Acute Dialysis Quality Initiative Research Articles

The concept of acute kidney disease and its place in the renal continuum

The paper discusses the concept of acute kidney disease, a relatively new concept in clinical medicine, the introduction of which is due to the presence of kidney diseases that do not meet strict criteria for acute kidney injury or chronic kidney disease. The article presents the criteria and severity stratification of acute kidney disease proposed by the Kidney Disease: Improving Global Outcomes Foundation, interpretation of the criteria and severity stratification by the Scientific Society of Nephrologists of Russia, associations of nephrologists and anesthesiologists-resuscitators of Russia, the National Society of Specialists in Hemapheresis and Extracorporeal Hemocorrection in accordance with the classification system of the Acute Dialysis Quality Initiative group. The role of acute kidney disease in the modern renal continuum is outlined. The article reviews the results of studies of acute kidney disease in patients with septic shock, patients who underwent total joint replacement, myocardial infarction with ST segment elevation and having acute kidney injury, patients with ischemic stroke, after coronary angiography, after acute surgery for type A aortic dissection, which demonstrate the prevalence of acute kidney disease and its outcomes. Despite the fact that acute kidney disease has a high prevalence among patients with various pathologies, worsens the prognosis and increases the risk of death or complications, its significance in modern medicine remains extremely underestimated. The article identifies the most common and studied biochemical markers that can potentially increase the proportion of patients at risk of adverse outcomes when used in clinical practice.

Left ventricular geometry characteristics and clinical outcomes in hemodialysis patients with heart failure with preserved ejection fraction

BackgroundThe relationships among left heart remodeling, cardiac function, and cardiovascular events (CEs) in patients with heart failure (HF) with preserved ejection fraction (HFpEF) undergoing maintenance hemodialysis (MHD) remain unclear. We evaluated the echocardiographic characteristics and clinical outcomes of such patients with diverse left ventricular geometric (LVG) configurations.MethodsOverall, 210 patients with HFpEF undergoing MHD (cases) and 60 healthy controls were enrolled. Cases were divided into four subgroups based on LVG and were followed up for three years. The primary outcomes were the first CEs and all-cause mortality.ResultsLeft ventricular ejection fraction (LVEF) and right ventricular systolic function did significantly differ between cases and controls, whereas echocardiographic parameters of cardiac structure, diastolic function, and left ventricular global longitudinal strain (LVGLS) differed significantly. The proportion of cases with left ventricular hypertrophy (LVH) was 67.1%. In addition, 2.38%, 21.90%, 12.86%, and 62.86% of cases presented with normal geometry (NG), concentric remodeling (CR), eccentric hypertrophy (EH), and concentric hypertrophy (CH), respectively. The left atrial diameter (LAD) was the largest and cardiac output index was the lowest in the EH subgroup. The score of Acute Dialysis Quality Initiative Workgroup (ADQI) HF class was worse in the EH subgroup than in other subgroups at baseline. The proportions of cases free of adverse CEs in the EH subgroup at 12, 24, and 36 months were 40.2%, 14.8%, and 0%, respectively, and the survival rates were 85.2%, 29.6%, 3.7%, respectively, which were significantly lower than those in other subgroups. Multivariate Cox regression revealed that age, TNI (Troponin I), EH, left ventricular mass index (LVMI), age and EH configuration were independent risk factors for adverse CEs and all-cause mortality in the cases.ConclusionMost patients with HFpEF receiving MHD have LVH and diastolic dysfunction. Among the four LVGs, patients with HFpEF undergoing MHD who exhibited EH had the highest risk of adverse CEs and all-cause mortality.

Effect of sacubitril valsartan on heart failure with mid-range or preserved ejection fraction in patients on maintenance hemodialysis: real-world experience in a single-center, prospective study

BackgroundThis study aimed to evaluate the effect of sacubitril valsartan (SV) on heart failure (HF) hospitalization and cardiovascular mortality in patients on hemodialysis with HF with preserved ejection fraction (EF; HFpEF).MethodsThis single-center, prospective study enrolled 155 stable hemodialysis patients with EF > 40% who were followed up for 12 months. Fifty-nine patients were treated with SV; the others were matched for EF (57.89 ± 9.35 vs. 58.00 ± 11.82, P = 0.9) at a ratio of 1:1 and included as controls. The target dosage of SV was 200 mg/day.ResultsTwenty-three (23/155; 14.84%) had HF with mid-range EF (HFmrEF), while 132 (85.16%) had HFpEF. After SV treatment, the peak early diastolic transmitral flow velocity/peak early diastolic mitral annular tissue velocity(E/e’) improved from 17.19 ± 8.74 to 12.80 ± 5.52 (P = 0.006), the left ventricular (LV) end-diastolic diameter decreased from 53.14 ± 7.67 mm to 51.56 ± 7.44 mm (P = 0.03), and the LV mass index decreased from 165.7 ± 44.6 g/m2 to 154.8 ± 24.0 g/m2 (P = 0.02). LVEF (P = 0.08) and LV global longitudinal strain (P = 0.7) did not change significantly. The composite outcome of first and recurrent HF hospitalization or cardiovascular death showed no difference between group. However, the Acute Dialysis Quality Initiative Workgroup (ADQI) HF class improved in 39 and 15 patients and worsened in 1 and 11 patients in the SV and control groups, respectively (P < 0.001). Age, diabetes mellitus, and pulmonary arterial pressure were independent risk factors for HF hospitalization and cardiovascular mortality in patients with HFpEF.ConclusionsSV improved LV hypertrophy, diastolic function, and the ADQI class for HF; however, it failed to reduce the composite endpoints of HF hospitalization and cardiovascular disease-related mortality over 12 months of follow-up in patients on maintenance hemodialysis with EF of > 40%.

Sampling from Extracorporeal Circuit: A Step Forward for Dose Monitoring in Continuous Renal Replacement Therapy

Introduction: Continuous renal replacement therapies (CRRTs) require constant monitoring and periodic treatment readjustments, being applied to highly complex patients, with rapidly changing clinical needs. To promote precision medicine in the field of renal replacement therapy and encourage dynamic prescription, the Acute Dialysis Quality Initiative (ADQI) recommends periodically measuring the solutes extracorporeal clearance with the aim of assessing the current treatment delivery and the gap from the therapeutic prescription (often intended as effluent dose). To perform this procedure, it is therefore necessary to obtain blood and effluent samples from the extracorporeal circuit to measure the concentrations of a target solute (usually represented by urea) in prefilter, postfilter, and effluent lines. However, samples must be collected simultaneously from the extracorporeal circuit ports, with the same suction flow at an unknown rate. Methods: The proposed study takes the first step toward identifying the technical factors that should be considered in determining the optimal suction rate to collect samples from the extracorporeal circuit to measure the extracorporeal clearance for a specific solute. Results: The results obtained identify the low suction rate (i.e., 1 mL/min) as an ideal parameter for an adequate sampling method. Low velocities do not perturb the external circulation system and ensure stability prevailing pressures in the circuit. Higher velocities can be performed only with blood flows above 120 mL/min preferably in conditions of appropriate filtration fraction. Discussion/Conclusions: The specific value of aspiration flow rate must be proportioned to the prescription of CRRT treatments set by the clinician.

Subclinical and clinical acute kidney injury share similar urinary peptide signatures and prognosis.

Acute kidney injury (AKI) is a frequent and severe condition in intensive care units (ICUs). In 2020, the Acute Dialysis Quality Initiative (ADQI) group proposed a new stage of AKI, referred to as stage 1S, which represents subclinical disease (sAKI) defined as a positive biomarker but no increase in serum creatinine (sCr). This study aimed to determine and compare the urinary peptide signature of sAKI as defined by biomarkers. This is an ancillary analysis of the prospective, observational, multinational FROG-ICU cohort study. AKI was defined according to the Kidney Disease Improving Global Outcome definition (AKIKDIGO). sAKI was defined based on the levels of the following biomarkers, which exceeded the median value: neutrophil gelatinase-associated lipocalin (pNGAL, uNGAL), cystatin C (pCysC, uCysC), proenkephalin A 119-159 (pPENKID) and liver fatty acid binding protein (uLFABP). Urinary peptidomics analysis was performed using capillary electrophoresis-mass spectrometry. Samples were collected at the time of study inclusion. One thousand eight hundred eighty-five patients had all biomarkers measured at inclusion, which included 1154 patients without AKI (non-AKIKDIGO subgroup). The non-AKIKDIGO subgroup consisted of individuals at a median age of 60 years [48, 71], among whom 321 (27.8%) died. The urinary peptide signatures of sAKI, regardless of the biomarkers used for its definition, were similar to the urinary peptide signatures of AKIKDIGO (inflammation, haemolysis, and endothelial dysfunction). These signatures were also associated with 1-year mortality. Biomarker-defined sAKI is a common and severe condition observed in patients within intensive care units with a urinary peptide signature that is similar to that of AKI, along with a comparable prognosis.

Update on persistent acute kidney injury in critical illnesses.

Acute kidney injury (AKI) affects about half of patients admitted to the intensive care unit (ICU), and worsens their short- and long-term outcomes. Apparently self-limiting AKI episodes initiate a progression toward chronic kidney disease (CKD) through cellular and molecular mechanisms that are yet to be explained. In particular, persistent AKI, defined in 2016 by the Acute Dialysis Quality Initiative as an AKI which lasts more than 48h from its onset, has been correlated with higher morbidity and mortality, and with a higher progression to acute kidney disease (AKD) and CKD than transient AKI (i.e. AKI with a reversal within 48h). This classification has been also used in the setting of solid organ transplantation, demonstrating similar outcomes. Due to its incidence and poor prognosis and because prompt interventions seem to change its course, persistent AKI should be recognized early and followed-up also after its recovery. However, while AKI and CKD are well-described syndromes, persistent AKI and AKD are relatively new entities. The purpose of this review is to highlight the key phases of persistent AKI in ICU patients in terms of both clinical and mechanistic features in order to offer to clinicians and researchers an updated basis from which to start improving patients' care and direct future research.

Effect of proximal artery restriction on flow reduction and cardiac function in hemodialysis patients with high-flow arteriovenous fistulas

ObjectiveArteriovenous fistula is the preferred vascular access for hemodialysis patients. High-flow arteriovenous fistula may cause high-output heart failure. Various procedures are used to reduce high-flow arteriovenous fistula. This study aimed to assess the efficacy of proximal artery restriction combined with distal artery ligation on flow reduction for high-flow arteriovenous fistula and on cardiac function and echocardiographic changes in patients undergoing hemodialysis. MethodsA retrospective analysis was performed on data collected from the medical records of patients undergoing hemodialysis with heart failure and high-flow arteriovenous fistula between May 2018 and May 2021. Thirty-one patients were treated with proximal artery restriction (banding juxta-anastomosis of the proximal artery) combined with distal artery ligation (anastomosis distal artery ligation). Changes in the Acute Dialysis Quality Initiative Workgroup cardiac function class, blood pressure, and echocardiography before and 6 months after flow restriction were compared, and post-intervention primary patency was followed-up. ResultsThe technical success rate of the surgery was 100%, and no surgery-related adverse events occurred. Blood flow and blood flow/cardiac output decreased significantly after flow restriction. Blood flow decreased from 2047.21 ± 398.08 mL/min to 1001.36 ± 240.42 mL/min, and blood flow/cardiac output decreased from 40.18% ± 6.76% to 22.34% ± 7.21% (P < .001). Post-intervention primary patency of arteriovenous fistula at 6, 12, and 24 months was 96.8%, 93.5%, and 75.2%, respectively. The Acute Dialysis Quality Initiative Workgroup cardiac function class improved significantly after 6 months of flow restriction (P < .001). The systolic and diastolic left heart function improved, as evidenced by a significant decrease in left atrial volume index, left ventricular end-diastolic/end-systolic diameters, left ventricular end-diastolic volume, left ventricular mass index, cardiac output, and cardiac index and an increase in lateral peak velocity of longitudinal contraction, average septal-lateral s', and lateral early diastolic peak velocity after flow restriction (P < .05). Systolic pulmonary artery pressure decreased from 32.36 ± 8.56 mmHg to 27.57 ± 8.98 mmHg (P < .05), indicating an improvement in right heart function. ConclusionsProximal artery restriction combined with distal artery ligation effectively reduced the blood flow of high-flow arteriovenous fistula and improved cardiac function.

Predictors of Acute Kidney Disease Severity in Hospitalized Patients with Acute Kidney Injury.

Acute kidney disease (AKD) forms part of the continuum of acute kidney injury (AKI) and worsens clinical outcomes. Currently, the predictors of AKD severity have yet to be established. We conducted a retrospective investigation involving 310 hospitalized patients with AKI and stratified them based on the AKD stages defined by the Acute Dialysis Quality Initiative criteria. Demographic, clinical, hematologic, and biochemical profiles, as well as 30-day outcomes, were compared between subgroups. In the analysis, the use of offending drugs (odds ratio, OR (95% confidence interval, CI), AKD stage 3 vs. non-AKD, 3.132 (1.304–7.526), p = 0.011, AKD stage 2 vs. non-AKD, 2.314 (1.049–5.107), p = 0.038), high AKI severity (OR (95% CI), AKD stage 3 vs. non-AKD, 6.214 (2.658–14.526), p < 0.001), and early dialysis requirement (OR (95% CI), AKD stage 3 vs. non-AKD, 3.366 (1.008–11.242), p = 0.049) were identified as independent predictors of AKD severity. Moreover, a higher AKD severity was associated with higher 30-day mortality and lower dialysis-independent survival rates. In conclusion, our study demonstrated that offending drug use, AKI severity, and early dialysis requirement were independent predictors of AKD severity, and high AKD severity had negative impact on post-AKI outcomes.

The RIFLE Classification: A Stratification Scheme for Patients of Acute Renal Failure after Coronary Artery Bypass Surgery

Background: Acute renal failure is linked to an increased risk of death and morbidity after cardiac surgery. Because there are no standard criteria for acute renal damage, there is a wide variation in the reports that have been published. The Acute Dialysis Quality Initiative Workgroup has developed new RIFLE criteria for acute renal dysfunction. The goal of current study was to appraise whether this definition of postoperative renal dysfunction after coronary artery bypass surgery (CABG) was accurate. Methods: Fifty patients with critical coronary artery disease &amp; undergoing CABG were enrolled in the study. Out of 50 patients, 25 patients had CABG with cardiopulmonary bypass (CPB) and remaining 25 underwent off pump CABG (OPCAB). Patients were distributed into various groups (based on the severity of renal impairment) using the RIFLE classification: Risk, Injury, Failure, Loss, End-stage kidney disease) depending on either serum creatinine level/ estimated glomerular filtration rate (eGFR) or urine output. The variation with 30 days-mortality, ICU stay and renal replacement therapy after CABG were identified. Results: After CABG, 10% of patients experienced renal impairment, as per definitions of RIFLE classification. In this study, there is no significant difference in ARF (RIFLE classification-normal and risk) with or without use of CPB. However, incidence of RIFLE- injury and failure is higher in CPB group than no CPB group. The postoperative proportions of death and renal failure necessitating renal replacement therapy (RRT) were 2% (number of patients, 1 of 50) and 2% (1 of 50), respectively in RIFLE-failure. For the whole study cohort, the median duration of postoperative ICU stay was 4.0 days, with interquartile ranges of 3.0 to 7.0 days. All the patients of Rifle classification-injury and failure had prolonged ICU stay (5 or more days). Conclusions: The RIFLE criteria are a useful tool for determining renal impairment after CABG. Increased renal replacement treatment, longer ICU stays, and a higher death rate are all linked to the severity of RIFLE classification. Cardiovasc j 2022; 14(2): 150-156

Biomarker-Guided Risk Assessment for Acute Kidney Injury: Time for Clinical Implementation?

Acute kidney injury (AKI) is a common and serious complication in hospitalized patients, which continues to pose a clinical challenge for treating physicians. The most recent Kidney Disease Improving Global Outcomes practice guidelines for AKI have restated the importance of earliest possible detection of AKI and adjusting treatment accordingly. Since the emergence of initial studies examining the use of neutrophil gelatinase-associated lipocalin (NGAL) and cycle arrest biomarkers, tissue inhibitor metalloproteinase-2 (TIMP-2) and insulin-like growth factor-binding protein (IGFBP7), for early diagnosis of AKI, a vast number of studies have investigated the accuracy and additional clinical benefits of these biomarkers. As proposed by the Acute Dialysis Quality Initiative, new AKI diagnostic criteria should equally utilize glomerular function and tubular injury markers for AKI diagnosis. In addition to refining our capabilities in kidney risk prediction with kidney injury biomarkers, structural disorder phenotypes referred to as “preclinical-” and “subclinical AKI” have been described and are increasingly recognized. Additionally, positive biomarker test findings were found to provide prognostic information regardless of an acute decline in renal function (positive serum creatinine criteria). We summarize and discuss the recent findings focusing on two of the most promising and clinically available kidney injury biomarkers, NGAL and cell cycle arrest markers, in the context of AKI phenotypes. Finally, we draw conclusions regarding the clinical implications for kidney risk prediction.

Acute Kidney Injury

Acute renal failure definitions have changed dramatically over the last 5 to 10 years as a result of criteria established through the following consensus statements/organizations: RIFLE (Risk, Injury, Failure, Loss of function, End stage renal disease), AKIN (Acute Kidney Injury Network), and KDIGO (Kidney Disease: Improving Global Outcomes). In 2002, the Acute Dialysis Quality Initiative was tasked with the goal of establishing a consensus statement for acute kidney injury (AKI). The first order of business was to provide a standard definition of AKI. Up to this point, literature comparison was challenging as studies lacked uniformity in renal injury definitions. Implementing results into evidence-based clinical practice was difficult. The panel coined the term “acute kidney injury,” encompassing previous terms, such as renal failure and acute tubular necrosis. This new terminology represented a broad range of renal insults, from dehydration to those requiring renal replacement therapy (RRT). This review provides an algorithmic approach to the epidemiology, pathophysiology, diagnosis, prevention, and management of AKI. Also discussed are special circumstances, including rhabdomyolysis, contrast-induced nephropathy, and hepatorenal syndrome. Tables outline the AKIN criteria, most current KDIGO consensus guidelines for definition of AKI, differential diagnosis of AKI, agents capable of causing AKI, treatment for specific complications associated with AKI, and options for continuous RRT. Figures show the RIFLE classification scheme and KDIGO staging with prevention strategies. This review contains 1 management algorithm, 2 figures, 6 tables, and 85 references. Keywords: Kidney, renal, KDIGO, azotemia, critical, urine, oliguria, creatinine, dialysis

Acute Kidney Injury

Acute renal failure definitions have changed dramatically over the last 5 to 10 years as a result of criteria established through the following consensus statements/organizations: RIFLE (Risk, Injury, Failure, Loss of function, End stage renal disease), AKIN (Acute Kidney Injury Network), and KDIGO (Kidney Disease: Improving Global Outcomes). In 2002, the Acute Dialysis Quality Initiative was tasked with the goal of establishing a consensus statement for acute kidney injury (AKI). The first order of business was to provide a standard definition of AKI. Up to this point, literature comparison was challenging as studies lacked uniformity in renal injury definitions. Implementing results into evidence-based clinical practice was difficult. The panel coined the term “acute kidney injury,” encompassing previous terms, such as renal failure and acute tubular necrosis. This new terminology represented a broad range of renal insults, from dehydration to those requiring renal replacement therapy (RRT). This review provides an algorithmic approach to the epidemiology, pathophysiology, diagnosis, prevention, and management of AKI. Also discussed are special circumstances, including rhabdomyolysis, contrast-induced nephropathy, and hepatorenal syndrome. Tables outline the AKIN criteria, most current KDIGO consensus guidelines for definition of AKI, differential diagnosis of AKI, agents capable of causing AKI, treatment for specific complications associated with AKI, and options for continuous RRT. Figures show the RIFLE classification scheme and KDIGO staging with prevention strategies. This review contains 1 management algorithm, 2 figures, 6 tables, and 85 references. Keywords: Kidney, renal, KDIGO, azotemia, critical, urine, oliguria, creatinine, dialysis

Acute Kidney Injury

Acute renal failure definitions have changed dramatically over the last 5 to 10 years as a result of criteria established through the following consensus statements/organizations: RIFLE (Risk, Injury, Failure, Loss of function, End stage renal disease), AKIN (Acute Kidney Injury Network), and KDIGO (Kidney Disease: Improving Global Outcomes). In 2002, the Acute Dialysis Quality Initiative was tasked with the goal of establishing a consensus statement for acute kidney injury (AKI). The first order of business was to provide a standard definition of AKI. Up to this point, literature comparison was challenging as studies lacked uniformity in renal injury definitions. Implementing results into evidence-based clinical practice was difficult. The panel coined the term “acute kidney injury,” encompassing previous terms, such as renal failure and acute tubular necrosis. This new terminology represented a broad range of renal insults, from dehydration to those requiring renal replacement therapy (RRT). This review provides an algorithmic approach to the epidemiology, pathophysiology, diagnosis, prevention, and management of AKI. Also discussed are special circumstances, including rhabdomyolysis, contrast-induced nephropathy, and hepatorenal syndrome. Tables outline the AKIN criteria, most current KDIGO consensus guidelines for definition of AKI, differential diagnosis of AKI, agents capable of causing AKI, treatment for specific complications associated with AKI, and options for continuous RRT. Figures show the RIFLE classification scheme and KDIGO staging with prevention strategies. This review contains 1 management algorithm, 2 figures, 6 tables, and 85 references. Keywords: Kidney, renal, KDIGO, azotemia, critical, urine, oliguria, creatinine, dialysis

Evaluation of five different renal recovery definitions for estimation of long-term outcomes of cardiac surgery associated acute kidney injury

BackgroundThe commonly used recommended criteria for renal recovery are not unequivocal. This study compared five different definitions of renal recovery in order to evaluate long-term outcomes of cardiac surgery associated acute kidney injury (CSA-AKI).MethodsPatients who underwent cardiac surgery between April 2009 and April 2013 were enrolled and divided into acute kidney injury (AKI) and non-AKI groups. The primary endpoint was 3-year major adverse events (MAEs) including death, new dialysis and progressive chronic kidney disease (CKD). We compared five criteria for complete renal recovery: Acute Renal Failure Trial Network (ATN): serum creatinine (SCr) at discharge returned to within baseline SCr + 0.5 mg/dL; Acute Dialysis Quality Initiative (ADQI): returned to within 50% above baseline SCr; Pannu: returned to within 25% above baseline SCr; Kidney Disease: Improving Global Outcomes (KDIGO): eGFR at discharge ≥60 mL/min/1.73 m2; Bucaloiu: returned to ≥90% baseline estimated glomerular filtration rate (eGFR). Multivariate regression analysis was used to compare risk factors for 3-year MAEs.ResultsThe rate of complete recovery for ATN, ADQI, Pannu, KDIGO and Bucaloiu were 84.60% (n = 1242), 82.49% (n = 1211), 60.49% (n = 888), 68.60% (n = 1007) and 46.32% (n = 680). After adjusting for confounding factors, AKI with complete renal recovery was a risk factor for 3-year MAEs (OR: 1.69, 95% CI: 1.20–2.38, P < 0.05; OR: 1.45, 95% CI: 1.03–2.04, P < 0.05) according to ATN and ADQI criteria, but not for KDIGO, Pannu and Bucaloiu criteria. We found that relative to patients who recovered to within 0% baseline SCr or recovered to ≥100% baseline eGFR, the threshold values at which significant differences in 3-year MAEs were observed were > 30% or > 0.4 mg/dL above baseline SCr or < 70% of baseline eGFR.ConclusionsADQI or ATN-equivalent criteria may overestimate the extent of renal recovery, while KDIGO, Pannu and Bucaloiu equivalent criteria may be more appropriate for clinical use. Our analyses revealed that SCr at discharge > 30% or > 0.4 mg/dL of baseline, or eGFR < 70% of baseline led to significant 3-year MAE incidence differences, which may serve as hints for new definitions of renal recovery.

Biomarkers and the Potential Role in Clinical Trials of Acute Kidney Injury: Consensus Report of Acute Dialysis Quality Initiative XIX

Biomarkers and the Potential Role in Clinical Trials of Acute Kidney Injury: Consensus Report of Acute Dialysis Quality Initiative XIX

Cardiorenal syndrome in patients with rheumatoid arthritis

In 2008, the term cardiorenal syndrome (CRS) was proposed by the Acute Dialysis Quality Initiative (ADQI) Group to denote pathological reciprocal conditions involving the heart and kidneys, which develop due to acute or chronic dysfunction of one of the organs, followed by acute or chronic dysfunction of the other one. The problem of CRS in patients with rheumatoid arthritis (RA) has not been studied. Of the greatest interest is CRS type 5 or secondary CRS that occurs in patients with systemic diseases, including in those with RA. Currently, there is no doubt that the risk of developing cardiovascular diseases in RA patients and the prevalence of non-ischemic and ischemic chronic heart failure (CHF) are higher than those in the general population. There is evidence that the prevalence of chronic kidney disease (CKD) and renal pathology-associated cardiovascular risk factors (RF) is high in patients with RA. In addition to traditional RFs for cardiovascular and kidney diseases, autoimmune inflammation is an independent predictor for CHF and CKD. The characteristics of CRS in RA should be investigated to develop an effective treatment strategy for this category of patients.

MON-281 CARDIORENAL SYNDROME-AN UNDERDIAGNOSED ENTITY IN CHILDREN

To determine the etiology, incidence and outcome of cardiorenal syndrome(CRS). Its often a underdiagnosed in children Prospective descriptive study of children < 18 years of age who were admitted to our hospital between June 2017 and August 2018 with 1)primary renal dysfunction (CKD KDIGO stage 3-5D and AKI stage II and III as per pRIFLE criteria) and developed secondary cardiac dysfunction (abnormal echocardiogram including low left ventricular ejection fraction, regional wall motion abnormalities, cardiogenic shock) or 2) primary cardiac disease (congenital or acquiredheart disease) and developed secondary renal dysfunction(AKI stages I-III with or without proteinuria).Baseline characteristics including age, sex, etiology, blood pressure, number of hospitalization were taken. Patients were classified into 5 types of CRS using the 7th acute dialysis quality initiative (ADQI) workgroup classification Total of78 children were included for analysis. who met the inclusion criteria, among those 9%,1%,33%,42% and 15% had CRS type 1,2,3,4 and 5, respectively. Cardiac disease leading to CRS were myocarditis(42%), dilated cardiomyopathy(42%) followed by rheumatic heart disease(14%); renal disease associated with CRS were chronic kidney disease(66%) followed by acute kidney injury(44%) and systemic disorder leading to CRS were severe sepsis(41%), MODS(25%), severe dengue(25%) and CMV infection(8%). The incidence of CRS is quite high in children with cardiac, renal and systemic diseases; risk factors of acute renal failure are multiple. Children presenting with these illnesses should be monitored for the occurrence of CRS so that early intervention may reduce mortality and morbidity.

Clinical practice guidelines for the provision of renal service in Hong Kong: General Nephrology.

Clinical practice guidelines for the provision of renal service in Hong Kong: General Nephrology.

Acute kidney injury: A definition with a rich past and an evolution

The term acute kidney injury (AKI) appeared in the society of nephrology in 2004 mirroring a key station of the constant development of the whole entity of acute renal failure. The long route from “acute Bright's disease” in the 19th century to modern “acute kidney stress” reflects the continuous effort of the society of nephrology to set the appropriate criteria and finally to formulate a precise and consensus definition in nomenclature of kidney injury. The most important definitions were the Risk, Injury, Failure, Loss of Kidney Function, and End-Stage Kidney Disease in 2004, Acute Kidney Injury Network (AKIN) in 2007, and Kidney Disease Improving Global Outcomes (KDIGO) in 2012 which had been proposed by the committees of Acute Dialysis Quality Initiative, AKIN, and KDIGO, respectively. Common basis of the above definitions was the clinical-laboratory criteria of urine output and serum creatinine while the target of every newer attempt was to increase the sensitivity of AKI and to offer a globally unified perception in terms of diagnosis and prevention. Since the emersion of KDIGO definition, the interest in defining AKI has been focused on the stage that precedes renal damage by the detection of clinically reliable biomarkers. Subsequently, the concept of acute injury is being lately realized as an attack in correspondence with heart attack or even more as an acute stress which can only be witnessed by the appropriate biomarkers. Recent research is focusing on the discovery of the ideal biomarker which must meet the requirements of high specificity, low cost, and ease of application.

Impact of Recurrent Acute Kidney Injury on Patient Outcomes

Background/Aims: Recurrent acute kidney injury (AKI) is common among patients after a first hospitalized AKI. However, little is known about the prognosis of recurrent AKI episodes in chronic kidney disease (CKD) development, cardiovascular events and mortality. Methods: A retrospective study included patients admitted to our Hospital from 2000 to 2010. AKI was defined according to the Acute Dialysis Quality Initiative criteria. In the follow-up period after the first AKI episode, clinical, laboratory data and the number of repeated AKI episodes, etiology and severity were recorded. Results: Among the 359 AKI survivor patients included, 250 new AKI episodes were observed in 122 patients (34%). Variables independently associated to new episodes were: type 2 DM [OR 1.2, 95%CI 1.2-3.8, p=0.001], ischemic heart disease [OR 1.9; 95%CI 1.1-3.6, p=0.012], and SCr at the first AKI event>2,6 mg/dl [OR 1.2; 95%CI 1.03-1.42, p=0.02]. Development of CKD during four years follow-up was more frequent in patients with recurrent AKI, HR [2.2 (95% CI: 1.09-4.3, p=0.003)] and 44% of recurrent AKI patients who developed CKD occurred during the first 6 months after the initial event. Cardiovascular events were more frequent among patients with recurrent AKI patients than in those with one AKI episode (47.2% vs 24%, p=0.001). Mortality at 4 years was higher in the patient subgroup with several episodes of AKI as compared with those with a single episode [HR: 4.5 (95% CI 2.7-7.5) p<0.001]. Conclusion: Episodes of recurrent AKI have a high potential to be associated with relevant complications such as cardiovascular events, mortality and CKD development.