Impact of End-Stage Renal Disease and Acute Kidney Injury on ICU Outcomes in Patients With Sepsis

Fluid Resuscitation and Sepsis Management in Patients with Chronic Kidney Disease or End-Stage Renal Disease: Scoping Review

Managing sepsis and fluid resuscitation in patients with chronic kidney disease or end-stage renal disease is challenging for health care providers. Nurses are essential for early identification and treatment of these patients. Nurse education on assessing perfusion and implementing 3-hour bundled care can improve mortality rates in patients with sepsis. In this scoping review, initial screening identified 1176 articles published from 2015 through 2023 in the National Library of Medicine database; 29 articles were included in the literature summary and evidence synthesis. A systematic review meta-analysis was not possible because of data heterogeneity. The review revealed that most patients with chronic kidney disease or end-stage renal disease received more conservative resuscitation than did the general population, most likely because of concerns about volume overload. However, patients with chronic kidney disease or end-stage renal disease could tolerate the standard initial fluid resuscitation bolus of 30 mL/kg for sepsis. Outcomes in patients with chronic kidney disease or end-stage renal disease were similar to outcomes in patients without those conditions, whether they received standard or conservative fluid resuscitation. Patients who received the standard (higher) fluid resuscitation volume did not have increased rates of complications such as longer duration of mechanical ventilation, increased mortality, or prolonged length of stay. Using fluid responsiveness to guide resuscitation was associated with improved outcomes. The standard initial fluid resuscitation bolus of 30 mL/kg may be safe for patients with chronic kidney disease or end-stage renal disease and sepsis. Fluid responsiveness could be a valuable resuscitation criterion, promoting better decision-making by multidisciplinary teams. Further research is required.

Risk factors and mortality in patients with sepsis, septic and non septic acute kidney injury in ICU

Acute kidney injury (AKI) has an incidence rate of 5-6% among intensive care unit (ICU) patients and sepsis is the most frequent etiology.

CXCL14 Overexpression Attenuates Sepsis-Associated Acute Kidney Injury by Inhibiting Proinflammatory Cytokine Production

CXCL14 is a relatively novel chemokine with a wide spectrum of biological activities. The present study was designed to investigate whether CXCL14 overexpression attenuates sepsis-associated acute kidney injury (AKI) in mice. Sepsis model has been established by cecal ligation and puncture (CLP). CLP induced AKI in mice as assessed by increased renal neutrophil gelatinase-associated lipocalin (NGAL) expression and serum creatinine levels. We found that renal CXCL14 expression in the kidney was significantly decreased at 12 hours after CLP. Correlation analysis demonstrated a negative association between renal CXCL14 expression and AKI markers including serum creatinine and renal NGAL. Moreover, CXCL14 overexpression reduced cytokine (TNF-α, IL-6, and IL-1β) production and NGAL expression in the kidney and decreased serum creatinine levels. In vivo and in vitro experiments found that CXCL14 overexpression inhibited M1 macrophage polarization but increased M2 polarization. Together, these results suggest that CXCL14 overexpression attenuates sepsis-associated AKI probably through the downregulation of macrophages-derived cytokine production. However, further studies are required to elucidate the underlying mechanism.

Urinary versus plasma neutrophil gelatinase-associated lipocalin (NGAL) as a predictor of mortality for acute kidney injury in intensive care unit patients

OBJECTIVE

To examine urinary and plasma neutrophil gelatinase-associated lipocalin (NGAL) levels in predicting ICU mortality.

DESIGN

Prospective observational.

SETTING

University Critical Care setting.

PARTICIPANTS

50 patients with acute kidney injury (AKI).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Serial urinary and plasma concentrations of NGAL were measured. Twenty-five patients had early progression (EP) and 25 patients had early improvement (EI) of AKI. Plasma concentrations of NGAL in the EP group (N=25) were significantly higher than those in the EI group (129 [IQR; 20] vs. 111 [IQR; 32] ng/mL; P=0.009), while urine NGAL levels on admission were similar in both groups (61 [IQR; 20] vs. 65 [IQR; 20] ng/mL; P=0.767). Plasma NGAL concentrations rapidly decreased to 87 [32] ng/mL in the EI group (P<0.001) and while it remained elevated in the EP group (138 [21] ng/mL). Within 28-days, 50% of the patients died in the EP group, whereas no patient died in the EI group (P<0.001). Plasma NGAL was a fair predictor for progression of AKI (AUC; 0.719±0.063; P=0.006). 48-hour changes in plasma NGAL levels predicted death within 28-days of ICU admission (AUC; 0.874±0.048; P<0.001).

CONCLUSION

Early progression of AKI was associated with more death within 28 and 90days. While one time measurement of plasma NGAL levels at the time ICU admission may represent the kidney health status in critical care settings, it does not reliably predict mortality. On the other hand, changes in plasma NGAL within 48h of admission improve the value of this biomarker in predicting ICU mortality.