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CCL-2 and CXCL-8: Potential Prognostic Biomarkers of Acute Kidney Injury after a Bothrops atrox Snakebite. Mediators Inflamm 2022; 2022:8285084. [PMID: 36117588 PMCID: PMC9473908 DOI: 10.1155/2022/8285084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/10/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022] Open
Abstract
In the Brazilian Amazon, the snake Bothrops atrox is the primary cause of snakebites. B. atrox (BaV) venom can cause systemic pathophysiological changes such as acute kidney injury (AKI), which leads to the production of chemokines and cytokines in response to the envenomation. These soluble immunological molecules act by modulating the inflammatory response; however, the mechanisms associated with the development of AKI are still poorly understood. Here, we characterize the profile of these soluble immunological molecules as possible predictive biomarkers of the development of AKI. The study involved 34 patients who had been victims of snakebites by Bothrops sp. These were categorized into two groups according to the development of AKI (AKI(-)/AKI(+)), using healthy donors as the control (HD). Peripheral blood samples were collected at three-time points: before antivenom administration (T0) and at 24 and 48 hours after antivenom (T1 and T2, respectively). The soluble immunological molecules (CXCL-8, CCL-5, CXCL-9, CCL-2, CXCL-10, IL-6, TNF, IL-2, IL-10, IFN-γ, IL-4, and IL-17A) were quantified using cytometric bead array. Our results demonstrated an increase in CXCL-9, CXCL-10, IL-6, IL-2, IL-10, and IL-17A molecules in the groups of patients who suffered Bothrops snakebites (AKI(-) and AKI(+)) before antivenom administration, when compared to HD. In the AKI(+) group, levels of CXCL-8 and CCL-2 molecules were elevated on admission and progressively decreased during the clinical evolution of patients after antivenom administration. In addition, in the signature analysis, these were produced exclusively by the group AKI(+) at T0. Thus, these chemokines may be related to the initiation and extension of AKI after envenomation by Bothrops and present themselves as two potential biomarkers of AKI at T0.
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2
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Uduman J, Yee J. Urine Sediment Exam Provides More Diagnostic Information in AKI than Novel Urinary Biomarkers: COMMENTARY. KIDNEY360 2022; 3:604-607. [PMID: 35727717 PMCID: PMC9136908 DOI: 10.34067/kid.0005562021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 06/15/2023]
Affiliation(s)
- Junior Uduman
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, Michigan
- Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Jerry Yee
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, Michigan
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Wen Y, Thiessen-Philbrook H, Moledina DG, Kaufman JS, Reeves WB, Ghahramani N, Ikizler TA, Go AS, Liu KD, Siew ED, Himmelfarb J, Kimmel PL, Hsu CY, Parikh CR. Considerations in Controlling for Urine Concentration for Biomarkers of Kidney Disease Progression After Acute Kidney Injury. Kidney Int Rep 2022; 7:1502-1513. [PMID: 35812275 PMCID: PMC9263319 DOI: 10.1016/j.ekir.2022.03.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/18/2022] [Accepted: 03/28/2022] [Indexed: 01/07/2023] Open
Abstract
Introduction Biomarkers of acute kidney injury (AKI) are often indexed to urine creatinine (UCr) or urine osmolarity (UOsm) to control for urine concentration. We evaluated how these approaches affect the biomarker-outcome association in patients with AKI. Methods The Assessment, Serial Evaluation, and Subsequent Sequelae in Acute Kidney Injury Study was a cohort of hospitalized patients with and without AKI between 2009 and 2015. Using Cox proportional hazards regression, we assessed the associations and predictions (C-statistics) of urine biomarkers with a composite outcome of incident chronic kidney disease (CKD) and CKD progression. We used 4 approaches to account for urine concentration: indexing and adjusting for UCr and UOsm. Results Among 1538 participants, 769 (50%) had AKI and 300 (19.5%) developed composite CKD outcome at median follow-up of 4.7 years. UCr and UOsm during hospitalization were inversely associated with the composite CKD outcome. The associations and predictions with CKD were significantly strengthened after indexing or adjusting for UCr or UOsm for urine kidney injury molecule-1 (KIM-1), interleukin-18 (IL-18), and monocyte chemoattractant protein-1 (MCP-1) in patients with AKI. There was no significant improvement with indexing or adjusting UCr or UOsm for albumin, neutrophil gelatinase-associated lipocalin (NGAL), and chitinase 3-like 1 (YKL-40). Uromodulin's (UMOD) inverse association with the outcome was significantly blunted after indexing but not adjusting for UCr or UOsm. Conclusion UCr and UOsm during hospitalization are inversely associated with development and progression of CKD. Indexing or adjusting for UCr or UOsm strengthened associations and improved predictions for CKD for only some biomarkers. Incorporating urinary concentration should be individualized for each biomarker in research and clinical applications.
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Affiliation(s)
- Yumeng Wen
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Heather Thiessen-Philbrook
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dennis G. Moledina
- Clinical and Translational Research Accelerator, Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James S. Kaufman
- Division of Nephrology, Department of Medicine, New York University School of Medicine, New York, New York, USA,Department of Medicine, Veterans Affairs New York Harbor Health Care System, New York, New York, USA
| | - W. Brian Reeves
- Department of Medicine, Joe R. and Teresa Lozano Long School of Medicine, University of Texas San Antonio, Texas, USA
| | - Nasrollah Ghahramani
- Division of Nephrology, Department of Medicine, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - T. Alp Ikizler
- Division of Nephrology, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Alan S. Go
- Kaiser Permanente Division of Research, Oakland, California, USA
| | - Kathleen D. Liu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Eddie D. Siew
- Division of Nephrology, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Jonathan Himmelfarb
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Paul L. Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Chi-yuan Hsu
- Kaiser Permanente Division of Research, Oakland, California, USA,Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Chirag R. Parikh
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Correspondence: Chirag R. Parikh, Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 416, Baltimore, Maryland 21205, USA.
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4
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El-Khoury JM, Hoenig MP, Jones GRD, Lamb EJ, Parikh CR, Tolan NV, Wilson FP. AACC Guidance Document on Laboratory Investigation of Acute Kidney Injury. J Appl Lab Med 2021; 6:1316-1337. [PMID: 33973621 DOI: 10.1093/jalm/jfab020] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a sudden episode of kidney damage or failure affecting up to 15% of hospitalized patients and is associated with serious short- and long-term complications, mortality, and health care costs. Current practices to diagnose and stage AKI are variable and do not factor in our improved understanding of the biological and analytical variability of creatinine. In addition, the emergence of biomarkers, for example, cystatin C, insulin-like growth factor binding protein 7, and tissue inhibitor of metalloproteinases 2, and electronic notification tools for earlier detection of AKI, highlights the need for updated recommendations to address these developments. CONTENT This AACC Academy guidance document is intended to provide laboratorians and clinicians up-to-date information regarding current best practices for the laboratory investigation of AKI. Topics covered include: clinical indications for further investigating potential AKI, analytical considerations for creatinine assays, the impact of biological variability on diagnostic thresholds, defining "baseline" creatinine, role of traditional markers (urine sodium, fractional excretion of sodium, fractional excretion of urea, and blood urea-to-creatinine ratio), urinary microscopic examination, new biomarkers, improving AKI-associated test utilization, and the utility of automated AKI alerts. SUMMARY The previous decade brought us a significant number of new studies characterizing the performance of existing and new biomarkers, as well as potential new tools for early detection and notification of AKI. This guidance document is intended to inform clinicians and laboratorians on the best practices for the laboratory investigation of AKI, based on expert recommendations where the preponderance of evidence is available.
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Affiliation(s)
- Joe M El-Khoury
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Melanie P Hoenig
- Renal Division, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Edmund J Lamb
- Department of Pathology, East Kent Hospitals University NHS Foundation Trust, Kent, UK
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins University, Baltimore, MD, USA
| | - Nicole V Tolan
- Department of Pathology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - F Perry Wilson
- Program of Applied Translational Research, Yale School of Medicine, New Haven, CT, USA
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5
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Karras A, Livrozet M, Lazareth H, Benichou N, Hulot JS, Fayol A, Chauvet S, Jannot AS, Penet MA, Diehl JL, Godier A, Sanchez O, Mirault T, Thervet E, Pallet N. Proteinuria and Clinical Outcomes in Hospitalized COVID-19 Patients: A Retrospective Single-Center Study. Clin J Am Soc Nephrol 2021; 16:514-521. [PMID: 33661756 PMCID: PMC8092053 DOI: 10.2215/cjn.09130620] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 01/14/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Kidney involvement is frequent among patients with coronavirus disease 2019 (COVID-19), and occurrence of AKI is associated with higher mortality in this population. The objective of this study was to describe occurrence and significance of proteinuria in this setting. DESIGN , SETTING, PARTICIPANTS MEASUREMENTS We conducted a single-center retrospective study to describe the characteristic features of proteinuria measured within 48 hours following admission among patients with COVID-19 admitted in a tertiary care hospital in France, and to evaluate its association with initiation of dialysis, intensive care unit admission, and death. RESULTS Among 200 patients with available data, urine protein-creatinine ratio at admission was ≥1 g/g for 84 (42%), although kidney function was normal in most patients, with a median serum creatinine of 0.94 mg/dl (interquartile range, 0.75-1.21). Median urine albumin-creatinine ratio was 110 mg/g (interquartile range, 50-410), with a urine albumin-protein ratio <50% in 92% of patients. Urine retinol binding protein concentrations, available for 85 patients, were ≥0.03 mg/mmol in 62% of patients. Urine protein-creatinine ratio ≥1 g/g was associated with initiation of dialysis (odds ratio, 4.87; 95% confidence interval, 2.03 to 13.0; P <0.001), admission to the intensive care unit (odds ratio, 3.55; 95% confidence interval, 1.93 to 6.71; P <0.001), and death (odds ratio, 3.56; 95% confidence interval, 1.90 to 6.54; P <0.001). CONCLUSIONS Proteinuria is very frequent among patients admitted for COVID-19 and may precede AKI. Low levels of albuminuria suggest a predominant tubular origin, confirmed by the elevated levels of urine retinol binding protein. Urine protein-creatinine ratio ≥1 g/g at admission is strongly associated with poor kidney and patient outcome.
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Affiliation(s)
- Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France,Université de Paris, Paris, France
| | - Marine Livrozet
- Université de Paris, Paris, France,Centre d'Investigation Clinique1418 and Departement Medico-Universitaire, CArdiologie Rein Transplantation nEurovasculaire, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Hélène Lazareth
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France,Université de Paris, Paris, France
| | - Nicolas Benichou
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France,Université de Paris, Paris, France
| | - Jean-Sébastien Hulot
- Université de Paris, Paris, France,Centre d'Investigation Clinique1418 and Departement Medico-Universitaire, CArdiologie Rein Transplantation nEurovasculaire, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Antoine Fayol
- Université de Paris, Paris, France,Centre d'Investigation Clinique1418 and Departement Medico-Universitaire, CArdiologie Rein Transplantation nEurovasculaire, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sophie Chauvet
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France,Université de Paris, Paris, France
| | - Anne-Sophie Jannot
- Université de Paris, Paris, France,Department of Bioinformatics, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marie-Aude Penet
- Université de Paris, Paris, France,Department of Internal Medicine, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Luc Diehl
- Université de Paris, Paris, France,Department of Intensive Care Medicine, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Anne Godier
- Université de Paris, Paris, France,Department of Anaesthesiology and Intensive Care, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Olivier Sanchez
- Université de Paris, Paris, France,Department of Pneumology and Intensive Care, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Tristan Mirault
- Université de Paris, Paris, France,Department of Vascular Medicine, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Eric Thervet
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France,Université de Paris, Paris, France
| | - Nicolas Pallet
- Université de Paris, Paris, France,Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
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6
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Nunes N, Popović I, Abreu E, Maciel D, Rodrigues J, Soto J, Algarra M, Petković M. Detection of Ru potential metallodrug in human urine by MALDI-TOF mass spectrometry: Validation and options to enhance the sensitivity. Talanta 2021; 222:121551. [PMID: 33167254 DOI: 10.1016/j.talanta.2020.121551] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/08/2020] [Accepted: 08/12/2020] [Indexed: 02/05/2023]
Abstract
We studied the possibility of detection of [Ru(η5-C5H5)(PPh3)2Cl] (abbreviated by RuCp) complex as a model system for Ru-based metallodrugs in human urine by using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) without previous purification or removal of inorganic salts. Inorganic salts might prevent the detection of RuCp by MALDI-TOF MS, most likely through the increased number and intensity of background/organic matrix signals. This problem might be overcome by the acquisition of matrix-free spectra and the addition of nanoparticles, such as carbon dots, to the urine solution. Our results suggest that RuCp is easily detectable by MALDI-TOF MS in all acquisition conditions, with the CHCA matrix being the best for acquisition in phosphate-containing solutions, whereas in urine, DHB and matrix-free approach demonstrated the highest sensitivity, precision, and reproducibility. The sensitivity of matrix-free MALDI detection of RuCp could be increased by the addition of carbon dots to the urine. Based on theoretical calculations for all matrix/analyte combinations, the model for the interaction of RuCp with carbon dots was established, and higher sensitivity explained.
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Affiliation(s)
- Nádia Nunes
- CQM-Centro de Química da Madeira, Universidade da Madeira, Campus da Penteada, 9020-105, Funchal, Portugal
| | - Iva Popović
- Department of Atomic Physics, VINČA Institute of Nuclear Sciences, University of Belgrade, Belgrade, Serbia
| | - Elder Abreu
- CQM-Centro de Química da Madeira, Universidade da Madeira, Campus da Penteada, 9020-105, Funchal, Portugal
| | - Dina Maciel
- CQM-Centro de Química da Madeira, Universidade da Madeira, Campus da Penteada, 9020-105, Funchal, Portugal
| | - João Rodrigues
- CQM-Centro de Química da Madeira, Universidade da Madeira, Campus da Penteada, 9020-105, Funchal, Portugal; School of Materials Science and Engineering, Center for Nano Energy Materials, Northwestern Polytechnical University, Xi'an, 710072, China
| | - Juan Soto
- Department of Physical Chemistry, Faculty of Science, University of Málaga, Campus de Teatinos s/n, 29071, Malaga, Spain
| | - Manuel Algarra
- Department of Inorganic Chemistry, Faculty of Science, University of Málaga, Campus de Teatinos s/n, 29071, Malaga, Spain.
| | - Marijana Petković
- CQM-Centro de Química da Madeira, Universidade da Madeira, Campus da Penteada, 9020-105, Funchal, Portugal.
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7
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Nunes N, Popović I, Abreu E, Maciel D, Rodrigues J, Soto J, Algarra M, Petković M. Detection of Ru potential metallodrug in human urine by MALDI-TOF mass spectrometry: Validation and options to enhance the sensitivity. Talanta 2021. [DOI: https://doi.org/10.1016/j.talanta.2020.121551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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8
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Bonavia A, Vece G, Karamchandani K. Prerenal acute kidney injury—still a relevant term in modern clinical practice? Nephrol Dial Transplant 2020; 36:1570-1577. [DOI: 10.1093/ndt/gfaa061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/24/2020] [Indexed: 12/11/2022] Open
Abstract
Abstract
The traditional taxonomy of acute kidney injury (AKI) has remained pervasive in clinical nephrology. While the terms ‘prerenal’, ‘intrarenal’ and ‘postrenal’ highlight the diverse pathophysiology underlying AKI, they also imply discrete disease pathways and de-emphasize the nature of AKI as an evolving clinical syndrome with multiple, often simultaneous and overlapping, causes. In a similar vein, prerenal AKI comprises a diverse spectrum of kidney disorders, albeit one that is often managed by using a standardized clinical algorithm. We contend that the term ‘prerenal’ is too vague to adequately convey our current understanding of hypoperfusion-related AKI and that it should thus be avoided in the clinical setting. Practice patterns among nephrologists indicate that AKI-related terminology plays a significant role in the approaches that clinicians take to patients that have this complex disease. Thus, it appears that precise terminology does impact the treatment that patients receive. We will outline differences in the diagnosis and management of clinical conditions lying on the so-called prerenal disease spectrum to advocate caution when administering intravenous fluids to these clinically decompensated patients. An understanding of the underlying pathophysiology may, thus, avert clinical missteps such as fluid and vasopressor mismanagement in tenuous or critically ill patients.
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Affiliation(s)
- Anthony Bonavia
- Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Pharmacology, Penn State College of Medicine, Hershey, PA, USA
| | - Gregory Vece
- The Pennsylvania State College of Medicine, Hershey, PA, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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9
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Zhang M, Jiang Y, Zhang Q, Chen Y, He Y, Lin Y, Peng H. Bidirectional and Temporal Association Between Hypertension and Microalbuminuria: A Longitudinal Study in Chinese Adults. J Am Heart Assoc 2019; 7:e010723. [PMID: 30571489 PMCID: PMC6404448 DOI: 10.1161/jaha.118.010723] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Although hypertension and microalbuminuria are closely interrelated, the magnitude and temporal sequence of the bidirectional association between hypertension and microalbuminuria are largely unknown. We aimed to delineate the bidirectional and temporal relationship between hypertension and microalbuminuria. Methods and Results Leveraging a longitudinal cohort of Chinese adults who had blood pressure and urinary albumin measured twice 4 years apart, we examined the temporal association between hypertension and microalbuminuria by bidirectional and cross-lagged panel analysis. All participants were free of cardiovascular disease and chronic kidney disease at baseline. Bidirectional association analysis found that baseline microalbuminuria predicted the risk of incident hypertension (odds ratio=1.75, P=0.028), and baseline blood pressure also significantly predicted the risk of microalbuminuria (odds ratios=1.27 and 1.21 for a per-SD increase in systolic and diastolic blood pressure, respectively; all P<0.05). Cross-lagged panel analysis demonstrated a bottom-line significant relationship of baseline systolic blood pressure to follow-up urinary albumin ( P=0.079), which is significantly weaker than the other direction of the relationship of baseline urinary albumin to follow-up blood pressures (all P<0.001). Conclusions These findings indicate a significant bidirectional association between microalbuminuria and hypertension in Chinese adults. Elevated urinary albumin excretion is more likely to precede hypertension. The causality between microalbuminuria and hypertension needs further investigation.
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Affiliation(s)
- Mingzhi Zhang
- 1 Department of Epidemiology School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases Medical College of Soochow University Suzhou China
| | - Yanbo Jiang
- 1 Department of Epidemiology School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases Medical College of Soochow University Suzhou China
| | - Qiu Zhang
- 3 Department of Chronic Disease Management Center for Disease Prevention and Control of Gusu District Suzhou China
| | - Yan Chen
- 4 Department of Nephrology The Affiliated Jiangyin Hospital of Southeast University Medical College Jiangyin China
| | - Yan He
- 1 Department of Epidemiology School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases Medical College of Soochow University Suzhou China
| | - Yao Lin
- 2 The State Key Laboratory of Radiation Medicine and Protection Medical College of Soochow University Suzhou China
| | - Hao Peng
- 1 Department of Epidemiology School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases Medical College of Soochow University Suzhou China
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10
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Biochemical Markers of Renal Hypoperfusion, Hemoconcentration, and Proteinuria after Extreme Physical Exercise. ACTA ACUST UNITED AC 2019; 55:medicina55050154. [PMID: 31108972 PMCID: PMC6571854 DOI: 10.3390/medicina55050154] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/18/2019] [Accepted: 05/15/2019] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Physical exercise increases the blood perfusion of muscles, but decreases the renal blood flow. There are several markers of renal hypoperfusion which are used in the differential diagnosis of acute kidney failure. Albuminuria is observed after almost any exercise. The aim of this study was to assess changes in renal hypoperfusion and albuminuria after a 100-km race. Materials and Methods: A total of 27 males who finished a 100-km run were studied. The mean age of the runners was 38.04 ± 5.64 years. The exclusion criteria were a history of kidney disease, glomerular filtration rate (GFR) <60 ml/min, and proteinuria. Blood and urine were collected before and after the race. The urinary albumin/creatinine ratio (ACR), fractional excretion of urea (FeUrea) and sodium (FeNa), plasma urea/creatinine ratio (sUrea/Cr), urine/plasma creatinine ratio (u/pCr), urinary sodium to potassium ratio (uNa/K), and urinary potassium to urinary potassium plus sodium ratio (uK/(K+Na)) were calculated. Results: After the race, significant changes in albuminuria and markers of renal hypoperfusion (FeNa, FeUrea, sUrea/Cr, u/sCr, urinary Na, uNa/K, uK/(K+Na)) were found. Fifteen runners (55.56%) had severe renal hypoperfusion (FeUrea <35, uNa/K <1, and uK/(Na+K) >0.5) after the race. The mean ACR increased from 6.28 ± 3.84 mg/g to 48.43 ± 51.64 mg/g (p < 0.001). The ACR was higher in the group with severe renal hypoperfusion (59.42 ± 59.86 vs. 34.68 ± 37.04 mg/g), but without statistical significance. Conclusions: More than 50% of the runners had severe renal hypoperfusion after extreme exercise. Changes in renal hemodynamics are probably an important, but not the only, factor of post-exercise proteinuria.
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11
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Abstract
OBJECTIVES Serum creatinine (SCr) is a late marker of acute kidney injury (AKI) due to the lag time between initiating injury and loss of function. We assessed the ability of urinary interleukin-18 (IL-18), kidney injury molecule-1 (KIM-1), and neutrophil gelatinase-associated lipocalin (NGAL) to predict AKI in critically ill children with circulatory collapse. METHODS Serum creatinine, estimated creatinine clearance (eCrCL), urine IL-18, KIM-1, and NGAL values were measured in 86 children with circulatory collapse on the day of admission, and the results were compared with those obtained 6 days later. Acute kidney injury was defined as a decrease in eCrCL of greater than 25% within the first 48 hours of enrollment. Areas under the curve (AUC) for receiver operating characteristic curve were calculated for the early detection of AKI. RESULTS Mean SCr concentration did not differ significantly during the first 6 days of hospital admission. In contrast, mean urine concentrations of IL-18, KIM-1, and NGAL rose significantly from day of admission to the sixth day of hospital stay (P < 0.001). Urinary KIM-1 emerged as having the strongest performance for the early detection of AKI, followed by NGAL, IL-18, and eCrCL. Urinary KIM-1 displayed the highest AUC of 0.81 (95% confidence interval [CI], 0.76-0.93; P < 0.001) for the early detection of AKI after circulatory collapse, followed by NGAL (0.77% CI, 0.70-0.84) and IL-18 (0.69% CI, 0.48-0.64). CONCLUSIONS Of a panel of 3 promising urinary biomarkers, KIM-1 demonstrated the best performance in predicting AKI in children with circulatory collapse before a change in SCr or eCrCL becomes apparent.
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12
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Palmer BF, Clegg DJ. The Use of Selected Urine Chemistries in the Diagnosis of Kidney Disorders. Clin J Am Soc Nephrol 2019; 14:306-316. [PMID: 30626576 PMCID: PMC6390907 DOI: 10.2215/cjn.10330818] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Urinary chemistries vary widely in both health and disease and are affected by diet, volume status, medications, and disease states. When properly examined, these tests provide important insight into the mechanism and therapy of various clinical disorders that are first detected by abnormalities in plasma chemistries. These tests cannot be interpreted in isolation, but instead require knowledge of key clinical information, such as medications, physical examination, and plasma chemistries, to include kidney function. When used appropriately and with knowledge of limitations, urine chemistries can provide important insight into the pathophysiology and treatment of a wide variety of disorders.
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Affiliation(s)
- Biff F Palmer
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Deborah Joy Clegg
- Department of Internal Medicine, University of California, Los Angeles School of Medicine, Los Angeles, California
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13
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Urinary Biochemistry in the Diagnosis of Acute Kidney Injury. DISEASE MARKERS 2018; 2018:4907024. [PMID: 30008975 PMCID: PMC6020498 DOI: 10.1155/2018/4907024] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/03/2018] [Accepted: 05/20/2018] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI) is a common complication, impacting short- and long-term patient outcomes. Although the application of the classification systems for AKI has improved diagnosis, early clinical recognition of AKI is still challenging, as increments in serum creatinine may be late and low urine output is not always present. The role of urinary biochemistry has remained unclear, especially in critically ill patients. Differentiating between a transient and persistent acute kidney injury is of great need in clinical practice, and despite studies questioning their application in clinical practice, biochemistry indices continue to be used while we wait for a novel early injury biomarker. An ideal marker would provide more detailed information about the type, intensity, and location of the injury. In this review, we will discuss factors affecting the fractional excretion of sodium (FeNa) and fractional excretion of urea (FeU). We believe that the frequent assessment of urinary biochemistry and microscopy can be useful in evaluating the likelihood of AKI reversibility. The availability of early injury biomarkers could help guide clinical interventions.
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Srisawat N, Sintawichai N, Kulvichit W, Lumlertgul N, Sitticharoenchai P, Thamrongsat N, Peerapornratana S. Current practice of diagnosis and management of acute kidney injury in intensive care unit in resource limited settings. J Crit Care 2018; 46:44-49. [PMID: 29669237 DOI: 10.1016/j.jcrc.2018.04.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/28/2018] [Accepted: 04/09/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE In a resource limited settings, there is sparse information about the management of acute kidney injury (AKI) based on systemic data collection. This survey aimed to described the current management of AKI in intensive care units (ICUs) across Thailand. MATERIALS AND METHODS Questionnaires were distributed to 160 physicians involved in the intensive care between January and December 2014 across Thailand. Distribution was done through an online survey platform or telephone interview. RESULTS The response rate was 80.6% (129 physicians). AKI diagnosis was mostly made by using KDIGO criteria (36.7%). A common diagnostic investigation of AKI was urinalysis (86%). Nephrologists had a major role (86.4%) in deciding the initiation and selection of renal replacement therapy (RRT) modality. Intermittent hemodialysis is the preferable mode of RRT (72.0%), followed by continuous renal replacement therapy (CRRT, 12%), sustained low efficiency dialysis (10.0%) and peritoneal dialysis (6.0%). Catheter insertion was predominantly performed by nephrologist (51.1%) with ultrasound guidance. The right internal jugular vein was the most common site of insertion (70.4%). The most common indication for CRRT was hemodynamic instability. CONCLUSIONS Amid increasing concern of AKI in the ICU, our study provides the insight into the management of AKI in resource limited settings.
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Affiliation(s)
- Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
| | - Nattaya Sintawichai
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Win Kulvichit
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Nuttha Lumlertgul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Patita Sitticharoenchai
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nicha Thamrongsat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Sadudee Peerapornratana
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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15
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Abstract
Background Fluid resuscitation is not only used to prevent acute kidney injury (AKI) but fluid management is also a cornerstone of treatment for patients with established AKI and renal failure. Ultrafiltration removes volume initially from the intravascular compartment inducing a relative degree of hypovolemia. Normal reflex mechanisms attempt to sustain blood pressure constant despite marked changes in blood volume and cardiac output. Thus, compensated shock with a normal blood pressure is a major cause of AKI or exacerbations of AKI during ultrafiltration. Methods We undertook a systematic review of the literature using MEDLINE, Google Scholar and PubMed searches. We determined a list of key questions and convened a 2-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated clinical practice recommendations and/or directions for future research. Results We defined three aspects of fluid monitoring: i) normal and pathophysiological cardiovascular mechanisms; ii) measures of volume responsiveness and impending cardiovascular collapse during volume removal, and; iii) measured indices of each using non-invasive and minimally invasive continuous and intermittent monitoring techniques. The evidence documents that AKI can occur in the setting of normotensive hypovolemia and that under-resuscitation represents a major cause of both AKI and mortality ion critically ill patients. Traditional measures of intravascular volume and ventricular filling do not predict volume responsiveness whereas dynamic functional hemodynamic markers, such as pulse pressure or stroke volume variation during positive pressure breathing or mean flow changes with passive leg raising are highly predictive of volume responsiveness. Numerous commercially-available devices exist that can acquire these signals. Conclusions Prospective clinical trials using functional hemodynamic markers in the diagnosis and management of AKI and volume status during ultrafiltration need to be performed. More traditional measure of preload be abandoned as marked of volume responsiveness though still useful to assess overall volume status.
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Affiliation(s)
- M.R. Pinsky
- Bioengineering, Cardiovascular Diseases and Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA - USA
| | - P. Brophy
- Division of Pediatric Nephrology, Hypertension, Dialysis and Transplantation, University of Iowa, Children's Hospital, Iowa City, Iowa - USA
| | - J. Padilla
- Universidad de Iberoamerica, San Jose - Costa Rica
| | - E. Paganini
- Division of Nephrology, Cleveland Clinic Foundation, Cleveland, OH - USA
| | - N. Pannu
- Division of Nephrology and CCM, University of Alberta, Edmonton, Alberta - Canada
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16
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Mohsenin V. Practical approach to detection and management of acute kidney injury in critically ill patient. J Intensive Care 2017; 5:57. [PMID: 28932401 PMCID: PMC5603084 DOI: 10.1186/s40560-017-0251-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 09/10/2017] [Indexed: 12/29/2022] Open
Abstract
Background Acute kidney injury (AKI) is a common complication in critically ill patients and is associated with high morbidity and mortality. This paper provides a critical review of the etiologies of AKI and a systematic approach toward its diagnosis and management with emphasis on fluid volume assessment and the use of urine biochemical profile and microscopy in identifying the nature and the site of kidney injury. Materials and methods The search of PubMed and selection of papers had employed observational designs or randomized control trials relevant to AKI. Results AKI is defined by the rate of rise of serum creatinine and a decline in urine output. The pathophysiology is diverse and requires a careful and systematic assessment of predisposing factors and localization of site of injury. The majority of AKIs are due to prerenal causes such as fluid volume deficit, sepsis, or renal as in acute tubular injury. The use of central venous and arterial blood pressure monitoring and inferior vena cava echocardiography complemented by urine analysis and microscopy allows assessment of fluid volume status and AKI etiology. Conclusions Timely intervention by avoidance of fluid volume deficit and nephrotoxic agents and blood pressure support can reduce the incidence of AKI in critically ill patients.
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Affiliation(s)
- Vahid Mohsenin
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, CT USA.,Department of Medicine, Lippard Laboratory of Clinical Investigation, Yale School of Medicine, 15 York Street, LLCI-106-E, New Haven, CT 06510 USA
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17
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Abstract
Acute kidney injury (AKI) is characterized by an acute decline in renal function and is associated to increased mortality rate, hospitalization time, and total health-related costs. The severity of this ‘fearsome’ clinical complication might depend on, or even be worsened by, the late detection of AKI, when the diagnosis is based on the elevation of serum creatinine (SCr). For these reasons, in recent years a great number of new tools, biomarkers and predictive models have been proposed to clinicians in order to improve diagnosis and prevent the development of AKI. The purpose of this narrative paper is to review the current state of the art in prediction and early detection of AKI and outline future challenges.
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Affiliation(s)
- Simona Pozzoli
- Chair of Nephrology - IRCCS San Raffaele Scientific Institute, Genomics of Renal Diseases and Hypertension Unit, Università Vita Salute San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Marco Simonini
- Chair of Nephrology - IRCCS San Raffaele Scientific Institute, Genomics of Renal Diseases and Hypertension Unit, Università Vita Salute San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
| | - Paolo Manunta
- Chair of Nephrology - IRCCS San Raffaele Scientific Institute, Genomics of Renal Diseases and Hypertension Unit, Università Vita Salute San Raffaele, Via Olgettina 60, 20132, Milan, Italy
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18
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Manoeuvrier G, Bach-Ngohou K, Batard E, Masson D, Trewick D. Diagnostic performance of serum blood urea nitrogen to creatinine ratio for distinguishing prerenal from intrinsic acute kidney injury in the emergency department. BMC Nephrol 2017; 18:173. [PMID: 28545421 PMCID: PMC5445342 DOI: 10.1186/s12882-017-0591-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 05/17/2017] [Indexed: 11/11/2022] Open
Abstract
Background The blood urea nitrogen to creatinine ratio (BCR) has been used since the early 1940s to help clinicians differentiate between prerenal acute kidney injury (PR AKI) and intrinsic AKI (I AKI). This ratio is simple to use and often put forward as a reliable diagnostic tool even though little scientific evidence supports this. The aim of this study was to determine whether BCR is a reliable tool for distinguishing PR AKI from I AKI. Methods We conducted a retrospective observational study over a 13 months period, in the Emergency Department (ED) of Nantes University Hospital. Eligible for inclusion were all adult patients consecutively admitted to the ED with a creatinine >133 μmol/L (1.5 mg/dL). Results Sixty thousand one hundred sixty patients were consecutively admitted to the ED. 2756 patients had plasma creatinine levels in excess of 133 μmol/L, 1653 were excluded, leaving 1103 patients for definitive inclusion. Mean age was 75.7 ± 14.8 years old, 498 (45%) patients had PR AKI and 605 (55%) I AKI. BCR was 90.55 ± 39.32 and 91.29 ± 39.79 in PR AKI and I AKI groups respectively. There was no statistical difference between mean BCR of the PR AKI and I AKI groups, p = 0.758. The area under the ROC curve was 0.5 indicating that BCR had no capacity to discriminate between PR AKI and I AKI. Conclusions Our study is the largest to investigate the diagnostic performance of BCR. BCR is not a reliable parameter for distinguishing prerenal AKI from intrinsic AKI.
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Affiliation(s)
| | - Kalyane Bach-Ngohou
- Department of Biology, Laboratory of Clinical Biochemistry, CHU Nantes, Nantes, France
| | - Eric Batard
- Department of Emergency Medicine, CHU Nantes, Nantes, France.,Service des Urgences, CHU Hotel Dieu, 44000, Nantes, France
| | - Damien Masson
- Department of Biology, Laboratory of Clinical Biochemistry, CHU Nantes, Nantes, France
| | - David Trewick
- Department of Emergency Medicine, CHU Nantes, Nantes, France. .,Service des Urgences, CHU Hotel Dieu, 44000, Nantes, France.
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Cerdá J, Mohan S, Garcia-Garcia G, Jha V, Samavedam S, Gowrishankar S, Bagga A, Chakravarthi R, Mehta R. Acute Kidney Injury Recognition in Low- and Middle-Income Countries. Kidney Int Rep 2017; 2:530-543. [PMID: 29034358 PMCID: PMC5637391 DOI: 10.1016/j.ekir.2017.04.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Acute kidney injury (AKI) is increasingly common around the world. Because of the low availability of effective therapies and resource limitations, early preventive and therapeutic measures are essential to decrease morbidity, mortality, and cost. Timely recognition and diagnosis of AKI requires a heightened degree of suspicion in the appropriate clinical and environmental context. In low- and middle-income countries (LMICs), early detection is impaired by limited resources and low awareness. In this article, we report the consensus recommendations of the 18th Acute Dialysis Quality Initiative meeting in Hyderabad, India, on how to improve recognition of AKI. We expect these recommendations will lead to an earlier and more accurate diagnosis of AKI, and improved research to promote a better understanding of the epidemiology, etiology, and histopathology of AKI in LMICs.
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Affiliation(s)
- Jorge Cerdá
- Department of Medicine, Division of Nephrology, Albany Medical College, Albany, New York, USA
- Correspondence: Jorge Cerdá, MD, MS, FACP, FASN, Division of Nephrology, Department of Medicine, Albany Medical College, Albany, NY 12209.Division of NephrologyDepartment of MedicineAlbany Medical CollegeAlbanyNY 12209
| | - Sumit Mohan
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Guillermo Garcia-Garcia
- Nephrology Service, Hospital Civil de Guadalajara “Fray Antonio Alcalde,” Hospital 278, Guadalajara, Mexico
| | - Vivekanand Jha
- George Institute for Global Health India, New Delhi and University of Oxford, Oxford, UK
| | | | | | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Ravindra Mehta
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
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Askenazi DJ, Heung M, Connor MJ, Basu RK, Cerdá J, Doi K, Koyner JL, Bihorac A, Golestaneh L, Vijayan A, Okusa M, Faubel S. Optimal Role of the Nephrologist in the Intensive Care Unit. Blood Purif 2016; 43:68-77. [PMID: 27923227 PMCID: PMC5340591 DOI: 10.1159/000452317] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
As advances in Critical Care Medicine continue, critically ill patients are surviving despite the severity of their illness. The incidence of acute kidney injury (AKI) has increased, and its impact on clinical outcomes as well as medical expenditures has been established. The role, indications and technological advancements of renal replacement therapy (RRT) have evolved, allowing more effective therapies with less complications. With these changes, Critical Care Nephrology has become an established specialty, and ongoing collaborations between critical care physicians and nephrologist have improved education of multi-disciplinary team members and patient care in the ICU. Multidisciplinary programs to support these changes have been stablished in some hospitals to maximize the delivery of care, while other programs have continue to struggle in their ability to acquire the necessary resources to maximize outcomes, educate their staff, and develop quality initiatives to evaluate and drive improvements. Clearly, the role of the nephrologist in the ICU has evolved, and varies widely among institutions. This special article will provide insights that will hopefully optimize the role of the nephrologist as the leader of the acute care nephrology program, as clinician for critically ill patients, and as teacher for all members of the health care team.
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Affiliation(s)
- David J. Askenazi
- Department of Pediatrics—Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, USA
| | - Michael Heung
- Department of Medicine—Division of Nephrology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael J. Connor
- Department of Medicine—Division of Renal Medicine, Emory University, Atlanta, Georgia, USA
| | - Rajit K. Basu
- Center for Acute Care Nephrology, Cincinnati Children’s Hospital Center, Cincinnati, Ohio, USA
| | - Jorge Cerdá
- Department of Medicine, Albany Medical College, Albany, New York, USA
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Bunkyo, Tokyo, Japan
| | - Jay L. Koyner
- Department of Medicine—Section of Nephrology, University of Chicago, Chicago, Illinois, USA
| | - Azra Bihorac
- Department of Anesthesiology—University of Florida, Gainesville, Florida, USA
| | | | - Anitha Vijayan
- Division of Nephrology, Washington University, St Louis, Missouri, USA
| | - Mark Okusa
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Sarah Faubel
- Department of Medicine—University of Colorado, and Denver VA Medical Center, Denver, Colorado, USA
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21
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Ostermann M, Joannidis M. Acute kidney injury 2016: diagnosis and diagnostic workup. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:299. [PMID: 27670788 PMCID: PMC5037640 DOI: 10.1186/s13054-016-1478-z] [Citation(s) in RCA: 205] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute kidney injury (AKI) is common and is associated with serious short- and long-term complications. Early diagnosis and identification of the underlying aetiology are essential to guide management. In this review, we outline the current definition of AKI and the potential pitfalls, and summarise the existing and future tools to investigate AKI in critically ill patients.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care Medicine, King's College London, Guy's & St Thomas' Foundation Hospital, Westminster Bridge Road, London, UK.
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Medical University of Innsbruck, Anichstr. 35, Innsbruck, Austria.
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22
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Urinary Strong Ion Difference as a Marker of Renal Dysfunction. A Retrospective Analysis. PLoS One 2016; 11:e0156941. [PMID: 27258049 PMCID: PMC4892615 DOI: 10.1371/journal.pone.0156941] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 05/23/2016] [Indexed: 12/21/2022] Open
Abstract
Introduction The kidneys play a crucial role in the regulation of electrolytes and acid-base homeostasis. Urinary Strong Ion Difference (SIDu = NaU + KU—ClU) represents an important aspect of renal acid-base regulation. We evaluated the role of SIDu as a marker of renal dysfunction in critically ill patients. Materials and Methods Patients admitted to the Medical Intensive Care Unit with a diagnosis of AKI for whom concomitant urinary samples available for SIDu calculation were retrospectively reviewed and staged according to KDIGO criteria for 3 days from inclusion. Patients were classified as Recovered (R-AKI) or Persistent-AKI (P-AKI) whether they exited KDIGO criteria within the 3-day observation period or not. A control group with normal renal function and normal serum acid-base and electrolytes was prospectively recruited in order to identify reference SIDu values. Results One-hundred-and-forty-three patients with a diagnosis of AKI were included: 77 with R-AKI, and 66 with P-AKI. Thirty-six controls were recruited. Patients with P-AKI had more severe renal dysfunction and higher mortality than patients with R-AKI (SCr 2.23(IQR:1.68–3.45) and 1.81(IQR1.5–2.5) mg/dl respectively, p<0.001; 24-h UO 1297(950) and 2100(1094) ml respectively, p = 0.003); 30-d mortality, 39% and 13% respectively; p<0.001). SIDu significantly differed between groups, with rising values from controls to P-AKI groups (16.4(12), 30(24) and 47.3(21.5) mEq/l respectively, p<0.001). Discussion SIDu may be a simple and inexpensive tool in AKI patients’ evaluation. Further research is needed to evaluate the ability of SIDu to identify patients with renal dysfunction before derangements in serum creatinine or urine output are observed.
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23
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Urine biochemistry assessment in critically ill patients: controversies and future perspectives. J Clin Monit Comput 2016; 31:539-546. [PMID: 27038161 DOI: 10.1007/s10877-016-9871-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 03/30/2016] [Indexed: 12/17/2022]
Abstract
In the past, urine biochemistry was a major tool in acute kidney injury (AKI) management. Classic papers published some decades ago established the values of the urine indices which were thought to distinguish "pre-renal" (functional) AKI attributed to low renal perfusion and "renal" (structural) AKI attributed to acute tubular necrosis (ATN). However, there were a lot of drawbacks and limitations in these studies and some recent articles have questioned the utility of measuring urine electrolytes especially because they do not seem to adequately inform about renal perfusion nor AKI duration (transient vs. persistent). At the same time, the "pre-renal" paradigm has been consistently criticized because hypoperfusion followed by ischemia and ATN does not seem to explain most of the AKI developing in critically ill patients and distinct AKI durations do not seem to be clearly related to different pathophysiological mechanisms or histopathological findings. In this new context, other possible roles for urine biochemistry have emerged. Some studies have suggested standardized changes in the urine electrolyte composition preceding increases in serum creatinine independently of AKI subsequent duration, which might actually be due to intra-renal microcirculatory changes and activation of sodium-retaining mechanisms even in the absence of impaired global renal blood flow. In the present review, the points of controversy regarding urine biochemistry assessment were evaluated as well as future perspectives for its role in AKI monitoring. An alternative approach for the interpretation of measured urine electrolytes is proposed which needs further larger studies to be validated and incorporated in daily ICU practice.
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24
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Pahwa AK, Sperati CJ. Urinary fractional excretion indices in the evaluation of acute kidney injury. J Hosp Med 2016; 11:77-80. [PMID: 26689284 DOI: 10.1002/jhm.2501] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 04/29/2015] [Accepted: 09/30/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Amit K Pahwa
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - C John Sperati
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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25
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Chen JP, Fang XM, Jin XJ, Kang RT, Liu KX, Li JB, Luo Y, Lu ZJ, Miao CH, Ma HX, Mei W, Ou YW, Qi SH, Qin ZS, Tian GG, Wu AS, Wang DX, Yu T, Yu YH, Zhao J, Zuo MZ, Zhang SH. Expert consensus on the perioperative management of patients with sepsis. World J Emerg Med 2015; 6:245-60. [PMID: 26702328 DOI: 10.5847/wjem.j.1920-8642.2015.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Jun-Ping Chen
- Department of Anesthesiology, Ningbo Number 2 Hospital, Ningbo, China
| | - Xiang-Ming Fang
- Department of Anesthesiology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiao-Ju Jin
- Department of Anesthesiology and Critical Care Medicine, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Rong-Tian Kang
- Department of Anesthesiology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ke-Xuan Liu
- Department of Anesthesiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jin-Bao Li
- Department of Anesthesiology and Intensive Care Medicine, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yan Luo
- Department of Anesthesiology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zhi-Jie Lu
- Department of Anesthesiology and Intensive Care Medicine, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Chang-Hong Miao
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, China
| | - Han-Xiang Ma
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Wei Mei
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang-Wen Ou
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Si-Hua Qi
- Department of Anesthesiology, Fourth Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Zai-Sheng Qin
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Guo-Gang Tian
- Department of Anesthesiology, People's Hospital of Sanya, Sanya, China
| | - An-Shi Wu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Surgical Intensive Care, Peking University First Hospital, Beijing, China
| | - Tian Yu
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical College, Zunyi, China
| | - Yong-Hao Yu
- Department of Anesthesiology, Tianjin Medical University General Hospital, and Tianjin Research Institute of Anesthesiology, Tianjin, China
| | - Jing Zhao
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming-Zhang Zuo
- Department of Anesthesiology, Beijing Hospital, Beijing, China
| | - Shi-Hai Zhang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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26
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Abstract
Acute kidney injury (AKI) is an epidemic problem. Sepsis has long been recognized as a foremost precipitant of AKI. Sepsis-associated AKI (SA-AKI) portends a high burden of morbidity and mortality in both children and adults with critical illness. Although our understanding of its pathophysiology is incomplete, SA-AKI likely represents a distinct subset of AKI contributed to by a unique constellation of hemodynamic, inflammatory, and immune mechanisms. SA-AKI poses significant clinical challenges for clinicians. To date, no singular effective therapy has been developed to alter the natural history of SA-AKI. Rather, current strategies to alleviate poor outcomes focus on clinical risk identification, early detection of injury, modifying clinician behavior to avoid harm, early appropriate antimicrobial therapy, and surveillance among survivors for the longer-term sequelae of kidney damage. Recent evidence has confirmed that patients no longer die with AKI, but from AKI. To improve the care and outcomes for sufferers of SA-AKI, clinicians need a robust appreciation for its epidemiology and current best-evidence strategies for prevention and treatment.
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Affiliation(s)
- Rashid Alobaidi
- Department of Pediatrics, Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Rajit K Basu
- Center for Acute Care Nephrology, Cincinnati Children's Hospital and Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital and Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio.
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Acute kidney injury in acute on chronic liver failure. Hepatol Int 2015; 10:245-57. [DOI: 10.1007/s12072-015-9652-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 07/13/2015] [Indexed: 12/11/2022]
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Nee PA, Bailey DJ, Todd V, Lewington AJ, Wootten AE, Sim KJ. Critical care in the emergency department: acute kidney injury. Emerg Med J 2015; 33:361-5. [PMID: 25969433 DOI: 10.1136/emermed-2015-204722] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 04/07/2015] [Indexed: 11/03/2022]
Abstract
Acute kidney injury (AKI) is common among emergency department patients admitted to hospital. There is evidence of inadequate management of the condition leading to adverse outcomes. We present an illustrative case of AKI complicating a gastrointestinal disorder in an older adult. We discuss the clinical presentation, assessment and management of AKI with reference to recent consensus guidelines on classification and treatment.
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Affiliation(s)
- Patrick A Nee
- Faculty of Education, Health and Community, Liverpool John Moores University, Liverpool, UK Department of Emergency and Critical Care Medicine, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, Merseyside, UK
| | - David J Bailey
- Department of Emergency Medicine, St Helens and Knowsley Teaching Hospitals NHS Trust, Merseyside, UK
| | - Victoria Todd
- Department of Biochemistry, St Helens and Knowsley Teaching Hospitals NHS Trust, Merseyside, UK
| | | | - Andrea E Wootten
- Department of Emergency Medicine, Wirral University Hospital, Merseyside, UK
| | - Kevin J Sim
- Intensive Care Unit, St Helens and Knowsley Teaching Hospitals NHS Trust, Merseyside, UK
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Pöss J, Ewen S, Schmieder RE, Muhler S, Vonend O, Ott C, Linz D, Geisel J, Rump LC, Schlaich M, Böhm M, Mahfoud F. Effects of renal sympathetic denervation on urinary sodium excretion in patients with resistant hypertension. Clin Res Cardiol 2015; 104:672-8. [PMID: 25715938 DOI: 10.1007/s00392-015-0832-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 02/19/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sympathetic overactivity increases sodium retention and contributes to the pathophysiology of hypertension. Renal sympathetic denervation lowers blood pressure and reduces sympathetic activity in certain patients with resistant hypertension. METHODS AND RESULTS This study aimed to assess the effect of renal denervation on urinary sodium excretion. 24-h urinary sodium excretion was estimated at baseline and after 6 months using the Kawasaki formula in 137 patients with resistant hypertension undergoing renal denervation. Sodium excretion was adjusted for cystatin C GFR and fractional sodium excretion was assessed. Mean office systolic blood pressure at baseline was 171 ± 2 mmHg despite an intake of 5.2 ± 0.1 antihypertensive drugs. Six months after renal denervation, systolic and diastolic BP decreased by 18 ± 2 mmHg (p < 0.0001) and 10 ± 1 mmHg (p < 0.001). 90 patients (65.7%) had SBP reductions ≥ 10 mmHg (responders). After 6 months, 24-h UNa increased by 13% compared to baseline (236 ± 9 vs. 268 ± 9 mmol/day, p < 0.003). This increase was most pronounced in patients with less response in BP. These findings were paralleled by a significant increase in fractional sodium excretion (1.19 ± 0.11 vs. 1.64 ± 0.14%, p < 0.0001) and were observed independently of the intake of antihypertensive drugs affecting sodium balance, such as mineralocorticoid receptor antagonists or diuretics. CONCLUSION RDN lowered BP and increased estimated UNa and fractional sodium excretion in patients with resistant hypertension independently of renal function and antihypertensive therapy.
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Affiliation(s)
- Janine Pöss
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str., Geb. 40, 66421, Homburg/Saar, Germany,
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Abstract
Acute kidney injury is common, dangerous and costly, affecting around one in five patients emergency admissions to hospital. Although survival decreases as disease worsens, it is now apparent that even modest degrees of dysfunction are not only associated with higher mortality but are an independent risk factor for death. This review focuses on the pathophysiology of acute kidney injury secondary to ischaemia - its commonest aetiology. The haemodynamic disturbances, endothelial injury, epithelial cell injury and immunological mechanisms underpinning its initiation and extension will be discussed along with the considerable and complex interplay between these factors that lead to an intense, pro-inflammatory state. Mechanisms of tubular recovery will be discussed but also the pathophysiology of abnormal repair with its direct consequences for long-term renal function. Finally, the concept of 'organ cross-talk' will be introduced as a potential explanation for the higher mortality observed with acute kidney injury that might be deemed modest in conventional biochemical terms.
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Affiliation(s)
- Nigel Suren Kanagasundaram
- Renal Services, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, High Heaton, Newcastle upon Tyne, UK
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Golledge J, Hankey GJ, Yeap BB, Almeida OP, Flicker L, Norman PE. Reported high salt intake is associated with increased prevalence of abdominal aortic aneurysm and larger aortic diameter in older men. PLoS One 2014; 9:e102578. [PMID: 25036037 PMCID: PMC4103816 DOI: 10.1371/journal.pone.0102578] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 06/20/2014] [Indexed: 11/18/2022] Open
Abstract
Background Salt intake has been implicated in the pathogenesis of abdominal aortic aneurysm (AAA) through studies in rodent models but not previously studied in humans. The aim of this study was to examine the association between reported addition of salt to food and the prevalence of AAA. Methods A risk factor questionnaire which contained a question about salt intake was included as part of a population screening study for AAA in 11742 older men. AAA presence was assessed by abdominal ultrasound imaging using a reproducible protocol. Results The prevalence of AAA was 6.9, 8.5 and 8.6% in men who reported adding salt to food never, sometimes and always, respectively, p = 0.005. Addition of salt to food sometimes (odds ratio [OR]: 1.22, 95% confidence interval [CI]: 1.03–1.44) or always (OR: 1.23, 95% CI 1.04–1.47) was independently associated with AAA after adjustment for other risk factors including age, waist-hip ratio, blood pressure, history of hypertension, high cholesterol, angina, diabetes, myocardial infarction and stroke. Salt intake was also independently associated with aortic diameter (beta 0.023, p = 0.012). In men with no prior history of hypertension, high cholesterol, angina, myocardial infarction or stroke (n = 4185), the association between addition of salt to food sometimes (OR: 1.41, 95% CI 0.96–2.08) or always (OR: 1.52, 95% CI 1.04–2.22) and AAA remained evident. Conclusion Reported salt intake is associated with AAA in older men. Additional studies are needed to determine whether reducing salt intake would protect against AAA.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Australia
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Australia
- * E-mail:
| | - Graeme J. Hankey
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
- Department of Neurology, Royal Perth Hospital, Perth, Australia
| | - Bu B. Yeap
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
- Department of Endocrinology, Fremantle Hospital, Fremantle, Australia
| | - Osvaldo P. Almeida
- School of Psychiatry & Clinical Neurosciences, University of Western Australia, Perth, Australia
- WA Centre for Health & Ageing, Centre for Medical Research, Perth, Australia
- Department of Psychiatry, Royal Perth Hospital, Perth, Australia
| | - Leon Flicker
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
- WA Centre for Health & Ageing, Centre for Medical Research, Perth, Australia
- Department of Geriatric Medicine, Royal Perth Hospital, Perth, Australia
| | - Paul E. Norman
- School of Surgery, University of Western Australia, Perth, Australia
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Intraluminal containment of commensal outgrowth in the gut during infection-induced dysbiosis. Cell Host Microbe 2014; 14:318-28. [PMID: 24034617 DOI: 10.1016/j.chom.2013.08.003] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 07/04/2013] [Accepted: 08/01/2013] [Indexed: 12/15/2022]
Abstract
Shifts in commensal microbiota composition are emerging as a hallmark of gastrointestinal inflammation. In particular, outgrowth of γ-proteobacteria has been linked to the etiology of inflammatory bowel disease and the pathologic consequences of infections. Here we show that following acute Toxoplasma gondii gastrointestinal infection of mice, control of commensal outgrowth is a highly coordinated process involving both the host response and microbial signals. Notably, neutrophil emigration to the intestinal lumen results in the generation of organized intraluminal structures that encapsulate commensals and limit their contact with the epithelium. Formation of these luminal casts depends on the high-affinity N-formyl peptide receptor, Fpr1. Consequently, after infection, mice deficient in Fpr1 display increased microbial translocation, poor commensal containment, and increased mortality. Altogether, our study describes a mechanism by which the host rapidly contains commensal pathobiont outgrowth during infection. Further, these results reveal Fpr1 as a major mediator of host commensal interaction during dysbiosis.
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Prowle JR. Acute kidney injury: an intensivist's perspective. Pediatr Nephrol 2014; 29:13-21. [PMID: 23361310 DOI: 10.1007/s00467-013-2411-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 12/28/2012] [Accepted: 01/03/2013] [Indexed: 01/05/2023]
Abstract
The changing epidemiology of acute kidney injury (AKI) in adults and children has resulted in more patients being treated for kidney injury occurring in the context of multi-organ failure requiring treatment in the intensive care unit (ICU). AKI complicating critical illness has complex, multi-factorial etiology, and supportive care, including organ support, remains the mainstay of therapy. In the day-to-day management of AKI in the ICU two of the major challenges are the inadequacy of current diagnostics for the early identification of AKI and the relationship between hemodynamic resuscitation strategies and the development of AKI. This review focuses on these areas from the intensivist's perspective. Given that the diagnosis of AKI is often delayed, the prevention of complications and limitation of secondary renal injury are of particular importance. Fluid overload is increasingly being associated with adverse patient outcomes in critical illness and may contribute to persistent renal dysfunction. Thus, hemodynamic management strategies in AKI should be tailored to limit fluid overload as much as possible.
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Affiliation(s)
- John R Prowle
- Adult Critical Care Unit and Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, UK, E1 1BB,
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Romanovsky A, Morgan C, Bagshaw SM. Pathophysiology and management of septic acute kidney injury. Pediatr Nephrol 2014; 29:1-12. [PMID: 23400860 DOI: 10.1007/s00467-013-2427-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 01/22/2013] [Accepted: 01/23/2013] [Indexed: 02/06/2023]
Abstract
Acute kidney injury (AKI) is a commonly encountered complication in critically ill children and portends a worse prognosis. Sepsis-induced AKI (SAKI) is a leading contributor to AKI in children and significantly modifies the risk for less favorable outcome. It has increasingly become clear that SAKI represents a unique and distinct cause of AKI. Studies focused on renal hemodynamics, bioenergetics, and immune-mediated injury have provided further insights into the pathobiology of SAKI; however, many of the nuanced mechanisms remain incompletely understood. Although there have been numerous strategies evaluated for the prevention and management of SAKI, no specific intervention has proven unequivocally efficacious. Currently, the mainstays for managing SAKI focus on alleviating ongoing kidney damage by optimizing systemic and kidney hemodynamic support, avoiding nephrotoxins, and mitigating the anticipated complications of kidney failure. The timely referral for renal support to manage azotemia, metabolic derangements, and fluid accumulation remains critical for this population. The extracorporeal removal of inflammatory mediators has shown some potential benefit in limiting systemic and kidney immune-mediated injury; however, the precise role of these technologies in the management of SAKI has yet to be defined.
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Affiliation(s)
- Adam Romanovsky
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 8440-122 Street, 3C1.12 Walter C. Mackenzie Centre, Edmonton, AB, T6G2B7, Canada
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Acute kidney injury in patients with cirrhosis: perils and promise. Clin Gastroenterol Hepatol 2013; 11:1550-8. [PMID: 23583467 PMCID: PMC3840046 DOI: 10.1016/j.cgh.2013.03.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Revised: 03/19/2013] [Accepted: 03/20/2013] [Indexed: 02/07/2023]
Abstract
A 62-year-old man with cirrhosis secondary to hepatitis C and chronic alcohol abuse was admitted to the intensive care unit with hematemesis and mental status changes. Physical examination showed ascites and stigmata of chronic liver disease. Blood pressure was noted as 87/42 mm Hg and laboratory studies showed a serum creatinine level of 0.8 mg/dL, an estimated glomerular filtration rate of 84 mL/min/1.73 m(2) calculated using the Modification of Diet in Renal Disease Study equation, a serum sodium level of 123 mEq/L, a total serum bilirubin level of 4.3 mg/dL, and an international normalization ratio of 1.6. The patient was resuscitated with packed red blood cells and fresh-frozen plasma and bleeding was controlled. However, on the third day of admission, creatinine level increased to 1.5 mg/dL. Examination of urine sediment showed 1 to 5 bilirubin-stained granular casts per high-powered field and a few renal tubular epithelial cells. The urine sodium level was 21 mEq/L and the fractional excretion of sodium was 0.43%.
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Vanmassenhove J, Glorieux G, Hoste E, Dhondt A, Vanholder R, Van Biesen W. Urinary output and fractional excretion of sodium and urea as indicators of transient versus intrinsic acute kidney injury during early sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R234. [PMID: 24119730 PMCID: PMC4057160 DOI: 10.1186/cc13057] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 09/16/2013] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The pathophysiology of acute kidney injury (AKI) in sepsis is ill defined. We investigated parameters associated with low glomerular filtration, and their predictive value to discriminate transient from intrinsic septic AKI. METHODS In 107 sepsis patients, AKI was defined by the Risk, Injury, Failure, Loss of Kidney Function, End-stage renal disease (RIFLE) urinary output or serum creatinine criterion, or both. Transient AKI (TAKI) versus intrinsic AKI was defined as RIFLE R, I, or F on the first day evolving to no AKI or not, respectively, over the following 5 days. Fractional excretion of sodium (FENa), urea (FEUrea), and NGAL (FENGAL) at admission (d0t0), 4 (d0t4), and 24 hours (d1) was determined. RESULTS Including versus not including the urinary-output criterion of RIFLE increased AKI from 43% to 64.5%. Median uNGAL levels and FENGAL were lower in no AKI versus transient AKI when AKI was defined based on creatinine (P = 0.002 and P = 0.04, respectively), but not when based on urinary output (P = 0.9 and P = 0.49, respectively). FENa < 1% and FEUrea <35% was present in 77.3% and 63.2% of patients. Urinary NGAL was higher (P < 0.001) in those with high versus low fractional sodium excretion, but this was only in patients with transient or intrinsic AKI (P < 0.001 in subgroups), and not in patients without AKI. The negative predictive value for either intrinsic AKI or not restoring diuresis in patients with FENa > 0.36% and FEUrea > 31.5% was 92% and 94.5% respectively. CONCLUSIONS A low FENa and FEUrea is highly prevalent in the first hours of sepsis. In sepsis, oliguria is an earlier sign of impending AKI than increase in serum creatinine. A combination of a high FENa and a low FEUrea is associated with intrinsic AKI, whereas a combined high FENa and FEUrea is strongly predictive of transient AKI.
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Maciel AT, Park M, Macedo E. Physicochemical analysis of blood and urine in the course of acute kidney injury in critically ill patients: a prospective, observational study. BMC Anesthesiol 2013; 13:31. [PMID: 24112801 PMCID: PMC3851869 DOI: 10.1186/1471-2253-13-31] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 10/03/2013] [Indexed: 12/12/2022] Open
Abstract
Background Sequential physicochemical alterations in blood and urine in the course of acute kidney injury (AKI) development have not been previously described. We aimed to describe these alterations in parallel to traditional renal and acid–base parameters. Methods One hundred and sixty eight consecutive critically ill patients with no previous kidney disease, who had an indwelling urinary catheter at ICU admission and who remained with the catheter for at least two days without dialysis were included. A sample of blood and spot urine were collected simultaneously, once daily, until catheter removal or dialysis requirement. Traditional acid–base and renal parameters were sequentially evaluated in parallel to blood and urinary physicochemical parameters. Patients were classified during this period as having or not AKI and, for patients with AKI, duration (transient or persistent) and severity (creatinine-based AKIN stage) were evaluated. Results One hundred and thirteen patients (67.3%) had AKI: 92 at ICU admission and 21 during the observation period. AKI development was characterized in blood by increased values of phosphate and unmeasured anions (SIG), decreased albumin, and in urine by decreased values of sodium (NaU), chloride (ClU) as well as high urinary strong ion difference (SIDu). These alterations began to occur before AKI diagnosis, and they reverted in transient AKI but remained in persistent AKI. NaU, ClU and albumin decreased, and phosphate, SIG and SIDu increased with AKI severity progression. NaU and ClU values increased again when AKIN stage 3 was reached. Conclusions Simultaneous physicochemical analysis of blood and urine revealed standardized alterations that characterize AKI development in critically ill patients. These alterations paralleled AKI duration and severity. Future studies should consider including sequential evaluation of urine biochemistry as part of the armamentarium for AKI diagnosis and management.
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Affiliation(s)
- Alexandre Toledo Maciel
- Intensive Care Unit, Department of Medical Emergencies, Hospital das Clínicas University of São Paulo, São Paulo, Brazil.
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Petejova N, Martinek A. Acute kidney injury following acute pancreatitis: A review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2013; 157:105-13. [PMID: 23774848 DOI: 10.5507/bp.2013.048] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 06/07/2013] [Indexed: 02/07/2023] Open
Abstract
UNLABELLED BACKROUND. Acute kidney injury (AKI) is a common serious complication of severe acute pancreatitis (SAP) and an important marker of morbidity and mortality in critically ill septic patients. AKI due to severe acute pancreatitis can be the result of hypoxemia, release of pancreatic amylase from the injured pancreas with impairment of renal microcirculation, decrease in renal perfusion pressure due to abdominal compartment syndrome, intraabdominal hypertension or hypovolemia. Endotoxins and reactive oxygen species (ROS) also play an important role in the pathophysiology of SAP and AKI. Knowledge of the pathophysiology and diagnosis of AKI following SAP might improve the therapeutic outcome of critically ill patients. METHODS AND RESULTS An overview of the pathophysiology, diagnosis and potential treatment options based on a literature search of clinical human and experimental studies from 1987 to 2013. CONCLUSIONS Early recognition of AKI and SAP in order to prevent severe complication like septic shock, intraabdominal hypertension or abdominal compartment syndrome leading to multiple organ dysfunction syndrome is a crucial tool of therapeutic measures in intensive care.
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Affiliation(s)
- Nadezda Petejova
- Department of Internal Medicine, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Czech Republic.
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Renal blood flow, fractional excretion of sodium and acute kidney injury: time for a new paradigm? Curr Opin Crit Care 2013; 18:585-92. [PMID: 22954663 DOI: 10.1097/mcc.0b013e328358d480] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Global renal blood flow is considered pivotal to renal function. Decreased global renal blood flow (decreased perfusion) is further considered the major mechanism of reduced glomerular filtration rate responsible for the development of acute kidney injury (AKI) in critically ill patients. Additionally, urinary biochemical tests are widely taught to allow the differential diagnosis of prerenal (functional) AKI and intrinsic [structural AKI (so-called acute tubular necrosis)]. In this review we will examine recent evidence regarding these two key clinical paradigms. RECENT FINDINGS Recent animal experiments and clinical studies in humans using cine-phase contrast magnetic resonance technology are not consistent with the decreased perfusion paradigm. They suggest instead that changes in the intra-renal circulation including modification in efferent arteriolar function and intra-renal shunting are much more likely to be responsible for AKI, especially in sepsis. Similarly, recent human studies indicate the urinary biochemistry has limited diagnostic or prognostic ability and is dissociated form biomarker and microscopic evidence of tubular injury. SUMMARY Intra-renal microcirculatory changes are likely more important than changes in global blood flow in the development of AKI. Urinary biochemistry is not a clinically useful diagnostic or prognostic tool in critically ill patients at risk of or with AKI.
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Schneider AG, Bellomo R. Urinalysis and pre-renal acute kidney injury: time to move on. Crit Care 2013; 17:141. [PMID: 23659200 PMCID: PMC3672654 DOI: 10.1186/cc12676] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Urinary indices are classically believed to allow differentiation of transient (or pre-renal) acute kidney injury (AKI) from persistent (or acute tubular necrosis) AKI. However, the data validating urinalysis in critically ill patients are weak. In the previous issue of Critical Care, Pons and colleagues demonstrate in a multicenter observational study that sodium and urea excretion fractions as well as urinary over plasma ratios performed poorly as diagnostic tests to separate such entities. This study confirms the limited diagnostic and prognostic ability of urine testing. Together with other studies, this study raises more fundamental questions about the value, meaning and pathophysiologic validity of the pre-renal AKI paradigm and suggests that AKI (like all other forms of organ injury) is a continuum of injury that cannot be neatly divided into functional (pre-renal or transient) or structural (acute tubular necrosis or persistent).
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Honoré PM, Jacobs R, Joannes-Boyau O, Boer W, De Waele E, Van Gorp V, Spapen HD. Fractional excretion of urea to differentiate transient from persistent acute kidney injury: should we still trust old tools in the biomarker era? J Crit Care 2013; 27:514-5. [PMID: 23062846 DOI: 10.1016/j.jcrc.2012.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 07/16/2012] [Indexed: 10/27/2022]
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Pons B, Lautrette A, Oziel J, Dellamonica J, Vermesch R, Ezingeard E, Mariat C, Bernardin G, Zeni F, Cohen Y, Tardy B, Souweine B, Vincent F, Darmon M. Diagnostic accuracy of early urinary index changes in differentiating transient from persistent acute kidney injury in critically ill patients: multicenter cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R56. [PMID: 23531299 PMCID: PMC3733426 DOI: 10.1186/cc12582] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Accepted: 03/21/2013] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Urinary indices have limited effectiveness in separating transient acute kidney injury (AKI) from persistent AKI in ICU patients. Their time-course may vary with the mechanism of AKI. The primary objective of this study was to evaluate the diagnostic value of changes over time of the usual urinary indices in separating transient AKI from persistent AKI. METHODS An observational prospective multicenter study was performed in six ICUs involving 244 consecutive patients, including 97 without AKI, 54 with transient AKI, and 93 with persistent AKI. Urinary sodium, urea and creatinine were measured at ICU admission (H0) and on 6-hour urine samples during the first 24 ICU hours (H6, H12, H18, and H24). Transient AKI was defined as AKI with a cause for renal hypoperfusion and reversal within 3 days. RESULTS Significant increases from H0 to H24 were noted in fractional excretion of urea (median, 31% (22 to 41%) and 39% (29 to 48%) at H24, P<0.0001), urinary urea/plasma urea ratio (15 (7 to 28) and 20 (9 to 40), P<0.0001), and urinary creatinine/plasma creatinine ratio (50 (24 to 101) and 57 (29 to 104), P=0.01). Fractional excretion of sodium did not change significantly during the first 24 hours in the ICU (P=0.13). Neither urinary index values at ICU admission nor changes in urinary indices between H0 and H24 performed sufficiently well to recommend their use in clinical setting (area under the receiver-operating characteristic curve≤0.65). CONCLUSION Although urinary indices at H24 performed slightly better than those at H0 in differentiating transient AKI from persistent AKI, they remain insufficiently reliable to be clinically relevant.
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Abstract
BACKGROUND Acute kidney injury (AKI) is a common and serious problem in critically ill patients. Tests currently used to detect AKI (i.e., serum creatinine, serum urea and various urinary indices) often result in serious delays in detection of clinically relevant injury. This delayed detection translates into a potential missed opportunity for therapeutic interventions at a time when kidney damage may be limitable or reversible. This is also recognized as a potential reason for the poor clinical outcomes often associated with AKI. OBJECTIVES To appraise the recent literature characterizing several novel serum and urinary biomarkers, including neutrophil gelatinase-associated lipocalin, IL-18 and kidney injury molecule-1, which are capable of detecting AKI at an earlier phase of injury. Also to discuss the pitfalls of current conventional testing in kidney injury. METHOD Narrative literature review. CONCLUSIONS These novel biomarkers can detect injury when damage may still be reversible, allow for early risk stratification and/or prognostication, and are associated in early clinical studies with important outcomes such as severity of AKI, need for renal replacement therapy and survival. There is optimism that these novel biomarkers will discriminate the underlying pathophysiology of AKI (i.e., ischemia, sepsis, toxins or multifactorial), discriminate AKI from other renal disease (i.e., chronic kidney disease) and aid in localizing the site of acute injury in the kidney. As such, the future may entail development of an 'AKI biomarker panel' (i.e., analogous to a cardiac or liver enzyme panel) for use in clinical practice.
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Affiliation(s)
- Sean M Bagshaw
- University of Alberta Hospital, 3C1.12 Walter C. Mackenzie Centre, Division of Critical Care Medicine, 8440-112 Street, Edmonton, Alberta, T6G2B7, Canada +1 780 407 6755 ; +1 780 407 1228 ;
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Maciel AT. Breaking old and new paradigms regarding urinary sodium in acute kidney injury diagnosis and management. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:115. [PMID: 23384365 PMCID: PMC4056518 DOI: 10.1186/cc11926] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Urinary sodium (NaU) is one of the oldest parameters used in the evaluation of azotemia and oliguria. Over the past years, however, it has progressively been considered as obsolete and useless, especially in sepsis. It is common sense that NaU frequently does not correlate well with global renal blood flow. If intrarenal microcirculatory changes are more important in acute kidney injury (AKI) than changes in global renal blood flow, we speculate that decreases in NaU may be viewed as a possible marker of microcirculatory impairment in the kidneys. Recent findings by our group (some not yet published) in which sodium retentive capacity is preserved until advanced stages of AKI and the observation of decreases in NaU preceding increases in creatinine bring us to conclude that the new paradigm of abolishing NaU consideration from daily approaches to managing patients at risk for AKI must be reevaluated.
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Youssef DM, Esh AM, Helmy Hassan E, Ahmed TM. Serum NGAL in Critically Ill Children in ICU from a Single Center in Egypt. ISRN NEPHROLOGY 2013; 2013:140905. [PMID: 24959537 PMCID: PMC4045414 DOI: 10.5402/2013/140905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 12/26/2012] [Indexed: 11/23/2022]
Abstract
Introduction. The mortality and morbidity associated with acute kidney injury (AKI), unfortunately, remain unacceptably high. We aimed to detect the extent of serum neutrophil gelatinase-associated lipocalin (NGAL) to early detect AKI in critically ill children.
Subjects and Methods. This is a case control study. It included 75 subjects that include 15 as controls and 60 critically ill children. Patients were further subdivided according to RIFLE criteria into two other categories: patients who developed AKI and patients who did not develop AKI. Serum NGAL assayed on admission and after 3 days.
Results. There was significant increase in the level of NGAL among patients group when compared with control group. Also, 21.7% of children admitted to PICU developed AKI from which 8.3% needed dialysis. The receiver operating characteristic curve of NGAL at day 0 revealed AUC of 0.63 with 95% CI of 0.50–0.77. At a cutoff value of 89.5 ng/mL, the sensitivity of NGAL was 84.6%, while specifcity was 59.6%, positive predictive value was 36.7%, negative predictive value was 68.4%, and accuracy was 93.3% in diagnosis of AKI.
Conclusion. We found that NGAL acts as a sensitive marker rather than a specific one for AKI. At the same time, it presents as a negative predictive value more valuable than being a positive predictive value in detecting AKI.
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Bagshaw SM, Bennett M, Devarajan P, Bellomo R. Urine biochemistry in septic and non-septic acute kidney injury: a prospective observational study. J Crit Care 2012; 28:371-8. [PMID: 23159144 DOI: 10.1016/j.jcrc.2012.10.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 10/02/2012] [Accepted: 10/02/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE Determine whether there are unique patterns to the urine biochemistry profile in septic compared with non-septic acute kidney injury (AKI) and whether urinary biochemistry predicts worsening AKI, need for renal replacement therapy and mortality. MATERIALS AND METHODS Prospective cohort study of critically ill patients with septic and non-septic AKI, defined by the RIFLE (Risk, Injury, Failure, Loss, End-Stage) criteria. Urine biochemistry parameters were compared between septic and non-septic AKI and were correlated with neutrophil gelatinase-associated lipocalin (NGAL), worsening AKI, renal replacement therapy (RRT), and mortality. RESULTS Eighty-three patients were enrolled, 43 (51.8%) with sepsis. RIFLE class was not different between groups (P = .43). Urine sodium (UNa) <20 mmol/L, fractional excretion of sodium (FeNa) <1%, and fractional excretion of urea (FeU) <35% were observed in 25.3%, 57.8%, and 33.7%, respectively. Septic AKI had lower UNa compared with non-septic AKI (P = .04). There were no differences in FeNa or FeU between groups. Urine NGAL was higher for FeNa ≥ 1% compared to FeNa<1% (177.4 ng/mL [31.9-956.5] vs 48.0 ng/mL [21.1-232.4], P = .04). FeNa showed low correlation with urine NGAL (P = .05) and plasma NGAL (P = .14). There was poor correlation between FeU and urine NGAL (P = .70) or plasma NGAL (P = .41). UNa, FeNa, and FeU showed poor discrimination for worsening AKI, RRT and mortality. CONCLUSION Urine biochemical profiles do not discriminate septic and non-septic AKI. UNa, FeNa, and FeU do not reliably predict biomarker release, worsening AKI, RRT or mortality. These data imply limited utility for these measures in clinical practice in critically ill patients with AKI.
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Affiliation(s)
- Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 3C1.12 Walter C Mackenzie Center, 8440-112 ST NW, Edmonton, Alberta, T6G 2B7, Canada.
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Macedo E, Mehta RL. Biomarkers for acute kidney injury: combining the new silver with the old gold. Nephrol Dial Transplant 2012; 28:1064-7. [PMID: 23048171 DOI: 10.1093/ndt/gfs332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Etienne Macedo
- Division of Nephrology, University of São Paulo, São Paulo, SP, Brazil
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Abstract
Acute kidney injury (formerly known as acute renal failure) is a syndrome characterised by the rapid loss of the kidney's excretory function and is typically diagnosed by the accumulation of end products of nitrogen metabolism (urea and creatinine) or decreased urine output, or both. It is the clinical manifestation of several disorders that affect the kidney acutely. Acute kidney injury is common in hospital patients and very common in critically ill patients. In these patients, it is most often secondary to extrarenal events. How such events cause acute kidney injury is controversial. No specific therapies have emerged that can attenuate acute kidney injury or expedite recovery; thus, treatment is supportive. New diagnostic techniques (eg, renal biomarkers) might help with early diagnosis. Patients are given renal replacement therapy if acute kidney injury is severe and biochemical or volume-related, or if uraemic-toxaemia-related complications are of concern. If patients survive their illness and do not have premorbid chronic kidney disease, they typically recover to dialysis independence. However, evidence suggests that patients who have had acute kidney injury are at increased risk of subsequent chronic kidney disease.
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Affiliation(s)
- Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
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Dewitte A, Biais M, Petit L, Cochard JF, Hilbert G, Combe C, Sztark F. Fractional excretion of urea as a diagnostic index in acute kidney injury in intensive care patients. J Crit Care 2012; 27:505-10. [PMID: 22520491 DOI: 10.1016/j.jcrc.2012.02.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 01/16/2012] [Accepted: 02/19/2012] [Indexed: 12/18/2022]
Abstract
PURPOSE Acute kidney injury (AKI) is a dynamic process that evolves from an early reversible condition to an established disease. Value of urine indices in the event of AKI is uncertain in critically ill patients. The aim of this study was to evaluate the performance of fractional excretion of urea (FeU) for differentiating persistent from transient AKI in patients admitted to the intensive care unit. METHODS This was an observational study. Forty-seven patients with AKI according to the RIFLE classification were included. Transient AKI was defined as AKI resolved within 3 days after inclusion. Persistent AKI was defined as persistent serum creatinine elevation or oliguria. RESULTS Fractional excretion of urea was lower in case of transient, 33% (25-39), than persistent AKI, 47% (36-61) (P = .001). Areas under the receiver operating characteristic curve for FeU in case of transient AKI were better than those for other urinary indexes, 0.78 (95% confidence interval, 0.63-0.92). Optimal cutoff point according to the receiver operating characteristic curve was 40%. In patients treated with diuretics, FeU was the only predictive index of transient AKI. Fractional excretion of urea gradually increased from days 1 to 7 in transient AKI, whereas plasma creatinine decreased. CONCLUSIONS Fractional excretion of urea less than 40% was found to be a sensitive and specific index in differentiating transient from persistent AKI in intensive care unit patients especially if diuretics had been administered.
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Affiliation(s)
- Antoine Dewitte
- Centre Hospitalier Universitaire de Bordeaux, Department of Anaesthesiology and Intensive Care Medicine, Place Amélie Raba-Léon, 33000 Bordeaux, France.
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