Acute kidney injury in the elderly population

Exploration of the Relationship Among Key Risk Factors of Acute Kidney Injury for Elderly Patients Considering Covid-19

Background: Previous systematic reviews and meta-analyses supported the relationship between frailty and risk of acute kidney injury (AKI) in elderly patients. However, few studies evaluated proactive management to wear down AKI risk in such frail populations. Purpose: To understand how AKI risk factors might influence each other and to identify the source factors for clinical decision aids. Methods: This study uses the decision-making trial and evaluation laboratory (DEMATEL) method to establish influential network-relationship diagrams (INRDs) to form the AKI risk assessment model for the elderly. Results: Based on the DEMATEL approach, the results of INRD identified the six key risk factors: comorbidity, malignancy, diabetes, creatinine, estimated glomerular filtration rate, and nutritional assessment. (The statistical significance confidence is 98.423%, which is higher than 95%; the gap error is 1.577%, which is lower than 5%). After considering COVID-19 as an additional risk factor in comorbidity, the INRD revealed a similar influential relationship among the essential aspects. Conclusion: While evaluating the geriatric population, physicians need to pay attention to patients' comorbidities and nutritional assessment; also, they should note patients' creatinine values and glomerular filtration rate. Physicians could establish a preliminary observation index and then design a series of preventive guidelines to reduce the incidence of AKI risk for the elderly.

Prevalence and risk factors of acute kidney injury in polytrauma patients at Muhimbili Orthopedic Institute, Tanzania

Background

Polytrauma can lead to multi-organ dysfunction in addition to the local injuries. Acute kidney injury (AKI) is one of the most common causes and contributors to the high morbidity and mortality. Prevalence of acute kidney injury in trauma patients is as reported to be as high as 40.3%. Early detection and management leads to better outcomes. The prevalence of AKI among polytrauma patients remains unknown in our setting.

Methodology

A cross-sectional study involving all adults with polytrauma who presented at the emergency department at Muhimbili Orthopedic Institute (MOI) was designed. A score of ≥18 on the New Injury Severity Score (NISS) screening tool was used to identify polytrauma patients. The Kidney Disease Improving Global Outcomes (KDIGO) criteria was used to identify patient with polytrauma who developed acute kidney injury. Descriptive statistics were then obtained followed by hypothesis testing between variables with the chi squared test. Logistic regression models were used to determine factors associated with acute kidney injury.

Results

More than half (56.4%) of the patients were between 26 and 40 years and 92.3% of the polytrauma patients were males. Almost 2/5th (38.5%) of the polytrauma patients had acute kidney injury – half of these had stage 1 AKI, 33.3% had stage 2 AKI and the remaining 16.7% had stage 3 AKI. On multivariate logistic regression, it was found that patients who were older than 45 years (OR 8.53, CI 1.65–43.89, p = 0.01) and those patients with Systemic Inflammatory Response Syndrome (SIRS) (OR 21.83, CI 1.66–286.2, p = 0.019) had higher risk of acute kidney injury.

Conclusion

There is high prevalence of AKI among polytrauma patients. Elderly patients and those with SIRS were seen to have higher likelihood of AKI.

Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers on Acute Kidney Injury in Emergency Medical Admissions

BACKGROUND

Acute kidney injury (AKI) has been observed in up to 20% of adult hospital admissions. Sepsis, diarrhea and heart failure, all causing reduced effective volume, are considered risk factors for AKI, especially among patients treated with medications that block the Renin-Angiotensin System (RAS), such as angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB). We aimed to determine the incidence of acute kidney injury (AKI) in emergency medical admissions in relation to the use and dosage of ACEi/ARB.

METHODS

A single-center observational study conducted in 577 consecutive medical admissions via the Emergency Room (ER) at a University General Hospital in Athens, Greece, between June and July 2018. Patients with incomplete medical records, discharged within 24 h, maintained on chronic renal replacement therapy, admitted to the Cardiology Department or the ICU were excluded. Thus, a total of 309 patients were finally included in this analysis.

RESULTS

We compared 86 (28%) patients who presented in the ER with AKI (AKIGroup) with 223 (72%) patients without AKI (non-AKI Group) at the time of admission. Patients in the AKI Group were more frequently male (58% vs. 46%, p = 0.06), with a higher frequency of diarrhea (16% vs. 6%, p = 0.006), edema (15% vs. 6%, p = 0.014) and lower systolic blood pressure (120 (107-135) vs. 126 (113-140), p = 0.007) at presentation, despite higher prevalence of hypertension (64% vs. 47%, p = 0.006). Overall, ACEi/ARB were more likely to have been prescribed in the AKI Group than in the non-AKI Group (49% vs. 28%, p = 0.001). Interestingly, AKI was more frequently observed in patients treated with the target or above target dosage of ACEi/ARB, but not in those receiving lower than the recommended dosage.

CONCLUSION

The risk of AKI in emergency medical admissions is higher among users of ACEIs/ARB at target or above target dosages. Physicians should adjust RAS blockade according to estimated Glomerular Filtration Rate (eGFR) and advise their patients to withhold ACEi/ARB in cases of acute illness.

Gerontolizing Nephrology: Spectrum of Histopathological Findings of Kidney Biopsy in the Elderly

Introduction:

The spectrum of renal disorder in the elderly differs from the younger population. There is a paucity of literature regarding kidney biopsy in elderly. This study aims to highlight the clinical profile and histopathological spectrum of the elderly patient undergoing a renal biopsy.

Materials and Methods:

This retrospective study included all patients (age ≥60 years) undergoing native renal biopsies from January 2012 to December 2017. The clinical profile, laboratory parameters, and renal biopsy findings of these patients were recorded from the case files.

Results:

Out of 1656 renal biopsies performed during the study period, 230 (13.9%%) performed on the elderly were included. Mean age was 64.02 ± 7.87 years (Range: 60-87 years), and males were predominant (70.4%). The commonest indication for biopsy was nephrotic syndrome (NS) (49.6%) followed by Rapidly progressive renal failure (RPRF) (20.9%) and Acute Kidney Injury (AKI) (15.7%). The most frequent histological diagnosis was membranous nephropathy (15.2%) followed by amyloidosis (13.9%) and Focal Segmental Glomerulosclerosis (FSGS) (13.0%). The commonest cause of NS was MGN (29.8%) followed by FSGS (24.6%) and amyloidosis (22.8%). The commonest cause of nephritic syndrome was Diffuse Proliferative Glomerulonephritis (29.4%) and Membranoproliferative Glomerulonephritis (29.4%). Hypertensive nephrosclerosis (40.0%) and diabetic nephropathy (26.7%)) were the commonest histological diagnosis in the patients who underwent renal biopsy for clinical Chronic kidney disease. Crescentic GN (35.4%) and Myeloma cast nephropathy 14.6%) were the commonest cause of RPRF while Acute Tubular Necrosis (41.7%) was the commonest cause of AKI. None of the patients had major complications.

Conclusion:

Renal biopsy is safe in the elderly and provides a wealth of information with regards to the diagnosis and prognosis of renal disorder.

Evaluation of kidney biopsies in elderly patients

OBJECTIVE

The renal parenchymal disease spectrum in geriatric patients is similar to that in younger patients and can be controlled by appropriate treatment. We evaluated the clinicopathological features of kidney biopsies from geriatric patients.

MATERIALS AND METHODS

One hundred nine native kidney biopsies from older patients (> 65 years old) obtained from 2005 to 2014 were evaluated retrospectively. The specimens were inspected by the same pathologist in the same laboratory by light microscopy and immunofluorescence.

RESULTS

The mean age of the patients was 72.4 ± 7.8 years (range 65-90 years), and 51.3% were female. The most frequent indication for kidney biopsy was proteinuria at the nephrotic level (56.8%). The most frequent histopathological diagnoses were focal segmental glomerulosclerosis in primary glomerulonephritis and secondary amyloidosis in secondary glomerulonephritis. The rate of major complications due to kidney biopsy was < 1%.

RESULT

Kidney biopsy is an effective and safe method of evaluating renal parenchymal diseases in older patients.

Incidence, characteristics and prognosis of acute kidney injury in Cameroon: a prospective study at the Douala General Hospital

Objective: There are limited data on AKI in sub-Saharan Africa. We aim to determine the incidence, characteristics and prognosis of AKI in Cameroon.

Patients and methods: A prospective study including all consenting acute admissions in the internal medicine and the ICU of a tertiary referral hospital in Cameroon from January 2015 to June 2016. Serum creatinine assay was done on admission, days 2 and 7 to diagnose AKI. For patients with AKI, serum creatinine was done on discharge, days 30, 60 and 90. AKI was defined according to the modified KDIGO 2012 criteria as an increase or decrease in serum creatinine of 3 mg/l or greater, or an increase of 50% or more from the reference value obtained at admission or the known baseline value. AKI severity was graded using KDIGO2012 criteria. Outcome measures were renal recovery, mortality and causes of death. Renal recovery was complete if serum creatinine between the first 90 days was less than baseline or reference, partial if less than diagnosis but not baseline or reference, no-recovery if creatinine did not decrease or if the patient remained on dialysis.

Results: Of the 2402 patients included, 536 developed AKI giving a global incidence of 22.3% and annual incidence of 15 per 100 patients-years. Of the 536 patients with AKI, 43.3% were at stage 3, 54.7% were males, median age was 56 years. Pre-renal AKI (61.4%) and acute tubular necrosis (28.9%) were the most frequent forms. Main etiologies were sepsis (50.4%) and volume depletion (31.6%). Renal outcome was unknown in 34% of patients. Of the 354 patients with known renal function at 3 months, 84.2% recovered completely, 14.7% partially and 1.1% progressed to CKD. Global mortality rate was 36.9% mainly due to sepsis.

Conclusions: AKI is frequent in our setting, mainly due to sepsis and hypovolemia. It carries a poor prognosis.

Characteristics of and risk factors for death in elderly patients with acute kidney injury: a multicentre retrospective study in China

Purpose of the study

The incidence of acute kidney injury (AKI) with a poor prognosis in the elderly has been increasing each year. This study aimed to investigate the clinical characteristics of and risk factors for death from AKI in the elderly and help improve prognosis.

Study design

This study was a retrospective cohort study based on data from adult patients (≥18 years old) admitted to 15 hospitals in China between 1 January 2009 and 31 December 2011. The characteristics of AKI in the elderly were compared with those in younger patients.

Results

In elderly patients with AKI, rates of hypertension, cardiovascular disease and multiple organ dysfunction syndrome (MODS) were higher than in younger patients (44.2% vs 31.2%, 16.1% vs 4.6% and 20.9% vs 16.9%, respectively), the length of ICU stay was longer (3.8 days vs 2.7 days, P=0.019) and renal biopsy (1.0% vs 7.13%, P<0.001) and dialysis (9.6% vs 19.2%, P<0.001) were performed less. Hospital-acquired (HA) AKI was more common than community-acquired (CA) AKI (60.3% vs 39.7%), while the most common cause of AKI was pre-renal (53.5%). Multiple logistic regression analysis showed that age (OR 1.041, 95% CI 1.023 to 1.059), cardiovascular disease (OR 1.980, 95% CI 1.402 to 2.797), cancer (OR 2.302, 95% CI 1.654 to 3.203), MODS (OR 3.023, 95% CI 1.627 to 5.620) and mechanical ventilation (OR 2.408, 95% CI 1.187 to 4.887) were significant risk factors for death.

Conclusions

HA-AKI and pre-renal AKI were more common in the elderly. Age, cardiovascular disease, cancer, MODS and mechanical ventilation were independent risk factors for death in the elderly with AKI.

Interpretation of Kidney Biopsy in Indian Patients Older than 60 Years: A Tertiary Care Experience

The adult population above the age of 60 years has significantly increased in India, with a life expectancy of 68.4 years in 2016. Data regarding the renal histopathology in these patients are scarce though the number of native kidney biopsies done in this subset of population is increasing. The present study is a retrospective analysis of 231 biopsies from a total of 700 biopsies, from patients above 60 years of age (M = 65.8%; F = 34.2%) with a mean age of 64 ± 6.03 years. The indications for kidney biopsy included nephrotic syndrome (NS) (30.4%), nephritic syndrome (19.1%), rapidly progressive renal failure (11.7%), acute kidney injury (AKI) (15.7%), and acute worsening of preexisting chronic kidney disease (CKD) (23%). The median percentage of glomerulosclerosis was 22% (5%–45%), and interstitial fibrosis and tubular atrophy was 30% (10%–50%). The most common cause for nephrotic syndrome was membranous nephropathy (31.4%) and for nephritic syndrome was benign arterionephrosclerosis (22.7%). Postinfectious glomerulonephritis (29.6%) was the leading cause for rapidly progressive renal failure. Acute injury on CKD was notable in patients with diabetic nephropathy (30.2%). The predominant causes for AKI were acute tubulointerstitial nephritis (33.3%), acute tubular necrosis (22.2%), and acute pyelonephritis (19.4%). The biopsy proven histopathological features enabled us in tailoring the therapy. None of the patients developed life-threatening complications following ultrasonography-guided biopsy.

Outcomes from a cohort of patients with acute kidney injury subjected to continuous venovenous hemodiafiltration: The role of negative fluid balance

Background

Several factors influence the outcomes in acute kidney injury (AKI), especially in intensive care unit (ICU) patients. In this scenario, continuous renal replacement therapies (CRRT) are used to control metabolic derangements and blood volume. Knowing this fact, it may be possible to change the course of the disease and decrease the high mortality rate observed. Thus, we aimed to evaluate the main risk factors for death in AKI patients needing CRRT.

Results

This was a prospective, observational cohort study of ICU patients (N = 183) with AKI who underwent continuous venovenous hemodiafiltration (CVVHDF) as their initial dialysis modality choice. The patients were predominantly male (62.8%) and their median age was 65 (55–76) years. The most frequent comorbidities were cardiovascular disease (39.3%), hypertension (32.8%), diabetes (24%), and cirrhosis (20.7%). The main cause of AKI was sepsis (52.5%). At beginning of CVVHDF, 152 patients (83%) were using vasopressors. The median SAPS 3 and SOFA score at ICU admission was 61 (50–74) and 10 (7–12), respectively. The dialysis dose delivered was 33.2 (28.9–38.7) ml/kg/h. The median time between ICU admission and CVVHDF initiation was 2 (1–4) days. The median cumulative fluid balance during the CVVHDF period was -1838 (-5735 +2993) ml. The mortality rate up to90 days was 58%. The independent mortality risk factors in propensity score model were: chronic obstructive pulmonary disease (OR = 3.44[1.14–10.4; p = 0.028]), hematologic malignancy (OR = 5.14[1.66–15.95; p = 0.005]), oliguria (OR = 2.36[1.15–4.9; p = 0.02]), positive daily fluid balance during CVVHDF (OR = 4.55[2.75–13.1; p<0.001]), and total SOFA score on first dialysis day (OR = 1.27[1.12–1.45; p<0.001]).

Conclusions

Dialysis-related factors may influence the outcomes. In our cohort, positive daily fluid balance during CRRT was associated with lower survival. Multicenter, randomized studies are needed to assess fluid balance as a primary outcome to define the best strategy in this patient population.

Geriatric patients with known acute kidney injury and normal renal function at the time of admittance to the intensive care unit/assessment of RRT requirement and mortality: retrospective case-control study

BACKGROUND

The objective of our study was to investigate the renal functions on admittance, chronic disease status, the diagnosis on admittance to the intensive care unit (ICU), need for mechanical ventilation and medication groups and their impact over mortality and renal replacement treatment (RRT) requirement in geriatric patients with and without known acute kidney injury (AKI) at the time of admittance.

METHODS

A total of 168 patients over 65 years of age having been monitored for more than 24 h in our Respiratory ICU and were assessed retrospectively. Factors influencing the RRT requirement and the mortality rates of patients with known AKI and normal renal function at the time of admittance were reviewed.

RESULTS

Of 80 patients, 8 (10 %) without AKI at the time of admittance to the ICU required RRT during the follow-up, however, 72 of those (90 %) completed the follow-up without developing AKI. Of 88 patients, 29 (33 %) with AKI at the time of admittance to the ICU required RRT, however, 59 of those (67 %) completed the follow-up without any need for RRT.

CONCLUSIONS

Presence of known AKI in the geriatric population at the time of their admittance to the respiratory ICU remarkably increased both the need for RRT and the mortality with respect to the geriatric population with normal renal functions. After having assessed the reasons justifying RRT and increasing the mortality during the intensive care, gastrointestinal bleeding and hypotension which necessitate the combined use of dopamine and noradrenaline were concluded to be prominent.

Role of COX-2/mPGES-1/prostaglandin E2 cascade in kidney injury

COX-2/mPGES-1/PGE2 cascade plays critical roles in modulating many physiological and pathological actions in different organs. In the kidney, this cascade is of high importance in regulating fluid metabolism, blood pressure, and renal hemodynamics. Under some disease conditions, this cascade displays various actions in response to the different pathological insults. In the present review, the roles of this cascade in the pathogenesis of kidney injuries including diabetic and nondiabetic kidney diseases and acute kidney injuries were introduced and discussed. The new insights from this review not only increase the understanding of the pathological role of the COX-2/mPGES-1/PGE2 pathway in kidney injuries, but also shed new light on the innovation of the strategies for the treatment of kidney diseases.

Raising awareness of acute kidney injury: a global perspective of a silent killer

Worldwide, acute kidney injury (AKI) is associated with poor patient outcomes. Over the last few years, collaborative efforts, enabled by a common definition of AKI, have provided a description of the epidemiology, natural history, and outcomes of this disease and improved our understanding of the pathophysiology. There is increased recognition that AKI is encountered in multiple settings and in all age groups, and that its course and outcomes are influenced by the severity and duration of the event. The effect of AKI on an individual patient and the resulting societal burden that ensues from the long-term effects of the disease, including development of chronic kidney disease (CKD) and end-stage renal disease (ESRD), is attracting increasing scrutiny. There is evidence of marked variation in the management of AKI, which is, to a large extent, due to a lack of awareness and an absence of standards for prevention, early recognition, and intervention. These emerging data point to an urgent need for a global effort to highlight that AKI is preventable, its course is modifiable, and its treatment can improve outcomes. In this article, we provide a framework of reference and propose specific strategies to raise awareness of AKI globally, with the goal to ultimately improve outcomes from this devastating disease.

Use of renal biopsy in the elderly

Renal biopsy is an essential tool in the management of kidney disease. A biopsy provides a diagnosis, guides therapy and aids in prognosis, and this is true for persons of all ages. For a variety of reasons, nephrologists are sometimes hesitant to perform a biopsy in an older person. There is the major issue of a lack of perceived benefit that the biopsy will not show a treatable lesion and that therapy may not be possible in an older person. Additionally, concerns of safety may also influence the decision to biopsy. In this review, we will address these issues in the context of clinical renal syndromes and common kidney diseases in the elderly and weigh the benefit of biopsy in various situations. In general, the indications are the same as in the adult population, as is the risk associated with the biopsy procedure. Therapy, as for adults, is often successful, although further assessment of risk-benefit ratio is necessary. Age, by itself, is not a contraindication to biopsy.

The dark side of high-intensity renal replacement therapy of acute kidney injury in critically ill patients

The impact of intensity or dose of renal replacement therapy (RRT) on outcome of critically ill patients has been a matter of controversy. Most definitions of an adequate dose of acute RRT are based on urea removal, while ignoring other crucial aspects of RRT adequacy in acute kidney injury (AKI). Although some clinical trials have found an improvement in survival with higher doses of intermittent hemodialysis or continuous RRT, results have not been consistent across all studies. The largest trials suggest that there is no additional survival benefit with doses of 35-45 ml/kg/h (CRRT) or daily intermittent hemodialysis. On the other hand, high-intensity treatment may cause life-threatening complications and thereby counteract the benefits of higher small-solute clearance. One important area for future investigations is the need to characterize the potential harm of high-dose RRT for AKI in critically ill patients.