Treatment-related acute renal failure in the elderly: a hospital-based prospective study

Factors involved in the development of hospital-acquired conditions in older patients in acute care settings: a scoping review

BACKGROUND

Older patients hospitalized in acute care settings are at significant risk of presenting hospital-acquired conditions. Healthcare professionals should consider many factors involved in the development of such conditions, including factors related to the patients, as well as those related to the processes of care and the structure of hospitals. The aim of this study was to describe and identify the factors involved in the development of hospital-acquired conditions in older patients in acute care settings.

METHODS

A scoping review was performed based on a structured search in eight databases in September 2022. Data were extracted with an extraction tool and classified into categories. Mapping and a narrative summary were used to synthetize data.

RESULTS

A total of 237 articles were included in the scoping review. Functional decline and delirium were the most frequent hospital-acquired conditions studied. Among all categories, factors related to the patients provided most of the data, whereas factors related to the processes of care and the structure of hospitals were less frequently explored. In most articles, one or two categories of factors were retrieved; fewer articles examined factors among three categories. Personal factors, medications, and the human and work environment were the most frequent subcategories of factors retrieved, whereas social factors, hydration and nutrition, and organizational factors were less common.

CONCLUSIONS

The development of hospital-acquired conditions in older patients in acute care settings involves many factors related to the patients, as well as to the processes of care and the structure of hospitals. Prevention of hospital-acquired conditions must involve to consider the complexities of older patients and of acute care hospitals. Not considering all categories of factors might affect the implementation of new practices of care and interventions.

In silico prediction of drug-induced nephrotoxicity: current progress and pitfalls

INTRODUCTION

Due to its role in absorption and metabolism, the kidney is an important target for drug toxicity. Drug-induced nephrotoxicity (DIN) presents a significant challenge in clinical practice and drug development. Conventional methods for assessing nephrotoxicity have limitations, highlighting the need for innovative approaches. In recent years, in silico methods have emerged as promising tools for predicting DIN.

AREAS COVERED

A literature search was performed using PubMed and Web of Science, from 2013 to February 2023 for this review. This review provides an overview of the current progress and pitfalls in the in silico prediction of DIN, which discusses the principles and methodologies of computational models.

EXPERT OPINION

Despite significant advancements, this review identified issues accentuates the pivotal imperatives of data fidelity, model optimization, interdisciplinary collaboration, and mechanistic comprehension in sculpting the vista of DIN prediction. Integration of multiple data sources and collaboration between disciplines are essential for improving predictive models. Ultimately, a holistic approach combining computational, experimental, and clinical methods will enhance our understanding and management of DIN.

Past, present, and future biomarkers of kidney function and injury: The relationship with antibiotics

Routinely used kidney biomarkers of injury and function such as serum creatinine and urine albumin to creatinine ratio, are neither sensitive nor specific. Future biomarkers are being developed for clinical use and have already been included in guidance from groups such as the U.S. Food and Drug Administration and the Predictive Safety Testing Consortium. These biomarkers have important implications for early identification of kidney injury and more accurate measurement of kidney function. Many antibiotics are either eliminated by the kidney or can cause clinically significant nephrotoxicity. As a result, clinicians should be familiar with new biomarkers of kidney function and injury, their place in clinical practice, and applications for antibiotic dosing.

Medication use and hospital-acquired acute kidney injury: an electronic health record-based study

BACKGROUND AND AIMS

Medications remain an important contributor to the development of acute kidney injury (AKI). This study aimed to examine associations between (i) administration of medications known to reduce glomerular filtration rate (GFR), that is, GFR modifiers and subsequent hospital-acquired AKI; and (ii) potentially medication-related AKI and patient adverse outcomes.

METHODS

A retrospective cohort study utilising electronic health record data of patients admitted to a tertiary hospital in Australia in 2015. Timing of medication administration was compared with timing of AKI development. AKI cases were identified using an algorithm based on serum creatinine level changes. Multilevel regression models were applied with adjustment for relevant demographic and clinical factors.

RESULTS

Among 11 503 admissions, AKI was identified in 955 patients (8.3%) and 637 (66.7% of 955) were preceded by administration of a GFR modifier. Patients without prior AKI were 17% more likely to develop AKI after administration of these medications (adjusted odds ratio 1.17, 95% confidence interval (CI) 1.003-1.37). Older age and comorbidity with diabetes, acute myocardial infarction, peripheral vascular disease, liver cirrhosis and multiple myeloma were also significant predictors. Patients with potentially medication-related AKI were 11.69 times more likely to die in hospital (95% CI 7.84-17.43) and stayed 3.49 times longer in hospital (95% CI 3.26-3.73), compared with those without AKI.

CONCLUSIONS

Administration of medications contributing to the reduction of GFR is associated with an increased risk of hospital-acquired AKI and worse patient outcomes. Caution is required when prescribing these medications to patients at risk of developing AKI, and monitoring patients for deterioration is needed if administered.

Drug induced nephrotoxicity- A mechanistic approach

The main goal of the treatment of patients is its effectiveness and safety. However, all currently prescribed drugs being used also have certain adverse effects, which might be seen as an unavoidable but necessary cost of pharmacotherapy. The kidney is the primary organ for xenobiotics elimination, making it particularly susceptible to the harmful effects of drugs and their metabolites during their excretion from the body. Moreover, certain medications have a preferential nephrotoxicity potential, which means that using them increases the risk of kidney injury. Drug nephrotoxicity is, therefore, both a significant problem and a complication of pharmacotherapy. It should be noted that, there is presently no accepted definition of drug-induced nephrotoxicity and no established diagnostic criteria. The current review briefly describes the pathogenic mechanism of drug-induced nephrotoxicity, the various basic drugs with nephrotoxicity potential and the renal biomarkers for the treatment of the drug-related kidney damage.

Renal Proximal Tubular Epithelial Cells: From Harvesting to Use in Studies

The kidneys are the body's main excretion organ with several additional functions, and the nephron represents their central structural unit. It is comprised of endothelial, mesangial, glomerular, and tubular epithelial cells, as well as podocytes. Treatment of acute kidney injury or chronic kidney disease (CKD) is complex due to broad etiopathogenic mechanisms and limited regeneration potential as kidney cells finish their differentiation after 34 weeks of gestation. Despite the ever-increasing prevalence of CKD, very limited treatment modalities are available. The medical community should therefore strive to improve existing treatments and develop new ones. Furthermore, polypharmacy is present in most CKD patients, while current pharmacologic study designs lack effectiveness in predicting potential drug-drug interactions and the resulting clinically relevant complications. An opportunity for addressing these issues lies in developing in vitro cell models based on patient-derived renal cells. Currently, several protocols have been described for isolating desired kidney cells, of which the most isolated are the proximal tubular epithelial cells. These play a significant role in water homeostasis, acid-base control, reabsorption of compounds, and secretion of xenobiotics and endogenous metabolites. When developing a protocol for the isolation and culture of such cells, one must focus on several steps. These include harvesting cells from biopsy specimens or after nephrectomies, using different digestion enzymes and culture mediums to facilitate the selective growth of only the desired cells. The literature reports several existing models, from simple 2D in vitro cultures to more complex ones created with bioengineering methods, such as kidney-on-a-chip models. While their creation and use depend on the target research, one should consider factors such as equipment, cost, and, even more importantly, source tissue quality and availability.

Drug-Induced Podocytopathies: Report of Four Cases and Review of the Literature

Kidney injury due to medications is a well-known clinical entity. Although drug-induced tubulointerstitial disease is commonly encountered, there are few reports in the literature associated with glomerular injury due to medications. The recognition of this type of kidney injury is crucial, as rapid discontinuation of the offending agent is critical to maximizing the likelihood of quick and effective renal function recovery. In this article, we present four cases that presented with nephrotic syndrome and were diagnosed with biopsy-proven podocytopathies, associated with exposure to a certain medication. All of them experienced complete resolution of nephrotic syndrome within days or weeks after discontinuation of the offending drug. We also present the data, which were found in a Medline search from the year 1963 until the present, regarding cases with podocytopathies associated with penicillamine, tamoxifen and the combination of pembrolizumab-axitinib, including only adult cases from the English literature. The Medline search revealed nineteen cases of penicillamine-induced minimal-change disease (MCD), one case of tamoxifen-induced MCD, and none associated with pembrolizumab-axitinib therapy. We also searched for the largest studies and meta-analyses regarding drug-induced podocytopathies after a Medline search from 1967 to the present of the English literature.

Incidence, Determinants, and Outcome of Contrast-induced Acute Kidney Injury following Percutaneous Coronary Intervention at a Tertiary Care Hospital

Contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary intervention (PCI) is the common cause of in-hospital acquired AKI and is associated with in-hospital mortality and prolonged hospital stay. We studied the incidence of CI-AKI after PCI, determinants of CI-AKI, and also assessed their length of hospital stay, in-hospital mortality, and need for dialysis. This was a hospital-based prospective observational study done on 204 adult subjects, who were candidates for PCI, at a tertiary care center in North India. Various clinical and biochemical parameters were monitored. Renal function was estimated at admission and 48 and 72 h after PCI. The incidence of CI-AKI post-PCI was 12.7%. Factors predicting the CI-AKI post-PCI on multiple logistic regression analysis are as follows: age ≥70 years, chronic kidney disease (CKD), hypotension, acute decompensated heart failure (ADHF), severe left ventricular systolic dysfunction (LVSD), and intra-aortic balloon pump (IABP) support. Contrast medium volume ≥200 mL and baseline estimated glomerular filtration rate <60 mL/min/1.73 m2 were significantly found to increase the risk of CI-AKI. Patients developing CI-AKI had significantly longer duration of hospital stay (6.4 ± 1.8 days vs. 3.1 ± 0.9 days; P <0.001). 15.4% of CI-AKI patients needed dialysis. In-hospital mortality was significantly higher in patients with CI-AKI (P <0.001). CI-AKI is a common complication following PCI, especially if the patient is elderly, has impaired renal function, hypotension, ADHF, severe LVSD and requires IABP support. The incidence of CI-AKI increases with the increases in contrast volume above 200 mL. The development of CI-AKI leads to a longer duration of hospital stay and increases in-hospital mortality.

Prevalence of inappropriate drug dose adjustment and associated factors among inpatients with renal impairment in Africa: A systematic review and meta-analysis

Objective

There is a high prevalence of inadequate dose adjustment among inpatients with renal insufficiency worldwide. There is, however, a paucity of studies that summarizes the topic in the African context. Therefore, this study aims to summarize the prevalence of inappropriate drug dose adjustment (IDDA) and associated factors among inpatients with renal impairment in Africa.

Methods

A literature search for English-language articles was conducted using reputable databases such as PubMed/MEDLINE, Google Scholar, and Science Direct. The search was carried out between 3 February and 3 March of 2022. All published articles that were online at the time of data collection were considered. Observational studies that examined the prevalence of IDDA for any type of drug in renal impairment as a primary or secondary outcome were included in our analysis. Statistical software such as Open Meta Analyst and Review Manager were used to examine outcome measures. I2 statistics, Logit event rate, and Der Simonian and Laird's random effect models were also used.

Results

Seven articles were qualified for the systematic review and meta-analysis. All included studies comprised a total of 1918 patients. A total of 5072 prescriptions were assessed, and 1879 (37%) of them had at least one drug that required a dose adjustment. The pooled prevalence of IDDA among adult patients with renal impairment was 13.7% (95% confidence interval (CI) = 7.9%-19.5%) in Africa. Based on the number of prescriptions containing medications that required dose adjustment, the pooled prevalence accounts for 39.3% (95% CI = 24.1%-54.4%) (932/1879). Factors associated with inappropriate drug prescribing and usage concerning renal function were the number/types of prescribed medicines (most common), age, stage of renal impairment, comorbidity, and unemployment.

Conclusions

In this study, IDDA practice appears to be a common challenge among inpatients with renal insufficiency in Africa. The number and type of medications prescribed, age, stage of renal impairment, comorbidity, and unemployment were factors associated with inappropriate drug prescribing and use. In addition to expanding such studies, hospitals across Africa must conduct research on the clinical outcomes of IDDA practices in patients with renal impairment.

Human iPSC-derived renal organoids engineered to report oxidative stress can predict drug-induced toxicity

Advances in regenerative medicine have led to the construction of many types of organoids, which reproduce important aspects of endogenous organs but may be limited or disorganized in nature. While their usefulness for restoring function remains unclear, they have undoubted usefulness in research, diagnostics, and toxicology. In toxicology, there is an urgent need for better models for human kidneys. We used human iPS-cell (hiPSC)-derived renal organoids to identify HMOX1 as a useful marker of toxic stress via the oxidative stress pathway, and then constructed an HMOX1 reporter in hiPSCs. We used two forms of hiPSC-derived HMOX1-reporter renal organoids to probe their ability to detect nephrotoxicants in a panel of blind-coded compounds. Our results highlight the potential usefulness, and some limitations, of HMOX1-reporter renal organoids as screening tools. The results may guide development of similar stress-reporting organoid assays for other stem-cell-derived organs and tissues.

Cytoprotective potentialities of carvacrol and its nanoemulsion against cisplatin-induced nephrotoxicity in rats: development of nano-encasulation form

Cisplatin (Cisp) is a widely distributed chemotherapeutic drug for cancers. Nephrotoxicity is one of the most common side effects of the use of this drug. Carvacrol (CV) is a common natural compound in essential oils and extracts of medicinal plants with potent in vivo and in vitro bioactivities. The work was extended to achieve the target of investigation of the protective potentialities of CV and its nanoemulsion as a cytoprotective drug against Cisp-induced nephrotoxicity in albino rats. CV-nanoemulsion was prepared by a hydrophilic surfactant polysorbate 80 (Tween 80) and deionized water. The TEM image of the particle distribution prepared nanoemulsion is mainly spherical in shape with particle size varying between 14 and 30 nm. Additionally, the Cisp administration caused the increasing of the levels of urea and creatinine in the blood and serum. These increasing of urea and creatinine levels caused consequently the turbulence of the oxidative stress as well as the rising of hs-CRP, IL-6, and TNF-α levels in the serum. Also, histopathological changes of the kidney tissue were observed. These changes back to normal by treatment with CV-nanoemulsion. Expression levels of nephrotoxicity-related genes including LGALS3, VEGF, and CAV1 in kidney tissue using qRT-PCR were measured. The results revealed that the expression of LGALS3, VEGF and CAV1 genes was highly significantly increased in only Cisp treated group when compared with other treated groups. While, these genes expressions were significantly decreased in Cisp + CV treated group when compared with Cisp treated rats (P < 0.001). In addition, there were no significant differences between Cisp + nano-CV treated group and both negative control and nanoemulsion alone groups but it was not significant. In addition, the Western blot of protein analysis results showed that the LGALS3 and CAV1 are highly expressed only in Cisp + CV treated group compared with other groups. There was no significant difference between Cisp + nano-CV treated animals and negative control for both mRNA and protein expression. Based on these results, CV was combined with calcium alginate; a more stable capsule is formed, allowing for the formation of a double wall in the microcapsule. These results supported the therapeutic effect of CV and its nano-emulsion as cytoprotective agents against Cisp nephrotoxicity.

Management of hypertension and renin-angiotensin-aldosterone system blockade in adults with diabetic kidney disease: Association of British Clinical Diabetologists and the Renal Association UK guideline update 2021

People with type 1 and type 2 diabetes are at risk of developing progressive chronic kidney disease (CKD) and end-stage kidney failure. Hypertension is a major, reversible risk factor in people with diabetes for development of albuminuria, impaired kidney function, end-stage kidney disease and cardiovascular disease. Blood pressure control has been shown to be beneficial in people with diabetes in slowing progression of kidney disease and reducing cardiovascular events. However, randomised controlled trial evidence differs in type 1 and type 2 diabetes and different stages of CKD in terms of target blood pressure. Activation of the renin-angiotensin-aldosterone system (RAAS) is an important mechanism for the development and progression of CKD and cardiovascular disease. Randomised trials demonstrate that RAAS blockade is effective in preventing/ slowing progression of CKD and reducing cardiovascular events in people with type 1 and type 2 diabetes, albeit differently according to the stage of CKD. Emerging therapy with sodium glucose cotransporter-2 (SGLT-2) inhibitors, non-steroidal selective mineralocorticoid antagonists and endothelin-A receptor antagonists have been shown in randomised trials to lower blood pressure and further reduce the risk of progression of CKD and cardiovascular disease in people with type 2 diabetes. This guideline reviews the current evidence and makes recommendations about blood pressure control and the use of RAAS-blocking agents in different stages of CKD in people with both type 1 and type 2 diabetes.

Identification of Risk Factors for Acute Kidney Injury from Intravenous Ketorolac in Geriatric Trauma Patients

BACKGROUND

Ketorolac is an effective analgesic but the potential for acute kidney injury (AKI) is concerning, particularly in geriatric "G-60 trauma" patients. The objectives of this study are to report the incidence of AKI in patients who receive ketorolac, identify risk factors for AKI, and develop a risk factor-guided algorithm for safe utilization.

METHODS

This retrospective cohort study included trauma patients age 60 years and older who received intravenous ketorolac. The primary endpoint was the incidence of AKI.

RESULTS

Among 316 patients evaluated, the incidence of AKI was 2.5%. Patients with AKI received more nephrotoxins, had more comorbidities, and higher use of loop diuretics or vasopressors. Loop diuretic therapy and number of comorbidities were independent predictors of AKI.

CONCLUSIONS

Risk for AKI with ketorolac was low, being more prevalent with comorbidities or receipt of loop diuretics.

Role of rivaroxaban in sunitinib-induced renal injuries via inhibition of oxidative stress-induced apoptosis and inflammation through the tissue nacrosis factor-α induced nuclear factor-κappa B signaling pathway in rats

Rivaroxaban (RIVA) inhibits factor Xa and exhibits antithrombotic and anti-inflammatory activities by inhibiting several cellular signaling molecules. Sunitinib (SUN) is FDA approved first-line drug for metastatic renal cancers and advanced cancerous states of gastrointestinal tract. Present hypothesis was aimed to examine the nephroprotective potential of RIVA in SUN-induced nephrotoxicity, mediated through the inhibition of oxidative stress-induced apoptosis and inflammation, via the TNF-α/NFk-B signaling pathways. Wistar rats 200-250 g were selected and divided randomely in 5 groups (n = 6): Group 1 kept as normal control; Group 2 as disease control and exposed to SUN 50 mg/kg thrice-weekly upto 21 days; Groups 3 and 4, were treatment groups and administered SUN 50 mg/kg thrice-weekly as of group 2 and treated with RIVA 5 and 10 mg/kg/daily for 21 days, respectively; and Group 5 fed with RIVA alone (10 mg/kg/daily for 21 days). Serum was separated from blood to estimate serum biochemical parameters and kidney tissues were collected to estimate antioxidant enzyme, mRNA and protein expression. SUN exposure significantly elevated levels of creatinine, urea, uric acid, blood urea nitrogen, albumin, and bilirubin, and decreased serum magnesium and iron levels. Malondialdehyde and catalase levels were significantly increased and glutathione and glutathione reductase levels were significantly decreased. Intracellular levels of caspase-3 and TNF-α were significantly increased; RIVA treatment restored the altered levels. In SUN-exposed animals, western blotting revealed significantly elevated NFk-B, IL-17, and MCP-1 expression, and IKBα levels were significantly downregulated; RIVA restored these levels to normal values.RIVA treatment significantly restored the apoptotic and inflammatory parameters in SUN-damaged renal tissues.

The protective effect of lycopene against oxidative kidney damage associated with combined use of isoniazid and rifampicin in rats

It is known that the combined use of antibiotics, such as isoniazid and rifampicin, in the treatment of tuberculosis causes oxidative kidney damage. The aim of this study was to biochemically and histopathologically investigate the effect of lycopene on oxidative kidney damage due to the administration of isoniazid and rifampicin in albino Wistar male rats. Lycopene at a dose of 5 mg/kg was orally administered to lycopene+isoniazid+rifampicin (LIR) rats, and normal sunflower oil (0.5 mL) was orally administered to isoniazid+rifampicin (IR) and healthy control (HG) rats as vehicle by gavage. One hour after the administration of lycopene and vehicle, 50 mg/kg isoniazid and rifampicin were given orally to the LIR and IR groups. This procedure was performed once a day for 28 days. Rats were sacrificed by a high dose of anesthesia at the end of this period, and oxidant-antioxidant parameters were measured in the removed kidney tissues. Creatinine and blood urea nitrogen (BUN) levels were measured in blood samples, and kidney tissues were also evaluated histopathologically. The combined administration of isoniazid and rifampicin changed the oxidant-antioxidant balance in favor of oxidants, and it increased blood urea nitrogen and creatinine levels, which are indicators of kidney function. Co-administration of isoniazid and rifampicin also caused oxidative kidney damage. Lycopene biochemically and histopathologically decreased oxidative kidney damage induced by isoniazid and rifampicin administration. These results suggested that lycopene may be beneficial in the treatment of nephrotoxicity due to isoniazid and rifampicin administration.

Treatment with human umbilical cord blood serum in a gentamicin-induced nephrotoxicity model in rats

Sold under the brand name of Garamycin, gentamicin (GM) is an antibiotic in the category of aminoglycoside, that although does have many antibacterial properties, owing to several side effects, its consumption is confined. The current study is aimed at gauging the protective influences of human umbilical cord blood serum (hUCBS) on nephrotoxicity which is induced by GM. In this regard, in the present experimental design, twenty-eight male Wistar rats with the weights of 220 ± 20 g were categorized randomly into 4 groups of seven. The groups included GM (100 mg/kg), control as well as hUCBS at doses of one and two percent together with GM (100 mg/kg) for ten days in an intraperitoneal manner. Blood sampling was collected from the heart directly 24 h after the final injection for obtaining blood serum; the parameters of C-reactive protein (CRP), total oxidant status (TOS), interleukin (IL)-6, lactate dehydrogenase (LDH), total antioxidant capacity (TAC), creatinine (Cr), blood urea nitrogen (BUN), blood serum glutathione (GSH) were gauged in blood serum samples to evaluate renal function. Moreover, for histology, an examination of kidney tissue was performed. In comparison to those of the GM group, in the treatment group, hUCBS significantly decreased the levels of BUN, Cr, LDH, TOS, IL-6, and the CRP levels, and significantly increased the TAC and GSH levels. It was revealed that the treatment of the animals with hUCBS culminates in the reduction of GM' toxic impacts on the kidney.

Machine Learning for Identifying Medication-Associated Acute Kidney Injury

One of the prominent problems in clinical medicine is medication-induced acute kidney injury (AKI). Avoiding this problem can prevent patient harm and reduce healthcare expenditures. Several researches have been conducted to identify AKI-associated medications using statistical, data mining, and machine learning techniques. However, these studies are limited to assessing the impact of known nephrotoxic medications and do not comprehensively explore the relationship between medication combinations and AKI. In this paper, we present a population-based retrospective cohort study that employs automated data analysis techniques to identify medications and medication combinations that are associated with a higher risk of AKI. By integrating multivariable logistic regression, frequent itemset mining, and stratified analysis, this study is designed to explore the complex relationships between medications and AKI in such a way that has never been attempted before. Through an analysis of prescription records of one million older patients stored in the healthcare administrative dataset at ICES (an independent, non-profit, world-leading research organization that uses population-based health and social data to produce knowledge on a broad range of healthcare issues), we identified 55 AKI-associated medications among 595 distinct medications and 78 AKI-associated medication combinations among 7748 frequent medication combinations. In addition, through a stratified analysis, we identified 37 cases where a particular medication was associated with increasing the risk of AKI when used with another medication. We have shown that our results are consistent with previous studies through consultation with a nephrologist and an electronic literature search. This research demonstrates how automated analysis techniques can be used to accomplish data-driven tasks using massive clinical datasets.

Sinapic acid attenuates cisplatin-induced nephrotoxicity through peroxisome proliferator-activated receptor gamma agonism in rats

AIM

The aim of this study was to investigate the involvement of peroxisome proliferator-activated receptor gamma (PPAR-γ) in renal protection offered by sinapic acid in cisplatin-induced nephrotoxicity in male rats.

MATERIALS AND METHODS

Nephrotoxicity was induced by single dose of cisplatin (5 mg/kg, intraperitoneal [i.p.]) in rats. Cisplatin-induced nephrotoxicity was assessed by measuring serum creatinine, creatinine clearance, urea, uric acid, potassium, magnesium levels, fractional excretion of sodium, and microproteinuria in rats. Superoxide anion generation, thiobarbituric acid reactive substances, myeloperoxidase activity, and reduced glutathione levels were measured to assess oxidative stress in renal tissues. Hematoxylin and eosin stain showed renal histological changes.

RESULTS

The significant changes in serum and urinary parameters, elevated oxidative stress, and renal histological changes established the induction of nephrotoxicity. Sinapic acid treatment (20 and 40 mg/kg, orally [p.o.]) provides dose-dependent and significant (P < 0.05) nephroprotection against cisplatin-mediated nephrotoxicity in rats. Nephroprotective effect of sinapic acid was abolished by PPAR-γ inhibitor, bisphenol A diglycidyl ether (30 mg/kg, i.p.) in rats.

CONCLUSION

It is concluded that PPAR-γ agonism serves as one of the mechanisms in sinapic acid-mediated renoprotection.

Proton Pump Inhibitors Augment the Risk of Major Adverse Cardiovascular Events and End-Stage Renal Disease in Patients With Acute Kidney Injury After Temporary Dialysis

Proton pump inhibitors (PPIs) have been reported to increase the risk of acute and chronic renal disease. However, the data are unclear in patients with acute kidney injury (AKI) requiring dialysis (AKI-D) who are often candidates for PPIs. To investigate this important issue, we identified 26,052 AKI-D patients from Taiwan's National Health Insurance Research Database weaning from dialysis. During a mean follow-up period of 3.52 years, the PPI users had a higher incidence of end-stage renal disease (ESRD) than the PPI nonusers (P < 0.001). After propensity score matching and treating mortality as a competing risk factor, the PPI users had a higher risk of ESRD (subhazard ratio (sHR) 1.40; 95% confidence interval (CI), 1.31-1.50) and major adverse cardiac events (MACE, sHR 1.53; 95% CI, 1.37-1.71) compared with the PPI nonusers with AKI-D survivors. In conclusion, the use of PPIs was associated with a higher risk of ESRD and MACE, compared with the PPI nonusers in AKI-D patients who weaned from dialysis.

Renal toxicity with mammalian target of rapamycin inhibitors: A meta-analysis of randomized clinical trials

A meta-analysis of randomized clinical trials (RCT) was done to determine the relative risk (RR) of acute kidney injury (AKI) with the use of mammalian target of rapamycin (mTOR) inhibitors. Citations from PubMed/Medline, clinical trials.gov, package inserts and abstracts from major conferences were reviewed to include RCTs comparing arms with or without mTOR inhibitors. The RR of all grade AKI in patients taking mTOR inhibitors compared to patients not on mTOR inhibitors was 1.55 (95% CI: 1.11 to 2.16, P=0.010). There was no significant difference in the risk of high-grade AKI for the two groups (RR=1.29, P=0.118, 95% CI: 0.94 to 1.77). There was no significant difference in the incidence rates for either all grade or high-grade AKI between the two groups. There was no publication bias and the trials were of high quality per Jadad scoring.

Melatonin ameliorates the drug induced nephrotoxicity: Molecular insights

BACKGROUND

Drug-induced nephrotoxicity is a frequent adverse event that can lead to acute or chronic kidney disease and increase the healthcare expenditure. It has high morbidity and mortality incidence in 40-70% of renal injuries and accounts for 66% cases of renal failure in elderly population.

OBJECTIVE

Amelioration of drug-induced nephrotoxicity has been long soughed to improve the effectiveness of therapeutic drugs. This study was conducted to review the melatonin potential to prevent the pathogenesis of nephrotoxicity induced by important nephrotoxic drugs.

METHODS

We analyzed the relevant studies indexed in Pubmed, Medline, Scielo and Web of science to explain the molecular improvements following melatonin co-administration with special attention to oxidative stress, inflammation and apoptosis as key players of drug-induced nephrotoxicity.

RESULTS

A robust consensus among researchers of these studies suggested that melatonin efficiently eradicate the chain reaction of free radical production and induced the endogenous antioxidant enzymes which attenuate the lipid peroxidation of cellular membranes and subcellular oxidative stress in drug-induced nephrotoxicity. This agreement was further supported by the melatonin role in disintegration of inflammatory process through inhibition of principle pro-inflammatory or apoptotic cytokines such as TNF-α and NF-κB. These studies highlighted that alleviation of drug-induced renal toxicity is a function of melatonin potential to down regulate the cellular inflammatory and oxidative injury process and to stimulate the cellular repair or defensive mechanisms.

CONCLUSION

The comprehensive nephroprotection and safer profile suggests the melatonin to be a useful adjunct to improve the safety of nephrotoxic drugs.

Delayed Hospital Discharges of Older Patients: A Systematic Review on Prevalence and Costs

PURPOSE OF THE STUDY

To determine the prevalence of delayed discharges of elderly inpatients and associated costs.

DESIGN AND METHODS

We searched Medline, Embase, Global Health, CAB Abstracts, Econlit, Web of Knowledge, EBSCO - CINAHL, The Cochrane Library, Health Management Information Consortium, and SCIE - Social Care Online for evidence published between 1990 and 2015 on number of days or proportion of delayed discharges for elderly inpatients in acute hospitals. Descriptive and regression analyses were conducted. Data on proportions of delayed discharges were pooled using a random effects logistic model and the association of relevant factors was assessed. Mean costs of delayed discharge were calculated in USD adjusted for Purchasing Power Parity (PPP).

RESULTS

Of 64 studies included, 52 (81.3%) reported delayed discharges as proportions of total hospital stay and 9 (14.1%) estimated the respective costs for these delays. Proportions of delayed discharges varied widely, from 1.6% to 91.3% with a weighted mean of 22.8%. This variation was also seen in studies from the same country, for example, in the United Kingdom, they ranged between 1.6% and 60.0%. No factor was found to be significantly associated with delays. The mean costs of delayed discharge also varied widely (between 142 and 31,935 USD PPP adjusted), reflecting the variability in mean days of delay per patient.

IMPLICATIONS

Delayed discharges occur in most countries and the associated costs are significant. However, the variability in prevalence of delayed discharges and available data on costs limit our knowledge of the full impact of delayed discharges. A standardization of methods is necessary to allow comparisons to be made, and additional studies are required-preferably by disease area-to determine the postdischarge needs of specific patient groups and the estimated costs of delays.

Expression profile of markers of oxidative stress, injury and apoptosis in anti-tuberculosis drugs induced nephrotoxicity

AIM

Isoniazid (INH), Rifampicin (RIF) and Pyrazinamide (PZA) are part of first-line anti-tuberculosis therapy used against infection caused by Mycobacterium tuberculosis. However, these drugs are known to be potentially harmful as these are associated with numerous side effects and when taken together their harmful outcomes are elevated in a synergistic manner. Identification of possible mechanism underlying RIF + INH + PZA induced nephrotoxicity may be advantageous in developing strategies to prevent their toxic implications.

METHODS

In this study rats were distributed in two groups of six each: Control (tap water) and Toxicant (INH + RIF + PZA) in dosage derived through extrapolation from human dosage for 28 days once in a day. Antioxidant activity and histology of kidney were examined. In addition, apoptosis was also studied using pro and anti-apoptotic markers and TUNEL staining to check nephrotoxicity.

RESULTS

Findings indicated that combined (INH, RIF and PZA) 28 day exposure in Wistar rats caused increase in number of free radicals/ reactive oxygen species which further cause changes in levels of enzymatic antioxidants such as glutathione, Superoxide dismutase, Catalase, and Glutathione-s-transferase. Altered content of pro (BAD&BAX) and anti-apoptotic genes (BCL-2&BCL2L1) genes, TUNEL positive cells and DNA fragmentation emphasized involvement of apoptosis.

CONCLUSION

This study concluded that nephrotoxicity is accompanied during combinational anti-tuberculosis drug therapy.

Outcomes of hospital-acquired acute kidney injury in elderly patients: a single-centre study

BACKGROUND

HAAKI is a common clinical problem in hospitalized patients. Its incidence is high in older patients and carries worse prognosis. The presence of multiple co-morbidities, aging process, and frequent diagnostic and therapeutic interventions predispose elderly patients to HAAKI. This study aims to evaluate the spectrum, risk factors and determinants of outcome of elderly patients with HAAKI.

METHODS

This prospective study was conducted during January 2014 to September 2015 in the Department of nephrology, Institute of Medical Sciences, BHU, Varanasi, UP, India. First 100 HAAKI elderly (> 60 years) patients, who fulfilled the inclusion criteria were enrolled for study. HAAKI was defined as per RIFLE criteria after minimum 48 h of hospitalization. Clinical, biochemical, and radiological evaluation were done. Follow up was done till discharge or up to 30 days whichever was later.

RESULTS

Till selection and enrollment of first 100 HAAKI patients, total 23507 patients were hospitalized. 11.2% (n = 2635) patients were ≥ 60 years of age. Among 2635 elderly patients, 3.79% (n = 100) developed HAAKI. Commonest causes of HAAKI were sepsis (37%) followed by drugs like NSAID, Contrast agent, Amphotericin B, and antibiotics including amino glycosides in (24%) patents. DM and HTN were the commonest risk factors. Mortality was noted in 45% cases and rest 55% patients recovered with partial or full recovery of renal function. ICU admission, Oliguria, RIFLE-F, need of RRT, and SOFA score > 11 were independent determinants of outcome of elderly patients with HAAKI.

CONCLUSION

HAAKI is associated with increased morbidity and mortality in elderly patients. Associated co-morbid conditions predispose elderly patients to HAAKI. ICU admission, Oliguria, severity of renal failure, requirement of RRT, and initial SOFA score were strong predictors of survival of elderly patients with HAAKI.

Drug-Induced Kidney Injury in the Elderly

The incidence of acute kidney injury in the elderly has grown over the past decade. One of the primary drivers is drug-induced nephrotoxicity, which is the result of a combination of the unique susceptibilities to kidney injury and the increased use of medications in the elderly population. Specific drug classes are associated with increased rates of kidney injury including agents that block the renin angiotensin system, antimicrobials, and chemotherapeutic agents. Mechanistically, injury may be due to hemodynamic effects, tubular or glomerular toxicity, and interstitial nephritis. Early recognition of nephrotoxicity is critical, as are preventative steps when applicable. Unfortunately, treatment for established drug-induced kidney injury is limited and supportive care is required. Limiting exposure to nephrotoxic drugs is critical in decreasing the incidence of acute kidney injury in the elderly patient.

Kidney toxicity related to herbs and dietary supplements: Online table of case reports. Part 3 of 5 series

BACKGROUND

No tabular summary of potentially life-threatening, kidney-toxic dietary supplements (DS; includes herbs) based on PubMed case reports is currently available online and continually updated to forewarn United States consumers, clinicians, and companies manufacturing DS. The purpose of this review was to create an online research summary table of kidney toxicity case reports related to DS.

METHODS

Documented PubMed case reports (1966 to May 2016, and cross-referencing) of DS appearing to contribute to kidney toxicity were listed in "DS Toxic Tables." Keywords included "herb" or "dietary supplement" combined with "kidney" to generate an overview list, and possibly "toxicity" to narrow the selection. Case reports were excluded if they involved herb combinations (some exceptions), Chinese herb mixtures, teas of mixed herb contents, mushrooms, poisonous plants, self-harm, excessive doses (except vitamins/minerals), legal or illegal drugs, drug-herbal interactions, and confounders of drugs or diseases. Since commercial DS often include a combination of ingredients, they were treated separately; so were foods. A few foods with kidney-toxic effects were listed in a fourth table. The spectrum of herbal or DS-induced kidney injuries included kidney stones, nephritis, nephrotic syndrome, necrosis, acute kidney injury (AKI; previously known as acute renal failure [ARF]), chronic kidney disease, kidney transplant, and death.

RESULTS

Approximately 7 herbs (minus 4 no longer for sale) and 10 dietary supplements (minus 3 excluded due to excessive doses + germanium that is no longer sold) have been related to kidney injury case reports published in PubMed (+crosslisting) in the last 50 + years (1966 to May 2016). The implicated herbs include Chinese yew (Taxus celbica) extract, impila (Callilepis laureola), morning cypress (Cupressus funebris Endl), St. John's wort (Hypericum perforatum), thundergod vine (Tripterygium wilfordii hook F), tribulus (Tribulus terrestris) and wormwood (Artemisia herba-alba). No longer sold in the United States are chocolate vine or mu tong (Caulis aristolochiae), guang fang ji (Aristolochia fangchi), ma huang (Ephedra sinica), and Tenshin Tokishigyaku-ka-goshuyu-shokyo-to. The DS include bile (sheep), chlorella, chromium (Cr), CKLS, creatine, gallbladder (fish), glucosamine, hydrazine, N.O.-Xplode, Spanish fly, and excess intakes of vitamins A, C, and D. Germanium (Ge) is not available for sale. The top two DS with the largest number of reported publications, but not always case reports, in descending order, were the aristolochic acid-containing herbs guang fang ji (mistaken identity) and chocolate vine or mu tong. The remaining DS featured one to three publications over a 50+ year period. Numerous case reports were reported for kidney-toxic foods: djenkol bean, gallbladders (carp fish, pufferfish, & snake), and star fruit (only in chronic kidney disease patients), and uncooked yam powder or juice.

CONCLUSION

This online "DS Toxic Table" provides clinicians, consumers, and manufacturers with a list of herbs that could potentially contribute to kidney injuries.

Drug management in acute kidney disease - Report of the Acute Disease Quality Initiative XVI meeting

AIMS

To summarize and extend the main conclusions and recommendations relevant to drug management during acute kidney disease (AKD) as agreed at the 16^th Acute Disease Quality Initiative (ADQI) consensus conference.

METHODS

Using a modified Delphi method to achieve consensus, experts attending the 16^th ADQI consensus conference reviewed and appraised the existing literature on drug management during AKD and identified recommendations for clinical practice and future research. The group focussed on drugs with one of the following characteristics: (i) predominant renal excretion; (ii) nephrotoxicity; (iii) potential to alter glomerular function; and (iv) presence of metabolites that are modified in AKD and may affect other organs.

RESULTS

We recommend that medication reconciliation should occur at admission and discharge, at AKD diagnosis and change in AKD phase, and when the patient's condition changes. Strategies to avoid adverse drug reactions in AKD should seek to minimize adverse events from overdosing and nephrotoxicity and therapeutic failure from under-dosing or incorrect drug selection. Medication regimen assessment or introduction of medications during the AKD period should consider the nephrotoxic potential, altered renal and nonrenal elimination, the effects of toxic metabolites and drug interactions and altered pharmacodynamics in AKD. A dynamic monitoring plan including repeated serial assessment of clinical features, utilization of renal diagnostic tests and therapeutic drug monitoring should be used to guide medication regimen assessment.

CONCLUSIONS

Drug management during different phases of AKD requires an individualized approach and frequent re-assessment. More research is needed to avoid drug associated harm and therapeutic failure.

A nephron model for study of drug-induced acute kidney injury and assessment of drug-induced nephrotoxicity

In this study, we developed a multilayer microfluidic device to simulate nephron, which was formed by "glomerulus", "Bowman's capsule", "proximal tubular lumen" and "peritubular capillary". In this microdevice, artificial renal blood flow was circulating and glomerular filtrate flow was single passing through, mimicking the behavior of a nephron. In this dynamic artificial nephron, we observed typical renal physiology, including the glomerular size-selective barrier, glomerular basement membrane charge-selective barrier, glucose reabsorption and para-aminohippuric acid secretion. To demonstrate the capability of our microdevice, we used it to investigate the pathophysiology of drug-induced acute kidney injury (AKI) and give assessment of drug-induced nephrotoxicity, with cisplatin and doxorubicin as model drugs. In the experiment, we loaded the doxorubicin or cisplatin in the "renal blood flow", recorded the injury of primary glomerular endothelial cells, podocytes, tubular epithelial cells and peritubular endothelial cells by fluorescence imaging, and identified the time-dependence, dose-dependence and the death order of four types of renal cells. Then by measuring multiple biomarkers, including E-cadherin, VEGF, VCAM-1, Nephrin, and ZO-1, we studied the mechanism of cell injuries caused by doxorubicin or cisplatin. Also, we investigated the effect of BSA in the "renal blood flow" on doxorubicin-or-cisplatin-induced nephrotoxicity, and found that BSA enhanced the tight junctions between cells and eased cisplatin-induced nephrotoxicity. In addition, we compared the nephron model and traditional tubule models for assessment of drug-induced nephrotoxicity. And it can be inferred that our biomimetic microdevice simulated the complex, dynamic microenvironment of nephron, yielded abundant information about drug-induced-AKI at the preclinical stage, boosted the drug safety evaluation, and provided a reliable reference for clinical therapy.

Improvement of drug prescribing in acute kidney injury with a nephrotoxic drug alert system

Objective

Electronic alert systems have shown their capacity for improving the detection of acute kidney injury (AKI). The aim of this study was to design and implement a clinical decision support system (CDSS) for improving drug selection and reducing nephrotoxic drug use in patients with AKI.

Methods

The study was designed as an intervention study comparing a pre and post cohort of patients admitted during April 2014 and April 2015, respectively (phase I and phase II). The intervention was a CDSS which provided kidney function and nephrotoxic drug information. Furthermore, an interruptive alert was designed to detect patients suffering an AKI event while taking a nephrotoxic drug and to see if the dose was then reduced or the drug was discontinued by the physicians.

Results

One-third of the inpatients were included in the analysis because they met the inclusion criteria (1004 and 1002 patients in phases I and II, respectively). 735 and 761 of them received at least one nephrotoxic alert (73% vs 76%; p=0.763). 65 and 88 patients suffered AKI during admission (6.5% vs 8.8%; p=0.051). In phase I, patients received 384 nephrotoxic alerts (55%) with 78 (20%) of them provoking a change or discontinuation of the nephrotoxic drug. In phase II this value increased to 154 out of 526 (29%) after implementation of the CDSS (p<0.01).

Conclusions

A CDSS with interruptive alerts that inform of the development of AKI in real time in patients with nephrotoxic drug prescription has a positive impact on the judicious use of these drugs.

Association Between Proton Pump Inhibitor Use and Risk of Progression of Chronic Kidney Disease

BACKGROUND & AIMS

Proton pump inhibitors (PPI) have been associated with acute kidney injury and recent studies suggest that they may be associated with the risk of chronic kidney disease (CKD).

METHODS

We performed a retrospective analysis using the Stockholm creatinine measurements database, which contains information on diagnoses, dispensation claims, and laboratory test results for all citizens in the Stockholm region from 2007 through 2010. We identified new users of PPIs (n = 105,305) and new users of H₂ blockers (H₂B; n = 9578); data on renal outcomes were collected for a median 2.7 years. The primary outcome was progression CKD, defined as doubling of creatinine or decrease in estimated glomerular filtration rate of 30% or more. Secondary outcomes were end-stage renal disease and acute kidney injury. Complete collection of repeated PPI and H₂B dispensations at pharmacies in Sweden allowed modeling the time-dependent risk associated with cumulative PPI exposure.

RESULTS

Users of PPIs, compared with users of H₂Bs, had an increased risk for doubled levels of creatinine (1985 events; adjusted hazard ratio [HR], 1.26; 95% CI, 1.05-1.51) and decrease in estimated glomerular filtration rate of 30% or more (11,045 events; 1.26; 95% CI, 1.16-1.36). PPI use also associated with development of end-stage renal disease (HR, 2.40; 95% CI, 0.76-7.58) and acute kidney injury (HR, 1.30; 95% CI, 1.00-1.69). There was a graded association between cumulative exposure to PPIs and risk of CKD progression. This was not the case for cumulative H₂B use.

CONCLUSIONS

Initiation of PPI therapy and cumulative PPI exposure is associate with increased risk of CKD progression in a large, North European healthcare system. Although consistent, the association was modest in magnitude, and cannot exclude residual confounding.

Sinapic acid modulates Nrf2/HO-1 signaling pathway in cisplatin-induced nephrotoxicity in rats

BACKGROUND

Cisplatin-induced nephrotoxicity is related to increased reactive oxygen species and inflammatory cytokines in the kidney. Sinapic acid (SA) has both antioxidant and anti-inflammatory activities.

AIMS

We determined the effects of SA on cisplatin-induced nephrotoxicity in rats, and the potential mechanisms by which it augments antioxidant responses and attenuates nephrotoxicity related to oxidative/nitrosative stress, apoptosis, and inflammation.

METHODS

Kidney function markers (i.e., serum urea, uric acid, creatinine, and lactate dehydrogenase), oxidative stress markers (i.e., lipid peroxidation and nitric oxide), antioxidant systems (i.e., superoxide dismutase, catalase, and reduced glutathione), inflammation markers (i.e., tumor necrosis factor-α [TNF-α], interleukin-6 [IL-6], and myeloperoxidase [MPO]), apoptotic markers (caspase 3, Bax, and Bcl-2), and the levels of nuclear factor-κB (NF-κB [p65]), Nrf2, and heme oxygenase-1 (HO-1) were assessed. Histopathological examinations of the kidney were also used to evaluate cisplatin-induced nephrotoxicity.

KEY FINDINGS

SA (10 and 20mg/kg) pretreatment ameliorated kidney function, upregulated antioxidant levels, and downregulated lipid peroxidation and nitric oxide levels in cisplatin-injected rats, resulting in significant reductions in oxidative stress and replenishment of endogenous antioxidant enzymes. Cisplatin upregulated cytokines (i.e., TNF-α and IL-6) and MPO, increased apoptosis, and downregulated Nrf2 and HO-1. SA pretreatment downregulated the pro-apoptotic caspase-3 and Bax proteins, and upregulated the anti-apoptotic Bcl-2 protein. SA pretreatment also alleviated the extent of histological impairment and reduced neutrophil infiltration in renal tubules.

SIGNIFICANCE

The results suggest that the Nrf2/HO-1 signaling pathway may be the primary target for protection from cisplatin-induced nephrotoxicity by SA, and that SA reduces oxidative stress, inflammation, and apoptosis by inhibiting NF-κB.

Issues of Acute Kidney Injury Staging and Management in Sepsis and Critical Illness: A Narrative Review

Acute kidney injury (AKI) has a high incidence on intensive care units around the world and is a major complication in critically ill patients suffering from sepsis or septic shock. The short- and long-term complications are thereby devastating and impair the quality of life. Especially in terms of AKI staging, the determination of kidney function and the timing of dialytic AKI management outside of life-threatening indications are ongoing matters of debate. Despite several studies, a major problem remains in distinguishing between beneficial and unnecessary "early" or even harmful renal replacement therapy (RRT). The latter might prolong disease course and renal recovery. AKI scores, however, provide an insufficient outcome-predicting ability and the related estimation of kidney function via serum creatinine or blood urea nitrogen (BUN)/urea is not reliable in AKI and critical illness. Kidney independent alterations of creatinine- and BUN/urea-levels further complicate the situation. This review critically assesses the current AKI staging, issues and pitfalls of the determination of kidney function and RRT timing, as well as the potential harm reflected by unnecessary RRT. A better understanding is mandatory to improve future study designs and avoid unnecessary RRT for higher patient safety and lower health care costs.

Drug-induced nephropathies

Drugs are associated frequently with the development of various types of acute and chronic kidney diseases. Nephrotoxicity is associated most commonly with injury in the tubulointerstitial compartment manifested as either acute tubular injury or acute interstitial nephritis. A growing number of reports has also highlighted the potential for drug-induced glomerular disease, including direct cellular injury and immune-mediated injury. Recognition of drug-induced nephropathies and rapid discontinuation of the offending agents are critical to maximizing the likelihood of renal function recovery. This review will focus on the pathology and pathogenesis of drug-induced acute interstitial nephritis and drug-induced glomerular diseases.

[Perioperative patient management in orthogeriatrics]

The management of major orthopedic surgery in the elderly prototypically reflects the perioperative risks of geriatric, often very frail patients reflecting an aging population. To improve outcome, the risks of anesthesia and surgery as well as of patient comorbidities must be thoroughly assessed and balanced using a multidisciplinary approach. Particular risks include cardiopulmonary morbidity, anemia, risk of hemorrhage and the management by anticoagulation, cerebral impairments as well as frailty and limited physiological reserves in general. Accordingly, an optimized therapy prior to, during, and after surgery will likely influence not only the immediate postoperative course but also hospital mortality and long-term outcome. Publications on the topic of perioperative management of geriatric patients are fortunately gaining in quality and quantity, not least against the background of the demographic developments. Accordingly, specific influencing factors relevant for perioperative management can be increasingly more identified. This short review summarizes the current state of knowledge to provide an overview and rationale for clinical decision making.

Nephrotoxicity of methadone: a systematic review

Background

Methadone is commonly administered for chronic pain relief and treatment of opioid dependence. Concurrent with its increased consumption, toxicities and fatalities have increased. One of the adverse effects of opioid analgesics, including methadone, is that of nephrotoxicity. Opioids can have an effect on renal function through several different mechanisms.

Methods

We searched common bibliographical databases for the terms methadone, toxicity, poisoning, kidney, renal, and nephrotoxicity and summarize our findings in this review.

Results

Methadone can have both direct and indirect effects on the kidney. These effects include rhabdomyolysis (leading to acute kidney injury), volumetric changes, renal lipidosis and amyloidosis, kidney growth during pregnancy, and kidney transplant rejection.

Conclusion

Improved understanding of the effects of methadone on kidney function can promote safer and more confident use of the drug.

Iloprost as an acute kidney injury-triggering agent in severely atherosclerotic patients

Background

Iloprost, a stable prostacyclin analog, is used as a rescue therapy for severe peripheral arterial disease (PAD). It has systemic vasodilatory and anti-aggregant effects, with severe vasodilatation potentially causing organ ischaemia when severe atherosclerosis is the underlying cause. In this study, we retrospectively analysed renal outcomes after iloprost infusion therapy in 86 patients.

Methods

Eighty-six patients with PAD who received iloprost infusion therapy were retrospectively analysed. Clinical and biochemical parameters were recorded before (initial, Cr1), during (third day, Cr2), and after (14th day following the termination of infusion therapy, Cr3) treatment. Acute kidney injury (AKI) was defined according to KDIGO guidelines as a ≥ 0.3 mg/dl (26.52 μmol/l) increase in creatinine levels from baseline within 48 hours.

Results:

Cr2 (1.46 ± 0.1 mg/dl) (129.06 ± 8.84 μmol/l) and Cr3 (1.53 ± 0.12 mg/dl) (135.25 ± 10.61 μmol/l) creatinine levels were significantly higher compared to the initial value (1.15 ± 0.6 mg/dl) (101.66 ± 53.04 μmol/l). AKI was observed in 36 patients (41.86%) on the third day of iloprost infusion. Logistic regression analysis revealed smoking and not using acetylsalicylic acid as primary predictors (p = 0.02 and p = 0.008, respectively) of AKI during iloprost treatment. On the third infusion day, patients’ urinary output significantly increased (1813.30 ± 1123.46 vs 1545.17 ± 873.00 cm³) and diastolic blood pressure significantly decreased (70.07 ± 15.50 vs 74.14 ± 9.42 mmHg) from their initial values.

Conclusion

While iloprost treatment is effective in patients with PAD who are not suitable for surgery, severe systemic vasodilatation can cause renal ischaemia, resulting in nonoliguric AKI. Smoking, no acetylsalicylic acid use, and lower diastolic blood pressure are the clinical risk factors for AKI during iloprost treatment.

Sinapic acid mitigates gentamicin-induced nephrotoxicity and associated oxidative/nitrosative stress, apoptosis, and inflammation in rats

AIMS

In this study, the renoprotective functions of sinapic acid (SA), a polyphenol, on gentamicin-induced nephrotoxicity and the pathway that mediates this function were examined.

MAIN METHODS

Kidney function markers (serum urea, uric acid, creatinine, LDH, and γ-GGT) and histopathological examinations of the kidney were used to evaluate gentamicin-induced nephrotoxicity. Oxidative stress markers (lipid peroxidation and total protein), renal nitrosative stress (nitric oxide), antioxidant enzymes (catalase and NP-SH), inflammation markers (NF-κB [p65], TNF-α, IL-6, and myeloperoxidase [MPO]), and apoptotic markers (caspase 3, Bax, and Bcl-2) were also assessed.

KEY FINDINGS

SA (10 and 20mg/kg) pretreatment along with gentamicin restored kidney function, upregulated antioxidant levels, and downregulated lipid peroxidation and nitric oxide levels, resulting in significant decreases in oxidative and nitrosative stress. Gentamicin promoted the upregulation of renal cytokines (TNF-α and IL-6), nuclear NF-κB (p65) expression, NF-κB-DNA binding activity, and MPO activity were significantly down regulated upon SA pretreatment. Furthermore, SA pretreatment downregulated caspase 3 and Bax protein expressions and upregulated Bcl-2 protein expression. SA pretreatment also mitigated the magnitude of histological damage and reduced neutrophil infiltration in renal tubules.

SIGNIFICANCE

These outcomes indicated that SA pretreatment mitigates renal impairment and structural injuries via the downregulation of oxidative/nitrosative stress, inflammation, and apoptosis in the kidney.

Drug Class Combination–Associated Acute Kidney Injury

Objective: To evaluate the quality of available evidence of drug class combinations and their association with the development of acute kidney injury (AKI). Data Sources: A search of MEDLINE and Embase databases was completed using the following terms: “risk factor AND (acute kidney injury or acute kidney failure) AND (drug or medication).” Study Selection and Data Extraction: Inclusion criteria were the following: English language, full-text availability, and at least 1 drug-combination. Each citation was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. The literature was evaluated using the quality of evidence component of GRADE. No standardized definition of AKI was applied throughout.. Data Synthesis: Out of 2139 total citations, 151 were assessed for full-text review, with 121 citations (6%) meeting inclusion criteria, producing76 unique drug class combinations. Overall, 56 combinations (73.7%) were considered very low quality; 12 (15.8%) were considered low quality. There were 8 (10.5%) of moderate quality, and no combination was considered high quality. 58 (76%) combinations that had a single citation,with a mean of 1.6 citations per drug class combination. The combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and diuretics was reported in 10 citations, the largest number of citations. Conclusions: Our study demonstrates a lack of well-designed studies addressing drug class combination–associated AKI. The combination of NSAIDs and diuretics with or without additional renin-angiotensin aldosterone agents had the strongest level of evidence. Despite limitations, the information included in this review may result in additional scrutiny about combining certain individual nephrotoxic drugs.

The impact of social isolation on delayed hospital discharges of older hip fracture patients and associated costs

Delayed discharges represent an inefficient use of acute hospital beds. Social isolation and referral to a public-funded rehabilitation unit were significant predictors of delayed discharges while admission from an institution was a protective factor for older hip fracture patients. Preventing delays could save between 11.2 and 30.7 % of total hospital costs for this patient group.

INTRODUCTION

Delayed discharges of older patients from acute care hospitals are a major challenge for administrative, humanitarian, and economic reasons. At the same time, older people are particularly vulnerable to social isolation which has a detrimental effect on their health and well-being with cost implications for health and social care services. The purpose of the present study was to determine the impact and costs of social isolation on delayed hospital discharge.

METHODS

A prospective study of 278 consecutive patients aged 75 or older with hip fracture admitted, as an emergency, to the Orthopaedics Department of Hospital Universitário de Santa Maria, Portugal, was conducted. A logistic regression model was used to examine the impact of relevant covariates on delayed discharges, and a negative binomial regression model was used to examine the main drivers of days of delayed discharges. Costs of delayed discharges were estimated using unit costs from national databases.

RESULTS

Mean age at admission was 85.5 years and mean length of stay was 13.1 days per patient. Sixty-two (22.3 %) patients had delayed discharges, resulting in 419 bed days lost (11.5 % of the total length of stay). Being isolated or at a high risk of social isolation, measured with the Lubben social network scale, was significantly associated with delayed discharges (odds ratio (OR) 3.5) as was being referred to a public-funded rehabilitation unit (OR 7.6). These two variables also increased the number of days of delayed discharges (2.6 and 4.9 extra days, respectively, holding all else constant). Patients who were admitted from an institution were less likely to have delayed discharges (OR 0.2) with 5.5 fewer days of delay. Total costs of delayed discharges were between 11.2 and 30.7 % of total costs (€2352 and €9317 per patient with delayed discharge) conditional on whether waiting costs for placement in public-funded rehabilitation unit were included.

CONCLUSION

High risk of social isolation, social isolation and referral to public-funded rehabilitation units increase delays in patients' discharges from acute care hospitals.

The Stockholm CREAtinine Measurements (SCREAM) project: protocol overview and regional representativeness

BACKGROUND

We here describe the construction of the Stockholm CREAtinine Measurement (SCREAM) cohort and assess its coverage/representativeness of the Stockholm county in Sweden. SCREAM has the principal aims to estimate the burden and consequences of chronic kidney disease (CKD) and to identify inappropriate drug use (prescription of nephrotoxic, contraindicated or ill-dosed drugs).

METHODS

SCREAM is a repository of laboratory data of individuals, residing or accessing healthcare in the region of Stockholm, who underwent creatinine assessments between 2006-11. Laboratory tests were linked to administrative databases with complete information on socioeconomic status, demographic data, healthcare utilization, diagnoses, vital status and dispensed prescription medicines.

RESULTS

SCREAM identified 1 118 507 adult Stockholm citizens with available creatinine tests between 2006-11. This corresponded to 66% of the complete population in the region. Geographical coverage was uniform, ranging between 62 and 72% throughout its 26 municipalities. Population coverage was higher across older age strata (50% coverage for age range 18-44 years, >75% for 45-64 years and >90% coverage for ≥65 years). Of note, 97 and 98% of all individuals with a diagnosis of diabetes mellitus or cardiovascular disease, respectively, were captured by SCREAM. Further, 89% of all deaths registered in the period occurred in individuals with a creatinine test undertaken.

CONCLUSION

SCREAM represents the largest cohort to estimate the burden and healthcare implications of CKD in Sweden. The coverage and representativeness of the region of Stockholm was high and in accordance to both the commonness of creatinine assessment, and the medical indications for creatinine testing. The inclusion of individuals who sought medical care and had a creatinine test undertaken resulted in a slight over-representation of elderly and comorbid patients.

Drug-related acute renal failure in hospitalised patients

INTRODUCTION

The information available on the incidence and the characteristics of patients with acute renal failure (ARF) related to drugs is scarce.

OBJECTIVES

To estimate the incidence of drug-related ARF in hospitalised patients and to compare their characteristics with those of patients with ARF due to other causes.

MATERIAL AND METHODS

We selected a prospective cohort of patients with ARF during hospital admission (July 2010-July 2011). Information on patients' demographics, medical antecedents, ARF risk factors, ARF severity according to the RIFLE classification and hospital drug administration was collected. We analysed the relationship of drugs with the ARF episodes using Spanish Pharmacovigilance System methods and algorithm.

RESULTS

A total of 194 cases had an episode of hospital-acquired ARF. The median age of patients was 72 years [IQR 20]; 60% were men. The ARF incidence during hospitalization was 9.6 per 1,000 admissions. According to the RIFLE classification, a risk of kidney damage or kidney injury was present in 77.8% of cases. In 105 (54.1%) cases, ARF was drug-related; the drugs most frequently involved were diuretics, agents acting on the renin-angiotensin system, immunosuppressants, β-blocking agents, calcium channel blockers, contrast media and non-steroid anti-inflammatory drugs. Patients with drug-related ARF had more multi-morbidity, fewer ARF risk factors and lower mortality.

CONCLUSIONS

Half of ARF episodes during hospitalisation were drug related. Patients with drug-related ARF had higher cardiovascular morbidity than those with ARF related to other causes, but they had a lower frequency of ARF risk factors and mortality.

Incidence, Characteristics and Risk Factors of Acute Kidney Injury among Dengue Patients: A Retrospective Analysis

BACKGROUND

Dengue induced acute kidney injury (AKI) imposes heavy burden of illness in terms of morbidity and mortality. A retrospective study was conducted to investigate incidence, characteristics, risk factors and clinical outcomes of AKI among dengue patients.

METHODOLOGY

A total 667 dengue patients (2008-2013) were retrospectively evaluated and were stratified into AKI and non-AKI groups by using AKIN criteria. Two groups were compared by using appropriate statistical methods.

RESULTS

There were 95 patients (14.2%) who had AKI, with AKIN-I, AKIN-II and AKIN-III in 76.8%, 16.8% and 6.4% patients, respectively. Significant differences (P<0.05) in demographics and clinico-laboratory characteristics were observed between patients with and without AKI. Presence of dengue hemorrhagic fever [OR (95% CI): 8.0 (3.64–17.59), P<0.001],rhabdomyolysis [OR (95% CI): 7.9 (3.04–20.49)], multiple organ dysfunction OR (95% CI):17.9 (9.14–35.12), P<0.001], diabetes mellitus [OR (95% CI): 4.7 (1.12–19.86), P = 0.034], late hospitalization [OR (95% CI): 2.1 (1.12–19.86), P = 0.033] and use of nephrotoxic drugs [OR(95% CI): 2.9 (1.12–19.86), P = 0.006] were associated with AKI. Longer hospital stay (>3days) was also observed among AKI patients (OR = 1.3, P = 0.044) [corrected].Additionally, 48.4% AKI patients had renal insufficiencies at discharge that were signicantly associated with severe dengue, secondary infection and diabetes mellitus. Overall mortality was 1.2% and all fatal cases had AKI.

CONCLUSIONS

The incidence of AKI is high at 14.2% among dengue patients, and those with AKI portended significant morbidity, mortality, longer hospital stay and poor renal outcomes. Our findings suggest that AKI in dengue is likely to increase healthcare burden that underscores the need of clinicians' alertness to this highly morbid and potentially fatal complication for optimal prevention and management.