Acute Kidney Injury Incidence in Hospitalized Patients and Implications for Nutrition Support

Novel insights into the protective effects of leonurine against acute kidney injury: Inhibition of ER stress-associated ferroptosis via regulating ATF4/CHOP/ACSL4 pathway

Acute kidney injury (AKI) is a common and serious global health problem with high risks of mortality and the development of chronic kidney diseases. Leonurine is a unique bioactive component from Leonurus japonicus Houtt. and exerts antioxidant, antiapoptotic or anti-inflammatory properties. This study aimed to explore the benefits of leonurine on AKI and the possible mechanisms involved, with a particular foc on the regulation of ferroptosis and endoplasmic reticulum (ER) stress. Our results showed that leonurine exhibited prominent protective effects against AKI, as evidenced by the amelioration of histopathological alterations and reduction of renal dysfunction. In addition, leonurine significantly suppressed ferroptosis in AKI both in vivo and in vitro by effectively restoring ultrastructural abnormalities in mitochondria, decreasing ASCL4 and 4-HNE levels, scavenging reactive oxygen species (ROS), as well as increasing GPX4 and GSH levels. In parallel, leonurine also markedly mitigated ER stress via down-regulating PERK, eIF-2α, ATF4, CHOP and CHAC1. Further studies suggested that ER stress was closely involved in erastin-induced ferroptosis, and leonurine protected tubular epithelial cells in vitro by inhibiting ER stress-associated ferroptosis via regulating ATF4/CHOP/ASCL4 signalling pathway. Mechanistically, ATF4 silencing in vitro regulated CHOP and ACSL4 expressions, ultimately weakening both ER stress and ferroptosis. Notably, analyses of single-cell RNA sequencing data revealed that ATF4, CHOP and ASCL4 in renal tubular cells were all abnormally upregulated in patients with AKI compared to healthy controls, suggesting their contributions to the pathogenesis of AKI. Altogether, these findings suggest that leonurine alleviates AKI by inhibiting ER stress-associated ferroptosis via regulating ATF4/CHOP/ASCL4 signalling pathway, thus providing novel mechanisms for AKI treatment.

Machine Learning for Predicting Risk and Prognosis of Acute Kidney Disease in Critically Ill Elderly Patients During Hospitalization: Internet-Based and Interpretable Model Study

BACKGROUND

Acute kidney disease (AKD) affects more than half of critically ill elderly patients with acute kidney injury (AKI), which leads to worse short-term outcomes.

OBJECTIVE

We aimed to establish 2 machine learning models to predict the risk and prognosis of AKD in the elderly and to deploy the models as online apps.

METHODS

Data on elderly patients with AKI (n=3542) and AKD (n=2661) from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database were used to develop 2 models for predicting the AKD risk and in-hospital mortality, respectively. Data collected from Xiangya Hospital of Central South University were for external validation. A bootstrap method was used for internal validation to obtain relatively stable results. We extracted the indicators within 24 hours of the first diagnosis of AKI and the fluctuation range of some indicators, namely delta (day 3 after AKI minus day 1), as features. Six machine learning algorithms were used for modeling; the area under the receiver operating characteristic curve (AUROC), decision curve analysis, and calibration curve for evaluating; Shapley additive explanation (SHAP) analysis for visually interpreting; and the Heroku platform for deploying the best-performing models as web-based apps.

RESULTS

For the model of predicting the risk of AKD in elderly patients with AKI during hospitalization, the Light Gradient Boosting Machine (LightGBM) showed the best overall performance in the training (AUROC=0.844, 95% CI 0.831-0.857), internal validation (AUROC=0.853, 95% CI 0.841-0.865), and external (AUROC=0.755, 95% CI 0.699-0.811) cohorts. In addition, LightGBM performed well for the AKD prognostic prediction in the training (AUROC=0.861, 95% CI 0.843-0.878), internal validation (AUROC=0.868, 95% CI 0.851-0.885), and external (AUROC=0.746, 95% CI 0.673-0.820) cohorts. The models deployed as online prediction apps allowed users to predict and provide feedback to submit new data for model iteration. In the importance ranking and correlation visualization of the model's top 10 influencing factors conducted based on the SHAP value, partial dependence plots revealed the optimal cutoff of some interventionable indicators. The top 5 factors predicting the risk of AKD were creatinine on day 3, sepsis, delta blood urea nitrogen (BUN), diastolic blood pressure (DBP), and heart rate, while the top 5 factors determining in-hospital mortality were age, BUN on day 1, vasopressor use, BUN on day 3, and partial pressure of carbon dioxide (PaCO2).

CONCLUSIONS

We developed and validated 2 online apps for predicting the risk of AKD and its prognostic mortality in elderly patients, respectively. The top 10 factors that influenced the AKD risk and mortality during hospitalization were identified and explained visually, which might provide useful applications for intelligent management and suggestions for future prospective research.

A Proposed Predictive Equation for Energy Expenditure Estimation Among Noncritically Ill Patients With Acute Kidney Injury

OBJECTIVE

The incidence of acute kidney injury (AKI) is identified more frequently in noncritical compared with intensive care settings. The prognosis of malnourished AKI patients is far worse than those with normal nutritional status. However, a method for estimating the optimal amount of energy required to guide nutritional support among noncritically ill AKI patients is yet to be determined.

METHODS

We evaluated the performance of weight-based formulas (20-30 kcal/kg/day) with the reference values of energy expenditure (EE) measured by indirect calorimetry (IC) among noncritically ill AKI patients during hospitalization. The statistics for assessing agreement, including total deviation index and accuracy within 10% represent the percentage of estimations falling within the IC value range of ±10%, were tested. Parameters for predicting the EE equation were also developed using a regression analysis model.

RESULTS

A total of 40 noncritically ill AKI patients were recruited. The mean age of participants was 62.5 ± 16.5 years with 50% being male. The average IC-derived EE was 1,124.6 ± 278.9 kcal/day with respiratory quotients 0.8-1.3, indicating good validity of the IC test. Receiving dialysis, protein catabolic rate, and age was not significantly associated with measured EE. Nearly all weight-based formulas overestimated measured EE. The magnitude of total deviation index values was broad with the proportion of patients achieving an accuracy of 10% being as low as 20%. The proposed equation to predict EE derived from this study was EE (kcal/day) = 618.27 + (8.98 x weight in kg) + 137.0 if diabetes - 199.7 if female (r2 = 0.68, P < .001). In the validation study with an independent group of noncritically ill AKI patients, predicted EE using the newly derived equation was also significantly correlated with measured EE by IC (r = 0.69, P = .004).

CONCLUSION

Estimation of EE by weight-based formulas usually overestimated measured EE among noncritically ill AKI patients. In the absence of IC, the proposed predictive equation, specifically for noncritically ill AKI patients might be useful, in addition to weight-based formulas, for guiding caloric dosing in clinical practice.

Serum total protein-to-albumin ratio predicts risk of death in septic acute kidney injury patients: A cohort study

OBJECTIVE

Sepsis is the leading cause of acute kidney injury (AKI). Increasing evidence shows that serum total protein-to-albumin ratio (TAR) could serve as an inflammation- and nutrition-based prognostic marker in various diseases. The purpose of this study was to assess the prognostic value of TAR in predicting the clinical outcomes of septic AKI patients.

METHODS

We retrospectively enrolled septic AKI patients between August 2015 and August 2022 at West China Hospital of Sichuan University. Patients admitted between August 2015 and August 2021 were defined as the original cohort. The primary outcomes were 30-day and 90-day all-cause mortality of septic AKI patients. The secondary outcomes were septic shock, transfer to the intensive care unit, mechanical ventilation, requirement for renal replacement therapy, and stage 3 AKI. The utility of TAR was further verified in a validation cohort of septic AKI patients admitted between September 2021 and August 2022.

RESULTS

In the original cohort, a total of 309 eligible patients with a median age of 58 years were enrolled, of which 70.2 % were males. In multivariate Cox analysis, after adjustments for age, sex, and other confounding factors, higher TAR at admission was associated with an increased risk of 30-day and 90-day all-cause mortality in septic AKI patients (HR 1.91, 95 % CI 1.18-3.09, P = 0.008; HR 1.54, 95 % CI 1.01-2.34, P = 0.043, respectively). Subgroup analysis revealed no significant interactions in most strata. TAR at AKI diagnosis or discharge was not significantly related to 30-day (P = 0.120 and 0.153, respectively) or 90-day mortality (P = 0.147 and 0.124, respectively). We found no relationship between baseline TAR and septic shock, transfer to the intensive care unit, mechanical ventilation, requirement for renal replacement therapy, or stage 3 AKI (all P > 0.05). In the validation cohort of 81 septic AKI patients, TAR at admission remained a significant prognosticator for 30-day and 90-day mortality (HR 4.367, 95 % CI 1.20-15.87, P = 0.025; HR 4.237, 95 % CI 1.59-11.27, P = 0.004).

CONCLUSIONS

TAR at admission is an independent risk factor for 30-day and 90-day mortality in septic AKI patients and could be used as a convenient and economic septic AKI prognostic indicator.

Characteristics and risk factors for renal recovery after acute kidney injury in critically ill patients in cohorts of elderly and non-elderly: a multicenter retrospective cohort study

BACKGROUND

The purpose of this study was to explore the risk factors for renal nonrecovery among elderly and nonelderly patients with acute kidney injury (AKI) in critically ill patients.

METHODS

A multicenter retrospective cohort of 583 critically ill patients with AKI was examined. We found the best cutoff value for predicting renal recovery by age was 63 years old through logistic regression. All patients were divided into two cohorts, age <63 and age ≥63-years old; on the basis of renal recovery at 30 days after AKI, the two patient cohorts were further divided into a renal recovery group and a renal nonrecovery group. Multivariate logistic regression was used to analyze the risk factors affecting renal recovery in the two cohorts.

RESULTS

The 30-day renal recovery rate of patients aged <63 years was 70.0% (198/283), multivariate analysis showed that the independent risk factors affecting renal nonrecovery in age <63 years old included AKI stage, blood lactate level and hemoglobin level. The 30-day renal recovery rate of patients aged ≥63 years was 28.7% (86/300), multivariate analysis showed that the independent risk factors for renal nonrecovery in age ≥63-years old included diabetes mellitus, surgery with general anesthesia, AKI stage, APACHE II score, eGFR, and hemoglobin level.

CONCLUSIONS

The renal nonrecovery after AKI in critically ill patients in patients aged ≥63 years was more strongly affected by multiple risk factors, such as diabetes mellitus, surgery with general anesthesia, eGFR, and APACHE II score, in addition to hemoglobin and AKI stage.

The prognostic effects of the geriatric nutritional risk index on elderly acute kidney injury patients in intensive care units

Introduction

The geriatric nutritional risk index (GNRI), a nutritional screening tool specifically for the aging population, has been proven to be associated with worse outcomes in chronic kidney disease patients, especially in the hemodialysis population. However, the predictive validity of GNRI in critically ill elderly patients with acute kidney injury (AKI) is yet to be determined. This analysis sought to examine the prognostic effects of GNRI on elderly AKI patients in intensive care units (ICUs).

Methods

We collected elderly AKI patient-relevant data from the Medical Information Mart for Intensive Care III database. AKI was diagnosed and staged according to the "Kidney Disease Improving Global Outcomes" criteria. In the study, 1-year mortality was considered the primary outcome, whereas in-hospital, ICU, 28-day and 90-day mortality, and prolonged length of stay in ICU and hospital were selected as the secondary outcomes.

Results

In all, 3,501 elderly patients with AKI were selected for this study, with a 1-year mortality rate of 36.4%. We classified the study population into low (≤98) and high (>98) GNRI groups based on the best cutoff value. The incidence of endpoints was remarkably lower in patients with elevated GNRI (p < 0.001). When stratified by the AKI stage, patients with high GNRI at AKI stages 1, 2, and 3 had markedly lower 1-year mortality than those with low GNRI (all p < 0.05). The multivariable regression analysis identified the independent prognostic ability of GNRI on the research outcomes (all p < 0.05). Restricted cubic spline exhibited a linear correlation between GNRI and 1-year death (p for non-linearity = 0.434). The prognostic implication of GNRI on 1-year mortality was still significant in patients with the most subgroups.

Conclusion

In critically ill elderly patients with AKI, elevated GNRI upon admission was strongly correlated with a lower risk of unfavorable outcomes.

Enteral nutrition product formulations: A review of available products and indications for use

When oral nutrition is not feasible, enteral nutrition (EN) therapy is often considered the preferred route of nutrition support to meet the nutrient needs of individuals with a functional gastrointestinal tract across multiple levels of care (critical care, acute care, and home care). Enteral formulations have progressively evolved over the last 50 years from the simple blending of hospital food thin enough to run through a feeding tube, to the development of commercial standard formulas, followed by specialized formulas with immune-modulating and disease-specific qualities, to the most recent shift to food-based or blenderized EN composed of natural, whole foods with perceived health benefits. With the vast number of enteral formulations on the market, clinicians may be overwhelmed trying to determine proven vs theoretical benefits. This review is intended to explore differences in enteral formulations, identify implications for clinical practice, and review evidenced-based clinical guidelines to assist clinicians in enteral formula selection.

Changes in Serum Creatinine May Cause Hypoglycemia among Non-Critically Ill Patients Admitted to Internal Medicine Units

Background: The association between changes in serum creatinine levels and hypoglycemia during hospitalization was investigated. Methods: This was a retrospective analysis of medical charts. Patients were categorized as having significant change in creatinine (SCIC) when serum creatinine levels rose or dropped ≥ 0.3 mg/dL from admission values at any time during their hospitalization. Patients were considered hypoglycemic if they had at least one documented glucose level ≤ 70 mg/dL during the hospitalization. Multiple logistic, linear and Cox regression analyses were used to ascertain the association between incident SCIC, severity and timing with incident hypoglycemia. Results: Included were 25,400 (mean age 69.9 ± 18.0, 49.3% were males). The rate of SCIC was 22.2%, and 62.2% of them were diagnosed upon admission. Patients with SCIC had a higher incidence of hypoglycemia compared to patients without (13.1% vs. 4.1%, respectively, p < 0.001). Patients with SCIC had an increased risk of hypoglycemia (OR 1.853, 95% CI 1.586−2.166, p < 0.001). The magnitude of SCIC was associated with the incidence (OR 1.316, 95% CI 1.197−1.447, p < 0.001) and the number of events (HR 0.054, 95% CI 0.021−0.087, p = 0.001). More than 60% of patients with hypoglycemia had their first event documented during days 0−6 after SCIC occurrence. Of those, the majority of events occurred on day 0−1, and the rate showed a gradual decrease throughout the first 5 days from SCIC occurrence. The results were similar for patients with and without DM. Conclusions: Changes in creatinine during hospitalization may cause hypoglycemia among patients admitted to internal medicine departments, regardless of DM status.

Prognostic significance of malnutrition risk in elderly patients with acute kidney injury in the intensive care unit

BACKGROUND

Malnutrition is common in critically ill patients, but nutrition status in critically ill patients with acute kidney injury (AKI) has been poorly studied. Our study aimed to investigate the relationship between malnutrition risk and the occurrence and prognosis of AKI in elderly patients in the intensive care unit (ICU).

METHODS

Data were extracted from the Beijing Acute Kidney Injury Trial (BAKIT). A total of 1873 elderly patients were included and compared according to the clinical characteristics of AKI and non-AKI groups, and those of survivors and non-survivors of AKI in this study. Receiver operating characteristic (ROC) curves were used to analyse the predictive value of the modified Nutrition Risk in Critically Ill (mNUTRIC) score for the occurrence and 28-day prognosis of AKI. Multivariate Cox regression analysis was used to evaluate the effect of the mNUTRIC score on the 28-day mortality in AKI patients.

RESULTS

Compared with the non-AKI group, AKI patients had higher mNUTRIC scores, and non-survivors had higher mNUTRIC scores than survivors in AKI population. Moreover, multivariate Cox regression showed that 28-day mortality in AKI patients increased by 9.8% (95% CI, 1.018-1.184) for every point increase in the mNUTRIC score, and the mNUTRIC score had good predictive ability for the occurrence of AKI and 28-day mortality in AKI patients. The mortality of AKI patients with mNUTRIC > 4 was significantly increased.

CONCLUSIONS

The elderly patients are at high risk of malnutrition, which affects the occurrence and prognosis of AKI. Adequate attention should be given to the nutritional status of elderly patients.

TRIAL REGISTRATION

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

Kynurenine pathway in kidney diseases

Kidney diseases have become one of the most common health care problems. Due to a growing number of advanced aged patients with concomitant disorders the prevalence of these diseases will increase over the coming decades. Despite available laboratory tests, accurate and rapid diagnosis of renal dysfunction has yet to be realized, and prognosis is uncertain. Moreover, data on diagnostic and prognostic markers in kidney diseases are lacking. The kynurenine (KYN) pathway is one of the routes of tryptophan (Trp) degradation, with biologically active substances presenting ambiguous properties. The KYN pathway is known to be highly dependent on immunological system activity. As the kidneys are one of the main organs involved in the formation, degradation and excretion of Trp end products, pathologies involving the kidneys result in KYN pathway activity disturbances. This review aims to summarize changes in the KYN pathway observed in the most common kidney disease, chronic kidney disease (CKD), with a special focus on diabetic kidney disease, acute kidney injury (AKI), glomerulonephritis and kidney graft function monitoring. Additionally, the importance of KYN pathway activity in kidney cancer pathogenesis is discussed, as are available pharmacological agents affecting KYN pathway activity in the kidney. Despite limited clinical data, the KYN pathway appears to be a promising target in the diagnosis and prognosis of kidney diseases. Modulation of KYN pathway activity by pharmacological agents should be considered in the treatment of kidney diseases.

The relationship of the geriatric nutritional risk index to mortality and length of stay in elderly patients with acute respiratory failure: A retrospective cohort study

BACKGROUND

Elderly people with acute respiratory failure (ARF) have prolonged length of hospital stay (LOS) and high mortality rates. Malnutrition is negatively correlated with these LOS and mortality. However, no tools have been used to detect the risk of malnutrition and assist in designing nutritional support for these patients. The geriatric nutritional risk index (GNRI) is reported as a novel tool for evaluating the risk of malnutrition. The aim of this study is to explore the relationship of the GNRI score with mortality and LOS in elderly patients with ARF.

METHODS

Data of elderly patients diagnosed with ARF were retrieved from the Medical Information Mart for Intensive Care III (MIMIC-III) database. A total of 1250 patients were divided into two groups based on their GNRI score: the malnutrition risk group (GNRI ≤ 98) and no risk group (GNRI > 98). The primary endpoints of this study were hospital mortality and hospital LOS.

RESULTS

The higher GNRI score was associated with lower hospital mortality and shorter hospital LOS. Odds ratio (OR) for hospital mortality of patients with nutritional risk (GNRI ≤ 98) was 1.264 (95% CI:1.067-1.497) in the adjusted model. Patients with GNRI ≤98 had longer hospital LOS (adjusted OR: 1.142, 95%CI: 1.044-1.250) compared with those with GNRI > 98. Subgroup analysis showed that higher GNRI was only significantly associated with lower hospital mortality in the patients that did not undergo mechanical ventilator (MV) treatment (adjusted OR: 0.985, 95% CI: 0.977-0.992, P < 0.01). Kaplan-Meier curve analysis showed that the 90-day survival was significantly lower in the group with nutrition risk (GNRI≤98) compared with the no risk group (GNRI > 98, p < 0.05).

CONCLUSION

These findings imply that GNRI is a useful prognostic tool in elderly patients with ARF.

Impact of nutritional index on contrast-associated acute kidney injury and mortality after percutaneous coronary intervention

The risk of malnutrition in acute kidney injury and mortality in coronary artery disease patients has not been studied. This study aimed to evaluate whether nutritional status assessed by Onodera's prognostic nutritional index (PNI) was related to percutaneous coronary intervention (PCI) outcomes. A total of 3731 patients who received PCI between January 2010 and December 2018 were included. The relationship between PNI at the time of PCI and the occurrence of contrast-associated acute kidney injury (AKI) and all-cause death was evaluated using logistic regression and Cox proportional hazards models, respectively. AKI occurred in 271 patients (7.3%). A low PNI was independently associated with an increased risk of AKI on multivariate logistic regression analysis (OR 0.96, 95% CI 0.94-0.98, P = 0.001). During the median follow-up of 4.3 years, Kaplan-Meier analysis showed that patients with AKI/low PNI < 47.8 had a higher death rate. After adjusting for various risk factors, a low PNI was a significant risk factor for mortality (HR 0.98, CI 0.96-0.99, P = 0.003). A low level of PNI was associated with increased mortality, especially in the group aged over 70 years and female sex. PNI was closely associated with acute kidney outcomes and patient mortality after PCI.

Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nephrology Nutrition

Nephrology nutrition encompasses therapeutic and preventive nutrition care for individuals through the life cycle and addresses a variety of kidney disorders. Most nephrology nutrition practice focuses on care of individuals with chronic kidney disease, those on dialysis, and recipients of kidney transplants. The Renal Dietitians Dietetic Practice Group, National Kidney Foundation Council on Renal Nutrition, along with the Academy of Nutrition and Dietetics Quality Management Committee, have revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs working in nephrology nutrition. The SOP and SOPP for RDNs in Nephrology Nutrition provide indicators that describe three levels of practice: competent, proficient, and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for delivering patient/client care. The SOPP describes the following six domains that focus on professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Specific indicators outlined in the SOP and SOPP depict how these standards apply to practice. The SOP and SOPP are complementary resources for RDNs and are intended to be used as a self-evaluation tool for assuring competent practice in nephrology nutrition and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.