Acute Kidney Injury In Septic Shock Research Articles

Early persistent exposure to high CVP is associated with increased mortality and AKI in septic shock: A retrospective study

PurposeThis study's objective was to investigate the association between exposure to different intensities of central venous pressure (CVP) over time in patients with septic shock with 28-day mortality and acute kidney injury (AKI). Materials and methodsWe obtained data from the AmsterdamUMCdb, which includes data on patients ≥18 years old with septic shock undergoing CVP monitoring. The primary outcome was mortality by day 28. Piecewise exponential additive mixed models were used to estimate the strength of the association over time. Results9668 patients were included in the study. They exhibited 8.2% overall mortality at 28 days and 41.1% AKI incidence. Daily time-weighted average CVP was strongly associated with increased mortality at 28 days, primarily within 24 h of ICU admission. The mortality rate of patients was lowest when the CVP was 6–12 cmH2O. When the time of high CVP (TWA-CVP >12 cmH2O) exposure within the first 24 h was >5 h, the risk of death increased by 2.69-fold. Additionally, patients exposed to high CVP had a significantly increased risk of developing AKI. ConclusionsThe optimal CVP range for patients with septic shock within 24 h of ICU admission is 6–12 cmH2O. Mortality increased when patients were exposed to high CVP for >5 h.

Construction and Validation of a Risk Prediction Model for Acute Kidney Injury in Patients Suffering from Septic Shock.

Background Acute kidney injury (AKI) is an important complication in critically ill patients, especially in sepsis and septic shock patients. Early prediction of AKI in septic shock can provide clinicians with sufficient information for timely intervention so that improve the patients' survival rate and quality of life. The aim of this study was to establish a nomogram that predicts the risk of AKI in patients with septic shock in the intensive care unit (ICU). Methods The data were collected from the Medical Information Mart for Intensive Care III (MIMIC-III) database between 2001 and 2012. The primary outcome was AKI in the 48 h following ICU admission. Univariate and multivariate logistic regression analyses were used to screen the independent risk factors of AKI. The performance of the nomogram was evaluated according to the calibration curve, receiver operating characteristic (ROC) curve, decision curve analysis, and clinical impact curve. Results A total of 2415 patients with septic shock were included in this study. In the training and validation cohort, 1091 (64.48%) of 1690 patients and 475 (65.52%) of 725 patients developed AKI, respectively. The predictive factors for nomogram construction were gender, ethnicity, congestive heart failure, diabetes, obesity, Simplified Acute Physiology Score II (SAPS II), angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARBs), bilirubin, creatinine, blood urea nitrogen (BUN), and mechanical ventilation. The model had a good discrimination with the area under the ROC curve of 0.756 and 0.760 in the training and validation cohorts, respectively. The calibration curve for probability of AKI in septic shock showed optimal agreement between prediction by nomogram and actual observation. Decision curve and clinical impact curve analysis indicated that the nomogram conferred high clinical net benefit. Conclusion The proposed nomogram can quickly and effectively predict the risk of AKI at an early stage in patients with septic shock in ICU, which can provide information for timely and efficient intervention in patients with septic shock in the ICU setting.

Heparin-Binding Protein (HBP): A Causative Marker and Potential Target for Heparin Treatment of Human Sepsis-Induced Acute Kidney Injury.

Sepsis-induced acute kidney injury (AKI) is a common condition with high morbidity and mortality. Neutrophil-derived heparin-binding protein (HBP) induces vascular leakage and is a promising biomarker of sepsis-induced organ dysfunction. It remains unknown if HBP is prognostic of AKI in septic shock and if HBP could play a role in the pathophysiology of sepsis-induced AKI. To determine the association of plasma HBP levels with development of AKI, investigate the role of HBP in the pathophysiology of sepsis-induced AKI, and test the effect of blocking HBP using heparin derivatives. In 296 septic shock patients from the randomized multicenter Vasopressin and Septic Shock Trial (VASST) plasma HBP levels were associated with development of AKI and need for renal replacement therapy (RRT). Human renal tubular cells were exposed to recombinant HBP to evaluate inflammation and heparin derivatives were used to abrogate these effects. Finally, mice were exposed to HBP with and without heparin derivatives and the kidneys examined for signs of inflammation. Plasma HBP levels were significantly higher in patients with AKI and those requiring RRT. HBP levels identified patients with moderate AKI with an area under curve (AUC) of 0.85. HBP increased IL-6 production in renal tubular epithelial cells. Different heparin derivatives abrogated the HBP-induced increased inflammatory response in vitro and in vivo. Elevated plasma HBP is associated with development of sepsis-induced AKI and HBP is involved in its pathophysiology. Our studies suggest that heparin(s) could be tested for efficacy and safety of prevention of sepsis-induced AKI.

Sustained low-efficiency dialysis in septic shock: Hemodynamic tolerability and efficacy.

Aim of the Study:Acute kidney injury (AKI) in septic shock has poor outcomes. Sustained low-efficiency dialysis (SLED) is increasingly replacing continuous renal replacement therapy as the preferred modality in Intensive Care Units (ICUs). However, the essential aspects of hemodynamic tolerability and efficacy of SLED in septic shock AKI has been minimally studied.Patients and Methods:We describe hemodynamic tolerability using modified vasopressor index (VI) and vasopressor dependency (VD) and efficacy using a combination of Kt/v, correction of acidosis, electrolyte, and fluid overload. Adult ICU patients of septic shock in AKI requiring SLED were included in this study.Results:One hundred and twenty-four patients of septic shock AKI requiring SLED were enrolled in the study. There were 74 nonsurvivors (NSs). Approximately, 56% (278/498) of the sessions in which vasopressors were required were studied. Metabolic acidosis (49%) was the predominant indication for the initiation of SLED in these patients. Baseline characteristics between survivors and NSs were comparable, except for age, severity scores, AKI stage, and coexisting illness. VI and VD prior to the initiation of SLED and delta VI and VD during SLED were significantly higher in NSs. Hemodynamic tolerability and efficacy of SLED was achievable only at lower vasopressor doses.Conclusion:VI, VD, and combination of Kt/v together with correction of acidosis, electrolyte, and fluid overload can be used to describe hemodynamic tolerability and efficacy of SLED in septic shock AKI. However, at higher vasopressor doses in septic shock, hemodynamic tolerability and efficacy of SLED requires further evidence.

Non-pulmonary infections but not specific pathogens are associated with increased risk of AKI in septic shock.

Little is known regarding the relationship between the anatomic infection site and etiologic pathogen with the occurrence of acute kidney injury (AKI) in severe infections. We set out to determine the association between the site of infection, type of pathogen in septic shock and occurrence of AKI. Using a large, international multicenter database that included data from 28 academic and community hospitals, we retrospectively analyzed adult (age >18 years) cases of septic shock occurring between January 1996 and December 2008. Early acute kidney injury (AKI) was classified by the RIFLE criteria at or within 24 h of shock diagnosis. Multivariate logistic regression was used to determine the association between the infection site/microbial pathogen and occurrence of AKI. Analyses were adjusted for demographics, illness severity, comorbidities and intensive care unit interventions (partial adjustment) ± site of infection and microbial pathogen (full adjustment). After exclusions, 4,493 cases from potentially eligible patients in the database were included in the analytic cohort of whom 3,298 (73.4 %) experienced AKI. Patients with AKI were older (p < 0.0001), had a higher mean Acute Physiology and Chronic Health Evaluation score (p < 0.0001), and had greater laboratory and hemodynamic abnormalities. The most common site of infection among septic shock patients with AKI was the lung (34.5 %), followed by gastrointestinal (GI) (26.2 %) and urinary (15.3 %) sources. Likewise, the most common infecting organism among septic shock patients with AKI was E. coli (23.9 %) followed by S. aureus (GI) (16.1 %) and other enterobacteriaceae (15.7 %). There was a large degree of variability in the occurrence of AKI based on the site of infection and the pathogen in unadjusted analysis (p < 0.0001), which persisted with partial (excluding infection site and microbial pathogen grouping) adjustment (p < 0.0001). Fully adjusted multivariate analysis showed significant variations in AKI only in relation to the anatomic source of infection, with non-pulmonary infections having higher risk than pulmonary infections. The pathogen group/pathogen had no significant independent impact on AKI. This study demonstrates that the presence of septic AKI varies significantly based on the site of infection but not the type of causative organism.

Le dosage plasmatique de Neutrophil Gelatinase-Associated Lipocalin (NGAL) prédit la défaillance rénale au cours du choc septique dès l’admission en réanimation

PurposeTo validate plasma Neutrophil Gelatinase-Associated Lipocalin (pNGAL) as an early biomarker in intensive care unit (ICU) for acute kidney injury (AKI) in critically ill adult with septic shock. Patients and methodFifty consecutive patients with septic shock were included in this observational cohort study. AKI was defined if patients met any RIFLE or AKIN criteria. The main objective was to evaluate diagnosis value of pNGAL measured with a point-of-care device at admission (D0), at 24hours (D1) and at 48hours (D2). ResultsAmong the 50 patients enrolled, 86% had AKI, 48% had persistent renal AKI and 30% required renal replacement therapy (RRT) during their ICU stay. At D0, pNGAL concentration was significantly higher in patients with AKI compared to patients without AKI (471ng/mL versus 134ng/mL, P<0.001). This level remained significantly higher in the AKI population at D1 and D2 and pNGAL concentration at D0 among AKI patients increased with kidney failure level. At D1, pNGAL was significantly higher for persistent renal AKI rather than transient prerenal (570ng/mL versus 337ng/mL, P=0.027). pNGAL concentration below 348ng/mL at D1 was never seen in patients with RRT. ConclusionPlasma NGAL is a useful, sensitive and early biomarker to predict persistent AKI in septic shock at ICU admission and help to discuss RRT.