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White KC, Serpa-Neto A, Hurford R, Clement P, Laupland KB, Ostermann M, Sanderson B, Gatton M, Bellomo R. How a positive fluid balance develops in acute kidney injury: A binational, observational study. J Crit Care 2024; 82:154809. [PMID: 38609773 DOI: 10.1016/j.jcrc.2024.154809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/03/2023] [Accepted: 01/12/2024] [Indexed: 04/14/2024]
Abstract
PURPOSE A positive fluid balance (FB) is associated with harm in intensive care unit (ICU) patients with acute kidney injury (AKI). We aimed to understand how a positive balance develops in such patients. METHODS Multinational, retrospective cohort study of critically ill patients with AKI not requiring renal replacement therapy. RESULTS AKI occurred at a median of two days after admission in 7894 (17.3%) patients. Cumulative FB became progressively positive, peaking on day three despite only 848 (10.7%) patients receiving fluid resuscitation in the ICU. In those three days, persistent crystalloid use (median:60.0 mL/h; IQR 28.9-89.2), nutritional intake (median:18.2 mL/h; IQR 0.0-45.9) and limited urine output (UO) (median:70.8 mL/h; IQR 49.0-96.7) contributed to a positive FB. Although UO increased each day, it failed to match input, with only 797 (10.1%) patients receiving diuretics in ICU. After adjustment, a positive FB four days after AKI diagnosis was associated with an increased risk of hospital mortality (OR 1.12;95% confidence intervals 1.05-1.19;p-value <0.001). CONCLUSION Among ICU patients with AKI, cumulative FB increased after diagnosis and was associated with an increased risk of mortality. Continued crystalloid administration, increased nutritional intake, limited UO, and minimal use of diuretics all contributed to positive FB. KEY POINTS Question How does a positive fluid balance develop in critically ill patients with acute kidney injury? Findings Cumulative FB increased after AKI diagnosis and was secondary to persistent crystalloid fluid administration, increasing nutritional fluid intake, and insufficient urine output. Despite the absence of resuscitation fluid and an increasing cumulative FB, there was persistently low diuretics use, ongoing crystalloid use, and a progressive escalation of nutritional fluid therapy. Meaning Current management results in fluid accumulation after diagnosis of AKI, as a result of ongoing crystalloid administration, increasing nutritional fluid, limited urine output and minimal diuretic use.
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Affiliation(s)
- Kyle C White
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Queensland University of Technology (QUT), Brisbane, Queensland, Australia.
| | - Ary Serpa-Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Rod Hurford
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Pierre Clement
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Kevin B Laupland
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia; Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, Department of Critical Care, London, UK
| | - Barnaby Sanderson
- King's College London, Guy's & St Thomas' Hospital, Department of Critical Care, London, UK
| | - Michelle Gatton
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Heidelberg, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
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Ma B, Jin G, Mao F, Zhou M, Li Y, Hu W, Cai X. Development of a nomogram to predict the incidence of acute kidney injury among ischemic stroke individuals during ICU hospitalization. Heliyon 2024; 10:e25566. [PMID: 38352771 PMCID: PMC10862667 DOI: 10.1016/j.heliyon.2024.e25566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 12/26/2023] [Accepted: 01/29/2024] [Indexed: 02/16/2024] Open
Abstract
Background Limited clinical prediction models exist to assess the likelihood of acute kidney injury (AKI) occurrence in ischemic stroke individuals. In this retrospective study, our aim was to construct a nomogram that utilizes commonly available clinical features to predict the occurrence of AKI during intensive care unit hospitalization among this patient population. Methods In this study, the MIMIC-IV database was utilized to investigate potential risk factors associated with the incidence of AKI among ischemic stroke individuals. A predictive nomogram was developed based on these identified risk factors. The discriminative performance of the constructed nomogram was assessed. Calibration analysis was utilized to evaluate the calibration performance of the constructed model, assessing the agreement between predicted probabilities and actual outcomes. Furthermore, decision curve analysis (DCA) was employed to assess the clinical net benefit, taking into account the potential risks and benefits associated with different decision thresholds. Results A total of 2089 ischemic stroke individuals were included and randomly allocated into developing (n = 1452) and verification cohorts (n = 637). Risk factors for AKI incidence in ischemic stroke individuals, determined through LASSO and logistic regression. The constructed nomogram had good performance in predicting the occurrence of AKI among ischemic stroke patients and provided significant improvement compared to existing scoring systems. DCA demonstrated satisfactory clinical net benefit of the constructed nomogram in both the validation and development cohorts. Conclusions The developed nomogram exhibits robust predictive performance in forecasting AKI occurrence in ischemic stroke individuals.
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Affiliation(s)
- Buqing Ma
- Department of Critical Care Medicine, Hangzhou First People's Hospital, Hangzhou, China
| | - Guangyong Jin
- Department of Critical Care Medicine, Hangzhou First People's Hospital, Hangzhou, China
| | - Fengkai Mao
- Affiliated Hospital of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, China
| | - Menglu Zhou
- Department of Neurology, Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Yiwei Li
- Department of Critical Care Medicine, Hangzhou First People's Hospital, Hangzhou, China
| | - Wei Hu
- Department of Critical Care Medicine, Hangzhou First People's Hospital, Hangzhou, China
| | - Xuwen Cai
- Department of Critical Care Medicine, Hangzhou First People's Hospital, Hangzhou, China
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Jiang M, Pan CQ, Li J, Xu LG, Li CL. Explainable machine learning model for predicting furosemide responsiveness in patients with oliguric acute kidney injury. Ren Fail 2023; 45:2151468. [PMID: 36645039 PMCID: PMC9848233 DOI: 10.1080/0886022x.2022.2151468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Although current guidelines didn't support the routine use of furosemide in oliguric acute kidney injury (AKI) management, some patients may benefit from furosemide administration at an early stage. We aimed to develop an explainable machine learning (ML) model to differentiate between furosemide-responsive (FR) and furosemide-unresponsive (FU) oliguric AKI. METHODS From Medical Information Mart for Intensive Care-IV (MIMIC-IV) and eICU Collaborative Research Database (eICU-CRD), oliguric AKI patients with urine output (UO) < 0.5 ml/kg/h for the first 6 h after ICU admission and furosemide infusion ≥ 40 mg in the following 6 h were retrospectively selected. The MIMIC-IV cohort was used in training a XGBoost model to predict UO > 0.65 ml/kg/h during 6-24 h succeeding the initial 6 h for assessing oliguria, and it was validated in the eICU-CRD cohort. We compared the predictive performance of the XGBoost model with the traditional logistic regression and other ML models. RESULTS 6897 patients were included in the MIMIC-IV training cohort, with 2235 patients in the eICU-CRD validation cohort. The XGBoost model showed an AUC of 0.97 (95% CI: 0.96-0.98) for differentiating FR and FU oliguric AKI. It outperformed the logistic regression and other ML models in correctly predicting furosemide diuretic response, achieved 92.43% sensitivity (95% CI: 90.88-93.73%) and 95.12% specificity (95% CI: 93.51-96.3%). CONCLUSION A boosted ensemble algorithm can be used to accurately differentiate between patients who would and would not respond to furosemide in oliguric AKI. By making the model explainable, clinicians would be able to better understand the reasoning behind the prediction outcome and make individualized treatment.
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Affiliation(s)
- Meng Jiang
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China,CONTACT Meng Jiang Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003Zhejiang Province, China
| | - Chun-qiu Pan
- Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China,Chun-qiu Pan Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, 510515Guangzhou, China
| | - Jian Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li-gang Xu
- Department of Critical Care Medicine, Wuhan Central Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chang-li Li
- Department of FSTC Clinic of The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China,Chang-li Li Department of FSTC Clinic of The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003Zhejiang Province, China
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Xing J, Loh SKN. Perioperative acute kidney injury: Current knowledge and the role of anaesthesiologists. PROCEEDINGS OF SINGAPORE HEALTHCARE 2023. [DOI: 10.1177/20101058231163406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
Background Among the different types of perioperative organ injury, acute kidney injury (AKI) occurs frequently and is consistently associated with increased rates of mortality and mortality. Despite development of many clinical trials to assess perioperative interventions, reliable means to prevent or reverse AKI are still lacking. Objectives This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and potential directions for future research. Methods A Pubmed search with the relevant keywords was done for articles published in the last 10 years. Results New insights into preoperative identification and optimisation, intraoperative strategies, including the choice of anaesthetic, haemodynamic and fluid management, have been made, with the aim of preventing perioperative AKI. Conclusion A patient-centric multidisciplinary approach is essential to protect kidney function of patients going for surgery. Much can be done by anaesthesiologists perioperatively, to reduce the risk of development of AKI, especially in susceptible patients. There is a need for further multicentred trials to enhance the currently generic perioperative recommendations.
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Affiliation(s)
- Jieyin Xing
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Samuel Kent Neng Loh
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
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Zhu S, Zheng Z, Wang L, Luo G, Zhang Y, Jia T, Wang Y, Dong H, Lei C. Association Between Loop Diuretics and Mortality in Patients With Cardiac Surgery-Associated Acute Kidney Injury: A Retrospective Propensity Score-Weighted Analysis. Anesth Analg 2023:00000539-990000000-00665. [PMID: 38009938 DOI: 10.1213/ane.0000000000006748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Although loop diuretics (LDs) have been widely used in clinical practice, their effect on mortality when administered to patients experiencing cardiac surgery-associated acute kidney injury (CS-AKI) remains unknown. The study aimed to investigate the effectiveness of LD use in patients with CS-AKI. METHODS Patients who underwent cardiac surgery with AKI were identified from the Medical Information Mart for Intensive Care III. Postoperative LD use in intensive care units (ICUs) was exposure. There were 2 primary outcome measures, the in-hospital mortality and ICU mortality; both were treated as time-to-event data and were analyzed via multivariable Cox proportional hazard models. Inverse probability weighting (IPW) was used to minimize bias. RESULTS The study enrolled a total of 5478 patients, with a median age of 67 years, among which 2205 (40.3%) were women. The crude in-hospital and ICU mortality rates were significantly lower in the LD use group (525 of 4150 [12.7%] vs 434 of 1328 [32.7%], P < .001; 402 of 4150 [9.69%] vs 333 of 1328 [25.1%], P < .001). Adjusted hazard ratios suggested significant reductions in both in-hospital (hazard ratio [HR], 0.428; 95% confidence interval [CI], 0.374-0.489) and ICU mortality (HR, 0.278; 95% CI, 0.238-0.327). The IPW data showed a similar reduction, in-hospital mortality (HR, 0.434; 95% CI, 0.376-0.502) and ICU mortality (HR, 0.296; 95% CI, 0.251-0.349). Such association may act differently for patients with different fluid balance (P value for interaction < .001). CONCLUSIONS LD use is associated with lower hospital and ICU mortality in CS-AKI patients in general. Patients under different conditions showed diverse responses toward such treatment indicating that personalized management is needed.
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Affiliation(s)
- Shouqiang Zhu
- From the Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ziyu Zheng
- From the Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
- Anesthesia Clinical Research Center, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Lini Wang
- From the Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Gang Luo
- From the Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yue Zhang
- From the Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Tao Jia
- From the Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yi Wang
- From the Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Hailong Dong
- From the Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Chong Lei
- From the Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Hayashi Y, Shimazui T, Tomita K, Shimada T, Miura RE, Nakada TA. Associations between fluid overload and outcomes in critically ill patients with acute kidney injury: a retrospective observational study. Sci Rep 2023; 13:17410. [PMID: 37833430 PMCID: PMC10575912 DOI: 10.1038/s41598-023-44778-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/12/2023] [Indexed: 10/15/2023] Open
Abstract
Increased fluid overload (FO) is associated with poor outcomes in critically ill patients, especially in acute kidney injury (AKI). However, the exact timing from when FO influences outcomes remains unclear. We retrospectively screened intensive care unit (ICU) admitted patients with AKI between January 2011 and December 2015. Logistic or linear regression analyses were performed to determine when hourly %FO was significant on 90-day in-hospital mortality (primary outcome) or ventilator-free days (VFDs). In total, 1120 patients were enrolled in this study. Univariate analysis showed that a higher %FO was significantly associated with higher mortality from the first hour of ICU admission (odds ratio 1.34, 95% confidence interval 1.15-1.56, P < 0.001), whereas multivariate analysis adjusted with age, sex, APACHE II score, and sepsis etiology showed the association was significant from the 27th hour. Both univariate and multivariate analyses showed that a higher %FO was significantly associated with shorter VFDs from the 1st hour. The significant associations were retained during all following observation periods after they showed significance. In patients with AKI, a higher %FO was associated with higher mortality and shorter VFDs from the early phase after ICU admission. FO should be administered with a physiological target or goal in place from the initial phase of critical illness.
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Affiliation(s)
- Yosuke Hayashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Takashi Shimazui
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Keisuke Tomita
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Tadanaga Shimada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Rie E Miura
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
- Smart119 Inc., 2-5-1 Chuo, Chiba, 260-0013, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan.
- Smart119 Inc., 2-5-1 Chuo, Chiba, 260-0013, Japan.
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Lu S, Huang W, He H, Huang X, Li J, Lei Y, Feng G, Xu W, Zhang X. Retrospective analysis on incidence and risk factors for early acute renal injury after lung transplantation. Transpl Immunol 2023; 80:101889. [PMID: 37414263 DOI: 10.1016/j.trim.2023.101889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/21/2023] [Accepted: 07/01/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Acute renal injury (AKI) is a common complication of lung transplantation. However, there has been no related research on whether the relationship between fluid balance and input and output influences the occurrence of early AKI. This study aimed to explore the relationship between early fluid balance and input and output on the incidence of early AKI after lung transplantation. METHODS Data from 31 patients who underwent lung transplantation in the Department of Intensive Care Medicine of the Sichuan Academy of Medical Sciences, Sichuan People's Hospital, from August 2018 to July 2021 were collected. To summarize the occurrence of early AKI after lung transplantation, The main indicators of lung transplantation patients were collected. The risk factors for early AKI after lung transplantation were analyzed. RESULTS Among the 31 patients who underwent lung transplantation, 21 had early postoperative AKI, with an incidence rate of 67.7%. Compared with the non-AKI group, the hospitalization and ICU hospitalization times of the AKI group were longer (P < 0.05). Multivariate regression analysis showed that intraoperative input volume, BMI, and fluid balance on the first day after lung transplantation were independent risk factors for AKI. CONCLUSION Intraoperative input volume, BMI, and fluid balance on the first day after lung transplantation were independent risk factors for AKI.
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Affiliation(s)
- Sen Lu
- Department of ICU, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Weiwei Huang
- Department of Critical Care Medicine, Chengdu Second People's Hospital, Chengdu 610072, China
| | - Hongli He
- Department of ICU, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Xiaobo Huang
- Department of ICU, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Jiajin Li
- Department of Critical Care Medicine, Mianyang People's Hospital, Mianyang 621053, China
| | - Yu Lei
- Department of ICU, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Gang Feng
- Department of Thoracic Surgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Wei Xu
- Department of Critical Care Medicine, Chengdu Seventh People's Hospital, Chengdu 610072, China.
| | - Xiaoqin Zhang
- Department of ICU, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610072, China.
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Teixeira JP, Zeidman A, Beaubien-Souligny W, Cerdá J, Connor MJ, Eggleston K, Juncos LA, da Silva JR, Wells C, Yessayan L, Barker AB, McConville W, Speer R, Wille KM, Neyra JA, Tolwani A. Proceedings of the 2022 UAB CRRT Academy: Non-Invasive Hemodynamic Monitoring to Guide Fluid Removal with CRRT and Proliferation of Extracorporeal Blood Purification Devices. Blood Purif 2023; 52:857-879. [PMID: 37742622 DOI: 10.1159/000533573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/29/2023] [Indexed: 09/26/2023]
Abstract
In 2022, we celebrated the 15th anniversary of the University of Alabama at Birmingham (UAB) Continuous Renal Replacement Therapy (CRRT) Academy, a 2-day conference attended yearly by an international audience of over 100 nephrology, critical care, and multidisciplinary trainees and practitioners. This year, we introduce the proceedings of the UAB CRRT Academy, a yearly review of select emerging topics in the field of critical care nephrology that feature prominently in the conference. First, we review the rapidly evolving field of non-invasive hemodynamic monitoring and its potential to guide fluid removal by renal replacement therapy (RRT). We begin by summarizing the accumulating data associating fluid overload with harm in critical illness and the potential for harm from end-organ hypoperfusion caused by excessive fluid removal with RRT, underscoring the importance of accurate, dynamic assessment of volume status. We describe four applications of point-of-care ultrasound used to identify patients in need of urgent fluid removal or likely to tolerate fluid removal: lung ultrasound, inferior vena cava ultrasound, venous excess ultrasonography, and Doppler of the left ventricular outflow track to estimate stroke volume. We briefly introduce other minimally invasive hemodynamic monitoring technologies before concluding that additional prospective data are urgently needed to adapt these technologies to the specific task of fluid removal by RRT and to learn how best to integrate them into practical fluid-management strategies. Second, we focus on the growth of novel extracorporeal blood purification devices, starting with brief reviews of the inflammatory underpinnings of multiorgan dysfunction and the specific applications of pathogen, endotoxin, and/or cytokine removal and immunomodulation. Finally, we review a series of specific adsorptive technologies, several of which have seen substantial clinical use during the COVID-19 pandemic, describing their mechanisms of target removal, the limited existing data supporting their efficacy, ongoing and future studies, and the need for additional prospective trials.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology and Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Amanda Zeidman
- Division of Nephrology, Department of Medicine, Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Jorge Cerdá
- Department of Medicine, Nephrology, Albany Medical College, Albany, New York, USA
| | - Michael J Connor
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine and Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Luis A Juncos
- Division of Nephrology, Department of Internal Medicine, Central Arkansas Veterans' Healthcare System, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Catherine Wells
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew B Barker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Wendy McConville
- School of Nursing, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Rajesh Speer
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Keith M Wille
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Ashita Tolwani
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
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Hu T, Huang R. Urine output for predicting in-hospital mortality of intensive care patients with cardiogenic shock. Heliyon 2023; 9:e16295. [PMID: 37274659 PMCID: PMC10238887 DOI: 10.1016/j.heliyon.2023.e16295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 06/06/2023] Open
Abstract
Background The role of urine output (UO) in the first 24 h of admission in the clinical management of cardiogenic shock (CS) patients has not been elucidated. Methods This study retrospectively analyzed intensive care CS patients in the MIMIC-IV database. Binomial logistic regression analysis was conducted to evaluate whether UO was an independent risk factor for in-hospital mortality in CS patients. The performance of UO in predicting mortality was evaluated by the receiver operating characteristic (ROC) curve and compared with the Oxford Acute Severity of Illness Score (OASIS). The clinical net benefit of UO in predicting mortality was determined using the decision curve analysis (DCA). Survival analysis was performed with Kaplan-Meier curves. Results After adjusting for confounding factors including diuretic use and acute kidney injury (AKI), UO remained an independent risk factor for in-hospital mortality in CS patients. The areas under the ROC curves (AUCs) of UO for predicting in-hospital mortality were 0.712 (UO, ml/day) and 0.701 (UO, ml/kg/h), which were comparable to OASIS (AUC = 0.695). In terms of clinical net benefit, UO was comparable to OASIS, with different degrees of benefit at different threshold probabilities. Survival analysis showed that the risk of in-hospital death in the low-UO (≤857 ml/day) group was 3.0143 times that of the high-UO (>857 ml/day) group. Conclusions UO in the first 24 h of admission is an independent risk factor for in-hospital mortality in intensive care CS patients and has moderate predictive value in predicting in-hospital mortality.
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Affiliation(s)
- Tianyang Hu
- Precision Medicine Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rongzhong Huang
- Precision Medicine Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Municipality Clinical Research Center for Geriatrics and Gerontology, Chongqing, China
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Lin CK, Tsai YH, Kao KC, Lin CM, Zhou SK, Ho MC, Huang SY, Fang YH, Chang CC, Lee WC, Lee YL, Chen MC, Hsieh MJ, Lin YC, Hung MS, Kuo WC, Lin BS. Serum vascular endothelial growth factor affects tissue fluid accumulation and is associated with deteriorating tissue perfusion and oxygenation in severe sepsis: a prospective observational study. Eur J Med Res 2023; 28:155. [PMID: 37085944 PMCID: PMC10120235 DOI: 10.1186/s40001-023-01119-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/11/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND Positive fluid balance and tissue fluid accumulation are associated with adverse outcomes in sepsis. Vascular endothelial growth factor (VEGF) increases in sepsis, promotes vascular permeability, and may affect tissue fluid accumulation and oxygenation. We used near-infrared spectroscopy (NIRS) to estimate tissue hemoglobin (Hb) oxygenation and water (H2O) levels to investigate their relationship with serum VEGF levels. MATERIAL AND METHODS New-onset severe sepsis patients admitted to the intensive care unit were enrolled. Relative tissue concentrations of oxy-Hb ([HbO2]), deoxy-Hb ([HbR]), total Hb ([HbT]), and H2O ([H2O]) were estimated by near-infrared spectroscopy (NIRS) for three consecutive days and serum VEGF levels were measured. Comparisons between oliguric and non-oliguric patients were conducted and the correlations between variables were analyzed. RESULTS Among 75 eligible patients, compared with non-oliguric patients, oliguric patients were administrated more intravascular fluids (median [IQR], 1926.00 [1348.50-3092.00] mL/day vs. 1069.00 [722.00-1486.75] mL/day, p < 0.001) and had more positive daily net intake and output (mean [SD], 1,235.06 [1303.14] mL/day vs. 313.17 [744.75] mL/day, p = 0.012), lower [HbO2] and [HbT] over the three-day measurement (analyzed by GEE p = 0.01 and 0.043, respectively) and significantly higher [H2O] on the third day than on the first two days (analyzed by GEE p = 0.034 and 0.018, respectively). Overall, serum VEGF levels were significantly negatively correlated with [HbO2] and [HbT] (rho = - 0.246 and - 0.266, p = 0.042 and 0.027, respectively) but positively correlated with [H2O] (rho = 0.449, p < 0.001). Subgroup analysis revealed a significant correlation between serum VEGF and [H2O] in oliguric patients (rho = 0.532, p = 0.003). Multiple regression analysis determined the independent effect of serum VEGF on [H2O] (standardized coefficient = 0.281, p = 0.038). CONCLUSIONS In severe sepsis, oliguria relates to higher positive fluid balance, lower tissue perfusion and oxygenation, and progressive tissue fluid accumulation. Elevated serum VEGF is associated with worsening tissue perfusion and oxygenation and independently affects tissue fluid accumulation.
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Affiliation(s)
- Chin-Kuo Lin
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, No. 6, West Sec. Chiapu Rd., Putzu City, Chiayi County, 61363, Taiwan
- Graduate Institute of Clinical Medicine Sciences, College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 33302, Taiwan
| | - Ying-Huang Tsai
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Linkou, Taoyuan City, 333, Taiwan
| | - Kuo-Chin Kao
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Linkou, Taoyuan City, 333, Taiwan
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan, 33302, Taiwan
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, 33305, Taiwan
| | - Chieh-Mo Lin
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, No. 6, West Sec. Chiapu Rd., Putzu City, Chiayi County, 61363, Taiwan
- Chang Gung University of Science and Technology, No. 2, West Sec. Jiapu Rd., Puzi City, Chiayi County, 61363, Taiwan
| | - Shao-Kui Zhou
- Institute of Imaging and Biomedical Photonics, National Yang Ming Chiao Tung University, No. 301, Gaotie 3Rd Road, Guiren Dist., Tainan City, 71150, Taiwan
| | - Meng-Chin Ho
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, No. 6, West Sec. Chiapu Rd., Putzu City, Chiayi County, 61363, Taiwan
| | - Shu-Yi Huang
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, No. 6, West Sec. Chiapu Rd., Putzu City, Chiayi County, 61363, Taiwan
- Chang Gung University of Science and Technology, No. 2, West Sec. Jiapu Rd., Puzi City, Chiayi County, 61363, Taiwan
| | - Yu-Hung Fang
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, No. 6, West Sec. Chiapu Rd., Putzu City, Chiayi County, 61363, Taiwan
| | - Che-Chia Chang
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, No. 6, West Sec. Chiapu Rd., Putzu City, Chiayi County, 61363, Taiwan
| | - Wei-Chun Lee
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, No. 6, West Sec. Chiapu Rd., Putzu City, Chiayi County, 61363, Taiwan
| | - Yueh-Lin Lee
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, No. 6, West Sec. Chiapu Rd., Putzu City, Chiayi County, 61363, Taiwan
| | - Min-Chi Chen
- Department of Public Health, Biostatistics Consulting Center, College of Medicine, Chang Gung University, No. 259, Wenhua 1st Road, Guishan Dist., Guishan, Taoyuan City, 33302, Taiwan
- Department of Hematology and Oncology, Chang Gung Memorial Hospital, No. 6, West Sec. Chiapu Rd, Putzu City, Chiayi County, 61363, Taiwan
| | - Meng-Jer Hsieh
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Linkou, Taoyuan City, 333, Taiwan
| | - Yu-Ching Lin
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, No. 6, West Sec. Chiapu Rd., Putzu City, Chiayi County, 61363, Taiwan
- Department of Respiratory Care, Chang Gung Memorial Hospital, No. 6, West Sec. Chiapu Rd, Putzu City, Chiayi County, 61363, Taiwan
- Department of Medicine, College of Medicine, Chang Gung University, No. 259, Wenhua 1st Road, Guishan Dist., Taoyuan City, 33302, Taiwan
| | - Ming-Szu Hung
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, No. 6, West Sec. Chiapu Rd., Putzu City, Chiayi County, 61363, Taiwan
- Department of Respiratory Care, Chang Gung Memorial Hospital, No. 6, West Sec. Chiapu Rd, Putzu City, Chiayi County, 61363, Taiwan
- Department of Medicine, College of Medicine, Chang Gung University, No. 259, Wenhua 1st Road, Guishan Dist., Taoyuan City, 33302, Taiwan
| | - Wen-Chun Kuo
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, No. 6, West Sec. Chiapu Rd., Putzu City, Chiayi County, 61363, Taiwan
| | - Bor-Shyh Lin
- Institute of Imaging and Biomedical Photonics, National Yang Ming Chiao Tung University, No. 301, Gaotie 3Rd Road, Guiren Dist., Tainan City, 71150, Taiwan.
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11
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Pfortmueller CA, Dabrowski W, Malbrain MLNG. Fluid de-resuscitation in critical illness - A journey into uncertain territory. J Crit Care 2023:154249. [PMID: 36870802 DOI: 10.1016/j.jcrc.2022.154249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 03/06/2023]
Affiliation(s)
- Carmen Andrea Pfortmueller
- Department of Intensive Care, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
| | - Wojciech Dabrowski
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland; International Fluid Academy, Lovenjoel, Belgium; Medical Data Management, Medaman, Geel, Belgium
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12
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Polz M, Bergmoser K, Horn M, Schörghuber M, Lozanović J, Rienmüller T, Baumgartner C. A system theory based digital model for predicting the cumulative fluid balance course in intensive care patients. Front Physiol 2023; 14:1101966. [PMID: 37123264 PMCID: PMC10133509 DOI: 10.3389/fphys.2023.1101966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 04/04/2023] [Indexed: 05/02/2023] Open
Abstract
Background: Surgical interventions can cause severe fluid imbalances in patients undergoing cardiac surgery, affecting length of hospital stay and survival. Therefore, appropriate management of daily fluid goals is a key element of postoperative intensive care in these patients. Because fluid balance is influenced by a complex interplay of patient-, surgery- and intensive care unit (ICU)-specific factors, fluid prediction is difficult and often inaccurate. Methods: A novel system theory based digital model for cumulative fluid balance (CFB) prediction is presented using recorded patient fluid data as the sole parameter source by applying the concept of a transfer function. Using a retrospective dataset of n = 618 cardiac intensive care patients, patient-individual models were created and evaluated. RMSE analyses and error calculations were performed for reasonable combinations of model estimation periods and clinically relevant prediction horizons for CFB. Results: Our models have shown that a clinically relevant time horizon for CFB prediction with the combination of 48 h estimation time and 8-16 h prediction time achieves high accuracy. With an 8-h prediction time, nearly 50% of CFB predictions are within ±0.5 L, and 77% are still within the clinically acceptable range of ±1.0 L. Conclusion: Our study has provided a promising proof of principle and may form the basis for further efforts in the development of computational models for fluid prediction that do not require large datasets for training and validation, as is the case with machine learning or AI-based models. The adaptive transfer function approach allows estimation of CFB course on a dynamically changing patient fluid balance system by simulating the response to the current fluid management regime, providing a useful digital tool for clinicians in daily intensive care.
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Affiliation(s)
- Mathias Polz
- Institute of Health Care Engineering with European Testing Center of Medical Devices, Graz University of Technology, Graz, STM, Austria
| | - Katharina Bergmoser
- Institute of Health Care Engineering with European Testing Center of Medical Devices, Graz University of Technology, Graz, STM, Austria
- CBmed Center for Biomarker Research in Medicine, Graz, STM, Austria
| | - Martin Horn
- Institute of Automation and Control, Graz University of Technology, Graz, STM, Austria
| | - Michael Schörghuber
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, STM, Austria
| | - Jasmina Lozanović
- Institute of Health Care Engineering with European Testing Center of Medical Devices, Graz University of Technology, Graz, STM, Austria
| | - Theresa Rienmüller
- Institute of Health Care Engineering with European Testing Center of Medical Devices, Graz University of Technology, Graz, STM, Austria
| | - Christian Baumgartner
- Institute of Health Care Engineering with European Testing Center of Medical Devices, Graz University of Technology, Graz, STM, Austria
- *Correspondence: Christian Baumgartner,
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13
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Inkinen N, Pettilä V, Valkonen M, Serlo M, Bäcklund M, Hästbacka J, Pulkkinen A, Selander T, Vaara ST. Non-interventional follow-up versus fluid bolus in RESPONSE to oliguria in hemodynamically stable critically ill patients: a randomized controlled pilot trial. Crit Care 2022; 26:401. [PMID: 36550559 PMCID: PMC9773608 DOI: 10.1186/s13054-022-04283-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Fluid bolus therapy is a common intervention to improve urine output. Data concerning the effect of a fluid bolus on oliguria originate mainly from observational studies and remain controversial regarding the actual benefit of such therapy. We compared the effect of a follow-up approach without fluid bolus to a 500 mL fluid bolus on urine output in hemodynamically stable critically ill patients with oliguria at least for 2 h (urine output < 0.5 mL/kg/h) in randomized setting. METHODS We randomized 130 patients in 1:1 fashion to receive either (1) non-interventional follow-up (FU) for 2 h or (2) 500 mL crystalloid fluid bolus (FB) administered over 30 min. The primary outcome was the proportion of patients who doubled their urine output, defined as 2-h urine output post-randomization divided by urine output 2 h pre-randomization. The outcomes were adjusted for the stratification variables (presence of sepsis or AKI) using two-tailed regression. Obtained odds ratios were converted to risk ratios (RR) with 95% confidence intervals (CI). The between-group difference in the continuous variables was compared using mean or median regression and expressed with 95% CIs. RESULTS Altogether 10 (15.9%) of 63 patients in the FU group and 22 (32.8%) of 67 patients in FB group doubled their urine output during the 2-h period, RR (95% CI) 0.49 (0.23-0.71), P = 0.026. Median [IQR] change in individual urine output 2 h post-randomization compared to 2 h pre-randomization was - 7 [- 19 to 17] mL in the FU group and 19[0-53] mL in the FB group, median difference (95% CI) - 23 (- 36 to - 10) mL, P = 0.001. Median [IQR] duration of oliguria in the FU group was 4 [2-8] h and in the FB group 2 [0-6] h, median difference (95%CI) 2 (0-4) h, P = 0.038. Median [IQR] cumulative fluid balance on study day was lower in the FU group compared to FB group, 678 [518-1029] mL versus 1071 [822-1505] mL, respectively, median difference (95%CI) - 387 (- 635 to - 213) mL, P < 0.001. CONCLUSIONS Follow-up approach to oliguria compared to administering a fluid bolus of 500 mL crystalloid in oliguric patients improved urine output less frequently but lead to lower cumulative fluid balance. Trial registration clinical. TRIALS gov, NCT02860572. Registered 9 August 2016.
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Affiliation(s)
- Nina Inkinen
- grid.460356.20000 0004 0449 0385Department of Anesthesia and Intensive Care, Central Finland Hospital Nova, Central Finland Health Care District, Hoitajantie 3, 40620 Jyväskylä, Finland ,grid.7737.40000 0004 0410 2071Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Pettilä
- grid.7737.40000 0004 0410 2071Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Miia Valkonen
- grid.7737.40000 0004 0410 2071Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maija Serlo
- grid.7737.40000 0004 0410 2071Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Minna Bäcklund
- grid.7737.40000 0004 0410 2071Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Johanna Hästbacka
- grid.7737.40000 0004 0410 2071Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anni Pulkkinen
- grid.460356.20000 0004 0449 0385Department of Anesthesia and Intensive Care, Central Finland Hospital Nova, Central Finland Health Care District, Hoitajantie 3, 40620 Jyväskylä, Finland
| | - Tuomas Selander
- grid.410705.70000 0004 0628 207XScience Service Center, Kuopio University Hospital, Kuopio, Finland
| | - Suvi T. Vaara
- grid.7737.40000 0004 0410 2071Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Abstract
Postoperative AKI is a common complication of major surgery and is associated with significant morbidity and mortality. The Kidney Disease Improving Global Outcomes AKI definition allows consensus classification and identification of postoperative AKI through changes in serum creatinine and/or urine output. However, such conventional diagnostic criteria may be inaccurate in the postoperative period, suggesting a potential to refine diagnosis by application of novel diagnostic biomarkers. Risk factors for the development of postoperative AKI can be thought of in terms of preoperative, intraoperative, and postoperative factors and, as such, represent areas that may be targeted perioperatively to minimize the risk of AKI. The treatment of postoperative AKI remains predominantly supportive, although application of management bundles may translate into improved outcomes.
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Affiliation(s)
- Naomi Boyer
- Department of Critical Care, Royal Surrey Hospital, Guildford, United Kingdom
- SPACeR Group (Surrey Peri-Operative, Anaesthesia and Critical Care Collaborative Research Group), Royal Surrey Hospital, Guildford, United Kingdom
| | - Jack Eldridge
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
- Adult Critical Care Unit, Royal London Hospital Barts Health National Health Service Trust, London, United Kingdom
| | - John R. Prowle
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
- Adult Critical Care Unit, Royal London Hospital Barts Health National Health Service Trust, London, United Kingdom
| | - Lui G. Forni
- Department of Critical Care, Royal Surrey Hospital, Guildford, United Kingdom
- SPACeR Group (Surrey Peri-Operative, Anaesthesia and Critical Care Collaborative Research Group), Royal Surrey Hospital, Guildford, United Kingdom
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, United Kingdom
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15
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Chang HH, Wu CL, Tsai CC, Chiu PF. Association between predialysis creatinine and mortality in acute kidney injury patients requiring dialysis. PLoS One 2022; 17:e0274883. [PMID: 36155549 PMCID: PMC9512211 DOI: 10.1371/journal.pone.0274883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/06/2022] [Indexed: 11/30/2022] Open
Abstract
Background Creatinine is widely used to estimate renal function, but this is not practical in critical illness. Low creatinine has been associated with mortality in many clinical settings. However, the associations between predialysis creatinine level, Sepsis-related Organ Failure Assessment (SOFA) score, fluid overload, and mortality in acute kidney injury patients receiving dialysis therapy (AKI-D) has not been fully addressed. Methods We extracted data for AKI-D patients in the eICU and MIMIC databases. We conducted a retrospective observational cohort study using the eICU dataset. The study cohort was divided into the high-creatine group and the low-creatinine group by the median value (4 mg/dL). The baseline patient information included demographic data, laboratory tests, medications, and comorbid conditions. The independent association of creatinine level with 30-day mortality was examined using multivariate logistic regression analysis. In sensitivity analyses, the associations between creatinine, SOFA score, and mortality were analyzed in patients with or without fluid overload. We also carried out an external validity using the MIMIC dataset. Results In all 1,600 eICU participants, the 30-day mortality rate was 34.2%. The crude overall mortality rate in the low-creatinine group (44.9%) was significantly higher than that in the high-creatinine group (21.9%; P < 0.001). In the fully adjusted models, the low-creatinine group was associated with a higher risk of 30-day mortality (odds ratio, 1.77; 95% confidence interval, 1.29–2.42; P < 0.001) compared with the high-creatinine group. The low-creatinine group had higher SOFA and nonrenal SOFA scores. In sensitivity analyses, the low-creatinine group had a higher 30-day mortality rate with regard to the BMI or albumin level. Fluid overloaded patients were associated with a significantly worse survival in the low-creatinine group. The results were consistent when assessing the external validity using the MIMIC dataset. Conclusions In patients with AKI-D, lower predialysis creatinine was associated with increased mortality risk. Moreover, the mortality rate was substantially higher in patients with lower predialysis creatinine with concomitant elevation of fluid overload status.
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Affiliation(s)
- Hsin-Hsiung Chang
- Division of Nephrology, Department of Internal Medicine, Antai Medical Care Corporation Antai Tian-Sheng Memorial Hospital, Dongguan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Paochien Hospital, Pingtung, Taiwan
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan City, Taiwan
- * E-mail:
| | - Chia-Lin Wu
- Division of Nephrology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chun-Chieh Tsai
- Division of Nephrology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Ping-Fang Chiu
- Division of Nephrology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
- Department of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Hospitality Management, MingDao University, Changhua, Taiwan
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16
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Li L, Zhang Z, Xiong Y, Hu Z, Liu S, Tu B, Yao Y. Relationship Between Initial Urine Output and Mortality in Patients Hospitalized in Cardiovascular Intensive Care Units: More Is Not Better. Front Cardiovasc Med 2022; 9:853217. [PMID: 35548447 PMCID: PMC9081925 DOI: 10.3389/fcvm.2022.853217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Backgrounds Decreased urine output (UO) is associated with adverse outcomes in certain patients, but this effect in patients admitted for cardiovascular diseases is still unproven. Moreover, the relationship between increased UO and prognosis is also unclear. Objective To investigate the relationship between decreased or increased UO and outcomes in patients with the cardiovascular intensive care unit (CICU). Methods This study was a retrospective cohort analysis based on the medical information mart for intensive care III (MIMIC-III) database. The patients' data were extracted from the Beth Israel Deaconess Medical Center (Boston, MA) between 2001 and 2012. With the initial 24-h UO range from 0.5 to 1.0 ml/kg/h as the reference, participants were divided into the several groups. The primary outcome was 30-day mortality. The secondary outcomes were 90-day mortality, ICU mortality, hospital mortality, use of mechanical ventilation (MV), and vasopressor agents in the first 24-h of ICU. The association between UO and mortality was assessed by multivariable logistic regression. Results A total of 13,279 patients admitted to CICU were included. Low UO (< 0.5 ml/kg/h) was strongly associated with 30-day mortality (unadjusted OR = 3.993, 95% CI: 3.447–4.625, p < 0.001), and very high UO (≥ 2.0 ml/kg/h) was also a significantly risk factor for 30-day mortality (Unadjusted OR = 2.069, 95% CI: 1.701–2.516, p < 0.001) compared with the reference. The same effects also were shown in the multivariable logistic regression, adjusted by age, gender, vital signs, common comorbidities, and use of diuretics, with an adjusted OR of 2.023 (95% CI: 1.693–2.417, p < 0.001) for low UO and 1.771 (95% CI: 1.389–2.256, p < 0.001) for very high UO. Moreover, both decreased UO and increased UO were risk factors for 90-day mortality, ICU mortality, hospital mortality, use of MV and vasopressor agents. Conclusion The decreased and increased UO both were significantly associated with short-term mortality, the relationship between UO and mortality was U-shape rather than linear.
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Yang HS, Hur M, Lee KR, Kim H, Kim HY, Kim JW, Chua MT, Kuan WS, Chua HR, Kitiyakara C, Phattharapornjaroen P, Chittamma A, Werayachankul T, Anandh U, Herath S, Endre Z, Horvath AR, Antonini P, Di Somma S. Biomarker Rule-in or Rule-out in Patients With Acute Diseases for Validation of Acute Kidney Injury in the Emergency Department (BRAVA): A Multicenter Study Evaluating Urinary TIMP-2/IGFBP7. Ann Lab Med 2022; 42:178-187. [PMID: 34635611 PMCID: PMC8548247 DOI: 10.3343/alm.2022.42.2.178] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/07/2021] [Accepted: 09/13/2021] [Indexed: 02/06/2023] Open
Abstract
Background Urine tissue inhibitor of metalloproteinases-2/insulin-like growth factor-binding protein 7 (TIMP-2/IGFBP7) (NephroCheck, Ortho Clinical Diagnostics, Raritan, NJ, USA) is a US Food and Drug Administration-approved biomarker for risk assessment of acute kidney injury (AKI) in critically ill adult patients in intensive care units; however, its clinical impact in the emergency department (ED) remains unproven. We evaluated the utility of NephroCheck for predicting AKI development and short-term mortality in the ED. Methods This was a prospective, observational, five-center international study. We consecutively enrolled ED patients admitted with ≥30% risk of AKI development (assessed by ED physician: ED score) or acute diseases. Serum creatinine was tested on ED arrival (T0), day 1, and day 2 (T48); urine for NephroCheck was collected at T0 and T48. We performed ROC curve and reclassification analyses. Results Among the 529 patients enrolled (213 females; median age, 65 years), AKI developed in 59 (11.2%) patients. The T0 NephroCheck value was higher in the AKI group than in the non-AKI group (median 0.77 vs. 0.29 (ng/m)2/1,000, P=0.001), and better predicted AKI development than the ED score (area under the curve [AUC], 0.64 vs. 0.53; P=0.04). In reclassification analyses, adding NephroCheck to the ED score improved the prediction of AKI development (P<0.05). The T0 NephroCheck value predicted 30-day mortality (AUC, 0.68; P<0.001). Conclusions NephroCheck can predict both AKI development and short-term mortality in at-risk ED patients. NephroCheck would be a useful biomarker for early ruling-in or ruling-out of AKI in the ED.
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Affiliation(s)
- Hyun Suk Yang
- Departments of Cardiovascular Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Mina Hur
- Departments of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Kyeong Ryong Lee
- Departments of Emergency Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Hanah Kim
- Departments of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Hahn Young Kim
- Departments of Neurology, Konkuk University School of Medicine, Seoul, Korea
| | - Jong Won Kim
- Departments of Emergency Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Mui Teng Chua
- Department of Emergency Medicine, Division of Nephrology, National University Hospital, National University Health System, Singapore
| | - Win Sen Kuan
- Department of Emergency Medicine, Division of Nephrology, National University Hospital, National University Health System, Singapore
| | - Horng Ruey Chua
- Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Chagriya Kitiyakara
- Departments of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Anchalee Chittamma
- Departments of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thiyapha Werayachankul
- Section of Translational Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Section of Pharmaceutical Care, Faculty of Pharmaceutical Sciences, Burapha University, Chonburi, Thailand
| | - Urmila Anandh
- Department of Nephrology, Yashoda Hospital, Secunderabad, India
| | - Sanjeeva Herath
- Department of Nephrology, Prince of Wales Hospital, Sydney, Australia
| | - Zoltan Endre
- Department of Nephrology, Prince of Wales Hospital, Sydney, Australia
| | - Andrea Rita Horvath
- New South Wales Health Pathology, Department of Chemical Pathology, Prince of Wales Hospital, Sydney, Australia
| | - Paola Antonini
- GREAT Network Italy, University of Rome La Sapienza, Rome, Italy
| | - Salvatore Di Somma
- GREAT Network Italy, University of Rome La Sapienza, Rome, Italy
- Department of Medical-Surgery Sciences and Translational Medicine, University of Rome La Sapienza, Rome, Italy
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Outcomes of CMS-mandated fluid administration among fluid-overloaded patients with sepsis: A systematic review and meta-analysis. Am J Emerg Med 2022; 55:157-166. [DOI: 10.1016/j.ajem.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/22/2022] [Accepted: 03/04/2022] [Indexed: 12/20/2022] Open
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Abstract
BACKGROUND Acute kidney injury (AKI) is a common and serious complication following lung transplantation (LTx), and it is associated with high mortality and morbidity. This study assessed the incidence of AKI after LTx and analyzed the associated perioperative factors and clinical outcomes. METHODS This retrospective study included all adult LTx recipients at the China-Japan Friendship Hospital in Beijing between March 2017 and December 2019. The outcomes were AKI incidence, risk factors, mortality, and kidney recovery. Multivariate analysis was performed to identify independent risk factors. Survival analysis was presented using the Kaplan-Meier curves. RESULTS AKI occurred in 137 of the 191 patients (71.7%), with transient AKI in 43 (22.5%) and persistent AKI in 94 (49.2%). AKI stage 1 occurred in 27/191 (14.1%), stage 2 in 46/191 (24.1%), and stage 3 in 64/191 (33.5%) of the AKI patients. Renal replacement therapy (RRT) was administered to 35/191 (18.3%) of the patients. Male sex, older age, mechanical ventilation (MV), severe hypotension, septic shock, multiple organ dysfunction (MODS), prolonged extracorporeal membrane oxygenation (ECMO), reintubation, and nephrotoxic agents were associated with AKI (P < 0.050). Persistent AKI was independently associated with pre-operative pulmonary hypertension, severe hypotension, post-operative MODS, and nephrotoxic agents. Severe hypotension, septic shock, MODS, reintubation, prolonged MV, and ECMO during or after LTx were related to severe AKI (stage 3) (P < 0.050). Patients with persistent and severe AKI had a significantly longer duration of MV, longer duration in the intensive care unit (ICU), worse downstream kidney function, and reduced survival (P < 0.050). CONCLUSIONS AKI is common after LTx, but the pathogenic mechanism of AKI is complicated, and prerenal causes are important. Persistent and severe AKI were associated with poor short- and long-term kidney function and reduced survival in LTx patients.
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Hamzaoui O. Combining fluids and vasopressors: A magic potion? JOURNAL OF INTENSIVE MEDICINE 2021; 2:3-7. [PMID: 36789229 PMCID: PMC9923992 DOI: 10.1016/j.jointm.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 09/30/2021] [Accepted: 09/30/2021] [Indexed: 11/28/2022]
Abstract
Early detection and prompt reversal of sepsis-induced tissue hypoperfusion are key elements while treating patients with septic shock. Fluid administration is widely accepted as the first-line therapy followed by vasopressor use in persistently hypotensive patients or in those with insufficient arterial pressure to ensure adequate tissue perfusion. Recent evidence suggests a beneficial effect of combining fluids with vasopressors in the early phase of sepsis. Compared with fluids alone, combining fluids and vasopressors increases mean systemic pressure and venous return and corrects hypotension better. This approach also limits fluid overload, which is an independent factor of poor outcomes in sepsis. It produces less hemodilution than fluids alone. As a consequence of these effects, combined treatment may improve outcomes in septic shock patients.
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21
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Muller L, Boulet N. Does crystalloid infusion rate really matter in critically ill patients? Anaesth Crit Care Pain Med 2021; 40:100982. [PMID: 34767978 DOI: 10.1016/j.accpm.2021.100982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Laurent Muller
- Department of Anaesthesia, Critical Care and Emergency Medicine - Nîmes University Hospital, University of Montpellier, Place du Professeur Debré, 30029 Nîmes, France; University of Montpellier (MUSE), Nîmes, France.
| | - Nicolas Boulet
- Department of Anaesthesia, Critical Care and Emergency Medicine - Nîmes University Hospital, University of Montpellier, Place du Professeur Debré, 30029 Nîmes, France; University of Montpellier (MUSE), Nîmes, France
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22
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Yanase F, Naorungroj T, Cutuli SL, Eastwood GM, Bellomo R. Rapid 500 mL albumin bolus versus rapid 200 mL bolus followed by slower continuous infusion in post-cardiac surgery patients: a pilot before-and-after study. CRIT CARE RESUSC 2021; 23:320-328. [PMID: 38046079 PMCID: PMC10692547 DOI: 10.51893/2021.3.oa9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To evaluate the haemodynamic effects of rapid fluid bolus therapy (FBT) (500 mL of 4% albumin over several minutes) versus combined FBT (rapid 200 mL FBT followed by a 300 mL infusion over 30 minutes). Design: Single centre, prospective, before-and-after trial. Setting: A tertiary intensive care unit in Australia. Participants: Fifty mechanically ventilated post-cardiac surgery patients. Interventions: Rapid 4% albumin FBT versus combined FBT. Main outcome measures: We recorded haemodynamic parameters from before FBT to 30 minutes after FBT. A mean arterial pressure (MAP) response was defined by a MAP increase > 10%, and a cardiac index (CI) response was defined by a CI increase > 15%. Results: Immediately after rapid FBT versus combined FBT, there was a CI response in 13 patients (52%) compared with five patients (20%) respectively (P = 0.038), and a MAP response in 11 patients (44%) in each group. However, from FBT administration to 30 minutes, there was a time and group interaction such that MAP was higher in the rapid FBT group (P = 0.003), as was the case for central venous pressure (P = 0.002) and mean pulmonary artery pressure (P < 0.001). Body temperature fell immediately and was lower with rapid FBT but became warmer than with combined FBT later (P < 0.001). At 30 minutes, a MAP response was seen in ten patients (40%) compared with nine patients (36%) (P < 0.99) and a CI response was present in eight patients (32%) compared with 11 patients (44%) (P = 0.56) in the rapid versus combined FBT groups respectively. Conclusion: Rapid FBT was superior to combined FBT in terms of mean MAP levels and immediate CI response. However, the number of MAP responders or CI responders was similar at 30 minutes.
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Affiliation(s)
- Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Salvatore L. Cutuli
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Dipartimento di Scienze dell’emergenza, anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Glenn M. Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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23
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Yang SY, Chiou TTY, Shiao CC, Lin HYH, Chan MJ, Wu CH, Sun CY, Wang WJ, Huang YT, Wu VC, Chen YC, Fang JT, Hwang SJ, Pan HC. Nomenclature and diagnostic criteria for acute kidney injury - 2020 consensus of the Taiwan AKI-task force. J Formos Med Assoc 2021; 121:749-765. [PMID: 34446340 DOI: 10.1016/j.jfma.2021.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 06/23/2021] [Accepted: 08/06/2021] [Indexed: 12/31/2022] Open
Abstract
Acute kidney injury (AKI) is a common syndrome that has a significant impact on prognosis in various clinical settings. To evaluate whether new evidence supports changing the current definition/classification/staging systems for AKI suggested by the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline, the Taiwan AKI-TASK Force, composed of 64 experts in various disciplines, systematically reviewed the literature and proposed recommendations about the current nomenclature and diagnostic criteria for AKI. The Taiwan Acute Kidney Injury (TW-AKI) Consensus 2020 was established following the principles of evidence-based medicine to investigate topics covered in AKI guidelines. The Taiwan AKI-TASK Force determined that patients with AKI have a higher risk of developing chronic kidney disease, end-stage renal disease, and death. After a comprehensive review, the TASK Force recommended using novel biomarkers, imaging examinations, renal biopsy, and body fluid assessment in the diagnosis of AKI. Clinical issues with regards to the definitions of baseline serum creatinine (sCr) level and renal recovery, as well as the use of biomarkers to predict renal recovery are also discussed in this consensus. Although the present classification systems using sCr and urine output for the diagnosis of AKI are not perfect, there is not enough evidence to change the current criteria in clinical practice. Future research should investigate and clarify the roles of the aforementioned tools in clinical practice for AKI.
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Affiliation(s)
- Shao-Yu Yang
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Terry Ting-Yu Chiou
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan; Chung Shan Medical University School of Medicine, Taichung, Taiwan
| | - Chih-Chung Shiao
- Division of Nephrology, Department of Internal Medicine, Camillians Saint Mary's Hospital Luodong, Saint Mary's Junior College of Medicine, Nursing and Management, Luodong, Taiwan; Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan
| | - Hugo You-Hsien Lin
- Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan; Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Jen Chan
- Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Che-Hsiung Wu
- Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan
| | - Chiao-Yin Sun
- Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Wei-Jie Wang
- Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Division of Nephrology, Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Vin-Cent Wu
- Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yung-Chang Chen
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Ji-Tsung Fang
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Shang-Jyh Hwang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Heng-Chih Pan
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs), Taiwan; Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan.
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24
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Chávez-Íñiguez JS, Maggiani-Aguilera P, Pérez-Flores C, Claure-Del Granado R, De la Torre-Quiroga AE, Martínez-Gallardo González A, Navarro-Blackaller G, Medina-González R, Raimann JG, Yanowsky-Escatell FG, García-García G. Nephrologist Interventions to Avoid Kidney Replacement Therapy in Acute Kidney Injury. Kidney Blood Press Res 2021; 46:629-638. [PMID: 34315155 DOI: 10.1159/000517615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/04/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Based on the pathophysiology of acute kidney injury (AKI), it is plausible that certain early interventions by the nephrologist could influence its trajectory. In this study, we investigated the impact of 5 early nephrology interventions on starting kidney replacement therapy (KRT), AKI progression, and death. METHODS In a prospective cohort at the Hospital Civil of Guadalajara, we followed up for 10 days AKI patients in whom a nephrology consultation was requested. We analyzed 5 early interventions of the nephrology team (fluid adjustment, nephrotoxic withdrawal, antibiotic dose adjustment, nutritional adjustment, and removal of hyperchloremic solutions) after the propensity score and multivariate analysis for the risk of starting KRT (primary objective), AKI progression to stage 3, and death (secondary objectives). RESULTS From 2017 to 2020, we analyzed 288 AKI patients. The mean age was 55.3 years, 60.7% were male, AKI KDIGO stage 3 was present in 50.5% of them, sepsis was the main etiology 50.3%, and 72 (25%) patients started KRT. The overall survival was 84.4%. Fluid adjustment was the only intervention associated with a decreased risk for starting KRT (odds ratio [OR]: 0.58, 95% confidence interval [CI]: 0.48-0.70, and p ≤ 0.001) and AKI progression to stage 3 (OR: 0.59, 95% CI: 0.49-0.71, and p ≤ 0.001). Receiving vasopressors and KRT were associated with mortality. None of the interventions studied was associated with reducing the risk of death. CONCLUSIONS In this prospective cohort study of AKI patients, we found for the first time that early nephrologist intervention and fluid prescription adjustment were associated with lower risk of starting KRT and progression to AKI stage 3.
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Affiliation(s)
- Jonathan S Chávez-Íñiguez
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Pablo Maggiani-Aguilera
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Christian Pérez-Flores
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Rolando Claure-Del Granado
- Division of Nephrology, Hospital Obrero #2 - C.N.S., Cochabamba, Bolivia.,Universidad Mayor de San Simon, School of Medicine, Cochabamba, Bolivia
| | - Andrés E De la Torre-Quiroga
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Alejandro Martínez-Gallardo González
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Guillermo Navarro-Blackaller
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Ramón Medina-González
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico
| | | | | | - Guillermo García-García
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
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25
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Alfano G, Ferrari A, Fontana F, Mori G, Magistroni R, Meschiari M, Franceschini E, Menozzi M, Cuomo G, Orlando G, Santoro A, Digaetano M, Puzzolante C, Carli F, Bedini A, Milic J, Coloretti I, Raggi P, Mussini C, Girardis M, Cappelli G, Guaraldi G. Incidence, risk factors and outcome of acute kidney injury (AKI) in patients with COVID-19. Clin Exp Nephrol 2021; 25:1203-1214. [PMID: 34196877 PMCID: PMC8245663 DOI: 10.1007/s10157-021-02092-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/07/2021] [Indexed: 01/08/2023]
Abstract
Background Acute kidney injury (AKI) is a severe complication of coronavirus disease-2019 (COVID-19). This study aims to evaluate incidence, risk factors and case-fatality rate of AKI in patients with COVID-19. Methods We reviewed the health medical records of 307 consecutive patients with COVID-19 hospitalized at the University Hospital of Modena, Italy. Results AKI was diagnosed in 69 out of 307 (22.4%) COVID-19 patients. Stages 1, 2, or 3 AKI accounted for 57.9%, 24.6% and 17.3%, respectively. AKI patients had a mean age of 74.7 ± 9.9 years. These patients showed higher serum levels of the main markers of inflammation and higher rate of severe pneumonia than non-AKI patients. Kidney injury was associated with a higher rate of urinary abnormalities including proteinuria (0.44 ± 0.85 vs 0.18 ± 0.29 mg/mg; P = < 0.0001) and microscopic hematuria (P = 0.032) compared to non-AKI patients. Hemodialysis was performed in 7.2% of the subjects and 33.3% of the survivors did not recover kidney function after AKI. Risk factors for kidney injury were age, male sex, CKD and higher non-renal SOFA score. Patients with AKI had a mortality rate of 56.5%. Adjusted Cox regression analysis revealed that COVID-19-associated AKI was independently associated with in-hospital death (hazard ratio [HR] = 4.82; CI 95%, 1.36–17.08) compared to non-AKI patients. Conclusion AKI was a common and harmful consequence of COVID-19. It manifested with urinary abnormalities (proteinuria, microscopic hematuria) and conferred an increased risk for death. Given the well-known short-term sequelae of AKI, prevention of kidney injury is imperative in this vulnerable cohort of patients. Supplementary Information The online version contains supplementary material available at 10.1007/s10157-021-02092-x.
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Affiliation(s)
- Gaetano Alfano
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy.
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy.
| | - Annachiara Ferrari
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Fontana
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - Giacomo Mori
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - Riccardo Magistroni
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Marianna Meschiari
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Erica Franceschini
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Marianna Menozzi
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Gianluca Cuomo
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Gabriella Orlando
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Antonella Santoro
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | | | - Cinzia Puzzolante
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Federica Carli
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Andrea Bedini
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Jovana Milic
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Irene Coloretti
- Department of Anesthesia and Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Paolo Raggi
- Department of Medicine, Division of Cardiology, Mazankowski Alberta Heart Institute, Alberta, Canada
| | - Cristina Mussini
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Massimo Girardis
- Department of Anesthesia and Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Gianni Cappelli
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Giovanni Guaraldi
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
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26
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Wang L, Pei F, Wu J, Ouyang B, Guan X. Kidney Injury in a Hemodilution Model of Hemorrhagic Shock and Fluid Resuscitation. Am J Med Sci 2021; 362:506-511. [PMID: 34116049 DOI: 10.1016/j.amjms.2021.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 03/01/2021] [Accepted: 06/04/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Fluid therapy is indispensable in treating patients with hemorrhagic shock. However, fluid overload correlates with kidney injury in patients with hemorrhagic shock. We hypothesized that hemodilution after fluid treatment contributes to the kidney injury. METHODS An animal model was established to mimic different severity of hemodilution, through resuscitating hemorrhagic shock with mixture of blood and lactated Ringer's solution (LR) in different ratios. A total of 20 rats were divided into the following four groups, the Sham group, Mild group, Moderate group, and Severe group. In the Sham group, rats were anesthetized and catheterized only. In the other three groups, shock was induced by extracting 40% of the estimated circulating blood. One hour later, rats were resuscitated with a mixture of blood and LR with ratio 1:0 in the Mild group, 0.5:0.5 in the Moderate group, and 0:1 in the Severe group. The histology of the kidneys was observed with hematoxylin and eosin (HE) staining. The mitochondria membrane potential ψ and adenosine triphosphate (ATP) production of the kidneys were measured. The serum creatinine (SCr) and blood urine nitrogen (BUN) were measured. RESULTS Renal tubular lumina dilation and mild interstitial edema occurred in the Mild group with HE staining. Proximal convoluted tubule damage, including tubular casts, narrow renal tubular lumina, and interstitial edema occurred in the Moderate group and Severe group. Mitochondrial JC-1 and ATP production decreased as hemodilution progressed. SCr and BUN increased in the Moderate group and Severe group. CONCLUSIONS The hemodilution post hemorrhagic shock and fluid resuscitation led to kidney injury.
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Affiliation(s)
- Luhao Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, PR China; Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou 510080, PR China
| | - Fei Pei
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, PR China
| | - Jianfeng Wu
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, PR China
| | - Bin Ouyang
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, PR China.
| | - Xiangdong Guan
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, PR China.
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27
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Abstract
OBJECTIVES The objectives of this study were to: 1) determine the association between vasopressor dosing intensity during the first 6 hours and first 24 hours after the onset of septic shock and 30-day in-hospital mortality; 2) determine whether the effect of vasopressor dosing intensity varies by fluid resuscitation volume; and 3) determine whether the effect of vasopressor dosing intensity varies by dosing titration pattern. DESIGN Multicenter prospective cohort study between September 2017 and February 2018. Vasopressor dosing intensity was defined as the total vasopressor dose infused across all vasopressors in norepinephrine equivalents. SETTING Thirty-three hospital sites in the United States (n = 32) and Jordan (n = 1). PATIENTS Consecutive adults requiring admission to the ICU with septic shock treated with greater than or equal to 1 vasopressor within 24 hours of shock onset. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Out of 1,639 patients screened, 616 were included. Norepinephrine (93%) was the most common vasopressor. Patients received a median of 3,400 mL (interquartile range, 1,851-5,338 mL) during the 24 hours after shock diagnosis. The median vasopressor dosing intensity during the first 24 hours of shock onset was 8.5 μg/min norepinephrine equivalents (3.4-18.1 μg/min norepinephrine equivalents). In the first 6 hours, increasing vasopressor dosing intensity was associated with increased odds ratio of 30-day in-hospital mortality, with the strength of association dependent on concomitant fluid administration. Over the entire 24 hour period, every 10 μg/min increase in vasopressor dosing intensity was associated with an increased risk of 30-day mortality (adjusted odds ratio, 1.33; 95% CI, 1.16-1.53), and this association did not vary with the amount of fluid administration. Compared to an early high/late low vasopressor dosing strategy, an early low/late high or sustained high vasopressor dosing strategy was associated with higher mortality. CONCLUSIONS Increasing vasopressor dosing intensity during the first 24 hours after septic shock was associated with increased mortality. This association varied with the amount of early fluid administration and the timing of vasopressor titration.
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28
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Luo D, Dai W, Lei L, Cai X. The clinical value of passive leg raising plus ultrasound to predict fluid responsiveness in children after cardiac surgery. BMC Pediatr 2021; 21:243. [PMID: 34011296 PMCID: PMC8132037 DOI: 10.1186/s12887-021-02703-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 05/05/2021] [Indexed: 11/17/2022] Open
Abstract
Background There are few non-invasive monitoring methods that can reliably predict fluid responsiveness (FR) in children. Here, we interrogate the value of doppler ultrasound evaluation of passive leg raising (PLR)-induced changes in stroke volume (SV) and cardiac output (CO) as a predictor of FR in children with mechanical ventilation after congenital cardiac surgery. Methods A total of 40 children with mechanical ventilation following congenital cardiac surgery, who required volume expansion (VE) were included in this study. Hemodynamic parameters such as heart rate (HR), mean arterial pressure (MAP), SV, and central venous pressure (CVP) were monitored before and after PLR and VE. Besides, we assessed changes in SV and CO by bedside ultrasound. Patients showing > 10 % increase in SV in response to VE were considered to be responders (26 patients), while the rest (14 patients) were defined as non-responders. Results Our data demonstrated that ΔSV-PLR and ΔCO- PLR were positively correlated with ΔSV-VE (r = 0.683, p < 0.001 and r = 0.374, p = 0.017, respectively), and the area under the ROC curve (AUC) of ΔSV-PLR was 0.879 (95 % CI [0.745 1.000], p < 0.001). The best cut-off value for ΔSV-PLR in predicting FR was 13 %, with its sensitivity and specificity were 81.8 and 86.3 %, respectively. ΔCVP, ΔHR, and ΔMAP were weak predictors of FR in the children. Conclusions Our study demonstrated that SV changes, as evaluated by noninvasive ultrasound combined with PLR, could effectively evaluate FR in children under mechanical ventilation after congenital cardiac surgery.
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Affiliation(s)
- Deqiang Luo
- Department of Intensive Care Unit, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street,Dong Lake District, 330000, Nanchang City, Jiangxi Province, China.,Department of Intensive Care Unit, The Fifth People's Hospital of Shangrao City, No.1, Jiannan Road, 334000, Shangrao City, Jiangxi province, China
| | - Wei Dai
- Department of Intensive Care Unit, The Fifth People's Hospital of Shangrao City, No.1, Jiannan Road, 334000, Shangrao City, Jiangxi province, China
| | - Lei Lei
- Department of Animal Science, Hubei Vocational College Of Bio-Technology, No.1, Yezihu Lake, Hongshan District, 430070, Wuhan City, Hubei province, China
| | - Xueying Cai
- Department of Intensive Care Unit, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street,Dong Lake District, 330000, Nanchang City, Jiangxi Province, China. .,Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Shangcheng District, 310006, Hangzhou City, Zhejiang Province, China.
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Du WW, Wang XX, Zhang D, Chen WQ, Zhang XL, Li PM. Retrospective analysis on incidence and risk factors of early onset acute kidney injury after lung transplantation and its association with mortality. Ren Fail 2021; 43:535-542. [PMID: 33736580 PMCID: PMC7993381 DOI: 10.1080/0886022x.2021.1883652] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Acute kidney injury (AKI) is a common complication after lung transplantation (LTx) which is closely related to the poor prognosis of patients. We aimed to explore potential risk factors and outcomes associated with early post-operative AKI after LTx. METHODS A retrospective study was conducted in 136 patients who underwent LTx at our institution from 2017 to 2019. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline. Univariate and multivariate analyses were conducted to identify risk factors related to AKI. The primary outcome was the incidence of AKI after LTx. Secondary outcomes were associations between AKI and short-term clinical outcomes and mortality. RESULTS Of the 136 patients analyzed, 110 developed AKI (80.9%). AKI was associated with higher baseline eGFR (odds ratio (OR) 1.01 (95% confidence interval (CI): 1.00-1.03)) and median tacrolimus (TAC) concentration (OR 1.15 (95% CI: 1.02-1.30)). Patients with AKI suffered longer mechanical ventilation days (p = .015) and ICU stay days (p = .011). AKI stage 2-3 patients had higher risk of 1-year mortality (HR 16.98 (95% CI: 2.25-128.45)) compared with no-AKI and stage 1 patients. CONCLUSIONS Our results suggested early post-operative AKI may be associated with higher baseline eGFR and TAC concentrations. AKI stage 1 may have no influence on survival rate, whereas AKI stage 2-3 may be associated with increased mortality at 1-year.
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Affiliation(s)
- Wen-Wen Du
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Xiao-Xing Wang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Dan Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Wen-Qian Chen
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Xiang-Lin Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Peng-Mei Li
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
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30
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A randomized trial of albumin infusion to prevent intradialytic hypotension in hospitalized hypoalbuminemic patients. Crit Care 2021; 25:18. [PMID: 33407747 PMCID: PMC7789619 DOI: 10.1186/s13054-020-03441-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intradialytic hypotension (IDH) is a frequent complication of intermittent hemodialysis (IHD), occurring from 15 to 50% of ambulatory sessions, and is more frequent among hospitalized patients with hypoalbuminemia. IDH limits adequate fluid removal and increases the risk for vascular access thrombosis, early hemodialysis (HD) termination, and mortality. Albumin infusion before and during therapy has been used for treating IDH with the varying results. We evaluated the efficacy of albumin infusion in preventing IDH during IHD in hypoalbuminemic inpatients. METHODS A randomized, crossover trial was performed in 65 AKI or ESKD patients with hypoalbuminemia (albumin < 3 g/dl) who required HD during hospitalization. Patients were randomized to receive 100 ml of either 0.9%sodium chloride or 25% albumin intravenously at the initiation of each dialysis. These two solutions were alternated for up to six sessions. Patients' vital signs and ultrafiltration removal rate were recorded every 15 to 30 min during dialysis. IDH was assessed by different definitions reported in the literature. All symptoms associated with a noted hypotensive event as well as interventions during the dialysis were recorded. RESULTS Sixty-five patients were submitted to 249 sessions; the mean age was 58 ([Formula: see text] 12), and 46 (70%) were male with a mean weight of 76 ([Formula: see text] 18) kg. The presence of IDH was lower during albumin sessions based on all definitions. The hypotension risk was significantly decreased based on the Kidney Disease Outcomes Quality Initiative definition; (15% with NS vs. 7% with albumin, p = 0.002). The lowest intradialytic SBP was significantly worse in patients who received 0.9% sodium chloride than albumin (NS 83 vs. albumin 90 mmHg, p = 0.035). Overall ultrafiltration rate was significantly higher in the albumin therapies [NS - 8.25 ml/kg/h (- 11.18 5.80) vs. 8.27 ml/kg/h (- 12.22 to 5.53) with albumin, p = 0.011]. CONCLUSION In hypoalbuminemic patients who need HD, albumin administration before the dialysis results in fewer episodes of hypotension and improves fluid removal. Albumin infusion may be of benefit to improve the safety of HD and achievement of fluid balance in these high-risk patients. ClinicalTrials.gov Identifier: NCT04522635.
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31
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Jhee JH, Park JY, An JN, Kim DK, Joo KW, Oh YK, Lim CS, Kim YS, Han SH, Yoo TH, Kang SW, Lee JP, Park JT. Cumulative fluid balance and mortality in elderly patients with acute kidney injury requiring continuous renal-replacement therapy: a multicenter prospective cohort study. Kidney Res Clin Pract 2020; 39:414-425. [PMID: 33318341 PMCID: PMC7770993 DOI: 10.23876/j.krcp.20.089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/10/2020] [Accepted: 08/12/2020] [Indexed: 11/05/2022] Open
Abstract
Background The effect of fluid balance on outcomes in elderly patients with acute kidney injury (AKI) requiring continuous renal-replacement therapy (CRRT) is not explained well. We investigated outcomes according to cumulative fluid balance (CFB) in elderly patients with AKI undergoing CRRT. Methods A total of 607 patients aged 65 years or older who started CRRT due to AKI were enrolled and stratified into two groups (fluid overload [FO] vs. no fluid overload [NFO]) based on the median CFB value for 72 hours before CRRT initiation. Propensity score-matching analysis was performed. Results The median age of included patients was 73.0 years and 60.0% of the population was male. The median 72-hour CFB value was 2,839.0 mL. The overall cumulative survival and 28-day survival rates were lower in the FO group than in the NFO group (P < 0.001 for both) and remained so after propensity score-matching. Furthermore, patients in the FO group demonstrated a higher overall mortality risk after adjustment for age, sex, systolic blood pressure, Charlson comorbidity index, Acute Physiology and Chronic Health Evaluation II score, serum albumin, creatinine, diuretic use, and mechanical ventilation status (hazard ratio, 1.38; 95% confidence interval, 1.13 to 1.89; P < 0.001). Among survivors, both the duration of CRRT and the total duration of hospitalization from CRRT initiation showed no difference between the FO and NFO groups. Conclusion A higher CFB value is associated with an increased risk of mortality in elderly patients with AKI requiring CRRT.
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Affiliation(s)
- Jong Hyun Jhee
- Division of Nephrology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Yoon Park
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Jung Nam An
- Department of Critical Care Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yun Kyu Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Chun Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Jung Tak Park
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
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Zhao H, Long L, Wang Z, Yan Y, Zhao H. Successful treatment of acute circulatory failure of unknown cause using critical ultrasound-guided reverse fluid resuscitation: A case report. Medicine (Baltimore) 2020; 99:e23594. [PMID: 33371091 PMCID: PMC7748311 DOI: 10.1097/md.0000000000023594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 11/09/2020] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Fluid resuscitation manages shock effectively. However, shock is not always caused by hypovolemia; various types of shock have variable volumetric reactivity. Combined echocardiography and lung ultrasound (LUS) is a new technique for assessing volume status and pulmonary edema in these patients. We report a case of unexplained acute circulatory failure and acute kidney injury (AKI) aggravated by active fluid resuscitation. We used the critical consultation ultrasonic examination (CCUE) protocol for evaluation, and successfully revived the patient with reverse fluid resuscitation. PATIENT CONCERNS An 82-year-old man with hypertension, atrial fibrillation, and left ventricular diastolic dysfunction (LVDD) was admitted with abdominal distention and lower extremity edema. He developed symptoms of acute circulatory failure, including low blood pressure, anuria, and skin spots. After positive fluid resuscitation, the blood pressure lowered further, and moist rales were audible over both lungs. DIAGNOSIS We performed bedside critical ultrasound for evaluation. The differential diagnoses based on the findings included left atrial and right heart dilatation, low cardiac output owing to reduced left ventricular ejection consequent to excessive circulatory capacity, right heart dilation, and left ventricular compression, and pulmonary edema caused by volume overload. INTERVENTIONS Infusion was withheld, and tracheal intubation and mechanical ventilation were instituted to assist breathing; reverse fluid resuscitation was initiated, using continuous renal replacement therapy (CRRT) to maintain a negative fluid balance. OUTCOMES Within 72 hours of fluid withdrawal, the blood pressure reverted to normal, symptoms of pulmonary edema were alleviated, and the circulation and tissue perfusion were restored. The symptoms of acute renal injury are relieved and allowing urine formation without support. LESSONS Not all patients with acute circulatory failure require positive fluid resuscitation. Fluid balance should be closely monitored and managed. Potential intolerance to the rapid increase in volume may lead to biventricular interaction, ultimately leading to acute circulatory failure. The shock caused by volume overload should be treated with reverse fluid resuscitation. Combined echocardiography and LUS is a powerful tool for the differential diagnosis of circulatory and respiratory dysfunction.
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Affiliation(s)
| | | | - Zekai Wang
- Department of Nephrology, Hebei General Hospital
| | - Yaru Yan
- Department of Ultrasound, The NO.1 Hospital of Shijiazhuang, Hebei, China
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Hou N, Li M, He L, Xie B, Wang L, Zhang R, Yu Y, Sun X, Pan Z, Wang K. Predicting 30-days mortality for MIMIC-III patients with sepsis-3: a machine learning approach using XGboost. J Transl Med 2020; 18:462. [PMID: 33287854 PMCID: PMC7720497 DOI: 10.1186/s12967-020-02620-5] [Citation(s) in RCA: 145] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/18/2020] [Indexed: 12/20/2022] Open
Abstract
Background Sepsis is a significant cause of mortality in-hospital, especially in ICU patients. Early prediction of sepsis is essential, as prompt and appropriate treatment can improve survival outcomes. Machine learning methods are flexible prediction algorithms with potential advantages over conventional regression and scoring system. The aims of this study were to develop a machine learning approach using XGboost to predict the 30-days mortality for MIMIC-III Patients with sepsis-3 and to determine whether such model performs better than traditional prediction models. Methods Using the MIMIC-III v1.4, we identified patients with sepsis-3. The data was split into two groups based on death or survival within 30 days and variables, selected based on clinical significance and availability by stepwise analysis, were displayed and compared between groups. Three predictive models including conventional logistic regression model, SAPS-II score prediction model and XGBoost algorithm model were constructed by R software. Then, the performances of the three models were tested and compared by AUCs of the receiver operating characteristic curves and decision curve analysis. At last, nomogram and clinical impact curve were used to validate the model. Results A total of 4559 sepsis-3 patients are included in the study, in which, 889 patients were death and 3670 survival within 30 days, respectively. According to the results of AUCs (0.819 [95% CI 0.800–0.838], 0.797 [95% CI 0.781–0.813] and 0.857 [95% CI 0.839–0.876]) and decision curve analysis for the three models, the XGboost model performs best. The risk nomogram and clinical impact curve verify that the XGboost model possesses significant predictive value. Conclusions Using machine learning technique by XGboost, more significant prediction model can be built. This XGboost model may prove clinically useful and assist clinicians in tailoring precise management and therapy for the patients with sepsis-3.
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Affiliation(s)
- Nianzong Hou
- Department of Hand and Foot Surgery, Zibo Central Hospital, Shandong First Medical University, Zibo, 255036, Shandong, China
| | - Mingzhe Li
- Independent researcher, , Leeds, LS29JT, UK
| | - Lu He
- Institute of Medicine and Nursing, Hubei University of Medicine, Shiyan, 442000, Hubei, China
| | - Bing Xie
- Department of Hand and Foot Surgery, Zibo Central Hospital, Shandong First Medical University, Zibo, 255036, Shandong, China
| | - Lin Wang
- Department of Critical Care Medicine, Zibo Central Hospital, Shandong First Medical University , Zibo, 255036, Shandong, China
| | - Rumin Zhang
- Department of Critical Care Medicine, Zibo Central Hospital, Shandong First Medical University , Zibo, 255036, Shandong, China
| | - Yong Yu
- Department of Critical Care Medicine, Zibo Central Hospital, Shandong First Medical University , Zibo, 255036, Shandong, China
| | - Xiaodong Sun
- Fengnan District Maternal and Child Health Care Hospital of Tangshan City, Tangshan, 063300, Hebei, China
| | - Zhengsheng Pan
- Department of Urology Surgery, Zibo Central Hospital, Shandong First Medical University , Zibo, 255036, China
| | - Kai Wang
- Department of Critical Care Medicine, Zibo Central Hospital, Shandong First Medical University , Zibo, 255036, Shandong, China.
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Joannes-Boyau O, Roquilly A, Constantin JM, Duracher-Gout C, Dahyot-Fizelier C, Langeron O, Legrand M, Mirek S, Mongardon N, Mrozek S, Muller L, Orban JC, Virat A, Leone M. Choice of fluid for critically ill patients: An overview of specific situations. Anaesth Crit Care Pain Med 2020; 39:837-845. [PMID: 33091593 DOI: 10.1016/j.accpm.2020.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation Sud, Centre Médico-Chirurgical Magellan, Centre Hospitalier Universitaire (CHU) de Bordeaux, 33000 Bordeaux, France.
| | - Antoine Roquilly
- CHU Nantes, Université de Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, 44093 Nantes, France
| | - Jean-Michel Constantin
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, 75013 Paris, France
| | - Caroline Duracher-Gout
- Département d'Anesthésie Réanimation Chirurgicale et SAMU de Paris, Université René Descartes Paris, 75006 Paris Cedex, France
| | - Claire Dahyot-Fizelier
- Anaesthesia and Intensive Care, University Hospital of Poitiers, Poitiers, France. INSERM UMR1070 - Pharmacology of Anti-infective Agents, University of Poitiers, 86000 Poitiers, France
| | - Olivier Langeron
- Service d'Anesthésie-Réanimation, Hôpital Henri Mondor Assistance Publique - Hôpitaux de Paris Université Paris-Est, 94 Créteil, France
| | - Matthieu Legrand
- Department of Anaesthesia and Perioperative Care, University of California, 500 Parnassus Avenue, San Francisco, USA
| | - Sébastien Mirek
- Service d'Anesthésie Réanimation, CHU Dijon, 21000 Dijon Cedex, France
| | - Nicolas Mongardon
- Service d'Anesthésie-Réanimation, Hôpital Henri Mondor Assistance Publique - Hôpitaux de Paris Université Paris-Est, 94 Créteil, France
| | - Ségolène Mrozek
- Département d'Anesthésie-Réanimation, CHU Toulouse, Hôpital Pierre Paul Riquet, 31000 Toulouse, France
| | - Laurent Muller
- Service des réanimations et Surveillance Continue, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes Caremeau, Place Du Pr Debré, 30000 Nîmes, France
| | | | - Antoine Virat
- Clinique Pont De Chaume, 330, Avenue Marcel Unal, 82000 Montauban, France
| | - Marc Leone
- Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Service d'Anesthésie et de Réanimation, Hôpital Nord, 13005 Marseille, France
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Fluid Overload and Mortality in Adult Critical Care Patients—A Systematic Review and Meta-Analysis of Observational Studies*. Crit Care Med 2020; 48:1862-1870. [DOI: 10.1097/ccm.0000000000004617] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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36
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Jentzer JC, Bihorac A, Brusca SB, Del Rio-Pertuz G, Kashani K, Kazory A, Kellum JA, Mao M, Moriyama B, Morrow DA, Patel HN, Rali AS, van Diepen S, Solomon MA. Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives. J Am Coll Cardiol 2020; 76:1084-1101. [PMID: 32854844 PMCID: PMC11032174 DOI: 10.1016/j.jacc.2020.06.070] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Azra Bihorac
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida
| | - Samuel B Brusca
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Gaspar Del Rio-Pertuz
- Department of Critical Care Medicine and Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Amir Kazory
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida
| | - John A Kellum
- Department of Critical Care Medicine and Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | - Brad Moriyama
- Department of Critical Care Medicine, Special Volunteer, National Institutes of Health, Bethesda, Maryland
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hena N Patel
- Division of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Aniket S Rali
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland; Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
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Clinical impact of disease-related malnutrition and fluid overload assessment via bioimpedance vector analysis in hospitalized patients. Clin Nutr ESPEN 2020; 39:131-136. [PMID: 32859306 DOI: 10.1016/j.clnesp.2020.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 06/28/2020] [Accepted: 07/10/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND This cohort study assessed the effect of disease-related malnutrition (DRM) and fluid overload (FO) evaluated by bioimpedance vector analysis (BIVA) on mortality among hospitalized patients. METHODS We examined adult patients hospitalized in an internal medicine ward. The malnutrition risk was assessed using the NRS2002 questionnaire, and body composition was estimated via BIVA. Clinical, epidemiological, and laboratory characteristics were compared between patients with and without DRM by BIVA (DRM-B). The effect of DRM and FO by BIVA on mortality was assessed via logistic regression analysis. RESULTS The study included 130 adult patients (62.3% men) with a mean age of 63 ± 19 years. Malnutrition risk at hospital admission was present in 43.8%. According to BIVA, 63.1% had normal body composition, 27.7% had DRM, and 9.2% obesity while FO was present in 53.1%. Patients with DRM-B were older (70 ± 16 vs. 61 ± 20 years, p = 0.05) and had a higher prevalence of cerebrovascular disease than patients without DRM-B (11% vs. 0%, p = 0.001). The overall mortality rate was 8.5% (n = 11) and was higher among patients with DRM-B than among those without DRM-B (16.7% vs. 5.3%, p = 0.03). No differences existed in mortality between patients with and without FO (8.7% vs. 8.2%, p = 0.91). DRM-B was associated with higher mortality rates adjusted for FO and comorbidities (odds ratio = 3.7, 95% confidence interval: 1.01-13.53, p = 0.04). CONCLUSION DRM and FO by BIVA were very frequent in our population. DRM-B was associated with a higher mortality rate, which emphasizes the importance of evaluating body composition in hospitalized patients.
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Hypertonic saline for fluid resuscitation in ICU patients post-cardiac surgery (HERACLES): a double-blind randomized controlled clinical trial. Intensive Care Med 2020; 46:1683-1695. [PMID: 32519005 DOI: 10.1007/s00134-020-06132-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Recent evidence questions a liberal approach to fluid resuscitation in intensive care unit (ICU) patients. Here, we assess whether use of hypertonic saline applied as single infusion at ICU admission after cardiac surgery can reduce cumulative perioperative fluid volume. METHODS Prospective randomized double-blind single-center clinical trial investigates effects of a single infusion of hypertonic saline (HS) versus normal saline (comparator). Primary endpoint was the cumulative amount of fluid administered in patients in the hypertonic saline versus the 0.9% saline groups (during ICU stay). Upon ICU admission, patients received a single infusion of 5 ml/kg body weight of 7.3% NaCl (or 0.9% NaCl) over 60 min. Patients undergoing cardiac surgery for elective valvular and/or coronary heart disease were included. Patients with advanced organ dysfunction, infection, and/or patients on chronic steroid medication were excluded. RESULTS A total of 101 patients were randomized to receive the study intervention (HS n = 53, NS n = 48). Cumulative fluid intake on the ICU (primary endpoint) did not differ between the HS and the NS groups [median 3193 ml (IQR 2052-4333 ml) vs. 3345 ml (IQR 2332-5043 ml)]. Postoperative urinary output until ICU discharge was increased in HS-treated patients [median 2250 ml (IQR 1640-2690 ml) vs. 1545 ml (IQR 1087-1976 ml)], and ICU fluid balance was lower in the HS group when compared to the NS group [296 ml (IQR - 441 to 1412 ml) vs. 1137 ml (IQR 322-2660 ml)]. CONCLUSION In a monocentric prospective double-blind randomized clinical trial, we observed that hypertonic saline did not reduce the total fluid volume administered on the ICU in critically ill cardiac surgery patients. Hypertonic saline infusion was associated with timely increase in urinary output. Variations in electrolyte and acid-base homeostasis were transient, but substantial in all patients.
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Zhao GJ, Xu C, Ying JC, Lü WB, Hong GL, Li MF, Wu B, Yao YM, Lu ZQ. Association between furosemide administration and outcomes in critically ill patients with acute kidney injury. Crit Care 2020; 24:75. [PMID: 32131879 PMCID: PMC7057586 DOI: 10.1186/s13054-020-2798-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/18/2020] [Indexed: 02/25/2023] Open
Abstract
Background Although current guidelines for AKI suggested against the use of furosemide in AKI management, the effect of furosemide on outcomes in real-world clinical settings remains uncertain. The aim of the present study was to investigate the association between furosemide administration and outcomes in critically ill patients with AKI using real-world data. Methods Critically ill patients with AKI were identified from the Medical Information Mart for Intensive Care (MIMIC)-III database. Propensity score (PS) matched analysis was used to match patients receiving furosemide to those without diuretics treatment. Linear regression, logistic regression model, and Cox proportional hazards model were used to assess the associations between furosemide and length of stay, recovery of renal function, and in-hospital and 90-day mortality, respectively. Results A total of 14,154 AKI patients were included in the data analysis. After PS matching, 4427 pairs of patients were matched between the patients who received furosemide and those without diuretics treatment. Furosemide was associated with reduced in-hospital mortality [hazard ratio (HR) 0.67; 95% CI 0.61–0.74; P < 0.001] and 90-day mortality [HR 0.69; 95% CI 0.64–0.75; P < 0.001], and it was also associated with the recovery of renal function [HR 1.44; 95% CI 1.31–1.57; P < 0.001] in over-all AKI patients. Nevertheless, results illustrated that furosemide was not associated with reduced in-hospital mortality in patients with AKI stage 0–1 defined by UO criteria, AKI stage 2–3 according to SCr criteria, and in those with acute-on-chronic (A-on-C) renal injury. Conclusions Furosemide administration was associated with improved short-term survival and recovery of renal function in critically ill patients with AKI. Furosemide was especially effective in patients with AKI UO stage 2–3 degree. However, it was not effective in those with AKI SCr stage 2–3 and chronic kidney disease. The results need to be verified in randomized controlled trials.
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Affiliation(s)
- Guang-Ju Zhao
- Emergency Intensive Care Unit, Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, People's Republic of China
| | - Chang Xu
- Emergency Intensive Care Unit, Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, People's Republic of China
| | - Jian-Chao Ying
- Emergency Intensive Care Unit, Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, People's Republic of China
| | - Wen-Biao Lü
- Emergency Intensive Care Unit, Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, People's Republic of China
| | - Guang-Liang Hong
- Emergency Intensive Care Unit, Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, People's Republic of China
| | - Meng-Fang Li
- Emergency Intensive Care Unit, Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, People's Republic of China
| | - Bing Wu
- Emergency Intensive Care Unit, Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, People's Republic of China
| | - Yong-Ming Yao
- Trauma Research Center, Fourth Medical of the Chinese PLA General Hospital, Beijing, 100048, People's Republic of China.
| | - Zhong-Qiu Lu
- Emergency Intensive Care Unit, Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, People's Republic of China.
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Abstract
OBJECTIVES The incidence of acute kidney injury in critically ill patients is increasing steeply. Acute kidney injury in this setting is associated with high morbidity and mortality. There is no doubt that renal replacement therapy for the most severe forms of acute kidney injury can be life saving, but there are a number of uncertainties about the optimal application of renal replacement therapy for patients with acute kidney injury. The objective of this synthetic review is to present current evidence supporting best practices in renal replacement therapy for critically ill patients with acute kidney injury. DATA SOURCES We reviewed literature regarding timing of initiation of renal replacement therapy, optimal vascular access for renal replacement therapy in acute kidney injury, modality selection and dose or intensity of renal replacement therapy, and anticoagulation during renal replacement therapy, using the following databases: MEDLINE and PubMed. We also reviewed bibliographic citations of retrieved articles. STUDY SELECTION We reviewed only English language articles. CONCLUSIONS Current evidence sheds light on many areas of controversy regarding renal replacement therapy in acute kidney injury, providing a foundation for best practices. Nonetheless, important questions remain to be answered by ongoing and future investigation.
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Bandak G, Sakhuja A, Andrijasevic NM, Gunderson TM, Gajic O, Kashani K. Use of diuretics in shock: Temporal trends and clinical impacts in a propensity-matched cohort study. PLoS One 2020; 15:e0228274. [PMID: 32053637 PMCID: PMC7018137 DOI: 10.1371/journal.pone.0228274] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 01/12/2020] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Fluid overload is common among critically ill patients and is associated with worse outcomes. We aimed to assess the effect of diuretics on urine output, vasopressor dose, acute kidney injury (AKI) incidence, and need for renal replacement therapies (RRT) among patients who receive vasopressors. PATIENTS AND METHODS This is a single-center retrospective study of all adult patients admitted to the intensive care unit between January 2006 and December 2016 and received >6 hours of vasopressor therapy and at least one concomitant dose of diuretic. We excluded patients from cardiac care units. Hourly urine output and vasopressor dose for 6 hours before and after the first dose of diuretic therapy was compared. Rates of AKI development and RRT initiation were assessed with a propensity-matched cohort of patients who received vasopressors but did not receive diuretics. RESULTS There was an increasing trend of prescribing diuretics in patients receiving vasopressors over the course of the study. We included 939 patients with median (IQR) age of 68(57, 78) years old and 400 (43%) female. The average hourly urine output during the first six hours following time zero in comparison with average hourly urine output during the six hours prior to time zero was significantly higher in diuretic group in comparison with patients who did not receive diuretics [81 (95% CI 73-89) ml/h vs. 42 (95% CI 39-45) ml/h, respectively; p<0.001]. After propensity matching, the rate of AKI within 7 days of exposure and the need for RRT were similar between the study and matched control patients (66 (15.6%) vs. 83 (19.6%), p = 0.11, and 34 (8.0%) vs. 37 (8.7%), p = 0.69, respectively). Mortality, however, was higher in the group that received diuretics. Ninety-day mortality was 191 (45.2%) in the exposed group VS 156 (36.9%) p = .009. CONCLUSIONS While the use of diuretic therapy in critically ill patients receiving vasopressor infusions augmented urine output, it was not associated with higher vasopressor requirements, AKI incidence, and need for renal replacement therapy.
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Affiliation(s)
- Ghassan Bandak
- Division of Pulmonary and Critical Care Medicine, Marshall Health, Huntington, WV, United States of America
| | - Ankit Sakhuja
- Division of Pulmonary and Critical Care Medicine, University of West Virginia, Morgantown, WV, United States of America
| | - Nicole M. Andrijasevic
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Tina M. Gunderson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, United States of America
- * E-mail:
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Selewski DT, Gist KM, Nathan AT, Goldstein SL, Boohaker LJ, Akcan-Arikan A, Bonachea EM, Hanna M, Joseph C, Mahan JD, Mammen C, Nada A, Reidy K, Staples A, Wintermark P, Griffin R, Askenazi DJ, Guillet R. The impact of fluid balance on outcomes in premature neonates: a report from the AWAKEN study group. Pediatr Res 2020; 87:550-557. [PMID: 31537009 PMCID: PMC7036003 DOI: 10.1038/s41390-019-0579-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/26/2019] [Accepted: 08/30/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND We evaluated the epidemiology of fluid balance (FB) over the first postnatal week and its impact on outcomes in a multi-center cohort of premature neonates from the AWAKEN study. METHODS Retrospective analysis of infants <36 weeks' gestational age from the AWAKEN study (N = 1007). FB was defined by percentage of change from birth weight. OUTCOME Mechanical ventilation (MV) at postnatal day 7. RESULTS One hundred and forty-nine (14.8%) were on MV at postnatal day 7. The median peak FB was 0% (IQR: -2.9, 2) and occurred on postnatal day 2 (IQR: 1,5). Multivariable models showed that the peak FB (aOR 1.14, 95% CI 1.10-1.19), lowest FB in first postnatal week (aOR 1.12, 95% CI 1.07-1.16), and FB on postnatal day 7 (aOR 1.10, 95% CI 1.06-1.13) were independently associated with MV on postnatal day 7. In a similar analysis, a negative FB at postnatal day 7 protected against the need for MV at postnatal day 7 (aOR 0.21, 95% CI 0.12-0.35). CONCLUSIONS Positive peak FB during the first postnatal week and more positive FB on postnatal day 7 were independently associated with MV at postnatal day 7. Those with a negative FB at postnatal day 7 were less likely to require MV.
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Affiliation(s)
- David T. Selewski
- 0000 0001 2189 3475grid.259828.cDivision of Nephrology, Department of Pediatric, Medical University of South Carolina, Charleston, SC USA
| | - Katja M. Gist
- 0000 0001 0703 675Xgrid.430503.1Department of Pediatrics, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Amy T. Nathan
- 0000 0001 2179 9593grid.24827.3bPerinatal Institute, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH USA
| | - Stuart L. Goldstein
- 0000 0001 2179 9593grid.24827.3bCenter for Acute Care Nephrology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH USA
| | - Louis J. Boohaker
- 0000000106344187grid.265892.2Pediatric and Infant Center for Acute Nephrology (PICAN) Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL USA
| | - Ayse Akcan-Arikan
- 0000 0001 2160 926Xgrid.39382.33Sections of Pediatric Critical Care Medicine and Renal, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
| | - Elizabeth M. Bonachea
- 0000 0001 2285 7943grid.261331.4Department of Pediatrics, Section of Neonatology, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH USA
| | - Mina Hanna
- 0000 0004 1936 8438grid.266539.dDepartment Pediatrics, University of Kentucky, Lexington, KY USA
| | - Catherine Joseph
- 0000 0001 2160 926Xgrid.39382.33Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
| | - John D. Mahan
- 0000 0001 2285 7943grid.261331.4Nationwide Children’s Hospital, The Ohio State University, College of Medicine, Columbus, OH USA
| | - Cherry Mammen
- 0000 0001 0684 7788grid.414137.4Division of Nephrology, British Columbia Children’s Hospital (BCCH), Vancouver, BC Canada
| | - Arwa Nada
- 0000 0004 0386 9246grid.267301.1Department of Pediatrics, Division of Nephrology, LeBonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN USA
| | - Kimberly Reidy
- 0000000121791997grid.251993.5Division of Nephrology, Department of Pediatrics, Children’s Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY USA
| | - Amy Staples
- 0000 0001 2188 8502grid.266832.bDepartment of Pediatrics, University of New Mexico, Albuquerque, NM USA
| | - Pia Wintermark
- 0000 0004 1936 8649grid.14709.3bDepartment of Pediatrics, McGill University, Montreal, QC Canada
| | - Russell Griffin
- 0000000106344187grid.265892.2Pediatric and Infant Center for Acute Nephrology (PICAN) Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL USA
| | - David J. Askenazi
- 0000000106344187grid.265892.2Pediatric and Infant Center for Acute Nephrology (PICAN) Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL USA
| | - Ronnie Guillet
- 0000 0004 1936 9174grid.16416.34Department of Pediatrics, Division of Neonatology, Golisano Children’s Hospital, University of Rochester, Rochester, NY USA
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Bamoulid J, Philippot H, Kazory A, Yannaraki M, Crepin T, Vivet B, Devillard N, Roubiou C, Bresson-Vautrin C, Chalopin JM, Courivaud C, Ducloux D. Acute kidney injury in non-critical care setting: elaboration and validation of an in-hospital death prognosis score. BMC Nephrol 2019; 20:419. [PMID: 31752723 PMCID: PMC6868787 DOI: 10.1186/s12882-019-1610-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 10/29/2019] [Indexed: 01/05/2023] Open
Abstract
Background Acute kidney injury (AKI) is still characterized by a high mortality rate. While most patients with AKI are admitted in conventional medical units, current available data are still obtained from studies designed for patients admitted in intensive care units (ICU). Our study aimed to elaborate and validate an in-hospital death prognosis score for AKI admitted in conventional medical care units. Methods We included two prospective cohorts of consecutive patients with AKI admitted between 2001 and 2004 (elaboration cohort (EC)) and between 2010 and 2014 (validation cohort (VC)). We developed a scoring system from clinical and biological parameters recorded at admission from the EC to predict in-hospital mortality. This score was then tested for validation in the VC. Results Three-hundred and twenty-three and 534 patients were included in the EC and VC cohorts, respectively. The proportion of in-hospital death were 15.5% (EC) and 8.9% (VC), mainly due to sepsis. The parameters independently associated with the in-hospital death in the EC were Glasgow score, oxygen requirement, fluid overload, blood diastolic pressure, multiple myeloma and prothrombin time. The in-hospital death prognosis score AUC was 0.845 +/− 0.297 (p < 0.001) after validation in the VC. Conclusions Our in-hospital death prognosis score is the first to be prospectively developed and validated for AKI admitted in a conventional medical care unit. Based on current parameters, easily collected at time of admission, this score could be a useful tool for physicians and nephrologists to determine the in-hospital death prognosis of this AKI population.
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Affiliation(s)
- Jamal Bamoulid
- CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, F-25030, Besançon, France. .,UMR1098, Federation hospitalo-universitaire INCREASE, F-25020, Besançon, France. .,Faculté de Médecine et de Pharmacie, Université de Franche-Comté, F-25020, Besançon, France. .,Structure Fédérative de Recherche, SFR FED4234, F-25000, Besançon, France.
| | - Hélène Philippot
- CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, F-25030, Besançon, France.
| | - Amir Kazory
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Maria Yannaraki
- CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, F-25030, Besançon, France
| | - Thomas Crepin
- CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, F-25030, Besançon, France.,UMR1098, Federation hospitalo-universitaire INCREASE, F-25020, Besançon, France.,Faculté de Médecine et de Pharmacie, Université de Franche-Comté, F-25020, Besançon, France.,Structure Fédérative de Recherche, SFR FED4234, F-25000, Besançon, France
| | - Bérengère Vivet
- CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, F-25030, Besançon, France
| | - Nadège Devillard
- CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, F-25030, Besançon, France
| | - Caroline Roubiou
- CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, F-25030, Besançon, France
| | - Catherine Bresson-Vautrin
- CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, F-25030, Besançon, France
| | - Jean-Marc Chalopin
- CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, F-25030, Besançon, France.,UMR1098, Federation hospitalo-universitaire INCREASE, F-25020, Besançon, France.,Faculté de Médecine et de Pharmacie, Université de Franche-Comté, F-25020, Besançon, France.,Structure Fédérative de Recherche, SFR FED4234, F-25000, Besançon, France
| | - Cécile Courivaud
- CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, F-25030, Besançon, France.,UMR1098, Federation hospitalo-universitaire INCREASE, F-25020, Besançon, France.,Faculté de Médecine et de Pharmacie, Université de Franche-Comté, F-25020, Besançon, France.,Structure Fédérative de Recherche, SFR FED4234, F-25000, Besançon, France
| | - Didier Ducloux
- CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, F-25030, Besançon, France.,UMR1098, Federation hospitalo-universitaire INCREASE, F-25020, Besançon, France.,Faculté de Médecine et de Pharmacie, Université de Franche-Comté, F-25020, Besançon, France.,Structure Fédérative de Recherche, SFR FED4234, F-25000, Besançon, France
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Girling BJ, Channon SW, Haines RW, Prowle JR. Acute kidney injury and adverse outcomes of critical illness: correlation or causation? Clin Kidney J 2019; 13:133-141. [PMID: 32296515 PMCID: PMC7147312 DOI: 10.1093/ckj/sfz158] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 10/07/2019] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Benedict J Girling
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Samuel W Channon
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Ryan W Haines
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - John R Prowle
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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Hatton GE, Du RE, Wei S, Harvin JA, Finkel KW, Wade CE, Kao LS. Positive Fluid Balance and Association with Post-Traumatic Acute Kidney Injury. J Am Coll Surg 2019; 230:190-199.e1. [PMID: 31733328 DOI: 10.1016/j.jamcollsurg.2019.10.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/13/2019] [Accepted: 10/21/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is common in severely injured trauma patients and is associated with poor outcomes. A positive fluid balance is associated with AKI and poor long-term renal outcomes among general ICU and cardiac surgery patients. Currently, the optimal endpoint of resuscitation of severely injured trauma patients is unknown, which may result in excess fluid administration. We hypothesized that positive fluid balance is common after severe trauma and is associated with increased AKI development. STUDY DESIGN A cohort study of adult (≥16 years old) trauma patients requiring ICU admission from January 2017 to June of 2017 was conducted. Patients were excluded for early death, rhabdomyolysis, or previous history of end-stage renal disease or congestive heart failure. Acute kidney injury within 7 days of admission was defined according to Kidney Disease Improving Global Outcomes creatinine-based criteria. Univariate and multivariable analyses were performed. RESULTS Of 364 patients, 74% were male. The median age was 41 years (interquartile range [IQR] 27 to 59 years), and the median Injury Severity Score (ISS) was 18 (IQR 10 to 29). Positive fluid balance (>2 L) was observed in 49% of patients. Acute kidney injury was diagnosed in 105 (29%) patients. After adjustment, there was an increased risk of AKI with a positive fluid balance >2 L (relative risk [RR] 1.98 [95% CI 1.24 to 3.17]). Additionally, the risk of AKI incrementally increased by 1.22 with each liter fluid positive above a zero balance (95% CI 1.11 to 1.34). CONCLUSIONS Positive fluid balance in excess of 2 L at 48 hours occurs in half of severely injured trauma patients, and fluid positivity is independently and incrementally associated with AKI development. Fluid responsiveness should be investigated as an end point of post-traumatic resuscitation to prevent unnecessary fluid administration and subsequent AKI.
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Affiliation(s)
- Gabrielle E Hatton
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School, Houston, TX; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School, Houston, TX.
| | - Reginald E Du
- McGovern Medical School at UTHealth, McGovern Medical School, Houston, TX; Center for Translational Injury Research, Houston, TX
| | - Shuyan Wei
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School, Houston, TX; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School, Houston, TX
| | - John A Harvin
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School, Houston, TX; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School, Houston, TX
| | - Kevin W Finkel
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School, Houston, TX; Division of Renal Diseases and Hypertension, Department of Medicine, McGovern Medical School, Houston, TX
| | - Charles E Wade
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School, Houston, TX; Center for Translational Injury Research, Houston, TX
| | - Lillian S Kao
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School, Houston, TX; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School, Houston, TX
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Alscher MD, Erley C, Kuhlmann MK. Acute Renal Failure of Nosocomial Origin. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:149-158. [PMID: 30961801 DOI: 10.3238/arztebl.2019.0149] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 10/02/2018] [Accepted: 01/13/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND 10-20% of hospitalized patients develop acute kidney injury (AKI)/acute renal failure during their hospital stay. The mortality of nosocomial AKI is approximately 30%. METHODS This review is based on relevant publications retrieved by a search in multiple databases (PubMed and Uptodate), archives, and pertinent medical journals. RESULTS The most common causes of nosocomial AKI are volume depletion, sepsis, heart diseases, polytrauma, liver diseases, and drug toxicity. AKI can also be of postrenal (obstructive) origin, or a result of renal diseases including glomeruloneph- ritis, vasculitis, tubulointerstitial nephritis, and cholesterol embolism. In about 13% of cases, nosocomial AKI develops on the basis of pre-existing chronic renal disease. Patients with AKI are at elevated risk of developing chronic renal disease and must be followed up appropriately after they are discharged from the hospital. Indispens- able elements of the evaluation of nosocomial AKI include renal ultrasonography, the exclusion of postrenal obstruction, urine chemistry, and microbiological urinaly- sis. Potentially nephrotoxic drugs and those that impair renal hemodynamics must be avoided to the greatest possible extent in patients with acute renal damage. Hypotension must be avoided as well. CONCLUSION Early, specific nephrological diagnosis and treatment are important components of the management of nosocomial AKI, particularly because causally directed treatment is available for some of the conditions that underlie it.
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Lin PC, Huang HC, Komorowski M, Lin WK, Chang CM, Chen KT, Li YC, Lin MC. A machine learning approach for predicting urine output after fluid administration. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 177:155-159. [PMID: 31319943 DOI: 10.1016/j.cmpb.2019.05.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/21/2019] [Accepted: 05/13/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE To develop a machine learning model to predict urine output (UO) in sepsis patients after fluid resuscitation. METHODS We identified sepsis patients in the Multiparameter Intelligent Monitoring in Intensive Care-III v1.4 database according to the Sepsis-3 criteria. We focused on two outcomes: whether the UO decreased after fluid administration and whether oliguria (defined as UO less than the threshold of 0.5 mL/kg/h) developed. A gradient tree-based machine learning model implemented with an eXtreme Gradient Boosting algorithm was used to integrate relevant physiological parameters for predicting the aforementioned outcomes. A confusion matrix was computed. RESULTS A total of 232,929 events in 19,275 patients were included. Using decreased UO as the outcome measure, the optimal model achieved an area under the curve (AUC) of 0.86; for predicting oliguria, most models achieved an AUC greater than 0.86, and the highest sensitivity was 92.2% when the model was applied to patients with baseline oliguria. CONCLUSIONS Machine learning could help clinicians evaluate fluid status in sepsis patients after fluid administration, thus preventing fluid overload-related complications.
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Affiliation(s)
- Pei-Chen Lin
- Graduate Institute of Biomedical Informatics, College of Medicine Science and Technology, Taipei Medical University, Taipei, Taiwan; Emergency Department, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Hsu-Cheng Huang
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Radiology, Taipei City Hospital, Yangming Branch, Taipei, Taiwan
| | - Matthieu Komorowski
- Department of Surgery and Cancer, Imperial College London, London, UK; Department of Bioengineering, Imperial College London, London, UK; Laboratory of Computational Physiology, Harvard-MIT Division of Health Sciences & Technology, Cambridge, MA, USA
| | - Wei-Kai Lin
- Institute of Information Science, Academia Sinica, Taipei, Taiwan
| | - Chun-Min Chang
- Institute of Information Science, Academia Sinica, Taipei, Taiwan
| | - Kuan-Ta Chen
- Institute of Information Science, Academia Sinica, Taipei, Taiwan
| | - Yu-Chuan Li
- International Center for Health Information Technology, Taipei Medical University, Taipei, Taiwan; Department of Dermatology, Wan Fang Hospital, Taipei, Taiwan
| | - Ming-Chin Lin
- Graduate Institute of Biomedical Informatics, College of Medicine Science and Technology, Taipei Medical University, Taipei, Taiwan; Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan.
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48
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Santos RPD, Carvalho ARS, Peres LAB, Ronco C, Macedo E. An epidemiologic overview of acute kidney injury in intensive care units. Rev Assoc Med Bras (1992) 2019; 65:1094-1101. [DOI: 10.1590/1806-9282.65.8.1094] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/13/2019] [Indexed: 12/21/2022] Open
Abstract
SUMMARY INTRODUCTION Acute kidney injury (AKI) is a frequent event among critically ill patients hospitalized in intensive care units (ICU) and represents a global public health problem, being imperative an interdisciplinary approach. OBJECTIV To investigate, through literature review, the AKI epidemiology in ICUs. METHODS: Online research in Medline, Scientific Electronic Library Online, and Latin American and Caribbean Literature in Health Sciences databases, with analysis of the most relevant 47 studies published between 2010 and 2017. RESULTS Data of the 67,033 patients from more than 300 ICUs from different regions of the world were analyzed. The overall incidence of AKI ranged from 2.5% to 92.2%, and the mortality from 5% to 80%. The length of ICU stay ranged from five to twenty-one days, and the need for renal replacement therapy from 0.8% to 59.2%. AKI patients had substantially higher mortality rates and longer hospital stays than patients without AKI. CONCLUSION AKI incidence presented high variability among the studies. One of the reasons for that were the different criteria used to define the cases. Availability of local resources, renal replacement therapy needs, serum creatinine at ICU admission, volume overload, and sepsis, among others, influence mortality rates in AKI patients.
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Affiliation(s)
| | | | | | | | - Etienne Macedo
- University of California San Diego, United States of America
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Fong KM, Au SY, Ng GWY, Leung AKH. Positive fluid balance and mortality in adult patients treated with extracorporeal membrane oxygenation: A retrospective study. J Intensive Care Soc 2019; 21:210-220. [PMID: 32782460 DOI: 10.1177/1751143719862240] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background Intravenous fluid is important for resuscitation and maintenance of circuit flow in patients with extracorporeal membrane oxygenation, but fluid overload is widely recognized as detrimental in critically ill patients. This study aimed to evaluate the association between positive fluid balance and outcomes in adult patients treated with extracorporeal membrane oxygenation. Methods This was a retrospective observational study of a tertiary hospital from October 2010 to January 2018. Patients aged ≥18 years who received extracorporeal membrane oxygenation for ≥48 h were included. The fluid balance was determined as the difference between fluid intake and fluid output, and the cumulative fluid balance was calculated as the sum of these values on the preceding days. The primary outcome was hospital mortality. Results Of the 123 included extracorporeal membrane oxygenation episodes, 79 were venovenous extracorporeal membrane oxygenation. The hospital mortality rate was 31.7%. Seventy-eight patients underwent continuous renal replacement therapy during their extracorporeal membrane oxygenation course. Non-survivors had a greater cumulative fluid balance (p≤0.001) and a lower cumulative fluid output (p = 0.006) than survivors on day 7. Fluid intake was not significantly different between survivors and non-survivors (p = 0.583). In the multivariate analysis, the cumulative fluid balance (per litre) on day 7, but not on day 3, was associated with increased hospital mortality (adjusted OR: 1.17, 95% CI: 1.06-1.29, p = 0.001). Conclusions In adult patients treated with extracorporeal membrane oxygenation, a higher positive cumulative fluid balance on day 7 was associated with increased hospital mortality. The association between positive fluid balance and mortality was mainly influenced by lower fluid output rather than an increase in fluid intake.
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Affiliation(s)
- Ka Man Fong
- Department of Intensive Care, Queen Elizabeth Hospital, Hong Kong SAR
| | - Shek Yin Au
- Department of Intensive Care, Queen Elizabeth Hospital, Hong Kong SAR
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50
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Tourneur JM, Weissbrich C, Putensen C, Hilbert T. Feasibility of a protocol to wean patients from continuous renal replacement therapy: A retrospective pilot observation. J Crit Care 2019; 53:236-243. [PMID: 31280144 DOI: 10.1016/j.jcrc.2019.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/13/2019] [Accepted: 06/29/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE To evaluate the feasibility of a protocol-based algorithm to wean acute kidney injury (AKI) patients from continuous renal replacement therapy (CRRT). METHODS The protocol was introduced on one of two similarly equipped ICUs, while on the other (reference) ICU, CRRT discontinuation was based on clinical judgement. Patients were allocated to either ICU and were subjected to physician- or protocol-directed weaning, respectively. According to the algorithm, periodical withdrawal trials (WTs) were mandatory. Interventions were recommended (administration of diuretics, fluid, vasopressors, inotropes, or human albumin) to achieve specific goals (sufficient urine output, balanced fluid status, adequate renal perfusion pressure, optimal oxygen delivery, normoalbuminemia). Clearly stated criteria defined when to abort a WT and to resume RRT for one cycle, followed by another WT. RESULTS Urine output and ScvO2 during WTs were higher with protocol-directed weaning, as well as the amount of administered fluids. WT abort ratio was 48% with a tendency to prolonged WT duration, compared to 64% in the reference patients. No relevant adverse side effects were observed. CONCLUSION Our data show the feasibility of a structured approach to wean AKI patients from RRT that bundles established interventions and brings the weaning into the physician's focus.
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Affiliation(s)
- Julia-Marie Tourneur
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127 Bonn, Germany
| | - Carsten Weissbrich
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127 Bonn, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127 Bonn, Germany
| | - Tobias Hilbert
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127 Bonn, Germany.
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