Impelling Factors for Contracting COVID-19 Among Surgical Professionals During the Pandemic: A Multinational Cohort Study

Background

Medical workers, including surgical professionals working in coronavirus disease 2019 (COVID-19) treating hospitals, were under enormous stress during the pandemic. This global study investigated factors endowing COVID-19 amongst surgical professionals and students.

Methods

This global cross-sectional survey was made live on February 18, 2021 and closed for analysis on March 13, 2021. It was freely shared on social and scientific media platforms and was sent via email groups and circulated through a personal network of authors. Chi-square test for independence, and binary logistic regression analysis were carried out on determining predictors of surgical professionals contracting COVID-19.

Results

This survey captured the response of 520 surgical professionals from 66 countries. Of the professionals, 92.5% (481/520) reported practising in hospitals managing COVID-19 patients. More than one-fourth (25.6%) of the respondents (133/520) reported suffering from COVID-19 which was more frequent in surgical professionals practising in public sector healthcare institutions (P = 0.001). Thirty-seven percent of those who reported never contracting COVID-19 (139/376) reported being still asked to practice self-isolation and wear a shield without the diagnosis (P = 0.001). Of those who did not contract COVID-19, 75.7% (283/376) were vaccinated (P < 0.001). Surgical professionals undergoing practice in the private sector (odds ratio (OR): 0.33; 95% confidence interval (CI): 0.14 - 0.77; P = 0.011) and receiving two doses of vaccine (OR: 0.55; 95% CI: 0.32 - 0.95; P = 0.031) were identified to enjoy decreased odds of contracting COVID-19. Only 6.9% of those who reported not contracting COVID-19 (26/376) were calculated to have the highest "overall composite level of harm" score (P < 0.001).

Conclusions

High prevalence of respondents got COVID-19, which was more frequent in participants working in public sector hospitals. Those who reported contracting COVID-19 were calculated to have the highest level of harm score. Self-isolation or shield, getting two doses of vaccines decreases the odds of contracting COVID-19.

Three-dimensional laparoscopic approach to distal oesophageal diverticula: Single-centre experience

Background

Epiphrenic oesophageal diverticula are rare and often asymptomatic. When symptoms are present, minimally invasive diverticulectomy is considered the gold standard of treatment. While there is an agreement on the pre-operative assessment, no consensus is achieved when it comes to surgical technique. In the present study, we report our experience and propose a standardised approach to manage this rare oesophageal disorder.

Materials and Methods

We prospectively analysed data of all consecutive patients who underwent three-dimensional (3D) laparoscopic distal oesophageal diverticulum resection during 2015-2020 at Upper gastrointestinal surgical department, St Thomas' Hospital, regarding pre-operative assessment, surgical technique, peri-and post-operative outcomes.

Results

Six patients were submitted to 3D laparoscopic diverticulectomy, five of which with additional anterior myotomy and fundoplication and one with additional hiatal hernia repair only. Three patients followed a specific diet in preparation for surgery. Median pre-operative Eckardt symptom score was five. Two patients had normal manometry. Median operative time was 180 min, median estimated blood loss was <100 ml, neither intraoperative complications nor conversions to open approach occurred. All patients reported a complete resolution of symptoms directly after surgery. Median follow-up was 66 months. Five patients have none or minimal residual symptoms. One had recurrence requiring a revision operation for intermittent dysphagia.

Conclusions

3D laparoscopic diverticulectomy offers a reasonable chance of treatment in patients with epiphrenic diverticula. Optimal selection of patients, optimisation for surgery, gaining the surgical experience of carrying out these techniques and impact on short- and long-term results are issues that still remain under debate.

EGS P16 Management of Acute Gallstone disease at an urban acute Trust during the pandemic

Background

Acute gallstone disease is a surgical emergency. Management has evolved over the years with emphasis on early surgery to improve outcomes. However, due to resource limitations, cholecystectomy is often delayed leading to repeated admissions, interval complications and increased costs.

Despite several nationwide initiatives to implement acute cholecystectomy pathways, the SWORD (Surgical Workload Outcomes Audit Data Tool) quality improvement project reports emergency Cholecystectomy rates for gallstone disease as low as 1.2% to 36.5% in NHS acute hospital trusts between 2012 and 2017.

We analysed the current situation at Barking, Havering and Redbridge NHS Trust serving a population of 750,000 during the pandemic.

Methods

Patients presenting with acute gallstone disease (acute cholecystitis, biliary colic, and gallstone pancreatitis) between September and December 2021 were retrospectively audited. We measured re-admission rates, number of emergency and elective cholecystectomies performed, post-operative complications and interval between operation and initial admission.

Results

240 patients were admitted with acute gallstone disease during the audit period. 133 (55%) patients were admitted with acute cholecystitis, 77 (32%) for biliary colic and 30 (13%) with gallstone pancreatitis. 91 (35%) were re-admissions while waiting surgical management. 110 (46%) patients had a definitive management, either during or following their initial admission.

At 3 months following end of audit period, 49 (44.5%) patients underwent cholecystectomy, of which only 10 (20%) were performed acutely. However, 70% of acute operations were performed during re-admissions. The average time between admission and operation was 63.57 days for new presentations, compared to 49.89 days for re-admissions. 47 of the 240 patients re-presented to hospital with symptoms before their operation during the study period: 11 (23%) with biliary colic, 29 (62%) with acute cholecystitis and 7 (15%) patients with acute gallstone pancreatitis.

From the main cohort of 240, 31 (13%) patients were either not deemed fit for surgery or lost to follow-up) while 99 (41%) patients were still awaiting decision about definitive management.

Conclusions

Provision of emergency cholecystectomies does not comply with national guidelines. Frequent re-admissions worsen patients’ experience. Cholecystectomies took place in very few patients at index admission during pandemic. More financial and cultural resources need to be allocated nationwide to surgically face the gallstone epidemic.

BS P04 Global Level of Harm experienced by Bariatric Surgeons for Bariatrics surgical interventions: An exploration of predictors

Background

COVID-19 pandemic has taken the world by surprise with the depth and breadth of its effect on all walks of life, bariatric surgery being no exception. With the scientific literature hitherto unable to comment and ascertain the influence of the COVID-19 pandemic on bariatric surgery and the level of harm experienced by bariatric surgeons, we- TUGS ‘Level of Harm’ collaborative group- attempted to gauge the effect of the said pandemic on bariatrics surgery specifically vis a vis the level of harm experienced by bariatric surgeons due to the pandemic.

Methods

A virtual questionnaire- developed on both: Google forms and Survey Monkey- was circulated via TUGS social media platforms to reach bariatric consultant surgeons, fellows and residents practising throughout the world in a bid to explore the influence of the COVID-19 pandemic on their surgical practice including but not limited to the annual surgical volume including re-do surgeries volume and postoperative complications. Moreover, they were also requested to categorise their respective level of harm vis a vis bariatric surgical interventions they undertake. After de-identification of the data, SPSS (V.26) was adopted to undergo statistical analysis. After exploring the dataset by descriptive analyses, the Chi-square test was applied to pursue the association of categorical variables with the reported level of harm. A double-sided p-value of less than 0.05 was considered statistically significant.

Results

16.8% of the respondents (21/125) indicated no harm vis a vis bariatrics surgery work whereas a comparative 18.4% of the respondents (23/125) reported moderate harm with significant worsening of symptoms. None of those who indicated less than 10% increase in surgery waitlisted patients being subjected to endoscopic interventions (0/14) reported Moderate Harm for bariatrics surgery work with significant worsening of symptoms whereas 1 in every 3 of those who indicated between 10% to 25% increase in surgery waitlisted patients being subjected to endoscopic interventions (5/15) reported such level of harm for bariatrics surgery work. (p &lt; 0.001) Upon exhaustive sub-group analysis, it was uncovered that 33.6% of bariatrics surgical professionals perceived no harm (no evidence of change in clinical condition) during gastric band or related surgery work with only 4% perceiving Moderate Harm (significant worsening of symptoms/ comorbidities control/ minor increase in medications) for such surgical interventions. All of those who reported No harm for gastric band or related surgical work reported that Single anastomosis duodeno–ileal bypass (SADI-S) accounts for 10% of their practice whereas none of those who indicated that SADI-S accounts for more than 10% of their practice reported No harm for such surgical work. (p = 0.019)

Conclusions

The global snapshot illustrates a trend of low harm vis a vis bariatrics surgery work in surgical professionals practising in the private sector with a lesser number of patients developing COVID-19 postoperatively and no postoperative COVID-19 related mortality. The patient being subjected to endoscopic intervention portends a higher level of harm for bariatrics surgical work- strict adherence to criteria and safety protocols being a logical inference. For gastric band and related surgery work, preoperative COVID-19 testing appears to be influenced by confounders in its effect on the surgeon's level of harm for the said interventions warranting further exploration. SADI-S, at a cut-off of 10%, exhibits strong interaction with the surgeon's level of harm for gastric band insertion and relation surgery work. Women surgical professionals came out to exhibit equivalent mental resilience and technical prowess at par with their male colleagues when it came to bariatrics surgical intervention.

Precursor-derived in-water peracetic acid impacts on broiler performance, gut microbiota, and antimicrobial resistance genes

Past antimicrobial misuse has led to the spread of antimicrobial resistance amongst pathogens, reportedly a major public health threat. Attempts to reduce the spread of antimicrobial resistant (AMR) bacteria are in place worldwide, among which finding alternatives to antimicrobials have a pivotal role. Such molecules could be used as "green alternatives" to reduce the bacterial load either by targeting specific bacterial groups or more generically, functioning as biocides when delivered in vivo. In this study, the effect of in-water peracetic acid as a broad-spectrum antibiotic alternative for broilers was assessed via hydrolysis of precursors sodium percarbonate and tetraacetylethylenediamine. Six equidistant peracetic acid levels were tested from 0 to 50 ppm using four pens per treatment and 4 birds per pen (i.e., 16 birds per treatment and 96 in total). Peracetic acid was administered daily from d 7 to 14 of age whilst measuring performance parameters and end-point bacterial concentration (qPCR) in crop, jejunum, and ceca, as well as crop 16S sequencing. PAA treatment, especially at 20, 30, and 40 ppm, increased body weight at d 14, and feed intake during PAA exposure compared to control (P < 0.05). PAA decreased bacterial concentration in the crop only (P < 0.05), which was correlated to better performance (P < 0.05). Although no differences in alpha- and beta-diversity were found, it was observed a reduction of Lactobacillus (P < 0.05) and Flectobacillus (P < 0.05) in most treatments compared to control, together with an increased abundance of predicted 4-aminobutanoate degradation (V) pathway. The analysis of the AMR genes did not point towards any systematic differences in gene abundance due to treatment administration. This, together with the rest of our observations could indicate that proximal gut microbiota modulation could result in performance amelioration. Thus, peracetic acid may be a valid antimicrobial alternative that could also positively affect performance.

The global level of harm among surgical professionals during the COVID-19 pandemic: A multinational cross-sectional cohort study

BACKGROUND

Health care workers, including surgical professionals, experienced psychological burnout and physical harm during the coronavirus 2019 pandemic. This global survey investigated the coronavirus 2019 pandemic impact on psychological and physical health.

METHODS

We conducted a global cross-sectional survey between February 18, 2021 and March 13, 2021. The primary outcome was to assess the psychological burnout, fulfillment, and self-reported physical level of harm. A validated Stanford Professional Fulfilment Index score with a self-reported physical level of harm was employed. We used a practical overall composite level of harm score to calculate the level of harm gradient 1-4, combining psychological burnout with self-reported physical level of harm score.

RESULTS

A total of 545 participants from 66 countries participated. The final analysis included 520 (95.4%) surgical professionals barring medical students. Most of the participants (81.3%) were professionally unfulfilled. The psychological burnout was evident in 57.7% and was significantly common in those <50 years (P = .002) and those working in the public sector (P = .005). Approximately 41.7% of respondents showed changes in the physical health with self-remedy and no impact on work, whereas 14.9% reported changes to their physical health with <2 weeks off work, and 10.1% reported changes in physical health requiring >2 weeks off work. Severe harm (level of harm 4) was detected in 10.6%, whereas moderate harm (level of harm 3) affected 40.2% of the participants. Low and no harm (level of harm 2 and level of harm 1) represented 27.5% and 21.7%, respectively.

CONCLUSION

Our study showed that high levels of psychological burnout, professional unfulfillment, work exhaustion, and severe level of harm was more frequent in younger professionals working in the public sector. The findings correlated with a high level of harm in surgical professionals impacting surgical services.

Near-Infrared Fluorescence Cholangiography can be a Useful Adjunct during Emergency Cholecystectomies

Background. Emergency cholecystectomy is the gold standard treatment for acute cholecystitis according to National Institute for Health and Care Excellence recommendations. The procedure is feasible but carries a higher risk of iatrogenic injury to the bile duct, which should be considered preventable. Intraoperative fluorescence cholangiography following injection of indocyanine green (ICG) has been reported to aid identification of the extrahepatic bile duct. Data on its feasibility in the context of emergency cholecystectomies are missing. Materials and Methods. Fluorescent ICG was used intraoperatively to enhance the biliary anatomy during 33 consecutive emergency laparoscopic cholecystectomies at our institution. Primary outcomes of surgery were considered the length of hospital stay, conversion to open and complications rate, including bile duct injury. Secondary outcome was operating time. A historical population of emergency cholecystectomies was used as control. Results. There were no common bile duct injuries, no adverse effects from ICG, no conversion to open surgery and no deaths. 90% of patients went home within 48 hours after the operation in the absence of complications. ICG demonstrated intraoperative biliary anatomy allowing greater confidence to the surgeon performing emergency cholecystectomies. Six patients were operated beyond 72 hours from admission, without experiencing any complication Clavien-Dindo ≥3. ICG population had the same post-operative hospitalisation and complications rate of the control group, with a shorter operating time. Conclusion. Intraoperative augmented visualisation of biliary anatomy with ICG cholangiography can be a useful technology tool, with the potential to extend the 72 hours window of safety for emergency cholecystectomies.

Functionalised thermally induced phase separation (TIPS) microparticles enabled for "click" chemistry

Due to their homogeneity, tuneable properties, low cost and ease of manufacture, thermally induced phase separation (TIPS) polymeric microparticles are emerging as an exciting class of injectable device for the treatment of damaged tissue or complex diseases, such as cancer. However, relatively little work has explored enhancing surface functionalisation of this system. Herein, we present the functionalisation of TIPS microparticles with both small molecules and an antibody fragment of Herceptin™, via a heterobifunctional pyridazinedione linker capable of participating in SPAAC "click" chemistry, and compare it to the traditional method of preparing active-targeted microparticle systems, that is, physisorption of antibodies to the microparticle surface. Antigen-binding assays demonstrated that functionalisation of microparticles with Herceptin Fab, via a pyridazinedione linker, provided an enhanced avidity to HER2+ when compared to traditional physisorption methods.

A novel adjuvant drug-device combination tissue scaffold for radical prostatectomy

Prostate cancer is a leading cause of death in men and despite improved surgical procedures that aid tumor resection, the risk of recurrence after surgery as a result of positive resection margins remains significant. Adjuvant chemotherapy is often required but this is associated with toxicity. Improved ways of delivering highly toxic chemotherapeutic drugs in a more controlled and targeted manner after the prostate has been removed during surgery could reduce the risk of recurrence and avoid systemic toxicity. The aim of this study was to develop a novel drug-device combination tissue scaffold that can be used to deliver the chemotherapeutic agent, docetaxel, into the tissue cavity that is created following radical prostatectomy. The device component investigated consisted of highly porous, poly(dl-lactide-co-glycolide) microparticles made using thermally induced phase separation. A facile method was established for loading docetaxel with high efficiency within one hour. Sustained drug release was observed from the microparticles when placed into a dynamic system simulating tissue perfusion. The drug released from the microparticles into perfusates collected at regular time intervals inhibited colony formation and exhibited sustained cytotoxicity against 3D spheroids of PC3 prostate cancer cells over 10 days. In conclusion, this study demonstrates the concept of combining docetaxel with the biodegradable microparticles at the point of care is technically feasible for achieving an effective drug-device combination tissue scaffold. This approach could provide an effective new approach for delivering adjuvant chemotherapy following radical prostatectomy.

Bioinspired Soot-Deposited Janus Fabrics for Sustainable Solar Steam Generation with Salt-Rejection

Inspired by lotus leaves, self-floating Janus cotton fabric is successfully fabricated for solar steam generation with salt-rejecting property. The layer-selective soot-deposited fabrics not only act as a solar absorber but also provide the required superhydrophobicity for floating on the water. With a polyester protector, the prepared Janus evaporator exhibits a sustainable evaporation rate of 1.375 kW m-2 h-1 and an efficiency of 86.3% under 1 sun (1 kW m-2) and also performs well under low intensity and inclined radiation. Furthermore, no special apparatus and/or tedious processes are needed for preparing this device. With a cost of less than $1 per m2, this flexible Janus absorber is a promising tool for portable solar vapor generator.

Oesophageal adenocarcinoma following gastric band surgery in two patients

Oesophageal adenocarcinoma following gastric band surgery has only been reported three times previously. The incidence is higher in morbidly obese patients, and its pathogenesis is correlated to reflux-induced microenvironmental changes. Bariatric surgery is transformative and its potential benefit for a substantial population is huge. Although no causal relationship with bariatric procedures has been evidenced to date, symptoms of adenocarcinoma—particularly anorexia, weight loss and dysphagia—can easily be overshadowed by alterations in eating patterns associated with weight-loss procedures. We report two cases of oesophageal adenocarcinoma in patients who had undergone a gastric banding procedure, and invite readers to consider the role that pre- and post-operative acid reflux dynamics may have precipitating neoplastic disease, and how endoscopic surveillance may play a role in prevention.

Uterocutaneous fistula due to held placenta in a low resource setting

Postcesarean section complication rate is higher in LMIC (Low and Middle Income Countries) due to lack of resources and specialists availability. A completely or incompletely held infected placenta might underlie a dehiscent cesarean section wound. Humanitarian and local surgeons should consider this differential diagnosis and be ready to practice hysterectomies when needed.

Surgical consent in sub-Saharan Africa: a modern challenge for the humanitarian surgeon

Surgical consent is one of the pillars of ethical conduct in Western world surgical practice. Recent studies have described the consenting processes for clinical trials in low- and middle-income countries (LMICs), but only a few have explored its practice before surgical procedures. The recent World Medical Association (WMA) Declaration of Lisbon recommends autonomy and independent decision-making. However, informed consent is influenced by cultural background, family structure, socioeconomic status, religion and education. The authors of the paper support the WMA recommendations, but agree the process for obtaining informed consent should be reviewed and developed to integrate in a culturally appropriate manner. This commentary reports the author's personal experience of surgical consent in Burundi and reviews the literature describing its practice and the specific challenges faced in Sub-Saharan Africa. Its aim is to encourage a debate among surgeons as to how surgical consent can be undertaken in different scenarios of LMICs.

Pancreatic stellate cells regulate blood vessel density in the stroma of pancreatic ductal adenocarcinoma

BACKGROUND/OBJECTIVES

The vascular heterogeneity of pancreatic ductal adenocarcinoma (PDAC) has never been characterised. We analysed the heterogeneous vascular density of human PDAC along with its prognostic correlation.

METHODS

Tissue Microarrays of 87 patients with different pancreatico-biliary pathologies were analysed in an automated manner (Ariol™) after CD31 staining to assess vascular density in juxta-tumoral and panstromal compartments. In vitro and ex vivo assays were carried out to assess the role of PSC.

RESULTS

PDAC has a distinct vascular density and distribution of vessels compared to cholangiocarcinoma. The PDAC juxta-tumoral stroma was hypovascular and the normal adjacent rim was hypervascular compared to the panstromal compartment. These features adversely affected patient prognosis, suggesting a model for spatio-temporal PDAC evolution. Mice aortic rings and 3D organotypic cultures demonstrated pro- and anti-angiogenic signalling from activated PSC and cancer cells respectively. ATRA-induced quiescence suppressed the pro-angiogenic activity of PSC.

CONCLUSION

Human PDAC has variable vascularity at microscopic level suggesting that novel stromal directed therapies would need to be determined by pathological characteristics.

Double-Wall Nanotubes and Graphene Nanoplatelets for Hybrid Conductive Adhesives with Enhanced Thermal and Electrical Conductivity

Improving the electrical and thermal properties of conductive adhesives is essential for the fabrication of compact microelectronic and optoelectronic power devices. Here we report on the addition of a commercially available conductive resin with double-wall carbon nanotubes and graphene nanoplatelets that yields simultaneously improved thermal and electrical conductivity. Using isopropanol as a common solvent for the debundling of nanotubes, exfoliation of graphene, and dispersion of the carbon nanostructures in the epoxy resin, we obtain a nanostructured conducting adhesive with thermal conductivity of ∼12 W/mK and resistivity down to 30 μΩ cm at very small loadings (1% w/w for nanotubes and 0.01% w/w for graphene). The low filler content allows one to keep almost unchanged the glass-transition temperature, the viscosity, and the curing parameters. Die shear measurements show that the nanostructured resins fulfill the MIL-STD-883 requirements when bonding gold-metalized SMD components, even after repeated thermal cycling. The same procedure has been validated on a high-conductivity resin characterized by a higher viscosity, on which we have doubled the thermal conductivity and quadrupled the electrical conductivity. Graphene yields better performances with respect to nanotubes in terms of conductivity and filler quantity needed to improve the resin. We have finally applied the nanostructured resins to bond GaN-based high-electron-mobility transistors in power-amplifier circuits. We observe a decrease of the GaN peak and average temperatures of, respectively, ∼30 °C and ∼10 °C, with respect to the pristine resin. The obtained results are important for the fabrication of advanced packaging materials in power electronic and microwave applications and fit the technological roadmap for CNTs, graphene, and hybrid systems.

Imbalance of desmoplastic stromal cell numbers drives aggressive cancer processes

Epithelial tissues have sparse stroma, in contrast to their corresponding tumours. The effect of cancer cells on stromal cells is well recognized. Increasingly, stromal components, such as endothelial and immune cells, are considered indispensable for cancer progression. The role of desmoplastic stroma, in contrast, is poorly understood. Targeting such cellular components within the tumour is attractive. Recent evidence strongly points towards a dynamic stromal cell participation in cancer progression that impacts patient prognosis. The role of specific desmoplastic stromal cells, such as stellate cells and myofibroblasts in pancreatic, oesophageal and skin cancers, was studied in bio-engineered, physiomimetic organotypic cultures and by regression analysis. For pancreatic cancer, the maximal effect on increasing cancer cell proliferation and invasion, as well as decreasing cancer cell apoptosis, occurs when stromal (pancreatic stellate cells) cells constitute the majority of the cellular population (maximal effect at a stromal cell proportion of 0.66-0.83), accompanied by change in expression of key molecules such as E-cadherin and β-catenin. Gene-expression microarrays, across three tumour types, indicate that stromal cells consistently and significantly alter global cancer cell functions such as cell cycle, cell-cell signalling, cell movement, cell death and inflammatory response. However, these changes are mediated through cancer type-specific alteration of expression, with very few common targets across tumour types. As highlighted by these in vitro data, the reciprocal relationship of E-cadherin and polymeric immunoglobulin receptor (PIGR) expression in cancer cells could be shown, in vivo, to be dependent on the stromal content of human pancreatic cancer. These studies demonstrate that context-specific cancer-stroma crosstalk requires to be precisely defined for effective therapeutic targeting. These data may be relevant to non-malignant processes where epithelial cells interact with stromal cells, such as chronic inflammatory and fibrotic conditions.

Biomarkers of acute renal injury and renal failure

Acute renal failure (ARF) is a frequent problem in the intensive care unit and is associated with a high mortality. Early recognition could help clinical management, but current indices lack sufficient predictive value for ARF. Therefore, there might be a need for biomarkers in detecting renal tubular injury and/or dysfunction at an early stage before a decline in glomerular filtration rate is noted by an increased serum creatinine. A MEDLINE/PubMed search was performed, including all articles about biomarkers for ARF. All publication types, human and animal studies, or subsets were searched in English language. An extraction of relevant articles was made for the purpose of this narrative review. These biomarkers include tubular enzymes (alpha- and pi-glutathione S-transferase, N-acetyl-glucosaminidase, alkaline phosphatase, gamma-glutamyl transpeptidase, Ala-(Leu-Gly)-aminopeptidase, and fructose-1,6-biphosphatase), low-molecular weight urinary proteins (alpha1- and beta2-microglobulin, retinol-binding protein, adenosine deaminase-binding protein, and cystatin C), Na+/H+ exchanger, neutrophil gelatinase-associated lipocalin, cysteine-rich protein 61, kidney injury molecule 1, urinary interleukins/adhesion molecules, and markers of glomerular filtration such as proatrial natriuretic peptide (1-98) and cystatin C. These biomarkers, detected in urine or serum shortly after tubular injury, have been suggested to contribute to prediction of ARF and need for renal replacement therapy. However, excretion of these biomarkers may also increase after reversible and mild dysfunction and may not necessarily be associated with persistent or irreversible damage. Large prospective studies in human are needed to demonstrate an improved outcome of biomarker-driven management of the patient at risk for ARF.