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Kuo G, Chen JJ, Yen CL, Fan PC, Lee CC, Chang CH. Association between early, small creatinine elevation and severe acute kidney injury in critically ill adult patients. J Crit Care 2022; 72:154142. [PMID: 36084379 DOI: 10.1016/j.jcrc.2022.154142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/18/2022] [Accepted: 08/19/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Early prediction of AKI is crucial for critically ill patients. We investigated the association between small increase in creatinine and subsequent severe AKI in ICU patients. METHODS We conducted this retrospective cohort with a multi-institutional database between 2007 and 2019. We included adult patients admitted to the ICU with creatinine changes that did not meet the criteria for AKI diagnosis within 48 h of ICU admission. The outcomes were stage 2 or 3 AKI, kidney replacement therapy, and mortality. RESULTS We identified 44,805 patients and divided them into 3 groups by baseline creatinine levels: <1 mg/dL, 1 to 2 mg/dL, and ≥ 2 mg/dL. Compared with patients with higher baseline creatinine levels, patients with normal baseline creatinine levels had fewer comorbidities and less severe condition at ICU admission. The odds ratios of their outcomes increased exponentially with creatinine elevation within the first 48 h of ICU admission. The increasing odds ratios were more prominent in patients with normal baseline creatinine (P for interaction <0.001). CONCLUSION Small creatinine elevation within the first 48 h of ICU admission was strongly associated with the AKI, kidney replacement therapy, and death. This association was more prominent in patients with normal baseline creatinine.
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Affiliation(s)
- George Kuo
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taiwan
| | - Jia-Jin Chen
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taiwan
| | - Chieh-Li Yen
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taiwan
| | - Pei-Chun Fan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taiwan; Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taiwan; Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taiwan; Chang Gung University, College of Medicine, Taoyuan, Taiwan.
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Patel P, Gupta S, Patel H, Bashar MDA. Assessment of APACHE II Score to Predict ICU Outcomes of Patients with AKI: A Single Center Experience from Haryana, North India. Indian J Crit Care Med 2022; 26:276-281. [PMID: 35519933 PMCID: PMC9015919 DOI: 10.5005/jp-journals-10071-24142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background The acute physiology and chronic health evaluation (APACHE) II severity score has shown a good calibration and discriminatory value across a range of disease processes and remains the most widely used source of prognostic information on the risk for death in patients admitted to intensive care units (ICUs). Objectives To study APACHE II scores in patients of acute kidney injury (AKI) admitted in the ICU and to find its association with outcome. Materials and methods One hundred patients with AKI aged 18 years or above were admitted in the ICU, department of general medicine, of a tertiary care institute in Haryana, North India, from October 2019 to September 2020, were studied. Patients who had known causes of chronic kidney disease (CKD), on maintenance hemodialysis, and those who underwent renal replacement therapy (RRT) or nephrectomy were excluded. All required investigations were performed, and data were collected. The patients were followed till discharge or in-hospital mortality. Results The mean age of the patients was 55.92 ± 18.18 years. Male–female ratio was 1.5:1. Thirty-five percent of the admitted patients had an in-hospital mortality. Sepsis (47%) was the most common cause of AKI, and 83% of the patients had underlying comorbid conditions. The mean APACHE II score of the expired patients on admission, i.e., 24.80 ± 13.65, was found to be significantly higher compared to the mean APACHE II score (17.25 ± 10.12) of the discharged patients (p-value <0.001). APACHE II score was found to have 57.14% sensitivity, 86.15% specificity, 69% PPV, 78.9% NPV, and 76% diagnostic accuracy to predict mortality among the AKI patients. Conclusion APACHE II scoring system has a good discrimination and calibration when applied to ICU-admitted AKI patients and is a good predictor of prognosis in them. How to cite this article Patel P, Gupta S, Patel H, Bashar MDA. Assessment of APACHE II Score to Predict ICU Outcomes of Patients with AKI: A Single-center Experience from Haryana, North India. Indian J Crit Care Med 2022;26(3):276–281.
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Affiliation(s)
- Paras Patel
- Department of General Medicine, MM Institute of Medical Sciences and Research, Ambala, Haryana, India
| | - Sunita Gupta
- Department of General Medicine, MM Institute of Medical Sciences and Research, Ambala, Haryana, India
- Sunita Gupta, Department of General Medicine, MM Institute of Medical Sciences and Research, Ambala, Haryana, India, e-mail:
| | - Happy Patel
- Department of Obstetrics and Gynaecology, Shri Vinova Bhave Civil Hospital, Silvaasa, Dadar and Nagar Haveli, India
| | - MD. Abu Bashar
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India
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Eerhart MJ, Reyes JA, Blanton CL, Danobeitia JS, Chlebeck PJ, Zitur LJ, Springer M, Polyak E, Coonen J, Capuano S, D’Alessandro AM, Torrealba J, van Amersfoort E, Ponstein Y, Van Kooten C, Burlingham W, Sullivan J, Pozniak M, Zhong W, Yankol Y, Fernandez LA. Complement Blockade in Recipients Prevents Delayed Graft Function and Delays Antibody-mediated Rejection in a Nonhuman Primate Model of Kidney Transplantation. Transplantation 2022; 106:60-71. [PMID: 34905763 PMCID: PMC8674492 DOI: 10.1097/tp.0000000000003754] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Complement activation in kidney transplantation is implicated in the pathogenesis of delayed graft function (DGF). This study evaluated the therapeutic efficacy of high-dose recombinant human C1 esterase inhibitor (rhC1INH) to prevent DGF in a nonhuman primate model of kidney transplantation after brain death and prolonged cold ischemia. METHODS Brain death donors underwent 20 h of conventional management. Procured kidneys were stored on ice for 44-48 h, then transplanted into ABO-compatible major histocompatibility complex-mismatched recipients. Recipients were treated with vehicle (n = 5) or rhC1INH 500 U/kg plus heparin 40 U/kg (n = 8) before reperfusion, 12 h, and 24 h posttransplant. Recipients were followed up for 120 d. RESULTS Of vehicle-treated recipients, 80% (4 of 5) developed DGF versus 12.5% (1 of 8) rhC1INH-treated recipients (P = 0.015). rhC1INH-treated recipients had faster creatinine recovery, superior urinary output, and reduced urinary neutrophil gelatinase-associated lipocalin and tissue inhibitor of metalloproteinases 2-insulin-like growth factor-binding protein 7 throughout the first week, indicating reduced allograft injury. Treated recipients presented lower postreperfusion plasma interleukin (IL)-6, IL-8, tumor necrosis factor-alpha, and IL-18, lower day 4 monocyte chemoattractant protein 1, and trended toward lower C5. Treated recipients exhibited less C3b/C5b-9 deposition on day 7 biopsies. rhC1INH-treated animals also trended toward prolonged mediated rejection-free survival. CONCLUSIONS Our results recommend high-dose C1INH complement blockade in transplant recipients as an effective strategy to reduce kidney injury and inflammation, prevent DGF, delay antibody-mediated rejection development, and improve transplant outcomes.
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Affiliation(s)
- Michael J. Eerhart
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Jose A. Reyes
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
- Department of Surgery, New York Medical College at Metropolitan Hospital Center, New York, NY, United States
| | - Casi L. Blanton
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Juan S. Danobeitia
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Peter J. Chlebeck
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Laura J. Zitur
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Megan Springer
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Erzsebet Polyak
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Jennifer Coonen
- Wisconsin National Primate Research Center, University of Wisconsin, Madison, WI, United States
| | - Saverio Capuano
- Wisconsin National Primate Research Center, University of Wisconsin, Madison, WI, United States
| | - Anthony M. D’Alessandro
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Jose Torrealba
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | | | | | - Cees Van Kooten
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - William Burlingham
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Jeremy Sullivan
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Myron Pozniak
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Yucel Yankol
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Luis A. Fernandez
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
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Biomarkers for Diagnosis and Prediction of Outcomes in Contrast-Induced Nephropathy. Int J Nephrol 2020; 2020:8568139. [PMID: 32411464 PMCID: PMC7204140 DOI: 10.1155/2020/8568139] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/29/2019] [Accepted: 01/03/2020] [Indexed: 12/16/2022] Open
Abstract
Background Serum creatinine is suboptimal as a biomarker in the early diagnosis of contrast-induced nephropathy (CIN). In this study, we investigated a panel of novel biomarkers in the early diagnosis of CIN and in assessing patient outcomes. Methods This single-centre, nested, prospective case-controlled study included 30 patients with CIN and 60 matched controls. Serum and urine samples were collected before contrast administration and at 24 hours, 48 hours, and ≥5 days after contrast administration. Concentrations of NGAL, cystatin C, β2M, IL18, IL10, KIM1, and TNFα were determined using Luminex and ELISA assays. Outcomes were biomarker diagnostic discrimination performance for CIN and mortality after generation of area under receiver operating characteristic curves (AUROCs). Results Median serum levels for 24 h cystatin C (p < 0.01) and 48 h β2M levels (p < 0.001) and baseline urine NGAL (p=0.02) were higher in CIN patients compared to controls with AUROCs of 0.75, 0.78, and 0.74, respectively, for the early diagnosis of CIN. Serum β2M levels were higher in CIN patients at all time points. Elevated baseline serum concentrations of IL18 (p < 0.001), β2M (p=0.04), TNFα (p < 0.001), and baseline urine KIM (p=0.01) and 24 h urine NGAL (p=0.02) were significantly associated with mortality. Baseline serum concentrations of IL18, β2M, and TNFα showed the best discrimination performance for mortality with AUROCs, all >0.80. Baseline NGAL was superior for excluding patients at risk for CIN, with positive and negative predictive ranges of 0.50–0.55 and 0.81–0.88, respectively. Cystatin C (p=0.003) and β2M (p=0.03) at 24 h independently predicted CIN risk. β2M predicted increased mortality of 40% at baseline and 50% at 24 hours. Conclusion Serum cystatin C at 24 h was the best biomarker for CIN diagnosis, while baseline levels of serum IL18, β2M, and TNFα were best for predicting prognosis.
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Outcome Prediction of Acute Kidney Injury Biomarkers at Initiation of Dialysis in Critical Units. J Clin Med 2018; 7:jcm7080202. [PMID: 30082648 PMCID: PMC6112021 DOI: 10.3390/jcm7080202] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 12/31/2022] Open
Abstract
: The ideal circumstances for whether and when to start RRT remain unclear. The outcome predictive ability of acute kidney injury (AKI) biomarkers measuring at dialysis initializing need more validation. This prospective, multi-center observational cohort study enrolled 257 patients with AKI undergoing renal replacement therapy (RRT) shortly after admission. At the start of RRT, blood and urine samples were collected for relevant biomarker measurement. RRT dependence and all-cause mortality were recorded up to 90 days after discharge. Areas under the receiver operator characteristic (AUROC) curves and a multivariate generalized additive model were applied to predict outcomes. One hundred and thirty-five (52.5%) patients died within 90 days of hospital discharge. Plasma c-terminal FGF-23 (cFGF-23) had the best discriminative ability (AUROC, 0.687) as compared with intact FGF-23 (iFGF-23) (AUROC, 0.504), creatinine-adjusted urine neutrophil gelatinase-associated lipocalin (AUROC, 0.599), and adjusted urine cFGF-23 (AUROC, 0.653) regardless whether patients were alive or not on day 90. Plasma cFGF-23 levels above 2050 RU/mL were independently associated with higher 90-day mortality (HR 1.76, p = 0.020). Higher cFGF-23 levels predicted less weaning from dialysis in survivors (HR, 0.62, p = 0.032), taking mortality as a competing risk. Adding cFGF-23 measurement to the AKI risk predicting score significantly improved risk stratification and 90-day mortality prediction (total net reclassification improvement = 0.148; p = 0.002). In patients with AKI who required RRT, increased plasma cFGF-23 levels correlated with higher 90-day overall mortality after discharge and predicted worse kidney recovery in survivors. When coupled to the AKI risk predicting score, cFGF-23 significantly improved mortality risk prediction. This observation adds evidence that cFGF-23 could be used as an optimal timing biomarker to initiate RRT.
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Abstract
The interleukin-1 (IL-1) family of cytokines and receptors is unique in immunology because the IL-1 family and Toll-like receptor (TLR) families share similar functions. More than any other cytokine family, the IL-1 family is primarily associated with innate immunity. More than 95% of living organisms use innate immune mechanisms for survival whereas less than 5% depend on T- and B-cell functions. Innate immunity is manifested by inflammation, which can function as a mechanism of host defense but when uncontrolled is detrimental to survival. Each member of the IL-1 receptor and TLR family contains the cytoplasmic Toll-IL-1-Receptor (TIR) domain. The 50 amino acid TIR domains are highly homologous with the Toll protein in Drosophila. The TIR domain is nearly the same and present in each TLR and each IL-1 receptor family. Whereas IL-1 family cytokine members trigger innate inflammation via IL-1 family of receptors, TLRs trigger inflammation via bacteria, microbial products, viruses, nucleic acids, and damage-associated molecular patterns (DAMPs). In fact, IL-1 family member IL-1a and IL-33 also function as DAMPs. Although the inflammatory properties of the IL-1 family dominate in innate immunity, IL-1 family member can play a role in acquired immunity. This overview is a condensed update of the IL-1 family of cytokines and receptors.
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Affiliation(s)
- Charles A. Dinarello
- Department of Medicine, University of Colorado Denver, Aurora, CO, USA
- Department of Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Saxena A, Meshram SV. Predictors of Mortality in Acute Kidney Injury Patients Admitted to Medicine Intensive Care Unit in a Rural Tertiary Care Hospital. Indian J Crit Care Med 2018; 22:231-237. [PMID: 29743761 PMCID: PMC5930526 DOI: 10.4103/ijccm.ijccm_462_17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Acute kidney injury (AKI) is a challenging problem faced by intensive care clinicians worldwide, and it is associated with high morbidity and mortality, especially in critically ill patients. Materials and Methods: A hospital-based prospective, observational study was conducted in patients of AKI admitted to the Intensive Care Unit (ICU) of the Department of Medicine in a rural tertiary care hospital located in central India. Data of all consecutive AKI inpatients related to demographic variables, clinical profile, and laboratory investigations were collected from patient's medical records. Results: Of the total 229 AKI patients enrolled in this study, 65 (28.4%) patients died during their hospital stay. The presence of metabolic acidosis, hypotension, Glasgow coma scale (GCS) and Acute Physiologic Assesment and Chronic Health Evaluation (APACHE 2) score, advanced AKI stage, higher serum creatinine and blood urea levels on diagnosis of AKI and the peak rise in their level within 48 h of diagnosis of AKI, the use of mechanical ventilator, leukocytosis, and hyperkalemia were significantly associated with in-hospital mortality in AKI patients (P < 0.05). Conclusion: The overall in-hospital mortality in patients of AKI admitted to medicine-ICU was 28.4%. Sepsis was the most common cause of AKI (24.5%). The presence of metabolic acidosis, hypotension, GCS and APACHE 2 score, advanced AKI stage, higher serum creatinine, and blood urea levels on diagnosis of AKI and the peak rise in their level within 48 h of diagnosis of AKI, use of mechanical ventilator, leukocytosis, and hyperkalemia were associated with in-hospital mortality in AKI patients.
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Affiliation(s)
- Amrish Saxena
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Shrikant V Meshram
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
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Yang T, Sun S, Zhao Y, Liu Q, Han M, Lin L, Su B, Huang S, Yang L. Biomarkers upon discontinuation of renal replacement therapy predict 60-day survival and renal recovery in critically ill patients with acute kidney injury. Hemodial Int 2017; 22:56-65. [PMID: 28078828 DOI: 10.1111/hdi.12532] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION There is no consensus on the specific indications for weaning critically ill patients with acute kidney injury (AKI) off renal replacement therapy (RRT). This study aimed to explore the prognostic value of several biomarkers measured upon discontinuation of RRT for their value in predicting 60-day survival and renal recovery in an effort to add knowledge to the decision-making process regarding RRT withdrawal. METHODS We prospectively enrolled 102 patients with AKI who required RRT from the intensive care unit. Serum osteopontin (sOPN), serum interleukin 6 (sIL-6), serum cystatin C (sCysC), sIL-18, serum neutrophil gelatinase-associated lipocalin and urinary IL-18 and urinary neutrophil gelatinase-associated lipocalin were measured upon discontinuation of RRT. Patients were followed up at 60 days for survival and renal recovery. FINDINGS Patients who survived showed lower levels of all serum and urinary biomarkers. Serum OPN (OR 1.029, 95% CI 1.013-1.047, P = 0.001), diabetes (OR 23.157, 95% CI 4.507-118.981, P < 0.001) and APACHE II score (OR 1.308, 95% CI 1.121-1.527, P = 0.001) were independent predictors of 60-day mortality. Patients whose sOPN values fell within the highest and middle tertiles showed 5.25- and 2.31-fold increased risks of mortality, respectively, compared with that of patients in the lowest tertile. The addition of sOPN to the clinical model resulted in significant net reclassification improvement of 0.453 (P = 0.026) and an integrated discriminative index of 0.155 (P = 0.032). Lower levels of sOPN and sIL-6 were associated with greater odds of 60-day survival (AUC 0.812 and 0.741). The AUC value for predicting survival reached its highest level when all biomarkers were combined with urine output (UO) and urinary and serum creatinine upon discontinuation of RRT (0.882). Lower sCysC performed as well as higher UO in predicting 60-day renal recovery with the greatest AUC of 0.743. DISCUSSION Upon discontinuation of RRT, serum and urinary biomarkers, particularly sOPN, may predict 60-day survival and renal recovery in critically ill patients with AKI. The serum levels of OPN, IL-6 and CysC may be useful when considering withdrawal of RRT on the basis of conventional indicators.
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Affiliation(s)
- Tingting Yang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Si Sun
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuliang Zhao
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qiang Liu
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mei Han
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Liping Lin
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Baihai Su
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Songmin Huang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lichuan Yang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Kuo G, Yang SY, Chuang SS, Fan PC, Chang CH, Hsiao YC, Chen YC. Using acute kidney injury severity and scoring systems to predict outcome in patients with burn injury. J Formos Med Assoc 2016; 115:1046-1052. [PMID: 27923537 DOI: 10.1016/j.jfma.2016.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/16/2016] [Accepted: 10/28/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND/PURPOSE Acute kidney injury (AKI) is a frequent complication of severe burn injury and is associated with mortality. The definition of AKI was modified by the Kidney Disease Improving Global Outcomes Group in 2012. So far, no study has compared the outcome accuracy of the new AKI staging guidelines with that of the complex score system. Hence, we compared the accuracy of these approaches in predicting mortality. METHODS This was a post hoc analysis of prospectively collected data from an intensive care burn unit in a tertiary care university hospital. Patients admitted to this unit from July 2004 to December 2006 were enrolled. Demographic, clinical, and laboratory data and prognostic risk scores were used as predictors of mortality. RESULTS A total of 145 adult patients with a mean age of 41.9 years were studied. Thirty-five patients (24.1%) died during the hospital course. Among the prognostic risk models, the Acute Physiology and Chronic Health Evaluation III system exhibited the strongest discriminative power and the AKI staging system also predicted mortality well (areas under the receiver operating characteristic curve: 0.889 vs. 0.835). Multivariate logistic regression analysis identified total burn surface area, ventilator use, AKI, and toxic epidermal necrolysis as independent risk factors for mortality. CONCLUSION Our results revealed that AKI stage has considerable discriminative power for predicting mortality. Compared with other prognostic models, AKI stage is easier to use to assess outcome in patients with severe burn injury.
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Affiliation(s)
- George Kuo
- Department of Nephrology, Kidney Research Center, Taoyuan City, Taiwan
| | - Shih-Yi Yang
- Department of Plastic Surgery, Linkou Burn Center, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Shiow-Shuh Chuang
- Department of Plastic Surgery, Linkou Burn Center, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Pei-Chun Fan
- Department of Nephrology, Kidney Research Center, Taoyuan City, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, Kidney Research Center, Taoyuan City, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yen-Chang Hsiao
- Department of Plastic Surgery, Linkou Burn Center, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Yung-Chang Chen
- Department of Nephrology, Kidney Research Center, Taoyuan City, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Hamzic-Mehmedbasic A. Inflammatory Cytokines as Risk Factors for Mortality After Acute Cardiac Events. Med Arch 2016; 70:252-255. [PMID: 27703283 PMCID: PMC5034984 DOI: 10.5455/medarh.2016.70.252-255] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 07/21/2016] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Inflammatory markers have been identified as potential indicators of future adverse outcome after acute cardiac events. AIM This study aimed to analyze baseline inflammatory cytokines levels in patients with acute heart failure (AHF) and/or acute coronary syndrome (ACS) according to survival. The main objective was to identify risk factors for mortality after an episode of AHF and/or ACS. METHODS In this prospective longitudinal study 75 patients with the diagnosis of AHF and/or ACS were enrolled. Baseline laboratory and clinical data were retrieved. Serum and urine interleukin-6 (IL-6) and interleukin-18 (IL-18) levels, plasma B-type natriuretic peptide (BNP) and serum cystatin C values were determined. The primary outcome was in-hospital mortality while secondary outcome was six-month mortality. RESULTS Median serum and urine IL-6 levels, serum and urine IL-18 levels, as well as median concentrations of plasma BNP and serum cystatin C, were significantly increased in deceased in comparison to surviving AHF and/or ACS patients. Univariate Cox regression analysis identified serum IL-6, serum IL-18, urine IL-6, urine IL-18 as well as serum cystatin C and Acute Physiology and Chronic Health Evaluation (APACHE) II score as risk factors for mortality after an episode of AHF and/or ACS. Multivariate Cox regression analysis revealed that only serum IL-6 is the independent risk factor for mortality after acute cardiac events (HR 61.7, 95% CI 2.1-1851.0; p=0.018). CONCLUSION Present study demonstrated the strong prognostic value of serum IL-6 in predicting mortality of patients with AHF and/or ACS.
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Affiliation(s)
- Aida Hamzic-Mehmedbasic
- Clinical Center University of Sarajevo, Clinic for Nephrology, Sarajevo, Bosnia and Herzegovina
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Chang CH, Fan PC, Lin CY, Yang CH, Chen YT, Chang SW, Yang HY, Jenq CC, Hung CC, Yang CW, Chen YC. Elevation of Interleukin-18 Correlates With Cardiovascular, Cerebrovascular, and Peripheral Vascular Events: A Cohort Study of Hemodialysis Patients. Medicine (Baltimore) 2015; 94:e1836. [PMID: 26496326 PMCID: PMC4620819 DOI: 10.1097/md.0000000000001836] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cardiocerebral vascular events are the major cause of mortality among patients with end-stage renal disease (ESRD). Subclinical inflammation and atherosclerosis have been implicated in the pathophysiology of ESRD. Evidence has shown the crucial role of interleukin-18 (IL-18) in inflammation. Interleukin-18 has been markedly upregulated in ESRD patients. Nevertheless, the ability of the IL-18 level to predict cardiocerebral vascular events and the correlation between IL-18 levels and cardiocerebral vascular events have not been established in hemodialysis patients.To determine whether the serum IL-18 level predicts cardiocerebral vascular events, the authors studied 171 ESRD patients. Samples were collected and patients were followed for 24 months. Demographic data, the duration of hemodialysis, nutrition status, inflammatory parameters, dialysis adequacy, and lipid profiles were analyzed to predict the outcome by using multivariate logistic regression. Cutoff points were calculated by acquiring the highest Youden index. The Kaplan-Meier method was used to scrutinize the cumulative proportion of events.The multivariate logistic regression model revealed that serum creatinine, C-reactive protein, and IL-18 levels were independent predictors for cardiocerebral vascular events. The odds ratio of events for each increase in IL-18 (pg/mL) was 1.008 for cardiocerebral vascular events. The area under the receiver operating characteristic curve of IL-18 was 0.779 ± 0.039, the overall correctness was 73%, and the Youden index was highest at a cutoff of 463 pg/mL. In the Kaplan-Meier model, patients with an IL-18 level higher than 463 pg/mL exhibited the highest probability of experiencing an adverse event during the entire follow-up period.Increased serum IL-18 could be considered as a predictor of cardiocerebral vascular events in dialysis patients. It is noteworthy that various comorbidities might interfere the expression of IL-18; therefore, further validation study is required to incorporate IL-18 in clinical use.
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Affiliation(s)
- Chih-Hsiang Chang
- From the Department of Nephrology, Kidney Research Center (C-HC, P-CF, C-YL, H-YY, C-CJ, C-CH, C-WY, Y-CC); Department of Cardiology, Chang Gung Memorial Hospital, Taipei (C-HY); College of Medicine (C-HC, P-CF, C-YL, H-YY, C-CJ, C-CH, C-WY, Y-CC, S-WC); Department of Biomedical Sciences (Y-TC); Clinical Informatics and Medical Statistics Research Center (CIMS), Chang Gung University, Taoyuan, Taiwan (S-WC)
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Abstract
Acute kidney injury (AKI) is a common and often lethal complication that is also associated with severe morbidity in hospitalized patients. During the last decade, the standardization of AKI diagnostic criteria has helped to facilitate several large-scale investigations of biomarkers of AKI. These studies have led to the international clinical implementation of several biomarkers of renal injury. This review summarizes the results of many of these multicenter investigations and discusses the clinical utility and interpretation of several of these new clinical tests. The merits of combining biomarkers of kidney function is also discussed.
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Schmid M, Dalela D, Tahbaz R, Langetepe J, Randazzo M, Dahlem R, Fisch M, Trinh QD, Chun FKH. Novel biomarkers of acute kidney injury: Evaluation and evidence in urologic surgery. World J Nephrol 2015; 4:160-168. [PMID: 25949930 PMCID: PMC4419126 DOI: 10.5527/wjn.v4.i2.160] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 12/30/2014] [Accepted: 01/19/2015] [Indexed: 02/06/2023] Open
Abstract
Patients undergoing urologic surgery are at risk of acute kidney injury (AKI) and consequently long-term deterioration in renal function. AKI is further associated with significantly higher odds of perioperative complications, prolonged hospital stay, higher mortality and costs. Therefore, better awareness and detection of AKI, as well as identification of AKI determinants in the urological surgery setting is warranted to pre-empt and mitigate further deterioration of renal function in patients at special risk. New consensus criteria provide precise definitions of diagnosis and description of the severity of AKI. However, they rely on serum creatinine (SCr), which is known to be an inaccurate marker of early changes in renal function. Therefore, several new urinary and serum biomarkers promise to address the gap associated with the use of SCr. Novel biomarkers may complement SCr measurement or most likely improve the diagnostic accuracy of AKI when used in combinations. However, novel biomarkers have to prove their clinical applicability, accuracy, and cost effectiveness prior to implementation into clinical practice. Most preferably, novel biomarkers should help to positively improve a patient’s long-term renal functional outcomes. The purpose of this review is to discuss currently available biomarkers and to review their clinical evidence within urologic surgery settings.
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Predictive value of urine interleukin-18 in the evolution and outcome of acute kidney injury in critically ill adult patients. Br J Anaesth 2015; 114:460-8. [DOI: 10.1093/bja/aeu382] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Chen YC, Tsai FC, Fang JT, Yang CW. Acute kidney injury in adults receiving extracorporeal membrane oxygenation. J Formos Med Assoc 2014; 113:778-85. [PMID: 24928419 DOI: 10.1016/j.jfma.2014.04.006] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 04/09/2014] [Accepted: 04/22/2014] [Indexed: 01/06/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) has been utilized for critically ill patients such as patients with postcardiotomy cardiogenic shock or life-threatening respiratory failure. Acute kidney injury (AKI) that develops during ECMO is associated with a very poor outcome, possibly because of accumulated extravascular water causing interstitial overload, impaired oxygen transport through tissues, and increased extravascular lung water volume with impaired O(2) transport. Increased water is associated with subsequent organ dysfunction, particularly of the heart, lungs, and brain. Based on single-center studies, the incidence of AKI is 70-85% in ECMO patients. Therefore, renal replacement therapy is required in approximately 50% of these patients. This review summarizes three modalities that can be used to introduce renal replacement therapy to patients on ECMO, the pathophysiology of AKI in ECMO, and the impact of AKI on mortality. This review also identifies specific research-focused questions that need to be addressed to predict AKI early and to improve outcomes in this at-risk adult population.
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Affiliation(s)
- Yung-Chang Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan; Chang Gung University College of Medicine, Taipei, Taiwan.
| | - Feng-Chun Tsai
- Chang Gung University College of Medicine, Taipei, Taiwan; Division of Cardiovascular Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan.
| | - Ji-Tseng Fang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan; Chang Gung University College of Medicine, Taipei, Taiwan
| | - Chih-Wei Yang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan; Chang Gung University College of Medicine, Taipei, Taiwan
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Nair AR, Masson GS, Ebenezer PJ, Del Piero F, Francis J. Role of TLR4 in lipopolysaccharide-induced acute kidney injury: protection by blueberry. Free Radic Biol Med 2014; 71:16-25. [PMID: 24657730 DOI: 10.1016/j.freeradbiomed.2014.03.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 02/19/2014] [Accepted: 03/08/2014] [Indexed: 12/20/2022]
Abstract
Inflammation has been implicated in the pathophysiology of kidney disorders. Previous studies have documented the contributions of various inflammatory cascades in the development of kidney and other organ dysfunctions. The Toll-like receptor 4 (TLR4) inflammatory pathway is a major contributor of inflammation in the kidney. Interestingly, lipopolysaccharide (LPS), a specific ligand for TLR4, has been shown to induce acute kidney injury (AKI) in animal models. We have previously studied the beneficial effects of nonpharmacological agents, particularly blueberries (BB), in attenuating inflammation and oxidative stress. We hypothesize that BB protect against the LPS-induced AKI by inhibiting TLR4 activation and kidney injury markers. Twelve-week-old male Sprague-Dawley rats received a BB solution or saline intragastric gavage for 2 days. One group of BB and saline-gavaged animals was injected with LPS (10 mg/kg bw). Another group of rats was injected with VIPER (0.1 mg/kg iv), a TLR4-specific inhibitory peptide, 2 h before LPS administration. Compared to LPS-administered rats, the BB-pretreated animals exhibited improved glomerular filtration rate, elevated renal blood flow, and a reduced renal vascular resistance. In addition, a reduction in the rate of production of free radicals, namely total reactive oxygen species (ROS) and superoxide, was observed in the BB-supplemented LPS group. Gene and protein expressions for TLR4, proinflammatory cytokine, and acute kidney injury markers were also attenuated in animals that were pretreated with BB as measured by real time RT-PCR and Western blotting, respectively. These results in the BB-pretreated group were consistent with those in the VIPER-treated rats, and indicate that BB protects against AKI by inhibiting TLR4 and its subsequent effect on inflammatory and oxidative stress pathways.
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Affiliation(s)
- Anand R Nair
- Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Gustavo S Masson
- Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA; Department of Physiology & Biophysics, Institute of Biomedical Sciences, University of Sao Paulo, Brazil
| | - Philip J Ebenezer
- Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Fabio Del Piero
- Pathobiological Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Joseph Francis
- Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA.
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Seijas M, Baccino C, Nin N, Lorente JA. [Definition and biomarkers of acute renal damage: new perspectives]. Med Intensiva 2014; 38:376-85. [PMID: 24880198 DOI: 10.1016/j.medin.2013.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 09/15/2013] [Accepted: 09/19/2013] [Indexed: 01/05/2023]
Abstract
The RIFLE and AKIN criteria have definitely help out to draw attention to the relationship between a deterioration of renal function that produces a small increase in serum creatinine and a worse outcome. However, the specific clinical utility of using these criteria remains to be well-defined. It is believed that the main use of these criteria is for the design of epidemiological studies and clinical trials to define inclusion criteria and objectives of an intervention. AKI adopting term, re-summoning former ARF terminology, it is appropriate to describe the clinical condition characterized by damage to kidney, in the same way as the term is used to describe acute lung damage where the lung injury situation still has not increased to a situation of organ failure (dysfunction). The serum and urine biomarkers (creatinine, urea, and diuresis) currently in use are not sensitive or specific for detecting kidney damage, limiting treatment options and potentially compromising the outcome. New biomarkers are being studied in order to diagnose an earlier and more specific AKI, with the potential to change the definition criteria of AKI with different stages, currently based in diuresis and serum creatinine.
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Affiliation(s)
- M Seijas
- Departamento de Nefrología, Hospital de Clínicas, Montevideo, Uruguay
| | - C Baccino
- Departamento de Nefrología, Hospital de Clínicas, Montevideo, Uruguay
| | - N Nin
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBER) de Enfermedades Respiratorias, Bunyola, Mallorca, España; Servicio de Medicina Intensiva, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, España.
| | - J A Lorente
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBER) de Enfermedades Respiratorias, Bunyola, Mallorca, España; Servicio de Medicina Intensiva, Hospital Universitario de Getafe, Getafe, Madrid, España; Universidad Europea de Madrid, Madrid, España
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Murugan R, Wen X, Shah N, Lee M, Kong L, Pike F, Keener C, Unruh M, Finkel K, Vijayan A, Palevsky PM, Paganini E, Carter M, Elder M, Kellum JA. Plasma inflammatory and apoptosis markers are associated with dialysis dependence and death among critically ill patients receiving renal replacement therapy. Nephrol Dial Transplant 2014; 29:1854-64. [PMID: 24619058 DOI: 10.1093/ndt/gfu051] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Survivors of critical illness complicated by acute kidney injury requiring renal replacement therapy (RRT) are at an increased risk of dialysis dependence and death but the mechanisms are unknown. METHODS In a multicenter, prospective, cohort study of 817 critically ill patients receiving RRT, we examined association between Day 1 plasma inflammatory [interleukin (IL)-1β, IL-6, IL-8, IL-10 and IL-18; macrophage migration inhibitory factor (MIF) and tumor necrosis factor]; apoptosis [tumor necrosis factor receptor (TNFR)-I and TNFR-II and death receptor (DR)-5]; and growth factor (granulocyte macrophage colony stimulating factor) biomarkers and renal recovery and mortality at Day 60. Renal recovery was defined as alive and RRT independent. RESULTS Of 817 participants, 36.5% were RRT independent and 50.8% died. After adjusting for differences in demographics, comorbid conditions; premorbid creatinine; nephrotoxins; sepsis; oliguria; mechanical ventilation; RRT dosing; and severity of illness, increased concentrations of plasma IL-8 and IL-18 and TNFR-I were independently associated with slower renal recovery [adjusted hazard ratio (AHR) range for all markers, 0.70-0.87]. Higher concentrations of IL-6, IL-8, IL-10 and IL-18; MIF; TNFR-I and DR-5 were associated with mortality (AHR range, 1.16-1.47). In an analysis of multiple markers simultaneously, increased IL-8 [AHR, 0.80, 95% confidence interval (95% CI) 0.70-0.91, P < 0.001] and TNFR-I (AHR, 0.63, 95% CI 0.50-0.79, P < 0.001) were associated with slower recovery, and increased IL-8 (AHR, 1.26, 95% CI 1.14-1.39, P < 0.001); MIF (AHR, 1.18, 95% CI 1.08-1.28, P < 0.001) and TNFR-I (AHR, 1.26, 95% CI 1.02-1.56, P < 0.03) were associated with mortality. CONCLUSIONS Elevated plasma concentrations of inflammatory and apoptosis biomarkers are associated with RRT dependence and death. Our data suggest that future interventions should investigate broad-spectrum immune-modulation to improve outcomes.
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Affiliation(s)
- Raghavan Murugan
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Xiaoyan Wen
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nilesh Shah
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Minjae Lee
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA Center for Clinical and Translational Sciences, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Lan Kong
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State Hershey College of Medicine, Hershey, PA, USA
| | - Francis Pike
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Christopher Keener
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Mark Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Kevin Finkel
- Division of Renal Diseases and Hypertension, University of Texas Medical School at Houston, Houston, TX, USA
| | - Anitha Vijayan
- Division of Renal Diseases, Washington University, St. Louis, MO, USA
| | - Paul M Palevsky
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA Renal Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | | | - Melinda Carter
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michele Elder
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John A Kellum
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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