Acute kidney injury after in-hospital cardiac arrest in a predominant internal medicine and cardiology patient population: incidence, risk factors, and impact on survival

Impact of Hypothermic Temperature Control on Plasma and Soft Tissue Pharmacokinetics of Penicillin/Beta-Lactamase Inhibitor Combinations in Patients Resuscitated After Cardiac Arrest

BACKGROUND AND OBJECTIVES

Penicillin/beta-lactamase inhibitors are often used to treat aspiration pneumonia in patients resuscitated after cardiac arrest (CA). The impact of hypothermic temperature control on the pharmacokinetics of amoxicillin/clavulanate (AMO/CLAV) and ampicillin/sulbactam (AMP/SULB) has not been studied. Our objective was to evaluate the effects of hypothermic temperature control on the plasma and soft tissue pharmacokinetics of AMO/CLAV and AMP/SULB, including pulmonary concentrations of AMP/SULB, in patients resuscitated after CA.

METHODS

This prospective clinical study involved ten adult patients after CA receiving either AMO/CLAV 2 g/0.2 g or AMP/SULB 2 g/1 g intravenously every 8 h. Patients underwent hypothermic temperature control (33 ± 1 °C) for 24 h, followed by normothermia. Plasma, urine, muscle, and subcutaneous pharmacokinetics were measured and plasma protein-binding assessed for each subject. Microdialysis determined unbound drug concentrations in soft tissues. The pulmonary concentration of AMP/SULB was analyzed in the epithelial lining fluid.

RESULTS

No significant differences in plasma pharmacokinetics or renal excretion of AMO/CLAV and AMP/SULB were observed between the two temperature conditions. Soft tissue concentrations showed no consistent trend. Pharmacokinetic/pharmacodynamic targets (time that the unbound plasma concentrations were above the minimal inhibitory concentration [MIC] for MIC up to 8 mg/L) were met but not for 16 mg/L. Pulmonary concentrations of AMP/SULB in the epithelial lining fluid showed no clear trend.

CONCLUSION

This study indicates that hypothermic temperature control does not significantly affect plasma concentrations, soft tissue concentrations, or renal excretion of AMO/CLAV and AMP/SULB in patients resuscitated after CA. However, pulmonary concentrations of AMP/SULB exhibited interindividual variability.

Causes and Clinical Outcomes of Acute Kidney Injury After Cardiac Arrest: A Retrospective Cohort Study

Background and Objectives: The development of acute kidney injury (AKI) in the post-cardiopulmonary resuscitation (post-CPR) period is a common pathology that has not been adequately investigated but contributes significantly to morbidity and mortality. We aimed to investigate the causes of AKI in the early post-CPR period. Materials and Methods: This study was performed retrospectively in 82 adult patients who survived for at least 2 days out of 312 patients admitted to the intensive care unit after cardiac arrest in 2013-2022. AKI developed in 40 (48.7%) of these 82 patients (AKI 1-3 patient, respectively: 14, 13, 13). Binary logistic regression analysis was performed separately to determine the risk factors for AKI and mortality. Results: Each unit increase in BMI increased the risk of developing AKI by 1.272-fold, and the increase was statistically significant [OR (95%CI) = 1.272 (1.089-1486); p = 0.002]. The use of VSP and INO treatment alone increased the risk of AKI by approximately 14-fold, and this increase was statistically significant [OR (95%CI) = 14.225 (1.172-172.669); p = 0.037]. The combined use of VSP and INO treatment increased the risk of AKI by approximately 42-fold, and this increase was statistically significant [OR (95%CI) = 42.089 (2.683-660.201); p = 0.008]. The COVID-19 period alone increased the risk of developing AKI by 2.8-fold compared to the non-COVID-19 period, but the statistical significance of this increase was limited [OR (95%CI) = 2.801 (0.859-9.126); p = 0.088]. The development of AKI was not associated with mortality [OR (95%CI) = 2.194 (0.700-6.872); p = 0.178]. Conclusions: Having VSP and/or INO support and high BMI in the post-CPR period are the most important reasons for the development of AKI. COVID-19 may also increase the risk of developing AKI.

Acute Kidney Injury in Deceased Organ Donors: Risk Factors And Impacts on Transplantation Outcomes

Background

Acute kidney injury in deceased donors (D-AKI) is one of the common causes of donor kidney discard. The risk factors for D-AKI and its impact on kidney transplantation outcomes are not yet fully understood.

Methods

This single-center, retrospective cohort study included 388 donors referred between June 2021 and December 2022. D-AKI was defined and staged according to kidney disease: Improving global outcomes criteria, and donor clinical variables were analyzed to identify risk factors for D-AKI. Delayed graft function and estimated glomerular filtration rate (eGFR) at 6 mo were evaluated in 369 kidney grafts transplanted from donors with and without D-AKI.

Results

AKI was present in 171 deceased donors (44.1%), with 117 (30.2%) classified as AKI stage 1 and 54 (14%) as AKI stages 2 or 3. Donor history of hypertension (odds ratio [OR] 1.93; 95% confidence interval [CI], 1.21-3.10; P = 0.005), history of diabetes (OR 2.2; 95% CI, 1.21-3.98; P = 0.008), and anoxia as the cause of death (OR 2.61; 95% CI, 1.5-4.61; P < 0.001) were independently associated with an increased risk of D-AKI. Multivariable mixed models identified donor age (β -0.49; 95% CI, -0.71 to -0.28; P < 0.001) as the only independent risk factor for lower eGFR at 6 mo. D-AKI was not associated with delayed graft function or lower eGFR at 6 mo.

Conclusions

Hypertension, diabetes, and anoxia as the cause of death were identified as risk factors for AKI in deceased donors. D-AKI should not be used as the sole criterion to assess the risk of poor graft outcomes. A broader range of donor variables should be considered when evaluating graft viability.

Serum lactate/creatinine ratio and acute kidney injury in cardiac arrest patients

OBJECTIVES

Serum lactate and creatinine levels upon admission in cardiac arrest (CA) patients significantly correlate with acute kidney injury (AKI) post-restoration of autonomic circulation. However, the association between serum lactate/creatinine ratio (LCR) and AKI in this population remains unclear. This study aimed to explore the relationship between LCR at admission and cardiac arrest-associated acute kidney injury (CA-AKI).

DESIGN AND METHODS

We conducted a secondary analysis of previously published data on CA patient resuscitation, categorizing them into tertiles based on LCR levels. Univariate and multivariate logistic regression models and subgroup analyses were employed to investigate the association between LCR and CA-AKI. Non-linear correlations were explored using restricted cubic splines, and a two-piece wise logistic proportional hazards model for both sides of the inflection point was constructed.

RESULTS

A total of 374 patients (72.19 % male) were included, with intensive care unit mortality, in-hospital mortality, and neurologic dysfunction rates of 51.87 %, 56.95 %, and 39.57 %, respectively. The overall CA-AKI incidence was 59.09 %. Multivariate logistic proportional hazards analysis revealed a negative association between LCR and CA-AKI incidence (adjusted odds ratio [OR] 0.85, 95 % confidence intervals [CI] = 0.78-0.93, P=0.001). Triple spline restriction analysis depicted an L-shaped correlation between baseline LCR and CA-AKI incidence. Particularly, a baseline LCR<0.051 was negatively associated with CA-AKI incidence (OR 0.494, 95 % CI=0.319-0.764, P=0.002). Beyond the LCR turning point, estimated dose-response curves remained consistent with a horizontal line.

CONCLUSIONS

Baseline LCR in CA patients exhibits an L-shaped correlation with AKI incidence following restoration of autonomic circulation. The threshold for CA-AKI is 0.051. This finding suggests that LCR may aid in identifying CA patients at high risk of AKI.

Serum urea increase during hospital stay is associated with worse outcomes after in-hospital cardiac arrest

BACKGROUND

Evaluate the association between serum urea at admission and during hospital stay with return of spontaneous circulation (ROSC) and in-hospital mortality in patients with in-hospital cardiac arrest (IHCA).

METHODS

This retrospective study included patients over 18 years with IHCA attended from May 2018 to December 2022. The exclusion criteria were the absence of exams to calculate delta urea and the express order of "do-not-resuscitate". Data were collected from the electronic medical records. Serum admission urea and urea 24 hours before IHCA were also collected and used to calculate delta urea.

RESULTS

A total of 504 patients were evaluated; 125 patients were excluded due to the absence of variables to calculate delta urea and 5 due to "do-not-resuscitate" order. Thus, we included 374 patients in the analysis. The mean age was 65.0 ± 14.5 years, 48.9% were male, 45.5% had ROSC, and in-hospital mortality was 91.7%. In logistic regression models, ROSC was associated with lower urea levels 24 hours before IHCA (OR: 0.996; CI95%: 0.992-1.000; p: 0.032). In addition, increased levels of urea 24 hours before IHCA (OR: 1.020; CI95%: 1.008-1.033; p: 0.002) and of delta urea (OR: 1.001; CI95%: 1.001-1.019; p: 0.023) were associated with in-hospital mortality. ROC curve analysis showed that the area under the ROC curve for mortality prediction was higher for urea 24 hours before IHCA (Cutoff > 120.1 mg/dL) than for delta urea (Cutoff > 34.83 mg/dL).

CONCLUSIONS

In conclusion, increased serum urea levels during hospital stay were associated with worse prognosis in IHCA.

Impact of Postarrest Vasoactive-Inotropic Score on Acute Kidney Injury in Cardiac Arrest Survivors: A Retrospective Cohort Study

Background

Postarrest acute kidney injury (AKI) is a major health burden because it is associated with prolonged hospitalization, increased dialysis requirement, high mortality, and unfavorable neurological outcomes. Managing hemodynamic instability during the early postarrest period is critical; however, the role of quantified vasopressor dependence in AKI development in relation to illness severity remains unclear.

Methods

A retrospective, observational cohort study that enrolled 411 non-traumatic adult cardiac arrest survivors without pre-arrest end-stage kidney disease between January 2017 and December 2019, grouped according to their baseline kidney function. The criteria for kidney injury were based on the Kidney Disease: Improving Global Outcomes definition and AKI staging system. The degree of vasopressor dependence within the first 24 h following return of spontaneous circulation (ROSC) was presented using the maximum vasoactive-inotropic score ( VIS max ).

Results

Of the 411 patients, 181 (44%) had early AKI after ROSC. Patients with AKI showed an increased risk of in-hospital mortality (adjusted OR [aOR] 5.40, 95% CI 3.36-8.69, p < 0.001) and unfavorable neurological outcome (aOR 5.70, 95% CI 3.45-9.43, p < 0.001) compared to patients without AKI. The risk of adverse outcomes increased with illness severity. Patients with vasopressor support had an increased risk of early AKI. A low VIS max was associated with AKI stage 1-2 (aOR 2.51, 95% CI 1.20-5.24), whereas a high VIS max was associated with an increased risk for AKI stage 3 (aOR 2.46, 95% CI 1.28-4.75).

Conclusions

Early AKI is associated with an increased risk of in-hospital mortality and unfavorable neurologic recovery in cardiac arrest survivors. Postarrest VIS max is an independent predictor of the development and severity of AKI following ROSC, regardless of baseline kidney function.

[Risk factors for early acute kidney injury after cardiac arrest in children in the pediatric intensive care unit and a prognostic analysis]

OBJECTIVES

To investigate the risk factors for acute kidney injury (AKI) in children with cardiac arrest (CA) and the influencing factors for prognosis.

METHODS

A retrospective analysis was performed on the medical records of the children who developed CA in the pediatric intensive care unit (PICU) of Hunan Children's Hospital from June 2016 to June 2021. According to the presence or absence of AKI within 48 hours after return of spontaneous circulation (ROSC) for CA, the children were divided into two groups: AKI (n=50) and non-AKI (n=113). According to their prognosis on day 7 after ROSC, the AKI group was further divided into a survival group (n=21) and a death group (n=29). The multivariate logistic regression analysis was used to investigate the risk factors for early AKI in the children with CA and the influencing factors for prognosis.

RESULTS

The incidence rate of AKI after CA was 30.7% (50/163). The AKI group had a 7-day mortality rate of 58.0% (29/50) and a 28-day mortality rate of 78.0% (39/50), and the non-AKI group had a 7-day mortality rate of 31.9% (36/113) and a 28-day mortality rate of 58.4% (66/113). The multivariate logistic regression analysis showed that long duration of cardiopulmonary resuscitation (OR=1.164, 95%CI: 1.088-1.246, P<0.001), low baseline albumin (OR=0.879, 95%CI: 0.806-0.958, P=0.003), and adrenaline administration before CA (OR=2.791, 95%CI: 1.119-6.961, P=0.028) were closely associated with the development of AKI after CA, and that low baseline pediatric critical illness score (OR=0.761, 95%CI: 0.612-0.945, P=0.014), adrenaline administration before CA (OR=7.018, 95%CI: 1.196-41.188, P=0.031), and mechanical ventilation before CA (OR=7.875, 95%CI: 1.358-45.672, P=0.021) were closely associated with the death of the children with AKI after CA.

CONCLUSIONS

Albumin should be closely monitored for children with ROSC after CA, especially for those with long duration of cardiopulmonary resuscitation, low baseline pediatric critical illness score, adrenaline administration before CA, and mechanical ventilation before CA, and such children should be identified and intervened as early as possible to reduce the incidence of AKI and the mortality rate.

Prognostic significance of the blood urea nitrogen to creatinine ratio in in-hospital cardiac arrest after targeted temperature management

BACKGROUND

Targeted temperature management (TTM) has been reported to improve outcomes in in-hospital cardiac arrest (IHCA) patients but little has been investigated into the relationship between prognoses and the blood urea nitrogen to creatinine ratio (BCR).

METHODS

A retrospective analysis of data from IHCA survivors treated with TTM between 2011 and 2018 was conducted based on the Research Patient Database Registry of the Partners HealthCare system in Boston. Serum laboratory data were measured during IHCA and within 24 hours after TTM completion. Intra-arrest and post-TTM BCRs were calculated, respectively. The primary outcome was neurologic status at discharge. The secondary outcome was in-hospital mortality.

RESULTS

The study included 84 patients; 63 (75%) were discharged with a poor neurologic status and 40 (47.6%) died. Regarding poor neurological outcome at discharge, multivariate analysis revealed that post-TTM BCR was a significant predictor (adjusted OR, 1.081; 95% CI, 1.002-1.165; p = 0.043) and intra-arrest BCR was a marginal predictor (adjusted OR, 1.067; 95% CI, 1.000-1.138; p = 0.050). Post-TTM BCR had an acceptably predictive ability to discriminate neurological status at discharge, with an area under the receiver-operating characteristic curve of 0.644 (95% CI, 0.516-0.773) and a post-TTM BCR cutoff value of 16.7 had a sensitivity of 61.9% and a specificity of 70.0%.

CONCLUSION

Post-TTM BCR was a significant predictor of the neurologic outcome at discharge among IHCA patients receiving TTM. IHCA patients with elevated intra-arrest BCR also had a borderline poor neurological prognosis at discharge.

The conundrum of the complex relationship between acute kidney injury and cardiac arrhythmias

Acute kidney injury (AKI) is defined by a rapid increase in serum creatinine levels, reduced urine output, or both. Death may occur in 16%-49% of patients admitted to an intensive care unit with severe AKI. Complex arrhythmias are a potentially serious complication in AKI patients with pre-existing or AKI-induced heart damage and myocardial dysfunction, fluid overload, and especially electrolyte and acid-base disorders representing the pathogenetic mechanisms of arrhythmogenesis. Cardiac arrhythmias, in turn, increase the risk of poor renal outcomes, including AKI. Arrhythmic risk in AKI patients receiving kidney replacement treatment may be reduced by modifying dialysis/replacement fluid composition. The most common arrhythmia observed in AKI patients is atrial fibrillation. Severe hyperkalemia, sometimes combined with hypocalcemia, causes severe bradyarrhythmias in this clinical setting. Although the likelihood of life-threatening ventricular arrhythmias is reportedly low, the combination of cardiac ischemia and specific electrolyte or acid-base abnormalities may increase this risk, particularly in AKI patients who require kidney replacement treatment. The purpose of this review is to summarize the available epidemiological, pathophysiological, and prognostic evidence aiming to clarify the complex relationships between AKI and cardiac arrhythmias.

Accumulated Epinephrine Dose is Associated With Acute Kidney Injury Following Resuscitation in Adult Cardiac Arrest Patients

The goal of this study was to investigate the association between total epinephrine dosage during resuscitation and acute kidney injury after return of spontaneous circulation in patients with cardiac arrest. We performed a secondary analysis of previously published data on the resuscitation of cardiac arrest patients. Bivariate, multivariate logistic regression, and subgroup analyses were conducted to investigate the association between total epinephrine dosage during resuscitation and acute kidney injury after return of spontaneous circulation. A total of 312 eligible patients were included. The mean age of the patients was 60.8 ± 15.2 years. More than half of the patients were male (73.4%) and had an out-of-hospital cardiac arrest (61.9%). During resuscitation, 125, 81, and 106 patients received ≤2, 3 - 4, and ≥5 mg epinephrine, respectively. After return of spontaneous circulation, there were 165 patients (52.9%) and 147 patients (47.1%) with and without acute kidney injury, respectively. Both bivariate and multivariate analysis showed a statistically significant association between total epinephrine dosage and acute kidney injury. The subgroup analysis showed that the strength of the association between epinephrine dosage and acute kidney injury varied by location of cardiac arrest. Further multivariate regression analysis found that the association between epinephrine dosage and acute kidney injury was only observed in patients with in-hospital cardiac arrest after adjusting for multiple confounding factors. Compared with in-hospital cardiac arrest patients who received ≤2 mg of epinephrine, patients with 3–4 mg of epinephrine or ≥5 mg of epinephrine had adjusted odds ratios of 4.2 (95% confidence interval 1.0–18.4) and 11.3 (95% confidence interval 2.0–63.0), respectively, to develop acute kidney injury. Therefore, we concluded that a higher epinephrine dosage during resuscitation was associated with an increased incidence of acute kidney injury after return of spontaneous circulation in adult patients with in-hospital cardiac arrest.