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Strauß C, Booke H, Forni L, Zarbock A. Biomarkers of acute kidney injury: From discovery to the future of clinical practice. J Clin Anesth 2024; 95:111458. [PMID: 38581927 DOI: 10.1016/j.jclinane.2024.111458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 04/08/2024]
Abstract
Purpose of this review Acute kidney injury (AKI) is a complex syndrome whose development is associated with an increased morbidity and mortality. Recent studies show that this syndrome is a common complication in critically ill and surgical patients the trajectory of which may differ. As AKI can be induced by different triggers, it is complex and therefore challenging to manage patients with AKI. This review strives to provide a brief historical perspective on AKI, elucidate recent developments in diagnosing and managing AKI, and show the current usage of novel biomarkers in both clinical routine and research. In addition, we provide a perspective on potential future developments and their impact of AKI understanding and management. Recent findings/developments Recent studies show the merits of stress and damage biomarkers, highlighting limitations of the current KDIGO definition that only uses the functional biomarkers serum creatinine and urine output. The use of novel biomarkers led to the introduction of the concept of "subclinical AKI". This new classification may allow a more distinct management of affected or at risk patients. Ongoing studies, such as BigpAK-2 and PrevProgAKI, investigate the implementation of biomarker-guided interventions in clinical practice and may demonstrate an improvement in patients' outcome. Summary The ongoing scientific efforts surrounding AKI have deepened our understanding of the syndrome prompting an expansion of existing concepts. A future integration of stress and damage biomarkers in AKI management, may lead to an individualized therapy in this area.
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Affiliation(s)
- Christian Strauß
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Germany
| | - Hendrik Booke
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Germany
| | - Lui Forni
- School of Medicine, Kate Granger Building, Manor Park, University of Surrey, GU2 7YH, UK
| | - Alexander Zarbock
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
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2
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Chen Y, Gong Y, Zou J, Li G, Zhang F, Yang Y, Liang Y, Dai W, He L, Lu H. Single-cell transcriptomic analysis reveals transcript enrichment in oxidative phosphorylation, fluid sheer stress, and inflammatory pathways in obesity-related glomerulopathy. Genes Dis 2024; 11:101101. [PMID: 38560497 PMCID: PMC10978546 DOI: 10.1016/j.gendis.2023.101101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 06/20/2023] [Accepted: 07/24/2023] [Indexed: 04/04/2024] Open
Abstract
Obesity-related glomerulopathy (ORG) is an independent risk factor for chronic kidney disease and even progression to end-stage renal disease. Efforts have been undertaken to elucidate the mechanisms underlying the development of ORG and substantial advances have been made in the treatment of ORG, but relatively little is known about cell-specific changes in gene expression. To define the transcriptomic landscape at single-cell resolution, we analyzed kidney samples from four patients with ORG and three obese control subjects without kidney disease using single-cell RNA sequencing. We report for the first time that immune cells, including T cells and B cells, are decreased in ORG patients. Further analysis indicated that SPP1 was significantly up-regulated in T cells and B cells. This gene is related to inflammation and cell proliferation. Analysis of differential gene expression in glomerular cells (endothelial cells, mesangial cells, and podocytes) showed that these cell types were mainly enriched in genes related to oxidative phosphorylation, cell adhesion, thermogenesis, and inflammatory pathways (PI3K-Akt signaling, MAPK signaling). Furthermore, we found that the podocytes of ORG patients were enriched in genes related to the fluid shear stress pathway. Moreover, an evaluation of cell-cell communications revealed that there were interactions between glomerular parietal epithelial cells and other cells in ORG patients, with major interactions between parietal epithelial cells and podocytes. Altogether, our identification of molecular events, cell types, and differentially expressed genes may facilitate the development of new preventive or therapeutic approaches for ORG.
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Affiliation(s)
- Yinyin Chen
- Department of Nephrology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Hunan Clinical Research Center for Chronic Kidney Disease, Changsha, Hunan 410000, China
| | - Yushun Gong
- Department of Nephrology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Hunan Clinical Research Center for Chronic Kidney Disease, Changsha, Hunan 410000, China
| | - Jia Zou
- Department of Nephrology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Hunan Clinical Research Center for Chronic Kidney Disease, Changsha, Hunan 410000, China
| | - Guoli Li
- Department of Nephrology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Hunan Clinical Research Center for Chronic Kidney Disease, Changsha, Hunan 410000, China
| | - Fan Zhang
- Department of Nephrology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Hunan Clinical Research Center for Chronic Kidney Disease, Changsha, Hunan 410000, China
| | - Yiya Yang
- Department of Nephrology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Hunan Clinical Research Center for Chronic Kidney Disease, Changsha, Hunan 410000, China
| | - Yumei Liang
- Department of Nephrology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Hunan Clinical Research Center for Chronic Kidney Disease, Changsha, Hunan 410000, China
| | - Wenni Dai
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, Hunan 410011, China
| | - Liyu He
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, Hunan 410011, China
| | - Hengcheng Lu
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, Hunan 410011, China
- Cardiovascular Research Institute of Jiangxi Province, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi 330006, China
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3
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Frelich M, Vodička V, Jor O, Burša F, Sklienka P. Predicting Acute Kidney Injury in Trauma Patients: Biomarkers as Early Indicators. Med Sci Monit 2024; 30:e942271. [PMID: 38204152 PMCID: PMC10795410 DOI: 10.12659/msm.942271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/20/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common cause of organ failure in patients after major trauma and is associated with increased morbidity and mortality. Early identification of patients at risk enables the implementation of a bundle of supportive care, which reduces the incidence of AKI. The primary objective of our study was to investigate whether the levels of biomarkers on admission predicted the onset of early AKI in patients with serious injuries. MATERIAL AND METHODS This prospective observational study included 98 adult patients of both sexes with a serious injury (injury severity score >16). At admission, blood samples were taken, and creatinine, neutrophil gelatinase-associated lipocalin (NGAL), high mobility group box 1 (HMGB-1), and markers of rhabdomyolysis (creatine kinase, myoglobin) were evaluated. The patients were provided with standard resuscitation care, and the occurrence of AKI was monitored during the first 7 days after admission to the Intensive Care Unit, according to the Kidney Disease Improving Global Outcomes diagnostic criteria. RESULTS AKI occurred in 25 (25.5%) patients, in whom the admission levels of HMGB-1, NGAL, creatinine, and myoglobin were significantly higher than in non-AKI patients (48.3±98.4 vs 113.0±209.4 µg/L, P=0.006; 150.2±349.9 vs 181.4±152.2 µg/L, P=0.004; 83.1±20.8 vs 118.8±32.2 µmol/L, P<0.005; 2734.4±2214.5 vs 4182.3±2477.1 µg/L, P=0.008, respectively). Creatine kinase was 14.5±9.2 µkat/L in non-AKI patients and 13.7±7.9 µkat/L in AKI patients (P=0.916). CONCLUSIONS Admission levels of HMGB-1, NGAL, creatinine, and myoglobin predicted the risk of AKI in severely injured patients.
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Affiliation(s)
- Michal Frelich
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Ostrava, Czech Republic
- Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Vojtěch Vodička
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Ostrava, Czech Republic
| | - Ondřej Jor
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Ostrava, Czech Republic
- Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Filip Burša
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Ostrava, Czech Republic
- Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Peter Sklienka
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Ostrava, Czech Republic
- Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
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Novak R, Salai G, Hrkac S, Vojtusek IK, Grgurevic L. Revisiting the Role of NAG across the Continuum of Kidney Disease. Bioengineering (Basel) 2023; 10:bioengineering10040444. [PMID: 37106631 PMCID: PMC10136202 DOI: 10.3390/bioengineering10040444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/28/2023] [Accepted: 03/30/2023] [Indexed: 04/07/2023] Open
Abstract
Acute and chronic kidney diseases are an evolving continuum for which reliable biomarkers of early disease are lacking. The potential use of glycosidases, enzymes involved in carbohydrate metabolism, in kidney disease detection has been under investigation since the 1960s. N-acetyl-beta-D-glucosaminidase (NAG) is a glycosidase commonly found in proximal tubule epithelial cells (PTECs). Due to its large molecular weight, plasma-soluble NAG cannot pass the glomerular filtration barrier; thus, increased urinary concentration of NAG (uNAG) may suggest injury to the proximal tubule. As the PTECs are the workhorses of the kidney that perform much of the filtration and reabsorption, they are a common starting point in acute and chronic kidney disease. NAG has previously been researched, and it is widely used as a valuable biomarker in both acute and chronic kidney disease, as well as in patients suffering from diabetes mellitus, heart failure, and other chronic diseases leading to kidney failure. Here, we present an overview of the research pertaining to uNAG’s biomarker potential across the spectrum of kidney disease, with an additional emphasis on environmental nephrotoxic substance exposure. In spite of a large body of evidence strongly suggesting connections between uNAG levels and multiple kidney pathologies, focused clinical validation tests and knowledge on underlining molecular mechanisms are largely lacking.
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Affiliation(s)
- Ruder Novak
- Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Grgur Salai
- Department of Pulmonology, University Hospital Dubrava, 10000 Zagreb, Croatia
| | - Stela Hrkac
- Department of of Clinical Immunology, Allergology and Rheumatology, University Hospital Dubrava, 10000 Zagreb, Croatia
| | - Ivana Kovacevic Vojtusek
- Department of Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Lovorka Grgurevic
- Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Department of Anatomy, “Drago Perovic”, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
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Kongtasai T, Paepe D, Meyer E, Mortier F, Marynissen S, Stammeleer L, Defauw P, Daminet S. Renal biomarkers in cats: A review of the current status in chronic kidney disease. J Vet Intern Med 2022; 36:379-396. [PMID: 35218249 PMCID: PMC8965260 DOI: 10.1111/jvim.16377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 12/22/2022] Open
Abstract
Serum creatinine concentration, the classical biomarker of chronic kidney disease (CKD) in cats, has important limitations that decrease its value as a biomarker of early CKD. Recently, serum symmetric dimethylarginine concentration was introduced as a novel glomerular filtration rate biomarker for the early detection of CKD in cats. However, data on its specificity are still limited. The limitations of conventional biomarkers and the desire for early therapeutic intervention in cats with CKD to improve outcomes have prompted the discovery and validation of novel renal biomarkers to detect glomerular or tubular dysfunction. Changes in the serum or urinary concentrations of these biomarkers may indicate early kidney damage or predict the progression of kidney before changes in conventional biomarkers are detectable. This review summarizes current knowledge on renal biomarkers in CKD in cats, a field that has progressed substantially over the last 5 years.
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Affiliation(s)
- Thirawut Kongtasai
- Small Animal Department, Faculty of Veterinary Science, Ghent University, Merelbeke, Belgium.,Department of Clinical Sciences and Public Health, Faculty of Veterinary Science, Mahidol University, Nakhon Pathom, Thailand
| | - Dominique Paepe
- Small Animal Department, Faculty of Veterinary Science, Ghent University, Merelbeke, Belgium
| | - Evelyne Meyer
- Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Femke Mortier
- Small Animal Department, Faculty of Veterinary Science, Ghent University, Merelbeke, Belgium
| | - Sofie Marynissen
- Small Animal Department, Faculty of Veterinary Science, Ghent University, Merelbeke, Belgium
| | - Lisa Stammeleer
- Small Animal Department, Faculty of Veterinary Science, Ghent University, Merelbeke, Belgium
| | - Pieter Defauw
- Lumbry Park Veterinary Specialists, Alton, United Kingdom
| | - Sylvie Daminet
- Small Animal Department, Faculty of Veterinary Science, Ghent University, Merelbeke, Belgium
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6
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Ramírez M, Chakravarti S, Busovsky-McNeal M, McKinstry J, Al-qaqaa Y, Sahulee R, Kumar TS, Li X, Goldberg JD, Gefen AM, Malaga-Dieguez L. Elevated Levels of Urinary Biomarkers TIMP-2 and IGFBP-7 Predict Acute Kidney Injury in Neonates after Congenital Heart Surgery. J Pediatr Intensive Care 2021; 11:153-158. [PMID: 35734207 PMCID: PMC9208843 DOI: 10.1055/s-0041-1740359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 10/19/2021] [Indexed: 12/15/2022] Open
Abstract
Objectives This article investigated the utility of urine biomarkers tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein-7 (IGFBP-7) in identifying acute kidney injury (AKI) in neonates after congenital heart surgery (CHS). TIMP-2 and IGFBP-7 are cell cycle arrest proteins detected in urine during periods of kidney stress/injury. Methods We conducted a single-center, prospective study between September 2017 and May 2019 with neonates undergoing CHS requiring cardiopulmonary bypass (CPB). Urine samples were analyzed using NephroCheck prior to surgery and 6, 12, 24, and 96 hours post-CPB. All patients were evaluated using the Acute Kidney Injury Network (AKIN) criteria. Wilcoxon rank sum tests were used to compare the medians of the [TIMP-2*IGFBP-7] values in the AKIN negative and positive groups at each time point. Receiver operating characteristic curves were used to measure how well the [TIMP-2*IGFBP-7] values predict AKIN status. Results Thirty-six patients were included. No patients met the AKIN criteria for AKI preoperatively. Postoperatively, 19 patients (53%) met the AKIN criteria for AKI diagnosis: 13 (36%) stage 1, 5 (14%) stage 2, and 1 (3%) stage 3. None required renal replacement therapy. At the 24-hour time points, patients who met the AKIN criteria for AKI had a statistically significantly higher [TIMP-2*IGFBP7] values than the patients without AKI (1.1 vs. 0.27 [ng/mL] 2 /1,000) at 24 hours (adj- p = 0.0019). Conclusion AKI is a serious complication associated with adverse outcomes in patients undergoing cardiac surgery. [TIMP-2*IGFBP-7] urinary level 24 hours after CPB is a good predictor of AKI in this population.
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Affiliation(s)
- Michelle Ramírez
- Pediatric Cardiac Intensive Care, NYU Hassenfeld Children's Hospital, New York, United States,Address for correspondence Michelle Ramírez, MD 550 First Avenue New York, NY 10016United States
| | - Sujata Chakravarti
- Pediatric Cardiac Intensive Care, NYU Hassenfeld Children's Hospital, New York, United States
| | - Melissa Busovsky-McNeal
- Pediatric Cardiac Intensive Care, NYU Hassenfeld Children's Hospital, New York, United States
| | - Jaclyn McKinstry
- Pediatric Cardiac Intensive Care, NYU Hassenfeld Children's Hospital, New York, United States
| | - Yasir Al-qaqaa
- Pediatric Cardiac Intensive Care, NYU Hassenfeld Children's Hospital, New York, United States
| | - Raj Sahulee
- Pediatric Cardiac Intensive Care, NYU Hassenfeld Children's Hospital, New York, United States
| | - T.K. Susheel Kumar
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, United States
| | - Xiaochun Li
- Division of Biostatistics and NYU + HHC CTSI BERD, NYU Grossman School of Medicine, New York, United States
| | - Judith D. Goldberg
- Division of Biostatistics and NYU + HHC CTSI BERD, NYU Grossman School of Medicine, New York, United States
| | - Ashley M. Gefen
- Department of Nephrology, Cohen Children's Medical Center, New York, United States
| | - Laura Malaga-Dieguez
- Department of Nephrology, NYU Hassenfeld Children's Hospital, New York, United States
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7
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Zarbock A, Küllmar M, Ostermann M, Lucchese G, Baig K, Cennamo A, Rajani R, McCorkell S, Arndt C, Wulf H, Irqsusi M, Monaco F, Di Prima AL, García Alvarez M, Italiano S, Miralles Bagan J, Kunst G, Nair S, L'Acqua C, Hoste E, Vandenberghe W, Honore PM, Kellum JA, Forni LG, Grieshaber P, Massoth C, Weiss R, Gerss J, Wempe C, Meersch M. Prevention of Cardiac Surgery-Associated Acute Kidney Injury by Implementing the KDIGO Guidelines in High-Risk Patients Identified by Biomarkers: The PrevAKI-Multicenter Randomized Controlled Trial. Anesth Analg 2021; 133:292-302. [PMID: 33684086 DOI: 10.1213/ane.0000000000005458] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Prospective, single-center trials have shown that the implementation of the Kidney Disease: Improving Global Outcomes (KDIGO) recommendations in high-risk patients significantly reduced the development of acute kidney injury (AKI) after surgery. We sought to evaluate the feasibility of implementing a bundle of supportive measures based on the KDIGO guideline in high-risk patients undergoing cardiac surgery in a multicenter setting in preparation for a large definitive trial. METHODS In this multicenter, multinational, randomized controlled trial, we examined the adherence to the KDIGO bundle consisting of optimization of volume status and hemodynamics, functional hemodynamic monitoring, avoidance of nephrotoxic drugs, and prevention of hyperglycemia in high-risk patients identified by the urinary biomarkers tissue inhibitor of metalloproteinases-2 [TIMP-2] and insulin growth factor-binding protein 7 [IGFBP7] after cardiac surgery. The primary end point was the adherence to the bundle protocol and was evaluated by the percentage of compliant patients with a 95% confidence interval (CI) according to Clopper-Pearson. Secondary end points included the development and severity of AKI. RESULTS In total, 278 patients were included in the final analysis. In the intervention group, 65.4% of patients received the complete bundle as compared to 4.2% in the control group (absolute risk reduction [ARR] 61.2 [95% CI, 52.6-69.9]; P < .001). AKI rates were statistically not different in both groups (46.3% intervention versus 41.5% control group; ARR -4.8% [95% CI, -16.4 to 6.9]; P = .423). However, the occurrence of moderate and severe AKI was significantly lower in the intervention group as compared to the control group (14.0% vs 23.9%; ARR 10.0% [95% CI, 0.9-19.1]; P = .034). There were no significant effects on other specified secondary outcomes. CONCLUSIONS Implementation of a KDIGO-derived treatment bundle is feasible in a multinational setting. Furthermore, moderate to severe AKI was significantly reduced in the intervention group.
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Affiliation(s)
- Alexander Zarbock
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Mira Küllmar
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Marlies Ostermann
- Department of Critical Care, Guy's & St Thomas' National Health Service Foundation Hospital, London, United Kingdom
| | - Gianluca Lucchese
- Department of Critical Care, Guy's & St Thomas' National Health Service Foundation Hospital, London, United Kingdom
| | - Kamran Baig
- Department of Critical Care, Guy's & St Thomas' National Health Service Foundation Hospital, London, United Kingdom
| | - Armando Cennamo
- Department of Critical Care, Guy's & St Thomas' National Health Service Foundation Hospital, London, United Kingdom
| | - Ronak Rajani
- Department of Critical Care, Guy's & St Thomas' National Health Service Foundation Hospital, London, United Kingdom
| | - Stuart McCorkell
- Department of Critical Care, Guy's & St Thomas' National Health Service Foundation Hospital, London, United Kingdom
| | | | - Hinnerk Wulf
- Department of Anesthesiology and Intensive Care Medicine
| | - Marc Irqsusi
- Department of Cardiac Surgery, University Hospital Marburg, Marburg, Germany
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Ambra Licia Di Prima
- Department of Anesthesia and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | | | - Stefano Italiano
- Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jordi Miralles Bagan
- Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Gudrun Kunst
- Department of Anesthetics, King's College Hospital, Denmark Hill, London, United Kingdom
| | - Shrijit Nair
- Department of Anesthetics, King's College Hospital, Denmark Hill, London, United Kingdom
| | - Camilla L'Acqua
- Department of Anesthesia and Critical Care, Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Eric Hoste
- Department of Intensive Care Medicine, University Hospital Gent, Gent, Belgium
| | - Wim Vandenberghe
- Department of Intensive Care Medicine, University Hospital Gent, Gent, Belgium
| | - Patrick M Honore
- Department of Intensive Care, CHU Brugmann University Hospital, Brussels, Belgium
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lui G Forni
- Department of Intensive Care Medicine, Royal Surrey County Hospital & Faculty of Health Sciences, University of Surrey, Guildford, United Kingdom
| | - Philippe Grieshaber
- Department of Cardiac Surgery, University Hospital Giessen, Giessen, Germany
| | - Christina Massoth
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Raphael Weiss
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Carola Wempe
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Melanie Meersch
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
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8
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Albert C, Haase M, Albert A, Zapf A, Braun-Dullaeus RC, Haase-Fielitz A. Biomarker-Guided Risk Assessment for Acute Kidney Injury: Time for Clinical Implementation? Ann Lab Med 2021; 41:1-15. [PMID: 32829575 PMCID: PMC7443517 DOI: 10.3343/alm.2021.41.1.1] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/23/2020] [Accepted: 08/02/2020] [Indexed: 01/01/2023] Open
Abstract
Acute kidney injury (AKI) is a common and serious complication in hospitalized patients, which continues to pose a clinical challenge for treating physicians. The most recent Kidney Disease Improving Global Outcomes practice guidelines for AKI have restated the importance of earliest possible detection of AKI and adjusting treatment accordingly. Since the emergence of initial studies examining the use of neutrophil gelatinase-associated lipocalin (NGAL) and cycle arrest biomarkers, tissue inhibitor metalloproteinase-2 (TIMP-2) and insulin-like growth factor-binding protein (IGFBP7), for early diagnosis of AKI, a vast number of studies have investigated the accuracy and additional clinical benefits of these biomarkers. As proposed by the Acute Dialysis Quality Initiative, new AKI diagnostic criteria should equally utilize glomerular function and tubular injury markers for AKI diagnosis. In addition to refining our capabilities in kidney risk prediction with kidney injury biomarkers, structural disorder phenotypes referred to as "preclinical-" and "subclinical AKI" have been described and are increasingly recognized. Additionally, positive biomarker test findings were found to provide prognostic information regardless of an acute decline in renal function (positive serum creatinine criteria). We summarize and discuss the recent findings focusing on two of the most promising and clinically available kidney injury biomarkers, NGAL and cell cycle arrest markers, in the context of AKI phenotypes. Finally, we draw conclusions regarding the clinical implications for kidney risk prediction.
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Affiliation(s)
- Christian Albert
- Medical Faculty, University Clinic for Cardiology and Angiology, Otto-von-Guericke-University Magdeburg, Magdeburg,
Germany
- Diaverum Renal Services, MVZ Potsdam, Potsdam,
Germany
| | - Michael Haase
- Diaverum Renal Services, MVZ Potsdam, Potsdam,
Germany
- Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg,
Germany
| | - Annemarie Albert
- Diaverum Renal Services, MVZ Potsdam, Potsdam,
Germany
- Department of Nephrology and Endocrinology, Klinikum Ernst von Bergmann, Potsdam,
Germany
| | - Antonia Zapf
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf,
Germany
| | | | - Anja Haase-Fielitz
- Department of Cardiology, Immanuel Diakonie Bernau, Heart Center Brandenburg, Brandenburg Medical School Theodor Fontane (MHB),
Germany
- Institute of Social Medicine and Health Systems Research, Otto-von-Guericke University Magdeburg, Magdeburg,
Germany
- Faculty of Health Sciences Brandenburg, Potsdam,
Germany
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9
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Ilaria G, Kianoush K, Ruxandra B, Francesca M, Mariarosa C, Davide G, Claudio R. Clinical adoption of Nephrocheck® in the early detection of acute kidney injury. Ann Clin Biochem 2020; 58:6-15. [PMID: 33081495 DOI: 10.1177/0004563220970032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute kidney injury is a common complication of acute illnesses and is associated with increased morbidity and mortality. Over the past years several acute kidney injury biomarkers for diagnostication, decision-making processes, and prognosis of acute kidney injury and its outcomes have been developed and validated. Among these biomarkers, tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7), the so-called cell cycle arrest biomarkers, showed a superior profile of accuracy and stability even in patients with substantial comorbidities. Therefore, in 2014, the US Food and Drug Administration approved the use of the product of TIMP-2 and IGFBP7 ([TIMP-2] × [IGFBP7]), known as cell cycle arrest biomarkers, to aid critical care physicians and nephrologists in the early prediction of acute kidney injury in the critical care setting. To date, Nephrocheck® is the only commercially available test for [TIMP-2] × [IGFBP7]. In this narrative review, we describe the growing clinical and investigational momentum of biomarkers, focusing on [TIMP-2] × [IGFBP7], as one of the most promising candidate biomarkers. Additionally, we review the current state of clinical implementation of Nephrocheck®.
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Affiliation(s)
- Godi Ilaria
- International Renal Research Institute of Vicenza (IRRIV) San Bortolo Hospital, Vicenza, Italy.,Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care Medicine, University of Padova, Padova, Italy
| | - Kashani Kianoush
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Boteanu Ruxandra
- International Renal Research Institute of Vicenza (IRRIV) San Bortolo Hospital, Vicenza, Italy
| | - Martino Francesca
- International Renal Research Institute of Vicenza (IRRIV) San Bortolo Hospital, Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Carta Mariarosa
- Clinical Chemistry and Laboratory medicine, San Bortolo Hospital, Vicenza, Italy
| | - Giavarina Davide
- Clinical Chemistry and Laboratory medicine, San Bortolo Hospital, Vicenza, Italy
| | - Ronco Claudio
- International Renal Research Institute of Vicenza (IRRIV) San Bortolo Hospital, Vicenza, Italy.,Department of Medicine, University of Padova, Padova, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
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10
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Abstract
Acute kidney injury (AKI) is a life-threatening illness that continues to have an in-hospital mortality rate of patients with AKI ranges from 20% to 50% or greater, depending on underlying conditions. However, it has only marginally declined over the past 25 years. Previous authoritative publications have been pointed out that the lack of useful biomarkers for AKI has limited progress in improving the outcomes of this disorder. The purpose of this paper is to review the recent biomarkers involved in the early detection of AKI and main reasons for the failure to identify new AKI biomarkers. So far, several new AKI biomarkers have been discovered and validated to improve early diagnosis, degree of severity, pathophysiology, differential diagnosis, prediction for major kidney adverse events (MAKE, risk groups for progressive renal failure, need for renal replacement therapy [RRT], or death). These biomarkers can be classified into functional, damage and pre-injury phase biomarkers. However, the clinical use of the studied biomarkers in AKI prediction remains unclear because large prospective multicenter trials have failed to demonstrate troponin-like diagnostic performance. Reasons for the failure to identify AKI biomarkers are the heterogeneity of AKI itself, biomarker limitations and long roads to the validation of candidates for new AKI biomarkers. In an effort to overcome these barriers to identifying new AKI biomarkers, kidney biopsy specimens should be obtained and assessed in human AKI populations. Research in this field should be carried out in a pan-social approach rather than conducted by just a few medical institutions.
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Affiliation(s)
- Dong-Jin Oh
- Division of Nephrology, Department of Internal Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
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11
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Chapman CL, Johnson BD, Parker MD, Hostler D, Pryor RR, Schlader Z. Kidney physiology and pathophysiology during heat stress and the modification by exercise, dehydration, heat acclimation and aging. Temperature (Austin) 2020; 8:108-159. [PMID: 33997113 PMCID: PMC8098077 DOI: 10.1080/23328940.2020.1826841] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/17/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
The kidneys' integrative responses to heat stress aid thermoregulation, cardiovascular control, and water and electrolyte regulation. Recent evidence suggests the kidneys are at increased risk of pathological events during heat stress, namely acute kidney injury (AKI), and that this risk is compounded by dehydration and exercise. This heat stress related AKI is believed to contribute to the epidemic of chronic kidney disease (CKD) occurring in occupational settings. It is estimated that AKI and CKD affect upwards of 45 million individuals in the global workforce. Water and electrolyte disturbances and AKI, both of which are representative of kidney-related pathology, are the two leading causes of hospitalizations during heat waves in older adults. Structural and physiological alterations in aging kidneys likely contribute to this increased risk. With this background, this comprehensive narrative review will provide the first aggregation of research into the integrative physiological response of the kidneys to heat stress. While the focus of this review is on the human kidneys, we will utilize both human and animal data to describe these responses to passive and exercise heat stress, and how they are altered with heat acclimation. Additionally, we will discuss recent studies that indicate an increased risk of AKI due to exercise in the heat. Lastly, we will introduce the emerging public health crisis of older adults during extreme heat events and how the aging kidneys may be more susceptible to injury during heat stress.
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Affiliation(s)
- Christopher L. Chapman
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Human Physiology, University of Oregon, Eugene, OR, USA
| | - Blair D. Johnson
- Department of Kinesiology, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Mark D. Parker
- Department of Physiology and Biophysics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Ophthalmology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - David Hostler
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY, USA
| | - Riana R. Pryor
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY, USA
| | - Zachary Schlader
- Department of Kinesiology, School of Public Health, Indiana University, Bloomington, IN, USA
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12
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Schanz M, Wasser C, Allgaeuer S, Schricker S, Dippon J, Alscher MD, Kimmel M. Urinary [TIMP-2]·[IGFBP7]-guided randomized controlled intervention trial to prevent acute kidney injury in the emergency department. Nephrol Dial Transplant 2020; 34:1902-1909. [PMID: 29961888 DOI: 10.1093/ndt/gfy186] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/15/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Early detection and prevention of acute kidney injury (AKI) is important to reduce morbidity and mortality. Discovery of early-detection biomarkers has enabled early preventive approaches. There are no data on early biomarker-guided intervention with nephrological consultation in emergency departments (EDs). METHODS In this prospective randomized controlled intervention trial, patients at high risk for AKI were screened with urinary [TIMP-2]·[IGFBP7] in the ED of Robert-Bosch-Hospital (Stuttgart, Germany). We screened 257 eligible patients of whom 100 met the inclusion criteria, with urinary [TIMP-2]·[IGFBP7] >0.3, and were included. The intervention group received immediate one-time nephrological consultation after randomization, implementing Kidney Disease: Improving Global Outcomes (KDIGO) 2012 recommendations on AKI. The primary outcome was the incidence of moderate to severe AKI within the first day after admission. Secondary outcomes were AKI occurrence within 3 days after admission, need for renal replacement therapy (RRT), length of hospital stay and death. RESULTS The primary outcome did not differ significantly (P = 0.9) between the groups, neither within the first day nor within the first 3 days after admission. The intervention group had significantly (P < 0.05) lower serum creatinine (SCr) on Day 2 and lower maximum SCr and tended (P = 0.08) to have higher urine output (UOP) at Day 3 than the non-intervention group. No patient in the intervention group needed RRT (0 versus 3) during the hospital stay (P = 0.09). CONCLUSIONS One-time routine nephrologist-guided application of the KDIGO bundle in ED patients with a risk for AKI cannot currently be recommended. However, due to the uniform trend of study endpoints in favour of intervention, further trials to investigate larger cohorts of more severely ill patients are warranted. TRIAL REGISTRATION www.ClinicalTrials.gov, study number NCT02730637.
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Affiliation(s)
- Moritz Schanz
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital Stuttgart, Stuttgart, Germany
| | - Christoph Wasser
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital Stuttgart, Stuttgart, Germany
| | - Sebastian Allgaeuer
- Division of Intensive Care Medicine, Robert-Bosch-Hospital Stuttgart, Germany
| | - Severin Schricker
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital Stuttgart, Stuttgart, Germany
| | - Juergen Dippon
- Department of Mathematics, University Stuttgart, Stuttgart, Germany
| | - Mark Dominik Alscher
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital Stuttgart, Stuttgart, Germany
| | - Martin Kimmel
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital Stuttgart, Stuttgart, Germany
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13
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Ferrari F, Romero-González G, Topete LR, Senzolo M, Lorenzin A, Husain-Syed F, Puci MV, Ferraro OE, Muraro E, Serrano-Soto M, Triviño AM, Castro AC, Xie Y, Yang B, De Cal M, Corradi V, Brendolan A, Scarpa M, Carta MR, Giavarina D, Bonato R, Ronco C. Routine Adoption of Urinary [IGFBP7]∙[TIMP-2] to Assess Acute Kidney Injury at Any Stage 12 hours After Intensive Care Unit Admission: a Prospective Cohort Study. Sci Rep 2019; 9:16484. [PMID: 31712687 PMCID: PMC6848119 DOI: 10.1038/s41598-019-52790-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 10/22/2019] [Indexed: 01/12/2023] Open
Abstract
The urinary tissue inhibitor of metalloproteinases-2 and insulin-like growth factor-binding protein 7 ([TIMP-2]∙[IGFBP7]) have been introduced to improve risk prediction of severe acute kidney injury (AKI) within 12 hours of measurement. We performed a prospective cohort study to evaluate if the predictive value of [TIMP-2]∙[IGFBP7] for AKI might continue after 12 hours. We enrolled 442 critically ill adult patients from June to December 2016. Urine samples were collected at admission for [TIMP-2]∙[IGFBP7] measurement. Baseline patient characteristics were recorded including patients' demographics, prior health history, and the main reason for admission to build a logistic regression model to predict AKI. AKI occurrence differed between patients with [TIMP-2]∙[IGFBP7] ≤0.3 and >0.3 (ng/ml)2/1000 (31.9% and 68.10% respectively; p < 0.001). Patients with AKI had higher biomarker values compared to those without AKI (0.66 (0.21-2.84) vs 0.22 (0.08-0.63) (ng/ml)2/1000; p < 0.001). [TIMP-2]∙[IGFBP7] at ICU admission had a lower performance in predicting AKI at any stage within 48 hours and 7 days after measurement (area under the receiver operating characteristic curve (AUC) equal to 0.70 (95%CI 0.65-0.76), AUC 0.68 (95%CI 0.63-0.73)). In the logistic regression model, 0.1 (ng/ml)2/1000-unit increment was likely to increase the risk of AKI by 2% (p = 0.002).
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Affiliation(s)
- Fiorenza Ferrari
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy.
- Intensive Care Unit, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy.
| | - Gregorio Romero-González
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
- Clínica Universidad de Navarra, Avenida Pio XII #36, 31008, Pamplona, Spain
| | - Lilia Rizo Topete
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
- University Hospital "José Eleuterio González", Francisco I Madero s/n and Gonzalitos, Colonia Mitras Centro - 64460 -Monterrey, Nuevo León, Mexico
| | - Mara Senzolo
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
| | - Anna Lorenzin
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
| | - Faeq Husain-Syed
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
- Department of Internal Medicine II, Division of Pulmonology, Nephrology and Critical Care Medicine, University Clinic Giessen and Marburg - Campus Giessen, 35392, Giessen, Germany
| | - Mariangela Valentina Puci
- Department of Public Health, Experimental and Forensic Medicine, Unit of Biostatistics and Clinical Epidemiology, University of Pavia, Via Forlanini, 2, 27100, Pavia, Italy
| | - Ottavia Eleonora Ferraro
- Department of Public Health, Experimental and Forensic Medicine, Unit of Biostatistics and Clinical Epidemiology, University of Pavia, Via Forlanini, 2, 27100, Pavia, Italy
| | - Eva Muraro
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
- DISCOG - Department of Surgery, Kidney and Pancreas Transplant, University of Padova, via Giustiniani 2, 35128, Padova, Italy
| | - Mara Serrano-Soto
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
- Nephrology Service Nephrology Service Marques de Valdecilla - Universitary Hospital Valdecilla Avenue 25, 39008, Santander, Cantabria, Spain
| | - Alejandra Molano Triviño
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
- Nephrology and Dialysis Service RTS - Fundación Cardioinfantil, calle 163 A N° 13B-60- 110111, Bogotá, Colombia
| | - Ana Coutinho Castro
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
- Department of Nephrology, Dialysis and Transplantation. Oporto Hospital Center Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - Yun Xie
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
- Department of Nephrology, Xin Hua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, South Chongqing Road no. 227, 200025, Shanghai, China
| | - Bo Yang
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
- Department of Nephrology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88, Chang Ling Road, Li Qi Zhuang Jie, Xi Qing District, Tianjin, P.R. China
| | - Massimo De Cal
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
| | - Valentina Corradi
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
| | - Alessandra Brendolan
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
| | - Marta Scarpa
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
- Intensive Care Unit, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
| | - Maria Rosa Carta
- Department of Laboratory Medicine, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
| | - Davide Giavarina
- Department of Laboratory Medicine, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
| | - Raffaele Bonato
- Intensive Care Unit, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi, 37- 36100, Vicenza, Italy
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14
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Schlader ZJ, Hostler D, Parker MD, Pryor RR, Lohr JW, Johnson BD, Chapman CL. The Potential for Renal Injury Elicited by Physical Work in the Heat. Nutrients 2019; 11:nu11092087. [PMID: 31487794 PMCID: PMC6769672 DOI: 10.3390/nu11092087] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 02/06/2023] Open
Abstract
An epidemic of chronic kidney disease (CKD) is occurring in laborers who undertake physical work in hot conditions. Rodent data indicate that heat exposure causes kidney injury, and when this injury is regularly repeated it can elicit CKD. Studies in humans demonstrate that a single bout of exercise in the heat increases biomarkers of acute kidney injury (AKI). Elevations in AKI biomarkers in this context likely reflect an increased susceptibility of the kidneys to AKI. Data largely derived from animal models indicate that the mechanism(s) by which exercise in the heat may increase the risk of AKI is multifactorial. For instance, heat-related reductions in renal blood flow may provoke heterogenous intrarenal blood flow. This can promote localized ischemia, hypoxemia and ATP depletion in renal tubular cells, which could be exacerbated by increased sodium reabsorption. Heightened fructokinase pathway activity likely exacerbates ATP depletion occurring secondary to intrarenal fructose production and hyperuricemia. Collectively, these responses can promote inflammation and oxidative stress, thereby increasing the risk of AKI. Equivalent mechanistic evidence in humans is lacking. Such an understanding could inform the development of countermeasures to safeguard the renal health of laborers who regularly engage in physical work in hot environments.
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Affiliation(s)
- Zachary J Schlader
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY 14214, USA.
- Department of Kinesiology, School of Public Health, Indiana University, Bloomington, IN 47405, USA.
| | - David Hostler
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - Mark D Parker
- Department of Physiology and Biophysics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14214, USA
- Department of Ophthalmology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - Riana R Pryor
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - James W Lohr
- Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - Blair D Johnson
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - Christopher L Chapman
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY 14214, USA
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15
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16
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Tai Q, Yi H, Wei X, Xie W, Zeng O, Zheng D, Sun J, Wang G, Wang S, Liu G. The Accuracy of Urinary TIMP-2 and IGFBP7 for the Diagnosis of Cardiac Surgery-Associated Acute Kidney Injury: A Systematic Review and Meta-Analysis. J Intensive Care Med 2018; 35:1013-1025. [PMID: 30376758 DOI: 10.1177/0885066618807124] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7) are recent promising markers for identification of cardiac surgery-associated acute kidney injury (CSA-AKI). The aim of this study was systematically and quantitatively to evaluate the accuracy of urinary TIMP-2 and IGFBP7 for the diagnosis of CSA-AKI. Methods: Three databases including PubMed, ISI web of knowledge, and Embase were systematically searched from inception to March 2018. Two investigators conducted the processes of literature search study selection, data extraction, and quality evaluation independently. Meta-DiSc and STATA were used for all statistical analyses. Results: A total of 8 studies comprising 552 patients were included in this meta-analysis. Pooled sensitivity and specificity with corresponding 95% confidence intervals (CIs) were 0.79 (95% CI, 0.71-0.86, I 2 = 74.2%) and 0.76 (95% CI, 0.72-0.80, I 2 = 80.8%), respectively. Pooled positive likelihood ratio (LR), negative LR, and diagnostic odds ratio were 3.49 (95% CI, 2.44-5.00, I 2 = 61.5%), 0.31(95% CI, 0.19-0.51, I 2 = 51.8%), and 14.89 (95% CI, 7.31-30.32, I 2 = 27.9%), respectively. The area under curve estimated by summary receiver operating characteristic was 0.868 (standard error [SE] 0.032) with a Q* value of 0.799 (SE 0.032). Sensitivity analysis demonstrated that one study notably affected the stability of pooled results. One of the subgroups investigated—AKI threshold—could account for partial heterogeneity. Conclusion: Urinary TIMP-2 and IGFBP7 is a helpful biomarker for early diagnosis of CSA-AKI. And, the potential of this biomarker with a broader spectrum of clinical settings may be the focus of future studies.
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Affiliation(s)
- Qiang Tai
- Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Province, PR China
- Significance for "*" refer to co-first author
| | - Huimin Yi
- Surgical Intensive Care Unit, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province, PR China
- Significance for "*" refer to co-first author
| | - Xuxia Wei
- Surgical Intensive Care Unit, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province, PR China
| | - Wenfeng Xie
- Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Province, PR China
| | - Ou Zeng
- Department of Cardiology Intensive Care Unit, First People's Hospital of Chenzhou, Hunan Province, PR China
| | - Donghua Zheng
- Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Province, PR China
| | - Jiaqi Sun
- Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Province, PR China
| | - Ganping Wang
- Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Province, PR China
| | - Siqi Wang
- Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Province, PR China
| | - Genglong Liu
- Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Province, PR China
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17
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van den Berg MF, Schoeman JP, Defauw P, Whitehead Z, Breemersch A, Goethals K, Daminet S, Meyer E. Assessment of acute kidney injury in canine parvovirus infection: Comparison of kidney injury biomarkers with routine renal functional parameters. Vet J 2018; 242:8-14. [PMID: 30503549 DOI: 10.1016/j.tvjl.2018.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 10/06/2018] [Accepted: 10/08/2018] [Indexed: 12/29/2022]
Abstract
Dogs with naturally occurring canine parvovirus (CPV) infection are at risk of developing acute kidney injury (AKI) due to several factors, including severe dehydration, hypotension and sepsis. Serum creatinine (sCr) and serum urea are insensitive markers for the assessment of early kidney injury. Therefore, the aim of this study was to investigate potential kidney injury in dogs with CPV infection using both routine renal functional parameters and several kidney injury biomarkers. Twenty-two dogs with CPV infection were prospectively enrolled and compared with eight clinically healthy control dogs. Urinary immunoglobulin G (uIgG) and C-reactive protein (uCRP) were measured to document glomerular injury, whereas urinary retinol-binding protein (uRBP) and neutrophil gelatinase-associated lipocalin (uNGAL) served as markers for tubular injury. These biomarkers were compared to routine renal functional parameters, including sCr, serum urea, urinary protein:creatinine ratio (UPC) and urine specific gravity (USG). Dogs with CPV infection had significantly higher concentrations of uIgG, uCRP, uRBP and uNGAL compared to healthy dogs. In contrast, sCr was significantly lower in dogs with CPV infection compared to controls, while serum urea was not significantly different. UPC and USG were both significantly higher in CPV-infected dogs. This study demonstrated that dogs with CPV infection had evidence of AKI, which remained undetected by the routine functional markers sCr and serum urea, but was revealed by UPC, uIgG, uCRP, uRBP and uNGAL. These results emphasize the added value of novel urinary kidney injury biomarkers to detect canine patients at risk of developing AKI.
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Affiliation(s)
- M F van den Berg
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium.
| | - J P Schoeman
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Onderstepoort 0110, South Africa
| | - P Defauw
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium
| | - Z Whitehead
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Onderstepoort 0110, South Africa
| | - A Breemersch
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium
| | - K Goethals
- Department of Nutrition, Genetics and Ethology, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium
| | - S Daminet
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium
| | - E Meyer
- Department of Pharmacology, Biochemistry and Toxicology, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium
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18
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Leow EH, Chan YH, Ng YH, Lim JKB, Nakao M, Lee JH. Prevention of Acute Kidney Injury in Children Undergoing Cardiac Surgery: A Narrative Review. World J Pediatr Congenit Heart Surg 2018; 9:79-90. [PMID: 29310552 DOI: 10.1177/2150135117743211] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Children undergoing cardiac surgery are at risk of developing acute kidney injury (AKI). Preventing cardiac surgery-associated AKI (CS-AKI) is important as it is associated with increased early- and long-term mortality and morbidity. Targeting modifiable risk factors (eg, avoiding poor renal perfusion, nephrotoxic drugs, and fluid overload) reduces the risk of CS-AKI. There is currently no strong evidence for the routine use of pharmacological approaches (eg, aminophylline, dexmedetomidine, fenoldopam, and steroids) to prevent CS-AKI. There is robust evidence to support the role of early peritoneal dialysis as a nonpharmacologic approach to prevent CS-AKI.
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Affiliation(s)
- Esther Huimin Leow
- 1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoke Hwee Chan
- 2 Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,3 Duke-NUS School of Medicine, Singapore, Singapore
| | - Yong Hong Ng
- 1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Joel Kian Boon Lim
- 1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Masakazu Nakao
- 4 Department of Paediatric Cardiothoracic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- 2 Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,3 Duke-NUS School of Medicine, Singapore, Singapore
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19
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Ortega LM, Heung M. The use of cell cycle arrest biomarkers in the early detection of acute kidney injury. Is this the new renal troponin? Nefrologia 2018; 38:361-367. [PMID: 29627229 DOI: 10.1016/j.nefro.2017.11.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 09/14/2017] [Accepted: 11/09/2017] [Indexed: 02/05/2023] Open
Abstract
Acute kidney injury (AKI) has a high prevalence in critical care patients. Early detection might prevent patients from developing chronic kidney disease and requirement for renal replacement therapy. If we compare AKI with acute coronary syndrome, in which an increase in cardiac troponin may trigger early diagnosis and therapeutic intervention, we could extrapolate a similar technique in patients with early AKI without changes in urinary frequency or serum creatinine. The objective is to identify biomarker-positive, creatinine-negative patients that would allow therapeutic interventions to be initiated before finding changes in serum creatinine, preventing kidney damage. Tissue inhibitor of metalloproteinase 2 and insulin-like growth factor binding protein 7 are cell cycle arrest biomarkers that have demonstrated, in recent clinical trials, to have good sensitivity and specificity for early detection of AKI. Other recent studies have shown that the joint use of these biomarkers with serum creatinine and urine production could improve the prognosis of AKI in critical patients. The application of these biomarkers in clinical practice would enable the early identification of patients at risk of AKI, establishing interventions that would improve the survival of renal function.
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Affiliation(s)
- Luis M Ortega
- Allegheny General Hospital Division of Nephrology and Hypertension, Temple University School of Medicine, United States.
| | - Michael Heung
- University of Michigan, Division of Nephrology, United States
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20
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Engelman DT, Kellum JA. Should urinary biomarkers be a standard component of evaluation after cardiac surgery? J Thorac Cardiovasc Surg 2018; 155:2453-2454. [PMID: 29395192 DOI: 10.1016/j.jtcvs.2017.12.095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 12/28/2017] [Indexed: 01/26/2023]
Affiliation(s)
- Daniel T Engelman
- Department of Surgery, Baystate Medical Center, Springfield, Mass; University of Massachusetts Medical School-Baystate, Springfield, Mass.
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pa
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21
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Ronco C, Ferrari F, Ricci Z. Recovery after Acute Kidney Injury: A New Prognostic Dimension of the Syndrome. Am J Respir Crit Care Med 2017; 195:711-714. [PMID: 28294655 DOI: 10.1164/rccm.201610-1971ed] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Claudio Ronco
- 1 International Renal Research Institute of Vicenza San Bortolo Hospital Vicenza, Italy.,3 Department of Nephrology, Dialysis, and Transplantation San Bortolo Hospital AULSS8 Berica Vicenza, Italy
| | - Fiorenza Ferrari
- 1 International Renal Research Institute of Vicenza San Bortolo Hospital Vicenza, Italy
| | - Zaccaria Ricci
- 2 Pediatric Cardiac Intensive Care Unit Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico Rome, Italy and
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22
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Chang AJ, Nomura Y, Barodka VM, Hori D, Magruder JT, Katz NM, Berkowitz DE, Hogue CW. Validation of a Real-Time Minute-to-Minute Urine Output Monitor and the Feasibility of Its Clinical Use for Patients Undergoing Cardiac Surgery. Anesth Analg 2017; 125:1883-1886. [PMID: 29190218 DOI: 10.1213/ane.0000000000002217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute kidney injury after cardiac surgery is associated with increased morbidity and mortality. Methods for measuring urine output in real time may better ensure renal perfusion perioperatively in contrast to the current standard of care where urine output is visually estimated after empiric epochs of time. In this study, we describe an accurate method for monitoring urine output continuously during cardiopulmonary bypass. This may provide a means for setting patient-specific targets for blood pressure and cardiopulmonary bypass flow as a potential strategy to reduce the risk for acute kidney injury.
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Affiliation(s)
- Aaron J Chang
- From the Center for Bioengineering Innovation and Design, Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Yohei Nomura
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Viachaslau M Barodka
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Daijiro Hori
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jonathan T Magruder
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nevin M Katz
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dan E Berkowitz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Charles W Hogue
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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23
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De Loor J, Herck I, Francois K, Van Wesemael A, Nuytinck L, Meyer E, Hoste EAJ. Diagnosis of cardiac surgery-associated acute kidney injury: differential roles of creatinine, chitinase 3-like protein 1 and neutrophil gelatinase-associated lipocalin: a prospective cohort study. Ann Intensive Care 2017; 7:24. [PMID: 28251598 PMCID: PMC5332341 DOI: 10.1186/s13613-017-0251-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 02/24/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND A common and serious complication of cardiac surgery prompting early detection and intervention is cardiac surgery-associated acute kidney injury (CSA-AKI). Urinary chitinase 3-like protein 1 (UCHI3L1) was found to predict AKI associated with critical illness in adults. Our aims were therefore to evaluate whether UCHI3L1 can also be used to predict AKI associated with elective cardiac surgery in adults, and to compare this predictive ability with that of urinary neutrophil gelatinase-associated lipocalin (UNGAL), more frequently assessed early serum creatinine (SCr) measurements, and various two-biomarker panels. METHODS This was a single-centre prospective cohort study at the eight-bed cardiac surgery ICU of Ghent University Hospital. AKI was diagnosed and classified according to the Kidney Disease|Improving Global Outcomes definitions for the diagnosis and staging of AKI, which are based on SCr and urine output (UO). Of the 211 enrolled elective cardiac surgery patients, we included 203 patients who had no AKI pre-operatively and at time of post-operative ICU admission (t1) in the primary endpoint analysis (i.e. AKI stage ≥1 within 48 h after t1), while 210 patients without AKI stage ≥2 pre-operatively and at t1 were included in the secondary endpoint analysis (i.e. AKI stage ≥2 within 12 h after t1). Systemic and/or urine concentrations of Cr, CHI3L1 and NGAL were measured more frequently than SCr in routine early post-operative ICU practice. UO was monitored hourly in the ICU. RESULTS Within 48 h after t1, 46.8% of the patients had developed AKI (70.5% stage 1, 20.0% stage 2 and 9.5% stage 3). In the early post-operative period, only SCr was a good predictor of AKI within 48 h after t1 (primary endpoint). SCHI3L1 combined with either UCHI3L1 or UNGAL was a good predictor of AKI stage ≥2 within 12 h after t1 (secondary endpoint). However, SCr and its absolute difference from pre-operative to early measures after surgery outperformed these combinations. CONCLUSIONS We found that more frequent assessment of the functional biomarker SCr in the early post-operative ICU period (first 4 h) after elective cardiac surgery in adult patients had good to excellent predictive value for CSA-AKI, indicating that routine SCr assessment must become more frequent in order to detect AKI more early. This performance was in contrast with the inadequate predictive value of the urinary renal stress or damage biomarkers UCHI3L1 and UNGAL.
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Affiliation(s)
- Jorien De Loor
- Laboratory of Biochemistry, Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium
| | - Ingrid Herck
- Division of Intensive Care, Department of Internal Medicine, Ghent University Hospital, Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Katrien Francois
- Division of Cardiac Surgery, Department of Surgery, Ghent University Hospital, Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Astrid Van Wesemael
- Department of Anaesthesiology, General Hospital Sint-Lucas Ghent, Groenebriel 1, 9000 Ghent, Belgium
| | - Lieve Nuytinck
- Bimetra – Clinical Research Centre Ghent, Ghent University Hospital, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Evelyne Meyer
- Laboratory of Biochemistry, Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium
| | - Eric A. J. Hoste
- Division of Intensive Care, Department of Internal Medicine, Ghent University Hospital, Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
- Research Foundation – Flanders, Egmontstraat 5, 1000 Brussels, Belgium
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24
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Routine adoption of TIMP2 and IGFBP7 biomarkers in cardiac surgery for early identification of acute kidney injury. Int J Artif Organs 2017; 40:714-718. [PMID: 29148021 PMCID: PMC6154726 DOI: 10.5301/ijao.5000661] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2017] [Indexed: 11/25/2022]
Abstract
Background and purpose Acute Kidney Injury (AKI) is a severe complication affecting many hospitalized patients after cardiac surgery, with negative impacts on short- and long-term clinical outcomes and on healthcare costs. Recently, clinical interest has been aimed at defining and classifying AKI, identifying risk factors and developing diagnostic strategies to identify patients at risk early on. Achieving an early and accurate diagnosis of AKI is a crucial issue, because prevention and timely detection may help to prevent negative clinical outcomes and avoid AKI-associated costs. In this retrospective study, we evaluate the NephroCheck Test as a diagnostic tool for early detection of AKI in a high-risk population of patients undergoing cardiac surgery at the San Bortolo Hospital of Vicenza. Methods We assessed the ability of the NephroCheck Test to predict the probability of developing CSA-AKI (cardiac surgery-associated AKI) and evaluated its accuracy as a diagnostic test, by building a multivariate logistic regression model for CSA-AKI prediction. Results Based on our findings, when the results of the NephroCheck Test are included in a multivariate model its performance is substantially improved, as compared to the benchmark model, which only accounts for the other clinical factors. We also define a rule – in terms of a probability cut-off – for discriminating cases that are at higher risk of developing AKI of any stage versus those in which AKI is less likely. Conclusions Our study has implications in clinical practice: when a Nephrocheck Test result is >0.3 ng/dL, an automated electronic alert prompts the physician to intervene by following a checklist of preventive measures.
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Wang Y, Zou Z, Jin J, Teng J, Xu J, Shen B, Jiang W, Zhuang Y, Liu L, Luo Z, Wang C, Ding X. Urinary TIMP-2 and IGFBP7 for the prediction of acute kidney injury following cardiac surgery. BMC Nephrol 2017; 18:177. [PMID: 28558754 PMCID: PMC5450378 DOI: 10.1186/s12882-017-0592-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/17/2017] [Indexed: 02/08/2023] Open
Abstract
Background Acute kidney injury (AKI) following cardiac surgery is common and associated with poor patient outcomes. Early risk assessment for development of AKI remains a challenge. The combination of urinary tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7) has been shown to be an excellent predictor of AKI following cardiac surgery, but reported studies are for predominately non-Asian populations. Methods Adult patients were prospectively enrolled at Zhongshan hospital in Shanghai, China. The primary analysis was prediction of AKI and stage 2–3 AKI by [TIMP-2]*[IGFBP7] measured 4 h after postoperative ICU admission assessed using receiver operating characteristic curve (ROC) analysis. Kinetics of [TIMP-2]*[IGFBP7] following ICU admission were also examined. Results We prospectively enrolled 57 cardiac surgery patients, of which 20 (35%) developed AKI and 6 (11%) developed stage 2–3 AKI. The area under the ROC curve (AUC) of [TIMP-2]*[IGFBP7] at 4 h after ICU admission was 0.80 (95% confidence interval (CI): 0.68–0.91) for development of AKI and 0.83 (95% CI: 0.69–0.96) for development of stage 2–3 AKI. Urinary [TIMP-2]*[IGFBP7] values at 4 h after ICU admission were significantly (P < 0.001) higher in patients who developed AKI than in patients who did not develop AKI (mean (standard error) of 1.08 (0.34) (ng/mL)2/1000 and 0.29 (0.05) (ng/mL)2/1000, respectively). The time-profile of [TIMP-2]*[IGFBP7] suggests the markers started to elevate by the time of ICU admission in patients who developed AKI and either decreased or remained flat in patients without AKI. Conclusion The combination of urinary TIMP-2 and IGFBP7 4 h after postoperative ICU admission identifies patients at risk for developing AKI, not just stage 2–3 AKI following cardiac surgery.
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Affiliation(s)
- Yimei Wang
- Departments of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, No 180 Fenglin Rd, Shanghai, China
| | - Zhouping Zou
- Departments of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, No 180 Fenglin Rd, Shanghai, China
| | - Jifu Jin
- Departments of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, No 180 Fenglin Rd, Shanghai, China
| | - Jie Teng
- Departments of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, No 180 Fenglin Rd, Shanghai, China
| | - Jiarui Xu
- Departments of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, No 180 Fenglin Rd, Shanghai, China
| | - Bo Shen
- Departments of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, No 180 Fenglin Rd, Shanghai, China
| | - Wuhua Jiang
- Departments of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, No 180 Fenglin Rd, Shanghai, China
| | - Yamin Zhuang
- Department of critical care medicine, Fudan University, No 180 Fenglin Rd, Shanghai, China
| | - Lan Liu
- Department of critical care medicine, Fudan University, No 180 Fenglin Rd, Shanghai, China
| | - Zhe Luo
- Department of critical care medicine, Fudan University, No 180 Fenglin Rd, Shanghai, China.
| | - Chunsheng Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Medical College, Fudan University, No 180 Fenglin Rd, Shanghai, China.
| | - Xiaoqiang Ding
- Departments of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, No 180 Fenglin Rd, Shanghai, China.
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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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Wang X, Chen H, Liu D, Zhang Q, Su L. The correlation between CVP-derived parameters and the prognosis of critically ill patients. J Crit Care 2017; 40:257-264. [PMID: 28666246 DOI: 10.1016/j.jcrc.2017.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 03/09/2017] [Accepted: 03/12/2017] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To investigate the effect of central venous pressure on the organ dysfunction and prognosis of critically ill patients. METHODS We conducted a retrospective observational cohort study of 488 ICU patients with central venous pressure and its derived parameters in a half-year period in one single ICU centre to compare the length of ICU stay, critical illness scores (SOFA and APACHE II), serum creatinine and lactate levels. RESULTS The initial, peak and mean CVP levels of critically ill patients and length of ICU stay, peak lactate levels and SOFA scores were significantly correlated. While the peak CVP and peak creatinine levels were significantly correlated, the correlation of initial and mean CVP levels with peak creatinine was not significant. Subgroup analysis showed that in the patients with a peak CVP value above 12mmHg, the length of stay was significantly prolonged, organ function was significantly worse, and the SOFA score was significantly higher. ROC analysis showed peak levels of CVP above 11.5mmHg had the greatest ability to predict mortality of critically ill patients. CONCLUSION Exposure to higher levels of central venous pressure in critically ill patients is associated with a poorer prognosis and worse organ function. Therefore, central venous pressure should be kept as low as possible during hemodynamic therapy in critically ill patients.
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Affiliation(s)
- Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, China
| | - Huan Chen
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, China
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, China.
| | - Qing Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, China
| | - Longxiang Su
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, China
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28
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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: 548] [Impact Index Per Article: 78.3] [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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Romagnoli S, Ricci Z. The good receipt for the kidneys: salty…but not too much. J Thorac Dis 2016; 8:2403-2406. [PMID: 27746988 DOI: 10.21037/jtd.2016.08.50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Stefano Romagnoli
- Department of Anesthesia and Intensive Care, Department of Health Science, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Zaccaria Ricci
- Depatment of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
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30
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Ricci Z, Romagnoli S, Di Chiara L. Latent AKI is… still AKI: the quantification of the burden of renal dysfunction. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:238. [PMID: 27561544 PMCID: PMC5000489 DOI: 10.1186/s13054-016-1428-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The association between pediatric cardiac surgery, acute kidney injury (AKI), and clinical outcomes has been studied several times in the recent literature. In this issue of Critical Care an interesting and original study analyzed the path from causal AKI entities to clinical AKI consequences through the application of structural equation modeling. The authors described the complex connections linking duration of cardiopulmonary bypass, cross clamp-time, and descriptors of low cardiac output syndrome to AKI modeled as a complex variable composed of post-operative serum creatinine increase of 50 % over baseline, urine output <0.5 ml/kg/h, and urine creatinine-normalized neutrophil gelatinase lipocalin within 12 h of surgery. Similarly, the causal relationships between AKI and hard outcomes in the analyzed population were verified and quantified. The authors, for the first time, produce a repeatable coefficient (0.741) that may become a useful quality benchmark and could be applied to test future interventions aiming to reduce the burden of AKI on children’s clinical course.
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Affiliation(s)
- Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Stefano Romagnoli
- Department of Health Science, University of Florence, Florence, Italy.,Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Luca Di Chiara
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
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Husain-Syed F, Slutsky AS, Ronco C. Lung–Kidney Cross-Talk in the Critically Ill Patient. Am J Respir Crit Care Med 2016; 194:402-14. [DOI: 10.1164/rccm.201602-0420cp] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Ronco C. Acute kidney injury: from clinical to molecular diagnosis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:201. [PMID: 27384344 PMCID: PMC4936182 DOI: 10.1186/s13054-016-1373-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The RIFLE classification was introduced in 2004 to describe the presence of acute kidney injury (AKI) and to define its clinical stage, based upon the serum creatinine level and urine output. The same criteria, although slightly modified, are used in the other scoring systems AKIN and KDIGO. Mortality and morbidity remain high in AKI, suggesting that current diagnostic methods are suboptimal, poorly accurate, and often timely inadequate in detecting the presence of early kidney injury. Conversely, a growing body of evidence indicates that new AKI biomarkers can be used to both rule out AKI and to assess high-risk conditions or the presence of subclinical forms. Neutrophil gelatinase-associated lipocalin or cell cycle arrest biomarkers seem to be sensitive and specific enough to be used in conjunction with existing markers of AKI for better classifying renal injury as well as dysfunction. Improvements in diagnosis, risk identification, stratification, prognosis, and therapeutic monitoring may improve prevention and protection from organ damage and help to identify patients at risk, allowing individualized therapy. In this view, we may say that AKI diagnosis has finally moved from clinical to molecular level with potential benefits for the patients because similar progress has been shown in other disciplines.
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Affiliation(s)
- Claudio Ronco
- Department of Nephrology Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Viale Rodolfi 37, Vicenza, 36100, Italy.
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Sgouralis I, Kett MM, Ow CPC, Abdelkader A, Layton AT, Gardiner BS, Smith DW, Lankadeva YR, Evans RG. Bladder urine oxygen tension for assessing renal medullary oxygenation in rabbits: experimental and modeling studies. Am J Physiol Regul Integr Comp Physiol 2016; 311:R532-44. [PMID: 27385734 DOI: 10.1152/ajpregu.00195.2016] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 07/02/2016] [Indexed: 11/22/2022]
Abstract
Oxygen tension (Po2) of urine in the bladder could be used to monitor risk of acute kidney injury if it varies with medullary Po2 Therefore, we examined this relationship and characterized oxygen diffusion across walls of the ureter and bladder in anesthetized rabbits. A computational model was then developed to predict medullary Po2 from bladder urine Po2 Both intravenous infusion of [Phe(2),Ile(3),Orn(8)]-vasopressin and infusion of N(G)-nitro-l-arginine reduced urinary Po2 and medullary Po2 (8-17%), yet had opposite effects on renal blood flow and urine flow. Changes in bladder urine Po2 during these stimuli correlated strongly with changes in medullary Po2 (within-rabbit r(2) = 0.87-0.90). Differences in the Po2 of saline infused into the ureter close to the kidney could be detected in the bladder, although this was diminished at lesser ureteric flow. Diffusion of oxygen across the wall of the bladder was very slow, so it was not considered in the computational model. The model predicts Po2 in the pelvic ureter (presumed to reflect medullary Po2) from known values of bladder urine Po2, urine flow, and arterial Po2 Simulations suggest that, across a physiological range of urine flow in anesthetized rabbits (0.1-0.5 ml/min for a single kidney), a change in bladder urine Po2 explains 10-50% of the change in pelvic urine/medullary Po2 Thus, it is possible to infer changes in medullary Po2 from changes in urinary Po2, so urinary Po2 may have utility as a real-time biomarker of risk of acute kidney injury.
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Affiliation(s)
- Ioannis Sgouralis
- National Institute for Mathematical and Biological Synthesis, University of Tennessee, Knoxville, Tennessee
| | - Michelle M Kett
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Connie P C Ow
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Amany Abdelkader
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Anita T Layton
- Department of Mathematics, Duke University, Durham, North Carolina
| | - Bruce S Gardiner
- School of Engineering and Information Technology, Murdoch University, Perth, Western Australia
| | - David W Smith
- School of Computer Science and Software Engineering, The University of Western Australia, Perth, Western Australia; and
| | - Yugeesh R Lankadeva
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia;
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Romagnoli S, Ricci Z. Statins and acute kidney injury following cardiac surgery: has the last word been told? J Thorac Dis 2016; 8:E451-4. [PMID: 27294251 DOI: 10.21037/jtd.2016.04.34] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Stefano Romagnoli
- 1 Department of Health Science, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy ; 2 Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla, Florence, Italy ; 3 Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, Rome, Italy
| | - Zaccaria Ricci
- 1 Department of Health Science, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy ; 2 Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla, Florence, Italy ; 3 Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, Rome, Italy
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