Risk factors, clinical features and outcome of new-onset acute kidney injury among critically ill patients: a database analysis based on prospective cohort study

Development and validation of a nomogram for predicting acute kidney injury in elderly patients in intensive care unit

BACKGROUND

This study aimed to develop and validate a nomogram for predicting acute kidney injury (AKI) in elderly patients in the intensive care unit (ICU).

METHODS

Population data regarding elderly patients in ICU were derived from the Medical Information Mart for Intensive Care IV database from 2008 to 2019. The nomogram model was constructed from the training set using LASSO regression and logistic regression analysis, and the performance of the model was evaluated by decision curve analysis, calibration curve, and receiver operating characteristic (ROC) curve.

RESULTS

According to inclusion and exclusion criteria, 14,373 elderly ICU patients were studied, of which 10,061 (70%) were assigned to the training set, and 4,312 (30%) were allocated to the validation set. Multivariate logistic analysis revealed that age, weight, myocardial infarction, congestive heart failure, dementia, diabetes, paraplegia, cancer, sepsis, body temperature, blood urea nitrogen, mechanical ventilation, urine volume, Sequential Organ Failure Assessment (SOFA) score, and Simplified Acute Physiology Score II (SAPS II) were independent risk factors for AKI in elderly ICU patients. The AUC values for the 15-factor nomogram were 0.812 (95% CI 0.802-0.822) and 0.802 (95% CI 0.787-0.818) in the training and validation sets, respectively. For clinical application, a simplified nomogram was constructed, which included age, weight, urine volume, SOFA score, and SAPS II, with the AUCs of 0.780 (95% CI 0.769-0.790) and 0.776 (95% CI 0.760-0.793), respectively. Calibration curve and decision curve analyses confirmed the models' high prediction accuracy and clinical value.

CONCLUSIONS

The nomogram developed in this study shows excellent predictive performance for AKI in elderly patients in the ICU.

Machine Learning to Assist in Managing Acute Kidney Injury in General Wards: Multicenter Retrospective Study

BACKGROUND

Most artificial intelligence-based research on acute kidney injury (AKI) prediction has focused on intensive care unit settings, limiting their generalizability to general wards. The lack of standardized AKI definitions and reliance on intensive care units further hinder the clinical applicability of these models.

OBJECTIVE

This study aims to develop and validate a machine learning-based framework to assist in managing AKI and acute kidney disease (AKD) in general ward patients, using a refined operational definition of AKI to improve predictive performance and clinical relevance.

METHODS

This retrospective multicenter cohort study analyzed electronic health record data from 3 hospitals in South Korea. AKI and AKD were defined using a refined version of the Kidney Disease: Improving Global Outcomes criteria, which included adjustments to baseline serum creatinine estimation and a stricter minimum increase threshold to reduce misclassification due to transient fluctuations. The primary outcome was the development of machine learning models for early prediction of AKI (within 3 days before onset) and AKD (nonrecovery within 7 days after AKI).

RESULTS

The final analysis included 135,068 patients. A total of 7658 (8%) patients in the internal cohort and 2898 (7.3%) patients in the external cohort developed AKI. Among the 5429 patients in the internal cohort and 1998 patients in the external cohort for whom AKD progression could be assessed, 896 (16.5%) patients and 287 (14.4%) patients, respectively, progressed to AKD. Using the refined criteria, 2898 cases of AKI were identified, whereas applying the standard Kidney Disease: Improving Global Outcomes criteria resulted in the identification of 5407 cases. Among the 2509 patients who were not classified as having AKI under the refined criteria, 2242 had a baseline serum creatinine level below 0.6 mg/dL, while the remaining 267 experienced a decrease in serum creatinine before the onset of AKI. The final selected early prediction model for AKI achieved an area under the receiver operating characteristic curve of 0.9053 in the internal cohort and 0.8860 in the external cohort. The early prediction model for AKD achieved an area under the receiver operating characteristic curve of 0.8202 in the internal cohort and 0.7833 in the external cohort.

CONCLUSIONS

The proposed machine learning framework successfully predicted AKI and AKD in general ward patients with high accuracy. The refined AKI definition significantly reduced the classification of patients with transient serum creatinine fluctuations as AKI cases compared to the previous criteria. These findings suggest that integrating this machine learning framework into hospital workflows could enable earlier interventions, optimize resource allocation, and improve patient outcomes.

Factors associated with contrast-associated acute kidney injury in an emergency department: A cohort study in Lebanon

BACKGROUND

Contrast-associated acute kidney injury (CA-AKI) is a common problem in hospitals, particularly in low-middle-income countries (LMIC), due to limited resources and a high prevalence of comorbidities. Kidney function evaluation using serum creatinine levels before contrast administration leads to increased length of stay and delayed patient care. This study aimed to identify factors associated with CA-AKI in emergency department (ED) patients in an LMIC. Identifying these factors is essential for enhancing patient care and guiding clinical practice by allowing for the early detection and management of patients at risk.

METHODS

This study is a retrospective cohort study conducted at the largest tertiary care center's ED in Lebanon between November 2018 and December 2019. The study included ED patients who underwent computed-tomography (CT) with contrast. Bivariate and logistic regression analyses were performed to compare the characteristics of patients who developed AKI with those who did not by using SPSS package. The Institutional Review Board (IRB) at the American University of Beirut (AUB) approved this study under protocol ID BIO-2020-0276, which was performed per the Declaration of Helsinki. The IRB waived the need to consent patients since many of them were not followed up at the time of the study.

RESULTS

The study included 1832 patients, of whom 10.4% (n = 190) developed CA-AKI. Patients aged over 65 had a 1.6-fold higher risk of CA-AKI (aOR = 1.55, 95%CI:1.09-2.2). High blood pressure (≥140 mmHg), high respiratory rate ( ≥ 22), and chronic kidney disease were significantly associated with CA-AKI. The use of loop diuretics (aOR = 2.21, 95%CI:1.49-3.28), beta-lactams (aOR = 4.11, 95%CI:2.63-6.42), and allopurinol (aOR = 2.74, 95%CI:1.43-5.25) were significantly associated with CA-AKI.

CONCLUSIONS

Identifying factors associated with CA-AKI in an emergency setting, such as age, comorbidities, and home medications, can help identify patients at low risk of developing CA-AKI.

Prophylactic proton pump inhibitor usage and new-onset acute kidney injury in critically ill patients: a retrospective analysis

Background

Proton pump inhibitors (PPIs) are widely prescribed for stress ulcer prophylaxis (SUP) in intensive care unit (ICU) patients. However, the potential association between prophylactic PPIs and the development of new-onset acute kidney injury (AKI) remains unclear.

Methods

Patients without AKI or end-stage renal disease and not undergoing renal replacement therapy upon admission to the ICU were identified from the Medical Information Mart for Intensive Care (MIMIC-IV) database. The exposure factor for the study was the initiation of prophylactic PPIs within 48 h of admission, with the primary outcome being the occurrence of new-onset AKI after 48 h. Multivariable regression models were employed to investigate the association between prophylactic PPIs and the risk of new-onset AKI. Various propensity score analyses, along with stratified and subgroup analyses and E-value calculations, were conducted to further evaluate the reliability of the results.

Results

A total of 7498 ICU patients were analyzed. The multivariable analysis showed a higher incidence of new-onset AKI in the PPI group (30.7%) compared with the control group (24.1%), yielding an adjusted odds ratio (OR) of 1.43 (95% confidence interval 1.22-1.67). Propensity score analyses confirmed these results, with ORs ranging from 1.34 to 1.49 (P ≤ .005). Results from multiple sensitivity analyses further supported these findings, with an E-value of 2.34 indicating robustness against unmeasured confounders.

Conclusions

Prophylactic PPI use is associated with an increased risk of new-onset AKI in ICU patients. Indiscriminate use of PPIs should be avoided.

Central Venous Pressure as a Predictor of Acute Kidney Injury in Cardiac Surgery: A Systematic Review of Observational Studies

Background/Objectives: Acute kidney injury (AKI) is a syndrome characterized by impaired kidney function, which is associated with reduced survival and increased morbidity. Central venous pressure (CVP) is a widely used hemodynamic parameter for assessing the volume status of patients and evaluating their response to fluid resuscitation. This systematic review aims to analyze various prospective and retrospective observational and controlled trials to determine the association between CVP and the risk of developing AKI in patients undergoing cardiac surgery. Additionally, it examines whether elevated CVP serves as an accurate predictor of AKI in this patient population. Methods: A systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, using PubMed as the primary database. The search focused on studies published after 2014 that included adult patients undergoing cardiac surgery with reported measurements of CVP and kidney function assessment. Studies conducted on animals, pediatric populations, those published before 2014, or in languages other than English were excluded from the review. Results: Through the analysis of 21 studies, a clear association between higher CVP and increased AKI risk emerged. The most critical CVP thresholds identified were 10 mmHg, 12 mmHg, 14 mmHg, and 20 mmHg, with risk increasing progressively beyond these values. CVP ≥ 10 mmHg was the most commonly reported cutoff for elevated AKI risk, showing 1.42 to 4.53 times increased odds. CVP ≥ 12 mmHg further amplified the risk, while CVP ≥ 14 mmHg was consistently associated with severe AKI and the need for RRT. The highest threshold (CVP ≥ 20 mmHg) showed the greatest risk escalation, linked to fluid overload, right heart failure, and mortality. Studies also suggest an optimal CVP range of 6-8 mmHg to minimize AKI incidence. Conclusions: Elevated CVP is an independent risk factor for the development of AKI in patients undergoing cardiac surgery. These findings suggest that CVP monitoring can play a significant role in predicting AKI and guiding perioperative management strategies.

Impact of Non-Dialysis-Requiring Acute Kidney Injury on Survival Outcomes in Non-critically Ill Hospitalized Medical Patients in a Resource-Limited Setting: A Retrospective Cohort Study

Introduction The severe consequences of acute kidney injury (AKI) have been well-documented in high-risk patient populations. However, the effects of milder forms in non-critically ill patients remain understudied, particularly in resource-limited settings. While the risk of mortality associated with these cases is considered low, it can still lead to various complications including prolonged hospitalization, which may influence long-term renal and patient survival. Hence, the objective of this study was to study the impact of non-dialysis-requiring AKI (NDR-AKI) on survival outcomes of non-critically ill medical patients admitted to St. Paul's Hospital Millennium Medical College in Ethiopia during the period from July 2019 to January 2022. Methods A retrospective cohort study was conducted among 300 non-critically ill medical patients, 93 with NDR-AKI and 207 without AKI. Descriptive statistics, including frequency distributions and median survival times, were employed to summarize the data. Kaplan-Meier curves and the log-rank test were utilized to compare survival experiences of groups. A Cox proportional hazards survival model was fitted to estimate the impact of NDR-AKI on time to recovery. Adjusted hazard ratio (AHR) with 95% confidence interval (CI) was used to report findings. Results Two hundred four (68.0%) were discharged after improvement and the median recovery time was 16 days (95%CI: 13.5-18.5 days). Having NDR-AKI was associated with a 43% lower rate of achieving recovery (AHR=0.57, 95%CI=0.38, 0.84, p-value=0.004). Females were found to have a 1.41 times higher rate of recovery (AHR=1.41, 95%CI=1.03,1.94, p-value=0.033). Additionally, having tuberculosis (AHR=0.41, 95%CI=0.23,0.72, p-value=0.002) and being on anticoagulant (AHR=0.67, 95%CI=0.47,0.95, p-value=0.027) were associated with a 59% and 33% lower rate of recovery, respectively. Conclusion NDR-AKI significantly delays recovery compared to patients without AKI suggesting that even milder forms of AKI in non-critically ill patients can negatively impact patient outcomes. Early identification, prompt management, and addressing underlying causes are key to improving recovery and reducing long-term morbidity and mortality. Strict screening and monitoring of high-risk groups such as men, patients with tuberculosis, and those on anticoagulants is also crucial.

The Impact of Acute Kidney Injury on Chronic Kidney Disease After Cardiac Surgery: A Systematic Review and Meta-analysis

OBJECTIVES

To evaluate the impact of acute kidney injury on transition to chronic kidney disease (CKD) after cardiac surgery and to determine frequency of incident CKD in these patients.

DESIGN

A systematic review and meta-analysis of observational studies.

SETTING

Electronic databases Medline and Embase were systematically searched from 1974 to February 6, 2023.

PARTICIPANTS

Eligible studies were original observational studies on adult cardiac surgery patients, written in the English language, and with clear kidney disease definitions. Exclusion criteria were studies with previously transplanted populations, populations with preoperative kidney impairment, ventricular assist device procedures, endovascular procedures, a kidney follow-up period of <90 days, and studies not presenting necessary data for effect size calculations.

INTERVENTIONS

Patients developing postoperative acute kidney injury after cardiac surgery were compared with patients who did not develop acute kidney injury.

MEASUREMENTS AND MAIN RESULTS

The search identified 4,329 unique studies, 87 underwent full-text review, and 12 were included for analysis. Mean acute kidney injury occurrence across studies was 16% (minimum-maximum: 8-50), while mean occurrence of CKD was 24% (minimum-maximum: 3-35), with high variability depending on definitions and follow-up time. Acute kidney injury was associated with increased odds of CKD in all individual studies. The pooled odds ratio across studies was 5.67 (95% confidence interval, 3.34-9.64; p < 0.0001).

CONCLUSIONS

Acute kidney injury after cardiac surgery was associated with a more than 5-fold increased odds of developing CKD. New-onset CKD occurred in almost 1 in 4 patients in the years after surgery.

Development of Acute Kidney Injury Predictor Score in Intensive Care Unit Patients in Padang, Indonesia

OBJECTIVE

This study aims to develop and create a specialized acute kidney injury (AKI) predictor score for the intensive care unit (ICU) patients in Padang, Indonesia.

PATIENTS AND METHODS

This study was a prospective observational study on 352 ICU patients at three specialized hospitals in Padang City; Dr. M. Djamil General Hospital, Dr. Rasidin General Hospital, and Siti Rahmah Islamic Hospital. Data regarding demographics, clinical characteristics, laboratory results, and outcomes related to AKI were gathered. The factors that predict AKI were identified using multivariate logistic regression analysis to determine independent factors. The predictor scores were created using regression coefficients and then internally confirmed.

RESULTS

Out of a total of 352 patients, 128 individuals (36.4%) suffered from AKI. Factors that independently predict the occurrence of AKI include age over 60 years old, having a history of chronic kidney disease, having sepsis, need for vasopressors, and having creatinine level 1.3 mg/dL (IQR 1.0-1.8) upon admission to ICU. An area under the curve (AUC) of 0.85 (95% CI 0.80-0.90) indicated the strong performance of the constructed predictor score.

CONCLUSION

The constructed AKI predictor score a scale factor of 10, resulting in a range of 0-10 for the AKI predictor score. It demonstrates a good level of accuracy in predicting AKI in ICU patients in Padang. This score can be used by healthcare professionals to quickly identify and categorize individuals based on their risk level, facilitating timely intervention and personalized treatment.

Hospital-Acquired Acute Kidney Injury in Non-Critical Medical Patients in a Developing Country Tertiary Hospital: Incidence and Predictors

Background

Acute kidney injury (AKI) is a frequent complication in critical patients, leading to a worse prognosis. Although its consequences are worse among critical patients, AKI is also associated with less favorable outcomes in non-critical patients. Therefore, understanding the magnitude of the problem in these patients is crucial, yet there is a scarcity of evidence in non-critical settings, especially in resource limited countries. Hence, the study aimed at determining the incidence and predictors of hospital acquired acute kidney injury (HAAKI) in non-critical medical patients who were admitted at a large tertiary hospital in Ethiopia.

Methods

A retrospective chart review study was conducted from September 25, 2022 to January 20, 2023 among 232 hospitalized non-critical medical patients admitted to St. Paul's Hospital Millennium Medical College between January 2020 and January 2022. The incidence of HAAKI was estimated using incidence density per total person day (PD) observation of the study participants. To identify predictors of HAAKI, a log binomial regression model was fitted at a p value of ≤0.05. The magnitude of association was measured using adjusted relative risk (ARR) with its 95% CI.

Results

During the median follow-up duration of 11 days (IQR, 6-19 days), the incidence of HAAKI was estimated to be 6.0 per 100 PD (95% CI = 5.5 to 7.2). Significant predictors of HAAKI were found to be having type 2 diabetes mellitus (ARR = 2.36, 95% CI = 1.03, 5.39, p-value=0.042), and taking vancomycin (ARR = 3.04, 95% CI = 1.38, 6.72, p-value=0.006) and proton pump inhibitors (ARR = 3.80, 95% CI = 1.34,10.82, p-value=0.012).

Conclusion

HAAKI is a common complication in hospitalized non-critical medical patients, and is associated with a common medical condition and commonly prescribed medications. Therefore, it is important to remain vigilant in the prevention and timely identification of these cases and to establish a system of rational prescribing habits.

Attributable mortality of acute kidney injury among critically ill patients with sepsis: a multicenter, retrospective cohort study

BACKGROUND

Sepsis and acute kidney injury (AKI) are common severe diseases in the intensive care unit (ICU). This study aimed to estimate the attributable mortality of AKI among critically ill patients with sepsis and to assess whether AKI was an independent risk factor for 30-day mortality.

METHODS

The information we used was derived from a multicenter prospective cohort study conducted in 18 Chinese ICUs, focusing on septic patients post ICU admission. The patients were categorized into two groups: those who developed AKI (AKI group) within seven days following a sepsis diagnosis and those who did not develop AKI (non-AKI group). Using propensity score matching (PSM), patients were matched 1:1 as AKI and non-AKI groups. We then calculated the mortality rate attributable to AKI in septic patients. Furthermore, a survival analysis was conducted comparing the matched AKI and non-AKI septic patients. The primary outcome of interest was the 30-day mortality rate following the diagnosis of sepsis.

RESULTS

Out of the 2175 eligible septic patients, 61.7% developed AKI. After the application of PSM, a total of 784 septic patients who developed AKI were matched in a 1:1 ratio with 784 septic patients who did not develop AKI. The overall 30-day attributable mortality of AKI was 6.6% (95% CI 2.3 ∼ 10.9%, p = 0.002). A subgroup analysis revealed that the 30-day attributable mortality rates for stage 1, stage 2, and stage 3 AKI were 0.6% (95% CI -5.9 ∼ 7.2%, p = 0.846), 4.7% (95% CI -3.1 ∼ 12.4%, p = 0.221) and 16.8% (95% CI 8.1 ∼ 25.2%, p < 0.001), respectively. Particularly noteworthy was that stage 3 AKI emerged as an independent risk factor for 30-day mortality, possessing an adjusted hazard ratio of 1.80 (95% CI 1.31 ∼ 2.47, p < 0.001).

CONCLUSIONS

The overall 30-day attributable mortality of AKI among critically ill patients with sepsis was 6.6%. Stage 3 AKI had the most significant contribution to 30-day mortality, while stage 1 and stage 2 AKI did not increase excess mortality.

Characteristics, Risk Factors, and Outcomes in Acute Kidney Injury Patients: A Retrospective Cross-Sectional Study, Palestine

BACKGROUND

Acute kidney injury (AKI) is a major medical problem affecting patients' quality of life and healthcare costs.

OBJECTIVES

This study evaluated the severity, risk factors, and outcomes of patients diagnosed with acute kidney injury (AKI), including community-acquired AKI (CA-AKI) and hospital-acquired AKI (HA-AKI), who were admitted to tertiary institutions in Palestine.

METHODS

This retrospective cross-sectional study was conducted at multiple tertiary care hospitals in Palestine by reviewing patient charts from January 2020 to March 2023. The study included all patients aged ≥18 years who were admitted to the hospital and diagnosed with AKI at admission (CA-AKI) or who developed AKI 48 hours after admission (HA-AKI). Patients with incomplete medical records and those with no reported creatinine levels during their stay, pregnant women, kidney transplant patients, and end-stage renal disease patients were excluded. Data were analyzed using SPSS v22.0. The incidence of AKI in each group was compared using the chi-squared test.

RESULTS

This study included 259 participants. HA-AKI was present in 27.3% of the patients, while CA-AKI was 72.7%. The most common stage among patients was stage 3 (55.7%, HA-AKI) (42.9%, CA-AKI), and the most common comorbidity contributing to AKI was CKD. NSAIDs, ACE-I/ARBs, and DIURETICs were the most nephrotoxic drugs contributing to AKI. Patients with hyperphosphatemia, hyperkalemia, severe metabolic acidosis, or stage 3 AKI require renal replacement therapy. In addition, our findings revealed a significant association among AKI mortality, age, and heart disease.

CONCLUSION

CA-AKI was more prevalent than HA-AKI in Palestinian patients admitted for AKI. Risk factors for AKI included diabetes, CKD, and medications (antibiotics, NSAID, diuretics, and ACE-I/ARB). Preventive measures, medication management, and disease state management are necessary to minimize AKI during hospital admission or in the community.

Septic acute kidney injury and gut microbiome: Should we change our approach?

Incidence of acute kidney injury (AKI) remained relatively stable over the last decade and the adjusted risks for it and mortality are similar across different continents and regions. Also, the mortality of septic-AKI can reach 70% in critically-ill patients. These sole facts can give rise to a question: is there something we do not understand yet? Currently, there are no specific therapies for septic AKI and the treatment aims only to maintain the mean arterial pressure over 65mmHg by ensuring a good fluid resuscitation and by using vasopressors, along with antibiotics. On the other hand, there is an increased concern about the different hemodynamic changes in septic AKI versus other forms and the link between the gut microbiome and the severity of septic AKI. Fortunately, progress has been made in the form of administration of pre- and probiotics, short chain fatty acids (SCFA), especially acetate, and also broad-spectrum antibiotics or selective decontaminants of the digestive tract in a successful attempt to modulate the microbial flora and to decrease both the severity of AKI and mortality. In conclusion, septic-AKI is a severe form of kidney injury, with particular hemodynamic changes and with a strong link between the kidney and the gut microbiome. By modulating the immune response we could not only treat but also prevent severe forms. The most difficult part is to categorize patients and to better understand the key mechanisms of inflammation and cellular adaptation to the injury, as these mechanisms can serve in the future as target therapies.

Incidence of acute kidney injury (AKI) and its impact on patient outcomes among adult hospitalized patients with carbapenem-resistant Gram-negative infections who received targeted treatment with a newer β-lactam or β-lactam/β-lactamase inhibitor-, polymyxin- or aminoglycoside-containing regimen

BACKGROUND

Limited comparative data exist on acute kidney injury (AKI) risk and AKI-associated outcomes in hospitalized patients with carbapenem-resistant Gram-negative infections (CR-GNIs) treated with a newer β-lactam/β-lactam-β-lactamase inhibitor (BL/BL-BLI)-, polymyxin (PB)- or aminoglycoside (AG)-containing regimen. This study quantified the risk of AKI and AKI-related outcomes among patients with CR-GNIs treated with a newer BL/BL-BLI-, PB- or AG-containing regimen.

METHODS

A multicentre, retrospective, observational study was performed (2016-20). The study included adult hospitalized patients with (i) baseline estimated glomerular filtration rates ≥30 mL/min/1.73 m2; (ii) CR-GN pneumonia, complicated urinary tract infection or bloodstream infection; and (iii) receipt of newer BL/BL-BLI, PG or AG within 7 days of index CR-GN culture for ≥3 days. Outcomes included AKI, in-hospital mortality and hospital costs.

RESULTS

The study included 750 patients and most (48%) received a newer BL/BL-BLI. The median (IQR) treatment duration was 8 (5-11), 5 (4-8) and 7 (4-8) days in the newer BL/BL-BLI group, AG group and PB group, respectively. The PB group had the highest adjusted AKI incidence (95% CI) (PB: 25.1% (15.6%-34.6%) versus AG: 8.9% (5.7%-12.2%) versus newer BL/BL-BLI: 11.9% (8.1%-15.7%); P = 0.001). Patients with AKI had significantly higher in-hospital mortality (AKI: 18.5% versus 'No AKI': 5.6%; P = 0.001) and mean hospital costs (AKI: $49 192 versus 'No AKI': $38,763; P = 0.043).

CONCLUSIONS

The AKI incidence was highest among PB patients and patients with AKI had worse outcomes. Healthcare systems should consider minimizing the use of antibiotics that augment AKI risk as a measure to improve outcomes in patients with CR-GNIs.

Factors associated with 30-day in-hospital mortality in critically ill adult patients receiving extracorporeal membrane oxygenation: A retrospective cohort study

OBJECTIVE

To identify factors associated with the 30-day in-hospital mortality rate among adult patients requiring extracorporeal membrane oxygenation (ECMO) in intensive care units.

RESEARCH METHODOLOGY

Retrospective cohort study including 148 patients who underwent ECMO for at least 48 h between March 2010 and August 2021. The patients were divided into survivors and non-survivors based on their 30-day in-hospital survival. We obtained the sociodemographic information and pre- and post-ECMO data from electronic medical records. Kaplan-Meier survival curves and Multivariate Cox proportional hazards regression were used to analyse the data.

SETTING

A tertiary-care university hospital in South Korea.

MAIN OUTCOME MEASURES

The 30-day in-hospital mortality rate was the principal outcome measure.

RESULTS

The 30-day in-hospital mortality rate was 49.3% (n = 73). Kaplan-Meier analysis demonstrated that the duration of ECMO support in the 50th percentile of surviving patients was 13 days. Multivariable Cox regression analysis showed that new-onset renal failure, lower mean arterial pressure, and ECMO weaning failure were associated with an increased 30-day in-hospital mortality risk among patients who received ECMO. Subgroup analysis also revealed a significant association between weaning failure and 30-day in-hospital mortality after adjusting for covariates in patients undergoing veno-arterial ECMO.

CONCLUSION

Close monitoring of post-ECMO renal function and mean arterial pressure is required to minimize the risk of 30-day in-hospital mortality, especially in adults within the first two weeks of ECMO initiation. Moreover, the success of ECMO weaning should be optimized by collaboration within the ECMO team.

IMPLICATIONS FOR CLINICAL PRACTICE

Critical care nurses should pay close attention to patients' response to weaning trials as well as alternations in renal function and mean arterial pressure during ECMO support. Furthermore, developing nursing care guidelines for adult patients receiving ECMO and standardized training programs for nurses in intensive care, are required in Korea.

The attributable mortality of sepsis for acute kidney injury: a propensity-matched analysis based on multicenter prospective cohort study

BACKGROUND

Both sepsis and AKI are diseases of major concern in intensive care unit (ICU). This study aimed to evaluate the excess mortality attributable to sepsis for acute kidney injury (AKI).

METHODS

A propensity score-matched analysis on a multicenter prospective cohort study in 18 Chinese ICUs was performed. Propensity score was sequentially conducted to match AKI patients with and without sepsis on day 1, day 2, and day 3-5. The primary outcome was hospital death of AKI patients.

RESULTS

A total of 2008 AKI patients (40.9%) were eligible for the study. Of the 1010 AKI patients with sepsis, 619 (61.3%) were matched to 619 AKI patients in whom sepsis did not develop during the screening period of the study. The hospital mortality rate of matched AKI patients with sepsis was 205 of 619 (33.1%) compared with 150 of 619 (24.0%) for their matched AKI controls without sepsis (p = 0.001). The attributable mortality of total sepsis for AKI patients was 9.1% (95% CI: 4.8-13.3%). Of the matched patients with sepsis, 328 (53.0%) diagnosed septic shock. The attributable mortality of septic shock for AKI was 16.2% (95% CI: 11.3-20.8%, p < 0.001). Further, the attributable mortality of sepsis for AKI was 1.4% (95% CI: 4.1-5.9%, p = 0.825).

CONCLUSIONS

The attributable hospital mortality of total sepsis for AKI were 9.1%. Septic shock contributes to major excess mortality rate for AKI than sepsis.

REGISTRATION FOR THE MULTICENTER PROSPECTIVE COHORT STUDY

registration number ChiCTR-ECH-13003934.

The AKI-to-CKD Transition: The Role of Uremic Toxins

After acute kidney injury (AKI), renal function continues to deteriorate in some patients. In a pro-inflammatory and profibrotic environment, the proximal tubules are subject to maladaptive repair. In the AKI-to-CKD transition, impaired recovery from AKI reduces tubular and glomerular filtration and leads to chronic kidney disease (CKD). Reduced kidney secretion capacity is characterized by the plasma accumulation of biologically active molecules, referred to as uremic toxins (UTs). These toxins have a role in the development of neurological, cardiovascular, bone, and renal complications of CKD. However, UTs might also cause CKD as well as be the consequence. Recent studies have shown that these molecules accumulate early in AKI and contribute to the establishment of this pro-inflammatory and profibrotic environment in the kidney. The objective of the present work was to review the mechanisms of UT toxicity that potentially contribute to the AKI-to-CKD transition in each renal compartment.

Short-term outcomes after transplantation of deceased donor kidneys with acute kidney injury: a retrospective analysis of a multicenter cohort of marginal donor kidneys with post-explantation biopsies

BACKGROUND

Deceased donor kidneys with acute kidney injury (AKI) are often discarded because of concerns about inferior transplant outcomes. A means of grading the quality of such kidneys is the performance of procurement biopsies.

METHODS

This is a retrospective study of 221 brain death donors with marginal kidneys transplanted in 223 recipients in Germany. Marginal kidneys were defined as kidneys with procurement biopsies done exceptionally to assess suitability for transplantation in otherwise potentially discarded organs. The impact of deceased donor AKI on patient survival and death-censored graft survival at 1, 3 and 5 years and graft function at 1 and 3 years after transplantation was investigated.

RESULTS

Recipients of kidneys with stage 3 AKI had a greater incidence of delayed graft function [DGF; ORStage 1: 1.435 (95% CI 0.438-0.702), ORStage 2: 2.463 (95% CI 0.656-9.245), ORStage 3: 4.784 (95% CI 1.421-16.101)] but a similar graft and patient survival compared to recipients of donors without AKI and with AKI stage 1 and 2 as well. The coexistence of recipient DGF and donor AKI was associated with the lowest graft survival and function rates.

CONCLUSION

The transplantation of deceased donor marginal kidneys with AKI confers a higher risk for DGF but is associated with acceptable graft and patient outcomes, which do not differ in comparison with marginal donor kidneys without AKI. Graft prognosis is especially poor if donor AKI and recipient DGF concur. Donor AKI was a risk factor independent of the histological lesions of procurement biopsies.

Acute Kidney Injury Among Patients with Multi-Drug Resistant Infection: A Study from Jordan

Background

Acute kidney injury (AKI) is a well-known complication for hospitalized patients. Sepsis and various infections play a significant role in increasing the incidence of AKI. The present study evaluated the risk for Multidrug-resistant (MDR) infections and its effect on the incidence of AKI, hospitalization, need for dialysis, and mortality.

Methods

In a retrospective study design, data were collected from all adult patients with a positive multi-drug resistant culture who were admitted to King Abdullah University Hospital (KAUH). Records of 436 patients were reviewed between January 2017 - December 2018 with at least one year of follow-up.

Results

The mean age was 57.3 years (SD± 23.1), and 58.5% were males. The most common source of positive cultures was sputum, with 50% positive cultures. The incidence of AKI was 59.2%. The most isolated microorganism was Acinetobacter baumannii (76.8%), followed by Pseudomonas aeruginosa (14.9%).On multivariate analysis, age (OR 1.1, 95% CI 1.1-1.2, P=0.001), HTN (OR 1.8, 95% CI 1.0-3.3, P=0.02), DM (OR 1.1, 95% CI 0.6-1.9, P=0.69) and the use of Foley catheter on chronic bases (OR 4.3, 95% CI 2.6-6.8, P<0.0001) were strong predictors of AKI. Among patients with AKI, 74.4% died compared to 44.4% among non-AKI patients (p<0.001).

Conclusion

In patients with MDR, AKI incidence, hospitalization, and mortality were high. Early detection and addressing the problem may decrease bad outcomes, and health education for reducing antibiotic abuse is needed to lower MDR.

The Potential of miR-370-3p and miR-495-3p Serving as Biomarkers for Sepsis-Associated Acute Kidney Injury

Objective

This study is aimed at evaluating the miR-370-3p and miR-495-3p expression in the urine of patients with sepsis-associated acute kidney injury (SA-AKI) and exploring its diagnosis value in for SA-AKI.

Methods

184 sepsis invalids were collected and divided two groups (non-AKI group or AKI group) according to whether they had acute kidney injury. RT-qPCR was utilized to measure miR-370-3p and miR-495-3p expressions. ROC curve was performed to evaluate the diagnostic value of miR-370-3p and miR-495-3p for SA-AKI. Patients diagnosed with SA-AKI were followed up for 28 days to record survival time. The prognostic performance of miR-370-3p and miR-495-3p for SA-AKI was evaluated by survival curves.

Results

Compared with non-AKI invalids, miR-370-3p and miR-495-3p expressions were obviously lower in the urine of AKI invalids. miR-370-3p and miR-495-3p expressions were markedly negatively correlated with biomarkers of renal injury. Furthermore, the area under the curve (AUC) of miR-370-3p and miR-495-3p for diagnosing sepsis SA-AKI was 0.896 and 0.814, respectively. The higher 28 days-survival rate was observed in patients with high miR-370-3p and miR-495-3p expressions.

Conclusions

A novel biomarker for the early diagnosis of SA-AKI may be miR-370-3p and miR-495-3p, which was clearly reduced in the urine of SA-AKI patients.

Clinical Value of Prognostic Nutritional Index and Neutrophil-to-Lymphocyte Ratio in Prediction of the Development of Sepsis-Induced Kidney Injury

Background

Sepsis-related acute kidney injury (S-AKI) is a frequent complication of hospitalized patients and is linked to increased morbidity and mortality. Early prediction and detection remain conducive to optimizing treatment strategies and limiting further insults. This study was aimed at evaluating the potential predictive value of the combined prognostic nutrition index (PNI) and neutrophil-to-lymphocyte ratio (NLR) to predict the risk of AKI in septic patients.

Methods

In this retrospective study, 1238 adult patients with sepsis who were admitted to the First Affiliated Hospital of Xi'an Jiaotong University from January 2015 to June 2021 were enrolled. Patients were divided into two groups: the non-AKI group (n = 731) and the S-AKI group (n = 507). Univariate and multivariate logistic regression analyses were performed to screen the independent predictive factors of S-AKI. A receiver operating characteristic (ROC) curve was used to evaluate the predictive value of PNI and NLR.

Results

Multivariate logistic regression analysis indicated that age, chronic liver disease, cardiovascular disease, respiratory rate (RR), white blood cells (WBC), blood urea nitrogen (BUN), creatinine (CRE), international normalized ratio (INR), neutrophil-to-lymphocyte ratio (NLR), and prognostic nutrition index (PNI) were independent prognostic factors of S-AKI. In the three models, the adjusted OR of PNI for S-AKI was 0.802 (0.776-0.829), 0.801 (0.775-0.829), and 0.717 (0.666-0.772), while that of NLR was 1.094 (1.078-1.111), 1.097 (1.080-1.114), and 1.044 (1.016-1.072), respectively. In addition, the area under the ROC curve of the PNI plus NLR group was significantly greater than that of the CRE plus BUN group (0.801, 95% CI: 0.775-0.827 vs. 0.750, 95% CI: 0.722-0.778, respectively; P < 0.001).

Conclusions

PNI and NLR have been identified as readily available and independent predictors in septic patients with S-AKI. PNI, in combination with NLR, is of vital significance for early warning and efficient intervention of S-AKI and is superior to combined BUN and CRE.

Perioperative acute kidney injury: impact and recent update

PURPOSE OF REVIEW

Acute kidney injury (AKI) is common in hospitalized patients and is a major risk factor for increased length of stay, morbidity, and mortality in postoperative patients. There are multiple barriers to reducing perioperative AKI - the etiology is multi-factorial and the diagnosis is fraught with issues. We review the recent literature on perioperative AKI and some considerations for anesthesiologists that examine the far-reaching effects of AKI on multiple organ systems.

RECENT FINDINGS

This review will discuss recent literature that addresses the epidemiology, use of novel biomarkers in risk stratification, and therapeutic modalities for AKI in burn, pediatrics, sepsis, trauma, cardiac, and liver disease, contrast-induced AKI, as well as the evidence assessing goal-directed fluid therapy.

SUMMARY

Recent studies address the use of risk stratification models and biomarkers, more sensitive than creatinine, in the preoperative identification of patients at risk for AKI. Although exciting, these scores and models need validation. There is a need for research assessing whether early AKI detection improves outcomes. Enhanced recovery after surgery utilizing goal-directed fluid therapy has not been shown to make an appreciable difference in the incidence of AKI. Reducing perioperative AKI requires a multi-pronged and possibly disease-specific approach.