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Goldstein SL, Krallman KA, Roy JP, Collins M, Chima RS, Basu RK, Chawla L, Fei L. Real-Time Acute Kidney Injury Risk Stratification-Biomarker Directed Fluid Management Improves Outcomes in Critically Ill Children and Young Adults. Kidney Int Rep 2023; 8:2690-2700. [PMID: 38106571 PMCID: PMC10719644 DOI: 10.1016/j.ekir.2023.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction Critically ill admitted patients are at high risk of acute kidney injury (AKI). The renal angina index (RAI) and urinary biomarker neutrophil gelatinase-associated lipocalin (uNGAL) can aid in AKI risk assessment. We implemented the Trial in AKI using NGAL and Fluid Overload to optimize CRRT Use (TAKING FOCUS 2; TF2) to personalize fluid management and continuous renal replacement therapy (CRRT) initiation based on AKI risk and patient fluid accumulation. We compared outcomes pre-TF2 and post-TF2 initiation. Methods Patients admitted from July 2017 were followed-up prospectively with the following: (i) an automated RAI result at 12 hours of admission, (ii) a conditional uNGAL order for RAI ≥8, and (iii) a CRRT initiation goal at 10% to 15% weight-based fluid accumulation. Results A total of 286 patients comprised 304 intensive care unit (ICU) RAI+ admissions; 178 patients received CRRT over the observation period (2014-2021). Median time from ICU admission to CRRT initiation was 2 days shorter (P < 0.002), and ≥15% pre-CRRT fluid accumulation rate was lower in the TF2 era (P < 0.02). TF2 ICU length of stay (LOS) after CRRT discontinuation and total ICU LOS were 6 and 11 days shorter for CRRT survivors (both P < 0.02). Survival rates to ICU discharge after CRRT discontinuation were higher in the TF2 era (P = 0.001). These associations persisted in each TF2 year; we estimate a conservative $12,500 health care cost savings per CRRT patient treated after TF2 implementation. Conclusion We suggest that automated clinical decision support (CDS) combining risk stratification and AKI biomarker assessment can produce durable reductions in pediatric CRRT patient morbidity.
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Affiliation(s)
| | - Kelli A. Krallman
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jean-Philippe Roy
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michaela Collins
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ranjit S. Chima
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | - Lin Fei
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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Hasson DC, Zhang B, Krallman K, Rose JE, Kempton KM, Steele P, Devarajan P, Goldstein SL, Alder MN. Acute kidney injury biomarker olfactomedin 4 predicts furosemide responsiveness. Pediatr Nephrol 2023; 38:3153-3161. [PMID: 37010559 DOI: 10.1007/s00467-023-05920-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/20/2023] [Accepted: 02/16/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is associated with increased morbidity and mortality in critically ill patients. Olfactomedin 4 (OLFM4), a secreted glycoprotein expressed in neutrophils and stressed epithelial cells, is upregulated in loop of Henle (LOH) cells following AKI. We hypothesized that urine OLFM4 (uOLFM4) will increase in patients with AKI and may predict furosemide responsiveness. METHODS Urine from critically ill children was collected prospectively and tested for uOLFM4 concentrations with a Luminex immunoassay. Severe AKI was defined by KDIGO (stage 2/3) serum creatinine criteria. Furosemide responsiveness was defined as > 3 mL/kg/h of urine output in the 4 h after a 1 mg/kg IV furosemide dose administered as part of standard of care. RESULTS Fifty-seven patients contributed 178 urine samples. Irrespective of sepsis status or AKI cause, uOLFM4 concentrations were higher in patients with AKI (221 ng/mL [IQR 93-425] vs. 36 ng/mL [IQR 15-115], p = 0.007). uOLFM4 concentrations were higher in patients unresponsive to furosemide (230 ng/mL [IQR 102-534] vs. 42 ng/mL [IQR 21-161], p = 0.04). Area under the receiver operating curve for association with furosemide responsiveness was 0.75 (95% CI, 0.60-0.90). CONCLUSIONS AKI is associated with increased uOLFM4. Higher uOLFM4 is associated with a lack of response to furosemide. Further testing is warranted to determine whether uOLFM4 could identify patients most likely to benefit from earlier escalation from diuretics to kidney replacement therapy to maintain fluid balance. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Denise C Hasson
- Division of Pediatric Critical Care Medicine, NYU Langone Health, Hassenfeld Children's Hospital, 430 East 34Th Street, New York, NY, 10016, USA.
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kelli Krallman
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - James E Rose
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kristalynn M Kempton
- Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Paul Steele
- Division of Anatomic and Clinical Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Matthew N Alder
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Robinson CH, Iyengar A, Zappitelli M. Early recognition and prevention of acute kidney injury in hospitalised children. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:657-670. [PMID: 37453443 DOI: 10.1016/s2352-4642(23)00105-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 07/18/2023]
Abstract
Acute kidney injury is common in hospitalised children and is associated with poor patient outcomes. Once acute kidney injury occurs, effective therapies to improve patient outcomes or kidney recovery are scarce. Early identification of children at risk of acute kidney injury or at an early injury stage is essential to prevent progression and mitigate complications. Paediatric acute kidney injury is under-recognised by clinicians, which is a barrier to optimisation of inpatient care and follow-up. Acute kidney injury definitions rely on functional biomarkers (ie, serum creatinine and urine output) that are inadequate, since they do not account for biological variability, analytical issues, or physiological responses to volume depletion. Improved predictive tools and diagnostic biomarkers of kidney injury are needed for earlier detection. Novel strategies, including biomarker-guided care algorithms, machine-learning methods, and electronic alerts tied to clinical decision support tools, could improve paediatric acute kidney injury care. Clinical prediction models should be studied in different paediatric populations and acute kidney injury phenotypes. Research is needed to develop and test prevention strategies for acute kidney injury in hospitalised children, including care bundles and therapeutics.
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Affiliation(s)
- Cal H Robinson
- Division of Paediatric Nephrology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, The University of Toronto, Toronto, ON, Canada
| | - Arpana Iyengar
- Department of Paediatric Nephrology, St John's National Academy of Health Sciences, Bangalore, India
| | - Michael Zappitelli
- Division of Paediatric Nephrology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada.
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Stanski NL, Rodrigues CE, Strader M, Murray PT, Endre ZH, Bagshaw SM. Precision management of acute kidney injury in the intensive care unit: current state of the art. Intensive Care Med 2023; 49:1049-1061. [PMID: 37552332 DOI: 10.1007/s00134-023-07171-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/12/2023] [Indexed: 08/09/2023]
Abstract
Acute kidney injury (AKI) is a prototypical example of a common syndrome in critical illness defined by consensus. The consensus definition for AKI, traditionally defined using only serum creatinine and urine output, was needed to standardize the description for epidemiology and to harmonize eligibility for clinical trials. However, AKI is not a simple disease, but rather a complex and multi-factorial syndrome characterized by a wide spectrum of pathobiology. AKI is now recognized to be comprised of numerous sub-phenotypes that can be discriminated through shared features such as etiology, prognosis, or common pathobiological mechanisms of injury and damage. The characterization of sub-phenotypes can serve to enable prognostic enrichment (i.e., identify subsets of patients more likely to share an outcome of interest) and predictive enrichment (identify subsets of patients more likely to respond favorably to a given therapy). Existing and emerging biomarkers will aid in discriminating sub-phenotypes of AKI, facilitate expansion of diagnostic criteria, and be leveraged to realize personalized approaches to management, particularly for recognizing treatment-responsive mechanisms (i.e., endotypes) and targets for intervention (i.e., treatable traits). Specific biomarkers (e.g., serum renin; olfactomedin 4 (OLFM4); interleukin (IL)-9) may further enable identification of pathobiological mechanisms to serve as treatment targets. However, even non-specific biomarkers of kidney injury (e.g., neutrophil gelatinase-associated lipocalin, NGAL; [tissue inhibitor of metalloproteinases 2, TIMP2]·[insulin like growth factor binding protein 7, IGFBP7]; kidney injury molecule 1, KIM-1) can direct greater precision management for specific sub-phenotypes of AKI. This review will summarize these evolving concepts and recent innovations in precision medicine approaches to the syndrome of AKI in critical illness, along with providing examples of how they can be leveraged to guide patient care.
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Affiliation(s)
- Natalja L Stanski
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Camila E Rodrigues
- Department of Nephrology, Prince of Wales Clinical School, UNSW Medicine, Sydney, NSW, Australia
- Nephrology Department, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Michael Strader
- Department of Medicine, School of Medicine, University College Dublin, Dublin, Ireland
| | - Patrick T Murray
- Department of Medicine, School of Medicine, University College Dublin, Dublin, Ireland
| | - Zoltan H Endre
- Department of Nephrology, Prince of Wales Clinical School, UNSW Medicine, Sydney, NSW, Australia
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, 2-124 Clinical Sciences Building, 8440-112 ST NW, Edmonton, AB, T6G 2B7, Canada.
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Liu Y, Guan X, Shao Y, Zhou J, Huang Y. The Molecular Mechanism and Therapeutic Strategy of Cardiorenal Syndrome Type 3. Rev Cardiovasc Med 2023; 24:52. [PMID: 39077418 PMCID: PMC11273121 DOI: 10.31083/j.rcm2402052] [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: 10/02/2022] [Revised: 11/17/2022] [Accepted: 11/22/2022] [Indexed: 07/31/2024] Open
Abstract
Cardiorenal syndrome type 3 (CRS3) is defined as acute kidney injury (AKI)-induced acute cardiac dysfunction, characterized by high morbidity and mortality. CRS3 often occurs in elderly patients with AKI who need intensive care. Approximately 70% of AKI patients develop into CRS3. CRS3 may also progress towards chronic kidney disease (CKD) and chronic cardiovascular disease (CVD). However, there is currently no effective treatment. Although the major intermediate factors that can mediate cardiac dysfunction remain elusive, recent studies have summarized the AKI biomarkers, identified direct mechanisms, including mitochondrial dysfunction, inflammation, oxidative stress, apoptosis and activation of the sympathetic nervous system (SNS) and renin-angiotensin-aldosterone system (RAAS), inflammasome, as well as indirect mechanisms such as fluid overload, electrolyte imbalances, acidemia and uremic toxins, which are involved in the pathophysiological changes of CRS3. This study reviews the main pathological characteristics, underlying molecular mechanisms, and potential therapeutic strategies of CRS3. Mitochondrial dysfunction and inflammatory factors have been identified as the key initiators and abnormal links between the impaired heart and kidney, which contribute to the formation of a vicious circle, ultimately accelerating the progression of CRS3. Therefore, targeting mitochondrial dysfunction, antioxidants, Klotho, melatonin, gene therapy, stem cells, exosomes, nanodrugs, intestinal microbiota and Traditional Chinese Medicine may serve as promising therapeutic approaches against CRS3.
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Affiliation(s)
- Yong Liu
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), 400037 Chongqing, China
| | - Xu Guan
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), 400037 Chongqing, China
| | - Yuming Shao
- Medical Division, Xinqiao Hospital, Army Medical University, 400037 Chongqing, China
| | - Jie Zhou
- Department of Oncology, Southwest Cancer Center, Southwest Hospital, Army Medical University, 400038 Chongqing, China
| | - Yinghui Huang
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), 400037 Chongqing, China
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