One--Year Progression and Risk Factors for the Development of Chronic Kidney Disease in Septic Shock Patients with Acute Kidney Injury: A Single-Centre Retrospective Cohort Study

Dexmedetomidine attenuates lipopolysaccharide-induced renal cell fibrotic phenotypic changes by inhibiting necroinflammation via activating α2-adrenoceptor: A combined randomised animal and in vitro study

BACKGROUND

Acute kidney injury (AKI) was reported to be one of the initiators of chronic kidney disease (CKD) development. Necroinflammation may contribute to the progression from AKI to CKD. Dexmedetomidine (Dex), a highly selective α2-adrenoreceptor (AR) agonist, has cytoprotective and "anti-" inflammation effects. This study was designed to investigate the anti-fibrotic properties of Dex in sepsis models.

METHODS

C57BL/6 mice were randomly treated with an i.p. injection of lipopolysaccharides (LPS) (10 mg/kg) alone, LPS with Dex (25 μg/kg), or LPS, Dex and Atipamezole (Atip, an α2-adrenoreceptor antagonist) (500 μg/kg) (n=5/group). Human proximal tubular epithelial cells (HK2) were also cultured and then exposed to LPS (1 μg/ml) alone, LPS and Dex (1 μM), transforming growth factor-beta 1 (TGF-β1) (5 ng/ml) alone, TGF-β1 and Dex, with or without Atip (100 μM) in culture media. Epithelial-mesenchymal transition (EMT), cell necrosis, necroptosis and pyroptosis, and c-Jun N-terminal kinase (JNK) phosphorylation were then determined.

RESULTS

Dex treatment significantly alleviated LPS-induced AKI, myofibroblast activation, NLRP3 inflammasome activation, and necroptosis in mice. Atip counteracted its protective effects. Dex attenuated LPS or TGF-β1 induced EMT and also prevented necrosis, necroptosis, and pyroptosis in response to LPS stimulation in the HK2 cells. The anti-EMT effects of Dex were associated with JNK phosphorylation.

CONCLUSIONS

Dex reduced EMT following LPS stimulation whilst simultaneously inhibiting pyroptosis and necroptosis via α2-AR activation in the renal tubular cells. The "anti-fibrotic" and cytoprotective properties and its clinical use of Dex need to be further studied.

Long-term renal outcomes of patients with COVID-19: a meta-analysis of observational studies

BACKGROUND

Kidney involvement is common in hospitalized coronavirus disease 2019 (COVID-19) patients during the acute phase, little is known about the long-term impact of COVID-19 on the kidney.

METHODS

This is a systematic review and meta-analysis on long-term renal outcomes among COVID-19 patients. We carried out a systematic literature search in PUBMED, EMBASE, SCOPUS, and Cochrane COVID-19 study register and performed the random-effects meta-analysis of rates. The search was last updated on November 23, 2022.

RESULTS

The study included 12 moderate to high-quality cohort studies involving 6976 patients with COVID-19-associated acute kidney injury and 5223 COVID-19 patients without acute kidney injury. The summarized long-term renal non-recovery rate, dialysis-dependent rate, and complete recovery rate among patients with COVID-19-associated AKI was 22% (12-33%), 6% (2-12%), and 63% (44-81%) during a follow-up of 90-326.5 days. Heterogeneity could be explained by differences in the prevalence of chronic kidney disease and proportion of acute kidney injury requiring renal replacement therapy using meta-regression; patients with more comorbidities or higher renal replacement therapy rate had higher non-recovery rates. The summarized long-term kidney function decrease rate among patients without acute kidney injury was 22% (3-51%) in 90-199 days, with heterogeneity partially explained by severity of infection.

CONCLUSION

Patients with more comorbidities tend to have a higher renal non recovery rate after COVID-19-associated acute kidney injury; for COVID-19 patients without acute kidney injury, decrease in kidney function may occur during long-term follow-up. Regular evaluation of kidney function during the post-COVID-19 follow-up among high-risk patients may be necessary.

Developing an ensemble machine learning model for early prediction of sepsis-associated acute kidney injury

Sepsis-associated acute kidney injury (S-AKI) is very common and early prediction is beneficial. This study aiming to develop an accurate ensemble model to predict the risk of S-AKI based on easily available clinical information. Patients with sepsis from the United States (US) database Medical Information Mart for Intensive Care-IV were used as a modeling cohort to predict the occurrence of AKI by combining Support Vector Machine, Random Forest, Neural Network, and Extreme Gradient Boost as four first-level learners via stacking algorithm. The external validation databases were the eICU Collaborative Research Database from US and Critical Care Database comprising infection patients at Zigong Fourth People's Hospital from China, whose AUROC values for the ensemble model 48-12 h before the onset of AKI were 0.774-0.788 and 0.756-0.813, respectively. In this study, an ensemble model for early prediction of S-AKI onset was developed and it demonstrated good performance in multicenter external datasets.

The predictive value of the Oxford Acute Severity of Illness Score for clinical outcomes in patients with acute kidney injury

Objective

To compare the performance of the Oxford Acute Severity of Illness Score (OASIS), the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, the Simplified Acute Physiology Score II (SAPS II), and the Sequential Organ Failure Assessment (SOFA) score in predicting 28-day mortality in acute kidney injury (AKI) patients.

Methods

Data were extracted from the Beijing Acute Kidney Injury Trial (BAKIT). A total of 2954 patients with complete clinical data were included in this study. Receiver operating characteristic (ROC) curves were used to analyze and evaluate the predictive effects of the four scoring systems on the 28-day mortality risk of AKI patients and each subgroup. The best cutoff value was identified by the highest combined sensitivity and specificity using Youden’s index.

Results

Among the four scoring systems, the area under the curve (AUC) of OASIS was the highest. The comparison of AUC values of different scoring systems showed that there were no significant differences among OASIS, APACHE II, and SAPS II, which were better than SOFA. Moreover, logistic analysis revealed that OASIS was an independent risk factor for 28-day mortality in AKI patients. OASIS also had good predictive ability for the 28-day mortality of each subgroup of AKI patients.

Conclusion

OASIS, APACHE II, and SAPS II all presented good discrimination and calibration in predicting the 28-day mortality risk of AKI patients. OASIS, APACHE II, and SAPS II had better predictive accuracy than SOFA, but due to the complexity of APACHE II and SAPS II calculations, OASIS is a good substitute.

Trial Registration

This study was registered at www.chictr.org.cn (registration number Chi CTR-ONC-11001875). Registered on 14 December 2011.

FYN and CD247: key Genes for Septic Shock Based on Bioinformatics and Meta-Analysis

BACKGROUND

Septic shock is sepsis accompanied by hemodynamic instability and high clinical mortality.

MATERIAL AND METHODS

GSE95233, GSE57065, GSE131761 gene-expression profiles of healthy control subjects and septic shock patients were downloaded from the Gene-Expression Omnibus (GEO) database, and differences of expression profiles and their intersection were analysed using GEO2R. Function and pathway enrichment analysis was performed on common differentially expressed genes (DEG), and key genes for septic shock were screened using a protein-protein interaction network created with STRING. Also, data from the GEO database were used for survival analysis for key genes, and a meta-analysis was used to explore expression trends of core genes. Finally, high-throughput sequencing using the blood of a murine sepsis model was performed to analyse the expression of CD247 and FYN in mice.

RESULTS

A total of 539 DEGs were obtained (p < 0.05). Gene ontology analysis showed that key genes were enriched in functions, such as immune response and T cell activity, and DEGs were enriched in signal pathways, such as T cell receptors. FYN and CD247 are in the centre of the protein-protein interaction network, and survival analysis found that they are positively correlated with survival from sepsis. Further, meta-analysis results showed that FYN could be useful for the prognosis of patients, and CD247 might distinguish between sepsis and systemic inflammatory response syndrome patients. Finally, RNA sequencing using a mouse septic shock model showed low expression of CD247 and FYN in this model.

CONCLUSION

FYN and CD247 are expected to become new biomarkers of septic shock.

Pulse pressure during the initial resuscitative period in patients with septic shock treated with a protocol-driven resuscitation bundle therapy

BACKGROUND/AIMS

Maintaining a mean arterial pressure (MAP) ≥ 65 mmHg during septic shock should be based on individual circumstances, but specific target is poorly understood. We investigated associations between time-weighted average (TWA) hemodynamic parameters during the initial resuscitative period and 28-day mortality.

METHODS

Prospectively collected data were obtained from a septic shock patient registry, according to the Sepsis-3 definition, between 2016 and 2018. The TWA systolic blood pressure, diastolic blood pressure, MAP, shock index, and pulse pressure (PP) during the first 6 hours after shock recognition were compared. Multivariable regression analysis was performed to assess associations between these parameters and 28-day mortality.

RESULTS

Of 340 patients with septic shock, 92 died. Only the median TWA PP differed between the survivors and non-survivors (39.2 mmHg vs. 43.0 mmHg, p = 0.020), whereas the other indexes did not. When PP was divided into quartiles (< 34, 34 to 40, 40 to 48, and > 48 mmHg), the mortality rate was higher in the highest quartile (41.2%). Multivariable logistic analysis revealed that PP (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.012 to 1.622; p = 0.039) and PP of > 48 mmHg (OR, 2.25; 95% CI, 1.272 to 3.981; p = 0.005) were independently associated with 28-day mortality.

CONCLUSION

PP was significantly associated with 28-day mortality in patients with septic shock and MAP maintained at > 65 mmHg during the first 6 hours. Further studies are warranted to optimize strategies for maintaining PP and MAP at > 65 mmHg during the early resuscitative period.

Sepsis-Associated Acute Kidney Disease and Long-term Kidney Outcomes

RATIONALE & OBJECTIVE

Sepsis-associated acute kidney injury often leads to acute kidney disease (AKD), predisposing patients to long-term complications such as chronic kidney disease (CKD), kidney failure with replacement therapy (KFRT), or mortality. Risk stratification of patients with AKD represents an opportunity to assist with prognostication of long-term kidney complications.

STUDY DESIGN

Single-center retrospective cohort.

SETTING & PARTICIPANTS

6,290 critically ill patients admitted to the intensive care unit with severe sepsis or septic shock. Patients were separated into cohorts based on incident acute kidney injury or not, and survivors identified who were alive and free of KFRT up to 90 days.

PREDICTORS

AKD stage (0A, 0C, or ≥1) using the last serum creatinine concentration available by discharge or up to 90 days postdischarge.

OUTCOME

Time to development of incident CKD, progression of CKD, KFRT, or death.

ANALYTICAL APPROACH

Multivariable Cox proportional hazards models.

RESULTS

Patients surviving kidney injury associated with sepsis often fail to return to baseline kidney function by discharge: 577/1,231 (46.9%) with stage 0C or 1 or greater AKD. AKD stage was significantly associated with the composite primary outcome. Stages 0C AKD and 1 or greater AKD were significantly and progressively associated with the primary outcome when compared with stage 0A AKD (adjusted HR [aHR], 1.74; 95% CI, 1.32-2.29, and aHR, 3.25; 95% CI, 2.52-4.20, respectively). Additionally, stage 1 or greater AKD conferred higher risk above stage 0C AKD (aHR, 1.87; 95% CI, 1.44-2.43). CKD incidence or progression and KFRT, more so than mortality, occurred with greater frequency in higher stages of AKD.

LIMITATIONS

Retrospective design, single center, exclusion of patients with KFRT within 90 days of discharge, potential ascertainment bias, and inability to subclassify above AKD stage 1.

CONCLUSIONS

Risk stratification using recommended AKD stages at hospital discharge or shortly thereafter associates with the development of long-term kidney outcomes following sepsis-associated acute kidney injury.

Role of thromboelastography in the evaluation of septic shock patients with normal prothrombin time and activated partial thromboplastin time

Coagulopathy is frequent in septic shock and plays a key role in multiple organ dysfunction. The aim of this study is to investigate application values of thromboelastography (TEG) for outcome in septic shock patients with a normal value of prothrombin time (PT) and active partial thromboplastin time (aPTT). Prospective observational study using 1298 consecutive septic shock patients with TEG at admission was conducted at the emergency department (ED) of a tertiary care hospital in South Korea between 2016 and 2019. After excluding overt-disseminated intravascular coagulation (DIC) defined by scoring system, we included patients with a normal value of international normalized ratio ≤ 1.3 and aPTT ≤ 34 s. The primary outcome was 28-day mortality. 893 patients were included and 129 patients with overt DIC were excluded. Of the 764 remaining patients, 414 (54.2%) patients showed normal PT and aPTT (28-day mortality rate, 11.4%). TEG values such as reaction time, kinetic time (K), alpha angle (α), maximum amplitude (MA) and lysis index (LY 30) showed no significant mean difference between the survivor and non-survivor groups. However, hypocoagulable TEG values such as α < 53° (12.0% vs. 23.4%; p = 0.039), and MA < 50 mm (6.3% vs. 21.3%; p = 0.002) were significantly higher in the non-survived group. In multivariate analysis, hypocoagulable state (defined as K > 3 and α < 53 and MA < 50) was independent factors associated with increased risk of death (OR 4.882 [95% CI, 1.698–14.035]; p = 0.003). In conclusion, septic shock patients with normal PT and aPTT can be associated with impaired TEG profile, such as hypocoagulability, associated with increased mortality.

Acute kidney disease and long-term outcomes in critically ill acute kidney injury patients with sepsis: a cohort analysis

BACKGROUND

Acute kidney injury (AKI) is frequent during hospitalization and may contribute to adverse short- and long-term consequences. Acute kidney disease (AKD) reflects the continuing pathological processes and adverse events developing after AKI. We aimed to evaluate the association of AKD, long-term adverse renal function and mortality in a cohort of patients with sepsis.

METHODS

We performed a retrospective analysis of adult patients with septic AKI admitted to the Division of Intensive Medicine of the Centro Hospitalar Lisboa Norte (Lisbon, Portugal) between January 2008 and December 2014. Patients were categorized according to the development of AKI using the Kidney Disease: Improving Global Outcomes (KDIGO) classification. AKI was defined as an increase in absolute serum creatinine (SCr) ≥0.3 mg/dL or by a percentage increase in SCr ≥50% and/or by a decrease in urine output to <0.5 mL/kg/h for >6 h. AKD was defined as presenting at least KDIGO Stage 1 criteria for >7 days after an AKI initiating event. Adverse renal outcomes (need for long-term dialysis and/or a 25% decrease in estimated glomerular filtration rate after hospital discharge) and mortality after discharge were evaluated.

RESULTS

From 256 selected patients with septic AKI, 53.9% developed AKD. The 30-day mortality rate was 24.5% (n = 55). The mean long-term follow-up was 45.9 ± 43.3 months. The majority of patients experience an adverse renal outcome [n = 158 (61.7%)] and 44.1% (n = 113) of patients died during follow-up. Adverse renal outcomes, 30-day mortality and long-term mortality after hospital discharge were more frequent among AKD patients [77.5 versus 43.2% (P < 0.001), 34.1 versus 6.8% (P < 0.001) and 64.8 versus 49.1% (P = 0.025), respectively]. The 5-year cumulative probability of survival was 23.2% for AKD patients, while it was 47.5% for patients with no AKD (log-rank test, P < 0.0001). In multivariate analysis, AKD was independently associated with adverse renal outcomes {adjusted hazard ratio [HR] 2.87 [95% confidence interval (CI) 2.0-4.1]; P < 0.001} and long-term mortality [adjusted HR 1.51 (95% CI 1.0-2.2); P = 0.040].

CONCLUSIONS

AKD after septic AKI was independently associated with the risk of long-term need for dialysis and/or renal function decline and with the risk of death after hospital discharge.

Long-term consequences of acute kidney injury: a narrative review

The incidence of acute kidney injury (AKI) has increased in the past decades. AKI complicates up to 15% of hospitalizations and can reach up to 50-60% in critically ill patients. Besides the short-term impact of AKI in patient outcomes, several studies report the association between AKI and adverse long-term outcomes, such as recurrent AKI episodes in 25-30% of cases, hospital re-admissions in up to 40% of patients, an increased risk of cardiovascular events, an increased risk of progression of chronic kidney disease (CKD) after AKI and a significantly increased long-term mortality. Despite the long-term impact of AKI, there are neither established guidelines on the follow-up care of AKI patients, nor treatment strategies to reduce the incidence of sequelae after AKI. Only a minority of patients have been referred to nephrology post-discharge care, despite the evidence of improved outcomes associated with nephrology referral by addressing cardiovascular risk and risk of progression to CKD. Indeed, AKI survivors should have specialized nephrology follow-up to assess kidney function after AKI, perform medication reconciliation, educate patients on nephrotoxic avoidance and implement strategies to prevent CKD progression. The authors provide a comprehensive review of the transition from AKI to CKD, analyse the current evidence on the long-term outcomes of AKI and describe predisposing risk factors, highlight the importance of follow-up care in these patients and describe the current therapeutic strategies which are being investigated on their impact in improving patient outcomes.

Progression of Acute Kidney Injury to Chronic Kidney Disease in Sepsis Survivors: 1-Year Follow-Up Study

BACKGROUND

Despite the fact that septic acute kidney injury (AKI) is considered to be reversible, it can result in permanent kidney damage. Unfortunately, there is a scarcity of long-term follow-up studies highlighting progression to chronic kidney disease (CKD) in sepsis survivors. To address this issue, we conducted this study to assess the development of CKD in sepsis patients with AKI, and to identify risk factors associated with its development.

METHODS

This retrospective cohort study evaluated medical records of patients admitted at the Aga Khan University Hospital between January-December 2017 with the diagnosis of sepsis and subsequent development of acute kidney injury (AKI). One-year follow-up data was then analyzed to determine whether the AKI resolved or progressed to chronic kidney disease.

RESULTS

1636 sepsis patients were admitted during the study period, out of which 996 (61%) met the inclusion criteria. 612 (61%) developed AKI during the admission. Mortality rate in the AKI group was 44% (n = 272). After 1 year, 47 (19%) patients eventually went on to develop CKD and 81% (n = 195) recovered fully. Risk factors for development of CKD were age ≥ 60 years (p = <0.001), diabetes (p = <0.001), hypertension (p = 0.001) and history of ischemic heart disease (p = <0.001).

CONCLUSION

Mortality rates in sepsis are alarmingly high and even those patients who manage to survive are at risk of developing permanent organ dysfunction. Our study revealed that almost one fifth of all septic AKI survivors went on to develop chronic kidney disease within 1 year, even when AKI was not severe. We recommend that clinicians focus on early recovery of renal function, irrespective of AKI severity, and ensure robust follow-up monitoring to reduce long term morbidity and mortality associated with this devastating illness.

Association between right ventricle dysfunction and poor outcome in patients with septic shock

OBJECTIVE

Sepsis-induced myocardial dysfunction (SIMD) can involve both the left and right ventricles. However, the characteristics and outcomes across various manifestations of SIMD remain unknown.

METHODS

This was a retrospective cohort study using a prospective registry of septic shock from January 2011 and April 2017. Patients with clinically presumed cardiac dysfunction underwent echocardiography within 72 hours after admission and were enrolled (n=778). SIMD was classified as left ventricle (LV) systolic/diastolic and right ventricle (RV) dysfunction, which were defined based on the American Society of Echocardiography criteria. The primary outcome was 28-day mortality.

RESULTS

Of the 778 septic shock patients who underwent echocardiography, 270 (34.7%) showed SIMD. The median age was 67.0 years old, and the male was predominant (57.3%). Among them, 67.3% had LV systolic dysfunction, 40.7% had RV dysfunction and 39.3% had LV diastolic dysfunction. Although serum lactate level and sequential organ failure assessment score were not significantly different between groups, SIMD group showed higher troponin I (0.1 vs 0.1 ng/mL; p=0.02) and poor clinical outcomes, including higher 28-day mortality (35.9 vs 26.8%; p<0.01), longer intensive care unit length of stay (5 vs 2 days; p<0.01) and prolonged mechanical ventilation (9 vs 4 days; p<0.01). Multivariate analysis showed that isolated RV dysfunction was an independent risk factor of 28-day mortality (OR 2.26, 95% CI 1.04 to 4.91).

CONCLUSIONS

One-third of patients with septic shock showed various myocardial dysfunctions. LV systolic dysfunction was common; however, only RV dysfunction was associated with short-term mortality.

A mortality analysis of septic shock, vasoplegic shock and cryptic shock classified by the third international consensus definitions (Sepsis-3)

INTRODUCTION

This study aimed to compare the 28-day mortality of patients with septic shock, defined by Sepsis-3 criteria and patients with vasoplegic or cryptic shock who are excluded from this new definition.

OBJECTIVES

This retrospective observational study was performed using a tertiary emergency department's septic shock registry and investigated the records of patients managed between January 2010 and December 2015. In 2,138 total patients, 1004 (47.0%) had septic shock, 476 (22.2%) had vasoplegic shock and 655 (30.6%) had cryptic shock.

RESULTS

There was significant variation in 28-day mortality among the three groups: 23.4% for septic shock, 8.8% for vasoplegic shock and 12.2% for cryptic shock (P < .001). In subgroup analysis of cryptic shock or septic shock according to lactate levels (2-3, 3-4 and >4 mmol/L), the mortality rate increased as lactate increased (cryptic shock: 9.5%, 14.8% and 18.0%; septic shock: 18.6%, 22.6% and 27.0%, respectively; P < .001). Multivariable analysis revealed odds ratios for mortality of 0.31 (95% CI 0.22-0.44; P < .001) for vasoplegic shock and 0.46 (95% CI 0.35-0.61; P < .001) for cryptic shock relative to septic shock. Survival curve analysis showed significant differences among patients with septic shock, vasoplegic shock and cryptic shock (Log rank test: P < .0001).

CONCLUSION

The new septic shock definition may be useful for identifying high-risk patients requiring intensive care. However, cryptic shock-associated mortality increased to 18.0% as serum lactate increased, which suggests that some cryptic shock patients may also require intensive management.

Diagnostics, Risk Factors, Treatment and Outcomes of Acute Kidney Injury in a New Paradigm

Acute kidney injury (AKI) is a common clinical condition among patients admitted in the hospitals. The condition is associated with both increased short-term and long-term mortality. With the development of a standardized definition for AKI and the acknowledgment of the impact of AKI on patient outcomes, there has been increased recognition of AKI. Two advances from past decades, the usage of computer decision support and the discovery of AKI biomarkers, have the ability to advance the diagnostic method to and further management of AKI. The increasingly widespread use of electronic health records across hospitals has substantially increased the amount of data available to investigators and has shown promise in advancing AKI research. In addition, progress in the finding and validation of different forms of biomarkers of AKI within diversified clinical environments and has provided information and insight on testing, etiology and further prognosis of AKI, leading to future of precision and personalized approach to AKI management. In this this article, we discussed the changing paradigms in AKI: from mechanisms to diagnostics, risk factors, and management of AKI.

Robust Association between Acute Kidney Injury after Radical Nephrectomy and Long-term Renal Function

The association between acute kidney injury (AKI) and long-term renal function after radical nephrectomy has not been evaluated fully. We reviewed 558 cases of radical nephrectomy. Postoperative AKI was defined by the Kidney Disease: Improving Global Outcomes (KDIGO) serum creatinine criteria. Values of estimated glomerular filtration rate (eGFR) were collected up to 36 months (median 35 months) after surgery. The primary outcome was new-onset chronic kidney disease (CKD) stage 3a or higher or all-cause mortality within three years after nephrectomy. The functional change ratio (FCR) of eGFR was defined as the ratio of the most recent GFR (24-36 months after surgery) to the new baseline during 3-12 months. A multivariable Cox proportional hazard regression analysis for new-onset CKD and a multivariable linear regression analysis for FCR were performed to evaluate the association between AKI and long-term renal outcomes. A correlation analysis was performed with the serum creatinine ratio and used to determine AKI and FCR. AKI occurred in 43.2% (n = 241/558) and our primary outcome developed in 40.5% (n = 226/558) of patients. The incidence of new-onset CKD was significantly higher in patients with AKI than those without at all follow-up time points after surgery. The Cox regression analysis showed a graded association between AKI and our primary outcome (AKI stage 1: Hazard ratio 1.71, 95% confidence interval 1.25-2.32; AKI stage 2 or 3: Hazard ratio 2.72, 95% confidence interval 1.78-4.10). The linear regression analysis for FCR showed that AKI was significantly associated with FCR (β = -0.168 ± 0.322, p = 0.011). There was a significant negative correlation between the serum creatinine ratio and FCR. In conclusion, our analysis demonstrated a robust and graded association between AKI after radical nephrectomy and long-term renal functional deterioration.

Relationship between low hemoglobin levels and mortality in patients with septic shock

Background

Hemoglobin levels are a critical parameter for oxygen delivery in patients with shock. On comparing target hemoglobin levels upon transfusion initiation, the correlation between the severity of decrease in hemoglobin levels and patient outcomes remains unclear. We evaluated the association between initial hemoglobin levels and mortality in patients with septic shock treated with protocol-driven resuscitation bundle therapy at an emergency department.

Methods

Data of adult patients diagnosed with septic shock between June 2012 and December 2016 were extracted from a prospectively compiled septic shock registry at a single academic medical center. Patients were classified into four groups according to initial hemoglobin levels: ≥9.0 g/dl, 8.0-8.9 g/dl, 7.0-7.9 g/dl, and <7.0 g/dl. The primary endpoint was 90-day mortality.

Results

In total, 2,265 patients (male, 58.3%; median age, 70.0 years [interquartile range, 60 to 78 years]) with septic shock were included. For the four groups, 90-day mortality rates were as follows: 29.1%, 43.0%, 46.5%, and 46.9% for ≥9.0 g/dl (n=1,808), 8.0-8.9 g/dl (n=217), 7.0-7.9 g/dl (n=135), and <7.0 g/dl (n=105), respectively (P<0.001). Multivariate logistic regression showed that initial hemoglobin levels were an independent factor associated with 90-day mortality and mortality proportionally increased with decreasing hemoglobin levels (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.36 to 2.61 for 8.0-8.9 g/dl; OR, 1.97; 95% CI, 1.31 to 2.95 for 7.0-7.9 g/dl; and OR, 2.35; 95% CI, 1.52 to 3.63 for <7.0 g/dl).

Conclusions

Low hemoglobin levels (<9.0 g/dl) were observed in approximately 20% of patients with septic shock, and the severity of decrease in these levels correlated with mortality.

Troponin Testing for Assessing Sepsis-Induced Myocardial Dysfunction in Patients with Septic Shock

(1) Background: Myocardial dysfunction in patients with sepsis is not an uncommon phenomenon, yet reported results are conflicting and there is no objective definition. Measurement of troponin may reflect the state of the heart and may correlate with echocardiographically derived data. This study aimed to evaluate the role of admission and peak troponin-I testing for the identification of sepsis-induced myocardial dysfunction (SIMD) by transthoracic echocardiography (TTE). (2) Methods: This was a retrospective cohort study using a prospective registry of septic shock at an Emergency Department from January 2011 and April 2017. All 1,776 consecutive adult septic shock patients treated with protocol-driven resuscitation bundle therapy and tested troponin-I were enrolled. SIMD was defined as left ventricular (LV) systolic/diastolic dysfunction, right ventricular (RV) diastolic dysfunction, or global/regional wall motion abnormalities (WMA). (3) Results: Of 660 (38.4%) septic shock patients with an elevated hs-TnI (≥0.04 ng/mL) at admission, 397 patients underwent TTE and 258 cases (65%) showed SIMD (LV systolic dysfunction (n = 163, 63.2%), LV diastolic dysfunction (n = 104, 40.3%), RV dysfunction (n = 97, 37.6%), and WMA (n = 186, 72.1%)). In multivariate analysis, peak hs-TnI (odds ratio 1.03, 95% confidence interval 1.01–1.06, p = 0.008) and ST-T wave changes in the electrocardiogram (odds ratio 1.82, 95% confidence interval 1.04–2.39, p = 0.013) were associated with SIMD, in contrast to hs-TnI level at admission. The area under the curve of peak hs-TnI was 0.668. When the peak hs-TnI cutoff value was 0.634 ng/mL, the sensitivity and specificity for SIMD were 58.6% and 59.1%, respectively. 4) Conclusions: About two-thirds of patients with an elevated hs-TnI level have various cardiac dysfunctions in terms of TTE. Rather than the initial level, the peak hs-TnI and ST-T change may be considered as a risk factor of SIMD.