SEA-MAKE score as a tool for predicting major adverse kidney events in critically ill patients with acute kidney injury: results from the SEA-AKI study

Heterogeneity in the definition of major adverse kidney events: a scoping review

Acute kidney injury (AKI) is associated with persistent renal dysfunction, the receipt of dialysis, dialysis dependence, and mortality. Accordingly, the concept of major adverse kidney events (MAKE) has been adopted as an endpoint for assessing the impact of AKI. However, applied criteria or observation periods for operationalizing MAKE appear to vary across studies. To evaluate this heterogeneity for MAKE evaluation, we performed a systematic scoping review of studies that employed MAKE as an AKI endpoint. Four major academic databases were searched, and we identified 122 studies with increasing numbers over time. We found marked heterogeneity in applied criteria and observation periods for MAKE across these studies, with some even lacking a description of criteria. Moreover, 13 different observation periods were employed, with 30 days and 90 days as the most common. Persistent renal dysfunction was evaluated by estimated glomerular filtration rate (34%) or serum creatinine concentration (48%); however, 37 different definitions for this component were employed in terms of parameters, cut-off criteria, and assessment periods. The definition for the dialysis component also showed significant heterogeneity regarding assessment periods and duration of dialysis requirement (chronic vs temporary). Finally, MAKE rates could vary by 7% [interquartile range: 1.7-16.7%] with different observation periods or by 36.4% with different dialysis component definitions. Our findings revealed marked heterogeneity in MAKE definitions, particularly regarding component assessment and observation periods. Dedicated discussion is needed to establish uniform and acceptable standards to operationalize MAKE in terms of selection and applied criteria of components, observation period, and reporting criteria for future trials on AKI and related conditions.

Association between Hematocrit and Acute Kidney Injury in Patients with Acute Myocardial Infarction

Backgrounds

Hematocrit is found an independent risk factor for acute kidney injury (AKI) in certain patients, but this effect in patients with acute myocardial infarction (AMI) is unclear. We aim to identify the relationship between hematocrit and AKI in patients with AMI.

Methods

The patient data for the discovery and validation cohorts were extracted from the electronic Intensive Care Unit database and the Medical Information Mart for Intensive Care III database, respectively, to identify the relationship between hematocrit and AKI. With normal hematocrit as the reference, patients were divided into five groups based on the initial hematocrit value. The primary outcome was AKI during hospitalization. A multivariable logistic regression and a marginal effect analysis were used to evaluate the relationship between hematocrit and AKI.

Results

In this study, a total of 9692 patients diagnosed with AMI were included, with 7712 patients in the discovery cohort and 1980 patients in the validation cohort. In the discovery cohort, hematocrit in 30-33%, 27-30% or < 27% were independent risk factors for AKI in the multivariate logistic analysis, with odds ratio (OR) of 1.774 (95% confidence interval [CI]: 1.203-2.617, p = 0.004), 1.834 (95% CI: 1.136-2.961, p = 0.013) and 2.577 (95% CI: 1.510-4.397, p < 0.001), respectively. Additionally, in the validation cohort, low hematocrit levels independently contributed to an increased risk of AKI among patients with AMI. During the analysis of marginal effects, a significant negative linear relationship between hematocrit levels and AKI was observed.

Conclusions

Decreased hematocrit was an independent risk factor for AKI in patients with AMI. The relationship between hematocrit and AKI was negative linear.

An early scoring system to predict mechanical ventilation for botulism: a single-center-based study

BACKGROUND

Early identification of patients requiring ventilator support will be beneficial for the outcomes of botulism. The present study aimed to establish a new scoring system to predict mechanical ventilation (MV) for botulism patients.

METHODS

A single-center retrospective study was conducted to identify risk factors associated with MV in botulism patients from 2007 to 2022. Univariate analysis and multivariate logistic regression analysis were used to screen out risk factors for constructing a prognostic scoring system. The area under the receiver operating characteristic (ROC) curve was calculated.

RESULTS

A total of 153 patients with botulism (66 males and 87 females, with an average age of 43 years) were included. Of these, 49 patients (32.0%) required MV, including 21 (13.7%) with invasive ventilation and 28 (18.3%) with non-invasive ventilation. Multivariate analysis revealed that botulinum toxin type, pneumonia, incubation period, degree of hypoxia, and severity of muscle involvement were independent risk factors for MV. These risk factors were incorporated into a multivariate logistic regression analysis to establish a prognostic scoring system. Each risk factor was scored by allocating a weight based on its regression coefficient and rounded to whole numbers for practical utilization ([botulinum toxin type A: 1], [pneumonia: 2], [incubation period ≤1 day: 2], [hypoxia <90%: 2], [severity of muscle involvement: grade II, 3; grade III, 7; grade IV, 11]). The scoring system achieved an area under the ROC curve of 0.82 (95% CI 0.75-0.89, P<0.001). At the optimal threshold of 9, the scoring system achieved a sensitivity of 83.7% and a specificity of 70.2%.

CONCLUSION

Our study identified botulinum toxin type, pneumonia, incubation period, degree of hypoxia, and severity of muscle involvement as independent risk factors for MV in botulism patients. A score ≥9 in our scoring system is associated with a higher likelihood of requiring MV in botulism patients. This scoring system needs to be validated externally before it can be applied in clinical settings.

The NUTRIC Score as a Tool to Predict Mortality and Increased Resource Utilization in Intensive Care Patients with Sepsis

The Nutrition Risk in Critically Ill score (NUTRIC) is an important nutritional risk assessment instrument for patients in the intensive care unit (ICU). The purpose of this study was to evaluate the power of the score to predict mortality in patients treated for sepsis and to forecast increased resource utilization and nursing workload in the ICU. The NUTRIC score predicted mortality (AUC 0.833, p < 0.001) with the optimal cut-off value of 6 points. Among patients with a score ≥ 6 on ICU admission, the 28-day mortality was 61%, and 10% with a score < 6 (p < 0.001). In addition, a NUTRIC score of ≥6 was associated with a more intense use of ICU resources, as evidenced by a higher proportion of patients requiring vasopressor infusion (98 vs. 82%), mechanical ventilation (99 vs. 87%), renal replacement therapy (54 vs. 26%), steroids (68 vs. 31%), and blood products (60 vs. 43%); the nursing workload was also significantly higher in this group. In conclusion, the NUTRIC score obtained at admission to the ICU provided a good discriminative value for mortality and makes it possible to identify patients who will ultimately require intense use of ICU resources and an associated increase in the nursing workload during treatment.

Development and validation of outcome prediction models for acute kidney injury patients undergoing continuous renal replacement therapy

Object

This study aimed to develop and validate a set of practical predictive tools that reliably estimate the 28-day prognosis of acute kidney injury patients undergoing continuous renal replacement therapy.

Methods

The clinical data of acute kidney injury patients undergoing continuous renal replacement therapy were extracted from the Medical Information Mart for Intensive Care IV database with structured query language and used as the development cohort. An all-subset regression was used for the model screening. Predictive models were constructed via a logistic regression, and external validation of the models was performed using independent external data.

Results

Clinical prediction models were developed with clinical data from 1,148 patients and validated with data from 121 patients. The predictive model based on seven predictors (age, vasopressor use, red cell volume distribution width, lactate, white blood cell count, platelet count, and phosphate) exhibited good predictive performance, as indicated by a C-index of 0.812 in the development cohort, 0.811 in the internal validation cohort and 0.768 in the external validation cohort.

Conclusions

The model reliably predicted the 28-day prognosis of acute kidney injury patients undergoing continuous renal replacement therapy. The predictive items are readily available, and the web-based prognostic calculator (https://libo220284.shinyapps.io/DynNomapp/) can be used as an adjunctive tool to support the management of patients.

Acute Kidney Injury in Patients with Severe ARDS Requiring Extracorporeal Membrane Oxygenation: Incidence, Prognostic Impact and Risk Factors

(1) Background: Acute kidney injury (AKI) is a common but under-investigated complication in patients receiving extracorporeal membrane oxygenation (ECMO). We aimed to define the incidence and clinical course, as well as the predictors of AKI in adults receiving ECMO support. (2) Materials and Methods: This is a retrospective analysis of all patients undergoing veno-venous ECMO treatment in a tertiary care center between December 2008 and December 2017. The primary endpoint was the new occurrence of an AKI of stage 2 or 3 according to the Kidney Disease: Improving Global Outcomes (KDIGO) classification after ECMO implantation. (3) Results: During the observation period, 103 patients underwent veno-venous ECMO implantation. In total, 59 patients (57.3%) met the primary endpoint with an AKI of stage 2 or 3 and 55 patients (53.4%) required renal replacement therapy. Patients with an AKI of 2 or 3 suffered from more bleeding and infectious complications. Whereas weaning failure from ECMO (30/59 (50.8%) vs. 15/44 (34.1%), p = 0.08) and 30-day mortality (35/59 (59.3%) vs. 17/44 (38.6%), p = 0.06) only tended to be higher in the group with an AKI of stage 2 or 3, long-term survival of up to five years was significantly lower in the group with an AKI of stage 2 or 3 (p = 0.015). High lactate, serum creatinine, and ECMO pump-speed levels, and low platelets, a low base excess, and a low hematocrit level before ECMO were independent predictors of moderate to severe AKI. Primary hypercapnic acidosis was more common in AKI non-survivors (12 (32.4%) vs. 0 (0.0%), p < 0.01). Accordingly, pCO2-levels prior to ECMO implantation tended to be higher in AKI non-survivors (76.12 ± 27.90 mmHg vs. 64.44 ± 44.31 mmHg, p = 0.08). In addition, the duration of mechanical ventilation prior to ECMO-implantation tended to be longer (91.14 ± 108.16 h vs. 75.90 ± 86.81 h, p = 0.078), while serum creatinine (180.92 ± 115.72 mmol/L vs. 124.95 ± 77.77 mmol/L, p = 0.03) and bicarbonate levels were significantly higher in non-survivors (28.22 ± 8.44 mmol/L vs. 23.36 ± 4.19 mmol/L, p = 0.04). (4) Conclusion: Two-thirds of adult patients receiving ECMO suffered from moderate to severe AKI, with a significantly increased morbidity and long-term mortality.

CRRT in developing world

Continuous renal replacement therapy (CRRT) has become a mainstay therapy in the intensive care unit (ICU) and its utilization continues to increase in developed countries. The wide variations of CRRT practice, however, are evident in developing countries while clinicians in these resource-limited countries encounter various barriers such as a limited number of nephrologists and trained staff, a gap of knowledge, machine unavailability, cultural and socioeconomic aspects, high-cost therapy without reimbursement, and administrative as well as governmental barriers. In this article, we demonstrate the situation of CRRT and discuss the barriers of CRRT in a resource-limited setting. We also discuss the strategies to improve CRRT practice. These recommendations can serve as a fundamental guideline for clinicians to implement CRRT in low-resource settings.

Low bicarbonate replacement fluid normalizes metabolic alkalosis during continuous veno-venous hemofiltration with regional citrate anticoagulation

Background

Metabolic alkalosis is a frequently occurring problem during continuous veno-venous hemofiltration (CVVH) with regional citrate anticoagulation (RCA). This study aimed to evaluate the effectiveness of switching from high to low bicarbonate (HCO₃⁻) replacement fluid in alkalotic critically ill patients with acute kidney injury treated by CVVH and RCA.

Methods

A retrospective-comparative study design was applied. Patients who underwent CVVH with RCA in the ICU between 09/2016 and 11/2017 were evaluated. Data were available from the clinical routine. A switch of the replacement fluid Phoxilium^® (30 mmol/l HCO₃⁻) to Biphozyl^® (22 mmol/l HCO₃⁻) was performed as blood HCO₃⁻ concentration persisted ≥ 26 mmol/l despite adjustments of citrate dose and blood flow. Data were collected from 72 h before the switch of the replacement solutions until 72 h afterwards.

Results

Of 153 patients treated with CVVH during that period, 45 patients were switched from Phoxilium^® to Biphozyl^®. Forty-two patients (42 circuits) were available for statistical analysis. After switching the replacement fluid from Phoxilium^® to Biphozyl^® the serum HCO₃⁻ concentration decreased significantly from 27.7 mmol/l (IQR 26.9–28.9) to 25.8 mmol/l (IQR 24.6–27.7) within 24 h (p < 0.001). Base excess (BE) decreased significantly from 4.0 mmol/l (IQR 3.1–5.1) to 1.8 mmol/l (IQR 0.2–3.4) within 24 h (p < 0.001). HCO₃⁻ and BE concentration remained stable from 24 h till the end of observation at 72 h after the replacement fluid change (p = 0.225). pH and PaCO₂ did not change significantly after the switch of the replacement fluid until 72 h.

Conclusions

This retrospective analysis suggests that for patients developing refractory metabolic alkalosis during CVVH with RCA the use of Biphozyl^® reduces external HCO₃⁻ load and sustainably corrects intracorporeal HCO₃⁻ and BE concentrations. Future studies have to prove whether correcting metabolic alkalosis during CVVH with RCA in critically ill patients is of relevance in terms of clinical outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00850-4.

Pragmatic Recommendations for the Prevention and Treatment of Acute Kidney Injury in Patients with COVID-19 in Low- and Middle-Income Countries

Current recommendations for the management of patients with COVID-19 and acute kidney injury (AKI) are largely based on evidence from resource-rich settings, mostly located in high-income countries. It is often unpractical to apply these recommendations to resource-restricted settings. We report on a set of pragmatic recommendations for the prevention, diagnosis, and management of patients with COVID-19 and AKI in low- and middle-income countries (LMICs). For the prevention of AKI among patients with COVID-19 in LMICs, we recommend using isotonic crystalloid solutions for expansion of intravascular volume, avoiding nephrotoxic medications, and using a conservative fluid management strategy in patients with respiratory failure. For the diagnosis of AKI, we suggest that any patient with COVID-19 presenting with an elevated serum creatinine level without available historical values be considered as having AKI. If serum creatinine testing is not available, we suggest that patients with proteinuria should be considered to have possible AKI. We suggest expansion of the use of point-of-care serum creatinine and salivary urea nitrogen testing in community health settings, as funding and availability allow. For the management of patients with AKI and COVID-19 in LMICS, we recommend judicious use of intravenous fluid resuscitation. For patients requiring dialysis who do not have acute respiratory distress syndrome (ARDS), we suggest using peritoneal dialysis (PD) as first choice, where available and feasible. For patients requiring dialysis who do have ARDS, we suggest using hemodialysis, where available and feasible, to optimize fluid removal. We suggest using locally produced PD solutions when commercially produced solutions are unavailable or unaffordable.