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Dagan A, Epstein D, Neuberger A, Isenberg J. Amikacin treatment in urinary tract infection patients: evaluating the risk of acute kidney injury - a retrospective cohort study. J Chemother 2024:1-5. [PMID: 38372170 DOI: 10.1080/1120009x.2024.2319454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 02/11/2024] [Indexed: 02/20/2024]
Abstract
The rise in ESBL-producing and carbapenem-resistant Gram-negative bacterial infections is alarming. Aminoglycosides remain attractive for treating urinary tract infections (UTIs). However, aminoglycosides-associated acute kidney injury (AKI) raises concerns, especially in patients with underlying renal impairment. We conducted a retrospective cohort study to evaluate the risk of AKI in patients with UTI empirically treated with amikacin. Among 395 patients (median age 41.9 years [IQR 28.3-67.1], 342 [86.6%] female), 162 (41.0%) received amikacin and 233 (59.0%) were empirically treated with other antibiotics. AKI incidence was low (5.6%) and not associated with amikacin exposure (OR 0.56, 95% CI 0.22-1.43, p = 0.23), even in those with pre-existing renal impairment or AKI on admission. The clinical outcomes (including cure by the third day, AKI, maximal creatinine, length of stay, mortality, and readmission) did not differ between the groups. Once-daily amikacin may offer a safe UTI treatment option amid increasing multi-drug resistance.
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Affiliation(s)
- Avner Dagan
- Department of Internal Medicine "H", Rambam Health Care Campus, Haifa, Israel
| | - Danny Epstein
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Ami Neuberger
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
- Department of Internal Medicine "D", Rambam Health Care Campus, Haifa, Israel
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Jonathan Isenberg
- Hemato-oncology Department, Rambam Health Care Campus, Haifa, Israel
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2
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Zollner-Schwetz I, König E. Treatment options for multidrug-resistant Gram-negatives in urinary tract infections. Curr Opin Urol 2023; 33:173-179. [PMID: 36861769 DOI: 10.1097/mou.0000000000001084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
PURPOSE OF REVIEW Infections due to multidrug-resistant (MDR) Gram-negative bacteria are challenging to treat because of limited treatment options and potential side effects of less frequently used anti-infectives. In the past few years, several new antimicrobial agents effective against MDR Gram-negatives have become available. This review focuses on the treatment options for complicated urinary tract infections (cUTIs) caused by MDR Gram-negatives. RECENT FINDINGS The novel combinations, betalactam or carbapenem and betalactamase inhibitor, ceftazidime/avibactam and meropenem/vaborbactam, are effective for infections caused by KPC-carbapenemase-producing pathogens. Imipenem/relebactam, another carbapenem/betalactamase inhibitor combination, has been approved for the treatment of cUTI. However, data on the efficacy of imipenem/relebactam against carbapenem-resistant pathogens is still limited. Ceftolozane/tazobactam is mainly used for the treatment of MDR Pseudomonas aeruginosa infections. For the treatment of cUTI caused by extended-spectrum betalactamases producing Enterobacterales aminoglycosides or intravenous fosfomycin should be considered. SUMMARY To ensure prudent use and to avoid the development of resistance to novel anti-infective substances, an interdisciplinary approach, including urologists, microbiologists, and infectious disease physicians, is strongly advised.
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Affiliation(s)
- Ines Zollner-Schwetz
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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3
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Aminoglycosides use has a risk of acute kidney injury in patients without prior chronic kidney disease. Sci Rep 2022; 12:17212. [PMID: 36241669 PMCID: PMC9568559 DOI: 10.1038/s41598-022-21074-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 09/22/2022] [Indexed: 01/06/2023] Open
Abstract
The outcome of acute kidney injury (AKI) as a result of aminoglycosides (AGs) use remains uncertain in patients without prior chronic kidney disease (CKD). Therefore, we explored the outcomes of AGs use on AKI episodes associated with renal recovery and progress in patients without prior CKD in Taiwan. This was a retrospective cohort study by using the Taipei Medical University Research Database from January 2008 to December 2019. 43,259 individuals without CKD who had received parenteral AGs were enrolled. The exposed and unexposed groups underwent propensity score matching for age, gender, patients in intensive care unit/emergency admission, and covariates, except serum hemoglobin and albumin levels. We identified an exposed group of 40,547 patients who used AGs (median age, 54.4 years; 44.3% male) and an unexposed group of 40,547 patients without AG use (median age, 55.7 years; 45.5% male). There was the risk for AKI stage 1 (adjusted hazard ratio [HR] 1.34; 95% confidence interval [CI] 1.00-1.79; p = 0.05) in patients that used AGs in comparison with the control subjects. Moreover, patients using AGs were significantly associated neither with the progression to acute kidney disease (AKD) stages nor with the progression to end-stage renal disease (ESRD) on dialysis. Further analyzed, there was an increased risk of AKI episodes for serum albumin levels less than 3.0 g/dL and hemoglobin levels less than 11.6 g/dL. Among patients without prior CKD, AGs-used individuals were associated with AKI risks, especially those at relatively low albumin (< 3.0 g/dL) or low hemoglobin (< 11.6 g/dL). That could raise awareness of AGs prescription in those patients in clinical practice.
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4
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Botros SR, Matouk AI, Anter A, Khalifa MMA, Heeba GH. Protective effect of empagliflozin on gentamicin-induced acute renal injury via regulation of SIRT1/NF-κB signaling pathway. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2022; 94:103907. [PMID: 35697188 DOI: 10.1016/j.etap.2022.103907] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/27/2022] [Accepted: 06/08/2022] [Indexed: 06/15/2023]
Abstract
Gentamicin is a highly effective antibiotic. However, its major complication is nephrotoxicity. This study investigated the beneficial effects of empagliflozin against gentamicin-induced nephropathy. Kidney damage was induced in male Wistar rats by administration of gentamicin (100 mg/kg/day, i.p.) for 8 days. Two doses of empagliflozin (10 and 20 mg/kg, p.o.) were concomitantly given with gentamicin for 8 days. Gentamicin administration increased serum creatinine, urea, and cystatin C concentrations. Empagliflozin in both doses ameliorated these changes via mitigation of gentamicin-induced increase in renal oxidative stress, inflammation, and apoptosis. Empagliflozin added to GM treatment led to lower measured levels of TGF-B, NF-κB and caspase 3, and only the higher dose increased PAX2 levels indicating an improvement in tubular regeneration. Additionally, empagliflozin (20 mg/kg/day) markedly prevented gentamicin-induced histopathological changes. The protective effects of empagliflozin may be mediated by decreasing gentamicin concentration in renal tissue and possibly other effects like antioxidant and antiapoptotic effects.
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Affiliation(s)
- Sandy R Botros
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, El-Minia, Egypt
| | - Asmaa I Matouk
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, El-Minia, Egypt.
| | - Aliaa Anter
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, El-Minia, Egypt
| | - Mohamed M A Khalifa
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, El-Minia, Egypt
| | - Gehan H Heeba
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, El-Minia, Egypt.
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5
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Akalya K, Murali TM, Vathsala A, Teo BW, Low S, Dharmasegaran D, Koh LP, Bonney GK, Hong WZ, Da Y, Chua HR. Elevated Urinary Tissue Inhibitor Of Metalloproteinase-2 And Insulin-Like Growth Factor Binding Protein-7 Predict Drug-Induced Acute Kidney Injury. Curr Drug Metab 2022; 23:223-232. [PMID: 35469565 DOI: 10.2174/1389200223666220425111931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 12/24/2021] [Accepted: 01/25/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Urinary tissue inhibitor of metalloproteinase-2 (TIMP2) and insulin-like growth factor binding protein-7 (IGFBP7) predict severe acute kidney injury (AKI) in critical illness. Earlier but subtle elevation of either biomarker from nephrotoxicity may predict drug-induced AKI. METHODS A prospective study involving serial urine collection in patients treated with vancomycin, aminoglycosides, amphotericin, foscarnet, or calcineurin inhibitors was performed. Urinary TIMP2 and IGFBP7, absolute levels, normalized with urine creatinine were examined in days leading to AKI onset by KDIGO criteria in cases, or at final day of nephrotoxic therapy in non-AKI controls who were matched for age, baseline kidney function and nephrotoxic exposure. RESULTS Urinary biomarker analyses were performed in 21 AKI patients and 28 non-AKI matched-controls; both groups had comparable baseline kidney function and duration of nephrotoxic drug therapy. Significantly higher absolute, normalized, and composite levels of TIMP2 and IGFBP7 were observed in AKI cases versus controls as early as 2-3 days before AKI onset (all P<0.05); >70% of patients with corresponding levels above 75th percentile developed AKI. Normalized TIMP2 at 2-3 days pre-AKI predicted AKI with the highest average AUROC of 0.81, followed by that of composite [TIMP2]x[IGFBP7] (0.78) after cross-validation. [TIMP2]x[IGFBP7] >0.01 (ng/mL)2 /1000 predicted AKI with a sensitivity of 79% and specificity of 60%. CONCLUSION Elevated urinary TIMP2 or IGFBP7 predicts drug-induced AKI with a lead-time of 2-3 days; an opportune time for interventions to reduce nephrotoxicity.
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Affiliation(s)
- K Akalya
- Division of Nephrology, University Medicine Cluster, National University Hospital (Singapore)
| | - Tanusya Murali Murali
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Anantharaman Vathsala
- Division of Nephrology, University Medicine Cluster, National University Hospital (Singapore).,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Boon-Wee Teo
- Division of Nephrology, University Medicine Cluster, National University Hospital (Singapore).,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Sanmay Low
- Renal Unit, Department of Medicine, Ng Teng Fong General Hospital, Singapore
| | - Dharmini Dharmasegaran
- Division of Nephrology, University Medicine Cluster, National University Hospital (Singapore)
| | - Liang-Piu Koh
- Department of Haematology, National University Cancer Institute, Singapore
| | - Glenn Kunnath Bonney
- Liver Transplantation, National University Centre for Organ Transplantation, Singapore
| | - Wei-Zhen Hong
- Division of Nephrology, University Medicine Cluster, National University Hospital (Singapore)
| | - Yi Da
- Division of Nephrology, University Medicine Cluster, National University Hospital (Singapore)
| | - Horng-Ruey Chua
- Division of Nephrology, University Medicine Cluster, National University Hospital (Singapore).,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
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6
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Takahara S, Tokura T, Nishida R, Uefuji A, Ichimura K, Nishihara H, Aoki K, Takayama H, Nakagawa N, Harada T. Ampicillin/sulbactam versus cefazolin plus aminoglycosides for antimicrobial prophylaxis in management of Gustilo type IIIA open fractures: A retrospective cohort study. Injury 2022; 53:1517-1522. [PMID: 35090733 DOI: 10.1016/j.injury.2022.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 01/15/2022] [Accepted: 01/17/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The antibiotic regimens for prophylaxis in the management of open fractures remain controversial. Although the use of aminoglycosides is widely accepted for treatment of Gustilo type III open fractures, aminoglycosides are often avoided in patients with risk factors. This study aimed to compare efficacy and safety of two regimens, cephazolin plus aminoglycoside (amikacin or gentamicin) and ampicillin/sulbactam (ABPC/SBT), in patients with Gustilo type IIIA open fractures. METHODS A total of 95 Gustilo type IIIA fractures in 90 patients were retrospectively reviewed in this study. The cohort was categorized into two groups that were treated in accordance with the institutional prescribed regimen in different periods: (1) cefazolin plus aminoglycoside (January 1, 2014-September 30, 2017) and (2) ABPC/SBT monotherapy (October 1, 2017-September 30, 2020). Cefazolin was used at 1-2 g every 8 h, aminoglycoside (amikacin or gentamicin) was used daily depending on body weight, and ABPC/SBT was used at 3 g every 8 h The antibiotic administration was continued within 3 days or until successful soft tissue coverage was achieved. The infection rate and the incidence of acute kidney injury (AKI) in both groups were assessed. RESULTS ABPC/SBT was used in 34 patients (36 fractures), and 56 patients (59 fractures) received cefazolin plus aminoglycoside for antibiotic prophylaxis. Infection developed in 2 of 36 fractures in ABPC/SBT group and 4 of 59 fractures in the cefazolin plus aminoglycoside group (p > 0.99). The average serum creatinine levels on admission, baseline, and peak during the hospital stay were not significantly different between the two groups. One case of AKI was identified in each group, indicating that incidence rate of AKI was not significantly different between the two groups. CONCLUSION We demonstrated the non-inferiority of ABPC/SBT therapy over cefazolin plus aminoglycoside regimen for type IIIA open fractures. The ABPC/SBT regimen may be an alternative option for managing Gustilo type IIIA open fractures. Further prospective studies with larger samples are needed to verify these results.
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Affiliation(s)
- Shunsuke Takahara
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan.
| | - Takeo Tokura
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Ryota Nishida
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Atsuo Uefuji
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Katsuhito Ichimura
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Hirotaka Nishihara
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Kenji Aoki
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Hiroyuki Takayama
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Natsuko Nakagawa
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Toshihiko Harada
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
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7
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Chua HR, Zheng K, Vathsala A, Ngiam KY, Yap HK, Lu L, Tiong HY, Mukhopadhyay A, MacLaren G, Lim SL, Akalya K, Ooi BC. Health Care Analytics With Time-Invariant and Time-Variant Feature Importance to Predict Hospital-Acquired Acute Kidney Injury: Observational Longitudinal Study. J Med Internet Res 2021; 23:e30805. [PMID: 34951595 PMCID: PMC8742216 DOI: 10.2196/30805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 09/26/2021] [Accepted: 10/29/2021] [Indexed: 12/29/2022] Open
Abstract
Background Acute kidney injury (AKI) develops in 4% of hospitalized patients and is a marker of clinical deterioration and nephrotoxicity. AKI onset is highly variable in hospitals, which makes it difficult to time biomarker assessment in all patients for preemptive care. Objective The study sought to apply machine learning techniques to electronic health records and predict hospital-acquired AKI by a 48-hour lead time, with the aim to create an AKI surveillance algorithm that is deployable in real time. Methods The data were sourced from 20,732 case admissions in 16,288 patients over 1 year in our institution. We enhanced the bidirectional recurrent neural network model with a novel time-invariant and time-variant aggregated module to capture important clinical features temporal to AKI in every patient. Time-series features included laboratory parameters that preceded a 48-hour prediction window before AKI onset; the latter’s corresponding reference was the final in-hospital serum creatinine performed in case admissions without AKI episodes. Results The cohort was of mean age 53 (SD 25) years, of whom 29%, 12%, 12%, and 53% had diabetes, ischemic heart disease, cancers, and baseline eGFR <90 mL/min/1.73 m2, respectively. There were 911 AKI episodes in 869 patients. We derived and validated an algorithm in the testing dataset with an AUROC of 0.81 (0.78-0.85) for predicting AKI. At a 15% prediction threshold, our model generated 699 AKI alerts with 2 false positives for every true AKI and predicted 26% of AKIs. A lowered 5% prediction threshold improved the recall to 60% but generated 3746 AKI alerts with 6 false positives for every true AKI. Representative interpretation results produced by our model alluded to the top-ranked features that predicted AKI that could be categorized in association with sepsis, acute coronary syndrome, nephrotoxicity, or multiorgan injury, specific to every case at risk. Conclusions We generated an accurate algorithm from electronic health records through machine learning that predicted AKI by a lead time of at least 48 hours. The prediction threshold could be adjusted during deployment to optimize recall and minimize alert fatigue, while its precision could potentially be augmented by targeted AKI biomarker assessment in the high-risk cohort identified.
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Affiliation(s)
- Horng-Ruey Chua
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kaiping Zheng
- Department of Computer Science, School of Computing, National University of Singapore, Singapore, Singapore
| | - Anantharaman Vathsala
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kee-Yuan Ngiam
- Division of Endocrine Surgery, Department of Surgery, National University Hospital, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hui-Kim Yap
- Division of Paediatric Nephrology, Department of Paediatrics, National University Children's Medical Institute, Singapore, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Liangjian Lu
- Division of Paediatric Nephrology, Department of Paediatrics, National University Children's Medical Institute, Singapore, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ho-Yee Tiong
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Urology, National University Hospital, Singapore, Singapore
| | - Amartya Mukhopadhyay
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Graeme MacLaren
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore, Singapore
| | - Shir-Lynn Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - K Akalya
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Beng-Chin Ooi
- Department of Computer Science, School of Computing, National University of Singapore, Singapore, Singapore
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8
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Rodrigues D, Baldissera GS, Mathos D, Sartori A, Zavascki AP, Rigatto MH. Amikacin for the treatment of carbapenem-resistant Klebsiella pneumoniae infections: clinical efficacy and toxicity. Braz J Microbiol 2021. [PMID: 34191252 DOI: 10.1007/s42770-02100551-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023] Open
Abstract
Infections by carbapenem-resistant Klebsiella pneumoniae (CRKp) are an increasing global threat with limited therapeutic options. Our objective was to evaluate clinical and microbiological outcomes of patients treated with amikacin for CRKp infections. We did a retrospective cohort of patients > 18 years old, with CRKp infections treated with amikacin in two tertiary care hospitals in Porto Alegre, Brazil. The impact of clinical factors, antibiotic treatment, and amikacin minimum inhibitory concentration (MIC) on patients' 30-day mortality was assessed. Microbiological clearance and nephrotoxicity (assessed by RIFLE score) were evaluated as secondary outcomes. A Cox regression analysis was done for mortality. We included 84 patients for analysis. Twenty-nine (34.5%) patients died in 30 days. Amikacin MIC values ranged from 0.125 to 8 μg/mL and did not influence on mortality, regardless of the prescribed dose of this antibiotic (P = 0.24). Bacterial clearance occurred in 17 (58.6%) of 29 patients who collected subsequent cultures. Two (16.6%) of the 12 persistently positive cultures changed the amikacin susceptibility profile from susceptible to intermediate. Twenty-nine (37.2%) patients developed acute kidney injury (AKI): risk 13, injury 11, and failure 5. Risk factors for AKI were higher baseline eGFR (P < 0.01) and combination therapy with colistin (P = 0.02). Comparing patients who received combination with colistin vs polymyxin B, AKI occurred in 60.0% vs 20.6%, respectively, P < 0.01. Fifteen of the 16 (16.6%) patients who developed renal injury or failure were receiving colistin. In conclusion, amikacin was an effective treatment for CRKp infections. Within susceptible range, amikacin MIC values did not influence on clinical outcomes. Combination therapy of amikacin and colistin was highly nephrotoxic and should be used with caution.
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Affiliation(s)
- Diógenes Rodrigues
- Medical Sciences Post-Graduation Program, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | | | - Douglas Mathos
- Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Aline Sartori
- Pontifícia Universidade Católica Do Rio Grande Do Sul Medical School, Porto Alegre, Brazil
| | - Alexandre P Zavascki
- Medical Sciences Post-Graduation Program, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
- Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Infectious Diseases Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Maria Helena Rigatto
- Medical Sciences Post-Graduation Program, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil.
- Infectious Diseases Service, Hospital São Lucas da PUCRS, Porto Alegre, Brazil.
- Infectious Diseases Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
- Pontifícia Universidade Católica Do Rio Grande Do Sul Medical School, Porto Alegre, Brazil.
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9
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Chinzowu T, Roy S, Nishtala PS. Risk of antimicrobial-associated organ injury among the older adults: a systematic review and meta-analysis. BMC Geriatr 2021; 21:617. [PMID: 34724889 PMCID: PMC8561875 DOI: 10.1186/s12877-021-02512-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 09/10/2021] [Indexed: 11/24/2022] Open
Abstract
Background Older adults (aged 65 years and above) constitute the fastest growing population cohort in the western world. There is increasing evidence that the burden of infections disproportionately affects older adults, and hence this vulnerable population is frequently exposed to antimicrobials. There is currently no systematic review summarising the evidence for organ injury risk among older adults following antimicrobial exposure. This systematic review and meta-analysis examined the relationship between antimicrobial exposure and organ injury in older adults. Methodology We searched for original research articles in PubMed, Embase.com, Web of Science core collection, Web of Science BIOSIS citation index, Scopus, Cochrane Central Register of Controlled Trials, ProQuest, and PsycINFO databases, using key words in titles and abstracts, and using MeSH terms. We searched for all available articles up to 31 May 2021. After removing duplicates, articles were screened for inclusion into or exclusion from the study by two reviewers. The Newcastle-Ottawa scale was used to assess the risk of bias for cohort and case-control studies. We explored the heterogeneity of the included studies using the Q test and I2 test and the publication bias using the funnel plot and Egger’s test. The meta-analyses were performed using the OpenMetaAnalyst software. Results The overall absolute risks of acute kidney injury among older adults prescribed aminoglycosides, glycopeptides, and macrolides were 15.1% (95% CI: 12.8–17.3), 19.1% (95% CI: 15.4–22.7), and 0.3% (95% CI: 0.3–0.3), respectively. Only 3 studies reported antimicrobial associated drug-induced liver injury. Studies reporting on the association of organ injury and antimicrobial exposure by age or duration of treatment were too few to meta-analyse. The funnel plot and Egger’s tests did not indicate evidence of publication bias. Conclusion Older adults have a significantly higher risk of sustaining acute kidney injury when compared to the general adult population. Older adults prescribed aminoglycosides have a similar risk of acute kidney injury to the general adult population. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02512-3.
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Affiliation(s)
- Tichawona Chinzowu
- Department of Pharmacy and Pharmacology & Centre for Therapeutic Innovation, University of Bath, Bath, BA2 7AY, UK.
| | - Sandipan Roy
- Department of Mathematical Science, University of Bath, Bath, BA2 7AY, UK
| | - Prasad S Nishtala
- Department of Pharmacy and Pharmacology & Centre for Therapeutic Innovation, University of Bath, Bath, BA2 7AY, UK
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10
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Rodrigues D, Baldissera GS, Mathos D, Sartori A, Zavascki AP, Rigatto MH. Amikacin for the treatment of carbapenem-resistant Klebsiella pneumoniae infections: clinical efficacy and toxicity. Braz J Microbiol 2021; 52:1913-1919. [PMID: 34191252 DOI: 10.1007/s42770-021-00551-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/21/2021] [Indexed: 11/28/2022] Open
Abstract
Infections by carbapenem-resistant Klebsiella pneumoniae (CRKp) are an increasing global threat with limited therapeutic options. Our objective was to evaluate clinical and microbiological outcomes of patients treated with amikacin for CRKp infections. We did a retrospective cohort of patients > 18 years old, with CRKp infections treated with amikacin in two tertiary care hospitals in Porto Alegre, Brazil. The impact of clinical factors, antibiotic treatment, and amikacin minimum inhibitory concentration (MIC) on patients' 30-day mortality was assessed. Microbiological clearance and nephrotoxicity (assessed by RIFLE score) were evaluated as secondary outcomes. A Cox regression analysis was done for mortality. We included 84 patients for analysis. Twenty-nine (34.5%) patients died in 30 days. Amikacin MIC values ranged from 0.125 to 8 μg/mL and did not influence on mortality, regardless of the prescribed dose of this antibiotic (P = 0.24). Bacterial clearance occurred in 17 (58.6%) of 29 patients who collected subsequent cultures. Two (16.6%) of the 12 persistently positive cultures changed the amikacin susceptibility profile from susceptible to intermediate. Twenty-nine (37.2%) patients developed acute kidney injury (AKI): risk 13, injury 11, and failure 5. Risk factors for AKI were higher baseline eGFR (P < 0.01) and combination therapy with colistin (P = 0.02). Comparing patients who received combination with colistin vs polymyxin B, AKI occurred in 60.0% vs 20.6%, respectively, P < 0.01. Fifteen of the 16 (16.6%) patients who developed renal injury or failure were receiving colistin. In conclusion, amikacin was an effective treatment for CRKp infections. Within susceptible range, amikacin MIC values did not influence on clinical outcomes. Combination therapy of amikacin and colistin was highly nephrotoxic and should be used with caution.
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Affiliation(s)
- Diógenes Rodrigues
- Medical Sciences Post-Graduation Program, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | | | - Douglas Mathos
- Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Aline Sartori
- Pontifícia Universidade Católica Do Rio Grande Do Sul Medical School, Porto Alegre, Brazil
| | - Alexandre P Zavascki
- Medical Sciences Post-Graduation Program, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil.,Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Infectious Diseases Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Maria Helena Rigatto
- Medical Sciences Post-Graduation Program, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil. .,Infectious Diseases Service, Hospital São Lucas da PUCRS, Porto Alegre, Brazil. .,Infectious Diseases Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. .,Pontifícia Universidade Católica Do Rio Grande Do Sul Medical School, Porto Alegre, Brazil.
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11
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Zohar I, Schwartz O, Yossepowitch O, David SSB, Maor Y. Aminoglycoside versus carbapenem or piperacillin/tazobactam treatment for bloodstream infections of urinary source caused by Gram-negative ESBL-producing Enterobacteriaceae. J Antimicrob Chemother 2021; 75:458-465. [PMID: 31691817 DOI: 10.1093/jac/dkz457] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/14/2019] [Accepted: 10/04/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES We studied the performance of aminoglycosides in treating bloodstream infections (BSIs) of urinary source caused by ESBL-producing Enterobacteriaceae (ESBL-EB). METHODS In a retrospective study of 193 patients with a clinical diagnosis of urinary tract infection, pyelonephritis or urosepsis and blood and urine cultures positive for ESBL-EB, patients were grouped according to whether they were treated with an aminoglycoside, a carbapenem or piperacillin/tazobactam. Multivariate analysis was used to define risk factors for mortality with inverse probability of treatment weighting used to minimize confounding. The primary efficacy outcome was 30 day mortality. The primary safety outcome was acute kidney injury (AKI) at 14 days. RESULTS Mean age was 79.3 years. Dementia, chronic kidney disease and the presence of a urinary catheter were common. Thirty-two (16.6%) patients died and risk factors for mortality included age, high Charlson score, presentation with severe sepsis/septic shock and infection with bacteria other than Escherichia coli. Aminoglycosides were non-inferior compared with other antibiotics regarding 30 day mortality [13.0% versus 21.2%, respectively; adjusted risk difference=10.29% (-0.82% to 21.41%)], but did not reach non-inferiority for bacteriuria recurrence [48.9% versus 44.7%, respectively; adjusted risk difference=-8.72% (-30.87% to 13.43%)]. AKI developed at a similar rate in both treatment groups: 12.0% versus 10.6%, respectively [OR=1.14 (0.46-2.81)]. Aminoglycosides were more efficacious in E. coli infections compared with other ESBL-EB. CONCLUSIONS We demonstrated the efficacy and safety of aminoglycosides in treating BSI of urinary source caused by ESBL-EB. This carbapenem-sparing approach can assist in avoiding excessive carbapenem use without compromising outcomes.
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Affiliation(s)
- Iris Zohar
- Infectious Disease Unit, Wolfson Medical Center, Holon, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orna Schwartz
- Microbiology Laboratory, Wolfson Medical Center, Holon, Israel
| | | | | | - Yasmin Maor
- Infectious Disease Unit, Wolfson Medical Center, Holon, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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12
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Jeon N, Park H, Segal R, Brumback B, Winterstein AG. Non-steroidal anti-inflammatory drug-associated acute kidney injury: does short-term NSAID use pose a risk in hospitalized patients? Eur J Clin Pharmacol 2021; 77:1409-1417. [PMID: 33772627 DOI: 10.1007/s00228-021-03121-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 03/09/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE While renal risk associated with short-term use of non-steroidal anti-inflammatory drugs (NSAID) has been anecdotally documented, no conclusive evidence is available on the renal safety, especially among hospitalized patients with reduced renal function. This study is to evaluate the risk of acute kidney injury (AKI) associated with NSAID use in hospital. METHODS A retrospective matched cohort study utilizing electronic health records from two large academic tertiary-care hospitals was conducted. We defined AKI based on changes in SCr according to published AKI criteria. The hospital acquired AKI risk associated with inpatient NSAID use was assessed using a time-dependent Cox proportional hazard regression in pooled cohort as well as two sub cohorts stratified by baseline renal function. RESULTS A total of 18,794 admissions were included in the final cohort. Of 9397 admissions exposed to NSAIDs, 7914 and 1483 admissions were in the "without" and "with baseline renal impairment" cohort, with the same number of matching non-exposed admissions in each of the stratified cohort. The AKI incidences were 6 and 22 events per 1000 patient-days in "without" and "with preexisting renal impairment" cohort, respectively. The adjusted analyses suggested that NSAID use increased AKI risk in patients with preexisting renal impairment (hazard ratio [HR]: 1.38 [1.04-1.83]) but not in the patients without preexisting renal impairment (HR: 0.83 [95% CIs: 0.63-1.08]) or in the pooled cohort (HR: 1.01 [95% CIs: 0.83-1.24]). CONCLUSION Our findings suggested that NSAID use is associated with an increased risk of AKI in the hospitalized patients with preexisting renal impairment but the association is not statistically significant in those who have preserved renal function. Further randomized controlled trials are needed to validate these observational findings.
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Affiliation(s)
- Nakyung Jeon
- College of Pharmacy, Chonnam National University, Gwang-ju, South Korea
| | - Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL, 32611, USA
| | - Richard Segal
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL, 32611, USA
| | - Babette Brumback
- Department of Biostatistics, College of Public Health and Health Professions & College of Medicine, University of Florida, 1225 Center Drive, Gainesville, FL, 32611, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL, 32611, USA. .,Center for Drug Evaluation and Safety (CoDES), University of Florida, 1225 Center Drive, Gainesville, FL, 32611, USA. .,Department of Epidemiology, College of Public Health and Health Profession & College of Medicine, University of Florida, 1225 Center Drive, Gainesville, FL, 32611, USA.
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13
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Hu W, Lian X, Lin J, Chen Y, Wu Y, Liu W, Yu F, Hao W. The Incidence, Characteristics, and Use of Suspected Nephrotoxic Drugs in Elderly Patients with Community-Acquired Acute Kidney Injury. Clin Interv Aging 2021; 16:35-42. [PMID: 33442243 PMCID: PMC7800449 DOI: 10.2147/cia.s286660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/03/2020] [Indexed: 01/22/2023] Open
Abstract
PURPOSE Acute kidney injury (AKI) is a major health problem with poor prognosis. However, little is known about elderly community-acquired-AKI (CA-AKI). This study aimed to investigate the incidence, clinical characteristics, outcomes and use of suspected nephrotoxic medications after CA-AKI in the elderly. MATERIALS AND METHODS A total of 36,445 patients aged over 60 years were recruited from 2013 to 2016. Through an electronic database, we collected the demographic and medical history data, and admission lab results from all patients. RESULTS A total of 2371 patients with CA-AKI were identified. The incidence of CA-AKI was 26.03% in the elderly. The proportion of CA-AKI patients with chronic comorbidities and Charlson comorbidity index score were higher than that of non-AKI patients. After CA-AKI, the proportions of exposure to non-steroidal anti-inflammatory drugs (NSAIDs), iodine contrast agent, angiotensin converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) were significantly decreased (p < 0.001). However, the proportion of other possible nephrotoxic drugs (including aminoglycosides, glycopeptide antibiotics, antifungal agents, beta lactam antibiotics, diuretic, ferralia, adrenergic receptor agonists and drugs for cardiac insufficiency therapy) still increased after CA-AKI (p < 0.001). Compared with non-AKI patients, CA-AKI patients had higher percentage of cardiogenic shock, multiple organ failure, transferring to intensive care unit, cardio-pulmonary resuscitation, hemodialysis, and mortality (p < 0.001). Moreover, CA-AKI patients had worse prognosis when more kinds of suspected nephrotoxic drugs were used (p < 0.001). CONCLUSION The incidence of CA-AKI in the elderly was high, with more complex chronic complications and poor clinical outcomes. The use of most suspected nephrotoxic drugs still increased and was associated with worse prognosis after CA-AKI.
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Affiliation(s)
- Wenxue Hu
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Geriatrics Institute, Guangzhou510080, People’s Republic of China
| | - Xingji Lian
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Geriatrics Institute, Guangzhou510080, People’s Republic of China
| | - Jieshan Lin
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Geriatrics Institute, Guangzhou510080, People’s Republic of China
| | - Yuanhan Chen
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Geriatrics Institute, Guangzhou510080, People’s Republic of China
| | - Yanhua Wu
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Geriatrics Institute, Guangzhou510080, People’s Republic of China
| | - Wei Liu
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Geriatrics Institute, Guangzhou510080, People’s Republic of China
| | - Feng Yu
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Geriatrics Institute, Guangzhou510080, People’s Republic of China
| | - Wenke Hao
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Geriatrics Institute, Guangzhou510080, People’s Republic of China
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14
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Petejova N, Martinek A, Zadrazil J, Kanova M, Klementa V, Sigutova R, Kacirova I, Hrabovsky V, Svagera Z, Stejskal D. Acute Kidney Injury in Septic Patients Treated by Selected Nephrotoxic Antibiotic Agents-Pathophysiology and Biomarkers-A Review. Int J Mol Sci 2020; 21:ijms21197115. [PMID: 32993185 PMCID: PMC7583998 DOI: 10.3390/ijms21197115] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 09/24/2020] [Accepted: 09/25/2020] [Indexed: 12/28/2022] Open
Abstract
Acute kidney injury is a common complication in critically ill patients with sepsis and/or septic shock. Further, some essential antimicrobial treatment drugs are themselves nephrotoxic. For this reason, timely diagnosis and adequate therapeutic management are paramount. Of potential acute kidney injury (AKI) biomarkers, non-protein-coding RNAs are a subject of ongoing research. This review covers the pathophysiology of vancomycin and gentamicin nephrotoxicity in particular, septic AKI and the microRNAs involved in the pathophysiology of both syndromes. PubMED, UptoDate, MEDLINE and Cochrane databases were searched, using the terms: biomarkers, acute kidney injury, antibiotic nephrotoxicity, sepsis, miRNA and nephrotoxicity. A comprehensive review describing pathophysiology and potential biomarkers of septic and toxic acute kidney injury in septic patients was conducted. In addition, five miRNAs: miR-15a-5p, miR-192-5p, miR-155-5p, miR-486-5p and miR-423-5p specific to septic and toxic acute kidney injury in septic patients, treated by nephrotoxic antibiotic agents (vancomycin and gentamicin) were identified. However, while these are at the stage of clinical testing, preclinical and clinical trials are needed before they can be considered useful biomarkers or therapeutic targets of AKI in the context of antibiotic nephrotoxicity or septic injury.
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Affiliation(s)
- Nadezda Petejova
- Department of Internal Medicine, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (A.M.); (V.H.)
- Department of Clinical Studies Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
- Department of Internal Medicine III—Nephrology, Rheumatology and Endocrinology, University Hospital and Faculty of Medicine and Dentistry, Palacky University Olomouc, 77900 Olomouc, Czech Republic; (J.Z.); (V.K.)
- Correspondence:
| | - Arnost Martinek
- Department of Internal Medicine, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (A.M.); (V.H.)
- Department of Clinical Studies Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
| | - Josef Zadrazil
- Department of Internal Medicine III—Nephrology, Rheumatology and Endocrinology, University Hospital and Faculty of Medicine and Dentistry, Palacky University Olomouc, 77900 Olomouc, Czech Republic; (J.Z.); (V.K.)
| | - Marcela Kanova
- Department of Anesthesiology and Resuscitation, University Hospital Ostrava, 70852 Ostrava, Czech Republic;
| | - Viktor Klementa
- Department of Internal Medicine III—Nephrology, Rheumatology and Endocrinology, University Hospital and Faculty of Medicine and Dentistry, Palacky University Olomouc, 77900 Olomouc, Czech Republic; (J.Z.); (V.K.)
| | - Radka Sigutova
- Department of Laboratory Diagnostics Institute of Clinical Biochemistry and Clinical Pharmacology, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (R.S.); (I.K.); (Z.S.); (D.S.)
- Department of Biomedical Sciences Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
| | - Ivana Kacirova
- Department of Laboratory Diagnostics Institute of Clinical Biochemistry and Clinical Pharmacology, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (R.S.); (I.K.); (Z.S.); (D.S.)
- Institute of Clinical Pharmacology Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
| | - Vladimir Hrabovsky
- Department of Internal Medicine, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (A.M.); (V.H.)
- Department of Clinical Studies Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
| | - Zdenek Svagera
- Department of Laboratory Diagnostics Institute of Clinical Biochemistry and Clinical Pharmacology, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (R.S.); (I.K.); (Z.S.); (D.S.)
- Department of Biomedical Sciences Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
| | - David Stejskal
- Department of Laboratory Diagnostics Institute of Clinical Biochemistry and Clinical Pharmacology, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (R.S.); (I.K.); (Z.S.); (D.S.)
- Department of Biomedical Sciences Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
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15
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Abstract
Acute kidney injury (AKI) is a common and critical clinical disorder with non-negligible morbidity and mortality and remains a large public health problem. Asia, as the world's largest and most populous continent, is crucial in eliminating unsatisfactory outcomes of AKI. The diversities in climate, customs, and economic status lead to various clinical features of AKI across Asia. In this review, we focus on the epidemiologic data and clinical features of AKI in different Asian countries and clinical settings, and we show the huge medical and economic burden of AKI in Asian countries. Drugs and sepsis are the most common etiologies for AKI, however, an adequate surveillance system has not been well established. There is significant undertreatment of AKI in many regions, and medical resources for renal replacement therapy are not universally available. Although substantial improvement has been achieved, health care for AKI still needs improvement, especially in developing regions.
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Affiliation(s)
- Junwen Huang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China; Peking University Institute of Nephrology, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Damin Xu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China; Peking University Institute of Nephrology, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Li Yang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China; Peking University Institute of Nephrology, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.
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16
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Pragasam AK, Jennifer SL, Solaimalai D, Muthuirulandi Sethuvel DP, Rachel T, Elangovan D, Vasudevan K, Gunasekaran K, Veeraraghavan B. Expected plazomicin susceptibility in India based on the prevailing aminoglycoside resistance mechanisms in Gram-negative organisms derived from whole-genome sequencing. Indian J Med Microbiol 2020; 38:313-318. [PMID: 33154241 DOI: 10.4103/ijmm.ijmm_20_384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Aminoglycoside resistance is a growing challenge, and it is commonly mediated by the aminoglycoside-modifying enzymes (AMEs), followed by 16S rRNA methyl transferase. Plazomicin, a novel aminoglycoside agent approved by the Food and Drug Administration for complicated urinary tract infections is proven to overcome resistance mediated by AMEs but not due to 16S rRNA methyl transferase (16SRMTases). We undertook this study to predict the efficacy of plazomicin in India based on the antimicrobial resistance profile derived from whole-genome sequencing (WGS). Methodology A total of 386 clinical isolates of Escherichia coli, Klebsiella pneumoniae and Acinetobacter baumannii subjected to WGS were screened for aminoglycoside-resistance mechanisms such as AMEs and 16SRMTases and its association with carbapenemases. Results AMEs was present in all E. coli, A. baumannii and in 90% of K. pneumoniae. In addition, up to 47% of E. coli and 38% of K. pneumoniae co-carried 16SRMTases with AMEs genes. However, A. baumannii showed 87% of isolates co-harbouring 16SRMTase. bla NDM, bla Oxa-48-like and bla Oxa-23-like were the most predominant carbapenemases in E. coli, K. pneumoniae and A. baumannii, respectively. Notably, 48% of NDM-producing E. coli and 35% of Oxa-48-like producing K. pneumoniae were identified to co-harbour AMEs + RMTAses, where plazomicin may not be useful. Conclusion Overall, 53%, 62% and 14% of carbapenemase-producing E. coli, K. pneumoniae and A. baumannii harbours only AMEs, indicating the role of plazomicin use. Plazomicin can be used both for ESBLs as "carbapenem-sparing agent" and carbapenemase producers as "colistin-sparing agent." For optimal use, it is essential to know the molecular epidemiology of resistance in a given geographical region where plazomicin empirical therapy is considered.
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Affiliation(s)
- Agila Kumari Pragasam
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - S Lydia Jennifer
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | | | | | - Tanya Rachel
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Divyaa Elangovan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Karthick Vasudevan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Karthick Gunasekaran
- Department of General Medicine (Unit.V), Christian Medical College, Vellore, Tamil Nadu, India
| | - Balaji Veeraraghavan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
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17
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Cobussen M, Haeseker MB, Stoffers J, Wanrooij VHM, Savelkoul PHM, Stassen PM. Renal safety of a single dose of gentamicin in patients with sepsis in the emergency department. Clin Microbiol Infect 2020; 27:S1198-743X(20)30376-1. [PMID: 32621972 DOI: 10.1016/j.cmi.2020.06.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To determine the effect of a single dose of gentamicin on the incidence and persistence of acute kidney injury (AKI) in patients with sepsis in the emergency department (ED). METHODS We retrospectively studied patients with sepsis in the ED in three hospitals. Local antibiotic guidelines recommended a single dose of gentamicin as part of empirical therapy in selected patients in one hospital, whereas the other two hospitals did not. Multivariate analysis was used to evaluate the effect of gentamicin and other potential risk factors on the incidence and persistence of AKI after admission. AKI was defined according to the KDIGO (Kidney Disease Improving Global Outcomes) criteria. RESULTS Of 1573 patients, 571 (32.9%) received a single dose of gentamicin. At admission, 181 (31.7%) of 571 of the gentamicin-treated and 228 (22.8%) of 1002 of the non-gentamicin-treated patients had AKI (p < 0.001). After admission, AKI occurred in 64 (12.0%) of 571 patients who received gentamicin and in 82 (8.9%) of 1002 people in the control group (p 0.06). Multivariate analysis showed that shock (odds ratio (OR), 2.72; 95% CI, 1.31-5.67), diabetes mellitus (OR, 1.49; 95% CI, 1.001-2.23) and higher baseline (i.e. before admission) serum creatinine levels (OR, 1.007; 95% CI, 1.005-1.009) were associated with the development of AKI after admission, but not receipt of gentamicin (OR, 1.29; 95% CI, 0.89-1.86). Persistent AKI was rare in both the group that received gentamicin (16/260, 6.2%) and the group that did not (15/454, 3.3%, p 0.09). CONCLUSIONS With regard to renal function, a single dose of gentamicin in patients with sepsis in the ED is safe. The development of AKI after admission was associated with shock, diabetes mellitus and higher baseline creatinine level.
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Affiliation(s)
- M Cobussen
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, the Netherlands; CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands; Department of Internal Medicine, Rijnstate Hospital, Arnhem, the Netherlands.
| | - M B Haeseker
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Medical Microbiology, ReinierHaga Medical Diagnostic Center, Delft, the Netherlands
| | - J Stoffers
- Department of Internal Medicine, Division of General Medicine, Section Acute Medicine, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Internal Medicine, Zuyderland Medical Center, Heerlen, the Netherlands
| | - V H M Wanrooij
- Department of Internal Medicine, Division of General Medicine, Section Acute Medicine, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Internal Medicine, Zuyderland Medical Center, Heerlen, the Netherlands
| | - P H M Savelkoul
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, the Netherlands; CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - P M Stassen
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands; Department of Internal Medicine, Division of General Medicine, Section Acute Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
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18
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Considerations for the optimal management of antibiotic therapy in elderly patients. J Glob Antimicrob Resist 2020; 22:325-333. [PMID: 32165285 DOI: 10.1016/j.jgar.2020.02.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 02/14/2020] [Accepted: 02/26/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To maximise efficacy and minimise toxicity, special considerations are required for antibiotic prescription in elderly patients. This review aims to provide practical suggestions for the optimal management of antibiotic therapy in elderly patients. METHODS This was a narrative review. A literature search of published articles in the last 15 years on antibiotics and elderly patients was performed using the Cochrane Library and PubMed electronic databases. The three priority areas were identified: (i) pharmacokinetics/pharmacodynamics (PK/PD) for optimising dosage regimens and route of administration; (ii) antibiotic dosages in some special subpopulations; and (iii) treatment considerations relating to different antibiotic classes and their adverse events. RESULTS Clinicians should understand the altered PK/PD of drugs in this population owing to co-morbid conditions and normal physiological changes associated with ageing. The body of evidence justifies the need for individualised dose selection, especially in patients with impaired renal and liver function. Clinicians should be aware of the major drug-drug interactions commonly observed in the elderly as well as potential side effects. CONCLUSION Antibiotic therapy in the elderly requires a comprehensive approach, including strategies to improve appropriate antibiotic prescribing, limit their use for uncomplicated infections and ensure the attainment of an optimal PK/PD target. To this purpose, further studies involving the elderly are needed to better understand the PK of antibiotics. Moreover, it is necessary to assess the role therapeutic drug monitoring in guiding antibiotic therapy in elderly patients in order to evaluate its impact on clinical outcome.
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19
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Da Y, Akalya K, Murali T, Vathsala A, Tan CS, Low S, Lim HN, Teo BW, Lau T, Ong L, Chua HR. Serial Quantification of Urinary Protein Biomarkers to Predict Drug-induced Acute Kidney Injury. Curr Drug Metab 2020; 20:656-664. [PMID: 31296157 DOI: 10.2174/1389200220666190711114504] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/28/2019] [Accepted: 07/01/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Drug-induced Acute Kidney Injury (AKI) develops in 10-15% of patients who receive nephrotoxic medications. Urinary biomarkers of renal tubular dysfunction may detect nephrotoxicity early and predict AKI. METHODS We prospectively studied patients who received aminoglycosides, vancomycin, amphotericin, or calcineurin inhibitors, and collected their serial urine while on therapy. Patients who developed drug-induced AKI (fulfilling KDIGO criteria) were matched with non-AKI controls in a 1:2 ratio. Their urine samples were batch-analyzed at time-intervals leading up to AKI onset; the latter benchmarked against the final day of nephrotoxic therapy in non- AKI controls. Biomarkers examined include clusterin, beta-2-microglobulin, KIM1, MCP1, cystatin-C, trefoil-factor- 3, NGAL, interleukin-18, GST-Pi, calbindin, and osteopontin; biomarkers were normalized with corresponding urine creatinine. RESULTS Nine of 84 (11%) patients developed drug-induced AKI. Biomarkers from 7 AKI cases with pre-AKI samples were compared with those from 14 non-AKI controls. Corresponding mean ages were 55(±17) and 52(±16) years; baseline eGFR were 99(±21) and 101(±24) mL/min/1.73m2 (all p=NS). Most biomarker levels peaked before the onset of AKI. Median levels of 5 biomarkers were significantly higher in AKI cases than controls at 1-3 days before AKI onset (all µg/mmol): clusterin [58(8-411) versus 7(3-17)], beta-2-microglobulin [1632(913-3823) versus 253(61-791)], KIM1 [0.16(0.13-0.76) versus 0.07(0.05-0.15)], MCP1 [0.40(0.16-1.90) versus 0.07(0.04-0.17)], and cystatin-C [33(27-2990) versus 11(7-19)], all p<0.05; their AUROC for AKI prediction were >0.80 (confidence intervals >0.50), with average accuracy highest for clusterin (86%), followed by beta-2-microglobulin, cystatin-C, MCP1, and KIM1 (57%) after cross-validation. CONCLUSION Serial surveillance of these biomarkers could improve the lead time for nephrotoxicity detection by days.
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Affiliation(s)
- Yi Da
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore 119074, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - K Akalya
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore 119074, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Tanusya Murali
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore 119074, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Anantharaman Vathsala
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore 119074, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Chuen-Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore 119077, Singapore
| | - Sanmay Low
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore 119074, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Hui-Ning Lim
- Department of Pharmacy, National University Hospital, Singapore 119074, Singapore
| | - Boon-Wee Teo
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore 119074, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Titus Lau
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore 119074, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Lizhen Ong
- Department of Laboratory Medicine, National University Hospital, Singapore 119074, Singapore
| | - Horng-Ruey Chua
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore 119074, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
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20
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Abstract
Substances toxic to the kidney are legion in the modern world. The sheer number and variety, their mutual interactions and, metabolism within the body are a challenge to research. Moreover, the kidney is especially prone to injury owing to its physiology. Acute kidney injury (AKI) induced by poisonous or primarily nephrotoxic substances, may be community acquired with ingestion or inhalation or nosocomial. Many nephrotoxic plants, animal poisons, medications, chemicals and illicit drugs can induce AKI by varying pathophysiological pathways. Moreover, the epidemiology of toxic AKI varies depending on country, regions within countries, socioeconomic status and health care facilities. In this review, we have selected nephrotoxic insults due to medication, plants, animal including snake venom toxicity, environmental, (agri)chemicals and also illicit drugs. We conclude with a section on diagnosis, clinical presentation and management of poisoning accompanied by various organ dysfunction and AKI.
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Affiliation(s)
- Nadezda Petejova
- a Department of Internal Medicine , University Hospital Ostrava , Ostrava , Czech Republic.,b Department of Clinical Studies, Faculty of Medicine , University of Ostrava , Ostrava , Czech Republic.,c Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology , University Hospital and Faculty of Medicine and Dentistry, Palacky University Olomouc , Olomouc , Czech Republic
| | - Arnost Martinek
- a Department of Internal Medicine , University Hospital Ostrava , Ostrava , Czech Republic.,b Department of Clinical Studies, Faculty of Medicine , University of Ostrava , Ostrava , Czech Republic
| | - Josef Zadrazil
- c Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology , University Hospital and Faculty of Medicine and Dentistry, Palacky University Olomouc , Olomouc , Czech Republic
| | - Vladimir Teplan
- a Department of Internal Medicine , University Hospital Ostrava , Ostrava , Czech Republic.,d Department of Nephrology , Institute for Postgraduate Education Prague , Vinohrady , Czech Republic
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22
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Karaiskos I, Lagou S, Pontikis K, Rapti V, Poulakou G. The "Old" and the "New" Antibiotics for MDR Gram-Negative Pathogens: For Whom, When, and How. Front Public Health 2019; 7:151. [PMID: 31245348 PMCID: PMC6581067 DOI: 10.3389/fpubh.2019.00151] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/23/2019] [Indexed: 12/15/2022] Open
Abstract
The recent expansion of multidrug resistant and pan-drug-resistant pathogens poses significant challenges in the treatment of healthcare associated infections. An important advancement, is a handful of recently launched new antibiotics targeting some of the current most problematic Gram-negative pathogens, namely carbapenem-producing Enterobacteriaceae (CRE) and carbapenem-resistant P. aeruginosa (CRPA). Less options are available against carbapenem-resistant Acinetobacter baumannii (CRAB) and strains producing metallo-beta lactamases (MBL). Ceftazidime-avibactam signaled a turning point in the treatment of KPC and partly OXA- type carbapenemases, whereas meropenem-vaborbactam was added as a potent combination against KPC-producers. Ceftolozane-tazobactam could be seen as an ideal beta-lactam backbone for the treatment of CRPA. Plazomicin, an aminoglycoside with better pharmacokinetics and less toxicity compared to other class members, will cover important proportions of multi-drug resistant pathogens. Eravacycline holds promise in the treatment of infections by CRAB, with a broad spectrum of activity similar to tigecycline, and improved pharmacokinetics. Novel drugs and combinations are not to be considered "panacea" for the ongoing crisis in the therapy of XDR Gram-negative bacteria and colistin will continue to be considered as a fundamental companion drug for the treatment of carbapenem-resistant Enterobacteriaceae (particularly in areas where MBL predominate), for the treatment of CRPA (in many cases being the only in vitro active drug) as well as CRAB. Aminoglycosides are still important companion antibiotics. Finally, fosfomycin as part of combination treatment for CRE infections and P. aeruginosa, deserves a greater attention. Optimal conditions for monotherapy and the "when and how" of combination treatments integrating the novel agents will be discussed.
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Affiliation(s)
- Ilias Karaiskos
- First Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Styliani Lagou
- Third Department of Medicine, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Pontikis
- ICU First Department of Respiratory Medicine, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasiliki Rapti
- Third Department of Medicine, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Garyphallia Poulakou
- Third Department of Medicine, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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23
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Low S, Vathsala A, Murali TM, Pang L, MacLaren G, Ng WY, Haroon S, Mukhopadhyay A, Lim SL, Tan BH, Lau T, Chua HR. Electronic health records accurately predict renal replacement therapy in acute kidney injury. BMC Nephrol 2019; 20:32. [PMID: 30704418 PMCID: PMC6357378 DOI: 10.1186/s12882-019-1206-4] [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] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 01/07/2019] [Indexed: 11/19/2022] Open
Abstract
Background Electronic health records (EHR) detect the onset of acute kidney injury (AKI) in hospitalized patients, and may identify those at highest risk of mortality and renal replacement therapy (RRT), for earlier targeted intervention. Methods Prospective observational study to derive prediction models for hospital mortality and RRT, in inpatients aged ≥18 years with AKI detected by EHR over 1 year in a tertiary institution, fulfilling modified KDIGO criterion based on serial serum creatinine (sCr) measures. Results We studied 3333 patients with AKI, of 77,873 unique patient admissions, giving an AKI incidence of 4%. KDIGO AKI stages at detection were 1(74%), 2(15%), 3(10%); corresponding peak AKI staging in hospital were 61, 20, 19%. 392 patients (12%) died, and 174 (5%) received RRT. Multivariate logistic regression identified AKI onset in ICU, haematological malignancy, higher delta sCr (sCr rise from AKI detection till peak), higher serum potassium and baseline eGFR, as independent predictors of both mortality and RRT. Additionally, older age, higher serum urea, pneumonia and intraabdominal infections, acute cardiac diseases, solid organ malignancy, cerebrovascular disease, current need for RRT and admission under a medical specialty predicted mortality. The AUROC for RRT prediction was 0.94, averaging 0.93 after 10-fold cross-validation. Corresponding AUROC for mortality prediction was 0.9 and 0.9 after validation. Decision tree analysis for RRT prediction achieved a balanced accuracy of 70.4%, and identified delta-sCr ≥ 148 μmol/L as the key factor that predicted RRT. Conclusion Case fatality was high with significant renal deterioration following hospital-wide AKI. EHR clinical model was highly accurate for both RRT prediction and for mortality; allowing excellent risk-stratification with potential for real-time deployment. Electronic supplementary material The online version of this article (10.1186/s12882-019-1206-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sanmay Low
- Division of Nephrology, University Medicine Cluster, National University Hospital, Level 10 Medicine Office, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228, Singapore.,Renal Unit, Department of Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Anantharaman Vathsala
- Division of Nephrology, University Medicine Cluster, National University Hospital, Level 10 Medicine Office, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tanusya Murali Murali
- Division of Nephrology, University Medicine Cluster, National University Hospital, Level 10 Medicine Office, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Long Pang
- Biostatistics, Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Graeme MacLaren
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Wan-Ying Ng
- Division of Nephrology, University Medicine Cluster, National University Hospital, Level 10 Medicine Office, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sabrina Haroon
- Division of Nephrology, University Medicine Cluster, National University Hospital, Level 10 Medicine Office, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Amartya Mukhopadhyay
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, Singapore, Singapore
| | - Shir-Lynn Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Bee-Hong Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Anaesthesia, National University Hospital, Singapore, Singapore
| | - Titus Lau
- Division of Nephrology, University Medicine Cluster, National University Hospital, Level 10 Medicine Office, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Horng-Ruey Chua
- Division of Nephrology, University Medicine Cluster, National University Hospital, Level 10 Medicine Office, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228, Singapore. .,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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24
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Wołyniec W, Ratkowski W, Kasprowicz K, Jastrzębski Z, Małgorzewicz S, Witek K, Grzywacz T, Żmijewski P, Renke M. Glomerular Filtration Rate Is Unchanged by Ultramarathon. J Strength Cond Res 2018; 32:3207-3215. [DOI: 10.1519/jsc.0000000000002348] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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