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Samoni S, De Rosa S, Ronco C, Castellano G. Update on persistent acute kidney injury in critical illnesses. Clin Kidney J 2023; 16:1813-1823. [PMID: 37915904 PMCID: PMC10616499 DOI: 10.1093/ckj/sfad107] [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: 02/03/2023] [Indexed: 11/03/2023] Open
Abstract
Acute kidney injury (AKI) affects about half of patients admitted to the intensive care unit (ICU), and worsens their short- and long-term outcomes. Apparently self-limiting AKI episodes initiate a progression toward chronic kidney disease (CKD) through cellular and molecular mechanisms that are yet to be explained. In particular, persistent AKI, defined in 2016 by the Acute Dialysis Quality Initiative as an AKI which lasts more than 48 h from its onset, has been correlated with higher morbidity and mortality, and with a higher progression to acute kidney disease (AKD) and CKD than transient AKI (i.e. AKI with a reversal within 48 h). This classification has been also used in the setting of solid organ transplantation, demonstrating similar outcomes. Due to its incidence and poor prognosis and because prompt interventions seem to change its course, persistent AKI should be recognized early and followed-up also after its recovery. However, while AKI and CKD are well-described syndromes, persistent AKI and AKD are relatively new entities. The purpose of this review is to highlight the key phases of persistent AKI in ICU patients in terms of both clinical and mechanistic features in order to offer to clinicians and researchers an updated basis from which to start improving patients' care and direct future research.
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Affiliation(s)
- Sara Samoni
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia De Rosa
- Centre for Medical Sciences – CISMed, University of Trento, Trento, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padova, Italy
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, Dialysis and Renal Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Giuseppe Castellano
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli studi di Milano, Milan, Italy
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Yang YC, Chen YS, Liao WC, Yin CH, Lin YS, Chen MW, Chen JS. Significant perioperative parameters affecting postoperative complications within 30 days following craniotomy for primary malignant brain tumors. Perioper Med (Lond) 2023; 12:54. [PMID: 37872604 PMCID: PMC10594926 DOI: 10.1186/s13741-023-00343-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 10/02/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND The occurrence of postoperative complications within 30 days (PC1M) of a craniotomy for the removal of a primary malignant brain tumor has been associated with a poor prognosis. However, it is still unclear to early predict the occurrence of PC1M. This study aimed to identify the potential perioperative predictors of PC1M from its preoperative, intraoperative, and 24-h postoperative parameters. METHODS Patients who had undergone craniotomy for primary malignant brain tumor (World Health Organization grades III and IV) from January 2011 to December 2020 were enrolled from a databank of Kaohsiung Veterans General Hospital, Taiwan. The patients were classified into PC1M and nonPC1M groups. PC1M was defined according to the classification by Landriel et al. as any deviation from an uneventful 30-day postoperative course. In both groups, data regarding the baseline characteristics and perioperative parameters of the patients, including a new marker-kinetic estimated glomerular filtration rate, were collected. Logistic regression was used to analyze the predictability of the perioperative parameters. RESULTS The PC1M group included 41 of 95 patients. An American Society of Anesthesiologists score of > 2 (aOR, 3.17; 95% confidence interval [CI], 1.19-8.45; p = 0.021), longer anesthesia duration (aOR, 1.16; 95% CI, 0.69-0.88; p < 0.001), 24-h postoperative change in hematocrit by > - 4.8% (aOR, 3.45; 95% CI, 1.22-9.73; p = 0.0019), and 24-h postoperative change in kinetic estimated glomerular filtration rate of < 0 mL/min (aOR, 3.99; 95% CI, 1.52-10.53; p = 0.005) were identified as independent risk factors for PC1M via stepwise logistic regression analysis. When stratified according to the age of ≥ 65 years (OR, 11.55; 95% CI, 1.30-102.79; p = 0.028), the reduction of kinetic estimated glomerular filtration rate was more robustly associated with a higher risk of PC1M. CONCLUSIONS Four parameters were demonstrated to significantly influence the risk of PC1M in patients undergoing primary malignant brain tumor removal. Measuring and verifying these markers, especially kinetic estimated glomerular filtration rate, would help early recognition of PC1M risk in clinical care.
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Affiliation(s)
- Yao-Chung Yang
- Division of Neurosurgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Yao-Shen Chen
- Department of Administration, Kaohsiung Veterans General Hospital, Kaohsiung City, 81362, Taiwan
| | - Wei-Chuan Liao
- Division of Neurosurgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chun-Hao Yin
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Institute of Health Care Management, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Yung-Shang Lin
- Division of Neurosurgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Meng-Wei Chen
- Department of Surgery, Kaohsiung Armed Force General Hospital, Kaohsiung, Taiwan
| | - Jin-Shuen Chen
- Department of Administration, Kaohsiung Veterans General Hospital, Kaohsiung City, 81362, Taiwan.
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Behal ML, Flannery AH, Barreto EF. Medication Management in the Critically Ill Patient with Acute Kidney Injury. Clin J Am Soc Nephrol 2023; 18:1080-1088. [PMID: 36723347 PMCID: PMC10564345 DOI: 10.2215/cjn.0000000000000101] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 02/02/2023]
Abstract
ABSTRACT AKI occurs frequently in critically ill patients. Patients with AKI, including those who require KRT, experience multiple pharmacokinetic and pharmacodynamic perturbations that dynamically influence medication effectiveness and safety. Patients with AKI may experience both subtherapeutic drug concentrations, which lead to ineffective therapy, and supratherapeutic drug concentrations, which increase the risk for toxicity. In critically ill patients with AKI not requiring KRT, conventional GFR estimation equations, especially those based on serum creatinine, have several limitations that can limit the accuracy when used for medication dosing. Alternative methods to estimate kidney function may be informative, including use of measured urinary creatinine clearance, kinetic eGFR, and equations that integrate novel kidney biomarkers. For critically ill patients with AKI requiring KRT, physicochemical properties of the drug, the KRT prescription and circuit configuration, and patient-specific factors each contribute to medication clearance. Evidence-based guidance for medication dosing during AKI requiring KRT is often limited. A working knowledge of the basic tenets of drug elimination during KRT can provide a framework for how to approach decision making when the literature is lacking. Iterative re-evaluation of a patient's progress toward therapeutic goals with a medication must occur over the arc of critical illness, including and especially in the setting of dynamic kidney function.
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Affiliation(s)
- Michael L. Behal
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
| | - Alexander H. Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
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Lijović L, Pelajić S, Hawchar F, Minev I, da Silva BHCS, Angelucci A, Ercole A, de Grooth HJ, Thoral P, Radočaj T, Elbers P. Diagnosing acute kidney injury ahead of time in critically ill septic patients using kinetic estimated glomerular filtration rate. J Crit Care 2023; 75:154276. [PMID: 36774818 DOI: 10.1016/j.jcrc.2023.154276] [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: 11/13/2022] [Revised: 01/10/2023] [Accepted: 02/02/2023] [Indexed: 02/12/2023]
Abstract
INTRODUCTION Accurate and actionable diagnosis of Acute Kidney Injury (AKI) ahead of time is important to prevent or mitigate renal insufficiency. The purpose of this study was to evaluate the performance of Kinetic estimated Glomerular Filtration Rate (KeGFR) in timely predicting AKI in critically ill septic patients. METHODS We conducted a retrospective analysis on septic ICU patients who developed AKI in AmsterdamUMCdb, the first freely available European ICU database. The reference standard for AKI was the Kidney Disease: Improving Global Outcomes (KDIGO) classification based on serum creatinine and urine output (UO). Prediction of AKI was based on stages defined by KeGFR and UO. Classifications were compared by length of ICU stay (LOS), need for renal replacement therapy and 28-day mortality. Predictive performance and time between prediction and diagnosis were calculated. RESULTS Of 2492 patients in the cohort, 1560 (62.0%) were diagnosed with AKI by KDIGO and 1706 (68.5%) by KeGFR criteria. Disease stages had agreement of kappa = 0.77, with KeGFR sensitivity 93.2%, specificity 73.0% and accuracy 85.7%. Median time to recognition of AKI Stage 1 was 13.2 h faster for KeGFR, and 7.5 h and 5.0 h for Stages 2 and 3. Outcomes revealed a slight difference in LOS and 28-day mortality for Stage 1. CONCLUSIONS Predictive performance of KeGFR combined with UO criteria for diagnosing AKI is excellent. Compared to KDIGO, deterioration of renal function was identified earlier, most prominently for lower stages of AKI. This may shift the actionable window for preventing and mitigating renal insufficiency.
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Affiliation(s)
- Lada Lijović
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam Public Health, Amsterdam Cardiovascular Science, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands; Department of Anesthesiology, Intensive Care and Pain Management, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia.
| | - Stipe Pelajić
- Department of Anesthesiology, Intensive Care and Pain Management, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia
| | - Fatime Hawchar
- Department of Anesthesiology and Intensive Care, Albert Szent-Györgyi Health Center, University of Szeged, Hungary
| | - Ivaylo Minev
- Department of Anaesthesiology, Emergency and Intensive care medicine, Medical University of Plovdiv, University hospital St. George, Bulgaria
| | - Beatriz Helena Cermaria Soares da Silva
- Diretoria de Ciencias Medicas, Universidade Nove de Julho - Campus Guarulhos, Sao Paulo, Brazil; Departamento de Anesthesiologia, Dor e Terapia Intensiva, Universidade Federal de Sao Paolo, Sao Paolo, Brazil
| | - Alessandra Angelucci
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano, Italy
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam Public Health, Amsterdam Cardiovascular Science, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Patrick Thoral
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam Public Health, Amsterdam Cardiovascular Science, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Tomislav Radočaj
- Department of Anesthesiology, Intensive Care and Pain Management, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia
| | - Paul Elbers
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam Public Health, Amsterdam Cardiovascular Science, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
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Rodrigues CE, Endre ZH. Definitions, phenotypes, and subphenotypes in acute kidney injury-Moving towards precision medicine. Nephrology (Carlton) 2023; 28:83-96. [PMID: 36370326 PMCID: PMC10100386 DOI: 10.1111/nep.14132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/23/2022] [Accepted: 10/31/2022] [Indexed: 11/13/2022]
Abstract
The current definition of acute kidney injury (AKI) is generic and, based only on markers of function, is unsuitable for guiding individualized treatment. AKI is a complex syndrome with multiple presentations and causes. Targeted AKI management will only be possible if different phenotypes and subphenotypes of AKI are recognised, based on causation and related pathophysiology. Molecular signatures to identify subphenotypes are being recognised, as specific biomarkers reveal activated pathways. Assessment of individual clinical risk needs wider dissemination to allow identification of patients at high risk of AKI. New and more timely markers for glomerular filtration rate (GFR) are available. However, AKI diagnosis and classification should not be limited to GFR, but include tubular function and damage. Combining damage and stress biomarkers with functional markers enhances risk prediction, and identifies a population enriched for clinical trials targeting AKI. We review novel developments and aim to encourage implementation of these new techniques into clinical practice as a strategy for individualizing AKI treatment akin to a precision medicine-based approach.
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Affiliation(s)
- Camila Eleuterio Rodrigues
- Nephrology Department, Prince of Wales Clinical School - UNSW Medicine, Sydney, New South Wales, Australia.,Nephrology Department, Hospital das Clínicas - University of São Paulo School of Medicine, São Paulo, Brazil
| | - Zoltán H Endre
- Nephrology Department, Prince of Wales Clinical School - UNSW Medicine, Sydney, New South Wales, Australia
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Khandelwal P, McLean N, Menon S. Update on Pediatric Acute Kidney Injury. Pediatr Clin North Am 2022; 69:1219-1238. [PMID: 36880931 DOI: 10.1016/j.pcl.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute kidney injury (AKI) is common in children and is associated with significant morbidity and mortality. In the last decade our understanding of AKI has improved significantly, and it is now considered a systemic disorder that affects other organs including heart, lung, and brain. In spite of its limitations, serum creatinine remains the mainstay in the diagnosis of AKI. However, newer approaches such as urinary biomarkers, furosemide stress test, and clinical decision support are being increasingly used and have the potential to improve the accuracy and timeliness of AKI diagnosis.
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Affiliation(s)
- Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, Academic Block, Ansari Nagar, New Delhi 110029, India
| | - Nadia McLean
- Cornwall Regional Hospital, c/o Cornwall Regional Hospital, PO Box 900, Mount Salem, Montego Bay #2 PO, St. James, Jamaica, West Indies
| | - Shina Menon
- Department of Pediatrics, Division of Nephrology, University of Washington, Seattle Children's Hospital, 4800 Sand Point Way NE, Mailstop OC9.820, Seattle, WA 98103, USA.
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Md Ralib A, Ramly NF, Nanyan S, Mat Nor MB. The Utility of the Creatinine Excretion to Production Ratio and the Plasma Creatinine and Cystatin C Based Kinetic Estimates of Glomerular Filtration Rates in Critically Ill Patients with Sepsis. Indian J Nephrol 2022; 32:600-605. [PMID: 36704601 PMCID: PMC9872923 DOI: 10.4103/ijn.ijn_519_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/19/2022] [Indexed: 01/29/2023] Open
Abstract
Introduction Creatinine kinetics denotes that under steady-state conditions, creatinine production (G) will equal creatinine excretion rate (E). The glomerular filtration (GFR) is impaired when excretion is less than production. The kinetic estimate of GFR (keGFR) and E/G ratio were proposed as a more accurate estimate of GFR in acute settings with rapidly changing kidney function. We evaluated keGFR and E/G to diagnose AKI, predict recovery, death or dialysis. Methods This is a prospective observational study of critically ill patients. Inclusion criteria were patients >18 years old with sepsis, defined as clinical infection with an increase in SOFA score >2, and plasma procalcitonin >0.5 ng/mL. Plasma creatinine and Cystatin C were measured on ICU admission and 4 h later, and their keGFR was calculated. Urine creatinine and urine output were measured over 4 h to calculate the E/G ratio. Results A total of 70 patients were recruited, of which 49 (70%) had AKI. Of these, 33 recovered within 3 days, and 15 had a composite outcome of death or dialysis. Day 1 keGFRCr and keGFRCysC discriminated AKI from non-AKI with AUCs of 0.85 (95% Confidence interval: 0.74-0.96), and 0.86 (0.76-0.97), respectively. The E/G ratio predicted AKI recovery (AUC: 0.81 (0.69-0.97)). The keGFRs were not predictive of death or dialysis, whereas E/G was predictive (AUC: 0.76 (0.63-0.89). Conclusion keGFR was strongly diagnostic of AKI. The E/G ratio predicted AKI recovery and a composite outcome of death and dialysis.
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Affiliation(s)
- Azrina Md Ralib
- Department of Anaesthesiology and Critical Care, Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Nur Fariza Ramly
- Department of Anaesthesiology and Critical Care, Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Suhaila Nanyan
- Department of Anaesthesiology and Critical Care, Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Mohd Basri Mat Nor
- Department of Anaesthesiology and Critical Care, Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
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Dumnicka P, Mazur-Laskowska M, Ceranowicz P, Sporek M, Kolber W, Tisończyk J, Kuźniewski M, Maziarz B, Kuśnierz-Cabala B. Acute Changes in Serum Creatinine and Kinetic Glomerular Filtration Rate Estimation in Early Phase of Acute Pancreatitis. J Clin Med 2022; 11:6159. [PMID: 36294481 PMCID: PMC9605446 DOI: 10.3390/jcm11206159] [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: 09/05/2022] [Revised: 10/04/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
In patients with acutely changing kidney function, equations used to estimate glomerular filtration rate (eGFR) must be adjusted for dynamic changes in the concentrations of filtration markers (kinetic eGFR, KeGFR). The aim of our study was to evaluate serum creatinine-based KeGFR in patients in the early phase of acute pancreatitis (AP) as a marker of changing renal function and as a predictor of AP severity. We retrospectively calculated KeGFR on day 2 and 3 of the hospital stay in a group of 147 adult patients admitted within 24 h from the onset of AP symptoms and treated in two secondary-care hospitals. In 34 (23%) patients, changes in serum creatinine during days 1-3 of the hospital stay exceeded 26.5 µmol/L; KeGFR values almost completely differentiated those with increasing and decreasing serum creatinine (area under receiver operating characteristic curve, AUROC: 0.990 on day 3). In twelve (8%) patients, renal failure was diagnosed during the first three days of the hospital stay according to the modified Marshall scoring system, which was associated with significantly lower KeGFR values. KeGFR offered good diagnostic accuracy for renal failure (area under receiver operating characteristic-AUROC: 0.942 and 0.950 on days 2 and 3). Fourteen (10%) patients developed severe AP. KeGFR enabled prediction of severe AP with moderate diagnostic accuracy (AUROC: 0.788 and 0.769 on days 2 and 3), independently of age, sex, comorbidities and study center. Lower KeGFR values were significantly associated with mortality. Significant dynamic changes in renal function are common in the early phase of AP. KeGFR may be useful in the assessment of kidney function in AP and the prediction of AP severity.
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Affiliation(s)
- Paulina Dumnicka
- Department of Medical Diagnostics, Faculty of Pharmacy, Jagiellonian University Medical College, 30-688 Kraków, Poland
| | | | - Piotr Ceranowicz
- Department of Physiology, Faculty of Medicine, Jagiellonian University Medical College, 31-531 Kraków, Poland
| | - Mateusz Sporek
- Department of Anatomy, Faculty of Medicine, Jagiellonian University Medical College, 31-034 Kraków, Poland
- Surgery Department, The District Hospital, 34-200 Sucha Beskidzka, Poland
| | - Witold Kolber
- Department of Surgery, Complex of Health Care Centers in Wadowice, 34-100 Wadowice, Poland
| | - Joanna Tisończyk
- Department of Medical Diagnostics, Faculty of Pharmacy, Jagiellonian University Medical College, 30-688 Kraków, Poland
| | - Marek Kuźniewski
- Chair and Department of Nephrology, Faculty of Medicine, Jagiellonian University Medical College, 30-688 Kraków, Poland
| | - Barbara Maziarz
- Department of Diagnostics, Chair of Clinical Biochemistry, Faculty of Medicine, Jagiellonian University Medical College, 31-066 Kraków, Poland
| | - Beata Kuśnierz-Cabala
- Chair of Medical Biochemistry, Faculty of Medicine, Jagiellonian University Medical College, 31-034 Kraków, Poland
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Early Estimation of Renal Function After Transplantation to Enable Appropriate Dosing of Critical Drugs: Retrospective Analysis of 103 Patients in a Single Center. Clin Pharmacokinet 2021; 59:1303-1311. [PMID: 32385733 PMCID: PMC7550320 DOI: 10.1007/s40262-020-00893-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Immediately after renal transplantation (RTX), estimation of renal function (eGFR) is important for drug dosing and the detection of potential complications. Conventional formulas cannot be used since the serum creatinine concentration is not at steady-state. In this study, we evaluated different dynamic renal function formulas (DRFFs) to estimate eGFR immediately after RTX. METHODS We retrospectively included 154 RTX patients, of whom 45 had delayed graft function (DGF) and required dialysis, and 6 had unstable graft function without the need for dialysis; 103 patients had early, and thereafter stable, graft function (EGF). DRFFs were evaluated to calculate eGFR 1 day after transplantation (T1) using a new dynamic creatinine clearance calculation (D3C), two previously published formulas (Jelliffe, and the kinetic eGFR [KeGFR]), and a naive predictor (Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI] at T1). The estimated DRFF-based renal functions at T1 were compared with the CKD-EPI after stabilization of renal function 3 days after transplantation (eGFR-T3), which was considered the underlying renal function immediately after RTX. RESULTS The D3C showed low bias (mean prediction error [MPE] - 4.5 ml/min/1.73 m2) and performed well on other outcome measures (R2 = 0.82, root mean squared error [RMSE] = 11.8 ml/min/1.73 m2, percentage of predictions within 30% of the reference value [p30%] = 76%). In addition, the D3C outperformed the KeGFR (MPE 20.5 ml/min/1.73 m2, R2 = 0.79, RMSE = 26.9 ml/min/1.73 m2, p30% = 29%), Jelliffe (MPE - 13.3 ml/min/1.73 m2, R2 = 0.76, RMSE = 19.1 ml/min/1.73 m2, p30% = 53%), and the naive predictor (bias - 24.8 ml/min/1.73 m2, R2 = 0.60, RMSE = 30.2 ml/min/1.73 m2, p30% = 21%). CONCLUSIONS The newly developed D3C enables reliable assessment of renal function immediately after RTX, provides crucial information for drug dosing, and might also advance the detection of functional decline, potentially improving treatment and renal outcome.
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Dasgupta MN, Montez-Rath ME, Hollander SA, Sutherland SM. Using kinetic eGFR to identify acute kidney injury risk in children undergoing cardiac transplantation. Pediatr Res 2021; 90:632-636. [PMID: 33446916 DOI: 10.1038/s41390-020-01307-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/12/2020] [Accepted: 11/18/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is common following pediatric cardiac transplantation. Since no treatments exist, strategies focus on early identification and prevention. Kinetic glomerular filtration rate (kGFR) was developed to assess renal function in the non-steady state. Although used to predict AKI in adults, kGFR has not been explored in children. Our study examines AKI and the ability of kGFR to identify AKI risk in pediatric heart transplant recipients. METHODS One hundred and seventy-five patients under 21 years who underwent cardiac transplantation at Lucile Packard Children's Hospital between September 2007-December 2017 were included. kGFR1 was calculated using pre-operative and immediate post-operative creatinines; kGFR2 was calculated with the first two post-operative creatinines. The primary outcome was AKI as defined by the Kidney Disease: Improving Global Outcomes criteria. RESULTS One hundred and thirty-one (75%) and 78 (45%) patients developed AKI and severe AKI, respectively; 5 (2.9%) required dialysis. kGFR was moderately associated with post-operative AKI risk. The adjusted area under the curve (AUC) for kGFR1 was 0.72 (discovery) and 0.65 (validation). The AUC for kGFR2 was 0.72 (discovery) and 0.68 (validation). CONCLUSIONS AKI is pervasive in children undergoing cardiac transplant, particularly in the 24 h after surgery. kGFR moderately identifies AKI risk and may represent a novel risk stratification technique. IMPACT Our research suggests that kGFR, a dynamic assessment of renal function that uses readily available laboratory values, can moderately identify AKI risk in children undergoing cardiac transplantation. Current published studies on kGFR are in adult populations; this study represents the first formal study of kGFR in a pediatric population. kGFR may serve as an early AKI indicator, allowing providers to implement preventative strategies sooner in a patient's clinical course.
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Affiliation(s)
| | | | - Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | - Scott M Sutherland
- Department of Pediatrics (Nephrology), Stanford University, Palo Alto, CA, USA
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Chen S, Chiaramonte R. In creatinine kinetics, the glomerular filtration rate always moves the serum creatinine in the opposite direction. Physiol Rep 2021; 9:e14957. [PMID: 34405576 PMCID: PMC8371355 DOI: 10.14814/phy2.14957] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION When the serum [creatinine] is changing, creatinine kinetics can still gauge the kidney function, and knowing the kinetic glomerular filtration rate (GFR) helps doctors take care of patients with renal failure. We wondered how the serum [creatinine] would respond if the kinetic GFR were tweaked. In every scenario, if the kinetic GFR decreased, the [creatinine] would increase, and vice versa. This opposing relationship was hypothesized to be universal. METHODS Serum [creatinine] and kinetic GFR, along with other parameters, are described by a differential equation. We differentiated [creatinine] with respect to kinetic GFR to test if the two variables would change oppositely of each other, throughout the gamut of all allowable clinical values. To remove the discontinuities in the derivative, limits were solved. RESULTS The derivative and its limits were comprehensively analyzed and proved to have a sign that is always negative, meaning that [creatinine] and kinetic GFR must indeed move in opposite directions. The derivative is bigger in absolute value at the higher end of the [creatinine] scale, where a small drop in the kinetic GFR can cause the [creatinine] to shoot upward, making acute kidney injury similar to chronic kidney disease in that regard. CONCLUSIONS All else being equal, a change in the kinetic GFR obligates the [creatinine] to change in the opposite direction. This does not negate the fact that an increasing [creatinine] can be compatible with a rising kinetic GFR, due to differences in how the time variable is treated.
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Affiliation(s)
- Sheldon Chen
- Section of NephrologyMD Anderson Cancer CenterHoustonTXUSA
| | - Robert Chiaramonte
- Internal MedicineThe State University of New York Downstate Health Sciences UniversityBrooklynNYUSA
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Christiadi D, Erlich J, Levy M, Herath S, Qian J, Boardman S, Campbell C, Kotwal S, Horvath AR, Endre Z. The kinetic estimated glomerular filtration rate ratio predicts acute kidney injury. Nephrology (Carlton) 2021; 26:782-789. [PMID: 34176181 DOI: 10.1111/nep.13918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/03/2021] [Accepted: 06/24/2021] [Indexed: 11/30/2022]
Abstract
AIM Kinetic estimated Glomerular Filtration Rate (KeGFR) approximates GFR under non-steady-state conditions. We investigated whether the ratio of KeGFR difference to baseline eGFR could predict acute kidney injury (AKI) earlier than a creatinine-based algorithm that triggered an AKI electronic Alert (eAlert). METHODS This retrospective, single-centre, proof-of-concept cohort study assessed all patients diagnosed with AKI by an automated serum creatinine-based eAlert. The kinetic eGFR, the kinetic eGFR difference from baseline and the ratio of difference to baseline was calculated in subjects with at least two serum creatinine (sCr) measurements within 72 h of AKI. RESULTS Patients in the AKI cohort (n = 140) had a significant decline in KeGFR ratio (AKI: 17% IQR 7% to 29%, Non-AKI: 0 IQR -12% to 9%; P-value <.0001). A decrease of the ratio greater than 10% predicted AKI with a sensitivity of 66%, a specificity of 77%, a positive predictive value of 63%, and negative predictive value of 80%. The median lead time between KeGFR ratio decrease and AKI was 24 h (IQR: 19-27 h). CONCLUSIONS KeGFR ratio is a cheap, simple method that predicted AKI 24 h before laboratory detection. KeGFR may facilitate triaging patients to increased monitoring or intervention.
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Affiliation(s)
- Daniel Christiadi
- Department of Nephrology, Prince of Wales Hospital, Randwick, New South Wales, Australia.,University of New South Wales, Kensington, New South Wales, Australia
| | - Jonathan Erlich
- Department of Nephrology, Prince of Wales Hospital, Randwick, New South Wales, Australia.,University of New South Wales, Kensington, New South Wales, Australia
| | - Melissa Levy
- Department of Nephrology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Sanjeeva Herath
- University of New South Wales, Kensington, New South Wales, Australia
| | - Jennifer Qian
- University of New South Wales, Kensington, New South Wales, Australia
| | - Sally Boardman
- University of New South Wales, Kensington, New South Wales, Australia
| | - Craig Campbell
- NSW Health Pathology, Department of Clinical Chemistry, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Sradha Kotwal
- Department of Nephrology, Prince of Wales Hospital, Randwick, New South Wales, Australia.,The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia
| | - Andrea R Horvath
- University of New South Wales, Kensington, New South Wales, Australia.,NSW Health Pathology, Department of Clinical Chemistry, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Zoltán Endre
- Department of Nephrology, Prince of Wales Hospital, Randwick, New South Wales, Australia.,University of New South Wales, Kensington, New South Wales, Australia
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13
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Levey AS. Defining AKD: The Spectrum of AKI, AKD, and CKD. Nephron Clin Pract 2021; 146:302-305. [PMID: 34167119 DOI: 10.1159/000516647] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/19/2021] [Indexed: 11/19/2022] Open
Abstract
Kidney Disease Improving Global Outcomes (KDIGO) guidelines address the definition, classification, and management of acute kidney injury (AKI) and chronic kidney disease (CKD). In practice, some clinical presentations of acute kidney diseases and disorders (AKD) do not meet the criteria for AKI or CKD. In principle, these presentations may be caused by the same diseases that cause AKI or CKD, which could be detected, evaluated, and treated before they evolve to AKI or CKD. In 2020, KDIGO convened a consensus conference to review recent evidence on the epidemiology of AKD and harmonize the definition and classification of AKD to be consistent with KDIGO definitions and classifications of AKI and CKD.
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Affiliation(s)
- Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
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14
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Sangla F, Marti PE, Verissimo T, Pugin J, de Seigneux S, Legouis D. Measured and Estimated Glomerular Filtration Rate in the ICU: A Prospective Study. Crit Care Med 2021; 48:e1232-e1241. [PMID: 33044285 DOI: 10.1097/ccm.0000000000004650] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To compare estimated glomerular filtration rate using classical static and kinetic equations with measured glomerular filtration rate assessed by plasma iohexol clearance in a mixed population of critical care patients. PATIENTS Unselected patients older than 18 and admitted to a general ICU. DESIGN Interventional prospective single center study. INTERVENTION Measurement of glomerular filtration rate by the plasma clearance of an IV single dose of iohexol and estimation of glomerular filtration rate with creatinine or cystatin C-based standard and kinetic equations as well as urinary creatinine clearance. MEASUREMENTS AND MAIN RESULTS Sixty-three patients were included with a median age of 66 years old. The median measured glomerular filtration rate was 51 mL/min/1.73 m (interquartile range, 19-85 mL/min/1.73 m). All used equations displayed significant biases, high errors, and poor accuracy when compared with measured glomerular filtration rate, overestimating renal function. The highest accuracy and lowest error were observed with cystatin C-based chronic kidney disease epidemiology collaboration equations. Both modification of diet in renal disease and Cockcroft-Gault equations displayed the lowest performance. Kinetic models did not improve performances, except in patients with unstable creatinine levels. Creatinine- but not cystatin C-based estimations largely derived over ICU stay, which appeared more related to sarcopenia than fluid balance. Finally, estimated glomerular filtration rate misclassified patients according to classical glomerular filtration rate categories in approximately half of the studied cases. CONCLUSIONS All known estimated glomerular filtration rate equations displayed high biases and unacceptable errors when compared with measured glomerular filtration rate in a mixed ICU population, with the lowest performance related to creatinine-based equations compared with cystatin C. In the ICU, we advocate for caution when using creatinine based estimated glomerular filtration rate equations. Drifting of serum creatinine levels over time should also be taken into consideration when assessing renal function in the ICU.
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Affiliation(s)
- Fréderic Sangla
- Division of Intensive Care, Department of Acute Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Pierre Emmanuel Marti
- Division of Intensive Care, Department of Acute Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Thomas Verissimo
- Laboratory of Nephrology, Department of Medicine and Cell Physiology, University hospital and University of Geneva, Geneva, Switzerland
| | - Jérôme Pugin
- Division of Intensive Care, Department of Acute Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Sophie de Seigneux
- Laboratory of Nephrology, Department of Medicine and Cell Physiology, University hospital and University of Geneva, Geneva, Switzerland.,Service of Nephrology, Department of Internal Medicine Specialties, University Hospital of Geneva, Geneva, Switzerland
| | - David Legouis
- Division of Intensive Care, Department of Acute Medicine, University Hospital of Geneva, Geneva, Switzerland.,Laboratory of Nephrology, Department of Medicine and Cell Physiology, University hospital and University of Geneva, Geneva, Switzerland
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15
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Christiadi D, Simpson C, O'brien K, Taylor K, Luxton G, Rossleigh M, Erlich J, Endre ZH. Cystatin C kidney functional reserve: a simple method to predict outcome in chronic kidney disease. Nephrol Dial Transplant 2021; 37:1118-1124. [PMID: 34043011 DOI: 10.1093/ndt/gfab188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Kidney Functional Reserve (KFR), the only clinical kidney stress test, is not routinely measured because complexity of measurement has limited clinical application. We investigated the utility of plasma cystatin C (CysC) after oral protein loading to determine KFR in stage 3 and 4 CKD. METHODS Following a 24 hour low protein diet, KFR was measured after oral protein by hourly plasma CysC and compared with simultaneous creatinine clearance (CrCl) and radionuclide Tc-99m-DTPA (mGFR) measurement in an observational, single-centre cohort study of adults with CKD 3 and CKD 4. Subjects were followed for three years for fast (F) or slow (S) CKD progression, dialysis requirement or death or a combination of major adverse kidney events (MAKE-F or -S). RESULT CysC, CrCl and Tc-99m DPTA mGFR measurements of KFR in 19 CKD 3 and 21 CKD 4 patients yielded good agreement. KFR was not correlated with baseline kidney function. Eight CKD 3 (42%) and 11 CKD 4 (52%) subjects reached their lowest serum CysC concentration four hours after protein loading. CysC KFR and baseline serum creatinine (sCr) predicted (death or dialysis) or MAKE-F with respective AUC = 0.73 (95% CI: 0.48 to 0.89) and 0.71 (95% CI: 0.51 to 0.84). Including CysC KFR, age, baseline sCr and nadir CysC predicted a decrease in sCr-eGFR greater than 1.2 mL/min per year (MAKE-S) with AUC = 0.89. CONCLUSIONS Serial CysC avoided timed urine collection and radionuclide exposure and yielded equivalent estimates of KFR. Serial CysC may facilitate monitoring of KFR in clinical practice.
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Affiliation(s)
- Daniel Christiadi
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Charles Simpson
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Kate O'brien
- Nutrition and Dietetics Services, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Kylie Taylor
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Grant Luxton
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Monica Rossleigh
- Department of Nuclear Medicine, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Jonathan Erlich
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Zoltán H Endre
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
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16
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Menon S, Basu RK, Barhight MF, Goldstein SL, Gist KM. Utility of Kinetic GFR for Predicting Severe Persistent AKI in Critically Ill Children and Young Adults. KIDNEY360 2021; 2:869-872. [PMID: 35373066 PMCID: PMC8791351 DOI: 10.34067/kid.0006892020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/15/2021] [Indexed: 02/04/2023]
Abstract
Kinetic eGFR can be part of a multidimensional approach for AKI prediction combined with biomarkers, fluid corrected creatinine, and renal angina.Kinetic eGFR on day 1 is not independently associated with severe day-3 AKI in children and young adults who are critically ill.
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Affiliation(s)
- Shina Menon
- Division of Pediatric Nephrology, Seattle Children’s Hospital, University of Washington, Seattle, Washington
| | - Rajit K. Basu
- Pediatric Critical Care Medicine, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Matthew F. Barhight
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Stuart L. Goldstein
- Center for Acute Care Nephology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Katja M. Gist
- Section of Pediatric Cardiology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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17
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Pelletier K, Lafrance JP, Roy L, Charest M, Bélanger MC, Cailhier JF, Albert M, Duca A, Elftouh N, Bouchard J. Estimating glomerular filtration rate in patients with acute kidney injury: a prospective multicenter study of diagnostic accuracy. Nephrol Dial Transplant 2021; 35:1886-1893. [PMID: 33151336 DOI: 10.1093/ndt/gfz178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 08/04/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Estimating glomerular filtration rate (GFR) in acute kidney injury (AKI) is challenging, with limited data comparing estimated and gold standard methods to assess GFR. The objective of our study was to assess the performance of the kinetic estimated GFR (KeGFR) and Jelliffe equations to estimate GFR in AKI, using a radioisotopic method (technetium-diethylenetriaminepentaacetic acid) as a reference measure. METHODS We conducted a prospective multicenter observational study in hospitalized patients with AKI. We computed the Jelliffe and KeGFR equations to estimate GFR and compared these estimations to measured GFR (mGFR) by a radioisotopic method. The performances were assessed by correlation, Bland-Altman plots and smoothed and linear regressions. We conducted stratified analyses by age and chronic kidney disease (CKD). RESULTS The study included 119 patients with AKI, mostly from the intensive care unit (63%) and with Stage 1 AKI (71%). The eGFR obtained from the Jelliffe and KeGFR equations showed a good correlation with mGFR (r = 0.73 and 0.68, respectively). The median eGFR by the Jelliffe and KeGFR equations was less than the median mGFR, indicating that these equations underestimated the mGFR. On Bland-Altman plots, the Jelliffe and KeGFR equations displayed a considerable lack of agreement with mGFR, with limits of agreement >40 mL/min/1.73 m2. Both equations performed better in CKD and the KeGFR performed better in older patients. Results were similar across AKI stages. CONCLUSIONS In our study, the Jelliffe and KeGFR equations had good correlations with mGFR; however, they had wide limits of agreement. Further studies are needed to optimize the prediction of mGFR with estimatation equations.
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Affiliation(s)
- Karyne Pelletier
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Jean-Philippe Lafrance
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Louise Roy
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Mathieu Charest
- Department of Nuclear Medicine, Hôpital du Sacré-Coeur de Montréal, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Marie-Claire Bélanger
- Department of Biochemistry, Centre Hospitalier de l'Université de Montréal, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Jean-François Cailhier
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Martin Albert
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Anatolie Duca
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Naoual Elftouh
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Josée Bouchard
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
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18
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Abstract
Acute kidney injury (AKI) and chronic kidney disease are common interconnected syndromes that represent a public health problem. Acute kidney disease (AKD) is defined as the post-AKI status of acute or subacute kidney damage/dysfunction manifested by persistence of AKI beyond 7 to 90 days after the initial AKI diagnosis. Limited clinical data exist regarding AKD epidemiology but its incidence is observed in ∼25% of AKI survivors. Useful risk-stratification tools to predict risk of AKD and its prognosis are needed. Interventions on fluid management, nephrotoxic exposure, and follow-up care hold promise to ameliorate the burden of AKD and its complications.
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Affiliation(s)
- Javier A Neyra
- Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky Medical Center, 800 Rose Street, MN668, Lexington, KY 40536, USA.
| | - Lakhmir S Chawla
- Department of Medicine, Veterans Affairs Medical Center, 3350 La Jolla Village Drive, San Diego, CA 92161, USA
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19
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Abramavicius S, Galaune V, Tunaityte A, Vitkauskiene A, Gumbrevicius G, Radzeviciene A, Maciulaitis R. The Glomerular Filtration Rate Estimators in the Pharmacokinetic Modelling in Acute Kidney Injury: An Observational Study. Antibiotics (Basel) 2021; 10:antibiotics10020158. [PMID: 33557261 PMCID: PMC7915939 DOI: 10.3390/antibiotics10020158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 12/29/2022] Open
Abstract
The glomerular filtration rate (GFR), according to which the drug dose for patients with chronic kidney disease (CKD) is adjusted, is computed with estimators (eGFR) that are developed specifically for CKD. These particular types of estimators are also used in population pharmacokinetic (pop PK) modelling in drug development. Similar approaches without scientific validation have been proposed for patients with acute kidney injury (AKI), yet it is uncertain which specific eGFR should be used for drug dosing or in pop PK models in patients with AKI. In our study, we included 34 patients with AKI and vancomycin (VCM) treatment, and we built both individual PK and pop PK (non-linear mixed-effects, one-compartment) models to see which eGFR estimator is the best covariate. In these models different eGFRs (Cockcroft-Gault, MDRD, CKD-EPI 2009, Jelliffe and Jelliffe, Chen et al., and Yashiro et al. 2013) were used. We included six additional patients to validate the final pop PK model. All eGFRs underrate the true renal clearance in the AKI, so we created pop PK models for VCM dosing in AKI with all eGFRs, to discover that the most accurate model was the one with the Cockcroft-Gault estimator. Since the eGFRs underestimate the true renal clearance in AKI, they are inaccurate for clinical drug dosing decisions, with the exception of the Cockcroft-Gault one, which is appropriate for the pop PK models intended for drug development purposes in AKI.
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Affiliation(s)
- Silvijus Abramavicius
- Laboratory of Preclinical Drug, Investigation Institute of Cardiology, Lithuanian University of Health Sciences, LT-47181 Kaunas, Lithuania; (S.A.); (V.G.); (G.G.); (A.R.); (R.M.)
| | - Vaidotas Galaune
- Laboratory of Preclinical Drug, Investigation Institute of Cardiology, Lithuanian University of Health Sciences, LT-47181 Kaunas, Lithuania; (S.A.); (V.G.); (G.G.); (A.R.); (R.M.)
| | - Agile Tunaityte
- Laboratory of Preclinical Drug, Investigation Institute of Cardiology, Lithuanian University of Health Sciences, LT-47181 Kaunas, Lithuania; (S.A.); (V.G.); (G.G.); (A.R.); (R.M.)
- Correspondence:
| | - Astra Vitkauskiene
- Department of Laboratory Medicine, Lithuanian University of Health Sciences, LT-47181 Kaunas, Lithuania;
| | - Gintautas Gumbrevicius
- Laboratory of Preclinical Drug, Investigation Institute of Cardiology, Lithuanian University of Health Sciences, LT-47181 Kaunas, Lithuania; (S.A.); (V.G.); (G.G.); (A.R.); (R.M.)
| | - Aurelija Radzeviciene
- Laboratory of Preclinical Drug, Investigation Institute of Cardiology, Lithuanian University of Health Sciences, LT-47181 Kaunas, Lithuania; (S.A.); (V.G.); (G.G.); (A.R.); (R.M.)
- Institute of Physiology and Pharmacology, Medical Academy, Lithuanian University of Health Sciences, LT-44307 Kaunas, Lithuania
| | - Romaldas Maciulaitis
- Laboratory of Preclinical Drug, Investigation Institute of Cardiology, Lithuanian University of Health Sciences, LT-47181 Kaunas, Lithuania; (S.A.); (V.G.); (G.G.); (A.R.); (R.M.)
- Nephrology Department, Lithuanian University of Health Sciences, LT-47181 Kaunas, Lithuania
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20
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Kinetic GFR Outperforms CKD-EPI for Slow Graft Function Prediction in the Immediate Postoperative Period Following Kidney Transplantation. J Clin Med 2020; 9:jcm9124003. [PMID: 33322021 PMCID: PMC7763889 DOI: 10.3390/jcm9124003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 01/10/2023] Open
Abstract
Background: Rapid identification of patients at high risk for slow graft function (SGF) is of major importance in the immediate period following renal graft transplantation, both for early therapeutic decisions and long-term prognosis. Due to the high variability of serum creatinine levels after surgery, glomerular filtration rate (GFR) estimation is challenging. In this situation, kinetic estimated GFR (KeGFR) equations are interesting tools but have never been assessed for the identification of SGF patients. Methods: We conducted a single-center retrospective cohort study, including all consecutive kidney allograft recipients in the University Hospitals of Geneva from 2008 to 2016. GFR was estimated using both CKD-EPI and KeGFR formulae. Their accuracies for SGF prediction were compared. Patients were followed up for one year after transplantation. Results: A total of 326 kidney recipients were analyzed. SGF occurred in 76 (23%) patients. KeGFR estimation stabilized from the day following kidney transplantation, more rapidly than CKD-EPI. Discrimination ability for SGF prediction was better for KeGFR than CKD-EPI (AUC 0.82 and 0.66, p < 0.001, respectively). Conclusion: KeGFR computed from the first day after renal transplantation was able to predict SGF with good discrimination, outperforming CKD-EPI estimation. SGF patients had lower renal graft function overall at the one-year follow up.
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21
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Latha AV, Rameshkumar R, Bhowmick R, Rehman T. Kinetic Estimated Glomerular Filtration Rate and Severity of Acute Kidney Injury in Critically Ill Children. Indian J Pediatr 2020; 87:995-1000. [PMID: 32436154 DOI: 10.1007/s12098-020-03314-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 04/17/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To study the Kinetic estimated Glomerular Filtration Rate (KeGFR) using serum creatinine (SCr) for the identification of acute kidney injury (AKI), stages of AKI, and extent of agreement with Kidney Disease Improving Global Outcomes (KDIGO) classification in critically ill children. METHODS A prospective observational study was conducted in a pediatric intensive care unit (PICU) in a tertiary care institute of South India from July through August 2018. Sixty children were enrolled. The patients with known End-Stage Renal Disease (ESRD), with previous renal transplantation, admission SCr more than 4 mg per dL, expired within 24 h of admission and patients who underwent Renal Replacement Therapy (RRT) before PICU admission were excluded. KeGFR was calculated for the first seven days, and the worst achieved value was determined. AKI staging by KDIGO was compared with AKI by KeGFR value. The requirement of RRT, multi-organ dysfunction syndrome (MODS), mechanical ventilation, cumulative fluid balance, PICU stay, and hospital mortality was recorded. RESULTS AKI detection by KeGFR method showed a sensitivity of 93% (95% CI 80% - 98.2%) and specificity of 76% (95% CI 49.8% - 92.2%) compared to KDIGO criteria. The good agreement between KDIGO and KeGFR values for AKI was noted (Kappa = 0.71, p < 0.001). It was observed that 81.3% (n = 13) of Group-I, 56% (n = 14) of Group-II, 77.8% (n = 7) of Group-III and 90% (n = 9) of Group-IV by KeGFR were graded as Stage-0, Stage-1, Stage-2 and Stage-3 of AKI by KDIGO criteria respectively (p < 0.001). There was no significant difference noted in secondary outcomes. The survival of children with AKI and those without AKI (by both KDIGO staging and KeGFR) showed no significant difference. CONCLUSIONS KeGFR is highly sensitive, and there is a good agreement with KDIGO criteria in the identification of AKI in critically ill children. Further research is required to validate these study results.
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Affiliation(s)
- Akarsh Vijayakumar Latha
- Department of Pediatrics, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | - Ramachandran Rameshkumar
- Department of Pediatrics, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India.
| | - Rohit Bhowmick
- Department of Pediatrics, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | - Tanveer Rehman
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
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22
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Chen S, Chiaramonte R. Estimating Creatinine Clearance in the Nonsteady State: The Determination and Role of the True Average Creatinine Concentration. Kidney Med 2020; 1:207-216. [PMID: 32734201 PMCID: PMC7380424 DOI: 10.1016/j.xkme.2019.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Creatinine clearance is a tenet of nephrology practice. However, with just a single creatinine concentration included in the denominator of the creatinine clearance equation, the resulting value seems to apply only in the steady state. Does the basic clearance formula work in the nonsteady state, and can it recapitulate the kinetic glomerular filtration rate (GFR) equation? In the kinetic state, a nonlinear creatinine trajectory is reducible into a “true average” value that can be found using calculus, proceeding from a differential equation based on the mass balance principle. Using the fundamental theorem of calculus, we prove definitively that the true average is the correct creatinine to divide by, even as the mathematical model accommodates clinical complexities such as volume change and other factors that affect creatinine kinetics. The true average of a creatinine versus time function between 2 measured creatinine values is found by a definite integral. To use the true average to compute kinetic GFR, 2 techniques are demonstrated, a graphical one and a numerical one. We apply this concept to a clinical case of an individual with acute kidney injury requiring dialysis; despite the effects of hemodialysis on serum creatinine concentration, kinetic GFR was able to track the underlying kidney function and provided critical information regarding kidney function recovery. Finally, a prior concept of the maximum increase in creatinine per day is made more clinically objective. Thus, the clearance paradigm applies to the nonsteady state as well when the true average creatinine is used, providing a fundamentally valid strategy to deduce kinetic GFRs from serum creatinine trends occurring in real-life acute kidney injury and kidney recovery.
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Affiliation(s)
- Sheldon Chen
- Section of Nephrology, MD Anderson Cancer Center, Houston, TX
- Address for Correspondence: Sheldon Chen, MD, MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1468, Houston, TX 77230-1402.
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Bairy M. Using Kinetic eGFR for Drug Dosing in AKI: Concordance between Kinetic eGFR, Cockroft-Gault Estimated Creatinine Clearance, and MDRD eGFR for Drug Dosing Categories in a Pilot Study Cohort. Nephron Clin Pract 2020; 144:299-303. [DOI: 10.1159/000507260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/14/2020] [Indexed: 11/19/2022] Open
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Kessy JP, Philemon RN, Hamel BC. Two cases of Prune Belly Syndrome from Kagera Region Tanzania. East Afr Health Res J 2020; 4:20-25. [PMID: 34308216 PMCID: PMC8279232 DOI: 10.24248/eahrj.v4i1.630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 06/07/2020] [Indexed: 11/26/2022] Open
Abstract
Prune Belly Syndrome is a rare congenital disorder with unknown aetiology, consisting of a triad of abdominal muscle wall weakness, undescended testes, and urinary tract abnormalities. We are unaware of any preceding report of Prune Belly Syndrome in Tanzania, and here we describe two cases reported in Kagera region. The first case is a 2 month old boy with the triad of Prune Belly Syndrome along with pectus carinatum who died due to septicaemia. This case posed a diagnostic challenge at birth and during the natal period. Paucity of comprehensive knowledge of congenital malformations at the peripheral health facilities may have also contributed to the diagnostic challenge in the first place. The second case is a neonate who was referred to regional referral hospital where he was diagnosed with Prune Belly Syndrome at the age of four weeks. Because of limited capacity to manage congenital malformations at the regional referral hospital, he was referred to an urologist at the zonal referral hospital. However, inadequacies in supporting systems to the parents compounded care of the neonate with Prune Belly Syndrome. High index of Prune Belly Syndrome suspicion is needed in a resource limited setting in order to timely make diagnosis. There is also a need to strengthen institutional and individual's capacity for prenatal screening to detect congenital anomalies at an early stage of foetus development. Multidisciplinary management approach is necessary in order to improve the quality of life for patients with Prune Belly Syndrome. Psychosocial and medical support systems should be put in place in order to enhance preparedness for patient care in resource limited settings including equipping the referral hospital with different specialists and ensuring availability of basic investigations for patients.
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Affiliation(s)
- Jonas P Kessy
- Bukoba Regional Referral Hospital, Paediatric and Child Health Department, Bukoba, Tanzania
| | - Rune N Philemon
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Ben C Hamel
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
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Kwong YD, Chen S, Bouajram R, Li F, Matthay MA, Mehta KM, Glidden DV, Liu KD. The value of kinetic glomerular filtration rate estimation on medication dosing in acute kidney injury. PLoS One 2019; 14:e0225601. [PMID: 31770424 PMCID: PMC6879155 DOI: 10.1371/journal.pone.0225601] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 11/07/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In acute kidney injury (AKI), medication dosing based on Cockcroft-Gault creatinine clearance (CrCl) or Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimated glomerular filtration rates (eGFR) are not valid when serum creatinine (SCr) is not in steady state. The aim of this study was to determine the impact of a kinetic estimating equation that incorporates fluctuations in SCrs on drug dosing in critically ill patients. METHODS We used data from participants enrolled in the NIH Acute Respiratory Distress Syndrome Network Fluid and Catheters Treatment Trial to simulate drug dosing category changes with the application of the kinetic estimating equation developed by Chen. We evaluated whether kinetic estimation of renal function would change medication dosing categories (≥60, 30-59, 15-29, and <15mL/min) compared with the use of CrCl or CKD-EPI eGFR. RESULTS The use of kinetic CrCl and CKD-EPI eGFR resulted in a large enough change in estimated renal function to require medication dosing recategorization in 19.3% [95 CI 16.8%-21.9%] and 23.4% [95% CI 20.7%-26.1%] of participants, respectively. As expected, recategorization occurred more frequently in those with AKI. When we examined individual days for those with AKI, dosing discordance was observed in 8.5% of total days using the CG CrCl and 10.2% of total days using the CKD-EPI equation compared with the kinetic counterparts. CONCLUSION In a critically ill population, use of kinetic estimates of renal function impacted medication dosing in a substantial proportion of AKI participants. Use of kinetic estimates in clinical practice should lower the incidence of medication toxicity as well as avoid subtherapeutic dosing during renal recovery.
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Affiliation(s)
- Yuenting D. Kwong
- Department of Medicine, Division of Nephrology, University of California at San Francisco School of Medicine, San Francisco, CA, United States of America
- * E-mail:
| | - Sheldon Chen
- Department of Medicine, Division of Nephrology, MD Anderson, Houston, TX, United States of America
| | - Rima Bouajram
- Department of Pharmaceutical Services, University of California at San Francisco Medical Center, San Francisco, CA, United States of America
| | - Fanny Li
- Department of Pharmaceutical Services, University of California at San Francisco Medical Center, San Francisco, CA, United States of America
| | - Michael A. Matthay
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco School of Medicine, San Francisco, CA, United States of America
| | - Kala M. Mehta
- Department of Epidemiology and Biostatistics, University of California at San Francisco School of Medicine, San Francisco, CA, United States of America
| | - David V. Glidden
- Department of Epidemiology and Biostatistics, University of California at San Francisco School of Medicine, San Francisco, CA, United States of America
| | - Kathleen D. Liu
- Department of Medicine, Division of Nephrology, University of California at San Francisco School of Medicine, San Francisco, CA, United States of America
- Department of Anesthesia, Division of Critical Care Medicine, University of California at San Francisco School of Medicine, San Francisco, CA, United States of America
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Yoshida T, Matsuura R, Komaru Y, Miyamoto Y, Yoshimoto K, Hamasaki Y, Noiri E, Morimura N, Nangaku M, Doi K. Kinetic estimated glomerular filtration rate as a predictor of successful continuous renal replacement therapy discontinuation. Nephrology (Carlton) 2019; 24:287-293. [DOI: 10.1111/nep.13396] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2018] [Indexed: 01/08/2023]
Affiliation(s)
- Teruhiko Yoshida
- Department of Nephrology and Endocrinology; The University of Tokyo; Tokyo Japan
| | - Ryo Matsuura
- Department of Nephrology and Endocrinology; The University of Tokyo; Tokyo Japan
| | - Yohei Komaru
- Department of Nephrology and Endocrinology; The University of Tokyo; Tokyo Japan
| | - Yoshihisa Miyamoto
- Department of Nephrology and Endocrinology; The University of Tokyo; Tokyo Japan
| | - Kohei Yoshimoto
- Department of Acute Medicine; The University of Tokyo; Tokyo Japan
| | - Yoshifumi Hamasaki
- Department of Nephrology and Endocrinology; The University of Tokyo; Tokyo Japan
| | - Eisei Noiri
- Department of Nephrology and Endocrinology; The University of Tokyo; Tokyo Japan
| | - Naoto Morimura
- Department of Acute Medicine; The University of Tokyo; Tokyo Japan
| | - Masaomi Nangaku
- Department of Nephrology and Endocrinology; The University of Tokyo; Tokyo Japan
| | - Kent Doi
- Department of Acute Medicine; The University of Tokyo; Tokyo Japan
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Kelly YP, Waikar SS, Mendu ML. When to stop renal replacement therapy in anticipation of renal recovery in AKI: The need for consensus guidelines. Semin Dial 2019; 32:205-209. [DOI: 10.1111/sdi.12773] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Yvelynne P. Kelly
- Division of Renal Medicine, Harvard Medical School Brigham and Women's Hospital Boston Massachusetts
| | - Sushrut S. Waikar
- Division of Renal Medicine, Harvard Medical School Brigham and Women's Hospital Boston Massachusetts
| | - Mallika L. Mendu
- Division of Renal Medicine, Harvard Medical School Brigham and Women's Hospital Boston Massachusetts
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Vanmassenhove J, Van Biesen W, Vanholder R, Lameire N. Subclinical AKI: ready for primetime in clinical practice? J Nephrol 2018; 32:9-16. [PMID: 30523562 DOI: 10.1007/s40620-018-00566-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 12/03/2018] [Indexed: 12/12/2022]
Abstract
There has been considerable progress over the last decade in the standardization of the acute kidney injury (AKI) definition with the publication of the RIFLE, AKIN, KDIGO and ERBP classification criteria. However, these classification criteria still rely on imperfect parameters such as serum creatinine and urinary output. The use of timed urine collections, kinetic eGFR (estimated glomerular filtration rate), real time measurement of GFR and direct measures of tubular damage can theoretically aid in a more timely diagnosis of AKI and improve patients' outcome. There has been an extensive search for new biomarkers indicative of structural tubular damage but it remains controversial whether these new markers should be included in the current classification criteria. The use of these markers has also led to the creation of a new concept called subclinical AKI, a condition where there is an increase in biomarkers but without clinical AKI, defined as an increase in serum creatinine and/or a decrease in urinary output. In this review we provide a framework on how to critical appraise biomarker research and on how to position the concept of subclinical AKI. The evaluation of biomarker performance and the usefulness of the concept 'subclinical AKI' requires careful consideration of the context these biomarkers are used in (clinical versus research setting) and the goal we want to achieve (risk assessment versus prediction versus early diagnosis versus prognostication). It remains currently unknown whether an increase in biomarkers levels without functional repercussion is clinically relevant and whether including biomarkers in classification criteria will improve patients' outcome.
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Affiliation(s)
- Jill Vanmassenhove
- Renal Division, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Wim Van Biesen
- Renal Division, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Raymond Vanholder
- Renal Division, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Norbert Lameire
- Renal Division, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
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Chen S. Kinetic glomerular filtration rate equation can accommodate a changing body volume: Derivation and usage of the formula. Math Biosci 2018; 306:97-106. [DOI: 10.1016/j.mbs.2018.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/10/2018] [Accepted: 05/21/2018] [Indexed: 10/16/2022]
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Khayat MI, Deeth JM, Sosnov JA. A bedside clinical tool using creatinine kinetics to predict worsening renal injury and early recovery. Clin Kidney J 2018; 12:248-252. [PMID: 30976404 PMCID: PMC6452207 DOI: 10.1093/ckj/sfy069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Indexed: 11/13/2022] Open
Abstract
Background Changing creatinine concentrations during acute renal failure are often confusing to clinicians to interpret and can cloud the patient's true current state of renal injury. By modifying the formula for kinetic estimate of glomerular filtration rate (KeGFR), a simple bedside clinical tool can be used to identify subtle changes in renal function. Methods The KeGFR was rewritten to instead calculate a predicted peak creatinine after renal injury. By comparing the changes in predicted peak creatinine at two or more subsequent time intervals, the patient's current state of renal injury can be determined: whether improving, worsening or unchanged from prior. Results Three case examples are provided using the equation for predicted peak creatinine. In each case, the creatinine concentration has continued to rise at three sequentially measured times. The change in predicted peak creatinine is analyzed for each case, demonstrating scenarios involving (i) improving renal injury, (ii) unchanged renal injury continued by unfavorable hemodynamics and (iii) worsening renal injury despite interventions. Conclusions The use of this model may provide clinicians with an easy bedside tool to assess a patient's state of acute kidney injury. Reassessment of how the creatinine is changing is already a nonquantitative part of a nephrologist's approach to acute kidney injury. Providing an assessment of the patient's changing renal function would be a useful addition to potentially detect early renal recovery or worsening renal injury and appropriately adjust treatment strategies.
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Affiliation(s)
- Maurice I Khayat
- Department of Nephrology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jonathan M Deeth
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jonathan A Sosnov
- Department of Nephrology, San Antonio Military Medical Center, JBSA Ft Sam Houston, TX, USA
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Teo SH, Endre ZH. Biomarkers in acute kidney injury (AKI). Best Pract Res Clin Anaesthesiol 2018; 31:331-344. [PMID: 29248140 DOI: 10.1016/j.bpa.2017.10.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 10/25/2017] [Indexed: 12/14/2022]
Abstract
Acute kidney injury is common in critically ill patients and portends a significant impact on mortality, progressive chronic kidney disease, and cardiovascular disease and mortality. Though most physicians alter therapy depending on changes in serum creatinine, this often represents delayed intervention. Various AKI biomarkers have been discovered and validated to improve timely detection, differentiation and stratification into risk groups for progressive renal decline, need for renal replacement therapy or death. This chapter will review AKI biomarkers validated over the past decade. We also describe the clinical performance of the biomarkers. We suggest that using AKI biomarkers to complement serum creatinine (or cystatin C) and urine output will better integrate patient care through earlier recognition and clinical outcome prediction after AKI.
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Affiliation(s)
- Su Hooi Teo
- Department of Nephrology, Singapore General Hospital, Singapore
| | - Zoltán Huba Endre
- Department of Nephrology, Prince of Wales Hospital, High Street, Randwick, Sydney, 2031, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, Australia; Department of Medicine, University of Otago-Christchurch; Christchurch, New Zealand; School of Medicine, University of Queensland, Brisbane, Australia.
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Chen S. Kinetic Glomerular Filtration Rate in Routine Clinical Practice-Applications and Possibilities. Adv Chronic Kidney Dis 2018; 25:105-114. [PMID: 29499881 DOI: 10.1053/j.ackd.2017.10.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 10/23/2017] [Accepted: 10/29/2017] [Indexed: 01/23/2023]
Abstract
When the [creatinine] is changing, the kidney function can still be tracked with a quantitative technique called kinetic glomerular filtration rate (GFR). The equation yields useful information on the severity of acute kidney injury, the clinical course of kidney and dialysis clearances, and the timing of kidney recovery. It has been validated in at least 3 independent studies, where it performed sufficiently well in intensive care unit and kidney transplant settings, and in head-to-head comparisons with biomarkers. Because it is based on a mathematical model, the kinetic GFR faces limitations depending on the accuracy of its assumptions. As the assumptions more accurately reflect the complexities of biology, some of these limitations can be overcome in a more sophisticated model. Kinetic GFR is an easy-to-use, low-cost tool that should be more widely incorporated into medical practice.
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Hekmat R, Eshraghi H, Esmailpour M, Hassankhani GG. Kinetic Glomerular Filtration Rate Estimation Compared With Other Formulas for Evaluating Acute Kidney Injury Stage Early After Kidney Donation. EXP CLIN TRANSPLANT 2017; 15:104-109. [PMID: 28260446 DOI: 10.6002/ect.mesot2016.o104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Kinetic glomerular filtration rate estimation may have more power and versatility than the Modification of Diet in Renal Disease or Cockcroft-Gault formula for evaluating kidney function when plasma creatinine fluctuates rapidly. After kidney donation, glomerular filtration rate rapidly fluctuates in otherwise healthy patients. We compared 3 formulas for estimating glomerular filtration rate: kinetic, Modification of Diet in Renal Disease, and Cockcroft-Gault, for determining stages of acute kidney injury early after kidney donation. MATERIALS AND METHODS In 42 living kidney donors, we measured serum creatinine, cystatin C, neutrophil gelatinase-associated lipocalin, and glomerular filtration rates before uninephrectomy and 3 days afterward. To estimate glomerular filtration rate, we used Cockcroft-Gault, Modification of Diet in Renal Disease, and kinetic equations. We sought the most accurate formula for staging acute kidney injury according to the risk, injury, failure, loss, and end-stage criteria. RESULTS The kinetic glomerular filtration rate model found more cases of stage 3 acute kidney injury than did the Modification of Diet in Renal Disease or Cockcroft-Gault formula. Receiver operating characteristic curves showed that the kinetic glomerular filtration rate model had more sensitivity and specificity than the Cockroft-Gault formula for discriminating among risk, injury, failure, loss, and end-stage criteria stages of acute kidney injury, based on serum creatinine changes. On day 2 after donation, a more sensitive marker with a shorter half-life (serum neutrophil gelatinase-associated lipocalin) was more significantly correlated with kinetic glomerular filtration rate estimation. CONCLUSIONS The kinetic glomerular filtration rate model was able to discriminate stages of acute kidney injury early after kidney donation according to risk, injury, failure, loss, and end-stage criteria better than the Modification of Diet in Renal Disease or Cockcroft-Gault formulas. The kinetic model detected failure-stage acute kidney injury ≥ 1 to 2 days earlier than the MDRD formula, CG formula detected no failure.
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Affiliation(s)
- Reza Hekmat
- Department of Nephrology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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Weinberg L, Harris L, Bellomo R, Ierino F, Story D, Eastwood G, Collins M, Churilov L, Mount P. Effects of intraoperative and early postoperative normal saline or Plasma-Lyte 148® on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial. Br J Anaesth 2017; 119:606-615. [DOI: 10.1093/bja/aex163] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2017] [Indexed: 11/12/2022] Open
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O'Sullivan ED, Doyle A. The clinical utility of kinetic glomerular filtration rate. Clin Kidney J 2017; 10:202-208. [PMID: 28396736 PMCID: PMC5381236 DOI: 10.1093/ckj/sfw108] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 09/27/2016] [Indexed: 01/12/2023] Open
Abstract
Background: In acutely unwell patients with rapidly changing renal function, estimating glomerular filtration rate (GFR) and predicting adverse renal outcomes are challenging and often inaccurate. Kinetic GFR (kGFR) is an estimate of immediate biomarker clearance derived from two discreet measurements that may better represent acute function. Our objective is to assess the clinical utility of kGFR as a predictive tool and examine the association of kGFR to adverse renal outcomes compared with measurements to traditional estimates. Methods: We compared the association of kGFR and Modification of Diet in Renal Disease (MDRD) with acute kidney injury (AKI), renal replacement therapy (RRT), cardiovascular morbidity, 30-day mortality and new chronic kidney disease development. A total of 107 acute admissions to a medical high dependency and intensive care unit were assessed retrospectively. Creatinine measurements and outcomes were recorded and kGFR was calculated at the earliest possible time point. This was then compared with simultaneous MDRD estimated GFR. Results: Mean age was 60 years old, AKI occurred in 25% of patients, acute cardiovascular events occurred in 13%, RRT was initiated in 15% and 30-day mortality was 30%. kGFR predicted the AKI more accurately than MDRD [area under the receiver operating characteristic curve (AUC) = 0.86 versus AUC = 0.64]. kGFR predicted the need for RRT more accurately than MDRD (AUC = 0.901 versus AUC = 0.79). Neither kGFR nor admission MDRD was associated with 30-day mortality or cardiovascular morbidity. Conclusions: Measuring kGFR in the acute setting could help clinicians better predict adverse renal outcomes.
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Affiliation(s)
- Eoin D O'Sullivan
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Arthur Doyle
- Queen Margaret Hospital, Renal Unit, Dunfermline, UK
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Acute kidney disease and renal recovery: consensus report of the Acute Disease Quality Initiative (ADQI) 16 Workgroup. Nat Rev Nephrol 2017; 13:241-257. [PMID: 28239173 DOI: 10.1038/nrneph.2017.2] [Citation(s) in RCA: 883] [Impact Index Per Article: 126.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Consensus definitions have been reached for both acute kidney injury (AKI) and chronic kidney disease (CKD) and these definitions are now routinely used in research and clinical practice. The KDIGO guideline defines AKI as an abrupt decrease in kidney function occurring over 7 days or less, whereas CKD is defined by the persistence of kidney disease for a period of >90 days. AKI and CKD are increasingly recognized as related entities and in some instances probably represent a continuum of the disease process. For patients in whom pathophysiologic processes are ongoing, the term acute kidney disease (AKD) has been proposed to define the course of disease after AKI; however, definitions of AKD and strategies for the management of patients with AKD are not currently available. In this consensus statement, the Acute Disease Quality Initiative (ADQI) proposes definitions, staging criteria for AKD, and strategies for the management of affected patients. We also make recommendations for areas of future research, which aim to improve understanding of the underlying processes and improve outcomes for patients with AKD.
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Pickering JW, Endre ZH. Bench to bedside: the next steps for biomarkers in acute kidney injury. Am J Physiol Renal Physiol 2016; 311:F717-F721. [PMID: 27465990 DOI: 10.1152/ajprenal.00268.2016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 07/21/2016] [Indexed: 12/15/2022] Open
Abstract
No new biomarker of acute kidney injury (AKI) has entered routine clinical practice after a decade of promise, although liver-fatty acid binding protein (L-FABP), neutrophil gelatinase-associated lipoprotein (NGAL), and the combination of tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP-7) are approved for use in some jurisdictions. Acceptance of creatinine as a surrogate of not just glomerular filtration rate (GFR) but also renal injury, changes in nephrologist workloads, failure to establish the added value of each biomarker to current clinical variables across multiple clinical settings, the lack of treatment options, and simply an insufficient passage of time, have all contributed to the lack of progress. Future studies should establish reference intervals for biomarkers, associate biomarkers with meaningful clinical outcomes including mortality and development of chronic kidney disease, and assess the added value to clinical models. The real value of biomarkers will be determined with intervention trials that use an elevated biomarker to triage to treatment. Ideally, such treatments will be linked directly to the physiological processes, which the biomarker identifies.
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Affiliation(s)
- John W Pickering
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand; Emergency Department, Christchurch Hospital, Christchurch, New Zealand;
| | - Zoltan H Endre
- Department of Nephrology, Prince of Wales Hospital, Sydney, Australia; and Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
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Endre ZH, Pianta TJ, Pickering JW. Timely Diagnosis of Acute Kidney Injury Using Kinetic eGFR and the Creatinine Excretion to Production Ratio, E/eG - Creatinine Can Be Useful! Nephron Clin Pract 2016; 132:312-6. [DOI: 10.1159/000444456] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 02/01/2016] [Indexed: 11/19/2022] Open
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Seelhammer TG, Maile MD, Heung M, Haft JW, Jewell ES, Engoren M. Kinetic estimated glomerular filtration rate and acute kidney injury in cardiac surgery patients. J Crit Care 2015; 31:249-54. [PMID: 26700609 DOI: 10.1016/j.jcrc.2015.11.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 09/28/2015] [Accepted: 11/06/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE To determine how a formula to estimate kinetically changing glomerular filtration rate (keGFR) relates to serum creatinine changes and to compare the discriminatory ability of keGFR to that of perioperative change in serum creatinine to predict acute kidney injury (AKI) and mortality. MATERIALS AND METHODS Retrospective cohort study at a single-tertiary-care Midwestern university hospital of 4022 patients admitted to the intensive care unit between January 2006 and January 2012 immediately after cardiac surgery. MEASUREMENTS AND MAIN RESULTS Of 4022 patients, 1031 (25.6%) developed at least AKI stage 1 and 1106 (27.5%) developed AKI-min. Patients who developed AKI stage 1 or AKI-min had a greater decrease in keGFR, both by absolute amounts and by percentage. After adjusting for other factors with logistic regression, keGFR had good discrimination (c statistic = 0.787 and 0.749, respectively) in predicting AKI and operative mortality. CONCLUSION Despite no change in immediate perioperative serum creatinine levels, keGFR fell and this predicted subsequent AKI. Using keGFR enables identification of patients who, despite unchanged postoperative creatinine, incur clinically significant kidney injury based on reduction in GFR and increased mortality.
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Affiliation(s)
| | | | - Michael Heung
- Anesthesiology & Critical Care, Mayo Clinic, Rochester, MN
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