Whole blood neutrophil gelatinase-associated lipocalin predicts acute kidney injury in burn patients

Physiological arterial pressure improves renal performance during normothermic machine perfusion in a porcine kidney DCD model

Background

Normothermic machine perfusion (NMP) provides a platform for kidney quality assessment. Donation after circulatory death (DCD) donor kidneys are associated with great ischemic injury and high intrarenal resistance (IRR). This experimental study aims to investigate the impact of different perfusion pressures on marginal kidney function and injury during NMP.

Methods

Twenty-seven slaughterhouse porcine kidneys were retrieved and subjected to 60 min of warm ischemia time to mimic DCD condition. These kidneys were randomized into 75 mmHg (subphysiological, n = 9), 95 mmHg (physiological, n = 9), and 115 mmHg NMP (high physiological, n = 9). Renal function and injury were assessed during NMP.

Results

Three groups showed comparable IRR, with the 115 mmHg group exhibiting the highest blood flow. The 95 mmHg group [0.48 (0.36-1.15) ml/min/100g] and 115 mmHg group [0.93 (0.45-1.41) ml/min/100g] showed significantly higher creatinine clearance compared to the 75 mmHg group [0.16 (0.08-0.37) ml/min/100g] during the first hour of NMP (p = 0.049, p = 0.009, respectively). The 115 mmHg group exhibited significantly higher oxygen consumption compared to the 75 mmHg group at 30 min of NMP [1.37 (1.05-1.92) versus 0.72 (0.61-0.82) mlO2/min/100g, p = 0.009]. Perfusate neutrophil gelatinase-associated lipocalin (NGAL) levels were consistently lowest in the 95 mmHg group and highest in the 75 mmHg group. Aspartate aminotransferase (AST) levels of the 115 mmHg group were significantly higher than the 75 mmHg group.

Conclusions

For kidneys with high IRR, both 95 mmHg and 115 mmHg perfusion pressures enable an early improvement in renal hemodynamics and function compared to 75 mmHg during NMP, while a high physiological perfusion can cause additional injury.

Acute kidney injury in patients with burns

Burn injury is associated with a high risk of acute kidney injury (AKI) with a prevalence of AKI among patients with burns of 9-50%. Despite an improvement in burn injury survival in the past decade, AKI in patients with burns is associated with an extremely poor short-term and long-term prognosis, with a mortality of >80% among those with severe AKI. Factors that contribute to the development of AKI in patients with burns include haemodynamic alterations, burn-induced systemic inflammation and apoptosis, haemolysis, rhabdomyolysis, smoke inhalation injury, drug nephrotoxicity and sepsis. Early and late AKI after burn injury differ in their aetiologies and outcomes. Sepsis is the main driver of late AKI in patients with burns and late AKI has been associated with higher mortality than early AKI. Prevention of early AKI involves correction of hypovolaemia and avoidance of nephrotoxic drugs (for example, hydroxocobalamin), whereas prevention of late AKI involves prevention and early recognition of sepsis as well as avoidance of nephrotoxins. Treatment of AKI in patients with burns remains supportive, including prevention of fluid overload, treatment of electrolyte disturbance and use of kidney replacement therapy when indicated.

Rhodomyrtus tomentosa as a new anticancer molecular strategy in breast histology via Her2, IL33, EGFR, and MUC1

The prevalence of breast cancer among patients in Indonesia is significant. Indonesian individuals maintain the belief that cancer cannot be cured alone by pharmaceuticals and treatment; herbal remedies must be used in conjunction. Rhodomyrtus tomentosa, also known as Haramonting, is an indigenous Indonesian medicinal plant renowned for its copious antioxidant properties. The objective of study was to assess the impact of haramonting on breast cancer by examining the expression of various biomarker proteins associated with breast cancer. Haramonting was administered to breast cancer model mice at different doses over a period of 30 days. Subsequently, blood and breast samples were obtained for immunohistochemistry and enzyme-linked immunosorbent assays (ELISA). Authors have discovered that there has been a notable rise in the proliferation of epithelial cells in the duct lobes, resulting in the formation of ducts and lobules. Additionally, the researchers discovered that the breasts exhibited distinct clinical and histological alterations. Haramonting possesses the capacity to restore the concentrations of malondialdehyde (MDA) and superoxide dismutase (SOD) to normal levels in the blood serum of rats afflicted with cancer. The histopathological analysis of the breast tissue revealed elevated levels of Her2, IL33, EGFR, and MUC1. The authors also discovered a notable increase in the growth of epithelial cells, with two or more layers of cells reaching towards the centre of the duct. The size of the epithelial cells exhibits variability; however, this state ameliorates with the administration of a dosage of 300 mg/kgBW of this botanical specimen. This study proposes that Haramonting may be effective in treating breast cancer.

Burn-Induced Acute Kidney Injury-Two-Lane Road: From Molecular to Clinical Aspects

Severe burn injuries lead to acute kidney injury (AKI) development, increasing the mortality risk up to 28-100%. In addition, there is an increase in hospitalization days and complications appearance. Various factors are responsible for acute or late AKI debut, like hypovolemia, important inflammatory response, excessive load of denatured proteins, sepsis, and severe organic dysfunction. The main measure to improve the prognosis of these patients is rapidly recognizing this condition and reversing the underlying events. For this reason, different renal biomarkers have been studied over the years for early identification of burn-induced AKI, like neutrophil gelatinase-associated lipocalin (NGAL), cystatin C, kidney injury molecule-1 (KIM-1), tissue inhibitor of metalloproteinase-2 (TIMP-2), interleukin-18 (IL-18), and insulin-like growth factor-binding protein 7 (IGFBP7). The fundamental purpose of these studies is to find a way to recognize and prevent acute renal injury progression early in order to decrease the risk of mortality and chronic kidney disease (CKD) onset.

Wound Healing in Older Adults With Severe Burns: Clinical Treatment Considerations and Challenges

Background:

The older adult population continues to rapidly expand in number, with a projection by the United States (US) Census Bureau that there will be more individuals older than > 65 years (77.0 million) than those younger than < 18 years (76.5 million) by 2034. This review provides an overview of aging as it relates to wound healing and burn injuries in older adult patients, summarizes current treatment practices, and addresses the key challenges and considerations for treating severe burn injuries in this specific patient population.

Materials and methods:

A narrative literature search was conducted, focusing on recent primary literature on burns and wound healing in elderly patients.

Results:

Studies showed that the aging process results in both physiologic (eg, nutritional and metabolic status) and anatomic changes (eg, thinning dermis) that contribute to a reduced capacity to recover from burn-injury trauma compared with younger patients. Owing to impaired vision, decreased coordination, comorbidities, and medication-induced side effects, older adults (ie, > 65 years) are susceptible to severe burn injury (deep-partial thickness and full-thickness), which is associated with significant morbidity and mortality.

Conclusion:

A better understanding of the effects of age-related changes regarding wound healing in older adult patients who incur severe burn injuries may provide insight into clinical strategies to improve outcomes among this population.

Urinary neutrophil gelatinase-associated lipocalin level as a biomarker of acute kidney injury following extracorporeal shock wave lithotripsy

Introduction

Although extracorporeal shock wave lithotripsy (ESWL) is minimally invasive and highly efficient for the management of kidney stones, adverse effects have been described. Available indicators of renal function exhibit insufficient sensitivity in acute renal injury (AKI). We aimed to evaluate the severity of the kidney tissue response to ESWL injury by measuring the urinary neutrophil gelatinase-associated lipocalin (uNGAL), which can indicate AKI in its early phase.

Material and methods

The prospective, controlled study included 62 patients with nephrolithiasis undergoing single ESWL treatment. uNGAL level was measured before the procedure, and 6 h and 12 h after.

Results

The median uNGAL level increased by 126.0%, 6 h after ESWL (p <0.001). The growth rate continued and 12 h after was higher by 583.7%, compared to the pre-treatment level (p <0.001). The median value of estimated glomerular filtration rate (eGFR) dropped by 15.3% 12 h after the treatment (p <0.001). It increased by 5.0% in the period 7 days to 3 months after (p <0.001) and after 3 months it was lower by 10.1% compared to pre-ESWL values (p <0.001). uNGAL level after 12 h was significantly negatively associated with eGFR, 12 h, 7 days and 3 months after the ESWL. The sensitivity of uNGAL 12 h after ESWL was 60.6%; its specificity was 75.0%, with a positive predictive value of 74.0% and negative predictive value of 61.7%.

Conclusions

uNGAL appears to be a useful biomarker for the assessment and prediction of AKI. It was noticed that uNGAL had the highest predictive value 12 h after the ESWL treatment.

Meta-Analysis of Renal Replacement Therapy for Burn Patients: Incidence Rate, Mortality, and Renal Outcome

Background: Renal replacement therapy (RRT) was often needed by some severe burn patients with acute kidney injury (AKI). The primary aim of this study was to review incidence rate and mortality of RRT in severe burn patients. Second aims were to review RRT complications and renal outcome.

Methods: We searched multiple databases for studies published between 1 January 1960 and 31 December 2019. Studies about adult populations with burn injury, providing epidemiologic data on prevalence or mortality of RRT, were included.

Results: A total of selected 57 studies, including 27,437 patients were enrolled in our analysis. The prevalence rates of RRT were 8.34% (95% CI 7.18–9.5%) in all burn patients and 37.05% (95% CI 29.85–44.24%) in AKI patients. The mortality of all burn patients with RRT was 65.52% (95% CI 58.41–72.64%). The prevalence rates of RRT in sample size≥100 group were 6.86% (95% CI 5.70–8.03%), which was lower than that of <100 group (17.61%, 95% CI 13.39–21.82%). With the increase of TBSA, the prevalence of RRT may have the increasing trend. The prevalence rates of RRT in Asian group was 12.75% (95% CI 9.50–16.00%), which was higher than that of European (10.45%, 95% CI 7.30–13.61%) and North America group (5.61%, 95% CI 4.27–6.95%). The prevalence rates of RRT in 2010–2019 group was 12.22% (95% CI 10.09–14.35%), which was higher than that of 2009–2000 group (5.17%, 95% CI 2.88–7.46%). The prevalence rates of RRT in 1989 and before group was the lowest, which was 1.56% (95% CI 0–3.68%). However, there was no significant correlation between the year of publication and the mortality of burn patients with RRT. Dialysis-requiring AKI in burn patients could increases the risk of chronic kidney disease progression and end-stage renal disease. About 35% of RRT patients need to maintain haemodialysis temporarily, even if they survive and leave hospital.

Conclusions: The prevalence rate of RRT is about 6–8%; approximately, one-third of burn patients with AKI need RRT. The prevalence rate of RRT increased over time, but the mortality did not change. The prevalence rates of RRT in Asian group was higher than that of European and North America group.

Neutrophil Gelatinase-associated Lipocalin Predicts Post-traumatic Acute Kidney Injury in Severely Injured Patients

BACKGROUND

Early detection of acute kidney injury (AKI) is crucial in the management of multiple-organ dysfunction syndrome in severely injured patients. Standard laboratory parameters usually increase with temporal delay. Therefore, we evaluated neutrophil gelatinase-associated lipocalin (NGAL) as an early marker for acute kidney injury.

PATIENTS AND METHODS

We retrospectively evaluated patients admitted to a level 1 trauma center. We collected clinicodemographic data and measured kidney-related factors and plasma cytokines.

RESULTS

A total of 39 patients were included. Patients with AKI had significantly higher levels not only of serum creatinine and urea, but also of NGAL (all p<0.001) than patients without AKI. The optimal NGAL cut-off value was determined to be 177 ng/ml, showing significant correlation with imminent or manifest AKI (p<0.001). Other independent markers correlated with AKI included pre-existing chronic kidney disease, use of catecholamines, and severe injury (p<0.001).

CONCLUSION

The serum level of NGAL is feasible early predictor of AKI.

Enhancing Military Burn- and Trauma-Related Acute Kidney Injury Prediction Through an Automated Machine Learning Platform and Point-of-Care Testing

CONTEXT.—

Delayed recognition of acute kidney injury (AKI) results in poor outcomes in military and civilian burn-trauma care. Poor predictive ability of urine output (UOP) and creatinine contribute to the delayed recognition of AKI.

OBJECTIVE.—

To determine the impact of point-of-care (POC) AKI biomarker enhanced by machine learning (ML) algorithms in burn-injured and trauma patients.

DESIGN.—

We conducted a 2-phased study to develop and validate a novel POC device for measuring neutrophil gelatinase-associated lipocalin (NGAL) and creatinine from blood samples. In phase I, 40 remnant plasma samples were used to evaluate the analytic performance of the POC device. Next, phase II enrolled 125 adults with either burns that were 20% or greater of total body surface area or nonburn trauma with suspicion of AKI for clinical validation. We applied an automated ML approach to develop models predicting AKI, using a combination of NGAL, creatinine, and/or UOP as features.

RESULTS.—

Point-of-care NGAL (mean [SD] bias: 9.8 [38.5] ng/mL, P = .10) and creatinine results (mean [SD] bias: 0.28 [0.30] mg/dL, P = .18) were comparable to the reference method. NGAL was an independent predictor of AKI (odds ratio, 1.6; 95% CI, 0.08-5.20; P = .01). The optimal ML model achieved an accuracy, sensitivity, and specificity of 96%, 92.3%, and 97.7%, respectively, with NGAL, creatinine, and UOP as features. Area under the receiver operator curve was 0.96.

CONCLUSIONS.—

Point-of-care NGAL testing is feasible and produces results comparable to reference methods. Machine learning enhanced the predictive performance of AKI biomarkers including NGAL and was superior to the current techniques.

The predisposing factors of AKI for prophylactic strategies in burn care

Background

Acute kidney injury (AKI) is one of the most severe complications of burn injury. AKI with severe burn injury causes high mortality. This study aims to investigate the incidence of and predisposing factors for AKI in burn patients.

Methods

This is a single-center, retrospective, descriptive criterion standard study conducted from June 27, 2015, to March 8, 2016. We used Kidney Disease Improving Global Outcomes criteria to define and select patients with AKI. The study was conducted by recruiting in hospital patients who suffered from the flammable cornstarch-based powder explosion and were treated under primary care procedures. A total of 49 patients who suffered from flammable dust explosion-related burn injury were enrolled and admitted on June 27, 2015. The patients with more than 20% total body surface area of burn were transferred to the intensive care unit. Patients received fluid resuscitation in the first 24 hours based on the Parkland formula. The primary measurements were the incidence of and predisposing factors for AKI in these patients. Demographic characteristics, laboratory data, and inpatient outcomes were also evaluated. The incidence of AKI in this cohort was 61.2% (n = 30). The mortality rate was 2.0% (n = 1) during a 59-day follow-up period. The multivariate analysis revealed inhalation injury (adjusted OR = 22.0; 95% CI [1.4–358.2]) and meeting ≥3 American Burn Association (ABA) sepsis criteria (adjusted OR = 13.7; 95% CI [1.7–110.5]) as independent risk factors for early advanced AKI.

Conclusions

The incidence rate of AKI was higher in this cohort than in previous studies, possibly due to the flammable dust explosion-related burn injury. However, the mortality was lower than that expected. In clinical practice, indicators of inflammation, including ABA sepsis criteria may help in predicting the risk of AKI in patients with burn injury.

Initial management of severe burn injury

PURPOSE OF REVIEW

Patients with severe burn injuries pose significant challenges for the intensivist. Though average burn sizes have decreased over time, severe burn injuries involving greater than 20% of the total body surface area still occur. Verified burn centers are limited, making the management of severely burn injured patients at nonspecialized ICUs likely. Current practices in burn care have increased survivability even from massive burns. It is important for intensivists to be aware of the unique complications and therapeutic options in burn critical care management. This review critically discusses current practices and recently published data regarding the evaluation and management of severe burn injury.

RECENT FINDINGS

Burn patients have long, complex ICU stays with accompanying multiorgan dysfunction. Recent advances in burn intensive care have focused on acute respiratory distress syndrome from inhalation injury, acute kidney injury (AKI), and transfusion, resulting in new strategies for organ failure, including renal replacement therapy and extracorporeal life support.

SUMMARY

Initial evaluation and treatment of acute severe burn injury remains an ongoing area of study. This manuscript reviews current practices and considerations in the acute management of the severely burn injured patient.

Predictive Value of Osteoprotegerin and Neutrophil Gelatinase-associated Lipocalin on Multiple Organ Failure in Multiple Trauma

BACKGROUND/AIM

Multiple organ dysfunction syndrome (MODS) is the leading cause of late posttraumatic mortality. This study analyzed the prognostic values of osteoprotegerin (OPG) and neutrophil gelatinase-associated lipocalin (NGAL/lipocalin 2) compared to interleukin-6 (IL-6) in multiply injured patients.

PATIENTS AND METHODS

A retrospective observational cohort study on multiply injured patients with an injury severity score (ISS) of ≥16 was performed. OPG, NGAL and IL-6 blood concentrations were measured. Statistical analysis comprised receiver-operating-characteristic (ROC) analysis with the corresponding area under the curve (AUC).

RESULTS

Thirty-nine patients with a mean ISS of 34±11 were included. Fourteen patients (36%) developed MODS and 8 patients (21%) died. Plasma levels of NGAL, OPG, and IL-6 were significantly elevated in the MODS+ group. Each biomarker positively correlated with MODS score and diagnosis of MODS.

CONCLUSION

NGAL and OPG might be indicative of MODS and could have the potential to be biomarkers in the early detection of patients at risk of posttraumatic MODS.

Early Recognition of Burn- and Trauma-Related Acute Kidney Injury: A Pilot Comparison of Machine Learning Techniques

Severely burned and non-burned trauma patients are at risk for acute kidney injury (AKI). The study objective was to assess the theoretical performance of artificial intelligence (AI)/machine learning (ML) algorithms to augment AKI recognition using the novel biomarker, neutrophil gelatinase associated lipocalin (NGAL), combined with contemporary biomarkers such as N-terminal pro B-type natriuretic peptide (NT-proBNP), urine output (UOP), and plasma creatinine. Machine learning approaches including logistic regression (LR), k-nearest neighbor (k-NN), support vector machine (SVM), random forest (RF), and deep neural networks (DNN) were used in this study. The AI/ML algorithm helped predict AKI 61.8 (32.5) hours faster than the Kidney Disease and Improving Global Disease Outcomes (KDIGO) criteria for burn and non-burned trauma patients. NGAL was analytically superior to traditional AKI biomarkers such as creatinine and UOP. With ML, the AKI predictive capability of NGAL was further enhanced when combined with NT-proBNP or creatinine. The use of AI/ML could be employed with NGAL to accelerate detection of AKI in at-risk burn and non-burned trauma patients.

Acute kidney injury in burn patients admitted to the intensive care unit: a systematic review and meta-analysis

Background

Acute kidney injury (AKI) is a common complication in burn patients admitted to the intensive care unit (ICU) associated with increased morbidity and mortality. Our primary aim was to review incidence, risk factors, and outcomes of AKI in burn patients admitted to the ICU. Secondary aims were to review the use of renal replacement therapy (RRT) and impact on health care costs.

Methods

We conducted a systematic search in PubMed, UpToDate, and NICE through 3 December 2018. All reviews in Cochrane Database of Systematic Reviews except protocols were added to the PubMed search. We searched for studies on AKI according to Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease (RIFLE); Acute Kidney Injury Network (AKIN); and/or Kidney Disease: Improving Global Outcomes (KDIGO) criteria in burn patients admitted to the ICU. We collected data on AKI incidence, risk factors, use of RRT, renal recovery, length of stay (LOS), mortality, and health care costs.

Results

We included 33 observational studies comprising 8200 patients. Overall study quality, scored according to the Newcastle-Ottawa scale, was moderate. Random effect model meta-analysis revealed that the incidence of AKI among burn patients in the ICU was 38 (30–46) %. Patients with AKI were almost evenly distributed in the mild, moderate, and severe AKI subgroups. RRT was used in 12 (8–16) % of all patients. Risk factors for AKI were high age, chronic hypertension, diabetes mellitus, high Total Body Surface Area percent burnt, high Abbreviated Burn Severity Index score, inhalation injury, rhabdomyolysis, surgery, high Acute Physiology and Chronic Health Evaluation II score, high Sequential Organ Failure Assessment score, sepsis, and mechanical ventilation. AKI patients had 8.6 (4.0–13.2) days longer ICU LOS and higher mortality than non-AKI patients, OR 11.3 (7.3–17.4). Few studies reported renal recovery, and no study reported health care costs.

Conclusions

AKI occurred in 38% of burn patients admitted to the ICU, and 12% of all patients received RRT. Presence of AKI was associated with increased LOS and mortality.

Trial registration

PROSPERO (CRD42017060420)

Artificial intelligence and machine learning for predicting acute kidney injury in severely burned patients: A proof of concept

BACKGROUND

Burn critical care represents a high impact population that may benefit from artificial intelligence and machine learning (ML). Acute kidney injury (AKI) recognition in burn patients could be enhanced by ML. The goal of this study was to determine the theoretical performance of ML in augmenting AKI recognition.

METHODS

We developed ML models using the k-nearest neighbor (k-NN) algorithm. The ML models were trained-tested with clinical laboratory data for 50 adult burn patients that had neutrophil gelatinase associated lipocalin (NGAL), urine output (UOP), creatinine, and N-terminal B-type natriuretic peptide (NT-proBNP) measured within the first 24 h of admission.

RESULTS

Half of patients (50%) in the dataset experienced AKI within the first week following admission. ML models containing NGAL, creatinine, UOP, and NT-proBNP achieved 90-100% accuracy for identifying AKI. ML models containing only NT-proBNP and creatinine achieved 80-90% accuracy. Mean time-to-AKI recognition using UOP and/or creatinine alone was achieved within 42.7 ± 23.2 h post-admission vs. within 18.8 ± 8.1 h via the ML-algorithm.

CONCLUSIONS

The performance of UOP and creatinine for predicting AKI could be enhanced by with a ML algorithm using a k-NN approach when NGAL is not available. Additional studies are needed to verify performance of ML for burn-related AKI.

Predictive Biomarkers for Acute Kidney Injury in Burn Patients

Acute kidney injury (AKI) is an independent and complicated risk factor in burn patients, which cause high mortality and morbidity rate. Diagnosing the biomarkers and early detection of AKI may be helpful in treatment and control the stability of these patients. In this study, we aim to identify predictive biomarkers in order to prevent AKI incidence and sudden death in burn victims. In this retrospective study, 258 burn patients who were admitted to burn center in Shiraz, Iran were evaluated during January 2016 to February 2018. Demographic characteristics, biochemical biomarkers, length of hospital stay, and mortality information were obtained from patient registries program and evaluated the biomarkers in identifying AKI patients into early and late groups. Receiver operating characteristic curve, area under the curve (AUC), univariate, and multivariate logistic regression analysis were used to diagnose the performance of biomarkers in order to predict the AKI. Of 258 patients, 40 (15.50%) were detected as AKI, with estimated mortality rate of 76.9%. Among all the variables, total BSA (P = .01), blood urea nitrogen (BUN; P = .001), potassium (P = .02), and mortality (P = .03) were significantly different in AKI developing. Moreover, AUC of serum creatinin, albumin, and BUN as predictive biomarkers were 0.73, 0.44, and 0.707, respectively. Among all variables, BUN marker was independently associated with AKI developing. Following burn shock, AKI is a common complication that causes increasing mortality and morbidity. Early diagnosis and identifying the biomarkers is preventing sudden death in burn patients and develop appropriate treatments in these victims.

Prediction of major adverse kidney events in critically ill burn patients

OBJECTIVE

We aimed at assessing the predictive value of plasmatic Neutrophil Gelatinase Associated Lipocalin (pNGAL) at admission and severity scores to predict major adverse kidney events (MAKE, defined as death and/or need for renal replacement therapy (RRT) and/or non-renal recovery at day 90) in critically ill burn patients.

MATERIAL AND METHODS

Single-center cohort study in a burn critical care unit in a tertiary center, including all consecutive severely burn patients (total burned body surface >20%) from January 2012 until January 2015 with a pNGAL dosage at admission. Reclassification of patients was assessed by Integrated Discrimination Improvement (IDI).

MEASUREMENTS AND RESULTS

87 patients were included. Mean age was 47.7 (IQ 25-75: 33.4-65.2) years; total burn body surface area was 40 (IQ 25-75: 30-55) % and ICU mortality 36%. 39 (44.8%) patients presented a MAKE, 32 (88.9%) patients died at day 90. pNGAL was higher in the MAKE group (423 [IQ 25-75: 327-518]pg/mL vs 184 [IQ 25-75: 147-220]pg/mL, p<0.001). In multivariate analysis, pNGAL and abbreviated burn severity index (ABSI) remained associated with MAKE (OR 1.005 [CI 95% 1.0005-1.009], p=0.03 and OR 1.682 [CI95%1.038-2.726], p=0.035 respectively). Adding pNGAL to abbreviated burn severity index, simplified organ failure assessment and the simplified acute physiology score 2 did outperform clinical scores for the prediction of MAKE and AKI and for most severe forms of AKI and allowed a statistically significant reclassification of patients compared to ABSI for MAKE, RRT, AKI at Day 7 and AKI during hospitalization with a number of patients needed to screen to detect one extra episode of MAKE was 44, 13 for severe AKI and 15 for AKI.

CONCLUSIONS

pNGAL at admission is associated with the risk of MAKE in this population, and outperform severity scores when associated. Interventional studies are now needed to assess if impact of biomarkers-guided strategies would improve outcome.

Risk Factors for Acute Kidney Injury in Patients With Burn Injury: A Meta-Analysis and Systematic Review

Acute kidney injury (AKI) is a fatal complication of burn injury. Few systematic reviews to date have focused on the risk factors predisposing to AKI in patients with burn injury. The aim of this article is to identify the risk factors for the occurrence of AKI in burn patients, thus providing theoretical evidence for prevention and treatment. We performed a systematic review and meta-analysis of studies determining the prevalence, risk factors, and outcomes of AKI in patients with burn injury. An electronic search (up to April 2016) was performed using Pubmed, Embase, Web of Knowledge, and the Cochrane Library databases. Finally, a total of 18 articles (nine prospective cohort, seven retrospective cohort, two case-control) meeting the eligibility criteria were included. The pooled incidence of AKI was 39.6% (95% confidence interval = 34.7-44.4%). Significant risk factors for the occurrence of AKI included age (odds ratio [OR] = 3.78 [1.28-6.27]), TBSA (OR = 15.66 [11.01-20.31]), full-thickness TBSA (OR = 15.66 [11.01-20.31]), flame burn (OR = 1.56 [1.09-2.25]), inhalation injury (OR = 2.97 [1.80-4.89]), abbreviated burn severity index on admission (OR = 2.42 [1.87-2.98]), sequential organ failure assessment score on admission (OR = 2.69 [1.39-3.98]), baseline blood urea nitrogen (OR = 2.11 [0.72-3.51]), serum creatinine (OR = 2.69 [1.39-3.98]), and sepsis (OR = 4.42 [1.75-11.18]). In addition, burn patients with AKI are more likely to have long stay in intensive care unit and high mortality. AKI is a common complication and occurs at a remarkable rate in burn patients. We identified 10 variables as independent risk factors for the development of AKI in burn patients. Our findings may help clinicians to develop effective preventive and therapeutic strategies and provide appropriate, timely initial treatment.

Neutrophil Gelatinase-associated Lipocalin as a Predictor of Acute Kidney Injury in Patients during Treatment with Colistimethate Sodium

Background

The emergence of multidrug-resistant, Gram-negative bacteria has resulted in reconsideration of colistimethate sodium (CMS) as a last resort for treatment of such infections. However, acute kidney injury (AKI) may represent a major limiting adverse effect of use of CMS. Early AKI detection in CMS-treated patients can help prevent progression to acute failure and reduce the need of renal replacement therapy. We hypothesized that plasma neutrophil gelatinase-associated lipocalin (NGAL) may be an early biomarker of AKI in CMS-treated patients.

Materials and Methods

This prospective cohort study included patients aged ≥20 years who received intravenous CMS between March 2014 and November 2015. AKI was defined according to Kidney Disease: Improving Global Outcomes criteria. The primary endpoint was the difference between the average time to AKI onset based on serum creatinine and empirically derived plasma NGAL levels.

Results

Among 109 CMS-treated patients, 23 patients (mean age, 61.3 ± 16.1 years; men, 65.2%) were evaluated. Thirteen (56.5%) patients fulfilled the AKI criteria. The mean time to AKI onset based on serum creatinine after CMS initiation was 78.15 ± 30.49 hours. AKI was detected approximately 22 hours earlier using plasma NGAL than when using serum creatinine as an indicator of AKI (P = 0.035). The baseline plasma NGAL level was 264.0 ± 167.3 ng/mL and 192.7 ± 65.3 ng/mL in patients with and without AKI, respectively (P = 0.218). The area under the curve for plasma NGAL level at 56 hours was 0.796 (95% confidence interval, 0.609–0.983; P = 0.017), with a sensitivity and specificity of 69.2% and 90.0%, respectively (cutoff value, 285 ng/mL).

Conclusion

NGAL level was found to be a strong predictor of AKI. This study provides additional evidence of the utility of NGAL for AKI in patients with treated CMS. Plasma NGAL represent sensitive and specific predictive early biomarkers for AKI in patient treated CMS.

Prospective observational study of point-of-care creatinine in trauma

Background

Patients with trauma are at risk for renal dysfunction from hypovolemia or urological injury. In austere environments, creatinine values are not available to guide resuscitation. A new portable device, the Stat Sensor Point-of-care (POC) Whole Blood Creatinine Analyzer, provides accurate results in <30 s and requires minimal training. This device has not been evaluated in trauma despite the theoretical benefit it provides. The purpose of this study is to determine the clinical impact of the POC device in trauma.

Methods

40 patients with trauma were enrolled in a prospective observational study. One drop of blood was used for creatinine determination on the Statsensor POC device. POC creatinine results were compared to the laboratory. Turnaround time (TAT) for POC and laboratory methods was calculated as well as time elapsed to CT scan if applicable.

Results

Patients (n=40) were enrolled between December 2014 and March 2015. POC creatinine values were similar to laboratory methods with a mean bias of 0.075±0.27 (p=0.08). Mean analytical TATs for the POC measurements were significantly faster than the laboratory method (11.6±10.0 min vs 78.1±27.9 min, n=40, p<0.0001). Mean elapsed time before arrival at the CT scanner was 52.9±34.2 min.

Conclusions

The POC device reported similar creatinine values to the laboratory and provided significantly faster results. POC creatinine testing is a promising development for trauma practice in austere environments and workup of a subset of stable patients with trauma. Further study is warranted to determine clinical impact, both in hospital-based trauma and austere environments.

Intraoperative biomarkers in renal transplantation

The emerging need for biomarkers in the management of renal transplantation is highlighted by the severity of related complications such as acute renal failure and ischaemia/reperfusion injury (IRI) and by the increasing efforts to identify novel markers of these events to predict and monitor delayed graft function (DGF) and long-term outcome. In clinical studies candidate markers such as kidney injury molecule-1, neutrophil gelatinase-associated lipocalin and interleukin-18 have been demonstrated to be valid biomarkers with high predictive value for DFG in a post-transplant setting. However, studies investigating biomarkers for early diagnosis of IRI and assumable DGF as well as identification of potential graft recipients at increased risk at the time point of transplantation lack further confirmation and translation into clinical practice. This review summarizes the current literature on the value of IRI biomarkers in outcome prediction following renal transplantation as well their capacity as surrogate end points from an intraoperative perspective.