Acute Kidney Injury Requiring Dialysis in Severe Sepsis

Temporal trends of post-contrast acute kidney injury in patients with intravenous administration of iodinated contrast medium

Little is known about whether preventative practices for post-contrast acute kidney injury (PC-AKI) recommended in guidelines have been adopted in clinical practice and translated into a lower incidence of PC-AKI. The aim of this study was to examine the yearly trends in the incidence of PC-AKI, and comorbidities and care practices associated with PC-AKI in hospitalized patients who received intravenous administration of iodinated contrast medium (ICM). Adult patients receiving intravenous ICM at the Second Xiangya Hospital of Central South University in China between 2015 and 2021 were included. Temporal trends in the incidence and risk factors for PC-AKI were evaluated using logistic regression analyses with adjustments for relevant variables. The incidence of PC-AKI has declined significantly from 5.3% in 2015 to 4.1% in 2021 (p < 0.001). This decreasing trend persisted after extensive multivariable adjustments. Of the comorbidities associated with PC-AKI, the proportion of patients with congestive heart failure or hypertension increased, while the proportion of patients older than 75 years, or with an estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2, diabetic nephropathy, or renal stone disease decreased. Among the care practices associated with PC-AKI, the proportion of patients using nephrotoxic drugs decreased, whereas the proportion of patients receiving intravenous fluids > 1000 mL on the day of ICM administration or using iso-osmolar ICM increased. In conclusion, a declining trend in PC-AKI incidence was observed in patients receiving intravenous ICM between 2015 and 2021, which may be related to increased awareness and efforts to prevent PC-AKI.

Increasing incidence of acute kidney injury in pediatric severe sepsis and related adverse hospital outcomes

BACKGROUND

Pediatric severe sepsis (PSS) is associated with increased mortality, and acute kidney injury (AKI) is an independent risk factor of mortality in PSS. However, there is little data on impact of AKI on hospital outcomes in PSS.

METHODS

We analyzed non-overlapping years of the Kids' Inpatient Database (KID) and National Inpatient Sample (NIS) database between 2003 and 2019 of all pediatric patients with severe sepsis between 1 and 18 years of age. Using ICD diagnosis codes, patients were divided into two groups based on AKI status and compared for outcomes measures including in-hospital mortality and healthcare resource utilization using length of stay and inflation-adjusted hospitalization charges.

RESULTS

We analyzed 192,712 hospitalizations due to PSS during the 17-year period. Prevalence of AKI was 23.6% with overall increasing trend, P<0.001. Prevalence of AKI was significantly increased in patients with diabetes mellitus, organ transplantation, HIV, urinary tract anomalies, and malnutrition, P<0.001. Mortality rate was significantly higher among patients with AKI (19.8% vs. 8.1%, P<0.001). PSS with AKI had significantly higher median length of stay (14 vs. 11 days) and total hospitalization charges ($168,106 vs. 100,906), P<0.001. Multivariate logistic regression analysis showed that AKI without kidney replacement therapy (KRT) was associated with 3.02 times increased odds of mortality (95% CI 2.99-3.17, P<0.001) and those requiring KRT had 6.4 times increased odds of mortality (95%CI 6.1-6.7, P<0.001). AKI without KRT was associated with 7.7 (95% CI 7.3-8.05) additional days of hospitalization and 154,536 (95% CI 149,500-159,572) additional US dollars in hospitalization charges.

CONCLUSION

Almost 1 in 4 hospitalizations with PSS had AKI and was associated with >3 times increased risk of mortality and need for KRT further adversely impacts mortality and healthcare utilization. A higher resolution version of the Graphical abstract is available as Supplementary information.

Increasing incidence of acute kidney injury in pediatric severe sepsis and related adverse hospital outcomes

BACKGROUND

Pediatric severe sepsis (PSS) is associated with increased mortality, and acute kidney injury (AKI) is an independent risk factor of mortality in PSS. However, there is little data on impact of AKI on hospital outcomes in PSS.

METHODS

We analyzed non-overlapping years of the Kids' Inpatient Database (KID) and National Inpatient Sample (NIS) database between 2003 and 2019 of all pediatric patients with severe sepsis between 1 and 18 years of age. Using ICD diagnosis codes, patients were divided into two groups based on AKI status and compared for outcomes measures including in-hospital mortality and healthcare resource utilization using length of stay and inflation-adjusted hospitalization charges.

RESULTS

We analyzed 192,712 hospitalizations due to PSS during the 17-year period. Prevalence of AKI was 23.6% with overall increasing trend, P<0.001. Prevalence of AKI was significantly increased in patients with diabetes mellitus, organ transplantation, HIV, urinary tract anomalies, and malnutrition, P<0.001. Mortality rate was significantly higher among patients with AKI (19.8% vs. 8.1%, P<0.001). PSS with AKI had significantly higher median length of stay (14 vs. 11 days) and total hospitalization charges ($168,106 vs. 100,906), P<0.001. Multivariate logistic regression analysis showed that AKI without kidney replacement therapy (KRT) was associated with 3.02 times increased odds of mortality (95% CI 2.99-3.17, P<0.001) and those requiring KRT had 6.4 times increased odds of mortality (95%CI 6.1-6.7, P<0.001). AKI without KRT was associated with 7.7 (95% CI 7.3-8.05) additional days of hospitalization and 154,536 (95% CI 149,500-159,572) additional US dollars in hospitalization charges.

CONCLUSION

Almost 1 in 4 hospitalizations with PSS had AKI and was associated with >3 times increased risk of mortality and need for KRT further adversely impacts mortality and healthcare utilization. A higher resolution version of the Graphical abstract is available as Supplementary information.

High resolution data modifies intensive care unit dialysis outcome predictions as compared with low resolution administrative data set

High resolution clinical databases from electronic health records are increasingly being used in the field of health data science. Compared to traditional administrative databases and disease registries, these newer highly granular clinical datasets offer several advantages, including availability of detailed clinical information for machine learning and the ability to adjust for potential confounders in statistical models. The purpose of this study is to compare the analysis of the same clinical research question using an administrative database and an electronic health record database. The Nationwide Inpatient Sample (NIS) was used for the low-resolution model, and the eICU Collaborative Research Database (eICU) was used for the high-resolution model. A parallel cohort of patients admitted to the intensive care unit (ICU) with sepsis and requiring mechanical ventilation was extracted from each database. The primary outcome was mortality and the exposure of interest was the use of dialysis. In the low resolution model, after controlling for the covariates that are available, dialysis use was associated with an increased mortality (eICU: OR 2.07, 95% CI 1.75-2.44, p<0.01; NIS: OR 1.40, 95% CI 1.36-1.45, p<0.01). In the high-resolution model, after the addition of the clinical covariates, the harmful effect of dialysis on mortality was no longer significant (OR 1.04, 95% 0.85-1.28, p = 0.64). The results of this experiment show that the addition of high resolution clinical variables to statistical models significantly improves the ability to control for important confounders that are not available in administrative datasets. This suggests that the results from prior studies using low resolution data may be inaccurate and may need to be repeated using detailed clinical data.

Utility of Citrate Dialysis in Patients with Contraindication for Heparin in a Limited-Resource Setting

Background: Hemodialysis among critical care patients with acute kidney injury (AKI) is challenging, especially if heparin is contraindicated. Objectives: This study assessed the utility of citrate dialysis for such patients in a limited-resource setting. Methods: In this prospective study, patients were divided into group A (heparin-free saline flush dialysis), group B (heparin-free citrate dialysis without flushing), and group C (heparin-free citrate dialysis with flushing). The subjects underwent completed sustained low-efficiency daily dialysis (blood flow = 150 mL/minute, dialysate = 300 mL/minute) or intermittent hemodialysis (blood flow = 250 mL/minute, dialysate flow = 500 mL/minute). Statistical tests using SPSS software (version 26) were used to determine safety and effectiveness differences. Results: Among 25 patients studied with multiple hemodialysis sessions, blood flow and dialysate flow were observed to be better in heparin-free citrate dialysis with flushing. There were further advantages of lesser dialyzer clotting and more reuse of dialyzers. Metabolic differences were insignificant. Heparin-free citrate dialysis with or without flushing was equally effective and safe, compared to heparin-free saline flush dialysis, in patients with or without liver impairment. Conclusions: Citrate dialysis is observed to be a safe and effective alternative to heparin-free saline flushing dialysis in intensive care unit patients with AKI. More such studies are required in limited-resource settings to utilize citrate dialysis in patients with heparin contraindication.

Incidence, risk factors, and prognosis of acute kidney injury in hospitalized patients with acute cholangitis

BACKGROUND

The association between acute cholangitis (AC) and acute kidney injury (AKI) remains unclear. We investigated the incidence, and clinical course of AKI in patients with AC, and the long-term prognosis.

METHODS

We performed a single-center retrospective study of patients hospitalized with AC in a tertiary care center from January 2011 to December 2017. The risk factors for AKI were evaluated, and AKI severity was analyzed using the Systemic Inflammatory Response System (SIRS), quick sequential organ failure assessment (qSOFA) score, and 2018 Tokyo Guidelines (TG) grade. To calculate the relative risk of death based on AKI, hazard ratios (HRs) and 95% confidence intervals (CIs) were obtained using Cox's proportional hazard models.

RESULTS

A total of 1,438 patients with AC were included, of whom 18.2% (n = 261) developed AKI. AKI patients were older, and had a lower systolic blood pressure and more comorbidities including hypertension (HT), chronic kidney disease, and cardiovascular accidents. Disease severity (as assessed by SIRS, qSOFA, and the Tokyo Guidelines grade) was higher in the AKI group, as was the in-hospital mortality rate. Multivariate analysis revealed that age, HT, SIRS and qSOFA scores ≥ 2, and TG grade of III were significant risk factors for AKI. Kaplan-Meier analysis revealed significantly higher mortality in the AKI than non-AKI group. AKI (HR = 1.853; 95% CI: 1.115-3.079) and TG grade III (HR = 2.139; 95% CI: 1.190-3,846) were independent predictors of all-cause AC mortality, even after adjusting for all covariates. The annual rate of decline in the estimated glomerular filtration rate was faster in the AKI than non-AKI group (2.9 ± 6.7 vs. 0.5 ± 5.3 mL/min/1.73 m2/year, p < 0.001).

CONCLUSIONS

AKI development increased AC severity and mortality. Our results suggest that clinicians should monitor AKI status and perform appropriate management as soon as possible.

Acute Kidney Injury in Extracorporeal Membrane Oxygenation Patients: National Analysis of Impact of Age

BACKGROUND

The aim of this study was to determine epidemiology and outcomes of acute kidney injury (AKI) in patients on extracorporeal membrane oxygenation (ECMO) and to assess if age modifies the effect of AKI on mortality.

METHODS

Using National (Nationwide) Inpatient Sample Database for hospitalizations in the USA from 2003 to 2014, we identified adult patients on ECMO support. Using International Classification of Diseases 9th Revision, we assessed the rates of AKI and AKI requiring dialysis (AKI-D) among them and associated survival. We used a multivariable logistic regression to identify risk factors of and differential effect of age on mortality from AKI.

RESULTS

AKI was seen in 63.9% of 17,942 ECMO hospitalizations: 21.9% of those with AKI required dialysis. The percentage of those with AKI increased steadily. Mortality was higher in those with AKI, with highest in those with AKI-D (70.8% vs. 61.7%; p < 0.001). While both age and AKI were independent predictors of mortality, age was neither a risk factor for AKI nor did it modify the effect of AKI on mortality.

CONCLUSIONS

AKI is common and is increasing among patients on ECMO support. Patients on ECMO have high mortality and AKI is an independent predictor of mortality. Though age is also an independent predictor of mortality in patients on ECMO, it is neither a predictor of AKI nor does not modify the relationship between AKI and mortality.

Improving the quality of care for patients requiring continuous renal replacement therapy

Continuous renal replacement therapy (CRRT) is the preferred extracorporeal kidney support therapy employed to support critically ill patients with acute or chronic kidney dysfunction in intensive care units. Significant heterogeneity in CRRT practice exists in part due to variable logistics, resources, and scarcity of evidence-based CRRT practices. Importantly, homogenization of practice patterns by developing substantial evidence and effective dissemination among providers is essential for optimizing CRRT practices. The emphasis on quality of CRRT delivery has prompted identification of potential quality indicators, development of multifaceted quality improvement initiatives, effective computer science utilization, and a surge of multidisciplinary quality assurance teams that advocate for "best" CRRT practices. This manuscript provides an overview of quality improvement methodologies and reviews candidate quality indicators of CRRT and the impact of quality improvement on enhancing CRRT delivery practices.

Identification of the candidate lncRNA biomarkers for acute kidney injury: a systematic review and meta-analysis

Background: This meta-analysis aims to summarize the studies of lncRNAs dysregulation in individual acute kidney injury (AKI) and identify the potential lncRNA biomarkers of AKI.Research design and methods: We systematically searched four databases to identify the lncRNA expression studies of AKI in animal models and patients. The lncRNAs expression data were extracted from 38 included studies, and lncRNA vote-counting strategy was applied to identify significant lncRNA biomarkers. The predicted targets of lncRNA biomarkers were obtained by searching Co-LncRNA, RBPmap, and LncBase v.2. Further, GO enrichment analysis and KEGG pathway analysis were performed.Results: We recognized a significant lncRNA signature of 21 up-regulated and 11 down-regulated lncRNAs, among which TapSAKI, XIST, MALAT1, CASC2, and HOXA-AS2 were dysregulated both in AKI rodent models and patients. About 28.0% of these lncRNAs mainly exist in the nucleus, which was also the most enriched GO cellular components term. The most relevant GO terms in biological process and molecular function associated with these lncRNAs were splicing, processing, and binding of mRNA.Conclusions: The present meta-analysis identified 31 significant dysregulated lncRNAs from 38 studies. TapSAKI, XIST, MALAT1, CASC2, and HOXA-AS2 were considered as the potential predictive biomarkers and therapeutic targets of AKI.

Trends of Acute Kidney Injury Requiring Dialysis Among Hospitalized Patients Undergoing Invasive Electrophysiology Procedures

Electrophysiology (EP) procedures carry the risk of kidney injury due to contrast/hemodynamic fluctuations. We aim to evaluate the national epidemiology of acute kidney injury requiring dialysis (AKI-D) in patients undergoing EP procedures. Using the National Inpatient Sample, we included 2,747,605 adult hospitalizations undergoing invasive diagnostic EP procedures, ablation and implantable device placement from 2006 to 2014. We examined the temporal trend of AKI-D and outcomes associated with AKI-D. The rate of AKI-D increased significantly in both diagnostic/ablation group (8-21/10,000 hospitalizations from 2006 to 2014, P = 0.02) and implanted device group (19-44/10,000 hospitalizations from 2006 to 2014, P < 0.01), but it was explained by temporal changes in demographics and comorbidities. Cardiac resynchronization therapy and pacemaker placement had higher risk of AKI-D compared to implantable cardioverter-defibrillator placement (23 vs. 31 vs. 14/10,000 hospitalizations in cardiac resynchronization therapy, pacemaker placement, and implantable cardioverter-defibrillator group, respectively). Development of AKI-D was associated with significant increase in in-hospital mortality (adjusted odds ratio, 9.6 in diagnostic/ablation group, P < 0.01; adjusted odds ratio, 5.1 in device implantation group, P < 0.01) and with longer length of stay (22.5 vs. 4.5 days in diagnostic/ablation group, 21.1 vs. 5.7 days in implanted device group) and higher cost (282,775 vs. 94,076 USD in diagnostic/ablation group, 295,660 vs. 102,007 USD in implanted device group). The incidence of AKI-D after EP procedures increased over time but largely explained by the change of demographics and comorbidities. This increasing trend, however, was associated with significant increase in resource utilization and in-hospital mortality in these patients.

Clinical features, risk factors, and outcomes of septic arthritis in patients on maintenance hemodialysis

The aim of this study was to investigate the clinical features, risk factors, and outcomes of septic arthritis in patients on maintenance hemodialysis (HD). We systematically reviewed medical records of 16 HD patients with septic arthritis admitted to our hospital from April 2008 to April 2018. A total of 16 HD in patients with bloodstream infection but without septic arthritis were randomly selected as controls. The incidence of septic arthritis in our patient group was 0.2% per year. Organisms isolated were Staphylococcus aureus in 11 (68.7%), Gram-negative bacilli in 3, streptococci in 1, and fungi in 1. Patients with septic arthritis were significantly older (72.7 ± 9.4 vs 63.5 ± 8.7 years, p = 0.035) and had more joint diseases (62.5% vs 12.5%, p = 0.003) and a longer duration of hospitalization (35.2 ± 5.7 vs 22.1 ± 3.5 days, p = 0.021) than the control group. In a logistic regression analysis, patients with older age and more joint diseases were more likely to have septic arthritis compared with controls (OR = 1.39, p = 0.024 and OR = 3.24, p = 0.003, respectively). These findings indicate that old age and joint diseases (osteoarthritis or inflammatory arthritis) were independent risk factors for septic arthritis in patients on HD when bloodstream infection occurred. Key Points • Patients with septic arthritis were significantly older and had more joint diseases than the control group. • Old age and joint diseases are independent risk factors for septic arthritis in patients on HD when bloodstream infection occurs.

Kidney Injury in Sepsis: Fuel to the Fire

How to cite this article: Chacko B. Kidney Injury in Sepsis: Fuel to the Fire. Indian J Crit Care Med 2020;24(4):216-217.

Hemodynamic Predictors for Sepsis-Induced Acute Kidney Injury: A Preliminary Study

The aim of our study was to assess the association between the macrohemodynamic profile and sepsis induced acute kidney injury (AKI). We also investigated which minimally invasive hemodynamic parameters may help identify patients at risk for sepsis-AKI. We included 71 patients with sepsis and septic shock. We performed the initial fluid resuscitation using local protocols and continued to give fluids guided by the minimally invasive hemodynamic parameters. We assessed the hemodynamic status by transpulmonary thermodilution technique. Sequential organ failure assessment (SOFA score) (AUC 0.74, 95% CI 0.61–0.83, p < 0.01) and cardiovascular SOFA (AUC 0.73, 95% CI 0.61–0.83, p < 0.01) were found to be predictors for sepsis-induced AKI, with cut-off values of 9 and 3 points respectively. Persistent low stroke volume index (SVI) ≤ 32 mL/m²/beat (AUC 0.67, 95% CI 0.54–0.78, p < 0.05) and global end-diastolic index (GEDI) < 583 mL/m² (AUC 0.67, 95% CI 0.54–0.78, p < 0.05) after the initial fluid resuscitation are predictive for oliguria/anuria at 24 h after study inclusion. The combination of higher vasopressor dependency index (VDI, calculated as the (dobutamine dose × 1 + dopamine dose × 1 + norepinephrine dose × 100 + vasopressin × 100 + epinephrine × 100)/MAP) and norepinephrine, lower systemic vascular resistance index (SVRI), and mean arterial blood pressure (MAP) levels, in the setting of normal preload parameters, showed a more severe vasoplegia. Severe vasoplegia in the first 24 h of sepsis is associated with a higher risk of sepsis induced AKI. The SOFA and cardiovascular SOFA scores may identify patients at risk for sepsis AKI. Persistent low SVI and GEDI values after the initial fluid resuscitation may predict renal outcome.

Epidemiology and Trends of Sepsis in Young Adults Aged 20-44 Years: A Nationwide Population-Based Study

Background: While sepsis may have especially marked impacts in young adults, there is limited population-based information on its epidemiology and trends. Methods: Population-based longitudinal study on sepsis in adults aged 20–44 years using the 2006–2015 Spanish national hospital discharge database. Cases are identified by an ICD-9-CM coding strategy. Primary endpoints are incidence and in-hospital mortality. Trends are assessed for annual percentage change (AAPC) in rates using Joinpoint regression models. Results: 28,351 cases are identified, representing 3.06‰ of all-cause hospitalisations and a crude incidence of 16.4 cases/100,000 population aged 20–44. The mean age is 36 years, 58% of cases are men, and around 60% have associated comorbidities. Seen in one third of cases, the source of infection is respiratory. Single organ dysfunction is recorded in 45% of cases. In-hospital mortality is 24% and associated with age, comorbidity and extent of organ dysfunction. Incidence rates increase over time in women (AAPC: 3.8% (95% CI: 2.1, 5.5)), whereas case-fatality decline with an overall AAPC of −5.9% (95% CI −6.6, −5.2). Our results indicate that sepsis is common in young adults and associated with high in-hospital mortality, though it shows a decreasing trend. The substantial increase in incidence rates in women needs further research.

Clinical Frailty Scale Score Before ICU Admission Is Associated With Mobility Disability in Septic Patients Receiving Early Rehabilitation

To clarify the relationship between mobility disability at the time of discharge from the ICU and clinical factors evaluated at ICU admission in septic patients.

Tako-Tsubo Cardiomyopathy in Severe Sepsis: Nationwide Trends, Predictors, and Outcomes

Background

There are limited data on the presentation of Takotsubo cardiomyopathy (TTC) in severe sepsis.

Methods and Results

This was a retrospective cohort study using the National Inpatient Sample database (2007–2013) of all adults with severe sepsis. TTC was identified in patients with severe sepsis using previously validated administrative codes. The primary outcome was in‐hospital mortality, and secondary outcomes included resource utilization and discharge disposition. Regression analysis was performed for the entire cohort and a propensity‐matched sample. An exploratory analysis was performed for predictors of TTC incidence and mortality in TTC. During this 7‐year period, in 7.1‐million hospitalizations for severe sepsis, TTC was diagnosed in 10 746 (0.15%) admissions. TTC was noted more commonly in whites, females, and among 65‐ to 79‐year‐old individuals. TTC was independently associated with lower in‐hospital mortality in severe sepsis (odds ratio, 0.58; 95% confidence interval, 0.51–0.65). This association was more prominent in females (odds ratio, 0.51; 95% confidence interval, 0.44–0.59]) compared with males (odds ratio, 0.69; 95% confidence interval, 0.55–0.85]). Presentation in later years of the study period, middle‐age, female sex, and white race were independent predictors for the diagnosis of TTC. Age ≥80 years, black race, greater comorbidity, and multiorgan dysfunction were independently associated with higher in‐hospital mortality among TTC admissions.

Conclusions

TTC is observed with increasing frequency in severe sepsis and was associated with a significantly lower in‐hospital mortality compared with patients without TTC. Presentation in later years of the study period, middle age, female sex, and white race were independent predictors for the diagnosis of TTC in severe sepsis.

Initial Fluid Resuscitation Following Adjusted Body Weight Dosing in Sepsis and Septic Shock

INTRODUCTION

Fluid administration is considered a fundamental part of early sepsis treatment. Despite abundant research, fundamental questions about the amount of fluids to be given remain unanswered. Recently, the idea of adjusting the fluid load to the ideal body weight emerged, as obesity rates are increasing, and fluid overload was proven to increase mortality.

AIM OF THE STUDY

The study aimed to determine whether advanced haemodynamic monitoring supports the adjustment of the initial fluid load to the ideal body weight (IBW).

METHODS

Seventy-one patients with sepsis and septic shock were enrolled in the study. The initial fluid resuscitation was performed using local protocols. The haemodynamic status was assessed after the initial fluid load by transpulmonary thermos-dilution technique and the renal outcome recorded at twenty-four hours.

RESULTS

68.6% of the patients included in the study had weight disorders ranging from BMI+20% to morbid obesity. Before IBW adjustment, only 49.3% received the 30 ml/kg fluid load recommended by Surviving Sepsis Campaign Guidelines (2016) (SSC). After IBW adjustment, 70.4% received the recommended fluid dose. The difference in fluid load/kg before and after the bodyweight adjustment was statistically significant (p<0.01). After the initial fluid load, the majority of the macro haemodynamic parameters were in the targeted range. There was no statistically significant difference between the urinary output outcome at 24 hours or the 28 days mortality rates between the patients resuscitated by the SSC and those who received less fluid.

CONCLUSIONS

Advanced haemodynamic monitoring was in favour of adjusting the initial fluid load to the IBW. There were no statistically significant differences either in the urinary output outcome at twenty-four hours, or in the twenty-eight-day mortality rates between the patients who received the 30 ml/kg IBW and those who received less than 30 ml/kg IBW.

Temporal trends, predictors, and outcomes of acute kidney injury and hemodialysis use in acute myocardial infarction-related cardiogenic shock

Background

There are limited data on acute kidney injury (AKI) complicating acute myocardial infarction with cardiogenic shock (AMI-CS). This study sought to evaluate 15-year national prevalence, temporal trends and outcomes of AKI with no need for hemodialysis (AKI-ND) and requiring hemodialysis (AKI-D) following AMI-CS.

Methods

This was a retrospective cohort study from 2000–2014 from the National Inpatient Sample (20% stratified sample of all community hospitals in the United States). Adult patients (>18 years) admitted with a primary diagnosis of AMI and secondary diagnosis of CS were included. The primary outcome was in-hospital mortality in cohorts with no AKI, AKI-ND, and AKI-D. Secondary outcomes included predictors, resource utilization and disposition.

Results

During this 15-year period, 440,257 admissions for AMI-CS were included, with AKI in 155,610 (35.3%) and hemodialysis use in 14,950 (3.4%). Older age, black race, non-private insurance, higher comorbidity, organ failure, and use of cardiac and non-cardiac organ support were associated with the AKI development and hemodialysis use. There was a 2.6-fold higher adjusted risk of developing AKI in 2014 compared to 2000. Presence of AKI-ND and AKI-D was associated with a 1.3 and 1.7-fold higher adjusted risk of mortality. Compared to the cohort without AKI, AKI-ND and AKI-D were associated with longer length of stay (9±10, 12±13, and 18±19 days respectively; p<0.001) and higher hospitalization costs ($101,859±116,204, $159,804±190,766, and $265,875 ± 254,919 respectively; p<0.001).

Conclusion

AKI-ND and AKI-D are associated with higher in-hospital mortality and resource utilization in AMI-CS.

Role of Loop Diuretic Challenge in Stage 3 Acute Kidney Injury

OBJECTIVE

To assess whether loop diuretic challenge predicts the need for dialysis among critically ill patients with acute kidney injury (AKI) stage 3.

PATIENTS AND METHODS

Adult patients admitted to intensive care units between January 1, 2004, and December 31, 2016, were screened. Acute kidney injury stage 3 was identified by an electronic surveillance tool, and patients who received loop diuretics in a dosage of at least 1mg/kg intravenous bolus furosemide equivalent were included. Urine output following loop diuretic challenge was modeled as a restricted cubic spline. We then compared the area under the receiver operating characteristic curve for urine outputs at 2 hours and 6 hours after loop diuretic challenge to predict the need for dialysis within the next 24 hours.

RESULTS

Of 687 patients included in the study, those who received dialysis were younger and had higher Sequential Organ Failure Assessment scores on the day of loop diuretic challenge. Urine outputs at 2 hours and 6 hours were lower in patients who needed dialysis, but urine output by 6 hours was better in predicting dialysis initiation within 24 hours (area under the curve, 0.71 vs 0.67; P=.02). The sensitivity and specificity of 6-hour urine output cutoff of 600 mL or less to predict dialysis was 80.9% and 50.5%, respectively, and that for 300 mL or less was 64.2% and 68.2%, respectively.

CONCLUSION

Among patients with stage 3 AKI, 6-hour urine output after the loop diuretic challenge had a modest discriminant capacity to identify dialysis initiation within the next 24 hours.

A prospective study of clinical characteristics and outcomes of acute kidney injury in a tertiary care Centre

Background

Acute kidney injury (AKI) is a major global health problem. We aim to evaluate the epidemiology, risk factors and outcomes of AKI episodes in our single centre.

Methodology

We prospectively identified 422 AKI and acute on chronic kidney disease episodes in 404 patients meeting KDIGO definitions using electronic medical records and clinical data from 15th July to 22nd October 2016, excluding patients with baseline estimated GFR (eGFR) of < 15 mL/min. Patients were followed up till 6 months after AKI diagnosis.

Results

The mean age was 65.8 ± 14.1. Majority of patients were male (58.2%) of Chinese ethnicity (68.8%). One hundred and thirty-two patients (32.6%) were diagnosed in acute care units. Seventy-five percent of patients developed AKI during admission in a non-Renal specialty. Mean baseline eGFR was 50.2 ± 27.7 mL/min. Mean creatinine at AKI diagnosis was 297 ± 161 μmol/L. Renal consultations were initiated at KDIGO Stages 1, 2 and 3 in 58.9, 24.5 and 16.6% of patients, respectively. Three hundred and ten (76.7%) patients had a single etiology of AKI with the 3 most common etiologies of AKI being pre-renal (27.7%), sepsis-associated (25.5%) and ischemic acute tubular necrosis (15.3%). One hundred and nine (27%) patients received acute renal replacement therapy. In-hospital mortality was 20.3%. Six-month mortality post-AKI event was 9.4%. On survival analysis, patients with KDIGO Stage 3 AKI had significantly shorter survival than other stages.

Conclusion

AKI is associated with significant in-hospital to 6-month mortality. This signifies the pressing need for AKI prevention, early detection and intervention in mitigating reversible risk factors in order to optimize clinical outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1466-z) contains supplementary material, which is available to authorized users.

Incidence, risk factors, and clinical outcomes of acute kidney injury associated with acute pyelonephritis in patients attending a tertiary care referral center

Acute kidney injury (AKI) associated with acute pyelonephritis (APN) rarely has been reported. The aim of this study was to evaluate the incidence and risk factors of AKI associated with APN. We retrospectively reviewed the medical records of 403 patients over 18-year old age hospitalized for APN management from October 2009 to September 2014 in tertiary care referral center. Demographic data, clinical symptoms and signs, and laboratory findings were gathered from the medical records and analyzed. The mean age of patients was 57 years and APN commonly occurred in female (87.6%). AKI occurred in 253 patients (62.8%). As per the RIFLE classification, renal injury was graded as ‘Risk’ (62.1%), ‘Injury’ (26.5%), and ‘Failure’ (11.4%). AKI patients were more likely a male gender and had complicated APN. The AKI group had a significantly higher tendency to present with shock. The prevalence of underlying chronic kidney disease (CKD) was significantly higher in the AKI group. There was no difference in mortality between the AKI and non-AKI groups. Multivariate analysis revealed that age over 65 (OR 1.93, 95% CI 1.18–3.13, p= .008), complicated (OR 2.13, 95% CI 1.35–3.34, p= .001) and bilateral APN (OR 1.71, 95% CI 1.01–2.88, p= .045), and initial shock (OR 2.44, 95% CI 1.05–5.71, p= .039) were independent risk factors for the occurrence of AKI in patients with APN. Physicians should attempt to prevent, detect, and manage AKI associated with APN in patients with above conditions.

Cefepime Pharmacokinetics in Critically Ill Pediatric Patients Receiving Continuous Renal Replacement Therapy

This retrospective study included pediatric intensive care unit patients receiving continuous veno-venous hemodiafiltration (CVVHDF) being treated with cefepime. The free drug concentration above one time the MIC (fT>1×MIC) and four times a presumed MIC (fT>4×MIC) of 8 μg/ml were calculated. Four patients received doses ranging from 48 to 64 mg/kg of body weight every 6 to 12 h. Three patients achieved 100% fT>1×MIC, with the fourth patient achieving 98% fT>1×MIC. Therapeutic drug monitoring should be considered for critically ill patients receiving cefepime on CVVHDF.

Increased incidence of acute kidney injury requiring dialysis in metropolitan France

Background

Acute kidney injury requiring dialysis (AKI-D) is associated with high mortality. Information about its epidemiology is nonetheless sparse in some countries. The objective of this study was to assess its epidemiology and prognosis in metropolitan France.

Methods

Using the French hospital discharge database, the study focused on adults hospitalized in metropolitan France between 2009 and 2014 and diagnosed with AKI-D according to the codes of the French common classification of medical procedures. Crude and standardized incidence rates (SIR) by gender and age were calculated. We explored the changes in patients’ characteristics, modalities of renal replacement therapy (RRT), in-hospital care, and mortality, along with their determinants. Trends over time in the SIR for AKI-D, its principal diagnoses, and comorbidities were analyzed with joinpoint models.

Results

Between 2009 and 2014, the AKI-D SIR increased from 475 (95% CI, 468 to 482) to 512 per million population (95% CI, 505 to 519). AKI-D was twice as high in men as women. Median age was 68 years. Over the study period, the AKI-D SIR steadily increased in all age groups, particularly in the elderly. The most common comorbidities were cardio-cerebrovascular diseases (64.8%), pulmonary disease (42.2%), CKD (33.8%), and diabetes (26.0%); all of these except CKD increased significantly over time. In 2009, heart failure (17.2%), sepsis (17.0%), AKI (13.0%), digestive diseases (10.7%), and shock (6.6%) were the most frequent principal diagnoses, with a significant increase in heart failure and digestive diseases. The proportion of patients with at least one ICU stay and continuous RRT increased from 80.3% to 83.9% and from 56.9% to 61.8% (p<0.001), respectively. In-hospital mortality was high but stable (47%) and higher in patients with an ICU stay.

Conclusions

This is the first exhaustive study in metropolitan France of the SIR for AKI-D. It shows this SIR has increased significantly over 6 years, together with ICU care and continuous RRT. In-hospital mortality is high but stable.

Renal replacement therapy: a practical update

Acute kidney injury (AKI) is defined as an abrupt decrease in kidney function, with the most severe form requiring some method of renal replacement therapy (RRT). The use of RRT is required in 5-10% of critically ill patients who develop severe AKI. Renal replacement therapy can be provided as either intermittent hemodialysis or one of the various modes of continuous renal replacement therapy (CRRT), with CRRT potentially conferring an advantage with respect to renal recovery and dialysis independence. There is no difference in mortality when comparing low (< 25 mL·kg^-1·hr^-1) vs high (> 40 mL·kg^-1·hr^-1) RRT dosing. Continuous renal replacement therapy may be run in different modes of increasing complexity depending on a given patient's clinical needs. Regional citrate anticoagulation is recommended as the therapy of choice for the majority of critically ill patients requiring CRRT.

Female sex reduces the risk of hospital-associated acute kidney injury: a meta-analysis

Background

Female sex has been included as a risk factor in models developed to predict the development of AKI. In addition, the commentary to the Kidney Disease Improving Global Outcomes Clinical Practice Guideline for AKI concludes that female sex is a risk factor for hospital-acquired AKI. In contrast, a protective effect of female sex has been demonstrated in animal models of ischemic AKI.

Methods

To further explore this issue, we performed a meta-analysis of AKI studies published between January, 1978 and April, 2018 and identified 83 studies reporting sex-stratified data on the incidence of hospital-associated AKI among nearly 240,000,000 patients.

Results

Twenty-eight studies (6,758,124 patients) utilized multivariate analysis to assess risk factors for hospital-associated AKI and provided sex-stratified ORs. Meta-analysis of this cohort showed that the risk of developing hospital-associated AKI was significantly greater in men than in women (OR 1.23 (1.11,1.36). Since AKI is not a single disease but instead represents a heterogeneous group of disorders characterized by an acute reduction in renal function, we performed subgroup meta-analyses. The association of male sex with AKI was strongest among studies of patients who underwent non-cardiac surgery. Male sex was also associated with AKI in studies which included unselected hospitalized patients and in studies of critically ill patients who received care in an intensive care unit. In contrast, cardiac surgery-associated AKI and radiocontrast-induced AKI showed no sexual dimorphism.

Conclusions

Our meta-analysis contradicts the established belief that female sex confers a greater risk of AKI and instead suggests a protective role.

Renal autoregulation in experimental septic shock and its response to vasopressin and norepinephrine administration

Evidence suggests that septic shock patients with chronic arterial hypertension may benefit from resuscitation targeted to achieve higher blood pressure values than other patients, possibly as a result of altered renal autoregulation. The effects of different vasopressor agents on renal autoregulation may be important in this context. We investigated the effects of arginine vasopressin (AVP) and norepinephrine (NE) on renal autoregulation in ovine septic shock. Sepsis was induced by fecal peritonitis. When shock developed (decrease in mean arterial pressure to <65 mmHg and no fluid-responsiveness), animals were randomized to receive NE or AVP in a crossover design. Before the switch to the second vasopressor, the first vasopressor was discontinued for 30 minutes to ensure complete washout of the first vasopressor. Renal autoregulation was evaluated by recording the change in renal blood flow (RBF) in response to manual, stepwise reductions in renal inflow pressure. In this model, the lower limit of renal autoregulation was not significantly altered 6 hours after sepsis induction (59±9 vs. 64±7 mmHg at baseline, p=0.096). After development of shock, the autoregulatory threshold was lower with AVP than with NE (59±5 vs. 65±7 mmHg, p=0.010). However, RBF was higher with NE both at the start of autoregulatory measurements (206±58 vs. 170±52 mL/min; p=0.050) and at the autoregulatory threshold (191±53 vs. 150±47 mL/min; p=0.008). As vasopressors may have different effects on renal autoregulation, blood pressure management in patients with septic shock should be individualized and take into account drug-specific effects.

Comparison of European ICU patients in 2012 (ICON) versus 2002 (SOAP)

PURPOSE

To evaluate differences in the characteristics and outcomes of intensive care unit (ICU) patients over time.

METHODS

We reviewed all epidemiological data, including comorbidities, types and severity of organ failure, interventions, lengths of stay and outcome, for patients from the Sepsis Occurrence in Acutely ill Patients (SOAP) study, an observational study conducted in European intensive care units in 2002, and the Intensive Care Over Nations (ICON) audit, a survey of intensive care unit patients conducted in 2012.

RESULTS

We compared the 3147 patients from the SOAP study with the 4852 patients from the ICON audit admitted to intensive care units in the same countries as those in the SOAP study. The ICON patients were older (62.5 ± 17.0 vs. 60.6 ± 17.4 years) and had higher severity scores than the SOAP patients. The proportion of patients with sepsis at any time during the intensive care unit stay was slightly higher in the ICON study (31.9 vs. 29.6%, p = 0.03). In multilevel analysis, the adjusted odds of ICU mortality were significantly lower for ICON patients than for SOAP patients, particularly in patients with sepsis [OR 0.45 (0.35-0.59), p < 0.001].

CONCLUSIONS

Over the 10-year period between 2002 and 2012, the proportion of patients with sepsis admitted to European ICUs remained relatively stable, but the severity of disease increased. In multilevel analysis, the odds of ICU mortality were lower in our 2012 cohort compared to our 2002 cohort, particularly in patients with sepsis.

Hospital Variation in Renal Replacement Therapy for Sepsis in the United States

OBJECTIVES

Acute renal replacement therapy in patients with sepsis has increased dramatically with substantial costs. However, the extent of variability in use across hospitals-and whether greater use is associated with better outcomes-is unknown.

DESIGN

Retrospective cohort study.

SETTING

Nationwide Inpatient Sample in 2011.

PATIENTS

Eighteen years old and older with sepsis and acute kidney injury admitted to hospitals sampled by the Nationwide Inpatient Sample in 2011.

INTERVENTIONS

We estimated the risk- and reliability-adjusted rate of acute renal replacement therapy use for patients with sepsis and acute kidney injury at each hospital. We examined the association between hospital-specific renal replacement therapy rate and in-hospital mortality and hospital costs after adjusting for patient and hospital characteristics.

MEASUREMENTS AND MAIN RESULTS

We identified 293,899 hospitalizations with sepsis and acute kidney injury at 440 hospitals, of which 6.4% (n = 18,885) received renal replacement therapy. After risk and reliability adjustment, the median hospital renal replacement therapy rate for patients with sepsis and acute kidney injury was 3.6% (interquartile range, 2.9-4.5%). However, hospitals in the top quintile of renal replacement therapy use had rates ranging from 4.8% to 13.4%. There was no significant association between hospital-specific renal replacement therapy rate and in-hospital mortality (odds ratio per 1% increase in renal replacement therapy rate: 1.03; 95% CI, 0.99-1.07; p = 0.10). Hospital costs were significantly higher with increasing renal replacement therapy rates (absolute cost increase per 1% increase in renal replacement therapy rate: $1,316; 95% CI, $157-$2,475; p = 0.03).

CONCLUSIONS

Use of renal replacement therapy in sepsis varied widely among nationally sampled hospitals without associated differences in mortality. Improving renal replacement standards for the initiation of therapy for sepsis may reduce healthcare costs without increasing mortality.

Racial Differences in Mortality from Severe Acute Respiratory Failure in the United States, 2008-2012

RATIONALE

Racial disparities in health and healthcare in the United States are well documented and are increasingly recognized in acute critical illnesses such as sepsis and acute respiratory failure.

OBJECTIVES

Using a large, representative, U.S. nationwide database, we examined the hypothesis that black and Hispanic patients with severe acute respiratory failure have higher mortality rates when compared with non-Hispanic whites.

METHODS

This retrospective analysis used discharge data from the Agency for Healthcare Research and Quality, Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, for the years 2008-2012. We identified hospitalizations with acute respiratory failure using a combination of International Classification of Diseases, Ninth Revision, Clinical Modification, codes. A logistic regression model was fitted to compare in-hospital mortality rates by race.

MEASUREMENTS AND MAIN RESULTS

After adjusting for sex, age, race, disease severity, type of hospital, and median household income for patient ZIP code, blacks had a greater odds ratio of in-hospital death when compared with non-Hispanic whites (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.11-1.14; P < 0.001), and Hispanics also had a greater odds ratio of in-hospital death when compared with non-Hispanic whites (OR, 1.17; 95% CI, 1.15-1.19; P < 0.001), and so did Asian and Pacific Islanders (OR, 1.15; 95% CI, 1.12-1.18; P < 0.001) and Native Americans (OR, 1.08; 95% CI, 1.00-1.15; P < 0.001) when compared with non-Hispanic whites (OR, 1.0).

CONCLUSIONS

Blacks, Hispanics, and other racial minorities in the United States were observed to exhibit significantly higher in-hospital sepsis-related respiratory failure associated mortality when compared with non-Hispanic whites.

Propafenone for supraventricular arrhythmias in septic shock-Comparison to amiodarone and metoprolol

PURPOSE

The occurence of supraventricular arrhythmias associate with an unfavourable prognosis in septic shock. Propafenone could be a feasible antiarrhythmic.

MATERIALS AND METHODS

Patients collected over a period of 24months were divided into the three groups based on antiarrhythmic: Group1(amiodarone), Group2(propafenone), Group3(metoprolol). Type of arrhythmia, cardioversion rates, demographic, haemodynamic, laboratory parameters were recorded in the first 24h. The outcome data were compared between the groups.

RESULTS

234 patients (99.1% ventilated) were included, the prevailing arrhythmia was acute onset atrial fibrillation (AF,69.7%). Except for the dosage of noradrenaline (0.35(0.14-0.78) in Group1(n=142)vs 0.25(0.10-0.50),p<0.01 in Group2(n=78)vs 0.14(0.07-0.25)μg/kg·min,p<0.05 in Group3(n=14)) the ejection fraction of left ventricle, rates of renal replacement therapy, arterial lactate and procalcitonin levels were not different between the groups. The cardioversion rate in Group1(74%) was lower than in Group2(89%) and Group3(92%). ICU and 28-day mortalities of Group1 were not significantly higher than in Group2 and Group3. Multivariate analysis demonstrated higher 12-month mortality in Group1 than in Group2 (HR1.58(1.04;2.38),p=0.03).

CONCLUSIONS

Propafenone demonstrated a higher cardioversion rate than amiodarone with a similar impact on the outcome. Patients remaining in acute onset arrhythmia did not demonstrate significantly higher ICU, 28-day and 12-month mortalities compared to those successfully cardioverted or to those having chronic AF.

Biomarkers of acute kidney injury: the pathway from discovery to clinical adoption

Acute kidney injury (AKI) is a common complication of critical illnesses and has a significant impact on outcomes, including mortality and morbidities. Unfortunately, apart from prophylactic measures, no effective treatment for this syndrome is known. Therefore, early recognition of AKI not only can provide better opportunities for preventive interventions, but also opens many gates for research and development of effective therapeutic options. Over the last few years, several new AKI biomarkers have been discovered and validated to improve early detection, differential diagnosis, and differentiation of patients into risk groups for progressive renal failure, need for renal replacement therapy (RRT), or death. These novel AKI biomarkers complement serum creatinine (SCr) and urine output, which are the standard diagnostic tools for AKI detection. In this article, we review the available literature on characteristics of promising AKI biomarkers that are currently the focus of preclinical and clinical investigations. These biomarkers include neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule 1 (KIM-1), liver-type fatty acid-binding protein, interleukin 18 (lL-18), insulin-like growth factor-binding protein 7, tissue inhibitor of metalloproteinase 2 (TIMP-2), calprotectin, urine angiotensinogen (AGT), and urine microRNA. We then describe the clinical performance of these biomarkers for diagnosis and prognostication. We also appraise each AKI biomarker's advantages and limitations as a tool for early AKI recognition and prediction of clinical outcomes after AKI. Finally, we review the current and future states of implementation of biomarkers in the clinical practice.

Epidemiology of AKI: Utilizing Large Databases to Determine the Burden of AKI

Large observational databases linking kidney function and other routine patient health data are increasingly being used to study acute kidney injury (AKI). Routine health care data show an apparent rise in the incidence of population AKI and an increase in acute dialysis. Studies also report an excess in mortality and adverse renal outcomes after AKI, although with variation depending on AKI severity, baseline, definition of renal recovery, and the time point during follow-up. However, differences in data capture, AKI awareness, monitoring, recognition, and clinical practice make comparisons between health care settings and periods difficult. In this review, we describe the growing role of large databases in determining the incidence and prognosis of AKI and evaluating initiatives to improve the quality of care in AKI. Using examples, we illustrate this use of routinely collected health data and discuss the strengths, limitations, and implications for researchers and clinicians.

The effects of acute renal denervation on kidney perfusion and metabolism in experimental septic shock

BACKGROUND

Perfusion deficits likely play an important role in the development of renal dysfunction in sepsis. Renal denervation may improve kidney perfusion and metabolism.

METHODS

We randomized 14 female sheep to undergo bilateral surgical renal denervation (n = 7) or sham procedure (n = 7) prior to induction of sepsis. Renal blood flow (RBF) was measured with a pre-calibrated flowprobe. Laser Doppler probes were implanted to measure cortical and medullary perfusion. Cortical glucose, lactate and pyruvate levels were measured using the microdialysis technique. Creatinine clearance was determined. Sepsis was induced by peritonitis and fluid resuscitation was provided to avoid hypovolemia.

RESULTS

RBF and cortical perfusion were higher in the denervated group during the first 6 h after induction of sepsis (P < 0.001 and P < 0.05, respectively), while medullary perfusion decreased similarly in both groups. After hypotension developed, RBF decreased to similar levels in both groups. Cortical pyruvate and lactate levels were lower in the denervated animals (P < 0.001 and P < 0.001, respectively). There were no differences between groups in creatinine clearance, urine output or time to oliguria.

CONCLUSION

Denervation thus caused an early increase in RBF that was distributed towards the kidney cortex. Although associated with an attenuation of early cortical metabolic alterations, denervation failed to prevent the deterioration in renal function.

Physiological aspects of Toll-like receptor 4 activation in sepsis-induced acute kidney injury

Sepsis‐induced acute kidney injury (SI‐AKI) is common and associated with high mortality. Survivors are at increased risk of chronic kidney disease. The precise mechanism underlying SI‐AKI is unknown, and no curative treatment exists. Toll‐like receptor 4 (TLR4) activates the innate immune system in response to exogenous microbial products. The result is an inflammatory reaction aimed at clearing a potential infection. However, the consequence may also be organ dysfunction as the immune response can cause collateral damage to host tissue. The purpose of this review is to describe the basis for how ligand binding to TLR4 has the potential to cause renal dysfunction and the mechanisms by which this may take place in gram‐negative sepsis. In addition, we highlight areas for future research that can further our knowledge of the pathogenesis of SI‐AKI in relation to TLR4 activation. TLR4 is expressed in the kidney. Activation of TLR4 causes cytokine and chemokine release as well as renal leucocyte infiltration. It also results in endothelial and tubular dysfunction in addition to altered renal metabolism and circulation. From a physiological standpoint, inhibiting TLR4 in large animal experimental SI‐AKI significantly improves renal function. Thus, current evidence indicates that TLR4 has the ability to mediate SI‐AKI by a number of mechanisms. The strong experimental evidence supporting a role of TLR4 in the pathogenesis of SI‐AKI in combination with the availability of pharmacological tools to target TLR4 warrants future human studies.

National Trends and Impact of Acute Kidney Injury Requiring Hemodialysis in Hospitalizations With Atrial Fibrillation

BACKGROUND

Atrial fibrillation (AF) is a common cause for hospitalization, but there are limited data regarding acute kidney injury requiring dialysis (AKI-D) in AF hospitalizations. We aimed to assess temporal trends and outcomes in AF hospitalizations complicated by AKI-D utilizing a nationally representative database.

METHODS AND RESULTS

Utilizing the Nationwide Inpatient Sample, AF hospitalizations and AKI-D were identified using diagnostic and procedure codes. Trends were analyzed overall and within subgroups and utilized multivariable logistic regression to generate adjusted odds ratios (aOR) for predictors and outcomes including mortality and adverse discharge. Between 2003 and 2012, 3751 (0.11%) of 3 497 677 AF hospitalizations were complicated by AKI-D. The trend increased from 0.3/1000 hospitalizations in 2003 to 1.5/1000 hospitalizations in 2012, with higher increases in males and black patients. Temporal changes in demographics and comorbidities explained a substantial proportion but not the entire trend. Significant comorbidities associated with AKI-D included mechanical ventilation (aOR 13.12; 95% CI 9.88-17.43); sepsis (aOR 8.20; 95% CI 6.00-11.20); and liver failure (aOR 3.72; 95% CI 2.92-4.75). AKI-D was associated with higher risk of in-hospital mortality (aOR 3.54; 95% CI 2.81-4.47) and adverse discharge (aOR 4.01; 95% CI 3.12-5.17). Although percentage mortality within AKI-D decreased over the decade, attributable risk percentage mortality remained stable.

CONCLUSIONS

AF hospitalizations complicated by AKI-D have quintupled over the last decade with differential increase by demographic groups. AKI-D is associated with significant morbidity and mortality. Without effective AKI-D therapies, focus should be on early risk stratification and prevention to avoid this devastating complication.

Changes in kidney perfusion and renal cortex metabolism in septic shock: an experimental study

BACKGROUND

The etiology of renal dysfunction in sepsis is currently attributed to altered perfusion, microcirculatory abnormalities and cellular alterations. To clarify these mechanisms, we characterized the changes in renal perfusion and cortex metabolism in a large animal model of sepsis.

METHODS

We studied 12 adult female sheep randomized to peritonitis-induced sepsis (n = 8) or to sham procedure (n = 4). A flow probe was positioned around the renal artery to measure renal blood flow (RBF). Laser Doppler was used to measure regional flow in the kidney cortex and medulla. A microdialysis probe was inserted into the renal cortex to measure cortical glucose, lactate, and pyruvate. Fluid resuscitation was provided to keep pulmonary artery occlusion pressure at baseline levels. All animals were observed for 18 h.

RESULTS

Hypotension occurred after 9 h in the septic animals (P = 0.02 versus baseline). RBF and cortical flow were significantly lower than at baseline from 12 h in the septic animals (P = 0.01 and P = 0.03, respectively). Cortical lactate and pyruvate levels increased in the septic animals from 3 and from 6 h, respectively (both P = 0.02 versus baseline), and the L/P ratio from 15 h (P = 0.01). There was a correlation between cortical flow and cortical L/P ratio after shock onset (r = -0.60, P = 0.002) but not before.

CONCLUSIONS

In this peritonitis model, sepsis was associated with metabolic alterations that may reflect early induction of cortical glycolysis. Septic shock was associated with reduced renal perfusion and decreased cortical and medullary blood flow, followed by signs of anaerobic metabolism in the cortex when flow reductions became critical.

Trends and Outcomes of Severe Sepsis in Patients on Maintenance Dialysis

BACKGROUND

Though the incidence of severe sepsis is rising, there is a lack of contemporary information regarding the epidemiology and outcomes of severe sepsis in those on maintenance dialysis. The objectives of this study were to measure the incidence and outcomes of severe sepsis in those on maintenance dialysis.

METHODS

Using data from Nationwide Inpatient Sample database from 2005 to 2010, we included all hospitalizations of adults with severe sepsis based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Those on maintenance dialysis were identified by ICD-9-CM codes. We calculated incidence of severe sepsis and mortality. We used logistic regression to assess independent effect of maintenance dialysis status on mortality.

RESULTS

Of the estimated 5,000,152 hospitalizations with severe sepsis, 322,734 (6.4%) were on maintenance dialysis. The unadjusted incidence of severe sepsis was 145.4 per 1,000 in those on maintenance dialysis in comparison to 3.5 per 1,000 in the general population. Mortality was higher in those with severe sepsis (30.3 vs. 26.2%; p < 0.001). Maintenance dialysis is an independent predictor of death in those with severe sepsis (OR 1.26; 95% CI 1.23-1.29).

CONCLUSIONS

Hospitalizations with severe sepsis are more prevalent and associated with poor outcomes in those on maintenance dialysis.

Dialysis-Requiring Acute Kidney Injury in Denmark 2000-2012: Time Trends of Incidence and Prevalence of Risk Factors-A Nationwide Study

Introduction

Dialysis-requiring acute kidney injury is a severe illness associated with poor prognosis. However, information pertaining to incidence rates and prevalence of risk factors remains limited in spite of increasing focus. We evaluate time trends of incidence rates and changing patterns in prevalence of comorbidities, concurrent medication, and other risk factors in nationwide retrospective cohort study.

Materials and Methods

All patients with dialysis-requiring acute kidney injury were identified between January 1^st 2000 and December 31^st 2012. By cross-referencing data from national administrative registries, the association of changing patterns in dialysis treatment, comorbidity, concurrent medication and demographics with incidence of dialysis-requiring acute kidney injury was evaluated.

Results

A total of 18,561 adult patients with dialysis-requiring AKI were identified between 2000 and 2012. Crude incidence rate of dialysis-requiring AKI increased from 143 per million (95% confidence interval, 137–144) in 2000 to 366 per million (357–375) in 2006, and remained stable hereafter. Notably, incidence of continuous veno-venous hemodialysis (CRRT) and use of acute renal replacement therapy in elderly >75 years increased substantially from 23 per million (20–26) and 328 per million (300–355) in 2000, to 213 per million (206–220) and 1124 per million (1076–1172) in 2012, respectively. Simultaneously, patient characteristics and demographics shifted towards increased age and comorbidity.

Conclusions

Although growth in crude incidence rate of dialysis-requiring AKI stabilized in 2006, continuous growth in use of CRRT, and acute renal replacement therapy of elderly patients >75 years, was observed. Our results indicate an underlying shift in clinical paradigm, as opposed to unadulterated growth in incidence of dialysis-requiring AKI.