AKI Episodes Research Articles

Intensive care unit continuous kidney replacement therapy: time to change dosage recommendations?

Continuous kidney replacement therapy (CKRT) is the predominant form of acute kidney support used for hemodynamically unstable adult ICU patients with severe AKI (KDIGO stage 3). The success of CKRT depends on the achieved doses. Practice patterns worldwide are highly variable. A contemporary understanding of treatment adequacy is essential. The KDIGO AKI clinical guidelines recommend delivering effluent volumes of 20-25ml/kg/hour for CKRT in the ICU setting, with the caveat that higher prescribed doses (25-30ml(kg/h) may be necessary to achieve adequate delivered CKRT doses. The reference landmark trials provide definitive evidence that increases of delivered CKRT doses beyond the recommended dose are not beneficial for unselected ICU patients with severe AKI. However, the minimum delivered CKRT intensity at which underdosing becomes harmful remains unknown. The answer to this question has clinical relevance (dosing of critically ill patients with obesity or Covid-19 disease, minimizing adverse effects of CKRT) and a relevant impact on the costs of CKRT. The delivered dose of CKRT for Japanese ICU patients with severe AKI has been generally smaller (median 15ml/h/kg) than the recommended delivered KDIGO dose. The most recently published retrospective cohort study by Okamoto et al. demonstrated that low delivered CKRT doses were associated with a higher mortality among critically ill patients with severe AKI. These data challenge the nation-wide accepted hypothesis that a lower limit of delivered CKRT (< 20ml/ kg/h) may adequately control uremia/volume overload. Thus, there is an unmet clinical need for prospective randomized trials defining the minimal effective dose of CKRT. Given the dynamic nature of the precipitating critical illness and the natural course of most episodes of AKI, CKRT dose targets are likely to vary. Doses should be tailored to the needs of the individual patient within the limits of the KDIGO guideline recommendations. The Japanese experience with low-dose CKRT is not practice changing.

Rifaximin alone vs combination with norfloxacin for secondary prophylaxis of spontaneous bacterial peritonitis with hepatic encephalopathy: randomized controlled trial

BackgroundIn liver cirrhosis, events of spontaneous bacterial peritonitis (SBP) and hepatic encephalopathy (HE) portend a poor prognosis. Gut dysbiosis remains a common pathogenetic mechanism for both SBP and HE. Recent data suggests the role of rifaximin in gut modulation and improving intestinal dysbiosis. Due to emergence of multidrug-resistant organisms, gut-selective antibiotics with minimal systemic effects are warranted for secondary prophylaxis in patients of cirrhosis. We compared rifaximin alone vs combination with norfloxacin for secondary prophylaxis of patients of cirrhosis presenting with SBP and HE. This was a prospective, open-label, RCT which included all patients of cirrhosis with SBP and HE on admission. On discharge, in addition to standard medical treatment, patients were randomized to rifaximin 400 mg three times a day (group I) and rifaximin 400 mg three times a day with norfloxacin 400 mg once a day (group II) as a secondary prophylaxis of SBP. Primary outcomes were recurrent episodes of SBP and HE at 6 months and 28-day, 90-day, and 6-month mortalities. Secondary outcomes included number of rehospitalizations, episodes of upper gastrointestinal bleed, new acute kidney injury episodes, and change in Child–Turcotte–Pugh (CTP) and model for end-stage liver disease (MELD) scores over next 6 months.ResultsAfter screening 87 patients of cirrhosis with SBP and HE, 12 patients had in-hospital mortality and another 25 were excluded, one patient was lost to follow-up, and, finally, 49 patients were randomized into group I (n = 24) and group II (n = 25). The HE was grade 2 (18 vs 16) and grade 3 (6 vs 9) in groups I and II respectively. Primary outcomes as recurrent SBP (3 vs 2; P = 0.67); recurrent HE at 6 months (5 vs 2; P = 0.24); and 28-day (2 vs 2; P = 1.0) and 90-day mortality (4 vs 3; P = 0.72) and 6-month mortality (6 vs 8, P = 0.52) were comparable between two groups respectively. Secondary outcomes as number of rehospitalizations (3 vs 8, P = 0.07), new episodes of UGI bleed (2 vs 3, P = 0.1), new AKI episodes (4 vs 1, P = 0.06), ∆CTP (− 4 vs − 4), and ∆MELD (− 9 vs − 8) over the next 6 months were not significantly different between two groups respectively.ConclusionsRifaximin was effective in secondary prevention of both SBP and HE in patients of cirrhosis.Trial registrationThe randomized controlled trial was registered in CTRI/2021/09/036321 dated September 7, 2021.

An Unusual Case of Relapsing and Remitting Acute Kidney Injury

Paroxysmal nocturnal haemoglobinuria (PNH), although a rare type of acquired hemolytic anemia, can be life-threatening if not diagnosed early. Kidney involvement in PNH varies from reversible acute kidney injury to irreversible chronic damage. Here, we report a case of recurrent acute kidney injury in a young male requiring renal replacement support. Repeated history of AKI with coombs negative hemolytic anemia led us to perform PNH profile after ruling out other causes. Although kidney involvement in PNH is not apparent, this case shows the importance of having a high index of suspicion which will help in preventing further episodes of AKI and thus, chronic kidney disease burden.

A National audit of the care of patients with acute kidney injury in England and Wales in 2019 and the association with patient outcomes

BackgroundAcute kidney injury (AKI) is a common complication of hospitalisations. This national audit assessed the care received by patients with AKI in hospital Trusts in England and Wales. MethodsTwenty four hospital Trusts across England and Wales took part. Patients with AKI stage2/3 were identified using the UK Renal Registry AKI master patient index. Data was returned through a secure portal with linkage to hospital episode statistic mortality and hospitalisation data. Completion rates of AKI care standards and regional variations in care were established. Results989 AKI episodes were included in the analyses. In-hospital 30-day mortality was 31-33.1% (AKI 2/3). Standard AKI interventions were completed in >80% of episodes. Significant inter-hospital variation remained in attainment of AKI care standards after adjustment for age and sex. Recording of urinalysis (41.9%) and timely imaging (37.2%) were low. Information on discharge summaries relating to medication changes/re-commencement and follow-up blood tests associated with reduced mortality. No quality indicators relating to clinical management associated with mortality. Better communication on discharge summaries associated with reduced mortality. ConclusionsOutcomes for patients with AKI in hospital remain poor. Regional variation in care exists. Work is needed to assess whether improving and standardising care improves patient outcomes.

Incidence, Risk Factors, and Outcomes Associated With Recurrent Neonatal Acute Kidney Injury in the AWAKEN Study

The incidence and associated outcomes of recurrent acute kidney injury (rAKI) in neonates remain largely unknown. To determine the incidence, risk factors, and clinical outcomes associated with rAKI in critically ill neonates. This cohort study was a secondary analysis of the multicenter, international Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates retrospective study. Comparisons were made among neonates with no AKI, a single AKI episode (sAKI), and rAKI. All neonates younger than 14 days who were admitted between January 1 and March 31, 2014, to 24 participating level II to IV neonatal intensive care units and received intravenous fluids for at least 48 hours were considered for inclusion. Neonates with congenital heart disease requiring surgery within the first week of life, lethal chromosomal anomalies, death within 48 hours of admission, or severe congenital kidney abnormalities were excluded. Data were analyzed from May 23, 2022, to December 8, 2023. Recurrent AKI using the neonatal Kidney Disease: Improving Global Outcomes criteria. Determination of each rAKI required a complete return to the baseline serum creatinine level that defined the prior AKI episode. Incidence and risk factors of rAKI and associations of rAKI with length of stay (LOS; ie, birth to hospital discharge) and mortality. The study cohort (n = 2162) included 1233 male neonates (57.0%). Gestational age distribution was less than 29 weeks for 276 neonates (12.8%), 29 to less than 36 weeks for 958 (44.3%), and 36 weeks or older for 928 (42.9%). Of 605 neonates with AKI, 133 (22.0%) developed rAKI with risk factors including younger gestational age, lower birthweight, and higher stage of initial AKI. Infants with rAKI experienced longer median LOS (no AKI, 17 [IQR, 8-34] days; sAKI, 18 [IQR, 9-45] days; rAKI, 60 [IQR, 25-109] days; P < .001). Time-varying Cox proportional hazards regression models suggest rAKI is independently associated with a lower hazard of discharge (adjusted hazard ratio, 0.7 [95% CI, 0.6-0.9]; P = .01) when compared with sAKI, but mortality did not differ between groups (adjusted hazard ratio, 1.4 [95% CI, 0.6-3.0]; P = .44). In this cohort study, neonatal rAKI was independently associated with longer LOS when compared with sAKI, suggesting that rAKI in neonates may be an important clinical distinction warranting further study and careful monitoring after an initial AKI episode.

Associations between abrupt transition, dialysis-requiring AKI, and early mortality in ESKD among U.S. veterans

BackgroundMortality is high within the first few months of starting chronic dialysis. Pre-ESKD trajectory of kidney function has been shown to be predictive of early death after dialysis initiation. We aim to better understand how two key aspects of pre-dialysis kidney function—an abrupt transition pattern and an episode of dialysis-requiring AKI (AKI-D) leading directly to ESKD—are associated with early mortality after dialysis initiation.MethodsWe extracted national data from U.S. Veterans Health Administration cross-linked with the United States Renal Data System (USRDS) to identify patients who initiated hemodialysis during 2009–2013. We defined abrupt transition as having a mean outpatient eGFR ≥ 30 ml/min/1.73m2 within 1 year prior to ESKD. AKI-D was identified using inpatient serum creatinine measurements (serum Cr increase by at least 50% from baseline) along with billing codes for inpatient receipt of dialysis for AKI within 30 days prior to the ESKD start date. We used multivariable proportional hazards models to examine the association between patterns of kidney function prior to ESKD and all-cause mortality within 90 days after ESKD.ResultsTwenty-two thousand eight hundred fifteen patients were identified in the final analytic cohort of Veterans who initiated hemodialysis and entered the USRDS. We defined five patterns of kidney function decline. Most (68%) patients (N = 15,484) did not have abrupt transition and did not suffer an episode of AKI-D prior to ESKD (reference group). The remaining groups had abrupt transition, AKI-D, or both. Patients who had an abrupt transition with (N = 503) or without (N = 3611) AKI-D had the highest risk of early mortality after ESKD onset after adjustment for demographics and comorbidities (adjusted HR 2.10, 95% CI 1.66–2.65 for abrupt transition with AKI-D; adjusted HR 2.10, 95% CI 1.90–2.33 for abrupt transition without AKI-D). In contrast, patients who experienced AKI-D without an abrupt transition pattern (N = 2141 had only a modestly higher risk of early death (adjusted HR 1.19, 95% CI 1.01–1.40).ConclusionsAn abrupt decline in kidney function within 1 year prior to ESKD occurred in nearly 1 in 5 incident hemodialysis patients (18%) in this national cohort of Veterans and was strongly associated with higher early mortality after ESKD onset.

“Post-renal acute kidney injury in patients with cancer: Clinical presentation and kidney and patient outcomes”

Background: Post-renal acute kidney injury (PR–AKI) is frequent in patients with cancer requiring emergent intervention. With our study we aimed to describe the clinical features and prognostic factors for kidney and overall survival (OS) in cancer patients with PR–AKI. Methods: This is a single-center retrospective study that included 306 cancer patients with PR–AKI admitted from January 2011 to December 2021. Previous kidney function, AKI episode, and progression to end-stage kidney disease (ESKD) were compared. Kaplan Meier and Cox proportional regression methods were used for survival analyses. Results: The most frequent type of malignancy was the prostate (52, 17%) followed by the uterus (50, 16.3%). The mean baseline eGFR was 62 ml/min/1.73 m2. AKI stage 3 was present in 157 patients (51.3%) and renal replacement therapy (RRT) was performed in 19 patients (6%). At discharge, 197 patients (64.4%) had a quick recovery, and during follow-up 8 (2.6%) patients progressed to ESKD. The risk factors associated with ESKD were previous decreased kidney function (eGFR&lt;30 ml min 1.73m2) (HR 33.275, [95% CI, 3.997–277.002], p = 0.001); glomerular disease, (HR 8.353, [95%CI, 1.022–68.279], p=0.048); concomitant prerenal AKI (HR 5.670, [95% CI, 1.143–28.131], p = 0.034); and need of RRT (HR 19.519, [95% CI, 4.871–78.215], p &lt; 0.001). Median OS was 6 months (IQR 1–24 months). We found differences in the global survival over 60 months, with longtime survivors including patients with Bricker (42.6% vs16.4%) and genito-urinary cancer (27.6% vs 11.7%). Gastric cancer (HR 2.943, [95%CI, 1.837–4.714], p&lt;0.001), metastatic disease (HR 1.913, [95%CI, 1.464–2.499], p &lt; 0.001), and direct tumoral invasion (HR 1.519, [95%CI, 1.115–2.070], p = 0.008) were related with a decreased survival. Conclusions: Gastric cancer, metastatic disease, and direct tumoral invasion were predictors of short survival. The main predictors of evolution to ESKD were previous kidney function, concomitant glomerular disease, and the need for RT.

Risk of de novo proteinuria following hospitalization with acute kidney injury

BackgroundAcute Kidney Injury (AKI) incidence has continued to rise and is recognized as a major risk factor for kidney disease progression and cardiovascular complications. Early recognition of factors associated with post-AKI complications is fundamental to stratifying patients that could benefit from closer follow-up and management after an episode of AKI. Recent studies have shown that proteinuria is a prevalent sequela after AKI and a strong predictor of complications post-AKI. This study aims to evaluate the frequency and timing of the development of de-novo proteinuria after an AKI episode in patients with known kidney function and no prior history of proteinuria.MethodsWe retrospectively analyzed data from adult AKI patients with pre- and post-kidney function information between Jan 2014 and March 2019. The presence of proteinuria determined before and after index AKI encounter was based on ICD-10 code and/or urine dipstick and UPCR during the follow-up period.ResultsOf 9697 admissions with AKI diagnoses between Jan 2014 and March 2019, 2120 eligible patients with at least one assessment of Scr and proteinuria before AKI index admission were included in the analysis. The median age was 64 (IQR 54–75) years, and 57% were male. 58% (n-1712) patients had stage 1 AKI, 19% (n = 567) stage 2 AKI, and 22% (n = 650) developed stage 3 AKI. De novo proteinúria was found in 62% (n = 472) of patients and was already present by 90 days post-AKI in 59% (209/354). After adjusting for age and comorbidities, severe AKI (stage 2/3 AKI) and diabetes, were independently associated with increased risk for De novo proteinuria.ConclusionSevere AKI is an independent risk factor for subsequent de novo proteinuria post-hospitalization. Further prospective studies are needed to determine whether strategies to detect AKI patients at risk of proteinuria and early therapeutics to modify proteinuria can delay the progression of kidney disease.

#4185 EPISODES OF AKI FOLLOWING HOSPITALISATION AND ASSOCIATION WITH ADVERSE OUTCOMES: ANALYSIS FROM A PROSPECTIVE COHORT STUDY

Abstract Background and Aims AKI is associated with adverse long-term outcomes, including mortality, cardiovascular events and CKD development and progression. Individuals who have sustained AKI are at increased risk of developing further AKI. This analysis presents the association of long-term risk related to recent and further episodes of AKI in a prospective cohort of recently hospitalised individuals. Method Two matched cohorts of hospitalised individuals who had survived to at least 90 days after hospital discharge were recruited. The cohorts consisted of people who had sustained AKI during hospital admission (exposed group), and those who had not (non-exposed group), and were matched 1:1 for age, baseline eGFR stage and diabetes. Renal function, albuminuria and new AKI episodes were measured at 3 months, one, three and five years after index hospitalisation. Mortality, further AKI episodes and episodes of heart failure were recorded. Kidney disease progression was defined as decrease in eGFR of ≥25% associated with a decline in eGFR stage. Multivariable analysis was performed with binary logistic regression to assess the associations between repeated AKI episodes and outcomes. Results 866 exposed and non-exposed participants were recruited and successfully matched. Over the 5-year follow-up period, 138 (34%) participants in the exposed group had ≥1 further AKI compared with 67 (16%) in the non-exposed group (OR 2.71 [95% CI 1.94 to 3.77]; p&amp;lt;0.001). Independent associations with developing AKI during the follow-up period were AKI during index admission, baseline eGFR, albuminuria at 3 months and smoking status. Binary logistic regression, including all matched participants, showed that AKI during follow-up was independently associated with 5-year kidney disease progression (adjusted OR 2.49, 95% CI 1.42-4.37, p = 0.002), mortality (adjusted OR 3.076 95% CI 2.039-4.639 p&amp;lt;0.001) and episodes of heart failure (adjusted OR 5.234 95% CI 3.355-8.164, p&amp;lt;0.001). There was an additive effect, with the frequency of adverse outcomes increasing as number of AKI exposures increased (Table 1). Exposure to AKI during index admission or follow-up episodes conferred similar risk of kidney disease progression. AKI during the follow-up period had a stronger association with mortality and heart failure episodes than AKI during the index admission in this survivor cohort. Conclusion Previous AKI episodes were associated with increased frequency of future AKI episodes. AKI episodes during follow up period were independently associated with adverse outcomes regardless of AKI exposure during index hospitalisation. Increasing number of exposures to AKI had an additive effect on the proportion of individuals showing kidney disease progression, mortality and heart failure episodes. In this cohort of AKI survivors, AKI during the follow-up period had a stronger association with these outcomes than exposure to AKI during the index admission. A strategy for improving long-term outcomes in AKI survivors may be improving the identification of those at greatest risk of future AKI and strategies to prevent or optimise early detection and management.

#4792 SECOND, THIRD, AND MORE HITS: IMPACT OF SUCCESSIVE AKI EPISODES ON CKD PROGRESSION AND AKI TO CKD TRANSITION

Abstract Background and Aims The second hit theory refers to the link between two or more deleterious events that cause AKI simultaneously (e.g., triple whammy) or successively (e.g., cardiac surgery after coronary angiography). We investigated the effect of 3 or more consecutive AKI episodes on baseline serum creatinine (SCr) and if these changes leaded to AKI to CKD transition (Transition), CKD progression (Progression) or stable SCr. Method Retrospective study of patients with AKI attended by nephrology during a 3-year period. AKI severity was categorized by KDIGO criteria. We searched for patient's successive admissions and if suffered a new AKI episode and included all patients with ≥3 AKI episodes during the study period. We analyzed the baseline SCr for every episode and investigated if serial AKI episodes leaded to incident CKD, Progression, or no changes in SCr. Results 144 individuals that suffered 525 AKI episodes were included. We observed 36 patients in the Transition, 70 in the Progression group, and 38 didn't vary their SCr. We found no statistically significant differences in hypertension, DM, Charlson's Index, admission to ICU, severity of AKI or length of stay between groups. See Table 1A. We found that progressors had shorter time to nephrology consultation, they were more prone to receive acute HD and to be dialysis dependent at discharge. With no difference in the mortality rate between groups. See Table 1B. Figure 1 plots baseline SCr of every episode that shows a trend to incremental cyphers. Conclusion In our study the clinical characteristics between Transition and Progression groups were similar. We observed more individuals in the Progression group and their time to nephrology consultation was significantly shorter, maybe because no nephrology specialists are afraid of managing CKD patients. Patients that progressed needed acute HD more frequently and were more dialysis dependent at discharge, this finding could be explained by their diminished renal reserve, with no differences in the rate of in-hospital mortality. Successive AKI episodes portend a higher risk of adverse clinical outcomes, with excessive burden for patients with previous CKD. New AKI therapies could change the course of these ominous outcomes? This issue is under intense investigation, but it is very difficult to translate bench to bedside. Therefore, now we can only count on prevention and timely nephrological attention.

#4613 PREVALENCE OF DKD RAPID PROGRESSION IN TYPE 2 DIABETES IN A DEVELOPING COUNTRY AND ITS CLINICAL PREDICTORS: A SINGLE CENTERED RETROSPECTIVE STUDY

Abstract Background and Aims A significant proportion of diabetic kidney patients experience a rapid decline in GFR, leading to ESRD within months. Although there is a large number of studies on DKD, at present, there is a lack of well-controlled long follow-up studies to assess the burden of rapid progression, distinguishing the clinical profile of rapid progressors from non-progressors and its predictors. Identifying independent risk factors that contribute specifically to rapid progression is essential to prevent end-stage renal disease. Here we conducted a retrospective, hospital-based cohort study aimed to assess the prevalence, clinical profile, and clinical predictors for the rapid progression of DKD in type 2 DM. Method Type 2 DKD patients attending tertiary care hospital in South India were involved between January 2018 and 2022. CKD5 and those without minimum 6 months follow-up were excluded. Patients were followed up for 3.5 years. A sustained decline of eGFR &amp;gt;10 mL/1.73 m2/year was defined as rapid progressors. Patients were categorized into rapid and non-rapid progressors. Clinical profiles, micro-macrovascular complications, cardiovascular events, and other risk factors for rapid progression were studied. Data were analyzed using SPSS22 Results In a median follow-up of 3.5 years, 220(61.3%) were rapidly progressed with median eGFR decline 12ml/1.73 m2/year(IQR 8.5-19.3), and 139(38.7%) were non-rapid progressors with median eGFR decline 1.6ml/1.73 m2(IQR-0-3.3).The baseline characteristics were given in Table 1. The presence of hypertension, proteinuria, diabetic retinopathy, and cardiovascular events (p-0.01) was higher in rapid progressors than non-progressors.On logistic regression analysis, independent predictors of rapid progression were proteinuria (OR4.7;95%CI(2.24-9.88); P = .001), diabetic retinopathy(OR 0.24; 95% CI(0.11-0.52); P = .001), and AKI episodes(OR 2.18;95% CI (1.28-3.71); P = .003) (Table 2). Conclusion The majority of type 2 DKD patients in our setting are rapid progressors. The higher degree of baseline proteinuria, presence of diabetic retinopathy, and AKI episodes were found independently associated with clinical predictors of progression.

Cyclic neutropenia and concomitant IgA nephropathy: a case report

BackgroundIgA nephropathy (IgAN) is universally recognized as one of the most common primary glomerular diseases in all ages. Cyclic neutropenia (CN) is a rare haematologic disorder that is associated with mutations of the ELANE gene. The co-occurrence of IgAN and CN is extremely rare. This is the first case report of a patient with IgAN and genetically confirmed CN.Case presentationWe report a case of a 10-year-old boy who presented with recurrent viral upper respiratory tract infections accompanied by several episodes of febrile neutropenia, haematuria, proteinuria and acute kidney injury. Upon first admission, his physical examination was unremarkable. His kidney function was impaired, whereas his urine microscopy showed evidence of macroscopic haematuria and proteinuria. Further workup showed elevated IgA. The renal histology was consistent with mesangial and endocapillary hypercellularity with mild crescentic lesions, while immunofluorescence microscopy showed IgA-positive staining, which was characteristic of IgAN. Moreover, genetic testing confirmed the clinical diagnosis of CN, therefore Granulocyte colony-stimulating factor (G-CSF) was initiated to stabilize the neutrophil count. Regarding proteinuria control, the patient was initially treated with an Angiotensin-converting-enzyme inhibitor for approximately 28 months. However, due to progressive proteinuria (> 1 g/24 h), Corticosteroids (CS) were added for a period of 6 months according to the revised 2021 KDIGO guidelines with favorable outcome.ConclusionsPatients with CN are more susceptible to recurrent viral infections, which can trigger IgAN attacks. In our case CS induced remarkable proteinuria remission. The use of G-CSF contributed to the resolution of severe neutropenic episodes, viral infections and concomitant AKI episodes, contributing to better prognosis of IgAN. Further studies are mandatory to determine whether there is a genetical predisposition for IgAN in children with CN.

Global Perspectives in Acute Kidney Injury: Spain.

Global Perspectives in Acute Kidney Injury: Spain.

Ethnic disparities in pregnancy-related acute kidney injury in a United Kingdom population.

The incidence of acute kidney injury in pregnancy (P-AKI) is rising and is associated with detrimental maternal and foetal outcomes. Ethnic disparities in pregnancy outcomes are well recognized, with females who identify as Black or Asian being more likely to die during pregnancy compared to females who identify as White ethnicity. This study reports rates of P-AKI and associated risk factors in pregnant females of different ethnicities. All pregnancies were recorded between 2016 and 2020. AKI episodes were identified using electronic alerts. Ethnicity, AKI stage (1-3),obstetric outcomes and risk factors for P-AKI (chronic hypertension, pregnancy-induced hypertension and pre-eclampsia, and haemorrhage) were assessed. There were 649 P-AKI episodes from 16,943 deliveries (3.8%). Black females were more likely to have P-AKI (5.72%) compared to those who were White (3.12%), Asian (3.74%), mixed ethnicity (2.89%) and Other/Not Stated (3.10%). Black females, compared to White females, were at greater risk of developing P-AKI if they had haemorrhage requiring blood transfusion (OR 2.44, 95% CI 1.31,4.54; p < 0.001) or pregnancy-induced hypertension (OR 1.79, 95% CI 1.12, 2.86; p < 0.001). After adjusting for risk factors, Black females had increased risk of developing P-AKI (OR 1.52, 95% CI 1.22, 1.80; p < 0.001) compared to White females. Black females were at increased risk of developing P-AKI compared to White females. Mode of delivery, pregnancy-induced hypertension and haemorrhage are likely to have contributed. The increased risk persists despite accounting for these variables, suggesting that other factors such as socioeconomic disparities need to be considered. The incidence of P-AKI is likely higher than previously stated in the literature. However, caution must be exercised, particularly with AKI stage 1, as the KDIGO system is not validated in pregnancy and gestational changes in renal physiology need to be considered. Pregnancy-specific AKI definitions are needed.

Acute Kidney Injury and Hair-Straightening Products: A Case Series

Keratin-based hair straightening treatment is a popular hair styling method. The majority of these products in Israel contain glycolic acid derivatives, which are considered safe when used topically. Systemic absorption of these products is possible and anecdotal reports have described kidney toxicity associated with their use. We report a series of cases of severe AKI following use of hair-straightening treatment occurring in Israel over the past several years. Case series. We retrospectively identified 26 patients from 14 medical centers in Israel who developed severe AKI and reported prior treatment with hair-straightening products between 2019 and 2022. The 26 patients described had a median age of 28.5 years (range, 14-58) and developed severe AKI following hair-straightening procedure. The most common symptoms at presentation were nausea, vomiting, and abdominal pain. Scalp rash was noted in 10 (38%) patients. Two patients developed a recurrent episode of AKI following a repeat hair-straightening treatment. Seven patients underwent kidney biopsies that demonstrated intra-tubular calcium oxalate deposition in six and microcalcification in tubular cells in one. In all biopsies, signs of acute tubular injury were present, and an interstitial infiltrate was noted in four cases. Three patients required temporary dialysis. Retrospective uncontrolled study, small number of kidney biopsies. This study describes cases of acute kidney injury with prior exposure to hair straightening treatments. Acute oxalate nephropathy was the dominant finding on kidney biopsies, which may be related to absorption of glycolic acid derivatives and their metabolism to oxalate. This case series suggests a potential under-recognized cause of AKI in the young healthy population. Further studies are needed to confirm this association and to assess the extent of this phenomenon as well as its pathogenesis.

Outcomes associated with acute kidney disease: A systematic review and meta-analysis.

Acute kidney disease (AKD) defines the period after kidney damage and it is a critical period of both repair and fibrotic pathways. However, the outcomes of patients with AKD have not been well-defined. In this meta-analysis, PubMed, Embase, Cochrane and China National Knowledge Infrastructure were searched on July 31,2022. We excluded studies including patients undergoing kidney replacement therapy at enrollment. The data was used to conduct a random-effects model for pool outcomes between patients with AKD and non-AKD (NKD). This study is registered with PROSPERO, CRD42021271773. The search generated 739 studies of which 21 studies were included involving 1,114,012 patients. The incidence rate of community-acquired AKD was 4.60%, 2.11% in hospital-acquired AKD without a prior AKI episode, and 26.11% in hospital-acquired AKD with a prior AKI episode. The all-cause mortality rate was higher in the AKD group (26.54%) than in the NKD group (7.78%) (odds ratio [OR]: 3.62, 95% confidence interval [CI]: 2.64 to 4.95, p<0.001, I2=99.11%). The rate of progression to end-stage kidney disease (ESKD) was higher in the AKD group (1.3%) than in the NKD group (0.14%) (OR: 6.58, p<0.001, I2=94.95%). The incident rate of CKD and progressive CKD was higher in the AKD group (37.2%) than in the NKD group (7.45%) (OR:4.22, p<0.001, I2=96.67%). Compared to the NKD group, patients with AKD without prior AKI had a higher mortality rate (OR: 3.00, p<0.001, I2=99.31%) and new-onset ESKD (OR:4.96, 95% CI, p=0.002, I2=97.37%). AKD is common in community and hospitalized patients who suffer from AKI and also occurs in patients without prior AKI. The patients with AKD, also in those without prior AKI had a higher risk of mortality, and new-onset ESKD than the NKD group. This study was supported by Ministry of Science and Technology (MOST) of the Republic of China (Taiwan) [grant number, MOST 107-2314-B-002-026-MY3, 108-2314-B-002-058, 110-2314-B-002-241, 110-2314-B-002-239], National Science and Technology Council (NSTC) [grant number, NSTC 109-2314-B-002-174-MY3, 110-2314-B-002-124-MY3, 111-2314-B-002-046, 111-2314-B-002-058], National Health Research Institutes [PH-102-SP-09], National Taiwan University Hospital [109-S4634, PC-1246, PC-1309, VN109-09, UN109-041, UN110-030, 111-FTN0011] Grant MOHW110-TDU-B-212-124005, Mrs. Hsiu-Chin Lee Kidney Research Fund and Chi-mei medical center CMFHR11136. JAN is supported, in part, by grants from the National Institute of Health, NIDDK (R01 DK128208 and P30 DK079337) and NHLBI (R01 HL148448-01).

Patient outcomes following AKI and AKD: a population-based cohort study

BackgroundAcute kidney injury (AKI) is common and associated with adverse outcomes as well as important healthcare costs. However, evidence examining the epidemiology of acute kidney disease (AKD)—recently defined as AKI persisting between 7 and 90 days—remains limited. The aims of this study were to establish the rates of early AKI recovery, progression to AKD and non-recovery; examine risk factors associated with non-recovery and investigate the association between recovery timing and adverse outcomes, in a population-based cohort.MethodsAll adult residents of Tayside & Fife, Scotland, UK, with at least one episode of community or hospital-managed AKI using KDIGO creatinine-based definition during the period 1 January 2010 to 31 December 2018 were identified. Logistic regression was used to examine factors associated with non-recovery, and Cox modelling was used to establish associations between AKI recovery timing and risks of mortality and development of de novo CKD.ResultsOver 9 years, 56,906 patients with at least one AKI episode were identified with 18,773 (33%) of these progressing to AKD. Of those progressing to AKD, 5059 (27%) had still not recovered at day 90 post AKI diagnosis. Risk factors for AKD included: increasing AKI severity, pre-existing cancer or chronic heart failure and recent use of loop diuretics. Compared with early AKI recovery, progression to AKD was associated with increased hazard of 1-year mortality and de novo CKD (HR = 1.20, 95% CI 1.13 to 1.26 and HR = 2.21, 95% CI 1.91 to 2.57 respectively).ConclusionsThese findings highlight the importance of early AKI recognition and management to avoid progression to AKD and long-term adverse outcomes.

Chlorthalidone and Advanced Chronic Kidney Disease.

Chlorthalidone and Advanced Chronic Kidney Disease.

Circulating Levels of Endotrophin Are Prognostic for Long-Term Mortality after AKI.

AKI involves a rapid decrease in kidney function that may be associated with structural damage. Early markers predicting AKI are emerging, but tools to assess patients' long-term health risks after AKI are still lacking. Endotrophin (ETP) is a bioactive molecule released during the formation of collagen type VI. We evaluated the potential of circulating ETP as a prognostic biomarker of adverse outcomes after AKI. We measured ETP in plasma samples collected 1 year after an episode of AKI, using the PRO-C6 ELISA in 801 patients (393 patients with AKI and 408 controls) from the prospective AKI Risk in Derby (ARID) study (ISRCTN25405995), who were then followed until year 3. Kidney disease progression was defined as ≥25% decline in eGFR combined with a decline in CKD stage. ETP levels were significantly higher in the AKI group compared with controls (P<0.001). In the AKI group, ETP could discriminate patients with kidney disease progression at year 3 (AUC=0.67, P<0.01), whereas eGFR could not (AUC=0.51, P=0.57). In logistic regression including common risk factors, ETP was independently associated with kidney disease progression in patients with AKI (OR=1.10, P<0.01). ETP could discriminate survivors from nonsurvivors at year 3 (AUC=0.64, P<0.01). In a Cox proportional hazards regression for mortality after AKI that included common risk factors, only ETP (HR=1.05; P<0.001) and age (HR=1.06, P<0.01) were retained in the final model. Patients in the AKI group had higher levels of plasma ETP at year 1 as compared with those who had not had AKI. In the AKI group, ETP levels predict kidney disease progression and mortality. Because ETP is a profibrotic molecule, our findings may indicate that ETP identifies patients with active fibrogenesis after AKI, suggestive of long-term renal remodeling, which is associated with patient outcome.

External validation of a deep-learning model to predict severe acute kidney injury based on urine output changes in critically ill patients

ObjectivesThe purpose of this study was to externally validate algorithms (previously developed and trained in two United States populations) aimed at early detection of severe oliguric AKI (stage 2/3 KDIGO) in intensive care units patients.MethodsThe independent cohort was composed of 10'596 patients from the university hospital ICU of Amsterdam (the “AmsterdamUMC database”) admitted to their intensive care units. In this cohort, we analysed the accuracy of algorithms based on logistic regression and deep learning methods. The accuracy of investigated algorithms had previously been tested with electronic intensive care unit (eICU) and MIMIC-III patients.ResultsThe deep learning model had an area under the ROC curve (AUC) of 0,907 (± 0,007SE) with a sensitivity and specificity of 80% and 89%, respectively, for identifying oliguric AKI episodes. Logistic regression models had an AUC of 0,877 (± 0,005SE) with a sensitivity and specificity of 80% and 81%, respectively. These results were comparable to those obtained in the two US populations upon which the algorithms were previously developed and trained.ConclusionExternal validation on the European sample confirmed the accuracy of the algorithms, previously investigated in the US population. The models show high accuracy in both the European and the American databases even though the two cohorts differ in a range of demographic and clinical characteristics, further underlining the validity and the generalizability of the two analytical approaches.Graphical abstract