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Hanna PE, Ouyang T, Tahir I, Katz-Agranov N, Wang Q, Mantz L, Strohbehn I, Moreno D, Harden D, Dinulos JE, Cosar D, Seethapathy H, Gainor JF, Shah SJ, Gupta S, Leaf DE, Fintelmann FJ, Sise ME. Sarcopenia, adiposity and large discordance between cystatin C and creatinine-based estimated glomerular filtration rate in patients with cancer. J Cachexia Sarcopenia Muscle 2024. [PMID: 38646842 DOI: 10.1002/jcsm.13469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 12/15/2023] [Accepted: 03/06/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Creatinine-based estimated glomerular filtration rate (eGFRCRE) may overestimate kidney function in patients with sarcopenia. While cystatin C-based eGFR (eGFRCYS) is less affected by muscle mass, it may underestimate kidney function in patients with obesity. We sought to evaluate the relationship between body composition defined by computed tomography (CT) scans and discordance between creatinine, eGFRCRE and eGFRCYS in adult patients with cancer. METHODS This study is a cross-sectional study of consecutive adults with cancer with an abdominal CT scan performed within 90 days of simultaneous eGFRCRE and eGFRCYS measurements between May 2010 and January 2022. Muscle and adipose tissue cross-sectional areas were measured at the level of the third lumbar vertebral body using a validated deep-learning pipeline. CT-defined sarcopenia was defined using independent sex-specific cut-offs for skeletal muscle index (<39 cm2/m2 for women and <55 cm2/m2 for men). High adiposity was defined as the highest sex-specific quartile of the total (visceral plus subcutaneous) adiposity index in the cohort. The primary outcome was eGFR discordance, defined by eGFRCYS > 30% lower than eGFRCRE; the secondary outcome was eGFRCYS > 50% lower than eGFRCRE. The odds of eGFR discordance were estimated using multivariable logistic regression modelling. Unadjusted spline regression was used to evaluate the relationship between skeletal muscle index and the difference between eGFRCYS and eGFRCRE. RESULTS Of the 545 included patients (mean age 63 ± 14 years, 300 [55%] females, 440 [80.7%] non-Hispanic white), 320 (58.7%) met the criteria for CT-defined sarcopenia, and 136 (25%) had high adiposity. A total of 259 patients (48%) had >30% eGFR discordance, and 122 (22.4%) had >50% eGFR discordance. After adjustment for potential confounders, CT-defined sarcopenia and high adiposity were both associated with >30% eGFR discordance (adjusted odds ratio [aOR] 1.90, 95% confidence interval [CI] 1.12-3.24; aOR 2.01, 95% CI 1.15-3.52, respectively) and >50% eGFR discordance (aOR 2.34, 95% CI 1.21-4.51; aOR 2.23, 95% CI 1.19-4.17, respectively). A spline model demonstrated that as skeletal muscle index decreases, the predicted difference between eGFRCRE and eGFRCYS widens considerably. CONCLUSIONS CT-defined sarcopenia and high adiposity are both independently associated with large eGFR discordance. Incorporating valuable information from body composition analysis derived from CT scans performed as a part of routine cancer care can impact the interpretation of GFR estimates.
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Affiliation(s)
- Paul E Hanna
- Division of Nephrology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Tianqi Ouyang
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ismail Tahir
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Nurit Katz-Agranov
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Qiyu Wang
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lea Mantz
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Ian Strohbehn
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Daiana Moreno
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Destiny Harden
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - James E Dinulos
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Duru Cosar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Harish Seethapathy
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Justin F Gainor
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sachin J Shah
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Shruti Gupta
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, MA, USA
| | - David E Leaf
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Meghan E Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Gupta S, Leaf DE. We need more data to help guide the care of patients with cancer who develop kidney related problems. BMJ 2024; 384:q751. [PMID: 38538030 DOI: 10.1136/bmj.q751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Gupta S, Glezerman IG, Hirsch JS, Chen KL, Devaraj N, Wells SL, Seitter RH, Kaunfer SA, Jose AM, Rao SP, Ortega JL, Green-Lingren O, Hayden R, Bendapudi PK, Chute DF, Sise ME, Jhaveri KD, Page VD, Abramson MH, Motwani SS, Xu W, Sehgal K, Reynolds KL, Bansal A, Abudayyeh A, Leaf DE. Derivation and external validation of a simple risk score for predicting severe acute kidney injury after intravenous cisplatin: cohort study. BMJ 2024; 384:e077169. [PMID: 38538012 PMCID: PMC10964715 DOI: 10.1136/bmj-2023-077169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVE To develop and externally validate a prediction model for severe cisplatin associated acute kidney injury (CP-AKI). DESIGN Multicenter cohort study. SETTING Six geographically diverse major academic cancer centers across the US. PARTICIPANTS Adults (≥18 years) receiving their first dose of intravenous cisplatin, 2006-22. MAIN OUTCOME MEASURES The primary outcome was CP-AKI, defined as a twofold or greater increase in serum creatinine or kidney replacement therapy within 14 days of a first dose of intravenous cisplatin. Independent predictors of CP-AKI were identified using a multivariable logistic regression model, which was developed in a derivation cohort and tested in an external validation cohort. For the primary model, continuous variables were examined using restricted cubic splines. A simple risk model was also generated by converting the odds ratios from the primary model into risk points. Finally, a multivariable Cox model was used to examine the association between severity of CP-AKI and 90 day survival. RESULTS A total of 24 717 adults were included, with 11 766 in the derivation cohort (median age 59 (interquartile range (IQR) 50-67)) and 12 951 in the validation cohort (median age 60 (IQR 50-67)). The incidence of CP-AKI was 5.2% (608/11 766) in the derivation cohort and 3.3% (421/12 951) in the validation cohort. Each of the following factors were independently associated with CP-AKI in the derivation cohort: age, hypertension, diabetes mellitus, serum creatinine level, hemoglobin level, white blood cell count, platelet count, serum albumin level, serum magnesium level, and cisplatin dose. A simple risk score consisting of nine covariates was shown to predict a higher risk of CP-AKI in a monotonic fashion in both the derivation cohort and the validation cohort. Compared with patients in the lowest risk category, those in the highest risk category showed a 24.00-fold (95% confidence interval (CI) 13.49-fold to 42.78-fold) higher odds of CP-AKI in the derivation cohort and a 17.87-fold (10.56-fold to 29.60-fold) higher odds in the validation cohort. The primary model had a C statistic of 0.75 and showed better discrimination for CP-AKI than previously published models, the C statistics for which ranged from 0.60 to 0.68 (DeLong P<0.001 for each comparison). Greater severity of CP-AKI was monotonically associated with shorter 90 day survival (adjusted hazard ratio 4.63 (95% CI 3.56 to 6.02) for stage 3 CP-AKI versus no CP-AKI). CONCLUSION This study found that a simple risk score based on readily available variables from patients receiving intravenous cisplatin could predict the risk of severe CP-AKI, the occurrence of which is strongly associated with death.
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Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
- Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Ilya G Glezerman
- Renal Service, Memorial Sloan Kettering Cancer Center and Department of Medicine, Weill Cornell Medical College, NY, NY, USA
| | - Jamie S Hirsch
- Northwell Health, New Hyde Park, NY, USA
- Division of Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
- Clinical Digital Solutions, Northwell Health, Lake Success, NY, USA
| | - Kevin L Chen
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Nishant Devaraj
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Sophia L Wells
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Robert H Seitter
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Sarah A Kaunfer
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Arunima M Jose
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Shreya P Rao
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Jessica L Ortega
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | | | - Robert Hayden
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Pavan K Bendapudi
- Harvard Medical School, Boston, MA, USA
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA, USA
| | - Donald F Chute
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Meghan E Sise
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Kenar D Jhaveri
- Northwell Health, New Hyde Park, NY, USA
- Division of Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Valda D Page
- Division of Internal Medicine, Section of Nephrology, University of Texas MD Anderson Cancer Center Houston, TX, USA
| | - Matthew H Abramson
- Renal Service, Memorial Sloan Kettering Cancer Center and Department of Medicine, Weill Cornell Medical College, NY, NY, USA
- Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Shveta S Motwani
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
- Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, MA, USA
- Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Wenxin Xu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Kartik Sehgal
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Kerry L Reynolds
- Harvard Medical School, Boston, MA, USA
- Division of Hematology-Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Anip Bansal
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus Aurora, Aurora, CO, USA
| | - Ala Abudayyeh
- Division of Internal Medicine, Section of Nephrology, University of Texas MD Anderson Cancer Center Houston, TX, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA, USA
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Kim H, Ali R, Short S, Kaunfer S, Krishnamurthy S, Durai L, Yilmam O, Shenoy T, Monson AE, Thomas C, Park I, Martini D, Newcomb R, Shapiro RM, Soiffer RJ, DeFilipp Z, Baron RM, Gupta S, Sise ME, Leaf DE. AKI treated with kidney replacement therapy in critically Ill allogeneic hematopoietic stem cell transplant recipients. Bone Marrow Transplant 2024; 59:178-188. [PMID: 37935783 DOI: 10.1038/s41409-023-02136-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 11/09/2023]
Abstract
Acute kidney injury (AKI) is a frequent complication following allogeneic hematopoietic stem cell transplantation (allo-HSCT), but few studies have focused on AKI treated with kidney replacement therapy (AKI-KRT), particularly among critically ill patients. We investigated the incidence, risk factors, and 90-day mortality associated with AKI-KRT in 529 critically ill adult allo-HSCT recipients admitted to the ICU within 1-year post-transplant at two academic medical centers between 2011 and 2021. AKI-KRT occurred in 111 of the 529 patients (21.0%). Lower baseline eGFR, veno-occlusive disease, thrombotic microangiopathy, admission to an ICU within 90 days post-transplant, and receipt of invasive mechanical ventilation (IMV), total bilirubin ≥5.0 mg/dl, and arterial pH <7.40 on ICU admission were each associated with a higher risk of AKI-KRT. Of the 111 patients with AKI-KRT, 97 (87.4%) died within 90 days. Ninety-day mortality was 100% in each of the following subgroups: serum albumin ≤2.0 g/dl, total bilirubin ≥7.0 mg/dl, arterial pH ≤7.20, IMV with moderate-to-severe hypoxemia, and ≥3 vasopressors/inotropes at KRT initiation. AKI-KRT was associated with a 6.59-fold higher adjusted 90-day mortality in critically ill allo-HSCT vs. non-transplanted patients. Short-term mortality remains exceptionally high among critically ill allo-HSCT patients with AKI-KRT, highlighting the importance of multidisciplinary discussions prior to KRT initiation.
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Affiliation(s)
- Helena Kim
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Rafia Ali
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Samuel Short
- Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Sarah Kaunfer
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Lavanya Durai
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Osman Yilmam
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Tushar Shenoy
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Audrey E Monson
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Charlotte Thomas
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Isabel Park
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Dylan Martini
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Richard Newcomb
- Division of Hematology & Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA, USA
| | - Roman M Shapiro
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Robert J Soiffer
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA, USA
| | - Rebecca M Baron
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Meghan E Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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Grange C, Lux F, Brichart T, David L, Couturier A, Leaf DE, Allaouchiche B, Tillement O. Iron as an emerging therapeutic target in critically ill patients. Crit Care 2023; 27:475. [PMID: 38049866 PMCID: PMC10694984 DOI: 10.1186/s13054-023-04759-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/24/2023] [Indexed: 12/06/2023] Open
Abstract
The multiple roles of iron in the body have been known for decades, particularly its involvement in iron overload diseases such as hemochromatosis. More recently, compelling evidence has emerged regarding the critical role of non-transferrin bound iron (NTBI), also known as catalytic iron, in the care of critically ill patients in intensive care units (ICUs). These trace amounts of iron constitute a small percentage of the serum iron, yet they are heavily implicated in the exacerbation of diseases, primarily by catalyzing the formation of reactive oxygen species, which promote oxidative stress. Additionally, catalytic iron activates macrophages and facilitates the growth of pathogens. This review aims to shed light on this underappreciated phenomenon and explore the various common sources of NTBI in ICU patients, which lead to transient iron dysregulation during acute phases of disease. Iron serves as the linchpin of a vicious cycle in many ICU pathologies that are often multifactorial. The clinical evidence showing its detrimental impact on patient outcomes will be outlined in the major ICU pathologies. Finally, different therapeutic strategies will be reviewed, including the targeting of proteins involved in iron metabolism, conventional chelation therapy, and the combination of renal replacement therapy with chelation therapy.
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Affiliation(s)
- Coralie Grange
- MexBrain, 13 Avenue Albert Einstein, Villeurbanne, France
- Institut Lumière-Matière, UMR 5306, Université Claude Bernard Lyon1-CNRS, Villeurbanne Cedex, France
| | - François Lux
- Institut Lumière-Matière, UMR 5306, Université Claude Bernard Lyon1-CNRS, Villeurbanne Cedex, France.
- Institut Universitaire de France (IUF), 75231, Paris, France.
| | | | - Laurent David
- Institut National des Sciences Appliquées, CNRS UMR 5223, Ingénierie des Matériaux Polymères, Univ Claude Bernard Lyon 1, Université Jean Monnet, 15 bd Latarjet, 69622, Villeurbanne, France
| | - Aymeric Couturier
- MexBrain, 13 Avenue Albert Einstein, Villeurbanne, France
- Nephrology, American Hospital of Paris, Paris, France
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Bernard Allaouchiche
- University of Lyon, University Lyon I Claude Bernard, APCSe VetAgro Sup UP, 2021. A10, Marcy L'Étoile, France
| | - Olivier Tillement
- Institut Lumière-Matière, UMR 5306, Université Claude Bernard Lyon1-CNRS, Villeurbanne Cedex, France
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Gupta S, Wells SL, Jose AM, Seitter RH, Feghali L, Devaraj N, Hartigan PM, Yacoubian S, Kwiatkowski DJ, Burke DM, Barlow J, Bueno R, Leaf DE. High-dose IV magnesium in mesothelioma patients receiving surgery with hyperthermic intraoperative cisplatin: Pilot studies and design of a phase II randomized clinical trial. J Surg Oncol 2023; 128:1141-1149. [PMID: 37702402 PMCID: PMC10592264 DOI: 10.1002/jso.27412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 07/20/2023] [Indexed: 09/14/2023]
Abstract
INTRODUCTION Hyperthermic intraoperative cisplatin (HIOC) is associated with acute kidney injury (AKI). Administration of high-dose magnesium attenuates cisplatin-induced AKI (CP-AKI) in animal models but has not been rigorously examined in humans. METHODS We tested the feasibility and safety of different doses of magnesium in mesothelioma patients receiving HIOC. In Pilot Study 1, we administered a 36-h continuous infusion of magnesium at 0.5 g/h, targeting serum magnesium levels between 3 and 4.8 mg/dL. In Pilot Study 2A, we administered a 6 g bolus followed by an infusion starting at 2 g/h, titrated to achieve levels between 4 and 6 mg/dL. We eliminated the bolus in Pilot Study 2B. RESULTS In Pilot Study 1, all five patients enrolled completed the study; however, median postoperative Mg levels were only 2.4 mg/dL. In Pilot Study 2A, two of four patients (50%) were withdrawn due to bradycardia during the bolus. In Pilot Study 2B, two patients completed the study whereas two developed postoperative bradycardia attributed to the magnesium. CONCLUSIONS A 0.5 g/h infusion for 36 h did not achieve therapeutic magnesium levels, while an infusion at 2 g/h was associated with bradycardia. These studies informed the design of a randomized clinical trial testing whether intravenously Mg attenuates HIOC-associated AKI.
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Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA
- Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, MA
| | - Sophia L. Wells
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Arunima M. Jose
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Robert H. Seitter
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Lea Feghali
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Nishant Devaraj
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Philip M. Hartigan
- Departments of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Stephanie Yacoubian
- Departments of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School, Boston, MA
| | | | - Donna M. Burke
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Julianne Barlow
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Raphael Bueno
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA
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Thomas C, Ali R, Park I, Kim H, Short S, Kaunfer S, Durai L, Yilmam OA, Shenoy T, Battinelli EM, Al-Samkari H, Leaf DE. Platelet Factor 4 Antibodies and Severe AKI. Kidney360 2023; 4:1672-1679. [PMID: 37907435 PMCID: PMC10758522 DOI: 10.34067/kid.0000000000000287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/19/2023] [Indexed: 11/02/2023]
Abstract
Key Points Patients testing positive for platelet factor 4 antibodies have a >50% higher odds of developing severe AKI compared with those who test negative. The relationship between platelet factor 4 antibodies and severe AKI was independent of demographics, comorbidities, laboratory values, and severity-of-illness characteristics. Background Heparin-induced thrombocytopenia, which results from production of antibodies that bind to heparin-platelet factor 4 (PF4) complexes, is a hypercoagulable state associated with considerable morbidity and mortality due to thrombotic complications. We investigated whether PF4 antibodies are associated with an increased risk of AKI. Methods We conducted a cohort study of hospitalized adults who underwent testing for PF4 antibodies at two large medical centers in Boston between 2015 and 2021. The primary exposure was PF4 test positivity. The primary outcome was severe AKI, defined by Kidney Disease: Improving Global Outcomes stage 3 as a ≥3-fold increase in serum creatinine or receipt of KRT within 7 days after the PF4 test. We used multivariable logistic regression to adjust for potential confounders. Results A total of 4224 patients were included in our analysis, 469 (11.1%) of whom had a positive PF4 test. Severe AKI occurred in 50 of 469 patients (10.7%) with a positive PF4 test and in 235 of 3755 patients (6.3%) with a negative test (unadjusted odds ratio, 1.79 [95% confidence interval, 1.30 to 2.47]). In multivariable analyses adjusted for demographics, comorbidities, laboratory values, and severity-of-illness characteristics, PF4 test positivity remained associated with a higher risk of severe AKI (adjusted odds ratio, 1.56 [95% confidence interval, 1.10 to 2.20]). Conclusions Among hospitalized adults, the presence of PF4 antibodies is independently associated with a 56% higher odds of developing severe AKI. Additional studies are needed to investigate potential mechanisms that may underlie these findings, such as pathogenic effects of PF4 antibodies on the microvasculature of the kidneys.
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Affiliation(s)
- Charlotte Thomas
- Harvard Medical School, Boston, Massachusetts
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rafia Ali
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Isabel Park
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Helena Kim
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Samuel Short
- Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Sarah Kaunfer
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lavanya Durai
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Osman A. Yilmam
- Harvard Medical School, Boston, Massachusetts
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tushar Shenoy
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elisabeth M. Battinelli
- Harvard Medical School, Boston, Massachusetts
- Division of Hematology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, Massachusetts
- Division of Hematology, Massachusetts General Hospital, Boston, Massachusetts
| | - David E. Leaf
- Harvard Medical School, Boston, Massachusetts
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Leaf DE, Gordon AC, Lawler PR. Adverse Effects of Tocilizumab Versus Baricitinib in Severe COVID-19. Crit Care Med 2023; 51:e184-e185. [PMID: 37589523 DOI: 10.1097/ccm.0000000000005933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, United Kingdom
| | - Patrick R Lawler
- Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Department of Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada
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Smilowitz NR, Hade EM, Kornblith LZ, Castellucci LA, Cushman M, Farkouh M, Gong MN, Heath A, Hunt BJ, Kim KS, Kindzelski A, Lawler P, Leaf DE, Goligher E, Leifer ES, McVerry BJ, Reynolds HR, Zarychanski R, Hochman JS, Neal MD, Berger JS. Effect of therapeutic-dose heparin on severe acute kidney injury and death in noncritically ill patients hospitalized for COVID-19: a prespecified secondary analysis of the ACTIV4a and ATTACC randomized trial. Res Pract Thromb Haemost 2023; 7:102167. [PMID: 37727846 PMCID: PMC10506136 DOI: 10.1016/j.rpth.2023.102167] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 07/02/2023] [Accepted: 07/07/2023] [Indexed: 09/21/2023] Open
Abstract
Background Acute kidney injury (AKI) in patients with COVID-19 is partly mediated by thromboinflammation. In noncritically ill patients with COVID-19, therapeutic-dose anticoagulation with heparin increased the probability of survival to hospital discharge with reduced use of cardiovascular or respiratory organ support. Objectives We investigated whether therapeutic-dose heparin reduces the incidence of AKI or death in noncritically ill patients hospitalized for COVID-19. Methods We report a prespecified secondary analysis of the ACTIV4a and ATTACC open-label, multiplatform randomized trial of therapeutic-dose heparin vs usual-care pharmacologic thromboprophylaxis on the incidence of severe AKI (≥2-fold increase in serum creatinine or initiation of kidney replacement therapy (KDIGO stage 2 or 3) or all-cause mortality in noncritically ill patients hospitalized for COVID-19. Bayesian statistical models were adjusted for age, sex, D-dimer, enrollment period, country, site, and platform. Results Among 1922 enrolled, 23 were excluded due to pre-existing end stage kidney disease and 205 were missing baseline or follow-up creatinine measurements. Severe AKI or death occurred in 4.4% participants assigned to therapeutic-dose heparin and 5.5% assigned to thromboprophylaxis (adjusted relative risk [aRR]: 0.72; 95% credible interval (CrI): 0.47, 1.10); the posterior probability of superiority for therapeutic-dose heparin (relative risk < 1.0) was 93.6%. Therapeutic-dose heparin was associated with a 97.7% probability of superiority to reduce the composite of stage 3 AKI or death (3.1% vs 4.6%; aRR: 0.64; 95% CrI: 0.40, 0.99) compared to thromboprophylaxis. Conclusion Therapeutic-dose heparin was associated with a high probability of superiority to reduce the incidence of in-hospital severe AKI or death in patients hospitalized for COVID-19.
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Affiliation(s)
| | - Erinn M. Hade
- NYU Grossman School of Medicine, New York, New York, USA
| | - Lucy Z. Kornblith
- Zuckerberg San Francisco General Hospital, University of California, San Francisco, California, USA
| | - Lana A. Castellucci
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- University of Ottawa, Ottawa, Ontario, Canada
| | - Mary Cushman
- Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Michael Farkouh
- Peter Munk Cardiac Centre at University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Michelle N. Gong
- Montefiore Medical Center, Bronx, New York, USA
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Anna Heath
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Keri S. Kim
- University of Illinois, Chicago, Illinois, USA
| | | | - Patrick Lawler
- Peter Munk Cardiac Centre at University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - David E. Leaf
- Brigham and Women’s Hospital Harvard Medical School, Boston, Massachusetts, USA
| | - Ewan Goligher
- University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Eric S. Leifer
- National Heart Lung & Blood Institute, NIH, Bethesda, Maryland, USA
| | - Bryan J. McVerry
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- UPMC, Pittsburgh, Pennsylvania, USA
| | | | - Ryan Zarychanski
- University of Manitoba, Winnipeg, Manitoba, Canada
- CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | | | - Matthew D. Neal
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- UPMC, Pittsburgh, Pennsylvania, USA
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10
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Hanna PE, Wang Q, Strohbehn IA, Moreno D, Harden D, Ouyang T, Katz-Agranov N, Seethapathy H, Reynolds KL, Gupta S, Leaf DE, Sise ME. Medication-Related Adverse Events and Discordancies in Cystatin C-Based vs Serum Creatinine-Based Estimated Glomerular Filtration Rate in Patients With Cancer. JAMA Netw Open 2023; 6:e2321715. [PMID: 37405775 PMCID: PMC10323710 DOI: 10.1001/jamanetworkopen.2023.21715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/19/2023] [Indexed: 07/06/2023] Open
Abstract
Importance Serum creatinine-based estimated glomerular filtration rate (eGFRcr) may overestimate the glomerular filtration rate (GFR) in patients with cancer. Cystatin C-based eGFR (eGFRcys) is an alternative marker of GFR. Objective To determine whether the therapeutic drug levels and adverse events (AEs) associated with renally cleared medications were higher in patients with cancer whose eGFRcys was more than 30% lower than their eGFRcr. Design, Setting, and Participants This cohort study analyzed adult patients with cancer at 2 major academic cancer centers in Boston, Massachusetts. These patients had their creatinine and cystatin C measured on the same day between May 2010 and January 2022. The date of the first simultaneous eGFRcr and eGFRcys measurement was considered to be the baseline date. Exposure The primary exposure was eGFR discordance, defined as an eGFRcys that was more than 30% lower than the eGFRcr. Main Outcomes and Measures The primary outcome was risk of the following medication-related AEs within 90 days of the baseline date: (1) supratherapeutic vancomycin trough level greater than 30 μg/mL, (2) trimethoprim-sulfamethoxazole-related hyperkalemia (>5.5 mEq/L), (3) baclofen toxic effect, and (4) supratherapeutic digoxin level (>2.0 ng/mL). For the secondary outcome, a multivariable Cox proportional hazards regression model was used to compare 30-day survival of those with vs without eGFR discordance. Results A total of 1869 adult patients with cancer (mean [SD] age, 66 [14] years; 948 males [51%]) had simultaneous eGFRcys and eGFRcr measurement. There were 543 patients (29%) with an eGFRcys that was more than 30% lower than their eGFRcr. Patients with an eGFRcys that was more than 30% lower than their eGFRcr were more likely to experience medication-related AEs compared with patients with concordant eGFRs (defined as eGFRcys within 30% of eGFRcr), including vancomycin levels greater than 30 μg/mL (43 of 179 [24%] vs 7 of 77 [9%]; P = .01), trimethoprim-sulfamethoxazole-related hyperkalemia (29 of 129 [22%] vs 11 of 92 [12%]; P = .07), baclofen toxic effects (5 of 19 [26%] vs 0 of 11; P = .19), and supratherapeutic digoxin levels (7 of 24 [29%] vs 0 of 10; P = .08). The adjusted odds ratio for vancomycin levels more than 30 μg/mL was 2.59 (95% CI, 1.08-7.03; P = .04). Patients with an eGFRcys more than 30% lower than their eGFRcr had an increased 30-day mortality (adjusted hazard ratio, 1.98; 95% CI, 1.26-3.11; P = .003). Conclusions and relevance Results of this study suggest that among patients with cancer with simultaneous assessment of eGFRcys and eGFRcr, supratherapeutic drug levels and medication-related AEs occurred more commonly in those with an eGFRcys more than 30% lower than their eGFRcr. Future prospective studies are needed to improve and personalize GFR estimation and medication dosing in patients with cancer.
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Affiliation(s)
- Paul E. Hanna
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Qiyu Wang
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Ian A. Strohbehn
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Daiana Moreno
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Destiny Harden
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Tianqi Ouyang
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Nurit Katz-Agranov
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Harish Seethapathy
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Kerry L. Reynolds
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Meghan E. Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
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11
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Green A, Rachoin JS, Schorr C, Dellinger P, Casey JD, Park I, Gupta S, Baron RM, Shaefi S, Hunter K, Leaf DE. Timing of invasive mechanical ventilation and death in critically ill adults with COVID-19: A multicenter cohort study. PLoS One 2023; 18:e0285748. [PMID: 37379286 DOI: 10.1371/journal.pone.0285748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/02/2023] [Indexed: 06/30/2023] Open
Abstract
PURPOSE To investigate if the timing of initiation of invasive mechanical ventilation (IMV) for critically ill patients with COVID-19 is associated with mortality. MATERIALS AND METHODS The data for this study were derived from a multicenter cohort study of critically ill adults with COVID-19 admitted to ICUs at 68 hospitals across the US from March 1 to July 1, 2020. We examined the association between early (ICU days 1-2) versus late (ICU days 3-7) initiation of IMV and time-to-death. Patients were followed until the first of hospital discharge, death, or 90 days. We adjusted for confounding using a multivariable Cox model. RESULTS Among the 1879 patients included in this analysis (1199 male [63.8%]; median age, 63 [IQR, 53-72] years), 1526 (81.2%) initiated IMV early and 353 (18.8%) initiated IMV late. A total of 644 of the 1526 patients (42.2%) in the early IMV group died, and 180 of the 353 (51.0%) in the late IMV group died (adjusted HR 0.77 [95% CI, 0.65-0.93]). CONCLUSIONS In critically ill adults with respiratory failure from COVID-19, early compared to late initiation of IMV is associated with reduced mortality.
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Affiliation(s)
- Adam Green
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Jean-Sebastien Rachoin
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Christa Schorr
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Phil Dellinger
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Jonathan D Casey
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Isabel Park
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Rebecca M Baron
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America
| | - Krystal Hunter
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
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12
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Lawler PR, Derde LPG, van de Veerdonk FL, McVerry BJ, Huang DT, Berry LR, Lorenzi E, van Kimmenade R, Gommans F, Vaduganathan M, Leaf DE, Baron RM, Kim EY, Frankfurter C, Epelman S, Kwan Y, Grieve R, O'Neill S, Sadique Z, Puskarich M, Marshall JC, Higgins AM, Mouncey PR, Rowan KM, Al-Beidh F, Annane D, Arabi YM, Au C, Beane A, van Bentum-Puijk W, Bonten MJM, Bradbury CA, Brunkhorst FM, Burrell A, Buzgau A, Buxton M, Cecconi M, Cheng AC, Cove M, Detry MA, Estcourt LJ, Ezekowitz J, Fitzgerald M, Gattas D, Godoy LC, Goossens H, Haniffa R, Harrison DA, Hills T, Horvat CM, Ichihara N, Lamontagne F, Linstrum KM, McAuley DF, McGlothlin A, McGuinness SP, McQuilten Z, Murthy S, Nichol AD, Owen DRJ, Parke RL, Parker JC, Pollock KM, Reyes LF, Saito H, Santos MS, Saunders CT, Seymour CW, Shankar-Hari M, Singh V, Turgeon AF, Turner AM, Zarychanski R, Green C, Lewis RJ, Angus DC, Berry S, Gordon AC, McArthur CJ, Webb SA. Effect of Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Initiation on Organ Support-Free Days in Patients Hospitalized With COVID-19: A Randomized Clinical Trial. JAMA 2023; 329:1183-1196. [PMID: 37039790 PMCID: PMC10326520 DOI: 10.1001/jama.2023.4480] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/07/2023] [Indexed: 04/12/2023]
Abstract
IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non-critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support-free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support-free days among critically ill patients was 10 (-1 to 16) in the ACE inhibitor group (n = 231), 8 (-1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support-free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Patrick R Lawler
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
- McGill University Health Centre, Montreal, QC, Canada
| | | | | | | | | | | | | | | | - Frank Gommans
- Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - David E Leaf
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rebecca M Baron
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edy Y Kim
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Slava Epelman
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Yvonne Kwan
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Richard Grieve
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stephen O'Neill
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Zia Sadique
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Paul R Mouncey
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Kathryn M Rowan
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Djillali Annane
- Hospital Raymond Poincaré (Assistance Publique Hôpitaux de Paris), Garches, France
- Université Versailles SQY - Université Paris Saclay, Montigny-le-Bretonneux, France
| | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Carly Au
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Abi Beane
- University of Oxford, Oxford, England
| | | | | | | | | | | | | | - Meredith Buxton
- Global Coalition for Adaptive Research, Larkspur, California
| | | | | | - Matthew Cove
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | | | | | | | | | - David Gattas
- The George Institute for Global Health, Sydney, Australia
| | - Lucas C Godoy
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | | | - Rashan Haniffa
- University of Oxford, Bangkok, Thailand
- National Intensive Care Surveillance (NICST), Colombo, Sri Lanka
| | - David A Harrison
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Thomas Hills
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | | | | | - Daniel F McAuley
- Queen's University Belfast, Belfast, Northern Ireland
- Royal Victoria Hospital, Belfast, Northern Ireland
| | | | - Shay P McGuinness
- Monash University, Melbourne, Australia
- Auckland City Hospital, Auckland, New Zealand
| | | | | | - Alistair D Nichol
- Monash University, Melbourne, Australia
- University College Dublin, Dublin, Ireland
| | - David R J Owen
- Department of Brain Sciences, Imperial College London, London, United Kingdom
- UK Dementia Research Institute of Imperial College London, London, United Kingdom
| | - Rachael L Parke
- Auckland City Hospital, Auckland, New Zealand
- University of Auckland, Auckland, New Zealand
| | | | | | - Luis Felipe Reyes
- Universidad de La Sabana, Chia, Colombia
- Clinica Universidad de La Sabana, Chia, Colombia
| | - Hiroki Saito
- St Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | | | | | | | | | | | - Alexis F Turgeon
- Université Laval, Québec City, Canada
- CHU de Québec-Université Laval Research Center, Québec City, Canada
| | - Anne M Turner
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | - Roger J Lewis
- Berry Consultants, Austin, Texas
- Harbor-UCLA Medical Center, Torrance, California
- Statistical Editor, JAMA
| | - Derek C Angus
- University of Pittsburgh, Pittsburgh, Pennsylvania
- Senior Editor, JAMA
| | | | - Anthony C Gordon
- Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, United Kingdom
| | | | - Steve A Webb
- Monash University, Melbourne, Australia
- St John of God Hospital, Subiaco, Australia
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13
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Vergara-Cadavid J, Johnson PC, Kim HT, Yi A, Sise ME, Leaf DE, Hanna PE, Ho VT, Cutler CS, Antin JH, Gooptu M, Kelkar A, Wells SL, Nikiforow S, Koreth J, Romee R, Soiffer RJ, Shapiro RM, Gupta S. Clinical Features of AKI in the Early Post-Transplant Period Following Reduced Intensity Allogeneic Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2023:S2666-6367(23)01206-X. [PMID: 37015320 DOI: 10.1016/j.jtct.2023.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 03/04/2023] [Accepted: 03/23/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplant (HCT) is a potentially curative therapy for patients with hematologic malignancies but is associated with acute kidney injury (AKI). Few studies have examined risk factors for AKI at engraftment, or its relationship with clinical outcomes. OBJECTIVE The objective of this study was to examine the incidence and risk factors for peri-engraftment AKI, as well as the association between AKI and overall survival and non-relapse mortality. METHODS We conducted a retrospective analysis of adult patients receiving reduced intensity conditioning (RIC) allogeneic HCT at the Dana-Farber Cancer Institute between 2012 and 2019. Peri-engraftment (day 0 to day 30) AKI incidence and severity was defined using modified Kidney Disease: Improving Global Outcomes criteria. Factors associated with peri-engraftment AKI risk were examined using Cox regression analysis. The impact of peri-engraftment AKI on overall survival and non-relapse mortality (defined as death without recurrent disease after HCT), was evaluated using Cox regression and Fine and Gray's competing risk model, respectively. Kidney recovery, defined as a return of serum creatinine within 25% of baseline or liberation from kidney replacement therapy (KRT), was examined at day 90 in relation to HCT. RESULTS Peri-engraftment AKI occurred in 330 of 987 patients (33.4%) at a median of 13 days [IQR 4-30] post-transplant. Factors associated with a higher multivariable-adjusted risk of AKI were supratherapeutic rapamycin (HR: 1.56, 95% CI: 1.20-2.03; p<0.001), fludarabine/melphalan conditioning (HR: 1.35, 95% CI: 1.01-1.81; p=0.05; compared to fludarabine/busulfan and fludarabine, cyclophosphamide, total body irradiation), HCT-Comorbidity Index ≥4 (HR: 1.43, 95% CI: 1.14-1.79; p=0.002), albumin <3.4 g/dl (HR: 2.04, 95% CI: 1.33-3.12; p=0.001), hemoglobin ≤12 (HR 1.96, 95% CI 1.38-2.78; p<0.001), supratherapeutic tacrolimus (HR 1.45, 95% CI 1.07 - 1.95; p=0.02), and baseline serum creatinine >1.1 mg/dl (HR: 1.87, 95% CI: 1.48-2.35; p<0.001). Peri-engraftment AKI was associated with worse overall survival (HR 1.40, 95% CI: 1.16-1.71; p<0.001) and non-relapse mortality (subdistribution HR 2.10, 95% CI: 1.52-2.89; p<0.001). Kidney recovery occurred in 18%, 15%, and 30% of patients with stage 1, 2, and 3 AKI without KRT, respectively, and 4 of 16 (25%) patients were liberated from KRT. CONCLUSION Peri-engraftment AKI is common among RIC allogeneic HCT recipients. We identified several important risk factors for peri-engraftment AKI. Peri-engraftment AKI is associated with worse overall survival and non-relapse morality, highlighting the importance of timely recognition and management of AKI.
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Affiliation(s)
| | - P Connor Johnson
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Haesook T Kim
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Harvard School of Public Health, Boston, MA
| | - Alisha Yi
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Meghan E Sise
- Division of Nephrology, Massachusetts General Hospital, MA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Paul E Hanna
- Division of Nephrology, Massachusetts General Hospital, MA
| | - Vincent T Ho
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Corey S Cutler
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Joseph H Antin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Mahasweta Gooptu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Amar Kelkar
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Sophia L Wells
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Sarah Nikiforow
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - John Koreth
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Rizwan Romee
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Robert J Soiffer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Roman M Shapiro
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.
| | - Shruti Gupta
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA.
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14
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Murakami N, Hayden R, Hills T, Al-Samkari H, Casey J, Del Sorbo L, Lawler PR, Sise M, Leaf DE. Reply to 'Use of convalescent plasma in the treatment of COVID-19'. Nat Rev Nephrol 2023; 19:272. [PMID: 36806371 PMCID: PMC9937737 DOI: 10.1038/s41581-023-00691-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Robert Hayden
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Thomas Hills
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Auckland District Health Board, Auckland, New Zealand
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA, USA
- Division of Hematology, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Casey
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lorenzo Del Sorbo
- Department of Medicine, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Patrick R Lawler
- Department of Medicine, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Meghan Sise
- Harvard Medical School, Boston, MA, USA
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Murakami N, Hayden R, Hills T, Al-Samkari H, Casey J, Del Sorbo L, Lawler PR, Sise ME, Leaf DE. Author Correction: Therapeutic advances in COVID-19. Nat Rev Nephrol 2023; 19:273. [PMID: 36747084 PMCID: PMC9901371 DOI: 10.1038/s41581-023-00686-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Robert Hayden
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Thomas Hills
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Auckland District Health Board, Auckland, New Zealand
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA, USA
- Division of Hematology, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Casey
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lorenzo Del Sorbo
- Department of Medicine, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Patrick R Lawler
- Department of Medicine, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Meghan E Sise
- Harvard Medical School, Boston, MA, USA
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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16
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Yilmam OA, Leaf DE. Safety of Nirmatrelvir/Ritonavir in Dialysis Patients with COVID-19: The End of the Beginning? Clin J Am Soc Nephrol 2023; 18:427-429. [PMID: 37026748 PMCID: PMC10103203 DOI: 10.2215/cjn.0000000000000129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Affiliation(s)
- Osman A Yilmam
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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17
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Tiu BC, Strohbehn IA, Zhao S, Ouyang T, Hanna P, Wang Q, Gupta S, Leaf DE, Reynolds KL, Sise ME. Safety of Immune Checkpoint Inhibitors in Patients With Advanced Chronic Kidney Disease: A Retrospective Cohort Study. Oncologist 2023:7055845. [PMID: 36821637 DOI: 10.1093/oncolo/oyad001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/13/2022] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Clinical trials of immune checkpoint inhibitors (ICIs) often do not include patients with advanced chronic kidney disease (CKD). We aimed to determine the safety of ICIs in patients with cancer and advanced CKD (stages 4-5 CKD, estimated glomerular filtration rate [eGFR] <30 mL/minute/1.73 m2). PATIENTS AND METHODS Patients with advanced CKD from the Mass General Brigham network who received ICIs (n = 91) were compared against those receiving nephrotoxic (n = 113) and non-nephrotoxic (n = 130) antineoplastic therapies, respectively. Rates of new-onset kidney failure (end-stage kidney disease or sustained eGFR ≤10 mL/minute/1.73 m2) and AKI were compared. Among ICI-treated patients, we modeled Fine-Gray subdistribution hazards to compare immune-related adverse event (irAE) risk and used Kaplan-Meier analysis to compare overall survival in patients with advanced CKD to those with eGFR ≥30 mL/minute/1.73 m2. RESULTS Rates of new-onset kidney failure were similar at 1 year following initiation of ICIs (10.0%), nephrotoxic (6.2%), and non-nephrotoxic antineoplastic therapies (9.3%) (P = .28). AKI rates were also similar: 17.5%, 17.6%, and 20% of patients in each cohort, respectively (P = .87). Advanced CKD did not increase the risk of developing irAEs (adjusted hazard ratio [HR] 1.28, 95% CI, 0.91-1.81). However, patients with advanced CKD who received ICIs had a decreased overall survival compared with patients with eGFR ≥30 mL/minute/1.73 m2 (HR 1.30 for death, 95% CI, 1.02-1.66, P = .03). CONCLUSION ICIs are not associated with increased risk of AKI or new-onset kidney failure compared with other antineoplastic therapies in patients with advanced CKD. Advanced CKD did not increase the risk of extra-renal irAEs, although these patients suffered from lower overall survival.
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Affiliation(s)
- Bruce C Tiu
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Ian A Strohbehn
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Sophia Zhao
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Tianqi Ouyang
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Paul Hanna
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Qiyu Wang
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Shruti Gupta
- Department of Medicine, Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David E Leaf
- Department of Medicine, Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Kerry L Reynolds
- Department of Medicine, Harvard Medical School, Boston, MA, USA.,Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Meghan E Sise
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
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18
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Hanna PE, Wang Q, Strohbehn I, Moreno D, Harden D, Ouyang T, Katz-Agranov N, Seethapathy H, Reynolds KL, Gupta S, Leaf DE, Sise ME. Medication-related adverse events in patients with cancer and discrepancies in cystatin C- versus creatinine-based eGFR. medRxiv 2023:2023.01.18.23284656. [PMID: 36711583 PMCID: PMC9882433 DOI: 10.1101/2023.01.18.23284656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background Creatinine-based estimated glomerular filtration rate (eGFRCRE) may overestimate kidney function in patients with cancer. Cystatin C-based eGFR (eGFRCYS) is an alternative marker of kidney function. We investigated whether patients with an eGFR discrepancy, defined as eGFRCYS >30% lower than the concurrent eGFRCRE, had an increased risk of adverse events resulting from renally-cleared medications. Patients and Methods We conducted a cohort study of adult patients with cancer who had serum creatinine and cystatin C measured on the same day between May 2010 and January 2022 at two academic cancer centers in Boston, MA. The primary outcome was the incidence of each of the following medication-related adverse events: 1) supratherapeutic vancomycin levels (>30μg/mL); 2) trimethoprim-sulfamethoxazole-related hyperkalemia (>5.5mEq/L); 3) baclofen-induced neurotoxicity; and 4) supratherapeutic digoxin levels (>2.0ng/mL). Results 1988 patients with cancer had simultaneous eGFRCYS and eGFRCRE. The mean age was 66 years (SD±14), 965 (49%) were female, and 1555 (78%) were non-Hispanic white. eGFR discrepancy occurred in 579 patients (29%). Patients with eGFR discrepancy were more likely to experience medication-related adverse events compared to those without eGFR discrepancy: vancomycin levels >30μg/mL (24% vs. 10%, p=0.004), trimethoprim- sulfamethoxazole-related hyperkalemia (24% vs. 12%, p=0.013), baclofen-induced neurotoxicity (25% vs. 0%, p=0.13), and supratherapeutic digoxin levels (38% vs. 0%, p=0.03). The adjusted OR for vancomycin levels >30μg/mL was 2.30 (95% CI 1.05 - 5.51, p = 0.047). Conclusion Among patients with cancer with simultaneous assessment of eGFRCYS and eGFRCRE, medication-related adverse events occur more commonly in those with eGFR discrepancy. These findings underscore the importance of accurate assessment of kidney function and appropriate dosing of renally-cleared medications in patients with cancer.
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Affiliation(s)
- Paul E Hanna
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Qiyu Wang
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Ian Strohbehn
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Daiana Moreno
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Destiny Harden
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Tianqi Ouyang
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Nurit Katz-Agranov
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Harish Seethapathy
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Kerry L Reynolds
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
- Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, MA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Meghan E Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
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19
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Abstract
This Guide to Statistics and Methods describes the use of target trial emulation to design an observational study so it preserves the advantages of a randomized clinical trial, points out the limitations of the method, and provides an example of its use.
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Affiliation(s)
- Miguel A Hernán
- CAUSALab, Departments of Epidemiology and Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Wei Wang
- Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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20
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Vasbinder A, Meloche C, Azam TU, Anderson E, Catalan T, Shadid H, Berlin H, Pan M, O’Hayer P, Padalia K, Blakely P, Khaleel I, Michaud E, Huang Y, Zhao L, Pop-Busui R, Gupta S, Eagle K, Leaf DE, Hayek SS. Relationship Between Preexisting Cardiovascular Disease and Death and Cardiovascular Outcomes in Critically Ill Patients With COVID-19. Circ Cardiovasc Qual Outcomes 2022; 15:e008942. [PMID: 36193749 PMCID: PMC9575399 DOI: 10.1161/circoutcomes.122.008942] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Preexisting cardiovascular disease (CVD) is perceived as a risk factor for poor outcomes in patients with COVID-19. We sought to determine whether CVD is associated with in-hospital death and cardiovascular events in critically ill patients with COVID-19. METHODS This study used data from a multicenter cohort of adults with laboratory-confirmed COVID-19 admitted to intensive care units at 68 centers across the United States from March 1 to July 1, 2020. The primary exposure was CVD, defined as preexisting coronary artery disease, congestive heart failure, or atrial fibrillation/flutter. Myocardial injury on intensive care unit admission defined as a troponin I or T level above the 99th percentile upper reference limit of normal was a secondary exposure. The primary outcome was 28-day in-hospital mortality. Secondary outcomes included cardiovascular events (cardiac arrest, new-onset arrhythmias, new-onset heart failure, myocarditis, pericarditis, or stroke) within 14 days. RESULTS Among 5133 patients (3231 male [62.9%]; mean age 61 years [SD, 15]), 1174 (22.9%) had preexisting CVD. A total of 1178 (34.6%) died, and 920 (17.9%) had a cardiovascular event. After adjusting for age, sex, race, body mass index, history of smoking, and comorbidities, preexisting CVD was associated with a 1.15 (95% CI, 0.98-1.34) higher odds of death. No independent association was observed between preexisting CVD and cardiovascular events. Myocardial injury on intensive care unit admission was associated with higher odds of death (adjusted odds ratio, 1.93 [95% CI, 1.61-2.31]) and cardiovascular events (adjusted odds ratio, 1.82 [95% CI, 1.47-2.24]), regardless of the presence of CVD. CONCLUSIONS CVD risk factors, rather than CVD itself, were the major contributors to outcomes in critically ill patients with COVID-19. The occurrence of myocardial injury, regardless of CVD, and its association with outcomes suggests it is likely due to multiorgan injury related to acute inflammation rather than exacerbation of preexisting CVD. REGISTRATION NCT04343898; https://clinicaltrials.gov/ct2/show/NCT04343898.
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Affiliation(s)
- Alexi Vasbinder
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Chelsea Meloche
- Department of Medicine (C.M., T.U.A., H.S., H.B.), University of Michigan, Ann Arbor
| | - Tariq U. Azam
- Department of Medicine (C.M., T.U.A., H.S., H.B.), University of Michigan, Ann Arbor
| | - Elizabeth Anderson
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Tonimarie Catalan
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Husam Shadid
- Department of Medicine (C.M., T.U.A., H.S., H.B.), University of Michigan, Ann Arbor
| | - Hanna Berlin
- Department of Medicine (C.M., T.U.A., H.S., H.B.), University of Michigan, Ann Arbor
| | - Michael Pan
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Patrick O’Hayer
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Kishan Padalia
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Pennelope Blakely
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Ibrahim Khaleel
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Erinleigh Michaud
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Yiyuan Huang
- Biostatistics Department, School of Public Health (Y.H., L.Z.), University of Michigan, Ann Arbor
| | - Lili Zhao
- Biostatistics Department, School of Public Health (Y.H., L.Z.), University of Michigan, Ann Arbor
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Medicine (R.P.-B.), University of Michigan, Ann Arbor
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA (S.G., D.E.L.)
| | - Kim Eagle
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA (S.G., D.E.L.)
| | - Salim S. Hayek
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
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Gupta S, Strohbehn IA, Wang Q, Hanna PE, Seethapathy R, Prosek JM, Herrmann SM, Abudayyeh A, Malik AB, Loew S, Carlos CA, Chang WT, Beckerman P, Mithani Z, Shah CV, Renaghan AD, de Seigneux S, Campedel L, Kitchlu A, Shin DS, Coppock G, Lumlertgul N, Garcia P, Ortiz-Melo DI, Rashidi A, Sprangers B, Aggarwal V, Benesova K, Jhaveri KD, Cortazar FB, Weins A, Zuo Y, Mooradian MJ, Reynolds KL, Leaf DE, Sise ME. Acute kidney injury in patients receiving pembrolizumab combination therapy versus pembrolizumab monotherapy for advanced lung cancer. Kidney Int 2022; 102:930-935. [PMID: 35964800 PMCID: PMC9523226 DOI: 10.1016/j.kint.2022.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 06/24/2022] [Accepted: 07/11/2022] [Indexed: 10/15/2022]
Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ian A Strohbehn
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Qiyu Wang
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Paul E Hanna
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Jason M Prosek
- Division of Nephrology, Department of Internal Medicine, the Ohio State University, Columbus, Ohio, USA
| | - Sandra M Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Ala Abudayyeh
- Division of Internal Medicine, Section of Nephrology, the University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - A Bilal Malik
- Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Sebastian Loew
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christopher A Carlos
- Department of Medicine, Division of Nephrology, University of California San Francisco, San Francisco, California, USA
| | - Wei-Ting Chang
- Department of Clinical Medicine, Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Internal Medicine, Division of Cardiology, Chi-Mei Medical Center, Tainan, Taiwan; Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Pazit Beckerman
- Institute of Nephrology and Hypertension, Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Zain Mithani
- Katz Family Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Chintan V Shah
- Department of Medicine, Division of Nephrology, Hypertension, and Renal Transplant, University of Florida, Gainesville, Florida, USA
| | - Amanda D Renaghan
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Sophie de Seigneux
- Service of Nephrology, Department of Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Luca Campedel
- Department of Medical Oncology, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, Institut universitaire de cancérologie, CLIP Galilée, Groupe de Recherche Interdisciplinaire Francophone en Onco-néphrologie (GRIFON), Paris, France
| | - Abhijat Kitchlu
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Sanghoon Shin
- Department of Medicine, Division of Hematology-Oncology, Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS), David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California, USA
| | - Gaia Coppock
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nuttha Lumlertgul
- Department of Critical Care, Guy's & St Thomas Hospital, London, UK; Division of Nephrology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pablo Garcia
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - David I Ortiz-Melo
- Division of Nephrology, Duke University Medical Center, Durham, North Carolina, USA
| | - Arash Rashidi
- Division of Nephrology and Hypertension, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Laboratory of Molecular Immunology (Rega Institute for Medical Research), KU Leuven, Leuven, Belgium; Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Vikram Aggarwal
- Department of Nephrology and Hypertension, Northwestern University and Feinberg School of Medicine, Chicago, Illinois, USA
| | - Karolina Benesova
- Department of Medicine V, Hematology, Oncology, and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, New York, USA
| | - Frank B Cortazar
- New York Nephrology Vasculitis and Glomerular Center, Albany, New York, USA
| | - Astrid Weins
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Yiqin Zuo
- Department of Pathology and Laboratory Medicine, University of Miami, Miami, Florida, USA
| | - Meghan J Mooradian
- Division of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kerry L Reynolds
- Division of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Meghan E Sise
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA.
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22
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Sprangers B, Leaf DE, Porta C, Soler MJ, Perazella MA. Diagnosis and management of immune checkpoint inhibitor-associated acute kidney injury. Nat Rev Nephrol 2022; 18:794-805. [PMID: 36168055 DOI: 10.1038/s41581-022-00630-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 11/10/2022]
Abstract
Since their introduction into clinical practice a decade ago, immune checkpoint inhibitors (ICIs) have had an overwhelming impact on cancer treatment. Use of these agents in oncology continues to grow; however, the increased use of these agents has been associated with a parallel increase in ICI-associated immune-related adverse events, which can affect virtually any organ, including the kidneys. ICI-associated acute kidney injury (ICI-AKI) occurs in 2-5% of patients treated with ICIs. Its occurrence can have important consequences, including the temporary or permanent discontinuation of ICIs or other concomitant anticancer therapies and the need for prolonged treatment with corticosteroids. Various mechanisms have been proposed to underlie the development of ICI-AKI, including loss of tolerance to self-antigens, reactivation of drug-specific effector T cells, and the production of kidney-specific autoantibodies. ICI-AKI most commonly manifests as acute tubulo-interstitial nephritis on kidney biopsy and generally shows a favourable response to early initiation of corticosteroids, with complete or partial remission achieved in most patients. The evaluation of patients with suspected ICI-AKI requires careful diagnostic work-up and kidney biopsy for patients with moderate-to-severe ICI-AKI to ensure accurate diagnosis and inform appropriate treatment.
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Affiliation(s)
- Ben Sprangers
- Division of Nephrology, Ziekenhuis Oost-Limburg, Genk, Belgium. .,Biomedical Research Institute, Department of Immunology and Infection, UHasselt, Diepenbeek, Belgium.
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Camillo Porta
- Division of Medical Oncology, Azienda Ospedaliero-Universitaria Corsorziale Policlinico di Bari, Bari, Italy.,Oncology, Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Maria José Soler
- Nephrology Research Group, Vall d'hebrón Institut de Recerca (VHIR), Barcelona, Spain.,Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Mark A Perazella
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA.,Veterans Affairs Medical Center, West Haven, Connecticut, USA
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23
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Sunderraj A, Cho C, Cai X, Gupta S, Mehta R, Isakova T, Leaf DE, Srivastava A. Modulation of the Association Between Age and Death by Risk Factor Burden in Critically Ill Patients With COVID-19. Crit Care Explor 2022; 4:e0755. [PMID: 36050992 PMCID: PMC9426819 DOI: 10.1097/cce.0000000000000755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Older age is a key risk factor for adverse outcomes in critically ill patients with COVID-19. However, few studies have investigated whether preexisting comorbidities and acute physiologic ICU factors modify the association between age and death. DESIGN Multicenter cohort study. SETTING ICUs at 68 hospitals across the United States. PATIENTS A total of 5,037 critically ill adults with COVID-19 admitted to ICUs between March 1, 2020, and July 1, 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary exposure was age, modeled as a continuous variable. The primary outcome was 28-day inhospital mortality. Multivariable logistic regression tested the association between age and death. Effect modification by the number of risk factors was assessed through a multiplicative interaction term in the logistic regression model. Among the 5,037 patients included (mean age, 60.9 yr [± 14.7], 3,179 [63.1%] male), 1,786 (35.4%) died within 28 days. Age had a nonlinear association with 28-day mortality (p for nonlinearity <0.001) after adjustment for covariates that included demographics, preexisting comorbidities, acute physiologic ICU factors, number of ICU beds, and treatments for COVID-19. The number of preexisting comorbidities and acute physiologic ICU factors modified the association between age and 28-day mortality (p for interaction <0.001), but this effect modification was modest as age still had an exponential relationship with death in subgroups stratified by the number of risk factors. CONCLUSIONS In a large population of critically ill patients with COVID-19, age had an independent exponential association with death. The number of preexisting comorbidities and acute physiologic ICU factors modified the association between age and death, but age still had an exponential association with death in subgroups according to the number of risk factors present. Additional studies are needed to identify the mechanisms underpinning why older age confers an increased risk of death in critically ill patients with COVID-19.
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Affiliation(s)
- Ashwin Sunderraj
- Graduate Medical Education, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Chloe Cho
- Undergraduate Medical Education, Northwestern University, Evanston, IL
| | - Xuan Cai
- Division of Nephrology & Hypertension, Center for Translational Metabolism and Health, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Shruti Gupta
- Department of Medicine, Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Rupal Mehta
- Division of Nephrology & Hypertension, Center for Translational Metabolism and Health, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Tamara Isakova
- Division of Nephrology & Hypertension, Center for Translational Metabolism and Health, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - David E Leaf
- Department of Medicine, Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Anand Srivastava
- Division of Nephrology & Hypertension, Center for Translational Metabolism and Health, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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24
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Gupta S, Garcia-Carro C, Prosek JM, Glezerman I, Herrmann SM, Garcia P, Abudayyeh A, Lumlertgul N, Malik AB, Loew S, Beckerman P, Renaghan AD, Carlos CA, Rashidi A, Mithani Z, Deshpande P, Rangarajan S, Shah CV, Seigneux SD, Campedel L, Kitchlu A, Shin DS, Coppock G, Ortiz-Melo DI, Sprangers B, Aggarwal V, Benesova K, Wanchoo R, Murakami N, Cortazar FB, Reynolds KL, Sise ME, Soler MJ, Leaf DE. Shorter versus longer corticosteroid duration and recurrent immune checkpoint inhibitor-associated AKI. J Immunother Cancer 2022; 10:jitc-2022-005646. [PMID: 36137651 PMCID: PMC9511654 DOI: 10.1136/jitc-2022-005646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Corticosteroids are the mainstay of treatment for immune checkpoint inhibitor-associated acute kidney injury (ICPi-AKI), but the optimal duration of therapy has not been established. Prolonged use of corticosteroids can cause numerous adverse effects and may decrease progression-free survival among patients treated with ICPis. We sought to determine whether a shorter duration of corticosteroids was equally efficacious and safe as compared with a longer duration. METHODS We used data from an international multicenter cohort study of patients diagnosed with ICPi-AKI from 29 centers across nine countries. We examined whether a shorter duration of corticosteroids (28 days or less) was associated with a higher rate of recurrent ICPi-AKI or death within 30 days following completion of corticosteroid treatment as compared with a longer duration (29-84 days). RESULTS Of 165 patients treated with corticosteroids, 56 (34%) received a shorter duration of treatment and 109 (66%) received a longer duration. Patients in the shorter versus longer duration groups were similar with respect to baseline and ICPi-AKI characteristics. Five of 56 patients (8.9%) in the shorter duration group and 12 of 109 (11%) in the longer duration group developed recurrent ICPi-AKI or died (p=0.90). Nadir serum creatinine in the first 14, 28, and 90 days following completion of corticosteroid treatment was similar between groups (p=0.40, p=0.56, and p=0.89, respectively). CONCLUSION A shorter duration of corticosteroids (28 days or less) may be safe for patients with ICPi-AKI. However, the findings may be susceptible to unmeasured confounding and further research from randomized clinical trials is needed.
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Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Clara Garcia-Carro
- Nephrology Department, San Carlos Clinical University Hospital, Madrid, Spain
| | - Jason M Prosek
- Division of Nephrology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Ilya Glezerman
- Renal Service, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Sandra M Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Pablo Garcia
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ala Abudayyeh
- Division of Internal Medicine, Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nuttha Lumlertgul
- Department of Critical Care, Guy's and St Thomas' Hospitals NHS Trust, London, UK.,Division of Nephrology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - A Bilal Malik
- Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Sebastian Loew
- Department of Nephrology and Medical Intensive Care, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Pazit Beckerman
- Institute of Nephrology and Hypertension, Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amanda D Renaghan
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Christopher A Carlos
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Arash Rashidi
- Division of Nephrology and Hypertension, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA
| | - Zain Mithani
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Priya Deshpande
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at the Mount Sinai Hospital, New York, NY, USA
| | - Sunil Rangarajan
- Division of Hematology/Oncology and Division of Nephrology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Chintan V Shah
- Division of Nephrology, Hypertension, and Renal Transplant, Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Sophie De Seigneux
- Service of Nephrology, Department of Medicine, University Hospitals of Geneva, Geneve, Switzerland
| | - Luca Campedel
- Department of Medical Oncology, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, Institut universitaire de cancérologie, CLIP Galilée, Groupe de Recherche Interdisciplinaire Francophone en Onco-néphrologie (GRIFON), Paris, France
| | - Abhijat Kitchlu
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Sanghoon Shin
- Division of Hematology-Oncology, VAGLAHS, Department of Medicine, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, CA, USA
| | - Gaia Coppock
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David I Ortiz-Melo
- Division of Nephrology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Laboratory of Molecular Immunology, Rega Institute for Medical Research, KU Leuven, Belgium.,Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Vikram Aggarwal
- Department of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Karolina Benesova
- Department of Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Rimda Wanchoo
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Frank B Cortazar
- New York Nephrology Vasculitis and Glomerular Center, Albany, New York, USA
| | - Kerry L Reynolds
- Division of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Meghan E Sise
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maria Jose Soler
- Nephrology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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25
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Ricardo AC, Chen J, Toth-Manikowski SM, Meza N, Joo M, Gupta S, Lazarous DG, Leaf DE, Lash JP. Hispanic ethnicity and mortality among critically ill patients with COVID-19. PLoS One 2022; 17:e0268022. [PMID: 35584148 PMCID: PMC9116663 DOI: 10.1371/journal.pone.0268022] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 04/20/2022] [Indexed: 01/22/2023] Open
Abstract
Background Hispanic persons living in the United States (U.S.) are at higher risk of infection and death from coronavirus disease 2019 (COVID-19) compared with non-Hispanic persons. Whether this disparity exists among critically ill patients with COVID-19 is unknown. Objective To evaluate ethnic disparities in mortality among critically ill adults with COVID-19 enrolled in the Study of the Treatment and Outcomes in Critically Ill Patients with COVID-19 (STOP-COVID). Methods Multicenter cohort study of adults with laboratory-confirmed COVID-19 admitted to intensive care units (ICU) at 67 U.S. hospitals from March 4 to May 9, 2020. Multilevel logistic regression was used to evaluate 28-day mortality across racial/ethnic groups. Results A total of 2153 patients were included (994 [46.2%] Hispanic and 1159 [53.8%] non-Hispanic White). The median (IQR) age was 62 (51–71) years (non-Hispanic White, 66 [57–74] years; Hispanic, 56 [46–67] years), and 1462 (67.9%) were men. Compared with non-Hispanic White patients, Hispanic patients were younger; were less likely to have hypertension, chronic obstructive pulmonary disease, coronary artery disease, or heart failure; and had longer duration of symptoms prior to ICU admission. During median (IQR) follow-up of 14 (7–24) days, 785 patients (36.5%) died. In analyses adjusted for age, sex, clinical characteristics, and hospital size, Hispanic patients had higher odds of death compared with non-Hispanic White patients (OR, 1.44; 95% CI, 1.12–1.84). Conclusions Among critically ill adults with COVID-19, Hispanic patients were more likely to die than non-Hispanic White patients, even though they were younger and had lower comorbidity burden. This finding highlights the need to provide earlier access to care to Hispanic individuals with COVID-19, especially given our finding of longer duration of symptoms prior to ICU admission among Hispanic patients. In addition, there is a critical need to address ongoing disparities in post hospital discharge care for patients with COVID-19.
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Affiliation(s)
- Ana C. Ricardo
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, IL, United States of America
- * E-mail:
| | - Jinsong Chen
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, IL, United States of America
| | - Stephanie M. Toth-Manikowski
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, IL, United States of America
| | - Natalie Meza
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, IL, United States of America
| | - Min Joo
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, IL, United States of America
| | - Shruti Gupta
- Department of Medicine, Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Deepa G. Lazarous
- Department of Pulmonary Critical Care and Sleep Medicine, Georgetown University Hospital, Washington, DC, United States of America
| | - David E. Leaf
- Department of Medicine, Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - James P. Lash
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, IL, United States of America
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26
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Kelly YP, Mistry K, Ahmed S, Shaykevich S, Desai S, Lipsitz SR, Leaf DE, Mandel EI, Robinson E, McMahon G, Czarnecki PG, Charytan DM, Waikar SS, Mendu ML. Controlled Study of Decision-Making Algorithms for Kidney Replacement Therapy Initiation in Acute Kidney Injury. Clin J Am Soc Nephrol 2022; 17:194-204. [PMID: 34911731 PMCID: PMC8823944 DOI: 10.2215/cjn.02060221] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 12/08/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES AKI requiring KRT is associated with high mortality and utilization. We evaluated the use of an AKI Standardized Clinical Assessment and Management Plan (SCAMP) on patient outcomes, including mortality, hospital length of stay, and intensive care unit length of stay. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a 12-month controlled study in the intensive care units of a large academic tertiary medical center. We alternated use of the AKI-SCAMP with use of a "sham" control form in 4- to 6-week blocks. The primary outcome was risk of inpatient mortality. Prespecified secondary outcomes included 30- and 60-day mortality, hospital length of stay, and intensive care unit length of stay. Generalized estimating equations were used to estimate the effect of the AKI-SCAMP on mortality and length of stay. RESULTS There were 122 patients in the AKI-SCAMP group and 102 patients in the control group. There was no significant difference in inpatient mortality associated with AKI-SCAMP use (41% versus 47% control). AKI-SCAMP use was associated with significantly reduced intensive care unit length of stay (mean, 8; 95% confidence interval, 8 to 9 days versus mean, 12; 95% confidence interval, 10 to 13 days; P<0.001) and hospital length of stay (mean, 25; 95% confidence interval, 22 to 29 days versus mean, 30; 95% confidence interval, 27 to 34 days; P=0.02). Patients in the AKI-SCAMP group were less likely to receive KRT in the context of physician-perceived treatment futility than those in the control group (2% versus 7%; P=0.003). CONCLUSIONS Use of the AKI-SCAMP tool for AKI KRT was not significantly associated with inpatient mortality, but was associated with reduced intensive care unit length of stay, hospital length of stay, and use of KRT in cases of physician-perceived treatment futility. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Acute Kidney Injury Standardized Clinical Assessment and Management Plan for Renal Replacement Initiation, NCT03368183. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_02_07_CJN02060221.mp3.
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Affiliation(s)
- Yvelynne P. Kelly
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kavita Mistry
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Salman Ahmed
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shimon Shaykevich
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sonali Desai
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of the Chief Medical Officer, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stuart R. Lipsitz
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ernest I. Mandel
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emily Robinson
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gearoid McMahon
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Peter G. Czarnecki
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - David M. Charytan
- Nephrology Division, New York University Grossman School of Medicine, New York, New York
| | - Sushrut S. Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Mallika L. Mendu
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of the Chief Medical Officer, Brigham and Women's Hospital, Boston, Massachusetts
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27
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Keene AB, Admon AJ, Brenner SK, Gupta S, Lazarous D, Leaf DE, Gershengorn HB. Association of Surge Conditions with Mortality Among Critically Ill Patients with COVID-19. J Intensive Care Med 2021; 37:500-509. [PMID: 34939474 PMCID: PMC8926920 DOI: 10.1177/08850666211067509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective To determine whether surge conditions were associated with increased
mortality. Design Multicenter cohort study. Setting U.S. ICUs participating in STOP-COVID. Patients Consecutive adults with COVID-19 admitted to participating ICUs between March
4 and July 1, 2020. Interventions None Measurements and Main Results The main outcome was 28-day in-hospital mortality. To assess the association
between admission to an ICU during a surge period and mortality, we used two
different strategies: (1) an inverse probability weighted
difference-in-differences model limited to appropriately matched surge and
non-surge patients and (2) a meta-regression of 50 multivariable
difference-in-differences models (each based on sets of randomly matched
surge- and non-surge hospitals). In the first analysis, we considered a
single surge period for the cohort (March 23 – May 6). In the second, each
surge hospital had its own surge period (which was compared to the same time
periods in matched non-surge hospitals). Our cohort consisted of 4342 ICU patients (average age 60.8 [sd 14.8], 63.5%
men) in 53 U.S. hospitals. Of these, 13 hospitals encountered surge
conditions. In analysis 1, the increase in mortality seen during surge was
not statistically significant (odds ratio [95% CI]: 1.30 [0.47-3.58],
p = .6). In analysis 2, surge was associated with an increased odds of death
(odds ratio 1.39 [95% CI, 1.34-1.43], p < .001). Conclusions Admission to an ICU with COVID-19 in a hospital that is experiencing surge
conditions may be associated with an increased odds of death. Given the high
incidence of COVID-19, such increases would translate into substantial
excess mortality.
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Affiliation(s)
- Adam B Keene
- 2006Albert Einstein College of Medicine, Bronx, NY, USA
| | - Andrew J Admon
- 1259University of Michigan, Ann Arbor, MI, USA.,20034VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Samantha K Brenner
- 576909Hackensack Meridian School of Medicine at Seton Hall, Nutley, NJ, USA.,Heart and Vascular Hospital, Hackensack Meridian Health Hackensack University Medical Center, Hackensack, NJ, USA
| | - Shruti Gupta
- 1861Brigham and Women's Hospital, Boston, MA, USA
| | | | - David E Leaf
- 1861Brigham and Women's Hospital, Boston, MA, USA
| | - Hayley B Gershengorn
- 2006Albert Einstein College of Medicine, Bronx, NY, USA.,12235University of Miami Miller School of Medicine, Miami, FL, USA
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Toth-Manikowski SM, Caldwell J, Joo M, Chen J, Meza N, Bruinius J, Gupta S, Hannan M, Kagalwalla M, Madrid S, Melamed ML, Pacheco E, Srivastava A, Viamontes C, Lash JP, Leaf DE, Ricardo AC. Sex-related differences in mortality, acute kidney injury, and respiratory failure among critically ill patients with COVID-19. Medicine (Baltimore) 2021; 100:e28302. [PMID: 34918709 PMCID: PMC8677989 DOI: 10.1097/md.0000000000028302] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/22/2021] [Indexed: 01/05/2023] Open
Abstract
Although the number of deaths due to coronavirus disease 2019 (COVID-19) is higher in men than women, prior studies have provided limited sex-stratified clinical data.We evaluated sex-related differences in clinical outcomes among critically ill adults with COVID-19.Multicenter cohort study of adults with laboratory-confirmed COVID-19 admitted to intensive care units at 67 U.S. hospitals from March 4 to May 9, 2020. Multilevel logistic regression was used to evaluate 28-day in-hospital mortality, severe acute kidney injury (AKI requiring kidney replacement therapy), and respiratory failure occurring within 14 days of intensive care unit admission.A total of 4407 patients were included (median age, 62 years; 2793 [63.4%] men; 1159 [26.3%] non-Hispanic White; 1220 [27.7%] non-Hispanic Black; 994 [22.6%] Hispanic). Compared with women, men were younger (median age, 61 vs 64 years, less likely to be non-Hispanic Black (684 [24.5%] vs 536 [33.2%]), and more likely to smoke (877 [31.4%] vs 422 [26.2%]). During median follow-up of 14 days, 1072 men (38.4%) and 553 women (34.3%) died. Severe AKI occurred in 590 men (21.8%), and 239 women (15.5%), while respiratory failure occurred in 2255 men (80.7%) and 1234 women (76.5%). After adjusting for age, race/ethnicity and clinical variables, compared with women, men had a higher risk of death (OR, 1.50, 95% CI, 1.26-1.77), severe AKI (OR, 1.92; 95% CI 1.57-2.36), and respiratory failure (OR, 1.42; 95% CI, 1.11-1.80).In this multicenter cohort of critically ill adults with COVID-19, men were more likely to have adverse outcomes compared with women.
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Affiliation(s)
| | - Jillian Caldwell
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Min Joo
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Jinsong Chen
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Natalie Meza
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Jacob Bruinius
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Mary Hannan
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | | | - Samantha Madrid
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Michal L. Melamed
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Esther Pacheco
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - James P. Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Ana C. Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
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29
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Hsu CM, Gupta S, Tighiouart H, Goyal N, Faugno AJ, Tariq A, Raichoudhury R, Sharma JH, Meyer L, Kshirsagar RK, Jose A, Leaf DE, Weiner DE. Kidney Recovery and Death in Critically Ill Patients With COVID-19-Associated Acute Kidney Injury Treated With Dialysis: The STOP-COVID Cohort Study. Am J Kidney Dis 2021; 79:404-416.e1. [PMID: 34871701 PMCID: PMC8641974 DOI: 10.1053/j.ajkd.2021.11.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/22/2021] [Indexed: 12/27/2022]
Abstract
Rationale & Objective Acute kidney injury treated with kidney replacement therapy (AKI-KRT) occurs frequently in critically ill patients with coronavirus disease 2019 (COVID-19). We examined the clinical factors that determine kidney recovery in this population. Study Design Multicenter cohort study. Setting & Participants 4,221 adults not receiving KRT who were admitted to intensive care units at 68 US hospitals with COVID-19 from March 1 to June 22, 2020 (the “ICU cohort”). Among these, 876 developed AKI-KRT after admission to the ICU (the “AKI-KRT subcohort”). Exposure The ICU cohort was analyzed using AKI severity as the exposure. For the AKI-KRT subcohort, exposures included demographics, comorbidities, initial mode of KRT, and markers of illness severity at the time of KRT initiation. Outcome The outcome for the ICU cohort was estimated glomerular filtration rate (eGFR) at hospital discharge. A 3-level outcome (death, kidney nonrecovery, and kidney recovery at discharge) was analyzed for the AKI-KRT subcohort. Analytical Approach The ICU cohort was characterized using descriptive analyses. The AKI-KRT subcohort was characterized with both descriptive analyses and multinomial logistic regression to assess factors associated with kidney nonrecovery while accounting for death. Results Among a total of 4,221 patients in the ICU cohort, 2,361 (56%) developed AKI, including 876 (21%) who received KRT. More severe AKI was associated with higher mortality. Among survivors, more severe AKI was associated with an increased rate of kidney nonrecovery and lower kidney function at discharge. Among the 876 patients with AKI-KRT, 588 (67%) died, 95 (11%) had kidney nonrecovery, and 193 (22%) had kidney recovery by the time of discharge. The odds of kidney nonrecovery was greater for lower baseline eGFR, with ORs of 2.09 (95% CI, 1.09-4.04), 4.27 (95% CI, 1.99-9.17), and 8.69 (95% CI, 3.07-24.55) for baseline eGFR 31-60, 16-30, ≤15 mL/min/1.73 m2, respectively, compared with eGFR > 60 mL/min/1.73 m2. Oliguria at the time of KRT initiation was also associated with nonrecovery (ORs of 2.10 [95% CI, 1.14-3.88] and 4.02 [95% CI, 1.72-9.39] for patients with 50-499 and <50 mL/d of urine, respectively, compared to ≥500 mL/d of urine). Limitations Later recovery events may not have been captured due to lack of postdischarge follow-up. Conclusions Lower baseline eGFR and reduced urine output at the time of KRT initiation are each strongly and independently associated with kidney nonrecovery among critically ill patients with COVID-19.
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Affiliation(s)
| | | | | | | | | | - Asma Tariq
- Tufts Medical Center / Tufts University, Boston, MA
| | | | - Jill H Sharma
- University Medical Center / Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, NV
| | - Leah Meyer
- Tufts Medical Center / Tufts University, Boston, MA
| | | | - Aju Jose
- St. Elizabeth's Medical Center / Boston University School of Medicine, Boston, MA
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30
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Douin DJ, Shaefi S, Brenner SK, Gupta S, Park I, Wright FL, Mathews KS, Chan L, Al-Samkari H, Orfanos S, Radbel J, Leaf DE. Tissue Plasminogen Activator in Critically Ill Adults with COVID-19. Ann Am Thorac Soc 2021; 18:1917-1921. [PMID: 33872546 PMCID: PMC8641829 DOI: 10.1513/annalsats.202102-127rl] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- David J. Douin
- University of Colorado School of MedicineAurora, Colorado
| | - Shahzad Shaefi
- Beth Israel Deaconess Medical CenterBoston, Massachusetts
| | | | - Shruti Gupta
- Brigham and Women’s Hospital, Harvard Medical SchoolBoston, Massachusetts
| | - Isabel Park
- Brigham and Women’s Hospital, Harvard Medical SchoolBoston, Massachusetts
| | | | | | - Lili Chan
- Icahn School of Medicine at Mount SinaiNew York, New York
| | | | - Sarah Orfanos
- Rutgers Robert Wood Johnson Medical SchoolNew Brunswick, New Jersey
| | - Jared Radbel
- Rutgers Robert Wood Johnson Medical SchoolNew Brunswick, New Jersey
| | - David E. Leaf
- Brigham and Women’s Hospital, Harvard Medical SchoolBoston, Massachusetts
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Gupta S, Short SAP, Sise ME, Prosek JM, Madhavan SM, Soler MJ, Ostermann M, Herrmann SM, Abudayyeh A, Anand S, Glezerman I, Motwani SS, Murakami N, Wanchoo R, Ortiz-Melo DI, Rashidi A, Sprangers B, Aggarwal V, Malik AB, Loew S, Carlos CA, Chang WT, Beckerman P, Mithani Z, Shah CV, Renaghan AD, Seigneux SD, Campedel L, Kitchlu A, Shin DS, Rangarajan S, Deshpande P, Coppock G, Eijgelsheim M, Seethapathy H, Lee MD, Strohbehn IA, Owen DH, Husain M, Garcia-Carro C, Bermejo S, Lumlertgul N, Seylanova N, Flanders L, Isik B, Mamlouk O, Lin JS, Garcia P, Kaghazchi A, Khanin Y, Kansal SK, Wauters E, Chandra S, Schmidt-Ott KM, Hsu RK, Tio MC, Sarvode Mothi S, Singh H, Schrag D, Jhaveri KD, Reynolds KL, Cortazar FB, Leaf DE. Acute kidney injury in patients treated with immune checkpoint inhibitors. J Immunother Cancer 2021; 9:jitc-2021-003467. [PMID: 34625513 PMCID: PMC8496384 DOI: 10.1136/jitc-2021-003467] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 12/17/2022] Open
Abstract
Background Immune checkpoint inhibitor-associated acute kidney injury (ICPi-AKI) has emerged as an important toxicity among patients with cancer. Methods We collected data on 429 patients with ICPi-AKI and 429 control patients who received ICPis contemporaneously but who did not develop ICPi-AKI from 30 sites in 10 countries. Multivariable logistic regression was used to identify predictors of ICPi-AKI and its recovery. A multivariable Cox model was used to estimate the effect of ICPi rechallenge versus no rechallenge on survival following ICPi-AKI. Results ICPi-AKI occurred at a median of 16 weeks (IQR 8–32) following ICPi initiation. Lower baseline estimated glomerular filtration rate, proton pump inhibitor (PPI) use, and extrarenal immune-related adverse events (irAEs) were each associated with a higher risk of ICPi-AKI. Acute tubulointerstitial nephritis was the most common lesion on kidney biopsy (125/151 biopsied patients [82.7%]). Renal recovery occurred in 276 patients (64.3%) at a median of 7 weeks (IQR 3–10) following ICPi-AKI. Treatment with corticosteroids within 14 days following ICPi-AKI diagnosis was associated with higher odds of renal recovery (adjusted OR 2.64; 95% CI 1.58 to 4.41). Among patients treated with corticosteroids, early initiation of corticosteroids (within 3 days of ICPi-AKI) was associated with a higher odds of renal recovery compared with later initiation (more than 3 days following ICPi-AKI) (adjusted OR 2.09; 95% CI 1.16 to 3.79). Of 121 patients rechallenged, 20 (16.5%) developed recurrent ICPi-AKI. There was no difference in survival among patients rechallenged versus those not rechallenged following ICPi-AKI. Conclusions Patients who developed ICPi-AKI were more likely to have impaired renal function at baseline, use a PPI, and have extrarenal irAEs. Two-thirds of patients had renal recovery following ICPi-AKI. Treatment with corticosteroids was associated with improved renal recovery.
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Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Samuel A P Short
- University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Meghan E Sise
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jason M Prosek
- Division of Nephrology, Department of Internal Medicine, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Sethu M Madhavan
- Division of Nephrology, Department of Internal Medicine, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Maria Jose Soler
- Nephrology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Marlies Ostermann
- Department of Critical Care & Nephrology, King's College London, Guy's and St Thomas' Hospital, London, UK
| | - Sandra M Herrmann
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Ala Abudayyeh
- Divison of Internal Medicine, Section of Nephrology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shuchi Anand
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ilya Glezerman
- Renal Service, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Shveta S Motwani
- Dana-Farber Cancer Institute Survivorship Program, Boston, Massachusetts, USA
| | - Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rimda Wanchoo
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - David I Ortiz-Melo
- Division of Nephrology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Arash Rashidi
- Division of Nephrology and Hypertension, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Laboratory of Molecular Immunology (Rega Institute for Medical Research), KU Leuven, Leuven, Belgium.,Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Vikram Aggarwal
- Department of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - A Bilal Malik
- Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Sebastian Loew
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christopher A Carlos
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Wei-Ting Chang
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Division of Cardiovascular Medicine, Chi-Mei Medical Center, Tainan, Taiwan.,Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Pazit Beckerman
- Institute of Nephrology and Hypertension, Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Tel Aviv, Israel
| | - Zain Mithani
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Chintan V Shah
- Division of Nephrology, Hypertension, and Renal Transplant, Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Amanda D Renaghan
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Sophie De Seigneux
- Service of Nephrology, Department of Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Luca Campedel
- Department of Medical Oncology, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Abhijat Kitchlu
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Sanghoon Shin
- Division of Hematology-Oncology, VAGLAHS, Department of Medicine, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California, USA
| | - Sunil Rangarajan
- Division of Hematology/Oncology and Division of Nephrology, The University of Alabama School of Medicine, Birmingham, Alabama, USA
| | - Priya Deshpande
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at the Mount Sinai Hospital, New York, New York, USA
| | - Gaia Coppock
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark Eijgelsheim
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Gronigen, The Netherlands
| | - Harish Seethapathy
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Meghan D Lee
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ian A Strohbehn
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dwight H Owen
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Marium Husain
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Clara Garcia-Carro
- Nephrology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, Barcelona, Spain.,Nephrology Department, San Carlos Clinical University Hospital, Madrid, Spain
| | - Sheila Bermejo
- Nephrology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Nuttha Lumlertgul
- Department of Critical Care & Nephrology, Guy's and St Thomas Hospital, London, UK.,Division of Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nina Seylanova
- Department of Critical Care & Nephrology, Guy's and St Thomas Hospital, London, UK.,Sechenov Biomedical Science and Technology Park, Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Lucy Flanders
- Department of Oncology, Guy's & St Thomas Hospital, London, UK
| | - Busra Isik
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Omar Mamlouk
- Divison of Internal Medicine, Section of Nephrology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jamie S Lin
- Divison of Internal Medicine, Section of Nephrology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pablo Garcia
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Aydin Kaghazchi
- Division of Epidemiology and Population Health, Stanford University, Palo Alto, California, USA
| | - Yuriy Khanin
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Sheru K Kansal
- Division of Nephrology and Hypertension, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA
| | - Els Wauters
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium.,Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Sunandana Chandra
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
| | - Kai M Schmidt-Ott
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Max Delbrück Center for Molecular Medicine, Helmholtz Association, Berlin, Germany
| | - Raymond K Hsu
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Maria C Tio
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Suraj Sarvode Mothi
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Harkarandeep Singh
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Deborah Schrag
- Division of Population Sciences, Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Kerry L Reynolds
- Division of Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Frank B Cortazar
- New York Nephrology Vasculitis and Glomerular Center, Albany, New York, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Friedman AN, Guirguis J, Kapoor R, Gupta S, Leaf DE, Timsina LR. Obesity, inflammatory and thrombotic markers, and major clinical outcomes in critically ill patients with COVID-19 in the US. Obesity (Silver Spring) 2021; 29:1719-1730. [PMID: 34109768 DOI: 10.1002/oby.23245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/10/2021] [Accepted: 06/04/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This study aimed to determine whether obesity is independently associated with major adverse clinical outcomes and inflammatory and thrombotic markers in critically ill patients with COVID-19. METHODS The primary outcome was in-hospital mortality in adults with COVID-19 admitted to intensive care units across the US. Secondary outcomes were acute respiratory distress syndrome (ARDS), acute kidney injury requiring renal replacement therapy (AKI-RRT), thrombotic events, and seven blood markers of inflammation and thrombosis. Unadjusted and multivariable-adjusted models were used. RESULTS Among the 4,908 study patients, mean (SD) age was 60.9 (14.7) years, 3,095 (62.8%) were male, and 2,552 (52.0%) had obesity. In multivariable models, BMI was not associated with mortality. Higher BMI beginning at 25 kg/m2 was associated with a greater risk of ARDS and AKI-RRT but not thrombosis. There was no clinically significant association between BMI and inflammatory or thrombotic markers. CONCLUSIONS In critically ill patients with COVID-19, higher BMI was not associated with death or thrombotic events but was associated with a greater risk of ARDS and AKI-RRT. The lack of an association between BMI and circulating biomarkers calls into question the paradigm that obesity contributes to poor outcomes in critically ill patients with COVID-19 by upregulating systemic inflammatory and prothrombotic pathways.
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Affiliation(s)
- Allon N Friedman
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John Guirguis
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rajat Kapoor
- Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lava R Timsina
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Gadi SRV, Brunker PAR, Al-Samkari H, Sykes DB, Saff RR, Lo J, Bendapudi P, Leaf DE, Leaf RK. Severe autoimmune hemolytic anemia following receipt of SARS-CoV-2 mRNA vaccine. Transfusion 2021; 61:3267-3271. [PMID: 34549821 PMCID: PMC8661722 DOI: 10.1111/trf.16672] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/03/2021] [Indexed: 01/02/2023]
Abstract
Background Large clinical trials have demonstrated the overall safety of vaccines for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). However, reports have emerged of autoimmune phenomena, including vaccine‐associated myocarditis, immune thrombocytopenia, and immune thrombotic thrombocytopenia. Case Presentation Here we present a novel case of a young woman who developed life‐threatening autoimmune hemolytic anemia (AIHA) after her first dose of a SARS‐CoV‐2 mRNA vaccine. Notably, initial direct antiglobulin testing was negative using standard anti‐IgG reagents, which are “blind” to certain immunoglobulin (IgG) isotypes. Further testing using an antiglobulin reagent that detects all IgG isotypes was strongly positive and confirmed the diagnosis of AIHA. The patient required transfusion with 13 units of red blood cells, as well as treatment with corticosteroids, rituximab, mycophenolate mofetil, and immune globulin. Conclusion As efforts to administer SARS‐CoV‐2 vaccines continue globally, clinicians must be aware of potential autoimmune sequelae of these therapies.
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Affiliation(s)
| | - Patricia A R Brunker
- Blood Transfusion Service, Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hanny Al-Samkari
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David B Sykes
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Center for Regenerative Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rebecca R Saff
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Janet Lo
- Division of Endocrinology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pavan Bendapudi
- Blood Transfusion Service, Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Hematology and Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rebecca Karp Leaf
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
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34
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Seethapathy H, Street S, Strohbehn I, Lee M, Zhao SH, Rusibamayila N, Chute DF, Gao X, Michaelson MD, Rahma OE, Choueiri TK, McGregor B, Sonpavde G, Salabao C, Kaymakcalan MD, Wei X, Gupta S, Motwani S, Leaf DE, Reynolds KL, Sise ME. Immune-related adverse events and kidney function decline in patients with genitourinary cancers treated with immune checkpoint inhibitors. Eur J Cancer 2021; 157:50-58. [PMID: 34482189 DOI: 10.1016/j.ejca.2021.07.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/23/2021] [Accepted: 07/26/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND In patients with genitourinary cancers, the effect of immune checkpoint inhibitors (ICIs) on kidney function is unknown. PATIENTS AND METHODS This is a retrospective cohort study of patients with renal cell carcinoma (RCC) and urothelial carcinoma who received ICIs at two major cancer centers between 2012 and 2018. Cumulative incidence and Fine and Gray subdistribution hazard models were performed to determine predictors of the co-primary outcomes, (1) acute kidney injury (AKI) and (2) sustained estimated glomerular filtration rate (eGFR) loss, defined as a >20% decline in eGFR sustained ≥90 days. We also determined the association between immune-related adverse events (irAE) and adverse kidney outcomes among patients surviving ≥1 year. RESULTS 637 patients were included; 320 (50%) patients had RCC and 317 (50%) patients had urothelial carcinoma. Half of the cohort had eGFR<60 mL/min/1.73 m2 at baseline. irAEs, AKI, and sustained eGFR loss were common, occurring in 33%, 25% and 16%, respectively. Compared to patients with urothelial carcinoma, patients with RCC were more likely to develop irAEs (aHR 1.61, 95% CI 1.20-2.18) and sustained eGFR loss (aHR 1.97, 95% CI 1.24-3.12), but not AKI (aHR 1.53, 95% CI 0.97-2.41). Among patients surviving ≥1 years, experiencing a non-renal irAE was associated with a significantly higher risk of sustained eGFR loss (aHR 1.71, 95% CI 1.14-2.57). CONCLUSION AKI and sustained eGFR loss are common in patients with genitourinary cancers receiving ICIs. irAEs may be a novel risk factor for kidney function decline among patients receiving ICIs.
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Affiliation(s)
- Harish Seethapathy
- Department of Internal Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA.
| | - Sarah Street
- Department of Internal Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Ian Strohbehn
- Department of Internal Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Meghan Lee
- Department of Internal Medicine, Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Sophia H Zhao
- Department of Internal Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Nifasha Rusibamayila
- Department of Internal Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Donald F Chute
- Department of Internal Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Xin Gao
- Department of Internal Medicine, Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Marc D Michaelson
- Department of Internal Medicine, Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Osama E Rahma
- Department of Medical Oncology, Dana Farber Cancer Center, Boston, MA, USA
| | - Toni K Choueiri
- Department of Medical Oncology, Dana Farber Cancer Center, Boston, MA, USA
| | - Brad McGregor
- Department of Medical Oncology, Dana Farber Cancer Center, Boston, MA, USA
| | - Guru Sonpavde
- Department of Medical Oncology, Dana Farber Cancer Center, Boston, MA, USA
| | - Cristina Salabao
- Department of Medical Oncology, Dana Farber Cancer Center, Boston, MA, USA
| | | | - Xiao Wei
- Department of Medical Oncology, Dana Farber Cancer Center, Boston, MA, USA
| | - Shruti Gupta
- Department of Medicine, Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Shveta Motwani
- Department of Medicine, Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David E Leaf
- Department of Medicine, Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Kerry L Reynolds
- Department of Internal Medicine, Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Meghan E Sise
- Department of Internal Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
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Churpek MM, Gupta S, Spicer AB, Parker WF, Fahrenbach J, Brenner SK, Leaf DE. Hospital-Level Variation in Death for Critically Ill Patients with COVID-19. Am J Respir Crit Care Med 2021; 204:403-411. [PMID: 33891529 PMCID: PMC8480242 DOI: 10.1164/rccm.202012-4547oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 04/22/2021] [Indexed: 01/10/2023] Open
Abstract
RATIONALE Variation in hospital mortality has been described for coronavirus disease 2019 (COVID-19), but the factors that explain these differences remain unclear. OBJECTIVE Our objective was to utilize a large, nationally representative dataset of critically ill adults with COVID-19 to determine which factors explain mortality variability. METHODS In this multicenter cohort study, we examined adults hospitalized in intensive care units with COVID-19 at 70 United States hospitals between March and June 2020. The primary outcome was 28-day mortality. We examined patient-level and hospital-level variables. Mixed-effects logistic regression was used to identify factors associated with interhospital variation. The median odds ratio (OR) was calculated to compare outcomes in higher- vs. lower-mortality hospitals. A gradient boosted machine algorithm was developed for individual-level mortality models. MEASUREMENTS AND MAIN RESULTS A total of 4,019 patients were included, 1537 (38%) of whom died by 28 days. Mortality varied considerably across hospitals (0-82%). After adjustment for patient- and hospital-level domains, interhospital variation was attenuated (OR decline from 2.06 [95% CI, 1.73-2.37] to 1.22 [95% CI, 1.00-1.38]), with the greatest changes occurring with adjustment for acute physiology, socioeconomic status, and strain. For individual patients, the relative contribution of each domain to mortality risk was: acute physiology (49%), demographics and comorbidities (20%), socioeconomic status (12%), strain (9%), hospital quality (8%), and treatments (3%). CONCLUSION There is considerable interhospital variation in mortality for critically ill patients with COVID-19, which is mostly explained by hospital-level socioeconomic status, strain, and acute physiologic differences. Individual mortality is driven mostly by patient-level factors. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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Affiliation(s)
- Matthew M Churpek
- University of Wisconsin Madison, 5228, Medicine; Division of Pulmonary and Critical Care, Madison, Wisconsin, United States;
| | - Shruti Gupta
- Brigham and Women's Hospital Department of Medicine, 370908, Division of Renal Medicine, Boston, Massachusetts, United States
| | - Alexandra B Spicer
- University of Wisconsin-Madison, 5228, Medicine; Division of Pulmonary and Critical Care, Madison, Wisconsin, United States
| | - William F Parker
- The University of Chicago, 2462, Department of Medicine, Chicago, Illinois, United States
| | - John Fahrenbach
- The University of Chicago, 2462, Department of Medicine, Chicago, Illinois, United States
| | - Samantha K Brenner
- Hackensack University Medical Center, 3673, Internal Medicine, Hackensack, New Jersey, United States
| | - David E Leaf
- Brigham and Women's Hospital, 1861, Division of Renal Medicine, Boston, Massachusetts, United States
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36
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Churpek MM, Gupta S, Spicer AB, Hayek SS, Srivastava A, Chan L, Melamed ML, Brenner SK, Radbel J, Madhani-Lovely F, Bhatraju PK, Bansal A, Green A, Goyal N, Shaefi S, Parikh CR, Semler MW, Leaf DE. Machine Learning Prediction of Death in Critically Ill Patients With Coronavirus Disease 2019. Crit Care Explor 2021; 3:e0515. [PMID: 34476402 PMCID: PMC8378790 DOI: 10.1097/cce.0000000000000515] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES Critically ill patients with coronavirus disease 2019 have variable mortality. Risk scores could improve care and be used for prognostic enrichment in trials. We aimed to compare machine learning algorithms and develop a simple tool for predicting 28-day mortality in ICU patients with coronavirus disease 2019. DESIGN This was an observational study of adult patients with coronavirus disease 2019. The primary outcome was 28-day inhospital mortality. Machine learning models and a simple tool were derived using variables from the first 48 hours of ICU admission and validated externally in independent sites and temporally with more recent admissions. Models were compared with a modified Sequential Organ Failure Assessment score, National Early Warning Score, and CURB-65 using the area under the receiver operating characteristic curve and calibration. SETTING Sixty-eight U.S. ICUs. PATIENTS Adults with coronavirus disease 2019 admitted to 68 ICUs in the United States between March 4, 2020, and June 29, 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The study included 5,075 patients, 1,846 (36.4%) of whom died by day 28. eXtreme Gradient Boosting had the highest area under the receiver operating characteristic curve in external validation (0.81) and was well-calibrated, while k-nearest neighbors were the lowest performing machine learning algorithm (area under the receiver operating characteristic curve 0.69). Findings were similar with temporal validation. The simple tool, which was created using the most important features from the eXtreme Gradient Boosting model, had a significantly higher area under the receiver operating characteristic curve in external validation (0.78) than the Sequential Organ Failure Assessment score (0.69), National Early Warning Score (0.60), and CURB-65 (0.65; p < 0.05 for all comparisons). Age, number of ICU beds, creatinine, lactate, arterial pH, and Pao2/Fio2 ratio were the most important predictors in the eXtreme Gradient Boosting model. CONCLUSIONS eXtreme Gradient Boosting had the highest discrimination overall, and our simple tool had higher discrimination than a modified Sequential Organ Failure Assessment score, National Early Warning Score, and CURB-65 on external validation. These models could be used to improve triage decisions and clinical trial enrichment.
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Affiliation(s)
- Matthew M Churpek
- Division of Pulmonary and Critical Care, Department of Medicine, University of Wisconsin, Madison, WI
| | - Shruti Gupta
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Alexandra B Spicer
- Division of Pulmonary and Critical Care, Department of Medicine, University of Wisconsin, Madison, WI
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Department of Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lili Chan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michal L Melamed
- Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Samantha K Brenner
- Department of Internal Medicine, Hackensack Meridian School of Medicine, Seton Hall, NJ
- Heart and Vascular Hospital, Hackensack Meridian Health Hackensack University Medical Center, Hackensack, NJ
| | - Jared Radbel
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Pavan K Bhatraju
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA
| | - Anip Bansal
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus Aurora, CO
| | - Adam Green
- Department of Critical Care Medicine, Cooper University Health Care, Camden, NJ
| | - Nitender Goyal
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Chirag R Parikh
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - David E Leaf
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
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Chute DF, Zhao S, Strohbehn IA, Rusibamayila N, Seethapathy H, Lee M, Zubiri L, Gupta S, Leaf DE, Rahma O, Drobni ZD, Neilan TG, Reynolds KL, Sise ME. Incidence and Predictors of CKD and Estimated GFR Decline in Patients Receiving Immune Checkpoint Inhibitors. Am J Kidney Dis 2021; 79:134-137. [PMID: 34174363 DOI: 10.1053/j.ajkd.2021.05.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 05/07/2021] [Indexed: 12/31/2022]
Affiliation(s)
- Donald F Chute
- Divisions of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Sophia Zhao
- Divisions of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Ian A Strohbehn
- Divisions of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Nifasha Rusibamayila
- Divisions of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Harish Seethapathy
- Divisions of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Meghan Lee
- Divisions of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Leyre Zubiri
- Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Shruti Gupta
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - David E Leaf
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Osama Rahma
- Division of Hematology and Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Zsofia D Drobni
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology Massachusetts General Hospital, Boston, MA
| | - Tomas G Neilan
- Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Kerry L Reynolds
- Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Meghan E Sise
- Divisions of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA.
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Vasquez CR, Gupta S, Miano TA, Roche M, Hsu J, Yang W, Holena DN, Reilly JP, Schrauben SJ, Leaf DE, Shashaty MGS. Identification of Distinct Clinical Subphenotypes in Critically Ill Patients With COVID-19. Chest 2021; 160:929-943. [PMID: 33964301 PMCID: PMC8099539 DOI: 10.1016/j.chest.2021.04.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 04/09/2021] [Accepted: 04/25/2021] [Indexed: 02/08/2023] Open
Abstract
Background Subphenotypes have been identified in patients with sepsis and ARDS and are associated with different outcomes and responses to therapies. Research Question Can unique subphenotypes be identified among critically ill patients with COVID-19? Study Design and Methods Using data from a multicenter cohort study that enrolled critically ill patients with COVID-19 from 67 hospitals across the United States, we randomly divided centers into discovery and replication cohorts. We used latent class analysis independently in each cohort to identify subphenotypes based on clinical and laboratory variables. We then analyzed the associations of subphenotypes with 28-day mortality. Results Latent class analysis identified four subphenotypes (SP) with consistent characteristics across the discovery (45 centers; n = 2,188) and replication (22 centers; n = 1,112) cohorts. SP1 was characterized by shock, acidemia, and multiorgan dysfunction, including acute kidney injury treated with renal replacement therapy. SP2 was characterized by high C-reactive protein, early need for mechanical ventilation, and the highest rate of ARDS. SP3 showed the highest burden of chronic diseases, whereas SP4 demonstrated limited chronic disease burden and mild physiologic abnormalities. Twenty-eight-day mortality in the discovery cohort ranged from 20.6% (SP4) to 52.9% (SP1). Mortality across subphenotypes remained different after adjustment for demographics, comorbidities, organ dysfunction and illness severity, regional and hospital factors. Compared with SP4, the relative risks were as follows: SP1, 1.67 (95% CI, 1.36-2.03); SP2, 1.39 (95% CI, 1.17-1.65); and SP3, 1.39 (95% CI, 1.15-1.67). Findings were similar in the replication cohort. Interpretation We identified four subphenotypes of COVID-19 critical illness with distinct patterns of clinical and laboratory characteristics, comorbidity burden, and mortality.
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Affiliation(s)
- Charles R Vasquez
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Shruti Gupta
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA; Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Todd A Miano
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Meaghan Roche
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse Hsu
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Wei Yang
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel N Holena
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John P Reilly
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sarah J Schrauben
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David E Leaf
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA; Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Michael G S Shashaty
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Meloche C, Azam TU, Anderson E, Shadid H, Berlin H, Pan M, Feroze R, O’Hayer P, Bitar A, Padalia K, Michaud E, Launius C, Blakely P, Gupta S, Leaf DE, Hayek S. CARDIOVASCULAR DISEASE AND OUTCOMES IN CRITICALLY ILL PATIENTS WITH COVID-19: A STOP-COVID ANCILLARY. J Am Coll Cardiol 2021. [PMCID: PMC8091444 DOI: 10.1016/s0735-1097(21)04482-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Short SAP, Gupta S, Brenner SK, Hayek SS, Srivastava A, Shaefi S, Singh H, Wu B, Bagchi A, Al-Samkari H, Dy R, Wilkinson K, Zakai NA, Leaf DE. d-dimer and Death in Critically Ill Patients With Coronavirus Disease 2019. Crit Care Med 2021; 49:e500-e511. [PMID: 33591017 PMCID: PMC8275993 DOI: 10.1097/ccm.0000000000004917] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Hypercoagulability may be a key mechanism for acute organ injury and death in patients with severe coronavirus disease 2019, but the relationship between elevated plasma levels of d-dimer, a biomarker of coagulation activation, and mortality has not been rigorously studied. We examined the independent association between d-dimer and death in critically ill patients with coronavirus disease 2019. DESIGN Multicenter cohort study. SETTING ICUs at 68 hospitals across the United States. PATIENTS Critically ill adults with coronavirus disease 2019 admitted to ICUs between March 4, 2020, and May 25, 2020, with a measured d-dimer concentration on ICU day 1 or 2. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary exposure was the highest normalized d-dimer level (assessed in four categories: < 2×, 2-3.9×, 4-7.9×, and ≥ 8× the upper limit of normal) on ICU day 1 or 2. The primary endpoint was 28-day mortality. Multivariable logistic regression was used to adjust for confounders. Among 3,418 patients (63.1% male; median age 62 yr [interquartile range, 52-71 yr]), 3,352 (93.6%) had a d-dimer concentration above the upper limit of normal. A total of 1,180 patients (34.5%) died within 28 days. Patients in the highest compared with lowest d-dimer category had a 3.11-fold higher odds of death (95% CI, 2.56-3.77) in univariate analyses, decreasing to a 1.81-fold increased odds of death (95% CI, 1.43-2.28) after multivariable adjustment for demographics, comorbidities, and illness severity. Further adjustment for therapeutic anticoagulation did not meaningfully attenuate this relationship (odds ratio, 1.73; 95% CI, 1.36-2.19). CONCLUSIONS In a large multicenter cohort study of critically ill patients with coronavirus disease 2019, higher d-dimer levels were independently associated with a greater risk of death.
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Affiliation(s)
- Samuel A P Short
- Larner College of Medicine, University of Vermont, Burlington, VT
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Samantha K Brenner
- Department of Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall, Nutley, NJ
- Department of Internal Medicine, Heart & Vascular Hospital, Hackensack Meridian Health Hackensack University Medical Center, Hackensack, NJ
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Benjamin Wu
- Division of Pulmonary, Critical Care & Sleep Medicine, NYU Langone Medical Center, New York, NY
| | - Aranya Bagchi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Boston, MA
| | - Rajany Dy
- Department of Medicine, University Medical Center of Southern Nevada Hospital, University of Nevada, Las Vegas, NV
| | - Katherine Wilkinson
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, VT
| | - Neil A Zakai
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, VT
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
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Al-Samkari H, Gupta S, Leaf RK, Wang W, Rosovsky RP, Brenner SK, Hayek SS, Berlin H, Kapoor R, Shaefi S, Melamed ML, Sutherland A, Radbel J, Green A, Garibaldi BT, Srivastava A, Leonberg-Yoo A, Shehata AM, Flythe JE, Rashidi A, Goyal N, Chan L, Mathews KS, Hedayati SS, Dy R, Toth-Manikowski SM, Zhang J, Mallappallil M, Redfern RE, Bansal AD, Short SAP, Vangel MG, Admon AJ, Semler MW, Bauer KA, Hernán MA, Leaf DE. Thrombosis, Bleeding, and the Observational Effect of Early Therapeutic Anticoagulation on Survival in Critically Ill Patients With COVID-19. Ann Intern Med 2021; 174:622-632. [PMID: 33493012 PMCID: PMC7863679 DOI: 10.7326/m20-6739] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hypercoagulability may be a key mechanism of death in patients with coronavirus disease 2019 (COVID-19). OBJECTIVE To evaluate the incidence of venous thromboembolism (VTE) and major bleeding in critically ill patients with COVID-19 and examine the observational effect of early therapeutic anticoagulation on survival. DESIGN In a multicenter cohort study of 3239 critically ill adults with COVID-19, the incidence of VTE and major bleeding within 14 days after intensive care unit (ICU) admission was evaluated. A target trial emulation in which patients were categorized according to receipt or no receipt of therapeutic anticoagulation in the first 2 days of ICU admission was done to examine the observational effect of early therapeutic anticoagulation on survival. A Cox model with inverse probability weighting to adjust for confounding was used. SETTING 67 hospitals in the United States. PARTICIPANTS Adults with COVID-19 admitted to a participating ICU. MEASUREMENTS Time to death, censored at hospital discharge, or date of last follow-up. RESULTS Among the 3239 patients included, the median age was 61 years (interquartile range, 53 to 71 years), and 2088 (64.5%) were men. A total of 204 patients (6.3%) developed VTE, and 90 patients (2.8%) developed a major bleeding event. Independent predictors of VTE were male sex and higher D-dimer level on ICU admission. Among the 2809 patients included in the target trial emulation, 384 (11.9%) received early therapeutic anticoagulation. In the primary analysis, during a median follow-up of 27 days, patients who received early therapeutic anticoagulation had a similar risk for death as those who did not (hazard ratio, 1.12 [95% CI, 0.92 to 1.35]). LIMITATION Observational design. CONCLUSION Among critically ill adults with COVID-19, early therapeutic anticoagulation did not affect survival in the target trial emulation. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Hanny Al-Samkari
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A., R.K.L., R.P.R.)
| | - Shruti Gupta
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.G., D.E.L.)
| | - Rebecca Karp Leaf
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A., R.K.L., R.P.R.)
| | - Wei Wang
- Brigham and Women's Hospital, Boston, Massachusetts (W.W.)
| | - Rachel P Rosovsky
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A., R.K.L., R.P.R.)
| | - Samantha K Brenner
- Heart and Vascular Hospital, Hackensack Meridian Health Hackensack University Medical Center, Hackensack, New Jersey (S.K.B.)
| | - Salim S Hayek
- University of Michigan Medical Center, Ann Arbor, Michigan (S.S.H., H.B.)
| | - Hanna Berlin
- University of Michigan Medical Center, Ann Arbor, Michigan (S.S.H., H.B.)
| | - Rajat Kapoor
- Indiana University School of Medicine, Indianapolis, Indiana (R.K.)
| | - Shahzad Shaefi
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (S.S.)
| | - Michal L Melamed
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York (M.L.M.)
| | - Anne Sutherland
- Rutgers New Jersey Medical School, Newark, New Jersey (A.S.)
| | - Jared Radbel
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (J.R.)
| | - Adam Green
- Cooper University Health Care, Camden, New Jersey (A.G.)
| | | | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, and Northwestern University Feinberg School of Medicine, Chicago, Illinois (A.S.)
| | - Amanda Leonberg-Yoo
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (A.L.)
| | - Alexandre M Shehata
- Hackensack Meridian Health Mountainside Medical Center, Glen Ridge, New Jersey (A.M.S.)
| | - Jennifer E Flythe
- University of North Carolina Kidney Center, UNC School of Medicine, and Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina (J.E.F.)
| | - Arash Rashidi
- University Hospitals Cleveland Medical Center, Cleveland, Ohio (A.R.)
| | | | - Lili Chan
- Icahn School of Medicine at Mount Sinai, New York, New York (L.C., K.S.M.)
| | - Kusum S Mathews
- Icahn School of Medicine at Mount Sinai, New York, New York (L.C., K.S.M.)
| | - S Susan Hedayati
- University of Texas Southwestern Medical Center, Dallas, Texas (S.S.H.)
| | - Rajany Dy
- University Medical Center of Southern Nevada Hospital, University of Nevada, Las Vegas, Nevada (R.D.)
| | | | - Jingjing Zhang
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (J.Z.)
| | - Mary Mallappallil
- Kings County Hospital Center, New York City Health and Hospital Corporation, Brooklyn, New York (M.M.)
| | - Roberta E Redfern
- ProMedica Research, ProMedica Toledo Hospital, Toledo, Ohio (R.E.R.)
| | - Amar D Bansal
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (A.D.B.)
| | - Samuel A P Short
- University of Vermont Larner College of Medicine, Burlington, Vermont (S.A.S.)
| | - Mark G Vangel
- Massachusetts General Hospital Biostatistics Center, Boston, Massachusetts (M.G.V.)
| | | | - Matthew W Semler
- Vanderbilt University Medical Center, Nashville, Tennessee (M.W.S.)
| | - Kenneth A Bauer
- Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts (K.A.B.)
| | - Miguel A Hernán
- Harvard T.H. Chan School of Public Health and Harvard-MIT Division of Health Sciences and Technology, Boston, Massachusetts (M.A.H.)
| | - David E Leaf
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.G., D.E.L.)
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Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA, USA.
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA, USA
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Gupta S, Leaf DE. Diphenhydramine for the prevention of cisplatin-associated acute kidney injury. Kidney Int 2021; 99:1025-1026. [PMID: 33745534 DOI: 10.1016/j.kint.2021.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/08/2021] [Indexed: 12/25/2022]
Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Molnar MZ, Kovesdy CP, Gupta S, Leaf DE. Response to "Is the outcome of SARS-CoV-2 infection in solid organ transplant recipients really similar to that of the general population?". Am J Transplant 2021; 21:1672-1673. [PMID: 33249749 PMCID: PMC7753479 DOI: 10.1111/ajt.16413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 10/30/2020] [Accepted: 11/15/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Miklos Z. Molnar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee,Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee,Correspondence Miklos Z. Molnar
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee,Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Hundemer GL, Srivastava A, Jacob KA, Krishnasamudram N, Ahmed S, Boerger E, Sharma S, Pokharel KK, Hirji SA, Pelletier M, Safa K, Kulvichit W, Kellum JA, Riella LV, Leaf DE. Acute kidney injury in renal transplant recipients undergoing cardiac surgery. Nephrol Dial Transplant 2021; 36:185-196. [PMID: 32892219 DOI: 10.1093/ndt/gfaa063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a key risk factor for chronic kidney disease in the general population, but has not been investigated in detail among renal transplant recipients (RTRs). We investigated the incidence, severity and risk factors for AKI following cardiac surgery among RTRs compared with non-RTRs with otherwise similar clinical characteristics. METHODS We conducted a retrospective cohort study of RTRs (n = 83) and non-RTRs (n = 83) who underwent cardiac surgery at two major academic medical centers. Non-RTRs were matched 1:1 to RTRs by age, preoperative (preop) estimated glomerular filtration rate and type of cardiac surgery. We defined AKI according to Kidney Disease: Improving Global Outcomes criteria. RESULTS RTRs had a higher rate of AKI following cardiac surgery compared with non-RTRs [46% versus 28%; adjusted odds ratio 2.77 (95% confidence interval 1.36-5.64)]. Among RTRs, deceased donor (DD) versus living donor (LD) status, as well as higher versus lower preop calcineurin inhibitor (CNI) trough levels, were associated with higher rates of AKI (57% versus 33% among DD-RTRs versus LD-RTRs; P = 0.047; 73% versus 36% among RTRs with higher versus lower CNI trough levels, P = 0.02). The combination of both risk factors (DD status and higher CNI trough level) had an additive effect (88% AKI incidence among patients with both risk factors versus 25% incidence among RTRs with neither risk factor, P = 0.004). CONCLUSIONS RTRs have a higher risk of AKI following cardiac surgery compared with non-RTRs with otherwise similar characteristics. Among RTRs, DD-RTRs and those with higher preop CNI trough levels are at the highest risk.
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Affiliation(s)
- Gregory L Hundemer
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Nephrology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Anand Srivastava
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kirolos A Jacob
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Neeraja Krishnasamudram
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Salman Ahmed
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Emily Boerger
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shreyak Sharma
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kapil K Pokharel
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc Pelletier
- Division of Cardiac Surgery, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | - Kassem Safa
- Transplant Center and Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Win Kulvichit
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leonardo V Riella
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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46
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Affiliation(s)
- David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
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Shaefi S, Shankar P, Mueller AL, O'Gara BP, Spear K, Khabbaz KR, Bagchi A, Chu LM, Banner-Goodspeed V, Leaf DE, Talmor DS, Marcantonio ER, Subramaniam B. Intraoperative Oxygen Concentration and Neurocognition after Cardiac Surgery. Anesthesiology 2021; 134:189-201. [PMID: 33331902 PMCID: PMC7855826 DOI: 10.1097/aln.0000000000003650] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Despite evidence suggesting detrimental effects of perioperative hyperoxia, hyperoxygenation remains commonplace in cardiac surgery. Hyperoxygenation may increase oxidative damage and neuronal injury leading to potential differences in postoperative neurocognition. Therefore, this study tested the primary hypothesis that intraoperative normoxia, as compared to hyperoxia, reduces postoperative cognitive dysfunction in older patients having cardiac surgery. METHODS A randomized double-blind trial was conducted in patients aged 65 yr or older having coronary artery bypass graft surgery with cardiopulmonary bypass. A total of 100 patients were randomized to one of two intraoperative oxygen delivery strategies. Normoxic patients (n = 50) received a minimum fraction of inspired oxygen of 0.35 to maintain a Pao2 above 70 mmHg before and after cardiopulmonary bypass and between 100 and 150 mmHg during cardiopulmonary bypass. Hyperoxic patients (n = 50) received a fraction of inspired oxygen of 1.0 throughout surgery, irrespective of Pao2 levels. The primary outcome was neurocognitive function measured on postoperative day 2 using the Telephonic Montreal Cognitive Assessment. Secondary outcomes included neurocognitive function at 1, 3, and 6 months, as well as postoperative delirium, mortality, and durations of mechanical ventilation, intensive care unit stay, and hospital stay. RESULTS The median age was 71 yr (interquartile range, 68 to 75), and the median baseline neurocognitive score was 17 (16 to 19). The median intraoperative Pao2 was 309 (285 to 352) mmHg in the hyperoxia group and 153 (133 to 168) mmHg in the normoxia group (P < 0.001). The median Telephonic Montreal Cognitive Assessment score on postoperative day 2 was 18 (16 to 20) in the hyperoxia group and 18 (14 to 20) in the normoxia group (P = 0.42). Neurocognitive function at 1, 3, and 6 months, as well as secondary outcomes, were not statistically different between groups. CONCLUSIONS In this randomized controlled trial, intraoperative normoxia did not reduce postoperative cognitive dysfunction when compared to intraoperative hyperoxia in older patients having cardiac surgery. Although the optimal intraoperative oxygenation strategy remains uncertain, the results indicate that intraoperative hyperoxia does not worsen postoperative cognition after cardiac surgery. EDITOR’S PERSPECTIVE
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Flythe JE, Assimon MM, Tugman MJ, Chang EH, Gupta S, Shah J, Sosa MA, Renaghan AD, Melamed ML, Wilson FP, Neyra JA, Rashidi A, Boyle SM, Anand S, Christov M, Thomas LF, Edmonston D, Leaf DE. Characteristics and Outcomes of Individuals With Pre-existing Kidney Disease and COVID-19 Admitted to Intensive Care Units in the United States. Am J Kidney Dis 2021; 77:190-203.e1. [PMID: 32961244 PMCID: PMC7501875 DOI: 10.1053/j.ajkd.2020.09.003] [Citation(s) in RCA: 135] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/15/2020] [Indexed: 12/13/2022]
Abstract
RATIONALE & OBJECTIVE Underlying kidney disease is an emerging risk factor for more severe coronavirus disease 2019 (COVID-19) illness. We examined the clinical courses of critically ill COVID-19 patients with and without pre-existing chronic kidney disease (CKD) and investigated the association between the degree of underlying kidney disease and in-hospital outcomes. STUDY DESIGN Retrospective cohort study. SETTINGS & PARTICIPANTS 4,264 critically ill patients with COVID-19 (143 patients with pre-existing kidney failure receiving maintenance dialysis; 521 patients with pre-existing non-dialysis-dependent CKD; and 3,600 patients without pre-existing CKD) admitted to intensive care units (ICUs) at 68 hospitals across the United States. PREDICTOR(S) Presence (vs absence) of pre-existing kidney disease. OUTCOME(S) In-hospital mortality (primary); respiratory failure, shock, ventricular arrhythmia/cardiac arrest, thromboembolic events, major bleeds, and acute liver injury (secondary). ANALYTICAL APPROACH We used standardized differences to compare patient characteristics (values>0.10 indicate a meaningful difference between groups) and multivariable-adjusted Fine and Gray survival models to examine outcome associations. RESULTS Dialysis patients had a shorter time from symptom onset to ICU admission compared to other groups (median of 4 [IQR, 2-9] days for maintenance dialysis patients; 7 [IQR, 3-10] days for non-dialysis-dependent CKD patients; and 7 [IQR, 4-10] days for patients without pre-existing CKD). More dialysis patients (25%) reported altered mental status than those with non-dialysis-dependent CKD (20%; standardized difference=0.12) and those without pre-existing CKD (12%; standardized difference=0.36). Half of dialysis and non-dialysis-dependent CKD patients died within 28 days of ICU admission versus 35% of patients without pre-existing CKD. Compared to patients without pre-existing CKD, dialysis patients had higher risk for 28-day in-hospital death (adjusted HR, 1.41 [95% CI, 1.09-1.81]), while patients with non-dialysis-dependent CKD had an intermediate risk (adjusted HR, 1.25 [95% CI, 1.08-1.44]). LIMITATIONS Potential residual confounding. CONCLUSIONS Findings highlight the high mortality of individuals with underlying kidney disease and severe COVID-19, underscoring the importance of identifying safe and effective COVID-19 therapies in this vulnerable population.
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Affiliation(s)
- Jennifer E Flythe
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina (UNC) Kidney Center, UNC School of Medicine, Chapel Hill, NC; Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC.
| | - Magdalene M Assimon
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina (UNC) Kidney Center, UNC School of Medicine, Chapel Hill, NC
| | - Matthew J Tugman
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina (UNC) Kidney Center, UNC School of Medicine, Chapel Hill, NC
| | - Emily H Chang
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina (UNC) Kidney Center, UNC School of Medicine, Chapel Hill, NC
| | - Shruti Gupta
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Jatan Shah
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Marie Anne Sosa
- Division of Nephrology, Department of Medicine, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Amanda DeMauro Renaghan
- Division of Nephrology, Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Michal L Melamed
- Department of Medicine/Nephrology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - F Perry Wilson
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT
| | - Javier A Neyra
- Division of Nephrology, Bone and Mineral Metabolism, Department of Internal Medicine, University of Kentucky, Lexington, KY
| | - Arash Rashidi
- Division of Nephrology and Hypertension, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Suzanne M Boyle
- Section of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Shuchi Anand
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Marta Christov
- Division of Nephrology, Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Leslie F Thomas
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic in Arizona, Scottsdale, AZ
| | - Daniel Edmonston
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Renal Section, Durham VA Medical Center, Durham, NC
| | - David E Leaf
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
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Affiliation(s)
| | | | - Wei Wang
- Brigham and Women's Hospital, Boston, MA
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50
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Gupta S, Wang W, Hayek SS, Chan L, Mathews KS, Melamed ML, Brenner SK, Leonberg-Yoo A, Schenck EJ, Radbel J, Reiser J, Bansal A, Srivastava A, Zhou Y, Finkel D, Green A, Mallappallil M, Faugno AJ, Zhang J, Velez JCQ, Shaefi S, Parikh CR, Charytan DM, Athavale AM, Friedman AN, Redfern RE, Short SAP, Correa S, Pokharel KK, Admon AJ, Donnelly JP, Gershengorn HB, Douin DJ, Semler MW, Hernán MA, Leaf DE. Association Between Early Treatment With Tocilizumab and Mortality Among Critically Ill Patients With COVID-19. JAMA Intern Med 2021; 181:41-51. [PMID: 33080002 PMCID: PMC7577201 DOI: 10.1001/jamainternmed.2020.6252] [Citation(s) in RCA: 313] [Impact Index Per Article: 104.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Therapies that improve survival in critically ill patients with coronavirus disease 2019 (COVID-19) are needed. Tocilizumab, a monoclonal antibody against the interleukin 6 receptor, may counteract the inflammatory cytokine release syndrome in patients with severe COVID-19 illness. OBJECTIVE To test whether tocilizumab decreases mortality in this population. DESIGN, SETTING, AND PARTICIPANTS The data for this study were derived from a multicenter cohort study of 4485 adults with COVID-19 admitted to participating intensive care units (ICUs) at 68 hospitals across the US from March 4 to May 10, 2020. Critically ill adults with COVID-19 were categorized according to whether they received or did not receive tocilizumab in the first 2 days of admission to the ICU. Data were collected retrospectively until June 12, 2020. A Cox regression model with inverse probability weighting was used to adjust for confounding. EXPOSURES Treatment with tocilizumab in the first 2 days of ICU admission. MAIN OUTCOMES AND MEASURES Time to death, compared via hazard ratios (HRs), and 30-day mortality, compared via risk differences. RESULTS Among the 3924 patients included in the analysis (2464 male [62.8%]; median age, 62 [interquartile range {IQR}, 52-71] years), 433 (11.0%) received tocilizumab in the first 2 days of ICU admission. Patients treated with tocilizumab were younger (median age, 58 [IQR, 48-65] vs 63 [IQR, 52-72] years) and had a higher prevalence of hypoxemia on ICU admission (205 of 433 [47.3%] vs 1322 of 3491 [37.9%] with mechanical ventilation and a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen of <200 mm Hg) than patients not treated with tocilizumab. After applying inverse probability weighting, baseline and severity-of-illness characteristics were well balanced between groups. A total of 1544 patients (39.3%) died, including 125 (28.9%) treated with tocilizumab and 1419 (40.6%) not treated with tocilizumab. In the primary analysis, during a median follow-up of 27 (IQR, 14-37) days, patients treated with tocilizumab had a lower risk of death compared with those not treated with tocilizumab (HR, 0.71; 95% CI, 0.56-0.92). The estimated 30-day mortality was 27.5% (95% CI, 21.2%-33.8%) in the tocilizumab-treated patients and 37.1% (95% CI, 35.5%-38.7%) in the non-tocilizumab-treated patients (risk difference, 9.6%; 95% CI, 3.1%-16.0%). CONCLUSIONS AND RELEVANCE Among critically ill patients with COVID-19 in this cohort study, the risk of in-hospital mortality in this study was lower in patients treated with tocilizumab in the first 2 days of ICU admission compared with patients whose treatment did not include early use of tocilizumab. However, the findings may be susceptible to unmeasured confounding, and further research from randomized clinical trials is needed.
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Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Wei Wang
- Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Lili Chan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kusum S Mathews
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michal L Melamed
- Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Samantha K Brenner
- Department of Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall, Nutley, New Jersey.,Department of Internal Medicine, Hackensack Meridian Health, Hackensack University Medical Center, Hackensack, New Jersey
| | - Amanda Leonberg-Yoo
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Edward J Schenck
- Divison of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine Center, New York, New York
| | - Jared Radbel
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jochen Reiser
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Anip Bansal
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus Aurora, Aurora
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yan Zhou
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Diana Finkel
- Department of Medicine, Division of Infectious Diseases, New Jersey Medical School, Rutgers University, Newark
| | - Adam Green
- Division of Critical Care, Cooper University Health Care, Camden, New Jersey
| | - Mary Mallappallil
- Division of Nephrology, Kings County Hospital Center, New York City Health and Hospital Corporation, Brooklyn, New York
| | - Anthony J Faugno
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Jingjing Zhang
- Division of Nephrology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Juan Carlos Q Velez
- Department of Nephrology, Ochsner Health System, New Orleans, Louisiana.,Ochsner Clinical School, University of Queensland, Brisbane, Australia
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David M Charytan
- Division of Nephrology, Department of Medicine, NYU (New York University) Langone Medical Center, New York, New York
| | | | - Allon N Friedman
- Department of Medicine, Indiana University School of Medicine/Indiana University Health, Indianapolis
| | | | | | - Simon Correa
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kapil K Pokharel
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew J Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - John P Donnelly
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor.,Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Miguel A Hernán
- Department of Epidemiology and Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Harvard-MIT (Massachusetts Institute of Technology) Program in Health Sciences and Technology, Boston, Massachusetts
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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