Hemodynamic Predictors for Sepsis-Induced Acute Kidney Injury: A Preliminary Study

Early Identification of Sepsis-Induced Acute Kidney Injury by Using Monocyte Distribution Width, Red-Blood-Cell Distribution, and Neutrophil-to-Lymphocyte Ratio

Sepsis-induced acute kidney injury (AKI) is a common complication in patients with severe illness and leads to increased risks of mortality and chronic kidney disease. We investigated the association between monocyte distribution width (MDW), red-blood-cell volume distribution width (RDW), neutrophil-to-lymphocyte ratio (NLR), sepsis-related organ-failure assessment (SOFA) score, mean arterial pressure (MAP), and other risk factors and sepsis-induced AKI in patients presenting to the emergency department (ED). This retrospective study, spanning 1 January 2020, to 30 November 2020, was conducted at a university-affiliated teaching hospital. Patients meeting the Sepsis-2 consensus criteria upon presentation to our ED were categorized into sepsis-induced AKI and non-AKI groups. Clinical parameters (i.e., initial SOFA score and MAP) and laboratory markers (i.e., MDW, RDW, and NLR) were measured upon ED admission. A logistic regression model was developed, with sepsis-induced AKI as the dependent variable and laboratory parameters as independent variables. Three multivariable logistic regression models were constructed. In Model 1, MDW, initial SOFA score, and MAP exhibited significant associations with sepsis-induced AKI (area under the curve [AUC]: 0.728, 95% confidence interval [CI]: 0.668-0.789). In Model 2, RDW, initial SOFA score, and MAP were significantly correlated with sepsis-induced AKI (AUC: 0.712, 95% CI: 0.651-0.774). In Model 3, NLR, initial SOFA score, and MAP were significantly correlated with sepsis-induced AKI (AUC: 0.719, 95% CI: 0.658-0.780). Our novel models, integrating MDW, RDW, and NLR with initial SOFA score and MAP, can assist with the identification of sepsis-induced AKI among patients with sepsis presenting to the ED.

Clozapine-Induced Severe Toxicity: Exploring the Pharmacokinetic Profile of Clozapine and Its Significance in Hemodynamic Instability - A Case Report

Hemodynamic instability in patients with clozapine intoxication can indirectly reflect the serum concentration of clozapine.We have described a case of a 32-year-old pregnant woman who developed life-threatening clozapine toxicity at 28 weeks of gestation. The levels of clozapine and norclozapine in the serum were high. We initiated hemoperfusion(HP) and other detoxification therapies to remove the drug. The patient had severely dilated peripheral blood vessels, which led to cardiac symptoms such as fatal hypotension and uncontrollable tachycardia, resulting in very high cardiac output and elevated Central venous oxygen saturation (ScvO2). Pharmacological intervention significantly improved the hemodynamics.In light of our observations in the ongoing case, we posit that evaluating hemodynamic parameters before and after blood detoxification could serve as a valuable means to gauge effectiveness and provide guidance for treatment.

Leucoglycemic index predicts post-operative vasopressor-inotropic requirement after adult cardiac surgery (LEUCOGLYPTICS): A retrospective single-center study

Background and Aims

Cardiac surgery often necessitates considerable post-operative vasoactive-inotropic support. Given an encouraging literature on the prognostic potential of leucoglycemic index (LGI) [serum glucose (mg/dl) × total leucocytes count (cells/mm3)/1000], we aimed to evaluate whether intensive care unit (ICU)-admission LGI can predict post-operative vasopressor-inotropic requirements following cardiac surgery on cardio-pulmonary bypass (CPB).

Material and Methods

The data of patients undergoing cardiac surgery at our tertiary care center between January 2015 and December 2020 was retrospectively reviewed. The vasopressor-inotropic requirement was estimated using the VIS (vasoactive-inotropic score) values over the first post-operative 72 hrs. Subsequently, VISi (indexed VIS) was computed as maxVIS[0-24hrs] + maxVIS[24-48hrs] +2 × maxVIS[48-72hrs]/10), and the study participants were divided into h-VISi (VISi ≥3) and l-VISi (VISi <3).

Results

Out of 2138 patients, 479 (22.40%) patients categorized as h-VISi. On univariate analysis: LGI, age, European System for Cardiac Operative Risk Evaluation score (EuroSCORE II), left-ventricle ejection fraction, prior congestive heart failure (CHF), chronic renal failure, angiotensin-converting enzyme inhibitors, combined surgeries, CPB and aortic cross-clamp (ACC) duration, blood transfusion, and immediate post-operative glucose were significant h-VISi predictors. Subsequent to multi-variate analysis, the predictive performance of LGI (OR: 1.09; 95% CI: 1.03-1.14; P = 0.002) prior CHF (OR: 2.35; 95% CI: 1.44-3.82; P = 0.001), CPB time (OR: 1.08; 95% CI: 1.02-1.14; P = 0.019), ACC time (OR: 1.03; 95% CI: 1.02-1.04; P = 0.008), and EuroSCORE II (OR: 1.14; 95% CI: 1.06-1.21; P < 0.001) remained significant. With 1484.75 emerging as the h-VISi predictive cut-off, patients with LGI ≥ 1484.75 also had a higher incidence of vasoplegia, low-cardiac output syndrome, new-onset atrial fibrillation, acute kidney injury, and mortality. LGI additionally exhibited a significant positive correlation with duration of mechanical ventilation and ICU stay (R = 0.495 and 0.564, P value < 0.001).

Conclusion

An elevated LGI of greater than 1484.75 independently predicted a VISindex ≥3 following adult cardiac surgery on CPB.

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.

Non-invasive Early Prediction of Septic Acute Kidney Injury by Doppler-Based Renal Resistive Indexes Combined With Echocardiographic Parameters: An Experimental Study

Non-invasive early prediction of septic acute kidney injury (S-AKI) is still urgent and challenging. Increased Doppler-based renal resistive index (RRI) has been shown to be associated with S-AKI, but its clinical use is limited, which may be explained by the complex effects of systemic circulation. Echocardiogram allows non-invasive assessment of systemic circulation, which may provide an effective supplement to RRI. To find the value of RRI combined with echocardiographic parameters in the non-invasive early prediction of S-AKI, we designed this experiment with repeated measurements of ultrasonographic parameters in the early stage of sepsis (3, 6, 12, and 24 h) in cecum ligation and puncture (CLP) rats (divided into AKI and non-AKI groups at 24 h based on serum creatinine), with sham-operated group serving as controls. Our results found that RRI alone could not effectively predict S-AKI, but when combined with echocardiographic parameters (heart rate, left ventricular end-diastolic internal diameter, and left ventricular end-systolic internal diameter), the predictive value was significantly improved, especially in the early stage of sepsis (3 h, AUC: 0.948, 95% CI 0.839–0.992, P < 0.001), and far earlier than the conventional renal function indicators (serum creatinine and blood urea nitrogen), which only significantly elevated at 24 h. Our method showed novel advances and potential in the early detection of S-AKI.

Collecting duct cells show differential retinoic acid responses to acute versus chronic kidney injury stimuli

Retinoic acid (RA) activates RA receptors (RAR), resulting in RA response element (RARE)-dependent gene expression in renal collecting duct (CD). Emerging evidence supports a protective role for this activity in acute kidney injury (AKI) and chronic kidney disease (CKD). Herein, we examined this activity in RARE-LacZ transgenic mice and by RARE-Luciferase reporter assays in CD cells, and investigated how this activity responds to neurotransmitters and mediators of kidney injury. In RARE-LacZ mice, Adriamycin-induced heavy albuminuria was associated with reduced RA/RAR activity in CD cells. In cultured CD cells, RA/RAR activity was repressed by acetylcholine, albumin, aldosterone, angiotensin II, high glucose, cisplatin and lipopolysaccharide, but was induced by aristolochic acid I, calcitonin gene-related peptide, endothelin-1, gentamicin, norepinephrine and vasopressin. Compared with age-matched normal human CD cells, CD-derived renal cystic epithelial cells from patients with autosomal recessive polycystic kidney disease (ARPKD) had significantly lower RA/RAR activity. Synthetic RAR agonist RA-568 was more potent than RA in rescuing RA/RAR activity repressed by albumin, high glucose, angiotensin II, aldosterone, cisplatin and lipopolysaccharide. Hence, RA/RAR  in CD cells is a convergence point of regulation by neurotransmitters and mediators of kidney injury, and may be a novel therapeutic target.

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.

miR-21 protects against lipopolysaccharide-stimulated acute kidney injury and apoptosis by targeting CDK6

Background

Septic acute kidney injury (AKI) causes a sharp deterioration of renal function, and it is a major reason for mortality in intensive care units. Although miR-21 has been proven to be dysregulated in patients with sepsis, the evidence is scarce concerning its role in mediating cellular apoptosis in AKI.

Methods

Mice were injected intraperitoneally with 10 mg/kg of lipopolysaccharide (LPS) to establish septic AKI model, miR-21 mimic and inhibitor were used to manipulate the expression of miR-21, the creatinine levels were detected by a creatinine assay kit, the renal cell proliferation and apoptosis were detected by MTT assay, flow cytometry assay and acridine orange/ethidium bromide (AO/EB) fluorescence staining, the renal function was evaluated by renal histology and tubular injury score, western blot analysis was used to detect the target protein levels. Several bioinformatics tools were performed to show the downstream target of miR-21, and further confirmed by luciferase reporter assay and caspase-3 activity assay.

Results

miR-21 silencing was able to promote renal function and decrease LPS-stimulated renal cell apoptosis in vitro and in vivo, and it could decrease the Bax/Bcl-2 ratio and caspase-3 activity. On the contrary, miR-21 overexpression had the opposite effects. Cyclin-dependent kinase 6 (CDK6) was confirmed as a target gene of miR-21 and was associated with renal cell apoptosis. Moreover, miR-21 was also found to be up-regulated in septic AKI.

Conclusions

Current evidences suggest that miR-21 has a potential application in treating septic AKI.