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Maciel AT. Optimizing Postoperative Acute Kidney Injury Monitoring Using a Urine Biochemical Approach-Time to Bring More Dynamism to Serum Creatinine Evaluation! Indian J Crit Care Med 2024; 28:729-733. [PMID: 39239174 PMCID: PMC11372670 DOI: 10.5005/jp-journals-10071-24771] [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] [Indexed: 09/07/2024] Open
Abstract
Glomerular filtration rate (GFR) impairment is common both intraoperatively and in the early postoperative period of major surgeries, even elective ones. In some patients, such impairment is subtle and short-lasting, not even detected by increases in serum creatinine (sCr) and, consequently, not of sufficient magnitude to fulfill acute kidney injury (AKI) sCr-based criteria. In patients with a GFR decrease of greater magnitude, significant increases in sCr will occur but, unfortunately, usually at a late time in its progression. Both urinary and serum biomarkers have been proposed to be capable of anticipating AKI development but they are not widely available nor cost-effective in most centers. In this context, a urine biochemical approach using urinary sodium concentration (NaU) and the fractional excretion of potassium (FeK) has been proposed, anticipating the level of renal microcirculatory stress and decreases in GFR. An educational postoperative case example is presented highlighting the relevance that this approach can have in the correct interpretation of sCr values, bringing more dynamism to renal function monitoring. How to cite this article Maciel AT. Optimizing Postoperative Acute Kidney Injury Monitoring Using a Urine Biochemical Approach-Time to Bring More Dynamism to Serum Creatinine Evaluation! Indian J Crit Care Med 2024;28(8):729-733.
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Affiliation(s)
- Alexandre T Maciel
- Imed Group Research Department, Adult ICU, Hospital São Camilo Pompéia Unit, São Paulo, Brazil
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Yanar KE, Eren E, Aktaş MS, Eroğlu MS, Kandemir Ö, Aydın G. Prognostic potential of inflammatory markers, oxidative status, thrombocyte indices, and renal biochemical markers in neonatal calf diarrhoea-induced systemic inflammatory response syndrome. Vet Immunol Immunopathol 2023; 265:110680. [PMID: 37980800 DOI: 10.1016/j.vetimm.2023.110680] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/08/2023] [Accepted: 11/08/2023] [Indexed: 11/21/2023]
Abstract
The study aimed to assess the prognostic value of inflammatory markers, indicators of oxidative stress, thrombocyte indices, and renal biochemical markers in neonatal calf diarrhoea (NCD) induced by systemic inflammatory response syndrome (SIRS) upon admission. A prospective, observational, and case-control study was conducted on 56 calves diagnosed with NCD. Mean concentrations of interleukin-6 (IL-6), malondialdehyde (MDA), glutathione (GSH), mean platelet volume (MPV), platelet distribution width (PDW), blood urea nitrogen (BUN), and creatinine (Crea) were measured. Furthermore, the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were also calculated for SIRS survivors [SIRS (survivor)] and non-survivors [SIRS (non-survivor)] induced by NCD. A prognostic cut-off value for predicting the prognosis of the SIRS's induced by NCD was obtained via receiver operating characteristic (ROC) curve analysis. Upon admission, the SIRS (non-survivor) calves had significantly higher (P < .001) average levels of IL-6, MDA, BUN, Crea, MPV, and PDW compared to the SIRS (survivor) calves and significantly lower (P < .001) average levels of GSH. Despite an apparent increase in the NLR and PLR values of calves diagnosed with SIRS, no significant difference was found between the survival and non-survivor SIRS cases. Positive predictive values (PPVs) for survival were determined as 100 %, 100 %, 80 %, 100 %, 80 %, and 80 %, respectively, using cut-off values of IL-6 (≤259.67 ng/L), MDA (≤2.87 nmol/mL), MPV (≤12.5 fL), PDW (≤34.25 %), BUN (≤168.3 mg/dL), and Crea (≤2.11 mg/dL). The determined threshold values are those obtained upon admission to the hospital. Based on the sensitivity, specificity, and PPVs derived from the ROC analysis, it has been concluded that IL-6, MDA, MPV, PDW, BUN, and Crea are the most relevant biomarkers used for predicting the prognosis of NCD-induced SIRS in calves. Furthermore, it is also noteworthy that IL-6 exhibited the highest effectiveness among all biomarkers.
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Affiliation(s)
- Kerim Emre Yanar
- Department of Internal Medicine, Faculty of Veterinary Medicine, Atatürk University, Erzurum, Turkey.
| | - Emre Eren
- Department of Internal Medicine, Faculty of Veterinary Medicine, Atatürk University, Erzurum, Turkey.
| | - Mustafa Sinan Aktaş
- Department of Internal Medicine, Faculty of Veterinary Medicine, Atatürk University, Erzurum, Turkey
| | - Muhammed Sertaç Eroğlu
- Department of Internal Medicine, Faculty of Veterinary Medicine, Atatürk University, Erzurum, Turkey
| | - Özge Kandemir
- Aksaray Technical Sciences Vocatinal School, Aksaray University, Aksaray, Turkey
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Argaiz ER, Rola P, Haycock KH, Verbrugge FH. Fluid management in acute kidney injury: from evaluating fluid responsiveness towards assessment of fluid tolerance. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:786-793. [PMID: 36069621 DOI: 10.1093/ehjacc/zuac104] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 06/15/2023]
Abstract
Despite the widespread use of intravenous fluids in acute kidney injury (AKI), solid evidence is lacking. Intravenous fluids mainly improve AKI due to true hypovolaemia, which is difficult to discern at the bedside unless it is very pronounced. Empiric fluid resuscitation triggered only by elevated serum creatinine levels or oliguria is frequently misguided, especially in the presence of fluid intolerance syndromes such as increased extravascular lung water, capillary leak, intra-abdominal hypertension, and systemic venous congestion. While fluid responsiveness tests clearly identify patients who will not benefit from fluid administration (i.e. those without an increase in cardiac output), the presence of fluid responsiveness does not guarantee that fluid therapy is indicated or even safe. This review calls for more attention to the concept of fluid tolerance, incorporating it into a practical algorithm with systematic venous Doppler ultrasonography assessment to use at the bedside, thereby lowering the risk of detrimental kidney congestion in AKI.
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Affiliation(s)
- Eduardo R Argaiz
- Department of Nephrology and Mineral Metabolism, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montréal, QC, Canada
| | - Korbin H Haycock
- Department of Emergency Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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de Morais DG, Sanches TRC, Santinho MAR, Yada EY, Segura GC, Lowe D, Navarro G, Seabra VF, Taniguchi LU, Malbouisson LMS, de André CDS, Andrade L, Rodrigues CE. Urinary sodium excretion is low prior to acute kidney injury in patients in the intensive care unit. FRONTIERS IN NEPHROLOGY 2022; 2:929743. [PMID: 37675036 PMCID: PMC10479577 DOI: 10.3389/fneph.2022.929743] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/31/2022] [Indexed: 09/08/2023]
Abstract
Background The incidence of acute kidney injury (AKI) is high in intensive care units (ICUs), and a better understanding of AKI is needed. Early chronic kidney disease is associated with urinary concentration inability and AKI recovery with increased urinary solutes in humans. Whether the inability of the kidneys to concentrate urine and excrete solutes at appropriate levels could occur prior to the diagnosis of AKI is still uncertain, and the associated mechanisms have not been studied. Methods In this single-center prospective observational study, high AKI risk in ICU patients was followed up for 7 days or until ICU discharge. They were grouped as "AKI" or "No AKI" according to their AKI status throughout admission. We collected daily urine samples to measure solute concentrations and osmolality. Data were analyzed 1 day before AKI, or from the first to the fifth day of admission in the "No AKI" group. We used logistic regression models to evaluate the influence of the variables on future AKI diagnosis. The expression of kidney transporters in urine was evaluated by Western blotting. Results We identified 29 patients as "No AKI" and 23 patients as "AKI," the latter being mostly low severity AKI. Urinary sodium excretion was lower in "AKI" patients prior to AKI diagnosis, particularly in septic patients. The expression of Na+/H+ exchanger (NHE3), a urinary sodium transporter, was higher in "AKI" patients. Conclusions Urinary sodium excretion is low before an AKI episode in ICU patients, and high expressions of proximal tubule sodium transporters might contribute to this.
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Affiliation(s)
- David Gomes de Morais
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Talita Rojas Cunha Sanches
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Mirela Aparecida Rodrigues Santinho
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo Yuki Yada
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Gabriela Cardoso Segura
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Diogo Lowe
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Guilherme Navarro
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Victor Faria Seabra
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Leandro Utino Taniguchi
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Carmen Diva Saldiva de André
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Lúcia Andrade
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Camila Eleuterio Rodrigues
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Maciel AT, Vitorio D, Osawa EA. Urine biochemistry assessment in the sequential evaluation of renal function: Time to think outside the box. Front Med (Lausanne) 2022; 9:912877. [PMID: 35957852 PMCID: PMC9360530 DOI: 10.3389/fmed.2022.912877] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/05/2022] [Indexed: 12/12/2022] Open
Abstract
Urine biochemistry (UB) remains a controversial tool in acute kidney injury (AKI) monitoring, being considered to be of limited value both in terms of AKI diagnosis and prognosis. However, many criticisms can be made to the studies that have established the so called “pre-renal paradigm” (used for decades as the essential physiological basis for UB assessment in AKI) as well as to more recent studies suggesting that UB has no utility in daily clinical practice. The aim of this article is to describe our hypothesis on how to interpret simple and widely recognized urine biochemical parameters from a novel perspective, propose the rationale for their sequential assessment and demonstrate their usefulness in AKI monitoring, especially in the critical care setting.
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Affiliation(s)
- Alexandre T. Maciel
- Research Department, Imed Group, São Paulo, Brazil
- Adult Intensive Care Unit, São Camilo Hospital–Pompéia Unit, São Paulo, Brazil
- *Correspondence: Alexandre T. Maciel,
| | - Daniel Vitorio
- Research Department, Imed Group, São Paulo, Brazil
- Adult Intensive Care Unit, São Camilo Hospital–Pompéia Unit, São Paulo, Brazil
| | - Eduardo A. Osawa
- Research Department, Imed Group, São Paulo, Brazil
- Adult Intensive Care Unit, São Camilo Hospital–Pompéia Unit, São Paulo, Brazil
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Bonavia A, Vece G, Karamchandani K. Prerenal acute kidney injury—still a relevant term in modern clinical practice? Nephrol Dial Transplant 2020; 36:1570-1577. [DOI: 10.1093/ndt/gfaa061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/24/2020] [Indexed: 12/11/2022] Open
Abstract
Abstract
The traditional taxonomy of acute kidney injury (AKI) has remained pervasive in clinical nephrology. While the terms ‘prerenal’, ‘intrarenal’ and ‘postrenal’ highlight the diverse pathophysiology underlying AKI, they also imply discrete disease pathways and de-emphasize the nature of AKI as an evolving clinical syndrome with multiple, often simultaneous and overlapping, causes. In a similar vein, prerenal AKI comprises a diverse spectrum of kidney disorders, albeit one that is often managed by using a standardized clinical algorithm. We contend that the term ‘prerenal’ is too vague to adequately convey our current understanding of hypoperfusion-related AKI and that it should thus be avoided in the clinical setting. Practice patterns among nephrologists indicate that AKI-related terminology plays a significant role in the approaches that clinicians take to patients that have this complex disease. Thus, it appears that precise terminology does impact the treatment that patients receive. We will outline differences in the diagnosis and management of clinical conditions lying on the so-called prerenal disease spectrum to advocate caution when administering intravenous fluids to these clinically decompensated patients. An understanding of the underlying pathophysiology may, thus, avert clinical missteps such as fluid and vasopressor mismanagement in tenuous or critically ill patients.
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Affiliation(s)
- Anthony Bonavia
- Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Pharmacology, Penn State College of Medicine, Hershey, PA, USA
| | - Gregory Vece
- The Pennsylvania State College of Medicine, Hershey, PA, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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Abstract
Commonest intervention in hospitalized patient is fluid therapy, and practically every critically ill patient receives fluid resuscitation. Commonest indication for fluid administration is to achieve hemodynamic stability and prevent or manage acute kidney injury (AKI). However, fluid administration is a two-edged sword, i.e., inadequate fluids give rise to hypoperfusion and organ injury and overzealous fluid therapy can give rise to fluid overload and related consequences. Though fluids are commonly given to prevent development of AKI, hypervolemia itself has the potential to cause AKI.
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Affiliation(s)
- Vijaya P Patil
- Division of Clinical Anaesthesiology, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Bindiya G Salunke
- Division of Clinical Anaesthesiology, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
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Urinary Sodium/Potassium Ratio in Acute Kidney Injury Accurately Differentiates Prerenal Azotemia from Acute Tubular Necrosis. ACTA MEDICA MARISIENSIS 2019. [DOI: 10.2478/amma-2019-0011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Objective: To develop a more accurate, cost effective, non-invasive test to differentiate between pre-renal renal failure (PRA) and acute tubular necrosis (ATN) in acute kidney injury (AKI).
Methods: Urine sodium/potassium (Na/K) ratios were compared with fractional excretion of sodium (FeNa) and renal failure index (RFI) as well as other commonly used indices to differentiate patients with PRA from ATN. Patients with a rise in serum creatinine > 0.5 mg/d identified from medical records for a six- to eighteen-month period, were reviewed and categorized either as PRA or ATN based on presenting findings, course in hospital or renal biopsy. All patients had urinary sodium and potassium, creatinine, and serum creatinine done.
Results: The Na/K was < 1 in PRA and > 1 in ATN, correctly identifying all 42 cases of PRA and all 28 patients with ATN. The FeNa was >1 and misdiagnosed 9 of 42 patients with PRA and was >1 and correctly diagnosed all patients with ATN. The RFI was >1 and misdiagnosed 11 of 42 patients with PRA but was >1 and correctly diagnosed all patients with ATN. The BUN/creatinine ratio, urine sodium concentration and U/P creatinine ratio all had a very poor correlation with the correct diagnosis.
Conclusion: The Na/K ratio correctly diagnosed all 42 cases of PRA and all 28 cases of ATN. It is easy to do, is cost effective, non-invasive, and is useful for following patients with PRA to see if and when they develop ATN.
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Amini N, Sarkaki A, Dianat M, Mard SA, Ahangarpour A, Badavi M. The renoprotective effects of naringin and trimetazidine on renal ischemia/reperfusion injury in rats through inhibition of apoptosis and downregulation of micoRNA-10a. Biomed Pharmacother 2019; 112:108568. [PMID: 30780111 DOI: 10.1016/j.biopha.2019.01.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/06/2019] [Accepted: 01/08/2019] [Indexed: 10/27/2022] Open
Abstract
Renal Ischemia-Reperfusion (IR) injury occurs due to circulatory shock and renal transplantation, leading to mortality and morbidity worldwide. The primary purpose of the current study was to evaluate the renoprotective effects of the naringin (NAR) and trimetazidine (TMZ) on IR injury, renal hemodynamics, antioxidant capacity, microRNA-10a, and expression of apoptosis factors. Forty rats were divided into five groups randomly: Sham, IR injury, (TMZ, 5 mg/kg), (NAR pretreatment, 100 mg/kg), and TMZ plus NAR. The sham group underwent the identical surgical procedure as the other groups, except for the application of clamps. After anesthesia, IR injury was induced by 45 min of ischemia, followed by reperfusion for 4 h. Tissue and blood samples were collected for evaluation of renal function, antioxidant activity and, biochemical and molecular parameters. Administration of the NAR, TMZ, and their combination decreased the plasma level of microRNA-10a, caspase-3, and Bcl-2 associated x protein (Bax) mRNA expression, but increased the B- cell lymphoma 2 (Bcl-2) mRNA expression in the kidney tissue. In addition, antioxidant activity, renal blood flow, creatinine clearance (CCr), and fractional excretion of sodium (FENa) were improved. The NAR, TMZ, and their combination can prevent renal I/R injury through promotion of the level of antioxidant enzymes, as well as decrease of microRNA-10a and anti-apoptosis properties. Our data also suggest that NAR, TMZ, or their combination might be beneficial as potent therapeutic factors against renal IR injury.
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Affiliation(s)
- Negin Amini
- Department of Physiology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Alireza Sarkaki
- Department of Physiology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; The Persian Gulf Physiology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mahin Dianat
- Department of Physiology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; The Persian Gulf Physiology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Seyyed Ali Mard
- Department of Physiology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Akram Ahangarpour
- Department of Physiology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammad Badavi
- Department of Physiology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; The Persian Gulf Physiology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
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Cho AY, Yoon HJ, Lee KY, Sun IO. Clinical characteristics of sepsis-induced acute kidney injury in patients undergoing continuous renal replacement therapy. Ren Fail 2018; 40:403-409. [PMID: 30015549 PMCID: PMC6052425 DOI: 10.1080/0886022x.2018.1489288] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective: The aim of this study was to investigate the clinical characteristics of sepsis-induced acute kidney injury (AKI) in patients undergoing continuous renal replacement therapy (CRRT). Methods: From 2011 to 2015, we enrolled 340 patients who were treated with CRRT for sepsis at the Presbyterian Medical Center. In all patients, CRRT was performed using the PRISMA platform. We divided these patients into two groups (survivors and non-survivors) according to the 28-day all-cause mortality. We compared clinical characteristics and analyzed the predictors of mortality. Results: The 28-day all-cause mortality was 62%. Survivors were younger than non-survivors and had higher platelet counts (178 ± 101 × 103/mL vs. 134 ± 84 × 103/mL, p < .01) and serum creatinine levels (4.2 ± 2.8 vs. 3.3 ± 2.7, p < .01). However, survivors had lower red blood cell distribution width (RDW) scores (14.9 ± 2.1 vs. 16.1 ± 3.3, p < .01) and APACHE II scores (24.5 ± 5.8 vs. 26.9 ± 5.7, p < .01) than non-survivors. Furthermore, survivors were more likely than non-survivors to have a urine output of >0.05 mL/kg/h (66% vs. 86%, p = .001) in the first day. In a multivariate logistic regression analysis, age, platelet count, RDW score, APACHE II score, serum creatinine level, and a urine output of <0.05 mL/kg/h the first day were prognostic factors for the 28-day all-cause mortality. Conclusion: Age, platelet count, APACHE II score, RDW score, serum creatinine level, and urine output the first day are useful predictors for the 28-day all-cause mortality in sepsis patients requiring CRRT.
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Affiliation(s)
- A Young Cho
- a Department of Internal Medicine, Division of Nephrology , Presbyterian Medical Center , Jeonju , Korea
| | - Hyun Ju Yoon
- a Department of Internal Medicine, Division of Nephrology , Presbyterian Medical Center , Jeonju , Korea
| | - Kwang Young Lee
- a Department of Internal Medicine, Division of Nephrology , Presbyterian Medical Center , Jeonju , Korea
| | - In O Sun
- a Department of Internal Medicine, Division of Nephrology , Presbyterian Medical Center , Jeonju , Korea
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Skowron B, Baranowska A, Kaszuba-Zwoińska J, Więcek G, Malska-Woźniak A, Heczko P, Strus M. Experimental model for acute kidney injury caused by uropathogenic Escherichia coli. POSTEP HIG MED DOSW 2017; 71:520-529. [PMID: 28665281 DOI: 10.5604/01.3001.0010.3833] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) is the rapid deterioration of renal function, diagnosed on the basis of an increase in serum creatinine and abnormal urinary parameters. AKI is associated with increased risk of mortality or chronic kidney disease (CKD). The aim of the study was to develop an experimental model for AKI resulting from Escherichia coli-induced pyelonephritis. E. coli was isolated from a patient with clinical symptoms of urinary tract infection (UTI). MATERIAL/METHODS The study included three groups of female Wistar rats (groups 1, 2 and 3), in which pyelonephritis was induced by transurethral inoculation with highly virulent E. coli (105, 107 and 109 cfu/ml, respectively). Urine and blood samples for analysis were obtained prior to the inoculation (day 0), as well as 7, 14 and 21 days thereafter. RESULTS Aside from a microbiological examination of urine samples, daily urine output, serum creatinine (CreaS), creatinine clearance (CrCl), interleukin 6 (IL-6), fractional excretion of sodium (FENa) and fractional excretion of urea (FEUrea) were determined. A histopathological examination of kidney and urinary bladder specimens was conducted as well. While UTI-related pyelonephritis developed irrespective of E. coli inoculum size, AKI was observed only following transurethral administration of E. coli at the intermediate and high dose, i.e. 107 and 109 cfu/ml, respectively (group 2 and 3). DISCUSSION An increase in CreaS and abnormal diuresis were accompanied by changes in parameters specific for various forms of AKI, i.e. FENa and FEUrea. Based on these changes, administration of E. coli at 107 cfu/ml was demonstrated to induce renal AKI, whereas inoculation with 109 cfu/ml seemed to cause not only ascending pyelonephritis, but perhaps also bacteremia and urosepsis (prerenal component of AKI).
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Affiliation(s)
- Beata Skowron
- Department of Pathophysiology, Jagiellonian University Medical College, Krakow, Poland
| | - Agnieszka Baranowska
- Department of Pathophysiology, Jagiellonian University Medical College, Krakow, Poland
| | | | - Grażyna Więcek
- Department of Microbiology, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Malska-Woźniak
- Department of Microbiology, Jagiellonian University Medical College, Krakow, Poland
| | - Piotr Heczko
- Department of Microbiology, Jagiellonian University Medical College, Krakow, Poland
| | - Magdalena Strus
- Department of Microbiology, Jagiellonian University Medical College, Krakow, Poland
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Cerdá J, Mohan S, Garcia-Garcia G, Jha V, Samavedam S, Gowrishankar S, Bagga A, Chakravarthi R, Mehta R. Acute Kidney Injury Recognition in Low- and Middle-Income Countries. Kidney Int Rep 2017; 2:530-543. [PMID: 29034358 PMCID: PMC5637391 DOI: 10.1016/j.ekir.2017.04.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Acute kidney injury (AKI) is increasingly common around the world. Because of the low availability of effective therapies and resource limitations, early preventive and therapeutic measures are essential to decrease morbidity, mortality, and cost. Timely recognition and diagnosis of AKI requires a heightened degree of suspicion in the appropriate clinical and environmental context. In low- and middle-income countries (LMICs), early detection is impaired by limited resources and low awareness. In this article, we report the consensus recommendations of the 18th Acute Dialysis Quality Initiative meeting in Hyderabad, India, on how to improve recognition of AKI. We expect these recommendations will lead to an earlier and more accurate diagnosis of AKI, and improved research to promote a better understanding of the epidemiology, etiology, and histopathology of AKI in LMICs.
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Affiliation(s)
- Jorge Cerdá
- Department of Medicine, Division of Nephrology, Albany Medical College, Albany, New York, USA
- Correspondence: Jorge Cerdá, MD, MS, FACP, FASN, Division of Nephrology, Department of Medicine, Albany Medical College, Albany, NY 12209.Division of NephrologyDepartment of MedicineAlbany Medical CollegeAlbanyNY 12209
| | - Sumit Mohan
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Guillermo Garcia-Garcia
- Nephrology Service, Hospital Civil de Guadalajara “Fray Antonio Alcalde,” Hospital 278, Guadalajara, Mexico
| | - Vivekanand Jha
- George Institute for Global Health India, New Delhi and University of Oxford, Oxford, UK
| | | | | | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Ravindra Mehta
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
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Ostermann M, Joannidis M. Acute kidney injury 2016: diagnosis and diagnostic workup. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:299. [PMID: 27670788 PMCID: PMC5037640 DOI: 10.1186/s13054-016-1478-z] [Citation(s) in RCA: 217] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute kidney injury (AKI) is common and is associated with serious short- and long-term complications. Early diagnosis and identification of the underlying aetiology are essential to guide management. In this review, we outline the current definition of AKI and the potential pitfalls, and summarise the existing and future tools to investigate AKI in critically ill patients.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care Medicine, King's College London, Guy's & St Thomas' Foundation Hospital, Westminster Bridge Road, London, UK.
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Medical University of Innsbruck, Anichstr. 35, Innsbruck, Austria.
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Urine sodium concentration to predict fluid responsiveness in oliguric ICU patients: a prospective multicenter observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:165. [PMID: 27236480 PMCID: PMC4884621 DOI: 10.1186/s13054-016-1343-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 05/12/2016] [Indexed: 12/21/2022]
Abstract
Background Oliguria is one of the leading triggers of fluid loading in patients in the intensive care unit (ICU). The purpose of this study was to assess the predictive value of urine Na+ (uNa+) and other routine urine biomarkers for cardiac fluid responsiveness in oliguric ICU patients. Methods We conducted a prospective multicenter observational study in five university ICUs. Patients with urine output (UO) <0.5 ml/kg/h for 3 consecutive hours with a mean arterial pressure >65 mmHg received a fluid challenge. Cardiac fluid responsiveness was defined by an increase in stroke volume >15 % after fluid challenge. Urine and plasma biochemistry samples were examined before fluid challenge. We examined renal fluid responsiveness (defined as UO >0.5 ml/kg/h for 3 consecutive hours) after fluid challenge as a secondary endpoint. Results Fifty-four patients (age 51 ± 37 years, Simplified Acute Physiology Score II score 40 ± 20) were included. Most patients (72 %) were not cardiac responders (CRs), and 50 % were renal responders (RRs) to fluid challenge. Patient characteristics were similar between CRs and cardiac nonresponders. uNa+ (37 ± 38 mmol/L vs 25 ± 75 mmol/L, p = 0.44) and fractional excretion of sodium (FENa+) (2.27 ± 2.5 % vs 2.15 ± 5.0 %, p = 0.94) were not statistically different between those who did and those who did not respond to the fluid challenge. Areas under the receiver operating characteristic (AUROC) curves were 0.51 (95 % CI 0.35–0.68) and 0.56 (95 % CI 0.39–0.73) for uNa+ and FENa+, respectively. Fractional excretion of urea had an AUROC curve of 0.70 (95 % CI 0.54–0.86, p = 0.03) for CRs. Baseline UO was higher in RRs than in renal nonresponders (1.07 ± 0.78 ml/kg/3 h vs 0.65 ± 0.53 ml/kg/3 h, p = 0.01). The AUROC curve for RRs was 0.65 (95 % CI 0.53–0.78) for uNa+. Conclusions In the present study, most oliguric patients were not CRs and half were not renal responders to fluid challenge. Routine urinary biomarkers were not predictive of fluid responsiveness in oliguric normotensive ICU patients.
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Jeganathan N, Ahuja N, Yau S, Otu D, Stein B, Balk RA. Impact of End-Stage Renal Disease and Acute Kidney Injury on ICU Outcomes in Patients With Sepsis. J Intensive Care Med 2016; 32:444-450. [PMID: 27146924 DOI: 10.1177/0885066616645308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE To report the characteristics and outcomes of patients with sepsis in the intensive care unit (ICU) with end-stage renal disease (ESRD) and acute kidney injury (AKI) compared to patients with nonkidney injury (non-KI). METHODS Retrospective study of all patients with sepsis admitted to the ICU of a university hospital within a 12-month time period. Data were obtained from the University Health Consortium database and a chart review of the electronic medical records. RESULTS We identified 39 cases of ESRD, 106 cases of AKI, and 103 cases of non-KI. Intensive care unit mortality was 15.4% for ESRD, 30.2% for AKI, and 13.6% for non-KI ( P < .01). Hospital mortality was 20.5% for ESRD, 32.1% for AKI, and 13.6% for non-KI ( P < .01). Early AKI and late AKI had an ICU mortality of 24.4% versus 50% ( P <.01), hospital mortality of 26.8% versus 50% ( P = .03), ICU length of stay (LOS) of 3 and 6 days ( P = .04), and hospital LOS of 7 and 12.5 days ( P <.01), respectively. CONCLUSION Patients with sepsis having AKI have a higher mortality rate than those with ESRD and non-KI. Hospital and ICU mortality rates for patients with ESRD were similar to non-KI patients. Late AKI compared to early AKI had a higher mortality and longer LOS.
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Affiliation(s)
- Niranjan Jeganathan
- 1 Division of Pulmonary and Critical Care Medicine, Rush University Medical Center and Rush Medical College, Chicago, IL, USA
| | - Neha Ahuja
- 2 Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Stephen Yau
- 2 Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Dara Otu
- 2 Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Brian Stein
- 1 Division of Pulmonary and Critical Care Medicine, Rush University Medical Center and Rush Medical College, Chicago, IL, USA
| | - Robert A Balk
- 1 Division of Pulmonary and Critical Care Medicine, Rush University Medical Center and Rush Medical College, Chicago, IL, USA
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Maciel AT, Delphino Salles L, Vitorio D. Simple blood and urinary parameters measured at ICU admission may sign for AKI development in the early postoperative period: a retrospective, exploratory study. Ren Fail 2016; 38:1607-1615. [PMID: 27101843 DOI: 10.3109/0886022x.2016.1144162] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Recent studies have suggested that some blood physicochemical and urinary biochemical parameters have a standardized behavior during acute kidney injury (AKI) development. The changes in these parameters frequently begin to occur before significant rises in serum creatinine (sCr) and may help in identifying patients with more subtle decreases in glomerular filtration rate (GFR). Surgical patients have an increased risk of AKI but renal impairment is usually not evident at ICU admission. We hypothesized that the surgical patients who have AKI diagnosed in the early postoperative period have an impaired GFR since ICU admission, indirectly inferred by alterations in these blood physicochemical and urinary biochemical parameters even in the presence of a still normal sCr. We retrospectively evaluated 112 surgical patients who were categorized according to AKI development during the first 3 ICU days. Twenty-eight patients developed AKI, most of them in the first day (D1) after ICU admission (D0). AKI patients had, at D0, lower serum pH and albumin, higher C - reactive protein (CRP), lower urine sodium (NaU) and fractional excretion of urea (FEUr). Fractional excretion of potassium (FEK) was high in both groups at D0 but remained high in the subsequent days only in AKI patients. Very low CRP and high serum albumin, high NaU and FEUr values at ICU admission had a significant negative predictive value for AKI. We concluded that some easily assessed parameters in blood and urine may help to identify patients with indirect signs of increased inflammatory response and decreased GFR at ICU admission, which could help to predict the risk of postoperative AKI development.
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Affiliation(s)
- Alexandre Toledo Maciel
- a Imed Research Group , Intensive Care Unit, Hospital São Camilo Pompéia , São Paulo , Brazil
| | - Lia Delphino Salles
- a Imed Research Group , Intensive Care Unit, Hospital São Camilo Pompéia , São Paulo , Brazil
| | - Daniel Vitorio
- a Imed Research Group , Intensive Care Unit, Hospital São Camilo Pompéia , São Paulo , Brazil
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- a Imed Research Group , Intensive Care Unit, Hospital São Camilo Pompéia , São Paulo , Brazil
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Keir I, Kellum JA. Acute kidney injury in severe sepsis: pathophysiology, diagnosis, and treatment recommendations. J Vet Emerg Crit Care (San Antonio) 2016; 25:200-9. [PMID: 25845505 DOI: 10.1111/vec.12297] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 01/11/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To review the unique pathophysiology of sepsis-induced acute kidney injury (AKI) and highlight the relevant aspects of the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Acute Kidney Injury that may apply to veterinary patients. DATA SOURCES Electronic search of MEDLINE database. HUMAN DATA SYNTHESIS Sepsis-induced AKI is diagnosed in up to 47% of human ICU patients and is seen as a major public health concern associated with increased mortality and increased progression to chronic kidney disease (CKD). Consensus criteria for the definition and classification of AKI has allowed for accurate description of the epidemiology of patients with AKI. AKI develops from a complex relationship between the initial insult and activation of inflammation and coagulation. In contrast to the traditional view, clinical and experimental data dispute the role of renal ischemia-reperfusion in the development of sepsis-induced AKI. Renal tubular dysfunction with activation of the tubuloglomerular feedback mechanism appears to be a crucial contributor to sepsis-induced AKI. Furosemide and n-acetylcysteine (NAC) do not appear to be helpful in the treatment of AKI. Hydroxyethyl starches (HES), dopamine, and supraphysiological concentrations of chloride are harmful in patients with AKI. VETERINARY DATA SYNTHESIS Community and hospital-acquired AKI is a significant factor affecting survival in critical ill patients. Sepsis-induced AKI occurs in 12% of dogs with abdominal sepsis and is an important contributor to mortality. Early detection of AKI in hospitalized patients currently offers the best opportunity to improve patient outcome. The use of urinary biomarkers to diagnose early AKI should be evaluated in critical care patients. CONCLUSION Veterinary clinical trials comparing treatment choices with the development of AKI are needed to make evidence-based recommendations for the prevention and treatment of AKI.
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Affiliation(s)
- Iain Keir
- Center for Critical Care Nephrology, The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, 15260
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Urine biochemistry assessment in critically ill patients: controversies and future perspectives. J Clin Monit Comput 2016; 31:539-546. [PMID: 27038161 DOI: 10.1007/s10877-016-9871-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 03/30/2016] [Indexed: 12/17/2022]
Abstract
In the past, urine biochemistry was a major tool in acute kidney injury (AKI) management. Classic papers published some decades ago established the values of the urine indices which were thought to distinguish "pre-renal" (functional) AKI attributed to low renal perfusion and "renal" (structural) AKI attributed to acute tubular necrosis (ATN). However, there were a lot of drawbacks and limitations in these studies and some recent articles have questioned the utility of measuring urine electrolytes especially because they do not seem to adequately inform about renal perfusion nor AKI duration (transient vs. persistent). At the same time, the "pre-renal" paradigm has been consistently criticized because hypoperfusion followed by ischemia and ATN does not seem to explain most of the AKI developing in critically ill patients and distinct AKI durations do not seem to be clearly related to different pathophysiological mechanisms or histopathological findings. In this new context, other possible roles for urine biochemistry have emerged. Some studies have suggested standardized changes in the urine electrolyte composition preceding increases in serum creatinine independently of AKI subsequent duration, which might actually be due to intra-renal microcirculatory changes and activation of sodium-retaining mechanisms even in the absence of impaired global renal blood flow. In the present review, the points of controversy regarding urine biochemistry assessment were evaluated as well as future perspectives for its role in AKI monitoring. An alternative approach for the interpretation of measured urine electrolytes is proposed which needs further larger studies to be validated and incorporated in daily ICU practice.
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Maciel AT. New concepts for bringing urine biochemistry back to clinical practice in the intensive care unit. Rev Bras Ter Intensiva 2016; 26:330-2. [PMID: 25607258 PMCID: PMC4304457 DOI: 10.5935/0103-507x.20140049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 07/18/2014] [Indexed: 11/20/2022] Open
Affiliation(s)
- Alexandre Toledo Maciel
- Grupo de Pesquisa Imed, Unidade de Terapia Intensiva, Hospital São Camilo, São Paulo, SP, Brasil
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Maciel AT, Nassar AP, Vitorio D. Very Transient Cases of Acute Kidney Injury in the Early Postoperative Period After Cardiac Surgery: The Relevance of More Frequent Serum Creatinine Assessment and Concomitant Urinary Biochemistry Evaluation. J Cardiothorac Vasc Anesth 2016; 30:56-63. [DOI: 10.1053/j.jvca.2015.04.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Indexed: 11/11/2022]
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Nagata I, Uchino S, Tokuhira N, Ohnuma T, Namba Y, Katayama S, Kawarazaki H, Toki N, Takeda K, Yasuda H, Izawa J, Uji M. Sepsis may not be a risk factor for mortality in patients with acute kidney injury treated with continuous renal replacement therapy. J Crit Care 2015. [DOI: 10.1016/j.jcrc.2015.06.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Maciel AT, Park M, Macedo E. Fractional excretion of potassium in the course of acute kidney injury in critically ill patients: potential monitoring tool? Rev Bras Ter Intensiva 2015; 26:143-7. [PMID: 25028948 PMCID: PMC4103940 DOI: 10.5935/0103-507x.20140021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Accepted: 04/07/2014] [Indexed: 11/26/2022] Open
Abstract
Objective To evaluate the behavior of fractional excretion of potassium in the course of
acute kidney injury in critically ill patients. Methods As part of a larger study in which we have evaluated blood and urinary parameters
in the course of acute kidney injury, 168 patients were included. Blood and urine
samples were collected daily until the removal of the urinary catheter or the
initiation of renal replacement therapy. We describe the evolution of fractional
excretion of potassium based on whether acute kidney injury was diagnosed, its
duration (transient or persistent) and its severity (creatinine-based Acute Kidney
Injury Network - AKIN stage). The diagnostic performance of fractional excretion
of potassium in predicting the duration of acute kidney injury and the need for
renal replacement therapy on the day of acute kidney injury diagnosis was also
evaluated. Results Fractional excretion of potassium was significantly higher in persistent acute
kidney injury compared to transient acute kidney injury on the day of acute kidney
injury diagnosis (24.8 vs. 13.8%, p<0.001). Both groups had the median
fractional excretion of potassium increasing in the two days preceding the acute
kidney injury diagnosis. Patients without acute kidney injury had stable low
fractional excretion of potassium values. The fractional excretion of potassium
was fairly accurate in predicting persistent acute kidney injury (area under the
curve: 0.712; 95% confidence interval: 0.614-0.811; p<0.001) on the day of
acute kidney injury diagnosis. The area under the curve was 0.663 (95% confidence
interval: 0.523-0.803; p=0.03) for renal replacement therapy. The fractional
excretion of potassium increased with maximum AKIN stage reached, in both
transient and persistent acute kidney injury. Conclusion Sequential fractional excretion of potassium assessment appears to be useful in
critically ill patients at risk for acute kidney injury.
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Affiliation(s)
- Alexandre Toledo Maciel
- Unidade de Terapia Intensiva, Departamento de Emergências Clínicas, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Marcelo Park
- Unidade de Terapia Intensiva, Departamento de Emergências Clínicas, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Etienne Macedo
- Departamento de Nefrologia, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
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Calzavacca P, Ishikawa K, Bailey M, May CN, Bellomo R. Systemic and renal hemodynamic effects of intra-arterial radiocontrast. Intensive Care Med Exp 2014; 2:32. [PMID: 26266929 PMCID: PMC4513043 DOI: 10.1186/s40635-014-0032-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 11/12/2014] [Indexed: 12/26/2022] Open
Abstract
Background Decreased renal blood flow (RBF) and vasoconstriction are considered major mechanisms of contrast-induced acute kidney injury (CIAKI). To understand the severity and duration of such putative effects, we measured systemic and renal hemodynamics after intra-arterial radiocontrast administration. The subjects were six Merino ewes. The setting was a university-affiliated research institute. This is a randomized cross-over experimental study. Methods Transit-time flow probes were implanted on the pulmonary and left renal arteries 2 weeks before experimentation. We simulated percutaneous coronary intervention by administering five intra-arterial boluses of 0.5 mL/kg saline (control) or radiocontrast (iodixanol) to a total of 2.5 mL/kg over 1 h. Cardiac output (CO), heart rate, mean arterial pressure (MAP), RBF, renal vascular conductance (RVC), urine output (UO), creatinine clearance (CrCl), and fractional excretion of sodium (FENa) were measured. Results In the first 8 h after intra-arterial administration of radiocontrast, CO, total peripheral conductance (TPC), and heart rate (HR) increased compared with those after normal saline administration. Thereafter, CO and TPC were similar between the two groups, but HR remained higher with radiocontrast (p < 0.001). After a short (30 min) period of renal vasoconstriction with preserved RBF secondary to an associated increase in MAP, RBF and RVC showed an earlier and greater increase (vasodilatation) with radiocontrast (p < 0.001) and remained higher during the first 2 days. Radiocontrast initially increased urine output (p < 0.001) and FENa (p = 0.003). However, the overall daily urine output decreased in the radiocontrast-treated animals at 2 days (p < 0.001) and 3 days (p = 0.006). Creatinine clearance was not affected. Conclusions In healthy animals, intra-arterial radiocontrast increased RBF, induced renal vasodilatation, and caused a delayed period of oliguria. Our findings suggest that sustained reduction in RBF and renal vasoconstriction may not occur in normal large mammals after intra-arterial radiocontrast administration.
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Affiliation(s)
- Paolo Calzavacca
- Department of Anaesthesia and Intensive Care, Uboldo Hospital, Vi aUboldo 21, Cernusco sul Naviglio, 20063, Milano, Italy,
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Acute Kidney Injury Induced by Systemic Inflammatory Response Syndrome is an Avid and Persistent Sodium-Retaining State. Case Rep Crit Care 2014; 2014:471658. [PMID: 25309760 PMCID: PMC4189521 DOI: 10.1155/2014/471658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 08/27/2014] [Accepted: 08/29/2014] [Indexed: 12/27/2022] Open
Abstract
Acute kidney injury (AKI) is a frequent complication of the systemic inflammatory response syndrome (SIRS), which is triggered by many conditions in the intensive care unit, including different types of circulatory shock. One under-recognized characteristic of the SIRS-induced AKI is its avidity for sodium retention, with progressive decreases in urinary sodium concentration (NaU) and its fractional excretion (FENa). This phenomenon occurs in parallel with increases in serum creatinine, being only transitorily mitigated by diuretic use. In the present case, we report a situation of two consecutive shocks: the first shock is hemorrhagic in origin and then the second shock is a septic one in the same patient. The SIRS and AKI triggered by the first shock were not completely solved when the second shock occurred. This could be viewed as a persistent avid sodium-retaining state, which may be appreciated even during renal replacement therapy (in the absence of complete anuria) and that usually solves only after complete AKI and SIRS resolution. We suggest that decreases in NaU and FENa are major characteristics of SIRS-induced AKI, irrespective of the primary cause, and may serve as additional monitoring tools in its development and resolution.
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Ramoutar V, Landa C, James LR. Acute tubular necrosis (ATN) presenting with an unusually prolonged period of marked polyuria heralded by an abrupt oliguric phase. CASE REPORTS 2014; 2014:bcr-2013-201030. [DOI: 10.1136/bcr-2013-201030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Risk factors for mortality in patients with septic acute kidney injury in intensive care units in Beijing, China: a multicenter prospective observational study. BIOMED RESEARCH INTERNATIONAL 2014; 2014:172620. [PMID: 25110659 PMCID: PMC4109370 DOI: 10.1155/2014/172620] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 06/14/2014] [Indexed: 12/16/2022]
Abstract
Objective. To discover risk factors for mortality of patients with septic AKI in ICU via a multicenter study. Background. Septic AKI is a serious threat to patients in ICU, but there are a few clinical studies focusing on this. Methods. This was a prospective, observational, and multicenter study conducted in 30 ICUs of 28 major hospitals in Beijing. 3,107 patients were admitted consecutively, among which 361 patients were with septic AKI. Patient clinical data were recorded daily for 10 days after admission. Kidney Disease: Improving Global Outcomes (KDIGO) criteria were used to define and stage AKI. Of the involved patients, 201 survived and 160 died. Results. The rate of septic AKI was 11.6%. Twenty-one risk factors were found, and six independent risk factors were identified: age, APACHE II score, duration of mechanical ventilation, duration of MAP <65 mmHg, time until RRT started, and progressive KIDGO stage. Admission KDIGO stages were not associated with mortality, while worst KDIGO stages were. Only progressive KIDGO stage was an independent risk factor. Conclusions. Six independent risk factors for mortality for septic AKI were identified. Progressive KIDGO stage is better than admission or the worst KIDGO for prediction of mortality. This trial is registered with ChiCTR-ONC-11001875.
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Adembri C, Selmi V, Vitali L, Nosi D, Tani A, Thyrion GDZ, Santoro G, Bonaccini L, Avveduto G, Caldini AL, Sgambati E. Expression and characterization of anionic components in the tubulointerstitial compartment of rat kidney during polymicrobial sepsis. Acta Histochem 2014; 116:94-105. [PMID: 23810033 DOI: 10.1016/j.acthis.2013.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 05/23/2013] [Accepted: 05/27/2013] [Indexed: 12/18/2022]
Abstract
The aim of the study was to evaluate sialic acids and hyaluronan expression, anionic components important for the structure and function of the renal tubulointerstitial compartment, in the early stages of sepsis. Two groups of rats were used: (1) sham-operated controls; (2) cecal ligation and puncture (CLP) (polymicrobial sepsis model). A search for microbial growth was made in the peritoneal fluid to document infection. Tubular function was evaluated by means of urinary protein loss, urinary Na(+) and urea excretion. Kidney samples were processed to analyze histology, sialic acids (lectin histochemistry) and hyaluronan (immunohistochemistry) expression. Results showed increased urinary protein loss and fractional excretion of Na(+) and urea reduction in the CLP group. Histological changes, particularly in the cortex and in proximal tubules of the CLP group, were observed. In septic rats, compared to controls, sialic acids decreased in amount and their acetylation increased in the tubules, although to a lesser extent in the proximal portion. Hyaluronan was expressed in the medullary interstitium and in a few areas of cortex in controls. In septic rats it increased in the cortical interstitium and appeared in proximal tubules. These results suggest correlation between expression changes of anionic components and tubulointerstitium morphofunctional alterations during sepsis. A role of these molecules in protection/defense and repair processes may be suggested.
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Kaur S, Jain S, Saha A, Chawla D, Parmar VR, Basu S, Kaur J. Evaluation of glomerular and tubular renal function in neonates with birth asphyxia. ACTA ACUST UNITED AC 2013; 31:129-34. [DOI: 10.1179/146532811x12925735813922] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Urine biochemistry in the early postoperative period after cardiac surgery: role in acute kidney injury monitoring. Case Rep Crit Care 2013; 2013:103450. [PMID: 24826346 PMCID: PMC4010051 DOI: 10.1155/2013/103450] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 07/07/2013] [Indexed: 11/17/2022] Open
Abstract
We have recently suggested that sequential urine electrolyte measurement in critically ill patients may be useful in monitoring kidney function. Cardiac surgery is one of the leading causes of acute kidney injury (AKI) in the intensive care unit (ICU). In this paper, we describe the sequential behavior of urine electrolytes in three patients in the early (first 60 hours) postoperative period after cardiac surgery according to AKI status: no AKI, transient AKI, and persistent AKI. We have found that the patient with no AKI had stable and high concentrations of sodium (NaU) and chloride (ClU) in sequential spot samples of urine. AKI development was characterized in the other two patients by decreases in NaU and ClU, which have started early after ICU admission. Transient AKI was marked by also transient and less severe decreases in NaU and ClU. Persistent AKI was marked by the less favorable clinical course with abrupt and prolonged declines in NaU and ClU values. These electrolytes in urine had a behavior like a “mirror image” in comparison with that of serum creatinine. We suggest that sequential urine electrolytes are useful in monitoring acute kidney injury development in the early postoperative period after cardiac surgery.
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Suh SH, Kim CS, Choi JS, Bae EH, Ma SK, Kim SW. Acute kidney injury in patients with sepsis and septic shock: risk factors and clinical outcomes. Yonsei Med J 2013; 54:965-72. [PMID: 23709433 PMCID: PMC3663224 DOI: 10.3349/ymj.2013.54.4.965] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The aim of this study was to investigate clinical characteristics and risk factors of acute kidney injury (AKI) in patients with sepsis and septic shock. Additionally, we explored whether the severity of AKI affects on the clinical outcomes. MATERIALS AND METHODS Data were collected retrospectively in a single center. Among 5680 patients who visited emergency department from January to December 2010, 992 patients with sepsis and septic shock were enrolled. Patients were divided into two groups, patients who developed AKI or not, to compare the baseline characteristics, and laboratory and physiologic data. Patients with AKI were subdivided according to its stages for survival analysis. RESULTS AKI was developed in 57.7% of patients. Multivariable logistic regression analysis revealed that development of septic AKI was associated with older age, pre-existing chronic kidney disease, use of angiotensin converting enzyme inhibitor or angiotensin receptor blocker, presence of shock, positive blood culture results, and low white blood cell and platelet counts. Hospital mortality was higher in AKI group. Crude Kaplan-Meier survival curves demonstrated reduced 30-day survival rate was significantly associated with the severity of acute kidney injury. CONCLUSION The development of septic AKI was associated with poor clinical outcomes. Furthermore, the severity of AKI was associated with increased mortality.
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Affiliation(s)
- Sang Heon Suh
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Chang Seong Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Joon Seok Choi
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Eun Hui Bae
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Seong Kwon Ma
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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Renal blood flow, fractional excretion of sodium and acute kidney injury: time for a new paradigm? Curr Opin Crit Care 2013; 18:585-92. [PMID: 22954663 DOI: 10.1097/mcc.0b013e328358d480] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Global renal blood flow is considered pivotal to renal function. Decreased global renal blood flow (decreased perfusion) is further considered the major mechanism of reduced glomerular filtration rate responsible for the development of acute kidney injury (AKI) in critically ill patients. Additionally, urinary biochemical tests are widely taught to allow the differential diagnosis of prerenal (functional) AKI and intrinsic [structural AKI (so-called acute tubular necrosis)]. In this review we will examine recent evidence regarding these two key clinical paradigms. RECENT FINDINGS Recent animal experiments and clinical studies in humans using cine-phase contrast magnetic resonance technology are not consistent with the decreased perfusion paradigm. They suggest instead that changes in the intra-renal circulation including modification in efferent arteriolar function and intra-renal shunting are much more likely to be responsible for AKI, especially in sepsis. Similarly, recent human studies indicate the urinary biochemistry has limited diagnostic or prognostic ability and is dissociated form biomarker and microscopic evidence of tubular injury. SUMMARY Intra-renal microcirculatory changes are likely more important than changes in global blood flow in the development of AKI. Urinary biochemistry is not a clinically useful diagnostic or prognostic tool in critically ill patients at risk of or with AKI.
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Schneider AG, Bellomo R. Urinalysis and pre-renal acute kidney injury: time to move on. Crit Care 2013; 17:141. [PMID: 23659200 PMCID: PMC3672654 DOI: 10.1186/cc12676] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Urinary indices are classically believed to allow differentiation of transient (or pre-renal) acute kidney injury (AKI) from persistent (or acute tubular necrosis) AKI. However, the data validating urinalysis in critically ill patients are weak. In the previous issue of Critical Care, Pons and colleagues demonstrate in a multicenter observational study that sodium and urea excretion fractions as well as urinary over plasma ratios performed poorly as diagnostic tests to separate such entities. This study confirms the limited diagnostic and prognostic ability of urine testing. Together with other studies, this study raises more fundamental questions about the value, meaning and pathophysiologic validity of the pre-renal AKI paradigm and suggests that AKI (like all other forms of organ injury) is a continuum of injury that cannot be neatly divided into functional (pre-renal or transient) or structural (acute tubular necrosis or persistent).
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Consumption of a high-salt diet by ewes during pregnancy alters nephrogenesis in 5-month-old offspring. Animal 2013; 6:1803-10. [PMID: 23031391 DOI: 10.1017/s1751731112000584] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Maternal nutrition during pregnancy can affect kidney development in the foetus, which may lead to adverse consequences in the mature kidney. It was expected that high-salt intake by pregnant ewes would lead to a reduction in foetal glomerular number but that the ovine kidney would adapt to maintain homoeostasis, in part by increasing the size of each glomerulus. Merino ewes that were fed either a control (1.5% NaCl) or high-salt (10.5% NaCl) diet during pregnancy, as well as their 5-month-old offspring, were subjected to a dietary salt challenge, and glomerular number and size and sodium excretion were measured. The high-salt offspring had 20% fewer glomeruli compared with the control offspring (P < 0.001), but they also had larger glomerular radii compared with the control offspring (P < 0.001). Consequently, the cross-sectional area of glomeruli was 18% larger in the high-salt offspring than in the control offspring (P < 0.05). There was no difference in the daily urinary sodium excretion between the two offspring groups (P > 0.05), although the high-salt offspring produced urine with a higher concentration of sodium. Our results demonstrated that maternal high-salt intake during pregnancy affected foetal nephrogenesis, altering glomerular number at birth. However, the ability to concentrate and excrete salt was not compromised, which indicates that the kidney was able to adapt to the reduction in the number of glomeruli.
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Abstract
BACKGROUND Acute kidney injury (AKI) is a common and serious problem in critically ill patients. Tests currently used to detect AKI (i.e., serum creatinine, serum urea and various urinary indices) often result in serious delays in detection of clinically relevant injury. This delayed detection translates into a potential missed opportunity for therapeutic interventions at a time when kidney damage may be limitable or reversible. This is also recognized as a potential reason for the poor clinical outcomes often associated with AKI. OBJECTIVES To appraise the recent literature characterizing several novel serum and urinary biomarkers, including neutrophil gelatinase-associated lipocalin, IL-18 and kidney injury molecule-1, which are capable of detecting AKI at an earlier phase of injury. Also to discuss the pitfalls of current conventional testing in kidney injury. METHOD Narrative literature review. CONCLUSIONS These novel biomarkers can detect injury when damage may still be reversible, allow for early risk stratification and/or prognostication, and are associated in early clinical studies with important outcomes such as severity of AKI, need for renal replacement therapy and survival. There is optimism that these novel biomarkers will discriminate the underlying pathophysiology of AKI (i.e., ischemia, sepsis, toxins or multifactorial), discriminate AKI from other renal disease (i.e., chronic kidney disease) and aid in localizing the site of acute injury in the kidney. As such, the future may entail development of an 'AKI biomarker panel' (i.e., analogous to a cardiac or liver enzyme panel) for use in clinical practice.
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Affiliation(s)
- Sean M Bagshaw
- University of Alberta Hospital, 3C1.12 Walter C. Mackenzie Centre, Division of Critical Care Medicine, 8440-112 Street, Edmonton, Alberta, T6G2B7, Canada +1 780 407 6755 ; +1 780 407 1228 ;
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Maciel AT. Breaking old and new paradigms regarding urinary sodium in acute kidney injury diagnosis and management. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:115. [PMID: 23384365 PMCID: PMC4056518 DOI: 10.1186/cc11926] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Urinary sodium (NaU) is one of the oldest parameters used in the evaluation of azotemia and oliguria. Over the past years, however, it has progressively been considered as obsolete and useless, especially in sepsis. It is common sense that NaU frequently does not correlate well with global renal blood flow. If intrarenal microcirculatory changes are more important in acute kidney injury (AKI) than changes in global renal blood flow, we speculate that decreases in NaU may be viewed as a possible marker of microcirculatory impairment in the kidneys. Recent findings by our group (some not yet published) in which sodium retentive capacity is preserved until advanced stages of AKI and the observation of decreases in NaU preceding increases in creatinine bring us to conclude that the new paradigm of abolishing NaU consideration from daily approaches to managing patients at risk for AKI must be reevaluated.
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Bagshaw SM, Bennett M, Devarajan P, Bellomo R. Urine biochemistry in septic and non-septic acute kidney injury: a prospective observational study. J Crit Care 2012; 28:371-8. [PMID: 23159144 DOI: 10.1016/j.jcrc.2012.10.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 10/02/2012] [Accepted: 10/02/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE Determine whether there are unique patterns to the urine biochemistry profile in septic compared with non-septic acute kidney injury (AKI) and whether urinary biochemistry predicts worsening AKI, need for renal replacement therapy and mortality. MATERIALS AND METHODS Prospective cohort study of critically ill patients with septic and non-septic AKI, defined by the RIFLE (Risk, Injury, Failure, Loss, End-Stage) criteria. Urine biochemistry parameters were compared between septic and non-septic AKI and were correlated with neutrophil gelatinase-associated lipocalin (NGAL), worsening AKI, renal replacement therapy (RRT), and mortality. RESULTS Eighty-three patients were enrolled, 43 (51.8%) with sepsis. RIFLE class was not different between groups (P = .43). Urine sodium (UNa) <20 mmol/L, fractional excretion of sodium (FeNa) <1%, and fractional excretion of urea (FeU) <35% were observed in 25.3%, 57.8%, and 33.7%, respectively. Septic AKI had lower UNa compared with non-septic AKI (P = .04). There were no differences in FeNa or FeU between groups. Urine NGAL was higher for FeNa ≥ 1% compared to FeNa<1% (177.4 ng/mL [31.9-956.5] vs 48.0 ng/mL [21.1-232.4], P = .04). FeNa showed low correlation with urine NGAL (P = .05) and plasma NGAL (P = .14). There was poor correlation between FeU and urine NGAL (P = .70) or plasma NGAL (P = .41). UNa, FeNa, and FeU showed poor discrimination for worsening AKI, RRT and mortality. CONCLUSION Urine biochemical profiles do not discriminate septic and non-septic AKI. UNa, FeNa, and FeU do not reliably predict biomarker release, worsening AKI, RRT or mortality. These data imply limited utility for these measures in clinical practice in critically ill patients with AKI.
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Affiliation(s)
- Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 3C1.12 Walter C Mackenzie Center, 8440-112 ST NW, Edmonton, Alberta, T6G 2B7, Canada.
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Maciel AT, Park M. Early diagnosis of acute kidney injury in a critically ill patient using a combination of blood and urinary physicochemical parameters. Clinics (Sao Paulo) 2012; 67:525-6. [PMID: 22666801 PMCID: PMC3351253 DOI: 10.6061/clinics/2012(05)21] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Alexandre Toledo Maciel
- Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Intensive Care Unit, Department of Medical Emergencies, Brazil.
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Studena S, Martinkova J, Slizova D, Krs O, Senkerik M, Springer D, Chládek J. A Rat Model of Early Sepsis: Relationships between Gentamicin Pharmacokinetics and Systemic and Renal Effects of Bacterial Lipopolysaccharide Combined with Interleukin-2. Biol Pharm Bull 2012; 35:1703-10. [DOI: 10.1248/bpb.b12-00205] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Sarka Studena
- Department of Pharmacology, Faculty of Medicine in Hradec Králové, Charles University in Prague
| | - Jirina Martinkova
- Department of Pharmacology, Faculty of Medicine in Hradec Králové, Charles University in Prague
| | - Dasa Slizova
- Department of Anatomy, Faculty of Medicine in Hradec Králové, Charles University in Prague
| | - Otakar Krs
- Department of Anatomy, Faculty of Medicine in Hradec Králové, Charles University in Prague
| | - Marian Senkerik
- Department of Pediatrics, Teaching Hospital in Hradec Kralove
| | - Drahomira Springer
- Department of Clinical Biochemistry and Laboratory Diagnostics, General Teaching Hospital in Prague
| | - Jaroslav Chládek
- Department of Pharmacology, Faculty of Medicine in Hradec Králové, Charles University in Prague
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Hall IE, Coca SG, Perazella MA, Eko UU, Luciano RL, Peter PR, Han WK, Parikh CR. Risk of poor outcomes with novel and traditional biomarkers at clinical AKI diagnosis. Clin J Am Soc Nephrol 2011; 6:2740-9. [PMID: 22034509 DOI: 10.2215/cjn.04960511] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND OBJECTIVES Studies have evaluated acute kidney injury (AKI) using biomarkers in various settings, but their prognostic utility within current practice is unclear. Thus, we sought to determine the prognostic utility of newer biomarkers or traditional markers (fractional excretion of sodium [FeNa] and urea [FeUrea] and microscopy) over clinical assessment alone. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This is a prospective cohort study of adults on the first day of meeting AKI criteria. We measured urine concentrations of neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and IL-18 and determined FeNa, FeUrea, and microscopy score for casts and tubular cells. Primary outcome was worsened AKI stage from enrollment to peak serum creatinine or in-hospital death. RESULTS In 249 recipients, 57% were ≥65 years old, 48% were from intensive care, and mean baseline GFR was 69 ± 30 ml/min per 1.73 m(2). AKI was considered prerenal in 164 (66%), acute tubular necrosis (ATN) in 51 (20%), and "other" in 34 (14%). All mean protein biomarker concentrations, FeNa, FeUrea, and microscopy scores were statistically different between prerenal and ATN. Seventy-two patients (29%) developed the primary outcome. There was an approximate three-fold increase in adjusted risk for the outcome for upper versus lower values of NGAL, KIM-1, IL-18, and microscopy score (P values <0.05). Net reclassification improved after adding these to baseline clinical assessment. FeNa and FeUrea were not useful. CONCLUSIONS On the first day of AKI, urine protein biomarkers and microscopy significantly improve upon clinical determination of prognosis, indicating their potential utility in current practice.
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Affiliation(s)
- Isaac E Hall
- Department of Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
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Benes J, Chvojka J, Sykora R, Radej J, Krouzecky A, Novak I, Matejovic M. Searching for mechanisms that matter in early septic acute kidney injury: an experimental study. Crit Care 2011; 15:R256. [PMID: 22030145 PMCID: PMC3334807 DOI: 10.1186/cc10517] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Revised: 08/30/2011] [Accepted: 10/26/2011] [Indexed: 11/21/2022] Open
Abstract
Introduction In almost half of all sepsis patients, acute kidney injury (AKI) develops. However, the pathobiologic differences between sepsis patients with and without AKI are only poorly understood. We used a unique opportunity to examine dynamic inflammatory, renal hemodynamic, and microvascular changes in two clinically relevant large-animal models of sepsis. Our aim was to assess variability in renal responses to sepsis and to identify both hemodynamic and nonhemodynamic mechanisms discriminating individuals with AKI from those in whom AKI did not develop. Methods Thirty-six pigs were anesthetized, mechanically ventilated, and instrumented. After a recovery period, progressive sepsis was induced either by peritonitis (n = 13) or by continuous intravenous infusion of live Pseudomonas aeruginosa (n = 15). Eight sham operated-on animals served as time-matched controls. All animals received standard intensive care unit (ICU) care, including goal-directed hemodynamic management. Before, and at 12, 18, and 22 hours of sepsis, systemic and renal (ultrasound flow probe) hemodynamics, renal cortex microcirculation (laser Doppler), inflammation (interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), oxidative stress (thiobarbituric acid reactive species (TBARS), nitrite/nitrate concentrations (NOx), and renal oxygen kinetics and energy metabolism were measured. Results In 14 (50%) pigs, AKI developed (62% in peritonitis, 40% in bacteria infusion model). Fecal peritonitis resulted in hyperdynamic circulation, whereas continuous bacteria infusion was associated with normodynamic hemodynamics. Despite insults of equal magnitude, comparable systemic hemodynamic response, and uniform supportive treatment, only those pigs with AKI exhibited a progressive increase in renal vascular resistance. This intrarenal vasoconstriction occurred predominantly in the live-bacteria infusion model. In contrast to AKI-free animals, the development of septic AKI was preceded by early and remarkable inflammatory response (TNF-α, IL-6) and oxidative stress (TBARS). Conclusions The observed variability in susceptibility to septic AKI in our models replicates that of human disease. Early abnormal host response accompanied by subsequent uncoupling between systemic and renal vascular resistance appear to be major determinants in the early phase of porcine septic AKI. Nonuniform and model-related renal hemodynamic responses that are unpredictable from systemic changes should be taken into consideration when evaluating hemodynamic therapeutic interventions in septic AKI.
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Affiliation(s)
- Jan Benes
- Department Of Anesthesia and Intensive Care, Charles University in Prague, Faculty of Medicine in Plzen, University Hospital Plzen, alej Svobody 80, 304 60, Czech Republic
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Hanson J, Hasan MMU, Royakkers AA, Alam S, Charunwatthana P, Maude RJ, Douthwaite ST, Yunus EB, Mantha ML, Schultz MJ, Faiz MA, White NJ, Day NP, Dondorp AM. Laboratory prediction of the requirement for renal replacement in acute falciparum malaria. Malar J 2011; 10:217. [PMID: 21813009 PMCID: PMC3199906 DOI: 10.1186/1475-2875-10-217] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 08/03/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute renal failure is a common complication of severe malaria in adults, and without renal replacement therapy (RRT), it carries a poor prognosis. Even when RRT is available, delaying its initiation may increase mortality. Earlier identification of patients who will need RRT may improve outcomes. METHOD Prospectively collected data from two intervention studies in adults with severe malaria were analysed focusing on laboratory features on presentation and their association with a later requirement for RRT. In particular, laboratory indices of acute tubular necrosis (ATN) and acute kidney injury (AKI) that are used in other settings were examined. RESULTS Data from 163 patients were available for analysis. Whether or not the patients should have received RRT (a retrospective assessment determined by three independent reviewers) was used as the reference. Forty-three (26.4%) patients met criteria for dialysis, but only 19 (44.2%) were able to receive this intervention due to the limited availability of RRT. Patients with impaired renal function on admission (creatinine clearance < 60 ml/min) (n = 84) had their laboratory indices of ATN/AKI analysed. The plasma creatinine level had the greatest area under the ROC curve (AUC): 0.83 (95% confidence interval 0.74-0.92), significantly better than the AUCs for, urinary sodium level, the urea to creatinine ratio (UCR), the fractional excretion of urea (FeUN) and the urinary neutrophil gelatinase-associated lipocalcin (NGAL) level. The AUC for plasma creatinine was also greater than the AUC for blood urea nitrogen level, the fractional excretion of sodium (FeNa), the renal failure index (RFI), the urinary osmolality, the urine to plasma creatinine ratio (UPCR) and the creatinine clearance, although the difference for these variables did not reach statistical significance. CONCLUSIONS In adult patients with severe malaria and impaired renal function on admission, none of the evaluated laboratory indices was superior to the plasma creatinine level when used to predict a later requirement for renal replacement therapy.
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Abstract
Until recently, no uniform standard existed for diagnosing and classifying acute renal failure. To clarify diagnosis, the Acute Dialysis Quality Initiative group stated its consensus on the need for a clear definition and classification system of renal dysfunction with measurable criteria. Today the term acute kidney injury has replaced the term acute renal failure, with an understanding that such injury is a common clinical problem in critically ill patients and typically is predictive of an increase in morbidity and mortality. A classification system, known as RIFLE (risk of injury, injury, failure, loss of function, and end-stage renal failure), includes specific goals for preventing acute kidney injury: adequate hydration, maintenance of renal perfusion, limiting exposure to nephrotoxins, drug protective strategies, and the use of renal replacement therapies that reduce renal injury.
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Affiliation(s)
- Susan Dirkes
- University of Michigan Health System, 6326 Sterling Dr, Newport, MI 48166, USA.
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Legrand M, Payen D. Understanding urine output in critically ill patients. Ann Intensive Care 2011; 1:13. [PMID: 21906341 PMCID: PMC3224471 DOI: 10.1186/2110-5820-1-13] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 05/24/2011] [Indexed: 02/06/2023] Open
Abstract
Urine output often is used as a marker of acute kidney injury but also to guide fluid resuscitation in critically ill patients. Although decrease of urine output may be associated to a decrease of glomerular filtration rate due to decrease of renal blood flow or renal perfusion pressure, neurohormonal factors and functional changes may influence diuresis and natriuresis in critically ill patients. The purpose of this review is to discuss the mechanisms of diuresis regulation, which may help to interpret the urine output in critically ill patients and the appropriate treatment to be initiated in case of changes in urine output.
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Affiliation(s)
- Matthieu Legrand
- Department of Anesthesiology and Critical Care and SAMU, Lariboisière Hospital, Assistance Publique- Hopitaux de Paris; University of Paris 7 Denis Diderot, 2 rue Ambroise-Paré, 75475 Paris Cedex 10, France.
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Abstract
Sepsis is a severe and dysregulated inflammatory response to infection characterized by end-organ dysfunction distant from the primary site of infection. Development of acute kidney injury (AKI) during sepsis increases patient morbidity, predicts higher mortality, has a significant effect on multiple organ functions, is associated with an increased length of stay in the intensive care unit, and hence consumes considerable healthcare resources. When compared with AKI of nonseptic origin, septic AKI is characterized by a distinct pathophysiology and therefore requires a different approach. Despite impressive advances in several fields of medicine, the pathophysiology, diagnostic procedures, and appropriate therapeutic interventions in sepsis are still highly debatable. Numerous immunomodulatory agents showing promise in preclinical studies fail to reduce the overwhelmingly high mortality rate of sepsis and provoke AKI when compared with other critically ill patients. Major impediments to progress in understanding, early diagnosis, and application of appropriate therapeutic modalities in sepsis-induced AKI include limited histopathologic information, few animal models that closely mimic human sepsis, and a relative shortage of specific diagnostic tools. Here we discuss the most recent advances in understanding the fundamental mechanisms of sepsis-induced AKI, characteristics of relevant animal models available, and potential therapies.
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Affiliation(s)
- Abolfazl Zarjou
- Division of Nephrology, THT 647, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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45
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Diskin CJ, Stokes TJ, Dansby LM, Radcliff L, Carter TB. Toward the optimal clinical use of the fraction excretion of solutes in oliguric azotemia. Ren Fail 2011; 32:1245-54. [PMID: 20954990 DOI: 10.3109/0886022x.2010.517353] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
While the fractional excretion of solutes have long been considered excellent research tools to investigate tubular physiology, their clinical use has become common over the last 40 years in the diagnoses of many disorders; however, none have reached the clinical utility of the fractional excretion of sodium in the ability to distinguish pre-renal azotemia from acute tubular necrosis. Nevertheless, there are many drugs and medical conditions that interfere with that utility and recently other solutes, including urea, uric acid and lithium, have been recently investigated to improve the diagnostic ability in clinical situations where the fractional excretion of sodium is known to be unreliable. We review the tubular physiology of these solutes and show how the differences in tubular physiology might be exploited to develop a strategy for their optimal clinical use.
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Affiliation(s)
- Charles J Diskin
- Hypertension, Nephrology, Dialysis, and Transplantation Clinic, Auburn University, Opelika, AL 36801, USA.
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46
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White LE, Chaudhary R, Moore LJ, Moore FA, Hassoun HT. Surgical sepsis and organ crosstalk: the role of the kidney. J Surg Res 2010; 167:306-15. [PMID: 21324390 DOI: 10.1016/j.jss.2010.11.923] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 11/19/2010] [Accepted: 11/29/2010] [Indexed: 02/06/2023]
Abstract
Acute kidney injury (AKI) is a common complication of hospitalized patients, and clinical outcomes remain poor despite advances in renal replacement therapy. The accepted pathophysiology of AKI in the setting of sepsis has evolved from one of simple decreased renal blood flow to one that involves a more complex interaction of intra-glomerular microcirculatory vasodilation combined with the local release of inflammatory mediators and apoptosis. Evidence from preclinical AKI models suggests that crosstalk occurs between kidneys and other organ systems via soluble and cellular inflammatory mediators and that this involves both the innate and adaptive immune systems. These interactions are reflected by genomic changes and abnormal rates of cellular apoptosis in distant organs including the lungs, heart, gut, liver, and central nervous system. The purpose of this article is to review the influence of AKI, particularly sepsis-associated AKI, on inter-organ crosstalk in the context of systemic inflammation and multiple organ failure (MOF).
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Affiliation(s)
- Laura E White
- Department of Surgery, The Methodist Hospital and Research Institute, Houston Texas, USA
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47
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Bagshaw SM, Bellomo R, Devarajan P, Johnson C, Karvellas CJ, Kutsiogiannis DJ, Mehta R, Pannu N, Romanovsky A, Sheinfeld G, Taylor S, Zappitelli M, Gibney RTN. Review article: Acute kidney injury in critical illness. Can J Anaesth 2010; 57:985-98. [DOI: 10.1007/s12630-010-9375-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Accepted: 08/12/2010] [Indexed: 01/18/2023] Open
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Hosseini F, Naseri MKG, Badavi M, Ghaffari MA, Shahbazian H, Rashidi I. Protective effect of beta carotene pretreatment on renal ischemia/reperfusion injury in rat. Pak J Biol Sci 2010; 12:1140-5. [PMID: 19899325 DOI: 10.3923/pjbs.2009.1140.1145] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Renal ischemia/reperfusion injury is a major cause of acute renal failure. The production of free radicals and reactive oxygen species are important factors contributing to ischemia/reperfusion injury. Thus, scavenging of the excess free radicals can be an important therapeutic approach. The present study examined the protective effect of beta carotene against renal ischemia/reperfusion injury in rat. Male adult Wistar rats (250-300 g) were exposed to 45 min of renal ischemia followed by 4 h of reperfusion. Beta carotene (10, 30 and 100 mg kg(-1)) or vehicle was administered for 5 days prior to ischemia. Renal function was assessed by plasma and urinary analysis. Present results showed that ischemia/reperfusion injury increased (p < 0.05-p < 0.001) serum urea and creatinine levels, as well as urinary excretion of protein and calcium and fractional excretion of sodium, while decreased glomerular filtration rate and potassium excretion. However, alterations in these biochemical indices due to ischemia/reperfusion injury were attenuated by beta carotene pretreatment (p < 0.05-p < 0.001), although not by all doses. Since, beta carotene administration improved renal function, it seems that beta carotene protects renal tissue against ischemia/reperfusion-induced oxidative damage.
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Affiliation(s)
- F Hosseini
- Physiology Research Center, Department of Physiology, School of Medicine, Ahwaz Jundishapur University of Medical Sciences, Ahwaz, Iran
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Prowle JR, Echeverri JE, Ligabo EV, Ronco C, Bellomo R. Fluid balance and acute kidney injury. Nat Rev Nephrol 2009; 6:107-15. [PMID: 20027192 DOI: 10.1038/nrneph.2009.213] [Citation(s) in RCA: 299] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Intravenous fluids are widely administered to patients who have, or are at risk of, acute kidney injury (AKI). However, deleterious consequences of overzealous fluid therapy are increasingly being recognized. Salt and water overload can predispose to organ dysfunction, impaired wound healing and nosocomial infection, particularly in patients with AKI, in whom fluid challenges are frequent and excretion is impaired. In this Review article, we discuss how interstitial edema can further delay renal recovery and why conservative fluid strategies are now being advocated. Applying these strategies in critical illness is challenging. Although volume resuscitation is needed to restore cardiac output, it often leads to tissue edema, thereby contributing to ongoing organ dysfunction. Conservative strategies of fluid management mandate a switch towards neutral balance and then negative balance once hemodynamic stabilization is achieved. In patients with AKI, this strategy might require renal replacement therapy to be given earlier than when more-liberal fluid management is used. However, hypovolemia and renal hypoperfusion can occur in patients with AKI if excessive fluid removal is pursued with diuretics or extracorporeal therapy. Thus, accurate assessment of fluid status and careful definition of targets are needed at all stages to improve clinical outcomes. A conservative strategy of fluid management was recently tested and found to be effective in a large, randomized, controlled trial in patients with acute lung injury. Similar randomized, controlled studies in patients with AKI now seem justified.
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Affiliation(s)
- John R Prowle
- Department of Intensive Care, Austin Health, 145 Studley Road Heidelberg, Vic 3084, Australia
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Bagshaw SM, Bennett M, Haase M, Haase-Fielitz A, Egi M, Morimatsu H, D'amico G, Goldsmith D, Devarajan P, Bellomo R. Plasma and urine neutrophil gelatinase-associated lipocalin in septic versus non-septic acute kidney injury in critical illness. Intensive Care Med 2009; 36:452-61. [PMID: 19956924 DOI: 10.1007/s00134-009-1724-9] [Citation(s) in RCA: 251] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Accepted: 09/30/2009] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Sepsis is the most common trigger for acute kidney injury (AKI) in critically ill patients. We sought to determine whether there are unique patterns to plasma and urine neutrophil gelatinase-associated lipocalin (NGAL) in septic compared with non-septic AKI. DESIGN Prospective observational study. SETTING Two adult ICUs in Melbourne, Australia. PATIENTS Critically ill patients with septic and non-septic AKI. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Blood and urine specimens collected at enrollment, 12, 24 and 48 h to measure plasma and urine NGAL. Eighty-three patients were enrolled (septic n = 43). Septic AKI patients had more co-morbid disease (p = 0.005), emergency surgical admissions (p < 0.001), higher illness severity (p = 0.008), more organ dysfunction (p = 0.008) and higher white blood cell counts (p = 0.01). There were no differences at enrollment between groups in AKI severity. Septic AKI was associated with significantly higher plasma (293 vs. 166 ng/ml) and urine (204 vs. 39 ng/mg creatinine) NGAL at enrollment compared with non-septic AKI (p < 0.001). Urine NGAL remained higher in septic compared with non-septic AKI at 12 h (p < 0.001) and 24 h (p < 0.001). Plasma NGAL showed fair discrimination for AKI progression (area under receiver-operator characteristic curve 0.71) and renal replacement therapy (AuROC 0.78). Although urine NGAL performed less well (AuROC 0.70, 0.70), peak urine NGAL predicted AKI progression better in non-septic AKI (AuROC 0.82). CONCLUSION Septic AKI patients have higher detectable plasma and urine NGAL compared with non-septic AKI patients. These differences in NGAL values in septic AKI may have diagnostic and clinical relevance as well as pathogenetic implications.
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Affiliation(s)
- Sean M Bagshaw
- Division of Critical Care Medicine, University of Alberta Hospital, University of Alberta, 3C1.16 Walter C Mackenzie Centre, 8440-122 Street, Edmonton, AB T6G2B7, Canada.
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