speculated that procalcitonin and interleukin-6 could be two effective biomarkers. There is a possibility of having a combined inflammatory multi-biomarker panel, with procalcitonin for predicting renal outcome and interleukin-6 for predicting mortality.
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Affiliation(s)
- A Brocca
- 1 IRRIV-International Renal Research Institute of Vicenza, Vicenza, Italy.,2 Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy.,3 Department of Medicine-DIMED, Medical School, University of Padova, Padova, Italy
| | - G M Virzì
- 1 IRRIV-International Renal Research Institute of Vicenza, Vicenza, Italy.,2 Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - M de Cal
- 1 IRRIV-International Renal Research Institute of Vicenza, Vicenza, Italy.,2 Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - D Giavarina
- 4 Clinical Chemistry and Haematology Laboratory, San Bortolo Hospital, Vicenza, Italy
| | - M Carta
- 4 Clinical Chemistry and Haematology Laboratory, San Bortolo Hospital, Vicenza, Italy
| | - C Ronco
- 1 IRRIV-International Renal Research Institute of Vicenza, Vicenza, Italy.,2 Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
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35
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Schrezenmeier EV, Barasch J, Budde K, Westhoff T, Schmidt-Ott KM. Biomarkers in acute kidney injury - pathophysiological basis and clinical performance. Acta Physiol (Oxf) 2017; 219:554-572. [PMID: 27474473 DOI: 10.1111/apha.12764] [Citation(s) in RCA: 201] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/06/2016] [Accepted: 07/26/2016] [Indexed: 12/12/2022]
Abstract
Various biomarkers of acute kidney injury (AKI) have been discovered and characterized in the recent past. These molecules can be detected in urine or blood and signify structural damage to the kidney. Clinically, they are proposed as adjunct diagnostics to serum creatinine and urinary output to improve the early detection, differential diagnosis and prognostic assessment of AKI. The most obvious requirements for a biomarker include its reflection of the underlying pathophysiology of the disease. Hence, a biomarker of AKI should derive from the injured kidney and reflect a molecular process intimately connected with tissue injury. Here, we provide an overview of the basic pathophysiology, the cellular sources and the clinical performance of the most important currently proposed biomarkers of AKI: neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), liver-type fatty acid-binding protein (L-FABP), interleukin-18 (IL-18), insulin-like growth factor-binding protein 7 (IGFBP7), tissue inhibitor of metalloproteinase 2 (TIMP-2) and calprotectin (S100A8/9). We also acknowledge each biomarker's advantages and disadvantages as well as important knowledge gaps and perspectives for future studies.
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Affiliation(s)
- E. V. Schrezenmeier
- Department of Nephrology; Charité - Universitätsmedizin Berlin; Berlin Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association; Berlin Germany
| | - J. Barasch
- Division of Nephrology; Columbia University College of Physicians and Surgeons; New York NY USA
| | - K. Budde
- Department of Nephrology; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - T. Westhoff
- Medical Department I; Universitätsklinikum Marien Hospital Herne; Ruhr University of Bochum; Bochum Germany
| | - K. M. Schmidt-Ott
- Department of Nephrology; Charité - Universitätsmedizin Berlin; Berlin Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association; Berlin Germany
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36
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Meersch M, Schmidt C, Hoffmeier A, Van Aken H, Wempe C, Gerss J, Zarbock A. Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial. Intensive Care Med 2017; 43:1551-1561. [PMID: 28110412 PMCID: PMC5633630 DOI: 10.1007/s00134-016-4670-3] [Citation(s) in RCA: 539] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 12/28/2016] [Indexed: 12/13/2022]
Abstract
Purpose Care bundles are recommended in patients at high risk for acute kidney injury (AKI), although they have not been proven to improve outcomes. We sought to establish the efficacy of an implementation of the Kidney Disease Improving Global Outcomes (KDIGO) guidelines to prevent cardiac surgery-associated AKI in high risk patients defined by renal biomarkers. Methods In this single-center trial, we examined the effect of a “KDIGO bundle” consisting of optimization of volume status and hemodynamics, avoidance of nephrotoxic drugs, and preventing hyperglycemia in high risk patients defined as urinary [TIMP-2]·[IGFBP7] > 0.3 undergoing cardiac surgery. The primary endpoint was the rate of AKI defined by KDIGO criteria within the first 72 h after surgery. Secondary endpoints included AKI severity, need for dialysis, length of stay, and major adverse kidney events (MAKE) at days 30, 60, and 90. Results AKI was significantly reduced with the intervention compared to controls [55.1 vs. 71.7%; ARR 16.6% (95 CI 5.5–27.9%); p = 0.004]. The implementation of the bundle resulted in significantly improved hemodynamic parameters at different time points (p < 0.05), less hyperglycemia (p < 0.001) and use of ACEi/ARBs (p < 0.001) compared to controls. Rates of moderate to severe AKI were also significantly reduced by the intervention compared to controls. There were no significant effects on other secondary outcomes. Conclusion An implementation of the KDIGO guidelines compared with standard care reduced the frequency and severity of AKI after cardiac surgery in high risk patients. Adequately powered multicenter trials are warranted to examine mortality and long-term renal outcomes. Electronic supplementary material The online version of this article (doi:10.1007/s00134-016-4670-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine University, Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Christoph Schmidt
- Department of Anesthesiology, Intensive Care and Pain Medicine University, Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Andreas Hoffmeier
- Department of Cardiac Surgery, University of Münster, Münster, Germany
| | - Hugo Van Aken
- Department of Anesthesiology, Intensive Care and Pain Medicine University, Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Carola Wempe
- Department of Anesthesiology, Intensive Care and Pain Medicine University, Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine University, Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
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37
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Bennett MR, Pleasant L, Haffner C, Ma Q, Haffey WD, Ying J, Wagner M, Greis KD, Devarajan P. A Novel Biomarker Panel to Identify Steroid Resistance in Childhood Idiopathic Nephrotic Syndrome. Biomark Insights 2017; 12:1177271917695832. [PMID: 28469399 PMCID: PMC5391984 DOI: 10.1177/1177271917695832] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 01/23/2017] [Indexed: 12/13/2022] Open
Abstract
Idiopathic nephrotic syndrome (NS) is the most common glomerular disorder of childhood. Response to initial treatment with corticosteroids is an indicator of prognosis, as resistant patients often present more progressive disease. In this cross-sectional pilot study, we set out to discover a panel of noninvasive biomarkers that could distinguish steroid-resistant nephrotic syndrome (SRNS) from steroid-sensitive nephrotic syndrome (SSNS). Information gleaned from such a panel could yield more individualized treatment plans and prevent unnecessary steroid exposure in patients unlikely to respond. Urine was collected from 50 pediatric patients diagnosed with idiopathic NS at Cincinnati Children's Hospital Medical Center. Isobaric tags for relative and absolute quantitation (iTRAQ) was used to discover 13 proteins that were differentially expressed in SSNS vs SRNS in a small 5 × 5 discovery cohort. Suitable assays were found for 9 of the 13 markers identified by iTRAQ and were used in a 25 SRNS × 25 SSNS validation cohort. Vitamin D-binding protein (VDBP), alpha-1 acid glycoprotein 1 (AGP1), alpha-1 acid glycoprotein 2 (AGP2), alpha-1-B glycoprotein (A1BG), fetuin-A, prealbumin, thyroxine-binding globulin and hemopexin, and alpha-2 macroglobulin were measured and combined with urine neutrophil gelatinase-associated lipocalin (NGAL), which had been previously shown to distinguish patients with SRNS. Urinary VDBP, prealbumin, NGAL, fetuin-A, and AGP2 were found to be significantly elevated in SRNS using univariate analysis, with area under the receiver operating characteristic curves (AUCs) ranging from 0.65 to 0.81. Multivariate analysis revealed a panel of all 10 markers that yielded an AUC of 0.92 for identification of SRNS. A subset of 5 markers (including VDBP, NGAL, fetuin-A, prealbumin, and AGP2) showed significant associations with SRNS and yielded an AUC of 0.85.
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Affiliation(s)
- Michael R Bennett
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Michael R Bennett, Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML 7022, Cincinnati, OH 45229, USA.
| | - LaTawnya Pleasant
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Christopher Haffner
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Qing Ma
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Wendy D Haffey
- Department of Cancer and Cell Biology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jun Ying
- Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael Wagner
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Kenneth D Greis
- Department of Cancer and Cell Biology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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38
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Seller-Pérez G, Más-Font S, Pérez-Calvo C, Villa-Díaz P, Celaya-López M, Herrera-Gutiérrez ME. Acute kidney injury: Renal disease in the ICU. Med Intensiva 2016; 40:374-82. [PMID: 27388683 DOI: 10.1016/j.medin.2016.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 04/21/2016] [Accepted: 05/01/2016] [Indexed: 12/26/2022]
Abstract
Acute kidney injury (AKI) in the ICU frequently requires costly supportive therapies, has high morbidity, and its long-term prognosis is not as good as it has been presumed so far. Consequently, AKI generates a significant burden for the healthcare system. The problem is that AKI lacks an effective treatment and the best approach relies on early secondary prevention. Therefore, to facilitate early diagnosis, a broader definition of AKI should be established, and a marker with more sensitivity and early-detection capacity than serum creatinine - the most common marker of AKI - should be identified. Fortunately, new classification systems (RIFLE, AKIN or KDIGO) have been developed to solve these problems, and the discovery of new biomarkers for kidney injury will hopefully change the way we approach renal patients. As a first step, the concept of renal failure has changed from being a "static" disease to being a "dynamic process" that requires continuous evaluation of kidney function adapted to the reality of the ICU patient.
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Affiliation(s)
- G Seller-Pérez
- Intensive Care Medicine, Complejo Hospitalario Universitario Carlos Haya, Málaga, Spain
| | - S Más-Font
- Intensive Care Medicine, Hospital General Universitario de Castellón, Spain
| | - C Pérez-Calvo
- Intensive Care Medicine, HU Fundación Jiménez Díaz, Madrid, Spain
| | - P Villa-Díaz
- Intensive Care Medicine, Hospital Universitario Principe de Asturias, Alcalá de Henares, Madrid, Spain
| | - M Celaya-López
- Intensive Care Medicine, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - M E Herrera-Gutiérrez
- Intensive Care Medicine, Complejo Hospitalario Universitario Carlos Haya, Málaga, Spain.
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39
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Katz N, Ronco C. Acute kidney stress--a useful term based on evolution in the understanding of acute kidney injury. Crit Care 2016; 20:23. [PMID: 26796793 PMCID: PMC4722620 DOI: 10.1186/s13054-016-1184-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Critical care physicians have debated an appropriate term for the clinical phase preceding acute kidney injury (AKI). The recent development of cell cycle arrest biomarkers that signal the potential development of AKI is part of an evolution in the molecular diagnosis and understanding of AKI. It is proposed that the pre-injury phase that leads to AKI can be described as “acute kidney stress”. This term has the potential to expand horizons in regard to the early detection of situations that will lead to AKI and the early implementation of corrective measures.
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Affiliation(s)
- Nevin Katz
- Division of Cardiac Surgery, Johns Hopkins University, 1800 Orleans Street, Suite 7107, Baltimore, MD, 21287, USA. .,Foundation for the Advancement of Cardiothoracic Surgical Care (FACTS-Care), 1912 Foxhall Road, McLean, VA, 22101, USA.
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Renal Transplantation, International Renal Research Institute Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy
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40
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Kellum JA, Bellomo R, Ronco C. Does this patient have acute kidney injury? An AKI checklist. Intensive Care Med 2015; 42:96-9. [DOI: 10.1007/s00134-015-4026-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 08/08/2015] [Indexed: 12/18/2022]
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