A Comparison of Traditional and Novel Definitions (RIFLE, AKIN, and KDIGO) of Acute Kidney Injury for the Prediction of Outcomes in Acute Decompensated Heart Failure

Timing of Worsening Renal Function in Patients Hospitalized for Heart Failure Exacerbation Who Were Being Treated With Intravenous Diuretic Therapy

BACKGROUND

This retrospective observational study investigated the incidence of worsening renal function (WRF) in patients hospitalized for heart failure (HF) and treated with intravenous diuretics in Japan.Methods and Results: Associations between WRF at any point and HF treatments, and the effects of WRF on outcomes were evaluated (Diagnosis Procedure Combination database). Of 1,788 patients analyzed (mean [±SD] age 80.5±10.2 years; 54.4% male), 641 (35.9%) had WRF during a course of hospitalization for worsening HF: 208 (32.4%) presented with WRF before admission (BA-WRF; estimated glomerular filtration rate decreased by ≥25% from baseline at least once between 30 days prior to admission and admission); 44 (6.9%) had WRF that persisted before and after admission (P-WRF); and 389 (60.7%) had WRF develop after admission (AA-WRF). Delayed initial diuretic administration, higher maximum doses of intravenous diuretics during hospitalization, and diuretic readministration during hospitalization were associated with a significantly higher incidence of AA-WRF. Patients with WRF at any time point were at higher risk of death during hospitalization compared with patients without WRF, with adjusted hazard ratios of 3.56 (95% confidence interval [CI] 2.23-5.69) for BA-WRF, 3.23 (95% CI 2.21-4.71) for AA-WRF, and 13.16 (95% CI 8.19-21.15) for P-WRF (all P<0.0001).

CONCLUSIONS

Forty percent of WRF occurred before admission for acute HF; there was no difference in mortality between patients with BA-WRF and AA-WRF.

Study Protocol of a Prospective, Monocentric, Single-Arm Study Investigating the Correlation of Endograft Properties with Aortic Stiffness in Abdominal Aortic Aneurysm Patients Subjected to Endovascular Aortic Repair

The number of endovascular aortic repairs (EVARs) has surpassed the number of open surgical repairs of abdominal aortic aneurysms (AAAs) worldwide. The available commercial endoprostheses are composed of materials that are stiffer than the native aortic wall. As a consequence, the implantation of stent-graft endoprostheses during EVAR increases aortic rigidity and thus aortic stiffness, resulting in a decrease in abdominal aorta compliance. EVAR has been found to have a possibly harmful effect not only on heart functions but also on other vascular beds, including kidney function, due to the decrease in aortic compliance that it causes. Aortic stiffness is measured by various hemodynamic indices like the pulse wave velocity (PWV), the central aortic pressure (CAP), and the augmentation index (AIx). In the literature, there are increasing numbers of studies investigating the properties of endografts, which are strongly related to increases in aortic stiffness. However, there is a lack of data on whether there is a correlation between the length of various endografts implanted during EVAR and the increase in the PWV, CAP, and AIx postoperatively compared to the preoperative values. The aim of this prospective, observational, monocentric, single-arm study is to investigate the correlation between endograft length and the postoperative increase in the PWV, CAP, and AIx in patients subjected to EVAR. Additionally, this study intends to identify other endograft properties related to increases in the PWV, CAP, and AIx. Other endpoints to be studied are the existence of immediate postoperative myocardial and kidney injury after EVAR. The prediction of cardiovascular events caused by endograft-related increased aortic stiffness could contribute to the improvement of various endograft properties so that the impact of endografts on the native aortic wall can be minimized.

Safety and feasibility of hyperthermic intraperitoneal chemotherapy during interval cytoreductive surgery in patients with advanced high-grade serous ovarian, fallopian tube, peritoneal cancer in an Australian context

AIMS

To assess the safety and feasibility of hyperthermic intraperitoneal chemotherapy (HIPEC) during cytoreduction surgery (CRS) in advanced high-grade serous ovarian, fallopian tube and peritoneal cancer within an Australian context.

METHODS

Data were collected from 25 consecutive patients undergoing CRS and HIPEC from December 2018 to July 2022 at the Peritoneal Malignancy Service at the Mater Hospital Brisbane, Australia. Data collected included demographics, clinical variables, surgical procedures and complications and intra-operative and post-operative indexes of morbidity.

RESULTS

Twenty-five women who underwent CRS and HIPEC from December 2018 to July 2022 were included in analysis. Findings indicate that CRS with HIPEC is associated with low morbidity.

CONCLUSION

While judicious patient selection is imperative, HIPEC during CRS was well tolerated by all patients and morbidity was comparable to results from the previously reported OVHIPEC-1 trial. HIPEC appears to be a safe and feasible addition to CRS for the treatment of advanced ovarian cancer in Australian practice.

Definition, Staging, and Role of Biomarkers in Acute Kidney Injury in the Context of Cardiovascular Interventions

Acute kidney injury (AKI) is a frequently occurring complication of cardiovascular interventions, and associated with adverse outcomes. Therefore, a clear definition of AKI is of paramount importance to enable timely recognition and treatment. Historically, changes in the serum creatinine and urine output have been used to define AKI, and the criteria have evolved over time with better understanding of the impact of AKI on the outcomes. However, the reliance on serum creatinine for these AKI definitions carries numerous limitations including delayed rise, inability to differentiate between hemodynamics versus structural injury and assay variability to name a few.

Extracorporeal membrane oxygenation and acute kidney injury: a single-center retrospective cohort

To assess the relationship between acute kidney injury (AKI) with outcomes among patients requiring extracorporeal membrane oxygenation (ECMO). This is a single-center, retrospective cohort study of adult patients admitted to intensive care units (ICU) at a tertiary referral hospital requiring ECMO from July 1, 2015, to August 30, 2019. We assessed the temporal relationship of AKI and renal replacement therapy with ECMO type (VV vs. VA). The primary outcome was in-hospital mortality rates. We used Kruskal-Wallis or chi-square tests for pairwise comparisons, cause-specific Cox proportional hazards models were utilized for the association between AKI prevalence and in-hospital mortality, and a time-dependent Cox model was used to describe the association between AKI incidence and mortality. After the screening, 190 patients met eligibility criteria [133 (70%) AKI, 81 (43%) required RRT]. The median age was 61 years, and 61% were males. Among AKI patients, 48 (36%) and 85 (64%) patients developed AKI before and after ECMO, respectively. The SOFA Day 1, baseline creatinine, respiratory rate (RR), use of vasopressin, vancomycin, proton pump inhibitor, antibiotics, duration of mechanical ventilation and ECMO, and ICU length of stay were higher in AKI patients compared with those without AKI (P < 0.01). While ICU and in-hospital mortality rates were 46% and 50%, respectively, there were no differences based on the AKI status. The type and characteristics of ECMO support were not associated with AKI risk. Among AKI patients, 77 (58%) were oliguric, and 46 (60%) of them received diuretics. Urine output in the diuretic group was only higher on the first day than in those who did not receive diuretics (P = 0.03). Among ECMO patients, AKI was not associated with increased mortality but was associated with prolonged duration of mechanical ventilation and ICU length of stay.

Global Comparison of Readmission Rates for Patients With Heart Failure

BACKGROUND

Heart failure (HF) readmission rates are low in some jurisdictions. However, international comparisons are lacking and could serve as a foundation for identifying regional patient management strategies that could be shared to improve outcomes.

OBJECTIVES

This study sought to summarize 30-day and 1-year all-cause readmission and mortality rates of hospitalized HF patients across countries and to explore potential differences in rates globally.

METHODS

We performed a systematic review and meta-analysis using MEDLINE, Embase, and CENTRAL for observational reports on hospitalized adult HF patients at risk for readmission or mortality published between January 2010 and March 2021. We conducted a meta-analysis of proportions using a random-effects model, and sources of heterogeneity were evaluated with meta-regression.

RESULTS

In total, 24 papers reporting on 30-day and 23 papers on 1-year readmission were included. Of the 1.5 million individuals at risk, 13.2% (95% CI: 10.5%-16.1%) were readmitted within 30 days and 35.7% (95% CI: 27.1%-44.9%) within 1 year. A total of 33 papers reported on 30-day and 45 papers on 1-year mortality. Of the 1.5 million individuals hospitalized for HF, 7.6% (95% CI: 6.1%-9.3%) died within 30 days and 23.3% (95% CI: 20.8%-25.9%) died within 1 year. Substantial variation in risk across countries was unexplained by countries' gross domestic product, proportion of gross domestic product spent on health care, and Gini coefficient.

CONCLUSIONS

Globally, hospitalized HF patients exhibit high rates of readmission and mortality, and the variability in readmission rates was not explained by health care expenditure, risk of mortality, or comorbidities.

Contemporary laboratory assessment of acute cardiorenal syndrome for early diagnosis: A call for action

Acute cardiorenal syndrome (CRS), categorized as CRS type 1 and 3, is defined by the interplay of acute kidney injury or dysfunction and acute cardiac disease. For optimized diagnosis and management of CRS, strategies targeting multi-organ dysfunction must be adopted. Early diagnosis of acute CRS is important to enable timely initiation of appropriate treatment to prevent serious morbidity and mortality; however, traditional biomarkers are suboptimal. Over the past 2 decades, numerous biomarkers have been investigated for a better and more rapid diagnosis of CRS. Yet, the uptake of these contemporary biomarkers has been slow, possibly owing to the use of imperfect gold-standard reference tests. We believe that there is now scope for use of contemporary laboratory test panels to improve the diagnosis of acute CRS. In this review, we briefly discuss a proposed set of biomarkers for the diagnosis of type 1 and type 3 CRS.

A comprehensive review of acute cardio-renal syndrome: need for novel biomarkers

Cardiorenal syndrome represents a wide-spectrum disorder involving the heart and kidneys as the primary affected organs. India has an increasingly high burden of acute CRS, coinciding with the rise in global statistics. Up to 2022, approximately 46.1% of all cardiorenal patients have been diagnosed with acute CRS in India. Acute CRS involves a sudden deterioration of kidney functionalities, referred to as acute kidney injury (AKI) in acute heart failure patients. The pathophysiology of CRS involves hyperactivation of the sympathetic nervous system (SNS) and the renin-angiotensin-aldosterone system (RAAS) following acute myocardial stress. The pathological phenotype of acute CRS is associated with perturbed inflammatory, cellular, and neurohormonal markers in circulation. These complications increase the risk of mortality in clinically diagnosed acute CRS patients, making it a worldwide healthcare burden. Hence, effective diagnosis and early prevention are crucial to prevent the progression of CRS in AHF patients. Present biomarkers, such as serum creatinine (sCr), cystatin C (CysC), glomerular filtration rate (GFR), blood urea nitrogen (BUN), serum and/or urine neutrophil gelatinase-associated lipocalin (NGAL), B-type natriuretic peptide (BNP), and NT-proBNP, are clinically used to diagnose AKI stages in CRS patients but are limitedly sensitive to the early detection of the pathology. Therefore, the need for protein biomarkers is emerging for early intervention in CRS progression. Here, we summarized the cardio-renal nexus in acute CRS, with an emphasis on the present clinicopathological biomarkers and their limitations. The objective of this review is to highlight the need for novel proteomic biomarkers that will curb the burgeoning concern and direct future research trials.

Predictive value of urinary cell cycle arrest biomarkers for all cause-acute kidney injury: a meta-analysis

The cell cycle arrest markers tissue inhibitor metalloproteinases-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) have been identified as potential biomarkers of acute kidney injury (AKI) in critically ill adults in intensive care units and cardiac surgery-associated AKI (CSA-AKI). However, the clinical impact on all-cause AKI remains unclear. Here, we report a meta-analysis performed to evaluate the predictive value of this biomarker for all-cause AKI. The PubMed, Cochrane, and EMBASE databases were systematically searched up to April 1, 2022. We used the Quality Assessment Tool for Diagnosis Accuracy Studies (QUADAS-2) to assess the quality. We extracted useful information from these studies and calculated the sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). Twenty studies with 3625 patients were included in the meta-analysis. The estimated sensitivity of urinary [TIMP-2] × [IGFBP7] in the diagnosis of all-cause AKI was 0.79 (95% CI 0.72, 0.84), and the specificity was 0.70 (95% CI 0.62, 0.76). The value of urine [TIMP-2] × [IGFBP7] in the early diagnosis of AKI was assessed using a random effects model. The pooled positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were 2.6 (95% CI 2.1, 3.3), 0.31 (95% CI 0.23, 0.40), and 8 (95% CI 6, 13), respectively. The AUROC was 0.81 (95% CI 0.78-0.84). No significant publication bias was observed in eligible studies. Subgroup analysis indicated that the diagnostic value was related to the severity of AKI, time measurement, and clinical setting. This study shows that urinary [TIMP-2] × [IGFBP7] is a reliable effective predictive test for all cause-AKI. However, whether and how urinary [TIMP-2] × [IGFBP7] can be used in clinical diagnosis still requires further research and clinical trials.

Oxygen delivery in pediatric cardiac surgery and its association with acute kidney injury using machine learning

OBJECTIVE

Acute kidney injury (AKI) after pediatric cardiac surgery with cardiopulmonary bypass (CPB) is a frequently reported complication. In this study we aimed to determine the oxygen delivery indexed to body surface area (Do2i) threshold associated with postoperative AKI in pediatric patients during CPB, and whether it remains clinically important in the context of other known independent risk factors.

METHODS

A single-institution, retrospective study, encompassing 396 pediatric patients, who underwent heart surgery between April 2019 and April 2021 was undertaken. Time spent below Do2i thresholds were compared to determine the critical value for all stages of AKI occurring within 48 hours of surgery. Do2i threshold was then included in a classification analysis with known risk factors including nephrotoxic drug usage, surgical complexity, intraoperative data, comorbidities and ventricular function data, and vasoactive inotrope requirement to determine Do2i predictive importance.

RESULTS

Logistic regression models showed cumulative time spent below a Do2i value of 350 mL/min/m2 was associated with AKI. Random forest models, incorporating established risk factors, showed Do2i threshold still maintained predictive importance. Patients who developed post-CPB AKI were younger, had longer CPB and ischemic times, and required higher inotrope support postsurgery.

CONCLUSIONS

The present data support previous findings that Do2i during CPB is an independent risk factor for AKI development in pediatric patients. Furthermore, the data support previous suggestions of a higher threshold value in children compared with that in adults and indicate that adjustments in Do2i management might reduce incidence of postoperative AKI in the pediatric cardiac surgery population.

Prognosis of Patients with Acute Kidney Injury due to Type 1 Cardiorenal Syndrome Receiving Continuous Renal Replacement Therapy

INTRODUCTION

The prognosis of patients with acute kidney injury (AKI) caused by type 1 cardiorenal syndrome (CRS) requiring continuous renal replacement therapy (CRRT) is unclear. We investigated the in-hospital mortality and prognostic factors in these patients.

METHODS

We retrospectively identified 154 consecutive adult patients who received CRRT for AKI caused by type 1 CRS between January 1, 2013, and December 31, 2019. We excluded patients who underwent cardiovascular surgery and those with stage 5 chronic kidney disease. The primary outcome was in-hospital mortality. Cox proportional hazards analysis was performed to analyze independent predictors of in-hospital mortality.

RESULTS

The median age of patients at admission was 74.0 years (interquartile range: 63.0-80.0); 70.8% were male. The in-hospital mortality rate was 68.2%. Age ≥80 years (hazard ratio [HR], 1.87; 95% confidence interval [CI], 1.21-2.87; p = 0.004), previous hospitalization for acute heart failure (HR, 1.67; 95% CI, 1.13-2.46; p = 0.01), vasopressor or inotrope use (HR, 5.88; 95% CI, 1.43-24.1; p = 0.014), and mechanical ventilation at CRRT initiation (HR, 2.24; 95% CI, 1.46-3.45; p < 0.001) were associated with in-hospital mortality.

CONCLUSION

In our single-center study, the use of CRRT for AKI due to type 1 CRS was associated with high in-hospital mortality.

THE RISK OF ACUTE KIDNEY INJURY AFTER ELECTIVE VERSUS EMERGENCY CORONARY INTERVENTION

OBJECTIVE

The aim: A serious and common complication after percutaneous coronary intervention is acute kidney injury, which is associated with an increased risk of renal, cardiovascular and even mortality; therefore, early prognosis and identification of patients at higher risk are essential for early initiation of preventive measures. The aim of this study is to predict and compare the risk for the development of CI-AKI in patient with ACS who undergo emergency PCI or elective (i.e. after medical stabilization) PCI by utilizing the sensitivity of serum NGAL as an early and reliable predictor for CI-AK.

PATIENTS AND METHODS

Materials and methods: The study include 37 patients with acute coronary syndrome, baseline serum creatinine, complete blood count and pre and two hours post operative serum neutrophil gelatinase-associated lipocalin were measured and all patients underwent percutaneous coronary intervention according to the standard protocol used in Al Najaf Cardiac Center.

RESULTS

Results: This is a Two-Arm study that included a total of 37 patients with acute coronary syndrome aged 38-83 years. Eighteen of them had emergency percutaneous coronary intervention while the remaining 19 had elective percutaneous coronary intervention (after medical stabilization). Elevation of serum neutrophil gelatinase-associated lipocalin level two hours after percutaneous coronary intervention was found to be significantly higher among emergency percutaneous coronary intervention group compared to elective group.

CONCLUSION

Conclusions: Acute coronary syndrome patients are undergoing emergency percutaneous coronary intervention are at an increasing risk for the development of contrast induced acute kidney injury than those undergoing elective percutaneous coronary intervention.

Acute kidney injury after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with advanced ovarian cancer

Background

Ovarian cancer is one of the most common gynecologic cancers with the highest mortality rate in China. Acute kidney injury (AKI) is a postoperative complication associated with all-cause mortality. The incidence and risk factors for AKI after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) have not been fully elucidated. The purpose of this study was to determine the incidence and associate ed risk factors of AKI among those patients undergoing CRS-HIPEC.

Methods

This retrospective study collected demographic, tumor-related, preoperative, intraoperative, and postoperative data from 282 advanced ovarian cancer patients who underwent CRS-HIPECs. AKI was defined and staged according to the clinical practice guideline of Kidney Disease Improving Global Outcomes (KDIGO) in 2012. The prognosis of AKI was determined according to the change in serum creatinine 90 days after the operation. We conducted univariate and multivariate logistic regression analyses to assess the association between variables of interest and the occurrence of AKI.

Results

Of 282 advanced ovarian cancer patients, 11.7% of them developed AKI. The Multivariate logistic regression analysis showed that the risk factors independently associated with AKI included cisplatin dose≥70mg/m² (OR=3.668, 95%CI 1.336-10.070, P=0.012); Baseline eGFR<60 mL/min/1.73 m² (OR=2.704, 95%CI 1.373-5.322, P=0.004); and concomitant medications of angiotensin convert enzyme inhibitor or angiotensin receptor blocker (ACEI or ARB) (OR=3.122, 95%CI 1.545-14.892, P=0.039).

Conclusion

Our study demonstrates that the incidence of AKI after CRS plus cisplatin-based HIPEC is not uncommon among advanced ovarian cancer patients. Cisplatin overdose, baseline kidney dysfunction, and use of ACEI or ARB are independent risk factors for the occurrence of AKI among those patients.

The incidence and outcome of AKI in patients with sepsis in the emergency department applying different definitions of AKI and sepsis

BACKGROUND

Sepsis is often accompanied with acute kidney injury (AKI). The incidence of AKI in patients visiting the emergency department (ED) with sepsis according to the new SOFA criteria is not exactly known, because the definition of sepsis has changed and many definitions of AKI exist. Given the important consequences of early recognition of AKI in sepsis, our aim was to assess the epidemiology of sepsis-associated AKI using different AKI definitions (RIFLE, AKIN, AKIB, delta check, and KDIGO) for the different sepsis classifications (SIRS, qSOFA, and SOFA).

METHODS

We retrospectively enrolled patients with sepsis in the ED in three hospitals and applied different AKI definitions to determine the incidence of sepsis-associated AKI. In addition, the association between the different AKI definitions and persistent kidney injury, hospital length of stay, and 30-day mortality were evaluated.

RESULTS

In total, 2065 patients were included. The incidence of AKI was 17.7-51.1%, depending on sepsis and AKI definition. The highest incidence of AKI was found in qSOFA patients when the AKIN and KDIGO definitions were applied (51.1%). Applying the AKIN and KDIGO definitions in patients with sepsis according to the SOFA criteria, AKI was present in 37.3% of patients, and using the SIRS criteria, AKI was present in 25.4% of patients. Crude 30-day mortality, prolonged length of stay, and persistent kidney injury were comparable for patients diagnosed with AKI, regardless of the definition used.

CONCLUSION

The incidence of AKI in patients with sepsis is highly dependent on how patients with sepsis are categorised and how AKI is defined. When AKI (any definition) was already present at the ED, 30-day mortality was high (22.2%). The diagnosis of AKI in sepsis can be considered as a sign of severe disease and helps to identify patients at high risk of adverse outcome at an early stage.

Analysis of Spinal Ischemia after Frozen Elephant Trunk for Acute Aortic Dissection: An Observational, Single-Center Study

BACKGROUND

This observational study aimed to evaluate the perioperative risk factors for spinal cord ischemia (SCI) in patients who underwent aortic repair with the frozen elephant trunk technique (FET) after acute aortic Stanford A dissection.

METHODS

From May 2015 to April 2019, 31 patients underwent aortic arch replacement with the FET technique, and spinal ischemia was observed in 4 patients. The risk factors for postoperative SCI were analyzed.

RESULTS

The mean age of patients with acute aortic dissection was 57.1 years, and 29.4% were female. Four patients developed SCI. There were no significant differences in characteristics such as age and body mass index. The female gender was associated with most of the SCI cases in the univariate analysis (75%, p = 0.016). Known perioperative and intraoperative risk factors were not related to postoperative SCI in our study. Patients who developed SCI had increased serum postoperative creatinine levels (p = 0.03). Twenty-four patients showed complete false lumen thrombosis up to zones 3-4, five patients up to zones 5-6 and two patients up to zones 7-9, which correlates with the postoperative development of SCI (p = 0.02). The total number of patent intercostal arteries was significantly reduced postoperatively in SCI patients (p = 0.044).

CONCLUSIONS

Postoperative acute kidney injury, the reduction in patent intercostal arteries after surgery and the extension of false lumen thrombosis up to and beyond zone 5 may play a significant role in the development of clinically relevant spinal cord injury after FET.

Selected Transesophageal Echocardiographic Parameters of Left Ventricular Diastolic Function Predict Length of Stay Following Coronary Artery Bypass Graft-A Prospective Observational Study

(1) Importance: Abnormal left ventricular (LV) diastolic function, with or without a diagnosis of heart failure, is a common finding that can be easily diagnosed by intra-operative transesophageal echocardiography (TEE). The association of diastolic function with duration of hospital stay after coronary artery bypass (CAB) is unknown. (2) Objective: To determine if selected TEE parameters of diastolic dysfunction are associated with length of hospital stay after coronary artery bypass surgery (CAB). (3) Design: Prospective observational study. (4) Setting: A single tertiary academic medical center. (5) Participants: Patients with normal systolic function undergoing isolated CAB from September 2017 through June 2018. (6) Exposures: LV function during diastole, as assessed by intra-operative TEE prior to coronary revascularization. (7) Main Outcomes and Measures: The primary outcome was duration of postoperative hospital stay. Secondary intermediate outcomes included common postoperative cardiac, respiratory, and renal complications. (8) Results: The study included 176 participants (mean age 65.2 ± 9.2 years, 73% male); 105 (60.2%) had LV diastolic dysfunction based on selected TEE parameters. Median time to hospital discharge was significantly longer for subjects with selected parameters of diastolic dysfunction (9.1/IQR 6.6−13.5 days) than those with normal LV diastolic function (6.5/IAR 5.3−9.7 days) (p < 0.001). The probability of hospital discharge was 34% lower (HR 0.66/95% CI 0.47−0.93) for subjects with diastolic dysfunction based on selected TEE parameters, independent of potential confounders, including a baseline diagnosis of heart failure. There was a dose−response relation between severity of diastolic dysfunction and probability of discharge. LV diastolic dysfunction based on those selected TEE parameters was also associated with postoperative cardio-respiratory complications; however, these complications did not fully account for the relation between LV diastolic dysfunction and prolonged length of hospital stay. (9) Conclusions and Relevance: In patients with normal systolic function undergoing CAB, diastolic dysfunction based on selected TEE parameters is associated with prolonged duration of postoperative hospital stay. This association cannot be explained by baseline comorbidities or common post-operative complications. The diagnosis of diastolic dysfunction can be made by TEE.

Kidney Injury in Critically Ill Patients Treated with Vancomycin and Zosyn or an Alternative: A Systematic Review and Meta-Analysis

Background: Zosyn^® (piperacillin-tazobactam; Pfizer Medical, New York, NY), a valuable antibiotic against gram-negative bacteria, combined with vancomycin (Z+V) is known for its high incidence of acute kidney injury (AKI), particularly in the intensive care unit (ICU), leading to the frequent use of alternatives for gram-negative coverage (Alt+V). Because there are limited data describing AKI on these alternative antibiotic agents, a systematic review and meta-analysis was conducted to determine if these regimens were indeed associated with decreased rates of AKI. Patients and Methods: A literature review was performed electronically from its inception to November 1, 2018, screening for relevant literature by title, abstract and full text according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines within the following databases: PubMed/Medline, CINAHL, Scopus, and Cochrane Central Register of Controlled Trials. Studies were included if they contained adults who had been admitted to the ICU for treatment and had received a combination of intravenous Z + V or Alt+V as well as had AKI measured during administration of these antibiotic agents. Studies were excluded if they represented pediatric populations, did not receive care in an ICU during their hospital admission, only received monotherapy for antibiotic treatment or received antibiotic treatment for less than 48 hours. Independent extraction was performed by two reviewers. Risk of bias was assessed using the Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) methodology for retrospective studies. Random-effects models were used to calculate any differences between rates of AKI after Z + V or Alt + V. Results: Fourteen articles (totaling 30,399 patients) were included. All studies available were retrospective in design. Compared with Alt + V, Z + V was associated with a higher risk ratio of AKI (1.79; 95% confidence interval [CI], 1.46-2.19; p < 0.001). Cefepime (C + V) was the most common alternative to Zosyn, and Z + V was associated with higher rates of kidney injury compared with C + V (1.70; 95% CI, 1.36-2.12; p < 0.00001). However, there was substantial heterogeneity in the data collected as well as high risk of bias. Conclusions: Zosyn plus vancomycin is associated with more risk of AKI compared with Alt+V coverage in ICU adult populations. However, the conclusions were limited by the retrospective nature of the studies, high bias of included articles, and heterogeneity of the included studies.

Identifying patients with heart failure in susceptible to de novo acute kidney injury: a machine learning approach (Preprint)

Background

Studies have shown that more than half of patients with heart failure (HF) with acute kidney injury (AKI) have newonset AKI, and renal function evaluation markers such as estimated glomerular filtration rate are usually not repeatedly tested during the hospitalization. As an independent risk factor, delayed AKI recognition has been shown to be associated with the adverse events of patients with HF, such as chronic kidney disease and death.

Objective

The aim of this study is to develop and assess of an unsupervised machine learning model that identifies patients with HF and normal renal function but who are susceptible to de novo AKI.

Methods

We analyzed an electronic health record data set that included 5075 patients admitted for HF with normal renal function, from which 2 phenogroups were categorized using an unsupervised machine learning algorithm called K-means clustering. We then determined whether the inferred phenogroup index had the potential to be an essential risk indicator by conducting survival analysis, AKI prediction, and the hazard ratio test.

Results

The AKI incidence rate in the generated phenogroup 2 was significantly higher than that in phenogroup 1 (group 1: 106/2823, 3.75%; group 2: 259/2252, 11.50%; P<.001). The survival rate of phenogroup 2 was consistently lower than that of phenogroup 1 (P<.005). According to logistic regression, the univariate model using the phenogroup index achieved promising performance in AKI prediction (sensitivity 0.710). The generated phenogroup index was also significant in serving as a risk indicator for AKI (hazard ratio 3.20, 95% CI 2.55-4.01). Consistent results were yielded by applying the proposed model on an external validation data set extracted from Medical Information Mart for Intensive Care (MIMIC) III pertaining to 1006 patients with HF and normal renal function.

Conclusions

According to a machine learning analysis on electronic health record data, patients with HF who had normal renal function were clustered into separate phenogroups associated with different risk levels of de novo AKI. Our investigation suggests that using machine learning can facilitate patient phengrouping and stratification in clinical settings where the identification of high-risk patients has been challenging.

Laboratory changes inherent to acute kidney injury induced by aminoglycosides in wistar rats

Abstract Acute kidney injury (AKI) is defined as an increase greater than 0.3 mg/L of serum creatinine within 48 hours and is a major cause of death in patients in intensive care units. Twenty-four Wistar rats were divided into three groups: Control (0.9% saline), Genta (gentamicin 50 mg.kg-1 BID) and Deh+Genta (gentamicin 50 mg.kg-1 BID + water restriction) and tested in an AKI model by aminoglycoside administration and dehydration implementation. The animals in the Deh+Genta group exhibited the lowest average weight and feed intake after the fifth day of the experiment. In this same period, water consumption by the Genta group was lower than the Control group, but in the following days of the experiment, polydipsia was noted for this group. The Deh+Genta group displayed the highest mean serum urea after the fifth day. The gentamicin-treated groups exhibited higher means than the Control group for serum creatinine, which proved to be a late renal marker for AKI. Serum GGT was higher in the Deh+Genta group, whereas urinary GGT was higher in the groups that received gentamicin, characterizing enzymuria, although severe dehydration can mask the results by indicating false negative values. The urinary GGT enzyme did not act as an early AKI biomarker. Decreased glomerular filtration rates enhanced the concentration of blood components and masked urinary and tissue components.

Decreased urinary uromodulin is potentially associated with acute kidney injury: a systematic review and meta-analysis

BACKGROUND

Urinary uromodulin (uUMOD) is one of the novel biomarkers for predicting AKI. However, currently available publications showed inconsistent results. We designed this meta-analysis to evaluate the potential association between uUMOD and AKI.

METHODS

We searched research articles with no language restriction in Medline, Web of Science, Cochrane Library, Embase, and 3 Chinese datasets from inception to February 2021. We used random-effects models to estimate the standardized mean difference (SMD) between patients with AKI or not, while the leave-one-out method and random-effects meta-regression to evaluate the sensitivity and the impact of potential confounders such as age and surgery.

RESULTS

The meta-analysis comprising 3148 subjects from 11 studies showed that the uUMOD of the AKI group is significantly lower than the non-AKI group (SMD: - 0.71; 95% confidence interval (CI), - 1.00, - 0.42, P < 0. 001, I2 = 78.8%). Subgroup analysis revealed the difference is also significant in a different age, surgery condition, and assay time but not acute rejection (AR) group, especially in children (SMD: - 1.21, 95% CI: - 1.80, - 0.61; P < 0.001) and patients undergoing surgery (SMD: - 1.03, 95% CI: - 1.75, - 0.30; P < 0.001). Lower uromodulin is associated with higher odds for AKI incidence (odds ratio = 2.47, 95% CI: 1.12, 5.47; P < 0.001, I2 = 89%). Meta-reggression found that age was associated with the SMD of uUMOD. The study outcome was reliably confirmed by the sensitivity analysis.

CONCLUSION

The present study suggested a negative association between uUMOD and AKI especially in children and surgical patients.

Risk factors and outcome variables of cardiorenal syndrome type 1 from the nephrologist's perspective

Background and aim

In cardiorenal syndrome (CRS) type 1, acute cardiac failure or acute decompensation of chronic heart failure causes acute kidney injury (AKI). Every individual AKI episode increases the risk for chronic kidney disease (CKD) in the long term. In this study, we aimed to evaluate epidemiological characteristics and outcome variables of CRS type 1 individuals from the nephrologist’s perspective.

Methods

The study was performed in a retrospective, observational manner. All AKI patients treated at the Brandenburg Hospital of the Medical School of Brandenburg between January and December 2019 were screened for diagnostic criteria of CRS type 1. Endpoints were in-hospital death, need for dialysis, and renal recovery.

Results

During the screening, 198 out of 1189 (16.6%) AKI subjects were assigned to the diagnosis CRS type 1. The overall in-hospital mortality was 19.2%; 9.6% of the patients required dialysis due to AKI. Complete recovery of kidney function was observed in 86 individuals (43.4%); incomplete recovery occurred in 55 patients (27.8%). Mortality-predictive variables were AKIN stage 2, longer ICU treatment, and insulin-dependent diabetes. Regarding dialysis, AKIN stage 3 and higher potassium at the time of diagnosis were predictive. Subjects with longer in-hospital stay recovered more often from CRS type 1.

Conclusions

The incidence of CRS type 1 is high (∼16% of all in-hospital AKI subjects) and the mortality is higher than the average mortality of AKI in general. At the same time, complete recovery of kidney function occurs less frequent. The kidney-related follow-up management of CRS type 1 needs to be significantly optimized to improve the long-term outcome of affected patients.

Tissue inhibitor metalloproteinase 2 (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7) best predicts the development of acute kidney injury

Background

Acute kidney injury (AKI) is routinely diagnosed by creatinine-based guidelines, which is sub-optimal marker after injury due to renal and non-renal factors. This has necessitated the need for more specific and sensitive biomarkers for early detection of AKI in at risk patients. This prospective cross-sectional study used the biomarkers of cell cycle arrest and Neutrophil Gelatinase Associated Lipocalin (NGAL) to assess AKI among hospitalized patients.

Methods

We conveniently enrolled 151 in-patients at the Trauma and Specialist Hospital, Winneba in Ghana. Socio-demographic and clinical information were collected using structured questionnaires. Blood samples were collected for the estimation of serum creatinine, and AKI diagnosed and staged using the KDIGO guideline. Fresh urine samples were collected and urinary NGAL, TIMP-2 (tissue inhibitor metalloproteinase 2) and IGFBP-7 (insulin-like growth factor binding protein 7) were estimated using ELISA kits.

Results

The cell cycle arrest biomarkers and NGAL were significantly (P < 0.001) higher among participants with AKI than those without AKI. [TIMP-2]∗[IGFBP-7] showed the best diagnostic performance (AUC = 0.94, CI = 0.90–0.98) followed by [IGFBP-7]∗NGAL] (AUC = 0.93, CI = 0.87–0.99), with NGAL having the least (AUC = 0.62, CI = 0.46–0.78). The cut-off for [TIMP-2]∗[IGFBP-7] showed the best predictive ability (95.8% sensitivity, 77.2% specificity, 44.2% PPV and 99% NPV). The cut-off for NGAL, on the other hand, showed the least predictive ability (62.5% sensitivity, 42.5% specificity, 17.0% PPV and 85.7% NPV).

Conclusion

Tissue inhibitor metalloproteinase 2 (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7) best predicts the development of AKI, and can be used in high risk patients for early diagnosis of AKI.

Incidence of acute kidney injury post cardiac surgery: a comparison of the AKIN and KDIGO criteria

Background and objectives

Data on urine output have not been routinely presented to define cardiac surgery-related acute kidney injury (AKI). We evaluated the incidence of AKI after cardiac surgery based on the AKIN and KDIGO criteria (considering serum creatinine concentration and urine output in the first 72 hours postoperatively) and compared the performance of the 2 criteria for AKI staging.

Methods

This was a prospective cohort study of adult patients undergoing coronary artery bypass grafting (CABG), valve replacement, or CABG + valve replacement between October 2017 and April 2018 at a single institution. Patients were excluded if baseline creatinine concentration (measured within 7 days before surgery) was ≥ 2.5 mg.dL^-1. Patients were evaluated for the development of AKI based on changes in urine output and serum creatinine concentration, measured daily from postoperative day 1 to 7, according to the AKIN and KDIGO criteria, which were then compared.

Results

A total of 198 patients were included. AKI occurred in 83.8% by AKIN and in 82.8% by KDIGO, when using both urine output and serum creatinine concentration as defining criteria. Using serum creatinine concentration alone, the incidence of AKI fell to 27.3% by AKIN and to 24.7% by KDIGO. A kappa coefficient of 0.98 was obtained between the AKIN and KDIGO criteria.

Conclusions

Almost perfect agreement was found between AKIN and KDIGO. AKI may be underdiagnosed after cardiac surgery if serum creatinine concentration is used as the only defining criterion. Our findings underscore the fundamental importance of using the urine output criterion in the assessment of patients at risk for AKI.

Outcomes after Acute Peritoneal Dialysis for Critical Cardiorenal Syndrome Type 1

INTRODUCTION

The aim of the study was to demonstrate the outcomes of peritoneal dialysis (PD) in critically ill cardiorenal syndrome type 1 (CRS1).

METHODS

A cohort of 147 patients with CRS1 who received PD from 2011 to 2019 in a referral hospital in Thailand was analyzed. The primary outcome was 30-day in-hospital mortality. Ultrafiltration and net fluid balance among survivors and nonsurvivors in the first 5 PD sessions were compared.

RESULTS

The 30-day mortality rate was 73.4%. Most patients were critically ill CRS1 (all patients had a respiratory failure of which 68% had cardiogenic shock). Blood urea nitrogen and creatinine at the commencement of PD were 60.1 and 4.05 mg/dL. In multivariable analysis, increasing age, unstable hemodynamics, and positive fluid balance in the first 5 PD sessions were associated with the risk of in-hospital mortality. The change of fluid balance per day during the first 5 dialysis days was significantly different among survivor and nonsurvivor groups (-353 vs. 175 mL per day, p = 0.01).

CONCLUSIONS

PD is a viable dialysis option in CRS1, especially in a resource-limited setting. PD can save up to 27% of lives among patients with critically ill CRS1.

Renal dysfunction in cardiovascular diseases and its consequences

It is well known that the heart and kidney and their synergy is essential for hemodynamic homeostasis. Since the early XIX century it has been recognized that cardiovascular and renal diseases frequently coexist. In the nephrological field, while it is well accepted that renal diseases favor the occurrence of cardiovascular diseases, it is not always realized that cardiovascular diseases induce or aggravate renal dysfunctions, in this way further deteriorating cardiac function and creating a vicious circle. In the same clinical field, the role of venous congestion in the pathogenesis of renal dysfunction is at times overlooked. This review carefully quantifies the prevalence of chronic and acute kidney abnormalities in cardiovascular diseases, mainly heart failure, regardless of ejection fraction, and the consequences of renal abnormalities on both organs, making cardiovascular diseases a major risk factor for kidney diseases. In addition, with regard to pathophysiological aspects, we attempt to substantiate the major role of fluid overload and venous congestion, including renal venous hypertension, in the pathogenesis of acute and chronic renal dysfunction occurring in heart failure. Furthermore, we describe therapeutic principles to counteract the major pathophysiological abnormalities in heart failure complicated by renal dysfunction. Finally, we underline that the mild transient worsening of renal function after decongestive therapy is not usually associated with adverse prognosis. Accordingly, the coexistence of cardiovascular and renal diseases inevitably means mediating between preserving renal function and improving cardiac activity to reach a better outcome.

Glycated Hemoglobin < 6.5% Is Associated With Uroseptic Shock in Diabetic Patients With Urinary Tract Infection

This study aimed to compare the clinical characteristics and treatment outcomes of diabetic and non-diabetic individuals with urinary tract infection (UTI) and determine whether glycated hemoglobin (HbA1c) levels <6. 5% leads to uroseptic shock in diabetic individuals. We retrospectively collected and analyzed the clinical data of 1,363 individuals with UTIs in Taiwan from January 2006 to January 2018. Of the 345 diabetic individuals, 61 (17.7%) developed uroseptic shock. Diabetic patients who developed uroseptic shock tended to be older and males and, had a history of congestive heart failure, urolithiasis, higher serum creatinine level during hospitalization, lower serum HbA1c level, bacteremia, and acute kidney injury. Backward stepwise multivariate logistic regression analysis showed that male gender [odds ratio (OR), 1.861; 95% confidence interval (CI), 1.009–3.433; P = 0.047], congestive heart failure (OR, 4.036; 95% CI, 1.542–10.565; P = 0.004), bacteremia (OR, 2.875; 95% CI, 1.539–5.370; P = 0.001), and HbA1c level <6.5% (OR, 2.923; 95% CI, 1.580–5.406; P = 0.001) were associated with an increased risk of developing uroseptic shock among diabetic patients during hospitalization due to UTI. HbA1c level <6.5% is independently associated with uroseptic shock in diabetic patients with UTI.

Relationship between endothelial function and vascular stiffness on lower limit of cerebral autoregulation in patients undergoing cardiovascular surgery

Hemodynamic management based on cerebral autoregulation range is a possible strategy for preserving major organ perfusion during cardiovascular surgery. The purpose of this study was to evaluate the relation of vascular properties with lower limit of cerebral autoregulation (LLA). LLA was monitored in 66 patients undergoing cardiovascular surgery using near-infrared spectroscopy. To determine the clinical importance of LLA monitoring, association of blood pressure excursions below LLA and acute kidney injury (AKI) was evaluated. Flow-mediated dilation (FMD) and pulse wave velocity (PWV) were measured for the evaluation of endothelial function and aortic stiffness. Variables associated with LLA were evaluated. Excluding patients on hemodialysis, there were 15 patients (25.9%) who developed AKI. Blood pressure excursions below LLA were higher in patients who developed AKI (4.55 mm Hg × hr vs. 1.23 mm Hg × hr, P = .017). In the univariate analysis, prevalence of ischemic heart disease (No IHD: 53 ± 13.0 mm Hg vs. IHD: 60.0 ± 13.6 mm Hg, P = .056) and FMD (r = -0.42, 95% CI -0.61 to -0.19, P < .001) were associated with LLA before cardiopulmonary bypass (CPB). During CPB, calcium channel blocker (No Ca blocker: 42 ± 10.6 mm Hg vs. Ca blocker: 49 ± 14.3 mm Hg, P = .033), diabetes (no DM: 44 ± 13.2 mm Hg vs. DM: 55 ± 10.0 mm Hg, P = .024), FMD (r = -0.32, 95% CI -0.55 to -0.05, P = .021), and PWV (r = 0.28, 95% CI 0.012 to 0.513, P = .041) were associated with LLA. Multivariate analysis showed that FMD was correlated with LLA before CPB (r = -2.19, 95% CI -3.621 to -0.755, P = .003), while PWV was correlated with LLA during CPB (r = 0.01, 95% CI 0.001-0.019, P = .023). Endothelial function and aortic stiffness may be important factors in determining LLA at different phases in cardiovascular surgery.

The risk of renal function deterioration in abdominal aortic stent graft patients with and without previous kidney function failure - an analysis of risk factors

Purpose

Kidney failure influences the treatment outcomes of abdominal aortic aneurysm (AAA). A prospective study of renal function before and after aortic stent-graft treatment was performed. Special attention was paid to the influence of preoperative kidney function as well as the impact of the radiological follow-up.

Material and methods

A total of 214 endovascularly treated AAA patients were included. In all cases, pre- and postope-rative estimated glomerular filtration rate (eGFR) and serum creatinine were noted. Patients were prospectively followed up for a minimum of two years.

Results

The baseline eGFR was 69.38 ± 16.29 ml/min/1.73 m². Chronic kidney disease at baseline was noted in 29% of patients. In the direct postoperative period, acute kidney injury was identified in 8.4% of cases. Additional endo-vascular procedures within two years of observation were performed in 5.6% of cases, and over the two years of follow-up, in the study group from one to six angio-computed tomographic scans (angio-CT) per patient were performed. The mean eGFR value after the 24-month follow-up was significantly lower than the preoperative value. Among the factors influencing kidney function, an angio-CT during the same hospital stay of the primary stent-graft procedures was identified. The type of stent-graft, contrast volume during the primary procedure, need for reintervention, concomitant disease presence, and statin use did not show statistical significance.

Conclusions

Angio-CT followed by stent-graft implantation over a short time interval (within the same hospitalisation) significantly worsened renal function in the late follow-up and should be avoided in elective AAA cases.

Effects of a High Dose of the Contrast Medium Iodixanol on Renal Function in Patients Following Percutaneous Coronary Intervention

Iodixanol is associated with lower rates of contrast-induced acute kidney injury (CI-AKI). However, the effects of high volumes of iodixanol on renal function after percutaneous coronary intervention (PCI) have not been fully elucidated. This study evaluates the effects of high-dose (>300 mL) iodixanol on renal function within 72 hours of PCI. We retrospectively reviewed 676 consecutive patients who received high-dose (>300 mL) iodixanol during PCI between October 2015 and December 2017 in 4 centers. Logistic regression analysis was used to identify significant independent predictors for CI-AKI. The incidence of CI-AKI was 3.5% (23/651). In patients administered 300 to 500 mL and >500 mL iodixanol, the incidence of CI-AKI was 3.9% and 1.7%, respectively. In patients with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m², the incidence of CI-AKI was 2.6%. In high-risk and very high-risk patients, stratified by the Mehran risk score, the incidence of CI-AKI was 3.3% and 4.3%, respectively. In patients received high-dose iodixanol (>300 mL), logistic regression analysis demonstrated that female sex, chronic kidney disease, and eGFR were independent risk factors for CI-AKI, but contrast volume was not. The administration of high (300-500 mL) and very high (>500 mL) dose of iodixanol is associated with low rates of CI-AKI.

Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives

Acute kidney injury (AKI) and cardiorenal syndrome (CRS) are increasingly prevalent in hospitalized patients with cardiovascular disease and remain associated with poor short- and long-term outcomes. There are no specific therapies to reduce mortality related to either AKI or CRS, apart from supportive care and volume status management. Acute renal replacement therapies (RRTs), including ultrafiltration, intermittent hemodialysis, and continuous RRT are used to manage complications of medically refractory AKI and CRS and may restore normal electrolyte, acid-base, and fluid balance before renal recovery. Patients who require acute RRT have a significant risk of mortality and long-term dialysis dependence, emphasizing the importance of appropriate patient selection. Despite the growing use of RRT in the cardiac intensive care unit, there are few resources for the cardiovascular specialist that integrate the epidemiology, diagnostic workup, and medical management of AKI and CRS with an overview of indications, multidisciplinary team management, and transition off of RRT.

Impact of pre-hospital renal function on the detection of acute kidney injury in acute decompensated heart failure

BACKGROUND

Acute kidney injury (AKI) is a serious complication in patients hospitalized for decompensated heart failure (HF). Currently, AKI definitions consider creatinine levels at admission as reference of baseline renal function (RF). However, renal impairment may already be present at admission. We aimed to study the impact on AKI detection of considering outpatient RF as reference.

METHODS

In a cohort of 458 patients hospitalized for decompensated HF, we studied the occurrence of AKI using the standardized KDIGO criteria and grading (stages: 1, 2, 3), and considering two different definitions according to the RF used as reference or baseline: the latest outpatient measurement prior to admission vs. the first measurement at admission. We compared the prevalence, timing and prognostic value for both AKI definitions.

RESULTS

The definition based on outpatient RF was associated with an increase in overall AKI detection from 20.1% to 33.8% (p < 0.001), and from 3.1% to 5.0% for advanced stages (2-3) (p < 0.001); additionally, 12.5% of patients already had criteria of AKI at admission (36.8% of AKI cases). Both definitions were associated with longer hospital stay. However, only AKI already present at admission, as based on pre-hospital creatinine, was independently associated with all-cause death, in-hospital and after discharge, and death or HF readmission in the follow-up: 1 stage (HR 2.72, 95%CI 1.83-4.06, p < 0.001) and 2-3 stage (HR 7.29, 95%CI, 3.02-17.64, p < 0.001).

CONCLUSIONS

Evaluation of AKI in patients admitted with HF should consider pre-hospital RF, since it improves early identification of AKI and has implications for risk assessment.

Renal kinetics in acute heart failure

AIMS

Worsening renal function (WRF) in acute heart failure (AHF) has multifactorial pathophysiological mechanisms and heterogeneous prognostic impacts. The aim of this study was to determine the characteristics and renal kinetics of this phenomenon.

METHODS AND RESULTS

We prospectively enrolled a cohort of 196 patients admitted for AHF to the Cardiology Department at Nhan Dan Gia Dinh Hospital, from July 2016 to March 2017. AHF was defined using the 2012 European Society of Cardiology criteria. The definition and severity of WRF were based on the 2012 Kidney Disease Improving Outcome criteria for acute kidney injury. Renal recovery was classified using the 2017 Acute Disease Quality Initiative 16 Workgroup Consensus. Among the 196 patients studied, WRF developed in 43.4%. In 80.0% of patients, WRF occurred within 48 hours of admission. In the WRF group, 89.4% were at stage 1, consistent with a relative increase in median serum creatinine of 49.5%. A total of 76.5% of the patients with WRF recovered at discharge, while rapid recovery occurred in 20.0% of patients.

CONCLUSIONS

Most cases of WRF were mild, and WRF was correlated with a high rate of recovery during hospitalisation. However, rapid renal recovery was not common.

Outcomes in acute kidney injury in noncritically ill patients lately referred to nephrologist in a developing country: a comparison of AKIN and KDIGO criteria

Background

In low-middle-income countries (LMICs), data regarding acute kidney injury (AKI) are scarce. AKI patients experience delayed diagnosis. This study aimed to evaluate whether delayed nephrologist consultation (NC) affected outcomes of AKI patients and compare Acute Kidney Injury Network (AKIN) and Kidney Disease: Improving Global Outcomes (KDIGO).

Methods

An observational, retrospective study was conducted in a tertiary public hospital in an LMIC.

Results

Overall, 103 AKI patients were analysed. In-hospital mortality was 61.16%, and dialysis was required in 38.83%. NC took place after 48 h in 68.93% of the patients. Mean time for NC was 5.22 ± 4.30 days. At NC, serum creatinine was 4.48 (±3.40) mg/dL and blood urea nitrogen was 68.21 (± 35.02) mg/dL. The AKIN and KDIGO stage stratifications were identical; KDIGO stage 3 was seen in 58.25% of the patients. The group with NC >  4 days had a mortality rate of 74.46% and the group with NC ≤ 4 days had a mortality rate of 50% (p = 0.011). Multivariate analysis showed that haemodialysis was independently associated with mortality. NC >  4 days was associated with death [odds ratio 2.66 (95% confidence interval, 1.36–4.35), p = 0.001]. Logistic regression showed an OR of 1.20 (95% CI, 1.05–1.37) (p = 0.008) for each day of delayed NC.

Conclusion

Delayed NC was associated with mortality even after adjustments, as was haemodialysis, though marginally. In AKI patients with NC > 4 days, there was a high prevalence of KDIGO stage 3, and AKIN and KDIGO criteria were identical.

Long-Term Outcomes of Open Surgery and Stent Graft Treatment in Patients Undergoing Repeat Thoracic Aortic Aneurysm Repair from Previous Anastomosis Site

Objective: The purpose of this study was to compare the long-term outcomes of open surgery and thoracic endovascular aortic repair (TEVAR) in patients undergoing repeat thoracic aortic repair from previous anastomosis site.

Methods: From January 2009 to December 2017, 68 patients needed repeat aortic surgery from previous anastomosis site. Twenty-three patients had dissected distal aorta and 45 patients had non-dissected distal aorta. Early and long-term outcomes of open surgery and TEVAR were compared in both groups.

Results: There were no significant differences in patient background between the two treatments in both groups. Open surgery was associated with longer intensive care unit stay, but there was no significant difference in in-hospital mortality in both groups. In patients with dissected distal aorta, there was no significant difference in long-term mortality (p=0.73). However, TEVAR was associated with higher risk of reintervention (p=0.038). In non-dissected distal aorta patients, acute kidney injury (p=0.002) and prolonged ventilation (p=0.032) were more often observed in open surgery. However, there were no significant differences in long-term mortality (p=0.23) and freedom from reintervention (p=0.13).

Conclusions: Long-term outcomes were similar between open surgery and TEVAR in both groups. However, TEVAR in patients with dissected distal aorta was associated with higher risk, for reintervention.

Acute kidney injury and adverse outcomes of critical illness: correlation or causation?

Critically ill patients who develop acute kidney injury (AKI) are more than twice as likely to die in hospital. However, it is not clear to what extent AKI is the cause of excess mortality, or merely a correlate of illness severity. The Bradford Hill criteria for causality (plausibility, temporality, magnitude, specificity, analogy, experiment & coherence, biological gradient and consistency) were applied to assess the extent to which AKI may be causative in adverse short-term outcomes of critical illness.

Plausible mechanisms exist to explain increased risk of death after AKI, both from direct pathophysiological effects of renal dysfunction and mechanisms of organ cross-talk in multiple-organ failure. The temporal relationship between increased mortality following AKI is consistent with its pathophysiology. AKI is associated with substantially increased mortality, an association that persists after accounting for known confounders. A biological gradient exists between increasing severity of AKI and increasing short-term mortality. This graded association shares similar features to the increased mortality observed in ARDS; an analogous condition with a multifactorial aetiology. Evidence for the outcomes of AKI from retrospective cohort studies and experimental animal models is coherent however both of these forms of evidence have intrinsic biases and shortcomings. The relationship between AKI and risk of death is maintained across a range of patient ages, comorbidities and underlying diagnoses.

In conclusion many features of the relationship between AKI and short-term mortality suggest causality. Prevention and mitigation of AKI and its complications are valid targets for studies seeking to improve short-term survival in critical care.

[Prognostic value of acute cardiorenal syndrome in patients with acute cardiac pathology]

AIM

To assess the prevalence and prognostic value of AKI in patients with acute decompensation of chronic heart failure (ADCHF) with a reduced ejection fraction (HFrEF) and with preserved ejection fraction (HFpEF) or acute coronary syndrome (ACS), to identify predictors of AKI.

MATERIALS AND METHODS

In a prospective study included 863 patients, of which 141 with ADCHF, 446 - non-ST-elevation acute coronary syndromes (NSTE-ACS) and 276 - ST-segment elevation myocardial infarction (STEMI). AKI was diagnosed according to KDIGO recommendations. The end point was defined as death from cardiovascular causes.

RESULT

During the follow-up from 1 to 37 months (median follow-up was 18 months) for patients with ADCHF in 24,8 % an endpoint was reported. For patients with ACS, the observation time ranged from 1 day to 14 months (median follow-up was 12 months), in 4,3 % - NSTE-ACS, 10,9 % - STEMI the end point was recorded. AKI developed in 14,8 % of patients with ADCHF HFpEF and 11,2 % ADCHF HFrEF, in 23,1 % - STEMI and 21,4 % - NSTE-ACS. AKI increases the risk of death from cardiovascular causes in patients with ADCHF HFrEF (OR 95 % 98,750 (11,158-873,976), р&lt;0,001) and STEMI (OR 95 % 5,395 (2,451-11,878), p&lt;0,001), but did not increase the risk of an endpoint occurrence in patients with ADCHF HFpEF (OR 95 % 1,875 (0,221-15,930), р=0,565) and NSTE-ACS (OR 95 % 1,199 (0,421-3,412), р=0,734). The multivariate analysis revealed risk factors for the development of AKI in patients with ADCHF HFrEF: high albuminuria (AU) from 30 mg / l (OR 95 % 5,763 (1,338-24,819), р=0,019), GFR&lt;45 ml / min initially at admission to hospital (OR 95 % 76,593 (1,193-36,446), p=0,031), age&gt;75 years (OR 15,933 (1,020-248,856), р=0,048). In patients with STEMI: age&gt;75 years (OR 95 % 3,248 (1,476-7,146), p=0,003), female gender (OR 95 % 2,321 (1,190-4,526), p=0,013), acute heart failure (AHF) Killip IV (OR 95 % 10,334 (1,777-60,110), p=0,009). Risk factors for the development of AKI in patients with NSTE-ACS: age&gt;75 years (OR 95 % 1,761 (1,051-2,949), р=0,032), PCI on RCA (OR 95 % 2,565 (1,193-5,517), р=0,016).

CONCLUSION

In patients with ADCHF HFrEF and STEMI development AKI is associated with a poor prognosis, but does not affect the prognosis of patients with ADCHF HFpEF and NSTE-ACS. AKI in patients with ADCHF HFrEF can be predicted using predictors: GFR&lt;45 ml / min, AU more than 30 mg / l and age&gt;75 years. In patients with STEMI, the predictors of AKI were age&gt;75 years, female gender, AHF Killip IV, and in patients with NSTE-ACS age&gt;75 years, PCI on RCA.

Urine KIM-1 as a Potential Biomarker of Acute Renal Injury After Circulatory Collapse in Children

OBJECTIVES

Serum creatinine (SCr) is a late marker of acute kidney injury (AKI) due to the lag time between initiating injury and loss of function. We assessed the ability of urinary interleukin-18 (IL-18), kidney injury molecule-1 (KIM-1), and neutrophil gelatinase-associated lipocalin (NGAL) to predict AKI in critically ill children with circulatory collapse.

METHODS

Serum creatinine, estimated creatinine clearance (eCrCL), urine IL-18, KIM-1, and NGAL values were measured in 86 children with circulatory collapse on the day of admission, and the results were compared with those obtained 6 days later. Acute kidney injury was defined as a decrease in eCrCL of greater than 25% within the first 48 hours of enrollment. Areas under the curve (AUC) for receiver operating characteristic curve were calculated for the early detection of AKI.

RESULTS

Mean SCr concentration did not differ significantly during the first 6 days of hospital admission. In contrast, mean urine concentrations of IL-18, KIM-1, and NGAL rose significantly from day of admission to the sixth day of hospital stay (P < 0.001). Urinary KIM-1 emerged as having the strongest performance for the early detection of AKI, followed by NGAL, IL-18, and eCrCL. Urinary KIM-1 displayed the highest AUC of 0.81 (95% confidence interval [CI], 0.76-0.93; P < 0.001) for the early detection of AKI after circulatory collapse, followed by NGAL (0.77% CI, 0.70-0.84) and IL-18 (0.69% CI, 0.48-0.64).

CONCLUSIONS

Of a panel of 3 promising urinary biomarkers, KIM-1 demonstrated the best performance in predicting AKI in children with circulatory collapse before a change in SCr or eCrCL becomes apparent.

The Japanese clinical practice guideline for acute kidney injury 2016

Acute kidney injury (AKI) is a syndrome which has a broad range of etiologic factors depending on different clinical settings. Because AKI has significant impacts on prognosis in any clinical settings, early detection and intervention is necessary to improve the outcomes of AKI patients. This clinical guideline for AKI was developed by a multidisciplinary approach with nephrology, intensive care medicine, blood purification, and pediatrics. Of note, clinical practice for AKI management which was widely performed in Japan was also evaluated with comprehensive literature search.

Combination of Amino-Terminal Pro- BNP , Estimated GFR , and High-Sensitivity CRP for Predicting Cardiorenal Syndrome Type 1 in Acute Myocardial Infarction Patients

Background Cardiorenal syndrome type 1 ( CRS 1) as a complication of acute myocardial infarction can lead to adverse outcomes, and a method for early detection is needed. This study investigated the individual and integrated effectiveness of amino-terminal pro-brain natriuretic peptide (Pro-BNP), estimated glomerular filtration rate (eGFR), and high-sensitivity C-reactive protein (CRP) as predictive factors for CRS 1 in patients with acute myocardial infarction. Methods and Results In a retrospective analysis of 2094 patients with acute myocardial infarction, risk factors for CRS 1 were analyzed by logistic regression. Receiver operating characteristic curves were constructed to determine the predictive ability of the biomarkers individually and in combination. Overall, 177 patients (8.45%) developed CRS 1 during hospitalization. On multivariable analysis, all 3 biomarkers were independent predictors of CRS 1 with odds radios and 95% confidence intervals for a 1-SD change of 1.792 (1.311-2.450) for log(amino-terminal pro-brain natriuretic peptide, 0.424 (0.310-0.576) for estimated glomerular filtration rate, and 1.429 (1.180-1.747) for high-sensitivity C-reactive peptide. After propensity score matching, the biomarkers individually and together significantly predicted CRS 1 with areas under the curve of 0.719 for amino-terminal pro-brain natriuretic peptide, 0.843 for estimated glomerular filtration rate, 0.656 for high-sensitivity C-reactive peptide, and 0.863 for the 3-marker panel (all P<0.001). Also, the integrated 3-marker panel performed better than the individual markers ( P<0.05). CRS 1 risk correlated with the number of biomarkers showing abnormal levels. Abnormal measurements for at least 2 biomarkers indicated a greater risk of CRS 1 (odds ratio 36.19, 95% confidence interval 8.534-153.455, P<0.001). Conclusions The combination of amino-terminal pro-brain natriuretic peptide, estimated glomerular filtration rate, and high-sensitivity C-reactive peptide at presentation may assist in the prediction of CRS 1 and corresponding risk stratification in patients with acute myocardial infarction.

Acute kidney injury after non-cardiovascular surgery: risk factors and impact on development of chronic kidney disease and long-term mortality

OBJECTIVE

To identify factors associated with acute kidney injury (AKI) and its progression to chronic kidney disease (CKD) in a non-cardiac/non-vascular surgery setting.

METHODS

This study examined the Veterans Affairs Surgical Quality database for surgical entries between 2000-2014. Demographics, comorbidities, laboratory findings and hospital outcomes were assessed. The primary end-point was the occurrence of AKI, defined as an increase of ≥0.3 mg/dL, 48 h post-operatively. Major adverse cardiac event (MACE) was defined as the composite first occurrence of myocardial infarction, cardiac arrest, and death in 30 days (secondary end-point) and was compared between two groups. Rates of progression to CKD in 1 year and long-term survival were examined.

MAIN OUTCOME MEASURES

Occurrence of AKI 48 h post-operatively.

RESULTS

AKI was documented in 8.5% of patients. Age, diabetes, and chronic obstructive pulmonary disease, chronic kidney disease, platelet count, serum albumin level, and duration of surgery were identified as independent predictors of AKI. In total, 6.4% patients developed MACE, which was more frequent in patients with AKI (p < .001). Age and pre-operative hematocrit <30% were independent predictors of progression to CKD. Pre-operative hematocrit with a cut-off value of 30% was the only modifiable factor to predict the long-term survival.

CONCLUSION

Development of AKI is associated with increased odds of various post-operative complications and long-term renal insufficiency and mortality.

Acute Kidney Injury Definition and Diagnosis: A Narrative Review

Acute kidney injury (AKI) is a complex syndrome characterized by a decrease in renal function and associated with numerous etiologies and pathophysiological mechanisms. It is a common diagnosis in hospitalized patients, with increasing incidence in recent decades, and associated with poorer short- and long-term outcomes and increased health care costs. Considering its impact on patient prognosis, research has focused on methods to assess patients at risk of developing AKI and diagnose subclinical AKI, as well as prevention and treatment strategies, for which an understanding of the epidemiology of AKI is crucial. In this review, we discuss the evolving definition and classification of AKI, and novel diagnostic methods.

Epidemiology of Cardiorenal Syndrome

Cardiorenal syndrome is a spectrum of disorders that emphasizes the bidirectional nature of cardiac and kidney injury. Observational and retrospective studies have helped us to understand the prevalence and burden of each of the 5 types of cardiorenal syndromes. Cardiorenal syndrome type 1 is the most common. The nature of epidemiologic data limits clear delineation between cardiorenal syndrome types 2 and 4. Overall, the presence of cardiac or renal dysfunction strongly predicts a poor outcome of the contrary organ.

The Japanese Clinical Practice Guideline for acute kidney injury 2016

Acute kidney injury (AKI) is a syndrome which has a broad range of etiologic factors depending on different clinical settings. Because AKI has significant impacts on prognosis in any clinical settings, early detection and intervention are necessary to improve the outcomes of AKI patients. This clinical guideline for AKI was developed by a multidisciplinary approach with nephrology, intensive care medicine, blood purification, and pediatrics. Of note, clinical practice for AKI management which was widely performed in Japan was also evaluated with comprehensive literature search.

Defining oliguria during cardiopulmonary bypass and its relationship with cardiac surgery-associated acute kidney injury

BACKGROUND

While urine flow rate ≤0.5 ml kg^-1 h^-1 is believed to define oliguria during cardiopulmonary bypass (CPB), it is unclear whether this definition identifies risk for acute kidney injury (AKI) . The purpose of this retrospective study was to evaluate if urine flow rate during CPB is associated with AKI.

METHODS

Urine flow rate was calculated in 503 patients during CPB. AKI in the first 48 h after surgery was defined by the Kidney Disease: Improving Global Outcomes classification. Adjusted risk factors associated with AKI and urine flow rate were assessed.

RESULTS

Patients with AKI [n=149 (29.5%)] had lower urine flow rate than those without AKI (P<0.001). The relationship between urine flow and AKI risk was non-linear, with an inflection point at 1.5 ml kg^-1 h^-1 Among patients with urine flow <1.5 ml kg^-1 h^-1, every 0.5 ml kg^-1 h^-1 higher urine flow reduced the adjusted risk of AKI by 26% (95% CI 13-37; P<0.001). Urine flow rate during CPB was independently associated with the risk for AKI. Age up to 80 years and preoperative diuretic use were inversely associated with urine flow rate; mean arterial pressure on CPB (when <87 mmHg) and CPB flow were positively associated with urine flow rate.

CONCLUSIONS

Urine flow rate during CPB <1.5 ml kg^-1 h^-1 identifies patients at risk for cardiac surgery-associated AKI. Careful monitoring of urine flow rate and optimizing mean arterial pressure and CPB flow might be a means to ensure renal perfusion during CPB.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT00769691 and NCT00981474.