Risk Of Acute Kidney Injury Research Articles

Acute kidney injury and outcomes in hospitalized children with autoimmune rheumatic disease

BackgroundAutoimmune rheumatic diseases (ARDs) in children can negatively impact renal function, potentially leading to acute kidney injury (AKI). This study compares the prevalence of AKI and other adverse in-hospital outcomes among hospitalized children with ARDs.MethodsA retrospective analysis was conducted using the United States Nationwide Inpatient Sample (NIS) database from 2005 to 2020. The study included children aged 1–17 years with ARDs, categorized into inflammatory arthritis, ANCA-associated vasculitis, systemic lupus erythematosus (SLE), systemic sclerosis (SSc), and other connective tissue diseases. Logistic regression assessed associations between ARD types and outcomes, including AKI, dialysis, and major adverse events.ResultsAmong 13,891 children with ARDs, 8.2% developed AKI and 1.3% required dialysis. Compared to inflammatory arthritis, ANCA-associated vasculitis significantly increased the risk of AKI (aOR = 11.20, 95% CI: 8.08–15.51) and dialysis (aOR = 40.60, 95% CI: 13.54-121.71). SLE also elevated risks of AKI (aOR = 4.16, 95% CI: 3.20–5.40) and dialysis (aOR = 11.34, 95% CI: 4.15–31.01). Children with SSc had increased risks of infection/pneumonia (aOR = 2.51, 95% CI: 1.84–3.41) and sepsis (aOR = 2.13, 95% CI: 1.26–3.58).ConclusionsChildren with ARDs, especially those with ANCA-associated vasculitis and SLE, face elevated risks of AKI and dialysis. These findings underscore the importance of vigilant monitoring and tailored management in this population.

External Validation of the Simple Postoperative Acute Kidney Injury Risk Index in Patients Admitted to the Intensive Care Unit After Noncardiac Surgery.

The Simple Postoperative AKI Risk (SPARK) index is a novel model for predicting risk of postoperative acute kidney injury (PO-AKI) among patients after noncardiac surgery. However, the performance of the index has been inconsistent partly due to heterogeneity in case mix and effects of the involved clinical features. To clarify potential reasons for poor performance, we tested the SPARK index in a cohort of high-risk patients requiring intensive care unit (ICU) care after noncardiac surgery and examined whether model modification by refitting coefficients of clinical features could optimize model performance. This was a single-center prospective cohort study. Preoperative variables of the SPARK index were extracted from electronic medical records. PO-AKI was defined by an increase in sCr ≥26.5 mmol/L within 48 hours or 150% compared with the preoperative baseline value within 7 days after surgery, whereas critical AKI was defined as AKI stage 2 or greater and/or any AKI connected to postoperative death or requiring renal replacement therapy during the hospital stay. Discrimination was evaluated by the area under the receiver operating characteristic curve (AUC), and calibration was evaluated by the Hosmer-Lemeshow χ2 test and calibration plot. Model modification was performed by rebuilding the model with the original variables of the SPARK index through proportional odds logistic regression among participants in the earlier study period and was validated in the later one. A total of 973 patients were enrolled, among whom 79 (8.1%) PO-AKI cases and 14 (1.4%) critical AKI cases occurred. Our study participants demonstrated a higher SPARK risk score than the SPARK discovery cohort (eg, 8.02% vs 1.20% allocated in the highest risk group), and the incidence of both outcomes increased through the classes of the score (incidence proportion of PO-AKI increased from 2.56% in the lowest risk group to 25.64% in the highest risk group). The AUCs for PO-AKI and critical AKI were 0.703 (95% confidence interval [CI], 0.641-0.765) and 0.699 (95% CI, 0.550-0.848), respectively. The sensitivity, specificity, negative predictive value and positive predictive value were 68.35%, 57.49%, 95.36%, and 12.44%, respectively, when using 10% of predicted probability of PO-AKI as threshold. Calibration plots suggested acceptable consistency between the predicted and actual risk. After model modification, external validation demonstrated a significantly improved AUC for PO-AKI. The SPARK index showed fair discrimination and calibration among patients admitted to the ICU after noncardiac surgery. Modification of the model improved the performance of the model in terms of predicting PO-AKI.

Association between the triglyceride–glucose index and the risk of acute kidney injury in critically ill patients with acute pancreatitis: a retrospective study

BackgroundThe triglyceride–glucose (TyG) index is increasingly recognized for its ability to predict cardiovascular and metabolic risks. This study investigated the correlation between the TyG index and the risk of acute kidney injury(AKI) in critical ill patients with acute pancreatitis(AP).MethodsThe Medical Information Mart for Intensive Care IV database was retrospectively searched to identify AP patients hospitalized in the intensive care unit. The primary outcome measure was the incidence of AKI. The secondary endpoint was in-hospital mortality and the rate of renal replacement therapy(RRT) use. Cox regression analysis and restricted cubic spline were used to analyze TyG index association with AKI risk. Kaplan–Meier survival analysis was performed to assess the incidence of endpoints in the different groups.ResultsA total of 848 patients were enrolled. The incidence of AKI was 61.56%.The in-hospital mortality was 11.69%. Kaplan–Meier analysis showed that the TyG index ≥ 8.78 group has a high incidence of AKI and high risk of requiring RRT (P < 0.001). Multivariable Cox regression analysis showed whether TyG index was a continuous variable (HR, 1.65 [95% CI 1.10–2.48], P = 0.015) or a categorical variable (HR, 1.72 [95% CI 1.09–2.79], P = 0.028), and the TyG index was independently associated with the risk of AKI in AP patients. The restricted cubic splines model illustrated the linear relationship between higher TyG index and increased risk of AKI in this specific patient population.ConclusionsHigh TyG index is an independent risk factor for AKI in critical ill patients with AP. Assessing the TyG index may be beneficial for early stratification and interventions to improve prognosis.

Associations of acute kidney injury with oral anticoagulants: a disproportionality analysis of the Food and Drug Administration Adverse Event Reporting System (FAERS) database

ABSTRACT Objective The FDA Adverse Event Reporting System (FAERS) was used to evaluate the associations between oral anticoagulants (OACs) and acute kidney injury (AKI). Methods Disproportionality analysis was applied to data in the FAERS database from January 2004 to December 2023 to detect adverse events (AEs) for various OACs. The adjusted reporting odds ratios (RORs) calculated using multiple logistic regression were used to explore the risk factors for OACs-associated AKI. Results The crude RORs for the associations of AKI with warfarin, rivaroxaban, dabigatran, apixaban, and edoxaban were 1.35, 2.14, 2.98, 1.33, and 3.56, respectively. The risk of OACs-associated AKI was affected by age and sex, being higher in those aged 65 years and males. The adjusted RORs for rivaroxaban, dabigatran, apixaban, and edoxaban were 1.26, 1.67, 0.65, and 2.06, respectively.Nearly 50% of AKI cases occurred within the first 2 months, and each OAC was of the early-failure type. Hospitalization and mortality rates for AKI patients after OACs were 45.53% and 22.98%, respectively. Conclusions The study revealed a strong association between AKI and OACs, emphasizing the need for regular renal function monitoring , especially in elderly male patients. Further in-depth research is needed to confirm these exploratory findings.

Volume of intraoperative normal saline versus lactated Ringer's solution on acute kidney injury: A secondary analysis of the SOLAR trial.

Evaluate whether intraoperative crystalloid volume modifies the relationship between the AKI risk and treatment group. Secondary analysis of a single-center multiple cross-over cluster trial. Intraoperative care. We enrolled 8616 adults who had colorectal or orthopedic surgery at a large academic institution. Clusters of patients were alternately assigned to intraoperative normal saline or lactated Ringer's solution. The primary outcome was the incidence of acute kidney injury (AKI) as a function of intraoperative crystalloid volume (0-1, 1-2, 3-4, or 4+ liters) and the type of crystalloid. Our secondary outcome was the change in postoperative serum chloride concentration during the first 24h. The risk of AKI did not differ significantly in patients given 0-1, 1-2, or 3-4L saline or lactated Ringers solutions. In contrast, patients given 2-3 or>4L of lactated Ringer's solution had a higher risk of AKI than those given saline. Patients assigned to normal saline had progressively greater plasma chloride concentrations than those given lactated Ringer's across all volume categories. While saline administration clearly causes volume-dependent hyperchloremia, we found no evidence to support the theory that large volumes of saline provoke AKI. Therefore, either fluid seems reasonable for intraoperative use.

Impact of intraoperative hypotension during laparoscopic liver resection on postoperative complications including acute kidney injury

Postoperative acute kidney injury is associated with an increase in hospital length of stay and mortality. Intraoperative hemodynamics and fluid management may contribute to acute kidney injury. The aim of this study is to evaluate the association between intraoperative duration of hypotension with adverse events after laparoscopic liver resection. A prospective cohort including adult patients undergoing laparoscopic liver resection between January 2010 and June 2022. Cumulative time below mean arterial blood pressure thresholds and association with major adverse events composing of postoperative acute kidney injury (≤2days) and complications (Dindo-Clavien ≥3a) ≤30days were assessed. In 360 patients, the median age was 61years, 206 (57%) were male, median body mass index was 26.3,and 129 (36%) patients had hepatocellular carcinoma. Acute kidney injury was recorded in 3(0.8%) patients as stage 1, 6 (1.7%) patients as stage 2, and 7 (1.9%) patients as stage 3. Major adverse events occurred in 31 (8.6%) patients, and the median estimated blood loss was 200mL. On continuous analysis, a threshold <60mmHg at ≥15minutes was found for major adverse events. The mean arterial blood pressure <55mmHg for ≥20minutes was associated with an increased risk of major adverse events (odds ratio 7.72; P < .001). In patients with >15minutes of mean arterial blood pressure <60mmHg, higher intravenous volume was associated with increase in major adverse events (P=.045), whereas adjusted intravenous volume was not associated with major adverse events (P=.657), acute kidney injury (P=.681), or blood loss (P=.875). Laparoscopic liver resection is a safe procedure with a low risk of acute kidney injury. After ≥15minutes at mean arterial blood pressure <60mmHg, the risk of major adverse events increases. Greater intravenous fluid infusion volume was associated with an observed risk for major adverse events, suggesting that mean arterial blood pressure should be managed by vasoactive agents.

WCN25-1158 Contrast-Associated Acute kidney Injury post coronary angiography, incidence, risk factors, and Clinical Outcomes in Omani Population

WCN25-1158 Contrast-Associated Acute kidney Injury post coronary angiography, incidence, risk factors, and Clinical Outcomes in Omani Population

Metabolomics based early warning model for acute kidney injury risk in patients exposed to diquat.

Acute kidney injury (AKI) is one of the most important indications of severe clinical symptoms in patients with diquat poisoning and is closely related to poor prognosis. However, current studies have rarely focused on early warnings of diquat-related AKI, which is not conducive to the treatment of patients with early clinical diquat poisoning. In this study, untargeted plasma metabolomics was employed to reveal the differences between diquat-poisoned patients with and without AKI, as well as between patients and healthy volunteers. The results showed that 48 metabolites were significantly changed in the patients, among which 3-hydroxybutyrylcarnitine, SAICAR, dodecanoic acid, and tetrahydrofolyl-[Glu](2) could be used to effectively differentiate the above three groups. Based on the ratios of the first two metabolites and the ratios of the last two metabolites, a decision tree model for the early warning of diquat-induced AKI was established with an accuracy rate of 88.7%. This model provides great support for accurate clinical diagnosis and intervention regarding the AKI risk of diquat-exposed patients.

Application of artificial intelligence and machine learning for risk stratification acute kidney injury among hematopoietic stem cell transplantation patients: PCRRTICONIC AI Initiative Group Meeting Proceedings.

Acute kidney injury (AKI) is a frequent, severe complication of hematopoietic stem cell transplantation (HSCT) and is associated with an increased risk of morbidity and mortality. Recent advances in artificial intelligence (AI) and machine learning (ML) have showcased their proficiency in predicting AKI, projecting disease progression, and accurately identifying underlying etiologies. This review examines the central aspects of AKI post-HSCT, veno-occlusive disease (VOD) in HSCT recipients, discusses present-day applications of artificial intelligence in AKI, and introduces a proposed ML framework for the early detection of AKI risk.

The Kinetics of Cystatin C and Serum Creatinine in Acute Kidney Injury.

Acute kidney injury (AKI) is a common condition affecting a significant portion of hospitalized and critically ill patients. Current AKI diagnosis relies on serum creatinine (sCr), which has several recognized limitations that impact the timely detection and response to AKI management. Serum cystatin C (sCys) has characteristics that can overcome the limitations of sCr, but head-to-head comparisons of these biomarkers is difficult to study prospectively. A quantitative assessment of the kinetics of sCys and sCr during AKI is necessary to support clinical workflow implementation for AKI diagnosis and management. A quantitative systems pharmacology (QSP) model was developed using MATLAB and Simbiology (The MathWorks, Natick, MA), to simulate the concentration-time profiles of sCr and sCys under varying degrees of AKI across a spectrum of baseline kidney function. The model incorporated parameters from existing literature and used a contemporary sCr and sCys GFR equation to assess the time to reach AKI diagnostic criteria for both biomarkers. The model demonstrated that sCys achieves steady-state concentration and meets AKI diagnostic thresholds significantly faster than sCr, with an advantage of six to 48 hours, depending on CKD stage. sCys exhibited greater sensitivity in detecting GFR reductions, with the ability to detect AKI within 12-24 hours post-AKI, compared to 12-72 hours for sCr. The study also identified that for sCys, absolute value diagnostic cutoffs are more effective than percentage-based thresholds and can provide consistent detection across different CKD stages. sCys has superior kinetics for early AKI detection compared to sCr, making it a valuable addition to AKI diagnostic protocols, particularly in high-risk populations. Daily monitoring of sCys in patients at risk for AKI would facilitate more timely detection and potentially improve clinical outcomes. Future research should focus on validating sCys diagnostic criteria and integrating it with other biomarkers to enhance AKI management.

Unilateral Ureterolithiasis Accompined By the Risk of Acute Kidney Injury: Case Report

Background: Urolithiasis is the condition of stone formation in the urinary tract, which remains a significant health issue worldwide. The incidence of cases is higher in men than women. Flank pain is the most common manifestation in patients with urolithiasis. The management of urolithiasis includes conservative treatment, lifestyle modifications, medication therapy, medical intervention, and surgical procedures. Complications of urolithiasis may include urinary tract infection and urinary tract obstruction, both of which have the potential to cause acute kidney injury. Case Report: A 36-year-old male presented with severe left flank pain (visual analogue scale 8) that had worsened since two days prior to hospital admission. The pain was continuous, non-radiating, and worsening. The complaint was accompanied by a burning sensation during urination, incomplete urination, and difficulty in passing urine. The patient also reported reddish and cloudy urine. Physical examination revealed tenderness in the left lumbar region and pain upon percussion of the left costovertebral angle (CVA). Hematologic tests showed leukocytosis, neutrophilia, elevated serum creatinine, and a decreased estimated glomerular filtration rate (eGFR). Routine urinalysis revealed increased white blood cells, red blood cells, and protein. A Urology Computed Tomography (CT) scan showed left ureterolithiasis at the L4 level, measuring 2.28 cm, along with hydroureter and grade IV hydronephrosis. An open left ureterolithotomy was performed based on medical indications and due to the limitations of urological facilities at our hospital. Conclusion: Flank pain is the most common manifestation in patients with urolithiasis. Early diagnosis of complications can improve the patient's prognosis. The management of urolithiasis depends on medical indications and can be adjusted according to available facilities.

Do novel antidiabetic therapies reduce the risk of contrast-associated acute kidney injury?

Do novel antidiabetic therapies reduce the risk of contrast-associated acute kidney injury?

Employing a Haemodynamic Score to Predict Acute Kidney Injury in Infants With Patent Ductus Arteriosus.

This study hypothesised that infants with a haemodynamically significant patent ductus arteriosus (hsPDA) as defined by a validated score have a higher incidence of acute kidney injury (AKI). A retrospective study was conducted including infants < 29 weeks' gestation, born at the Rotunda Hospital. The El-Khuffash patent ductus arteriosus (PDA) severity score was applied following an echocardiographic assessment. Mann Whitney-U and χ2 tests were utilised to assess for association with AKI. We report a cohort of n = 86 infants with PDA of a mean (standard deviation) gestation of 27 (1) weeks and birth weight of 957 g (235 g). Ten (11.6%) of infants developed AKI. Birth weight, gestation, death-by-discharge, high-risk PDA score, PDA treatment, and ibuprofen receipt were associated with AKI. The presence of a high-risk PDA score was independently associated with the occurrence of AKI. Therapeutic intervention and ibuprofen use proved significant in their associations with AKI. A high-risk El-Khuffash PDA score is predictive of AKI in our cohort. Ductal diameter in isolation is ineffective as a measure of haemodynamic significance in the context of AKI prediction. Both PDA treatment and ibuprofen-use are associated with an increased risk of AKI. Further work to validate the use of this score for AKI prediction is warranted.

P-1102. Real-World Effectiveness of Dalbavancin for Invasive Gram-Positive Bacterial Infections

Abstract Background Emerging data suggest dalbavancin (DAL) may be used in complicated infections including bacteremia, prosthetic joints, osteomyelitis, and endovascular infections. The purpose of this study was to evaluate the real-world effectiveness of DAL for the treatment of invasive gram-positive infections (GPIs). Methods This multicenter, retrospective cohort study included adult patients receiving DAL for treatment of confirmed/presumed invasive GPI between February 2021 and December 2023. Invasive infections included those requiring ≥ 4 weeks of therapy. Patients were excluded if they received DAL for chronic suppression. The intention to treat (ITT) population included patients who received ≥ 1 DAL dose; the per protocol (PP) population received ≥ 2 doses within 7 days of expected administration dates. The primary outcome was clinical failure in the PP group at 90 days post-treatment. Secondary outcomes were logistical failures, clinical failures, and treatment-emergent adverse events in the ITT group at 90 days post-treatment. Results The ITT population included 150 patients (mean age 50.2 years, 65% male, 35% obese, 41% illicit drug use); the PP population included 107 patients. The most common infectious syndrome was osteomyelitis (63.3%, 95/150); the most common pathogens were MRSA (38%, 57/150) and MSSA (37%, 44/150). The most common dosing regimen was 1500 mg on day 1, followed by 1500 mg on day 8 (90%, 96/150). Among the PP population with follow-up, 22% (19/87) experienced clinical failure at 90 days post-treatment. No factors were significantly associated with clinical failure. Logistical failure occurred in 17% (26/150). Results of univariate regression analyses showed receipt of first dose at an infusion center vs. inpatient setting significantly increased logistical failure (OR 4.53, 95% CI 1.62 – 16.17; P = 0.008) while blood-based infectious syndromes significantly decreased logistical failure (OR 0.26, 95% CI 0.06 – 0.82; P = 0.038). Receipt of vancomycin within 6 weeks of DAL significantly increased risk of acute kidney injury (OR 4.12, 95% CI 1.20 – 14.68; P = 0.024). Conclusion Dalbavancin is a safe and effective treatment option for invasive GPIs; however there are modifiable risk factors associated with secondary outcomes of logistical failure and toxicity. Disclosures Julie Ann Justo, PharmD, MS, FIDSA, BCPS, Shionogi: Advisor/Consultant Bruce M. Jones, Pharm.D., FIDSA, BCPS, AbbVie: Advisor/Consultant|AbbVie: Honoraria|Ferring: Honoraria|Innoviva: Honoraria|Paratek: Honoraria Bryan White, PharmD, BCPS, BCIDP, Melinta: Advisor/Consultant|Shionogi: Grant/Research Support Joseph Sassine, MD, Ansun BioPharma: Grant/Research Support|Cidara Therapeutics: Grant/Research Support|Community Infusion Solutions: Grant/Research Support|F2G: Grant/Research Support|Shionogi: Grant/Research Support

P-1234. Evaluation of Empirically Dosed Parenteral Vancomycin Using Weight-Based Versus Bayesian-Based Modeling

Abstract Background Vancomycin is an efficacious antibiotic in treating infections caused by Staphylococcus Aureus (including MRSA), streptococci, and enterococci. Intravenous administration of vancomycin requires close monitoring to optimize safety and efficacy. As per ASHP/IDSA/SIDP guidelines, an empiric maintenance dose of 15-20 mg/kg (based on actual body weight) administered every 8-12 hours (based on normal renal function) with a target AUC of 400-600 is recommended for most adults. Given the lack of data comparing empiric Bayesian modeling to weight-based dosing of vancomycin, our study aims to evaluate the relationship between these two regimens. Methods This is an IRB approved retrospective cohort study conducted at One Brooklyn Health Brookdale. A random sample of non-critically ill hospitalized patients aged 18 or older who have been treated with empirically dosed vancomycin (15-20 mg/kg) administered at the recommended frequency for suspected or documented infections between January 1, 2023 and December 31, 2023 will be included. Patients will be excluded if they have acute kidney injury (AKI), are on hemodialysis, or have a BMI &amp;gt;30 kg/m2. Pertinent patient data will be collected such as patient demographics, laboratory values and etc. Statistical analysis will be conducted using SAS statistical software. Results A total of 97 patients met inclusion criteria. Primary outcome was defined as the difference in numbers of patients achieving AUC 400-600 using empiric weight-based versus Bayesian modeling dosing. Patients were about 26% more likely to have a therapeutic AUC when being dosed on a weight-based regimen. Secondary outcomes looked at the correlation between weight and weight-based dosing and Bayesian modeling dosing in terms of subtherapeutic or supratherapeutic AUC and found that there was no association. Safety outcome was defined as the difference in number of patients at an increased risk of AKI (AUC &amp;gt; 650) using empiric weight-based versus Bayesian modeling dosing. Patients were 50% less likely to be at an increased risk of AKI when being dosed on the weight-based regimen. Conclusion Bayesian-based modeling for empiric dosing was associated with higher rates of supra-therapeutic AUC and individuals were at a higher risk of getting AKI. Disclosures All Authors: No reported disclosures

P-1250. Pharmacokinetic Evaluation of Colistin Methanesulfonate in Critically Ill Patients: Implications for Clinical Management

Abstract Background The study aims to assess the pharmacokinetics of colistin methanesulfonate (CMS) and colistin, and its impact on clinical outcomes, particularly clinical cure (CC), and the development of acute kidney injury (AKI) in critically ill patients with normal baseline renal function. Methods This prospective observational study focuses on adult critically ill patients with MDR/XDR infections treated with intravenous CMS. Patients receive a loading dose (LD) of 9 MU followed by a maintenance dose (MD) of 3 MU every 8 hours. Pharmacokinetic (PK) sampling occurs pre- and post-LD, and during MD. Colistin plasma levels are quantified using liquid chromatography–mass spectrometry (LC–MS). Clinical outcomes, including clinical cure, impact on renal failure and mortality, are assessed. Results A total of 144 serum samples were analyzed from the 12 patients, with 60% having pneumonia. Predominant pathogens were Klebsiella pneumoniae (7) and Acinetobacter spp. (5). The mean estimated creatinine clearance (CrCl) was 120 ± 22 mL/minute (range: 75.4–215.2). All patients received combination therapy, with 80% receiving meropenem and 40% receiving tigecycline. The clinical cure rate was 50% (6/12), with a mortality rate of 25% (3/12). The mean LD colistin Cmax was 3.1 ± 1.2 mg/L (range: 1.6–5.5) and 2.4 ± 1.3 mg/L (range: 1.4–5.8) among the CC and CF groups, respectively (P = 0.14). MD colistin Css avg was 2.3 ± 1.4 mg/L and 1.8 ± 1.2 mg/L in CC and CF groups, respectively. The mean AUC0–24/MIC ratio of MD colistin was 94.3 ± 68.2 and 78.1 ± 53.6 for CC and CF groups, respectively (P = 0.28). In pneumonia, AUC0–24/MIC for Acinetobacter spp. was higher in the CC (72.1 ± 11.3) than in the CF group (41.5 ± 15.8) (P = 0.06). Renal injury was observed in 40% (5/12) of patients at the end of therapy, with acute kidney injury (AKI) being the most common complication. Additionally, a subset of patients (n = 3) demonstrated evidence of chronic kidney disease (CKD) progression, highlighting the nephrotoxic potential of colistin therapy. Conclusion The findings underscore the importance of therapeutic drug monitoring in optimizing colistin therapy and the necessity for vigilant monitoring of renal function to mitigate the risk of AKI and CKD progression. Disclosures All Authors: No reported disclosures

Acute Kidney Injury, Renal Replacement Therapy, and Extracorporeal Membrane Oxygenation Treatment During the COVID-19 Pandemic: Single-Center Experience

Background and Objectives: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) was described in December 2019 for the first time, and it was responsible for a global pandemic. An alarming number of patients with coronavirus disease 2019 (COVID-19) also developed acute kidney injury (AKI), especially those who required extracorporeal membrane oxygenation (ECMO) therapy for acute respiratory distress syndrome (ARDS). The aim of our retrospective observational study was to assess the prognostic significance of AKI in these patients. This study observed, in COVID-19 patients admitted to an intensive care unit (ICU), AKI stages and the need for renal replacement therapy (RRT), assessing the risk factors and outcomes. Moreover, we evaluated the mortality rate of patients treated by ECMO. Materials and Methods: Between November 2020 and December 2022, among 396 patients admitted to our intensive care unit (ICU) diagnosed with SARS-CoV-2 infection, we selected patients with severe ARDS requiring veno-venous (vv) ECMO support and AKI. Results: The 30-day mortality after ECMO positioning was 85.7%. A Cox regression revealed a significant advantage for RRT with a high cut-off (HCO) hemofilter both for ICU mortality (HR 0.17 [95% CI: 0.031–0.935], p = 0.035) and 15 day-mortality after the start of vv-ECMO (HR 0.13 [95%CI: 0.024–0.741], p= 0.021), whereas the early onset of vasoplegic shock after ECMO implantation indicated a higher risk of death (HR 11.55 [95% CI: 1.117–119.567], p = 0.04) during the ICU stay. Conclusions: COVID-19 induces a high risk of AKI and RRT. In our cohort, hypertension, pre-existing renal disease, and mechanical ventilation represented independent risk factors for AKI. Patients requiring ECMO support had a high mortality rate. The early implementation of RRT reduced the risk of death during the ICU stay.

Impact of vancomycin area under the curve in early or later phase on efficacy and nephrotoxicity in patients with enterococcal bloodstream infections: a multicenter study

BackgroundThe optimal pharmacokinetic and pharmacodynamic (PK/PD) parameters of vancomycin that can improve outcomes in enterococcal infections remain controversial. To clarify the therapeutic target for this antibiotic, this study aimed to determine vancomycin PK/PD parameters associated with efficacy in the early (during 72 h) or later (after 72 h) phase of treatment and nephrotoxicity in enterococcal bloodstream infection patients.MethodsThis multicenter retrospective study reviewed medical records of patients with enterococcal bloodstream infections treated with intravenous vancomycin infusion for at least 72 h between January 2016 and March 2024 at Phramongkutklao Hospital or Nopparatrajathanee Hospital in Bangkok, and Rachaburi Hospital in Rachaburi Province, Thailand. Patients with data available on serum vancomycin concentration were analyzed. The primary outcomes were 30-day mortality and acute kidney injury. The estimates of the mean 24-h area under the curve in the first 72 h (AUC24) and in steady state (AUCss) were determined by Bayesian theorem.ResultsOverall, 201 vancomycin concentrations were measured within the first 72 h after vancomycin treatment, while 156 were in a steady state (> 72 h). According to Classification and Regression Tree analysis, vancomycin AUC at 420 mg·h/l was the PK/PD target for 30-day mortality. Results reveal that patients with AUC24 (early phase) and AUCss < 420 mg·h/l (later phase) had significantly higher 14-day, 30-day, and in-hospital mortality than AUC ≥ 420 mg·h/l groups. In addition, patients with AUC24 ≥ 420 mg·h/l in the early phase had significantly reduced microbiological failure (p = 0.004). Patients with AUC ≥ 700 mg·h/l in early and later phases had significantly increased acute kidney injury risk. In addition, patients receiving concomitant nephrotoxic drugs had an AUC cutoff value of 650 mg·h/l. Multivariate Cox regression analysis showed that vancomycin AUCss < 420 mg·h/l, unknown source of bacteremia, and acute kidney injury were significantly associated with 30-day mortality.ConclusionsAUC 420–650 mg·h/l in early and later phases was the target of vancomycin’s PK/PD in enterococcal bacteremia patients for efficacy and to prevent acute kidney injury. This study suggests close monitoring of vancomycin levels to ensure efficacy and safety.

Therapeutic drug monitoring versus Bayesian AUC-based dosing for vancomycin in routine practice: a cost-benefit analysis.

AUC-based dosing with validated Bayesian software is recommended as a good approach to guide bedside vancomycin dosing. To compare treatment and vancomycin-associated acute kidney injury (AKI) costs between Bayesian AUC-based dosing and conventional therapeutic drug monitoring (TDM) using steady-state plasma concentrations of vancomycin administered as continuous infusion in hospitalized non-critically ill patients with severe Gram-positive infection. A cost-benefit analysis presented as a return on investment (ROI) analysis from a hospital perspective was conducted using a decision tree model (TDM versus AUC-based dosing) to simulate treatment cost (personnel, serum sampling and drug cost), vancomycin-associated AKI risk and cost up to 14 days. ROI was calculated against AUC-based software cost. One-way and probabilistic sensitivity analyses (respectively OWSA and PSA) were performed to check for robustness. In base case, an overall cost per patient of €621.0 with TDM and €543.6 with AUC-based dosing resulted in a treatment saving of €77.4 per patient when applying AUC-based dosing. This saving against the software cost (€26.9/patient) generated an ROI per patient of €1.9 per invested € in software [€1.9 (95% CI 1.6-2.2) in PSA]. Enrolling 900 AUC-based dosed patients annually translated to a net saving of €45 469. Software break-even was reached after 313 patients. In OWSA, a higher AKI risk with TDM strongly contributed to a positive ROI. AUC-based dosing appeared a cost-saving strategy compared with conventional TDM when applying base-case settings of vancomycin-associated AKI risk, treatment and AKI costs.

Risk of acute kidney injury following repeated contrast exposure in trauma patients.

This study investigates the risk of contrast-associated acute kidney injury (CA-AKI) in trauma patients, focusing on the impact of cumulative contrast medium doses. A retrospective review was conducted at a level 1 trauma center (2019-2021). The study included patients who underwent intravascular contrast-enhanced examinations for torso trauma within 7 days post-injury. The total contrast medium volume within 7 days was calculated. Multivariate logistic regression (MLR) identified AKI risk factors. Among the 264 patients, 7.2% (19/264) developed AKI, with 3.4% (9/264) classified as KDIGO stage 3. Approximately 42.8% of patients underwent at least two contrast-enhanced examinations. The mean total contrast medium given was 129.5mL (range 80-410ml). Multiple logistic regression (MLR) analysis identified four independent risk factors for AKI: diabetes mellitus, initial eGFR < 30, use of inotropic agents, and contrast medium exposure. The odds ratio of AKI increased by 2.92 (95% CI 1.30-6.53) for every 100ml increase in contrast dose. The contrast volume exposure only plays an important role in severe trauma patients (ISS ≥ 25). Moreover, when correlated with eGFR, the contrast medium exposure volume demonstrated better predictive ability for AKI with a best cut-off value of Contrast volume to eGFR ratio > 1.86. While repetitive contrast-enhanced examinations are sometimes inevitable, they do come with costs. The CA-AKI risk increases as the amount of contrast medium accumulates in trauma patients who require repetitive examinations.