Acute Kidney Injury Developed Research Articles

Acute kidney injury developed in the intensive care unit: a population-based prospective cohort study in the Brazilian Amazon

The Brazilian Amazon is a vast area with limited health care resources. To assess the epidemiology of critically ill acute kidney injury (AKI) patients in this area, a prospective cohort study of 1029 adult patients of the three intensive care units (ICUs) of Rio Branco city, the capital of Acre state, were evaluated from February 2014 to February 2016. The incidence of AKI was 53.3%. Risk factors for AKI included higher age, nonsurgical patients, admission to the ICU from the ward, higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores at ICU admission, and positive fluid balance > 1500 ml/24 hours in the days before AKI development in the ICU, with aOR of 1.3 (95% CI 1.03–1.23), 1.47 (95% CI 1.07–2.03), 1.96 (95% CI 1.40–2.74), 1.05 (95% CI 1.03–1.08) for each unit increase, and 1.62 (95% CI 1.16–2.26), respectively. AKI was associated with higher ICU mortality (aOR 2.03, 95% CI 1.29–3.18). AKI mortality was independently associated with higher age, nonsurgical patients, sepsis at ICU admission, presence of shock or use of vasoactive drugs, mechanical ventilation and mean positive fluid balance in the ICU > 1500 ml/24 hours, both during ICU follow-up, with aOR 1.27 (95% CI 1.14–1.43) for each 10-year increase, 1.64 (95% CI 1.07–2.52), 2.35 (95% CI 1.14–4.83), 1.88 (95% CI 1.03–3.44), 6.73 (95% CI 4.08–11.09), 2.31 (95% CI 1.52–3.53), respectively. Adjusted hazard ratios for AKI mortality 30 and 31–180 days after ICU discharge were 3.13 (95% CI 1.84–5.31) and 1.69 (95% CI 0.99–2.90), respectively. AKI incidence was strikingly high among critically ill patients in the Brazilian Amazon. The AKI etiology, risk factors and outcomes were similar to those described in high-income countries, but mortality rates were higher.

Rhabdomyolysis-related acute kidney injury in patients with COVID-19.

Viral and bacterial infections may be complicated by rhabdomyolysis, which has a spectrum of clinical presentations ranging from asymptomatic laboratory abnormalities to life-threatening conditions such as renal failure. Direct viral injury as well as inflammatory responses may cause rhabdomyolysis in the course of coronavirus disease 2019 (COVID-19). When presented with acute kidney injury (AKI), rhabdomyolysis may be related to higher morbidity and mortality. To compare rhabdomyolysis-related AKI with other AKIs during COVID-19. A total of 115 patients with COVID-19 who had AKI were evaluated retrospectively. Fifteen patients had a definite diagnosis of rhabdomyolysis (i.e., creatine kinase levels increased to > 5 times the upper normal range with a concomitant increase in transaminases and lactate dehydrogenase). These patients were aged 61.0 ± 19.1 years and their baseline creatinine levels were 0.87 ± 0.13 mg/dL. Patients were treated according to national COVID-19 treatment guidelines. They were compared with patients with COVID-19 who had AKI due to other reasons. For patients with rhabdomyolysis, creatinine reached 2.47 ± 1.17 mg/dL during follow-up in hospital. Of these patients, 13.3% had AKI upon hospital admission, and 86.4% developed AKI during hospital follow-up. Their peak C-reactive protein reached as high as 253.2 ± 80.6 mg/L and was higher than in patients with AKI due to other reasons (P < 0.01). Peak ferritin and procalcitonin levels were also higher for patients with rhabdomyolysis (P = 0.02 and P = 0.002, respectively). The mortality of patients with rhabdomyolysis was calculated as 73.3%, which was higher than in other patients with AKI (18.1%) (P = 0.001). Rhabdomyolysis was present in 13.0% of the patients who had AKI during COVID-19 infection. Rhabdomyolysis-related AKI is more proinflammatory and has a more mortal clinical course.

Association of Neighborhood Social Determinants of Health with Acute Kidney Injury during Hospitalization.

Acute kidney injury (AKI) is common among hospitalized patients. However, the contribution of social determinants of health (SDOH) to AKI risk remains unclear. This study evaluated the association between neighborhood measures of SDOH and AKI development and recovery during hospitalization. This is a retrospective cohort study of adults without end-stage kidney disease admitted to a large southern U.S. healthcare system from 10/2014 to 9/2017. Neighborhood SDOH measures included: 1) Socioeconomic status: Area Deprivation Index (ADI) scores, 2) Food access: Low Income Low Access (LILA) scores, 3) Rurality: Rural Urban Commuting Area (RUCA) scores, and (4) Residential segregation: dissimilarity and isolation scores. The primary study outcome was AKI based on serum creatinine (SCr)-KDIGO criteria. Our secondary outcome was lack of AKI recovery (requiring dialysis or elevated SCr at discharge). The association of SDOH measures with AKI was evaluated using generalized estimating equation models adjusted for demographics and clinical characteristics. Among 26,769 patients, 26% developed AKI during hospitalization. Compared with those who did not develop AKI, those who developed AKI were older (median 60 vs. 57 years), more commonly men (55% vs. 50%), and more commonly self-identified as Black (38% vs. 33%). Patients residing in most disadvantaged neighborhoods (highest ADI tertile) had 10% (95%CI: 1.02-1.19) greater adjusted odds of developing AKI during hospitalization than counterparts in least disadvantaged areas (lowest ADI tertile). Patients living in rural areas had 25% higher adjusted odds of lack of AKI recovery by hospital discharge (95% CI: 1.07, 1.46). Food access and residential segregation were not associated with AKI development or recovery. Hospitalized patients from the most socioeconomically disadvantaged neighborhoods and from rural areas had higher odds of developing AKI and not recovering from AKI by hospital discharge, respectively. A better understanding of the mechanisms underlying these associations is needed to inform interventions to reduce AKI risk during hospitalization among disadvantaged populations.

Acute Kidney Injury in COVID-19 Pneumonia Patients Admitted to the Intensive Care Unit.

This retrospective study was conducted at the Izmir Tepecik Training and Research Hospital from January 2020 to December 2021. It aimed to determine acute kidney injury (AKI) frequency and associated factors in critically ill COVID-19 patients. Out of 177 patients, 49.7% developed AKI, with an average onset of 7.63 days. AKI stages varied, and progression occurred in 27 patients within 48 hours. ICU and hospital mortality rates were significantly higher in AKI patients (86.4% and 92%, respectively) compared to non-AKI patients (19.1% and 22.5%). The study highlights age, sequential organ failure assessment (SOFA) score, and nephrotoxic agent presence as significant factors influencing AKI development in COVID-19 patients. Key Words: Critical care unit, COVID-19, Acute kidney failure.

Beyond the Valve: Incidence, Outcomes, and Modifiable Factors of Acute Kidney Injury in Patients with Infective Endocarditis Undergoing Valve Surgery-A Retrospective, Single-Center Study.

Background/Objectives: Infective endocarditis (IE) often requires surgical intervention, with postoperative acute kidney injury (AKI), posing a significant concern. This retrospective study aimed to investigate AKI incidence, its impact on short-term mortality, and identify modifiable factors in patients with IE scheduled for valve surgery. Methods: This single-center study enrolled 130 consecutive IE patients from 2013 to 2021 undergoing valve surgery. The creatinine levels were monitored pre- and postoperatively, and AKI was defined by Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Patient demographics, comorbidities, procedural details, and complications were recorded. Primary outcomes included AKI incidence; the relevance of creatinine levels for AKI detection; and the association of AKI with 30-, 60-, and 180-day mortality. Modifiable factors contributing to AKI were explored as secondary outcomes. Results: Postoperatively, 35.4% developed AKI. The highest creatinine elevation occurred on the second postoperative day. Best predictive value for AKI was a creatinine level of 1.35 mg/dL on the second day (AUC: 0.901; sensitivity: 0.89, specificity: 0.79). Elevated creatinine levels on the second day were robust predictors for short-term mortality at 30, 60, and 180 days postoperatively (AUC ranging from 0.708 to 0.789). CK-MB levels at 24 h postoperatively and minimum hemoglobin during surgery were identified as independent predictors for AKI in logistic regression. Conclusions: This study highlights the crucial role of creatinine levels in predicting short-term mortality in surgical IE patients. A specific threshold (1.35 mg/dL) provides a practical marker for risk stratification, offering insights for refining perioperative strategies and optimizing outcomes in this challenging patient population.

Impact of once-daily versus multiple-daily dosing of gentamicin on the incidence of acute kidney injury in patients treated with synergistic combinations of antibiotics

BackgroundGentamicin is a commonly used antibiotic with synergistic effects that is administered once or multiple times daily. However, the influence of the daily administration frequency on renal function has not yet been identified. This study aimed to investigate the effect of the daily dosing frequency on worsening renal function in patients receiving gentamicin.MethodsThis study included 35 patients undergoing gentamicin treatment who had at least one serum trough level measured and underwent therapeutic drug monitoring (TDM). We evaluated the influence of daily dosing frequency on gentamicin trough concentration and the risk of acute kidney injury (AKI).ResultsCompared to patients who received gentamicin once-daily dosing (n = 22), patients who received multiple-daily dosing (n = 13) had significantly higher initial and minimum trough concentrations after TDM. The proportion of patients with trough concentrations lower than 1.0 µg/mL was significantly higher in the once-daily dosing group at the initial trough concentration, whereas there was no significant difference at the minimum trough concentration after TDM. AKI developed in nine patients; however, there was no significant difference in the incidence of AKI according to the frequency of daily gentamicin dosing. In contrast, a higher minimum trough concentration after TDM was found to be a risk factor for AKI development with an odds ratio of 9.2 (95% confidence intervals; 1.3–65.5).ConclusionA higher trough concentration of gentamicin correlated with a higher incidence of AKI. The risk of developing AKI may be reduced by choosing a once-daily dosing regimen or implementing TDM.

Biomarker-guided detection of acute kidney injury in abdominal aortic surgery: the new and the old.

Acute kidney injury (AKI) is a common complication in patients undergoing major vascular surgery. Despite significant research efforts in this area, the incidence of AKI remains high, posing a significant challenge to healthcare systems, especially in situations where resources are limited. Early prediction of AKI severity and individualized postoperative care is therefore essential. The primary objective of this exploratory study was to assess the diagnostic value of urine cell-cycle arrest biomarkers [(TIMP-2) × (IGFBP7)] and soluble urokinase plasminogen activator receptor (suPAR) for predicting moderate or severe AKI within 24 h after open aortic surgery, and compared to routine kidney biomarkers. Seventy-five patients undergoing elective aortic surgery were included. Clinical parameters, urine and blood samples were collected preoperatively, immediately postoperatively, and 24 h later. AKI was defined using KDIGO criteria. Individual and combined diagnostic performance of biomarkers were evaluated. Of the 75 patients, 61% developed AKI, of which 28% developed moderate or severe AKI within 24 h of surgery. Baseline demographics, comorbidities and kidney parameters did not differ between patients with moderate or severe AKI (AKI II/III) and none or mild AKI (AKI 0/I), except for higher preoperative suPAR levels in later AKI II/III patients. Urine osmolality, Cystatin C and serum creatinine had the highest predictive power for AKI II/III with AUCs of 0.75-0.72. (TIMP-2) × (IGFBP7), and neither (TIMP-2) × (IGFBP7) nor suPAR individually showed superior diagnostic value. Combining CysC or SCr with urine osmolality and 6 h urine output gave the best performance with AUCs of 0.86 (95% CI, 0.74-0.96) and 0.85 (95% CI, 0.75-0.95) respectively. Our study suggests that routine parameters like urine osmolality, CysC, SCr and 6 h urine output perform best in predicting postoperative AKI after aortic surgery compared to the new biomarkers (TIMP-2) × (IGFBP7) and suPAR. Combining biomarkers, particularly CysC or SCr with urine output, urine osmolality, may enhance diagnostic accuracy. Further validation in larger cohorts and clinical settings is warranted to establish their clinical utility.

Risk factors for acute kidney injury in patients hospitalized with COVID-19.

Acute kidney injury (AKI) occurs frequently in COVID-19 patients and is associated with greater morbidity and mortality. Knowing the risks of AKI allows for identification, prevention, and timely treatment. This study aimed to identify the risk factors associated with AKI in hospitalized patients. A descriptive, retrospective, cross-sectional, and analytical component study of adult patients hospitalized with COVID-19 from March 1 to December 31, 2020 was carried out. AKI was defined by the creatinine criteria of the KDIGO-AKI guidelines. Information, regarding risk factors, was obtained from electronic medical records. Out of the 934 patients, 42.93% developed AKI, 60.59% KDIGO-1, and 9.9% required renal replacement therapy. Patients with AKI had longer hospital stay, higher mortality, and required more intensive care unit (ICU) admission, mechanical ventilation, and vasopressor support. Multivariate analysis showed that age (OR 1.03; 95% CI 1.02-1.04), male sex (OR 2.13; 95% CI 1.49-3.04), diabetes mellitus (DM) (OR 1.55; 95% CI 1.04-2.32), chronic kidney disease (CKD) (OR 2.07; 95% CI 1.06-4.04), C-reactive protein (CRP) (OR 1.02; 95% CI 1.00-1.03), ICU admission (OR 1.81; 95% CI 1.04-3.16), and vasopressor support (OR 7.46; 95% CI 3.34-16.64) were risk factors for AKI, and that bicarbonate (OR 0.89; 95% CI 0.84-0.94) and partial pressure arterial oxygen/inspired oxygen fraction index (OR 0.99; 95% CI 0.98-0.99) could be protective factors. A high frequency of AKI was documented in COVID-19 patients, with several predictors: age, male sex, DM, CKD, CRP, ICU admission, and vasopressor support. AKI occurred more frequently in patients with higher disease severity and was associated with higher mortality and worse outcomes.

Hemodynamic Changes in Intrarenal Blood Flow are Associated With Poor Prognosis in Patients With Acute Decompensated Heart Failure.

To evaluate a potential role of different patterns of intrarenal blood flow using Doppler ultrasound as a part of determining the severity of venous congestion, predicting impairment of renal function and an unfavorable prognosis in patients with acute decompensated chronic heart failure (ADCHF). This prospective observational single-site study included 75 patients admitted in the intensive care unit for ADCHF. Upon admission all patients underwent bedside renal venous Doppler ultrasound to determine the blood flow pattern (continuous, biphasic, monophasic). In one hour after the initiation of intravenous diuretic therapy, sodium concentration was measured in a urine sample. The primary endpoint was the development of acute kidney injury (AKI). The secondary endpoints were the development of diuretic resistance (a need to increase the furosemide daily dose by more than 2 times compared with the baseline), decreased natriuretic response (defined as urine sodium concentration less than 50-70 mmol/l), and in-hospital death. According to the data of Doppler ultrasound, normal renal blood flow was observed in 40 (53%) patients, biphasic in 21 (28%) patients, and monophasic in 14 (19%) patients. The monophasic pattern of intrarenal blood flow was associated with the highest incidence of AKI: among 14 patients in this group, AKI developed in 100% of cases (OR 3.8, 95% CI: 2.5-5.8, p&lt;0.01), while among patients with normal and moderate impairment of renal blood flow, there was no significant increase in the risk of developing AKI. The odds of in-hospital death were increased 25.77 times in patients with monophasic renal blood flow (95% CI: 5.35-123.99, p&lt;0.001). Patients with a monophasic intrarenal blood flow pattern were also more likely to develop diuretic resistance compared to patients with other blood flow patterns (p&lt;0.001) and had a decreased sodium concentration to less than 50 mmol/l (p&lt;0.001) in a spot urine test obtained one hour after the initiation of furosemide administration. Patients with monophasic intrarenal blood flow are at a higher risk of developing AKI, diuretic resistance with decreased natriuretic response, and in-hospital death.

Incidence, risk factors, and outcomes of the transition of HIPEC-induced acute kidney injury to acute kidney disease: a retrospective study

Background Acute kidney injury (AKI) is recognized as a common complication following cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). Characterized by prolonged renal function impairment, acute kidney disease (AKD) is associated with a higher risk of chronic kidney disease (CKD) and mortality. Methods From January 2018 to December 2021, 158 patients undergoing CRS-HIPEC were retrospectively reviewed. Patients were separated into non-AKI, AKI, and AKD cohorts. Laboratory parameters and perioperative features were gathered to evaluate risk factors for both HIPEC-induced AKI and AKD, with the 90-day prognosis of AKD patients. Results AKI developed in 21.5% of patients undergoing CRS-HIPEC, while 13.3% progressed to AKD. The multivariate analysis identified that ascites, GRAN%, estimated glomerular filtration rate (eGFR), and intraoperative (IO) hypotension duration were associated with the development of HIPEC-induced AKI. Higher uric acid, lessened eGFR, and prolonged IO hypotension duration were more predominant in patients proceeding with AKD. The AKD cohort presented a higher risk of 30 days of in-hospital mortality (14.3%) and CKD progression (42.8%). Conclusions Our study reveals a high incidence of AKI and AKI-to-AKD transition. Early identification of risk factors for HIPEC-induced AKD would assist clinicians in taking measures to mitigate the incidence.

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

BackgroundSepsis 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.MethodsThe 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.ResultsOut 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).ConclusionsThe 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.

Incidence of acute kidney injury in patients with acute ischaemic stroke undergoing CT angiography (CTA) and CT perfusion (CTP): a systematic review and meta-analysis

Background and purposeWe conducted a systematic review and meta-analysis to assess the incidence of acute kidney injury (AKI) in patients undergoing CT angiography (CTA) and CT perfusion (CTP) for acute...

Perioperative Left Ventricular Assist Device Use in Patients With Reduced Ejection Fraction Reduces Cardiac Surgery-Associated Acute Kidney Injury.

Background Cardiac surgery may precipitate acute kidney injury (AKI), particularly in patients with poor baseline cardiac function. This is thought to be due to intraoperative renal hypoperfusion, which results in increased morbidity and mortality. This study evaluated the perioperative use of the Impella LD (Abiomed, Danvers, MA) left ventricular assist device (LVAD) in the prevention of postoperative AKI in patients with reduced left ventricular ejection fraction (LVEF) undergoing cardiac surgery. Methods A retrospective analysis was performed at Northwest Medical Center, Tucson, AZ, USA, on patients undergoing valve surgery, coronary arterybypassgrafting(CABG), or both by a single surgeon. Those with preoperative LVEF ≤35% and preoperative serum creatinine ≥1 mg/dL were included and segregated based on intraoperative LVAD implantation. Postoperative renal functionwas assessed using serum creatinine levels and KDIGO (Kidney Disease Improving Global Outcomes) criteria to define AKI. Results Twenty-three patients were enrolled. There were no significant differences in age, demographics, baseline characteristics, or comorbidities between the treatment (n = 12) and the control group (n = 11). In the treatment group, 8% developed AKI by POD#7, while 64% of controls did. The treatment group had a significantly lower mean creatinine change from POD#0-7 (0.07 vs. 0.59, p = 0.02). However, there was no significant difference between groups in the mean creatinine change from baseline to discharge (0.46 vs. 0.42, p = 0.47). Conclusions Our study suggests that intraoperative Impella implantation may reduce the incidence of early postoperative AKI. LVAD implantation is an approach to increase and ensure adequate end-organ (renal) perfusion andcan improve postoperative recovery without dialysis requirements. Additional studies are required to understand its protective effects during the perioperative period fully.

Acute kidney injury following treatment with CD19-specific CAR T-cell therapy in children, adolescent, and young adult patients with B-cell acute lymphoblastic leukemia.

CD19-specific chimeric antigen receptor (CAR) T-cell therapy has shown promising disease responses in patients with high-risk B-cell malignancies. However, its use may be related to complications such as immune-mediated complications, infections, and end-organ dysfunction. The incidence of post-CAR T-cell therapy acute kidney injury (AKI) in the children, adolescent, and young adult (CAYA) patient population is largely unreported. The objectives of this study were to determine the incidence of AKI in CAYA patients with high-risk B-cell malignancies treated with CD19-CAR T-cell therapy, evaluate potential risk factors for developing AKI, and determine patterns of kidney function recovery. We conducted a retrospective analysis of 34 CAYA patients treated with CD19-CAR T-cell at a single institution. There was a cumulative incidence of any grade AKI by day 30 post-infusion of 20% (n = 7), with four cases being severe AKI (stages 2-3) and one patient requiring kidney replacement therapy. All episodes of AKI developed within the first 14days after receiving CAR T-cell therapy and 50% of patients with AKI recovered kidney function to baseline within 30days post-infusion. No evaluated pre-treatment risk factors were associated with the development of subsequent AKI; there was an association between AKI and cytokine release syndrome and neurotoxicity. We conclude that the risk of developing AKI following CD19-CAR T-cell therapy is highest early post-infusion, with most cases of AKI being severe. Frequent monitoring to facilitate early recognition and subsequent management of kidney complications after CD19-CAR T-cell therapy may reduce the severity of AKI in the CAYA patient population.

Clinical profile and outcome of acute kidney injury in children admitted to paediatric intensive care unit: A prospective observational study

Introduction: Acute kidney injury (AKI) is a commonly encountered problem in the paediatric intensive care unit (PICU). There are limited reports on paediatric AKI from the Indian subcontinent. Objective: To determine the incidence, aetiology and outcome in paediatric AKI using Acute Kidney Injury Network (AKIN) criteria. Method: This prospective observational study was conducted in the PICU of a teaching hospital in Western Maharashtra, India, from July 2016 to June 2017 on patients aged 1 month to 17 years. Results: The incidence of AKI was 18.8% (80/426). The mean age was 70 ± 60 months. Most (66.3%) cases had stage I AKI and 54% developed AKI within 72 hours. Sepsis (35%), pneumonia (25%) and tropical febrile illnesses (18.7%) were the common aetiologies. Complete recovery (CR) was seen in 79% and partial recovery (PR) in 21%. CR was highest in stage I (91%) as compared to stages II and III (p=0.005). Mortality was 22% (18/80). Mortality significantly increased with the stage of AKI (p=0.003). Mechanical ventilation, inotrope support, shock and the stage of AKI had a significant association with mortality on bivariate analysis. Mechanical ventilation was found to be a significant independent predictor of mortality (p= 0.011). Renal replacement therapy was needed in 6 (8%) cases. Conclusions: About one-fifth of children admitted to ICU developed AKI and most experienced mild transient AKI. Moderate to severe AKI carried high mortality suggesting a dose-response effect. Infections remain the commonest cause and mechanical ventilation was an independent predictor of mortality.

Temporal Relationship and Clinical Outcomes of Acute Kidney Injury Following Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis.

Conduct a systematic review and meta-analysis to assess prevalence and timing of acute kidney injury (AKI) development after acute respiratory distress syndrome (ARDS) and its association with mortality. Ovid MEDLINE(R), Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Ovid PsycINFO database, Scopus, and Web of Science thought April 2023. Titles and abstracts were screened independently and in duplicate to identify eligible studies. Randomized controlled trials and prospective or retrospective cohort studies reporting the development of AKI following ARDS were included. Two reviewers independently extracted data using a pre piloted abstraction form. We used Review Manager 5.4 software (Cochrane Library, Oxford, United Kingdom) and Open Meta software (Brown University, Providence, RI) for statistical analyses. Among the 3646 studies identified and screened, 17 studies comprising 9359 ARDS patients met the eligibility criteria and were included in the meta-analysis. AKI developed in 3287 patients (40%) after the diagnosis of ARDS. The incidence of AKI at least 48 hours after ARDS diagnosis was 20% (95% CI, 0.18-0.21%). The pooled risk ratio (RR) for the hospital (or 30-d) mortality among ARDS patients who developed AKI was 1.93 (95% CI, 1.71-2.18). AKI development after ARDS was identified as an independent risk factor for mortality in ARDS patients, with a pooled odds ratio from multivariable analysis of 3.69 (95% CI, 2.24-6.09). Furthermore, two studies comparing mortality between patients with late vs. early AKI initiation after ARDS revealed higher mortality in late AKI patients with RR of 1.46 (95% CI, 1.19-1.8). However, the certainty of evidence for most outcomes was low to very low. While our findings highlight a significant association between ARDS and subsequent development of AKI, the low to very low certainty of evidence underscores the need for cautious interpretation. This systematic review identified a significant knowledge gap, necessitating further research to establish a more definitive understanding of this relationship and its clinical implications.

Vasoactive-Inotropic Score as a Promising Predictor of Acute Kidney Injury in Adult Patients Requiring Extracorporeal Membrane Oxygenation.

Acute kidney injury (AKI) is a common complication in patients supported by extracorporeal membrane oxygenation (ECMO). Vasoactive-Inotropic Score (VIS) serves as an indicator of the extent of cardiovascular drug support provided. Our objective is to assess the relationship between the VIS and ECMO-associated AKI (EAKI). This single-center retrospective study extracted adult patients treated with ECMO between August 2016 and September 2022 from an intensive care unit (ICU) in a university hospital. A total of 126 patients requiring ECMO support were included in the study, of which 76% developed AKI. Multivariate logistic regression analysis identified VIS-max Day1 (odds ratio [OR]: 1.025, 95% confidence interval [CI]: 1.007-1.044, p = 0.006), VIS-max Day2 (OR: 1.038, 95% CI: 1.007-1.069, p = 0.015), VIS-mean Day1 (OR: 1.048, 95% CI: 1.013-1.084, p = 0.007), and VIS-mean Day2 (OR: 1.059, 95% CI: 1.014-1.107, p = 0.010) as independent risk factors for EAKI. VIS-max Day1 showing the best predictive effect (Area under the receiver operating characteristic curve (AUROC): 0.80, sensitivity: 71.87%, specificity: 80.00%) for EAKI with a cutoff value of 33.33. Surprisingly, VIS-mean Day2 was also excellent at predicting 7 day mortality (AUROC: 0.77, sensitivity: 87.50%, specificity: 56.38%) with a cutoff value of 8.67. In conclusion, VIS could independently predict EAKI and 7 day mortality in patients with ECMO implantation, which may help clinicians to recognize the poor prognosis in time for early intervention.

Chloride as a Prognostic Factor in Children with Diabetic Ketoacidosis: A Retrospective Cohort Study

Introduction: In the management of Diabetic Ketoacidosis (DKA), importance is given to electrolytes such as sodium and potassium, but not chloride. There is evidence that high chloride levels can lead to Acute Kidney Injury (AKI). However, chloride as a prognostic factor has not been thoroughly investigated. Aim: To evaluate the role of chloride as a prognostic factor in the treatment of children with DKA. Materials and Methods: This retrospective cohort study collected data from 22 children with severe DKA, aged under 14 years, admitted to the Department of Paediatrics, SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India, between January 2016 and October 2020. Data included demographic details, blood glucose, arterial blood gas, renal function tests, serum electrolytes at admission and at 24 hours, and outcome parameters. All children received regular monitoring and standard treatment as per the International Society for Paediatric and Adolescent Diabetes (ISPAD) guidelines. The children were divided into two groups: Recovery within 48 hours (Group-A) and more than 48 hours (Group-B). Electrolyte and renal parameters after 24 hours of treatment were compared. Univariate analysis was performed using Statistical Package for Social Sciences (SPSS) version 21.0. Student's t-test, Chisquare test, and odds ratio were used for statistical analysis. A p-value of &lt;0.05 was considered significant. Results: Among the 22 children, 50% recovered within 48 hours, while the remaining half took more than 48 hours. A total of 13 had hyperchloraemia at 24 hours (59%). The mean serum chloride at 24 hours was 115.91 mmol/L in Group-B compared to 106.09 mmol/L in Group-A (p=0.0079*). Two developed AKI, requiring renal replacement therapy and ventilatory support, and eventually died. Conclusion: In the present study, children with severe DKA who developed hyperchloraemia after 24 hours of admission, following fluid resuscitation with 0.9% normal saline and subsequent standard treatment, took a longer time to recover

COVID-19 disease among children and young adults enrolled in the North American Pediatric Renal Trials and Collaborative Studies registry.

Coronavirus disease of 2019 (COVID-19) has disproportionately affected adults with kidney disease. Data regarding outcomes among children with kidney disease are limited. The North American Pediatric Renal Trials Collaborative Studies Registry (NAPRTCS) has followed children with chronic kidney disease (CKD) since 1987 at 87 participating centers. This study aimed to evaluate the impact of COVID-19 among participants enrolled in the three arms of the registry: CKD, dialysis, and transplant. This was a retrospective cohort study of COVID-19 among participants in the NAPRTCS CKD, dialysis, and transplant registries from 2020 to 2022. Where appropriate, t-tests, chi-square analyses, and univariate logistic regression were used to evaluate the data. The cohort included 1505 NAPRTCS participants with recent data entry; 260 (17%) had documented COVID-19. Infections occurred in all three registry arms, namely, 10% (n = 29) in CKD, 11% (n = 67) in dialysis, and 26% (n = 164) in transplant. The majority of participants (75%) were symptomatic. Hospitalizations occurred in 17% (n = 5) of participants with CKD, 27% (n = 18) maintenance dialysis participants, and 26% (n = 43) of transplant participants. Fourteen percent (n = 4) of CKD participants and 10% (n = 17) of transplant participants developed acute kidney injury (AKI), and a total of eight participants (one CKD, seven transplant) required dialysis initiation. Among transplant participants with moderate to severe illness, 40-43% developed AKI and 29-40% required acute dialysis. There were no reported deaths. COVID-19 was documented in 17% of active NAPRTCS participants. While there was no documented mortality, the majority of participants were symptomatic, and a quarter required hospitalization.

Early Post-Infusion Clearance of High-Dose Methotrexate Predicts Delayed Methotrexate Elimination and Acute Kidney Injury

Introduction High-dose methotrexate (HDMTX) is used for the treatment of hematologic malignancies but its use may be limited by delayed methotrexate elimination and acute kidney injury (AKI). Current guidelines for glucarpidase recommend administration between 48-60 hours following the start of a 24-hour HDMTX infusion based on methotrexate concentration at 36-, 42-, or 48-hours [Ramsey 2016]. However, this may be too late to prevent permanent toxicities in cases where significant AKI develops early during infusion. Recent evidence from pig models have shown that early methotrexate measurements can predict the development of AKI [Buddington 2023]. The aim of this study is to determine whether early elimination of methotrexate (soon after completion of the infusion) is a useful “early clearance biomarker” of delayed methotrexate elimination and AKI in humans. Methods Retrospective data from two sites in Spain that collected two or more early measurements of methotrexate levels from the end of HDMTX infusion were analyzed from a larger HDMTX registry. Methotrexate half-life was calculated employing exponential decay equations and the slope of a line connecting two out of three early time points; each combination was tested, and the best performing pair is reported. Early levels were tagged according to visual exploration and k-means cluster analysis (Figure 1). Delayed methotrexate elimination was defined as a concentration above 1 μmol/L after 42-hours from the start of infusion (micromolar criterion) or above 2 standard deviations (SD) from the population mean modeled using MTXPK.org at 42- or 48-hours from the start of infusion (SD criterion). Receiver operating characteristic (ROC) curves were fitted, with their respective area under the curve (AUC) and confidence intervals for delayed methotrexate elimination and AKI. Additionally, a logistic regression model was employed to predict AKI using a base model with covariates (age, sex, HDMTX dose, and first course) plus early methotrexate clearance. Results Data from 144 patients who received 453 HDMTX courses were included. Patient characteristics were as follows: 41% females, age ranged from 1.2 to 81.5 years at the time of HDMTX infusion; diagnoses included acute lymphoblastic leukemia, 79%; non-Hodgkin lymphoma, 21%. Median methotrexate dose was 4,856.9 mg/m 2 [IQR 2,871.7 - 4,985.0], with 88% of the courses infused over 24 hours and 12% over 4 hours. Delayed methotrexate elimination was found in 41% and 6.6% of the courses according to the micromolar criterion and SD criterion, respectively. AKI developed in 29.6% of courses. Median time for the first, second and third measurements were 0.25 [IQR 0.00 - 0.71], 6.32 [IQR 5.86 - 6.69] and 12 [IQR 11.68 - 12.50] hours, respectively. Half-life estimation between the second and third early time-points predicted delayed methotrexate elimination by the micromolar criterion with an ROC AUC of 0.81 [CI95 0.76 - 0.87] or SD criterion with an ROC AUC of 0.84 [CI95 0.68 - 1.00] (Fig. 2) and any grade AKI with an ROC AUC of 0.62 [CI95 0.55 - 0.69]. After adjusting for age, sex, HDMTX dose, and first course, half-life remained statistically significant in the logistic regression model, with an odds ratio of 1.4 [CI95 1.1 - 1.8] (p &amp;lt; 0.01). The addition of half-life to the base model improved the overall performance (ANOVA, p &amp;lt; 0.01). Conclusions The half-life of methotrexate elimination soon after completing the HDMTX infusion defines an early clearance biomarker that predicts delayed methotrexate elimination and AKI. It requires only the measurement of 2 early methotrexate levels soon after completing the infusion, and thus represents a practical and applicable method to identify patients at risk who may need pre-emptive interventions like increased hydration or glucarpidase.