Acute Kidney Injury Classification Research Articles

A Cohort Study of Acute Kidney Injury in Egyptian Neonates; Etiology, Risk Factors, Diagnosis and Three Months Follow Up.

Introduction: Acute kidney injury (AKI) is a major contributor of neonatal mortality and morbidity. Understanding the different anatomy of the neonatal kidney could help physician understand pathology of AKI and consequently could treat it efficiently. Aim of the study: This one year duration prospective Cohort study involved twenty seven admitted neonates who had acute kidney injury (AKI). Methods: Laboratory and radiologic diagnosis of AKI, further AKIN and pRIFLE classification and follow up after one and three months. Results: AKI had an incidence of 1.35%, mainly in full-term (59%). Hypertension was presented in full-term (75%) and preterm (45.5%). Hematuria presented by 18.8% (full-term) and 27.3% (preterm). Proteinuria occurred in full-term (46.7%) and preterm (36.4%). Urinary tract infection was more among (45.5%) preterm than full term (25%). Oliguric AKI was found in full term (68.8%) and preterm (72.7%). Anuric AKI present in full-term (31.1%) and preterm (9.1%). Post renal AKI were present 18.8 %( full term) and 9.1 %( preterm). Perinatal asphyxia (18.8%) and sepsis (27.3%) were the most common risk factor. Both full-term (37.5%) and preterm (18.2%) needed peritoneal dialysis. Ultrasonography showed bilateral Grade 2 (50%) and 1(25%) nephropathy and bilateral back pressure (18%). pRIFLE was inversely correlate with age and urine output and positively correlated with hypertension at baseline. At one month; 43.8% full-term, 18.2 % preterm were found hypertensive, 18.8% fullterm had proteinuria, pRIFLE was inversely correlated with urine output and proteinuria and eCCL was significantly improved after one month in both preterm and full-term. At three month, chronic kidney disease was 12.5% and 9.1% in full-term and preterm respectively. Total recovery was higher in preterm neonates than in full-term ones. Conclusion: Sepsis and asphyxia are considered the most common causes of AKI. Limitation: A longer follow up is mandatory. Further follow up studies of AKI in preterm neonates are mandatory.

MO364ASSOCIATION OF AKI-EVENT DEFINED BY DIFFERENT DEFINITIONS WITH IN-HOSPITAL MORTALITY

Abstract Background and Aims Studies have shown that millions of hospitalized patients suffer from Acute Kidney Injury (AKI) per year which increases mortality risk for these patients. Different definitions for AKI have been proposed during the past years such as RIFLE (2002) and AKIN (2004). In 2012, KDIGO published a clinical practice guideline harmonizing AKIN and RIFLE into one general guideline which classifies AKI into 3 stages, where stage 1 is defined as an absolute increase of SCr ≥ 0.3 mg/dl over 48 hours or a relative increase in SCr ≥ 50% from baseline within the previous 7 days. A recent study [Sparrow et al., 2019] evaluated the impact of further categorizing AKI stage 1 into 2 stages based on SCr criteria. The study separates KDIGO AKI stage 1 and AKIN stage 1 into 2 stages (KDIGO-4 and AKIN-4) based on the different SCr criteria. Having different AKI definitions makes it challenging to analyze AKI incidence and associated outcomes among studies. The present study aimed to investigate the incidence of AKI events defined by 4 different definitions (standard AKIN and KDIGO, and modified AKIN-4 and KDIGO-4) and its association with in-hospital mortality. Method Retrospective clinical data available for all adult (≥18 years old) hospital admissions to a local health district in Athens, Greece between October 1999 and March 2019 was used in the analysis. We excluded patients whose time between admission and discharge was less than 7 days. Also, patients with less than 5 Scr measurements were omitted from the analysis resulting in the final cohort of 7242 admissions. We used the AKIN, KDIGO, AKIN-4, and KDIGO-4 definitions to check the incidence of AKI. As our second goal, we assessed associations of AKI-events with in-hospital mortality, adjusted for characteristics (age, sex, AKI staging) using multivariable logistic regression. Results The incidence of in-hospital AKI using the modified KDIGO-4 was 6.72% for stage 1a, 15.71% for stage 1b, 8.06% for stage 2, and 2.97% for stage 3; however, these percentages for AKIN-4 were 11.5%, 5.83%,1.75%, and 0.33% for stage 1a, stage 1b, stage 2, and stage 3, respectively. Using the standard KDIGO and AKIN definition, 19.08 and 14.05 % developed stage 1, respectively. To find the association between AKI stages and in-hospital mortality, we considered the most severe stage of AKI reached by a patient. Results of logistic regression models show that in-hospital mortality increased as the stage of AKI events increased for both KDIGO-4 and AKIN-4 (Table 1). Table 2 shows the same results using the original KDIGO and AKIN definitions. Conclusion The results of both definitions (AKIN-4 and KDIGO-4) show a significant association with mortality, but KDIGO-4 has a larger odds ratio meaning that AKI classification based on KDIGO-4 has a stronger association with mortality than AKI classification based on AKIN-4. However, based on our results, splitting stage 1 to stage 1a and stage 1b does not seem to make a difference; hence, using KDIGO-4 as a replacement for KDIGO would not have a significant impact on capturing AKI events.

Renal Recovery in Critically Ill Adult Patients Treated with Veno-Venous Or Veno-Arterial Extra Corporeal Membrane Oxygenation: a Retrospective Cohort Analysis.

IntroductionPatients on extracorporeal membrane oxygenator (ECMO) therapy are critically ill and often develop acute kidney injury (AKI) during hospitalisation. Little is known about the association of exposure to and the effect of the type of ECMO and extent of renal recovery after AKI development.Aim of the study In patients who developed AKI, renal recovery was characterised as complete, partial or dialysis-dependent at the time of hospital discharge in both the Veno-Arterial (VA) and Veno-Venous (VV) ECMO treatment groups.Material and methods The study consisted of a single-centre retrospective cohort that includes all adult patients (n=125) who received ECMO treatment at a tertiary academic medical centre between 2015 to 2019. Data on demographics, type of ECMO circuit, comorbidities, exposure to nephrotoxic factors and receipt of renal replacement therapy (RRT) were collected as a part of the analysis. Acute Kidney Injury Network (AKIN) criteria were used for the diagnosis and classification of AKI. Group differences were assessed using Fisher’s exact tests for categorical data and independent t-tests for continuous outcomes.Results Sixty-four patients received VA ECMO, and 58 received VV ECMO. AKI developed in 58(91%) in the VA ECMO group and 51 (88%) in the VV ECMO group (p=0.77). RRT was prescribed in significantly higher numbers in the VV group 38 (75%) compared to the VA group 27 (47%) (p=0.0035). At the time of discharge, AKI recovery rate in the VA group consisted of 15 (26%) complete recovery and 5 (9%) partial recovery; 1 (2%) remained dialysis-dependent. In the VV group, 22 (43%) had complete recovery (p=0.07), 3(6%) had partial recovery (p=0.72), and 1 (2%) was dialysis-dependent (p>0.99). In-hospital mortality was 64% in the VA group and 49% in the VV group (p=0.13).Conclusions Renal outcomes in critically ill patients who develop AKI are not associated with the type of ECMO used. This serves as preliminary data for future studies in the area.

POS-019 ACUTE KIDNEY INJURY IN ONCOLOGY AND TUMOR LYSIS SYNDROME

Acute kidney injury (AKI) is a common and serious complication in patients with neoplasia, it leads to a number of negative consequences, including length of hospitalization, denial of active cancer treatment, worsening of overall prognosis, and increase in costs. AKI may disturb the bioavailability and/or safety profile of many oncologic drugs, potentially leading to suboptimal treatments, or enhance risk for drug-induced toxicities. The aim of our work is to study the epidemiology, causes, therapeutics and prognosis of AKI in cancer patients. Retrospective study including all patients admitted to our university hospital for a period of 2 years from January 2018 to December 2019, known to be carriers of neoplastic disease and presenting acute renal injury selected according to the criteria of the Acute Kidney Injury Classification Network (AKIN). The patients were followed until their discharge or their death. 110 patients had an associated cancer pathology. The mean age was 44.46 ± 18.66 years, with a female predominance of 65%, a male / female sex ratio of 0.75. 41% of patients were admitted to medical services and 32% of patients hospitalized for surgery. The mean serum creatinine was 97.9 ± 63.6 mg / L. The mechanism of acute renal failure was dominated by the obstructive origin found in (56%) of cases, followed by myelomatous cylinder nephropathy (20%), nephrotoxicity of cancer chemotherapy (10%), syndrome. tumor lysis in (8%) and sepsis in (6%). The use of hemodialysis was necessary in 82% of cases. Only 18.68% recovered normal renal function. The death rate was 13.18%. AKI is a serious complication of cancer or of its treatments and is responsible for additional morbidity and mortality.

Impact of goal-directed hemodynamic management on the incidence of acute kidney injury in patients undergoing partial nephrectomy: a pilot randomized controlled trial

BackgroundThe incidence of acute kidney injury (AKI) remains high after partial nephrectomy. Ischemia-reperfusion injury produced by renal hilum clamping during surgery might have contributed to the development of AKI. In this study we tested the hypothesis that goal-directed fluid and blood pressure management may reduce AKI in patients following partial nephrectomy.MethodsThis was a pilot randomized controlled trial. Adult patients who were scheduled to undergo partial nephrectomy were randomized into two groups. In the intervention group, goal-directed hemodynamic management was performed from renal hilum clamping until end of surgery; the target was to maintain stroke volume variation < 6%, cardiac index 3.0–4.0 L/min/m2 and mean arterial pressure > 95 mmHg with crystalloid fluids and infusion of dobutamine and/or norepinephrine. In the control group, hemodynamic management was performed according to routine practice. The primary outcome was the incidence of AKI within the first 3 postoperative days.ResultsFrom June 2016 to January 2017, 144 patients were enrolled and randomized (intervention group, n = 72; control group, n = 72). AKI developed in 12.5% of patients in the intervention group and in 20.8% of patients in the control group; the relative reduction of AKI was 39.9% in the intervention group but the difference was not statistically significant (relative risk 0.60, 95% confidence interval [CI] 0.28–1.28; P = 0.180). No significant differences were found regarding AKI classification, change of estimated glomerular filtration rate over time, incidence of postoperative 30-day complications, postoperative length of hospital stay, as well as 30-day and 6-month mortality between the two groups.ConclusionFor patients undergoing partial nephrectomy, goal-directed circulatory management during surgery reduced postoperative AKI by about 40%, although not significantly so. The trial was underpowered. Large sample size randomized trials are needed to confirm our results.Trial registrationClinicaltrials.gov identifier: NCT02803372. Date of registration: June 6, 2016.

Clinical phenotypes of acute kidney injury are associated with unique outcomes in critically ill septic children.

BackgroundAssessment of acute kidney injury (AKI) in septic patients remains imprecise. In adults, the classification of septic patients by clinical AKI phenotypes (severity and timing) demonstrates unique associations with patient outcome vs. broadly defined AKI.MethodsIn a multinational prospective observational study, AKI diagnosis in critically ill septic children was stratified by duration (transient vs. persistent) and severity (mild vs. severe by creatinine change and urine output). The outcomes of interest were mortality and intensive care unit resource complexity at 28 days.ResultsSeven hundred and fifty-seven septic children were studied (male 52.7%, age 4.6 years (1.5–11.9)). Mortality (overall 12.1%) was different between severe AKI and mild AKI (18.3 vs. 4.4%, p < 0.001) as well as intensive care unit (ICU) complexity (overall 34.5%, 45 vs. 21.7%, p < 0.001). Patients with Persistent AKI had fewer ICU-free days (17 (7, 21) vs. 24 (17, 26), p < 0.001) and higher ICU complexity (52.8 vs. 22.9%, p = 0.002) than transient AKI, even after exclusion of patients with early mortality. AKI phenotypes incorporating temporal and severity data correlate with unique survival (range 4.4–21.6%) and ICU-free days (range of 15–25 days)ConclusionsThe outcome of septic children with AKI changes by clinical phenotype. Our findings underscore the importance of prognostic enrichment in sepsis and AKI for the purpose of trial design and patient management.Impact Although AKI occurs commonly in patients with sepsis (S-AKI), outcomes for children with S-AKI varies based on the severity and timing of the AKI.Existing S-AKI pediatric data utilize a broad singular definition of kidney injury. Increasing the precision of AKI classification results in a new understanding of how S-AKI associates with patient outcome.A refined classification of S-AKI identifies subgroups of children, making possible a targeted and a personalized medicine approach to S-AKI study and management.

The effect of admission and pre-admission serum creatinine as baseline to assess incidence and outcomes of acute kidney injury in acute medical admissions.

Acute kidney injury (AKI) in hospital-admitted patients is a common complication associated with increased mortality. The diagnosis of AKI relies on the ascertainment of peak increase in serum creatinine (SCr). This study evaluated the incidence of AKI using the increase from mean 7-365 days pre-admission (AKIpre) and admission (AKIadm) SCr levels, and examined the associations of AKI and changes in SCr levels with all-cause mortality. A total of 2436 patients admitted to a tertiary hospital were recruited and followed-up for a median of 47.70 (interquartile range 18.20) months. AKI incidence and severity were defined according to the Kidney Disease: Improving Global Outcomes-AKI Guidelines. Follow-up data were collected from the Hospital Episode Statistics and Office of National Statistics. Mortality was evaluated during a short- (30 days), mid- (1 year) and long-term (4 years) period. No difference in the AKI rates using AKIpre and AKIadm (12.5% versus 12.2%; P = 0.695) or in the AKI severity (P = 0.261) was evident. Agreement between the two definitions was modest (Kappa-statistic = 0.596, P < 0.001). Patients with AKIpre or AKIadm had increased all-cause mortality compared with those without AKI during all follow-up periods. In fully adjusted regression analysis, AKIpre [hazard ratio (HR) = 2.226, 95% confidence interval (CI) 1.140-4.347; P = 0.027] and AKIadm (HR = 2.105, 95% CI 1.090-4.064; P = 0.027) remained associated with 30-day mortality. Results for the 1- and 4-year periods were similar. Increases of >4.00 μmol/L and >6.06% from pre-admission or >6.00 μmol/L and >17.24% from admission SCr levels presented increased mortality risk during follow-up. Use of admission or pre-admission SCr provides similar incidence rates, but they diagnose different sets of patients. Even minor increases in SCr, below those required for the classification of AKI, were associated with increased mortality. These findings can help the clinicians to identify patients at higher risk for adverse outcomes.

Acute Kidney Injury in Children

Recent literature data has shown that acute kidney injury (AKI) is a common occurrence in critically ill children and that it is associated with high rates of morbidity and mortality, even after adjusting for other risk factors. In addition, it can result in long-term sequelae translated by the development of arterial hypertension, microalbuminuria and chronic renal dysfunction. High degree of suspicion, early diagnosis based on the recognition of patients at risk and the use of new criteria for the diagnosis and classification of AKI and, whenever possible, using the new biomarkers can positively alter the prognosis of these patients. Although there is still no specific treatment for AKI, it is recommended to focus on the immediate institution of preventive measures in order to maintain renal hemodynamics, early treatment of septic patients, elimination of exogenous nephrotoxins, recognition and management of patients with AKI secondary to high levels of endotoxins, control and normalization of volume after the initial phase of fluid resuscitation, sufficient nutritional support, and recognition and treatment of the underlying causes are necessary. Patients that fail with conservative care will need renal replacement therapy.

Cardiac surgery-associated acute kidney injury: pathophysiology and diagnostic modalities and management.

Acute kidney injury is a disease spectrum that can present with from mild renal dysfunction to complete renal failure that would require renal replacement therapy. Cardiac surgery-associated acute kidney injury is a complication that carries a grave disease burden. Risk factors are identified as being either modifiable or non-modifiable. This literature review aims to define the pathophysiology of cardiac surgery-associated acute kidney injury, the current definition and classification of acute kidney injury and the available diagnostic modalities, especially the use of biomarkers.

Intrawound Antibiotic Powder in Acetabular Fracture Open Reduction Internal Fixation Does Not Reduce Surgical Site Infections

To compare the risks of surgical site infection (SSI) and postoperative complications after acetabular fracture open reduction internal fixation (ORIF) in patients receiving topical intrawound antibiotic powder compared with those not receiving antibiotic powder (control group). Retrospective cohort. Level I trauma center. We reviewed 789 acetabular fracture ORIF cases from 2010 to 2019 at our institution, with mean follow-up of 18 months (3-112 months). Overall, 326 patients comprised the control group and 463 received topical antibiotic powder (294 vancomycin and 169 vancomycin/tobramycin). The study groups were compared for risk of SSI, seroma formation, wound dehiscence, acute kidney injury (AKI), and other postoperative complications. There were 63 total SSI (8.0%), 50 (6.3%) deep SSI and 13 suprafascial SSI (1.6%) cases. There was no difference in the risk of total SSI (8.3% vs. 7.8%, P = 0.80) or deep SSI (6.1% vs. 6.5%, P = 0.64). This was confirmed by multivariate analysis adjusting for covariates (odds ratio = 0.93; 95% confidence interval, 0.52-1.67; P = 0.80). Similar results were demonstrated when comparing the control group with the vancomycin and vancomycin/tobramycin subgroups. The control group and antibiotic powder groups had similar risks of all outcomes of interest, including seroma formation (1.8% vs. 1.7%, P = 1.00), wound dehiscence (1.2% vs. 2.2%, P = 0.42), total AKI (5.2% vs. 8.2%, P = 0.12), and RIFLE classification AKI (injury; 0.9% vs. 2.2%, P = 0.50). The addition of topical intrawound antibiotic powder, whether vancomycin alone or vancomycin/tobramycin before closure, does not reduce the risk of SSI after acetabular fracture ORIF compared with standard normal saline irrigation alone. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prognostic value of dynamic plasma endostatin for the prediction of mortality in acute kidney injury: A prospective cohort study.

ObjectiveThe aim of the current study was to evaluate the value of plasma endostatin for predicting 30-day mortality of patients with acute kidney injury (AKI).MethodsPatients who underwent non-cardiac major surgery and developed AKI in the first 48 hours after admission to the intensive care unit were consecutively included. Concentrations of plasma neutrophil gelatinase-associated lipocalin (NGAL), cystatin C (Cys C), and endostatin were measured at three time points: 0, 24, and 48 hours after the AKI diagnosis. Clinical patient characteristics were recorded after AKI was diagnosed.ResultsA total of 256 new-onset AKI patients were enrolled. Of these, 48 (18.7%) patients died within 30 days. The difference in plasma endostatin values between 0 and 24 hours (ΔEndostatin-24h) yielded the best area under the curve (AUC) of 0.747 for predicting 30-day mortality in AKI patients; NGAL and Cys C achieved AUC of 0.672 and 0.647, respectively. The predictive AUC increased to 0.833 when ΔEndostatin-24h was combined with sequential organ failure assessment score and AKI classification.ConclusionDynamic plasma endostatin is useful for predicting 30-day mortality in AKI patients. The predictive power of dynamic plasma endostatin can be significantly improved when it is combined with clinical patient data.

Acute Kidney Injury in Acute Ischemic Stroke Patients in Clinical Trials.

Acute ischemic stroke patients are at risk of acute kidney injury due to volume depletion, contrast exposure, and preexisting comorbid diseases. We determined the occurrence rate and identified predictors associated with acute kidney injury in acute ischemic stroke patients. Multiple specialized ICUs within academic medical centers. Post hoc analysis of pooled data from prospective randomized clinical trials. Acute ischemic stroke patients recruited within 3 hours or within 5 hours of symptom onset. IV recombinant tissue plasminogen activator, endovascular treatment, IV albumin, or placebo. Serum creatinine levels from baseline and within day 5 or discharge were used to classify acute kidney injury classification into stages. Any increase in serum creatinine was seen in 697 (36.1%) and acute kidney injury was seen in 68 (3.5%) of 1,931 patients with acute ischemic stroke. Severity of acute kidney injury was grade I, II, and III in 3.1%, 0.4%, and 0.05% patients, respectively. Patients with albumin (5.5% compared with 2.6%; p = 0.001), preexisting hypertension (4.3% compared with 1.5%; p = 0.0041), and preexisting renal disease (9.1% compared with 3.0%; p < 0.0001) had higher risk of acute kidney injury. The risk of acute kidney injury was lower between those who either underwent CT angiography (2.0% compared with 4.7%; p = 0.0017) or endovascular treatment (1.6% compared with 4.2%; p = 0.0071). In the multivariate analysis, hypertension (odds ratio, 2.6; 95% CI, 1.2-5.6) and renal disease (odds ratio, 3.5; 95% CI, 1.9-6.5) were associated with acute kidney injury. The risk of death was significantly higher among patients with acute kidney injury (odds ratio, 2.7; 95% CI, 1.4-4.9) after adjusting for age and National Institutes of Health Stroke Scale score strata. The occurrence rate of acute kidney injury in acute ischemic stroke patients was low and was not higher in patients who underwent CT angiogram or those who received endovascular treatment. Occurrence of acute kidney injury increased the risk of death within 3 months among acute ischemic stroke patients.

Acute Kidney Injury in SARS-CoV-2 Infected Critically Ill Patients

Objective: The main objective of this study is to evaluate the frequency of acute kidney injury (AKI) in COVID-19 infected patients who are hospitalized in the intensive care unit (ICU). Materials and Methods: This study was performed retrospectively on patients above 18 years of age who had a positive polymerase chain reaction (PCR), a typical chest computed tomography (CT) for COVID-19 disease. The patients were hospitalized in the medical ICU and kidney disease improving global outcomes (KDIGO) criteria was used for AKI classification. Results: We included 16 patients. The median age was 75 years and 88% were male. The most common co-morbid diseases were hypertension (HT) (56%) and cardiovascular disease (CVD) (44%). The median acute physiology and chronic health evaluation II (APACHE II) and sequential organ failure assessment (SOFA) scores were 26 (19-32) and 7 (4-9) respectively. Patients median serum blood urea nitrogen (BUN) and creatinine levels were 27.8 (19.2-44.7) mg/dL, 1.32 (0.97-2.81) mg/dL respectively. According to the KDIGO classification: there was no AKI in 25% of the patients while, 19% stage 1, 12% stage 2 and 44% stage 3 AKI was observed. AKI developed in 75% of the patients. Conclusion: In this study we detected a high frequency of AKI in SARS-CoV2 infected patients hospitalized in the ICU.

Incidence and Risk Factors for Acute Kidney Injury in Severely Injured Patients Using Current Kidney Disease: Improving Global Outcomes Definitions

Acute kidney injury (AKI) is a significant cause of morbidity and mortality for critically injured trauma patients. The Kidney Disease: Improving Global Outcomes (KDIGO) practice guideline is the most up-to-date classification for AKI. The aims of this study were to determine the incidence and risk factors for AKI in critically injured trauma patients using the current KDIGO definitions. A prospective cohort study was performed at our academic, level 1 trauma center, from September 2017 to August 2018. All adult trauma patients admitted to the surgical ICU were included. The primary outcome was the development of AKI, as defined by KDIGO. Secondary outcomes included hospital and ICU length of stay, ventilator days, and mortality. There were 466 patients included and 314 (67%) developed AKI. Those who developed AKI were more often hypotensive on admission (7% vs 2%), had higher Injury Severity Scores (ISS) (19 vs 13), were more likely to have severe injuries to the chest (40% vs 24%) and extremities (20% vs 6%), received transfusion (41% vs 21%), sustained crush injuries (8% vs 1%), received radiocontrast (75% vs 47%), nephrotoxic medication (74% vs 60%), or vasopressors (15% vs 3%). After multivariate analysis, risk factors independently associated with AKI include age, Injury Severity Score (ISS), severe extremity injuries, radiocontrast, and vasopressors. Those who developed AKI had higher mortality (9% vs 2%). Using current KDIGO criteria, the incidence of AKI in critically injured trauma patients was higher than previously reported. Older patients, with more severe injuries to their extremities and chest and who have suffered crush injuries, appear to be the most a risk. AKI in the critically injured patient results in an almost 5-fold increase in mortality.

Protocolo diagnóstico y tratamiento de la insuficiencia renal en el paciente cirrótico

Acute renal failure is a highly frequent complication that involves a very poor prognosis for patients with hepatic cirrhosis. The early and accurate classification of acute renal failure using the new Acute Kidney Injury (AKI) classification, modified for patients with hepatic cirrhosis, and the correct differential diagnosis are essential for providing appropriate treatment. This task is not always easy and requires a careful assessment. Patients with AKI stage ≥ 1B have poorer prognoses and therefore require more specific treatment. The differential diagnosis between hepatorenal syndrome and acute tubular necrosis is vitally important, because the 2 aetiologies have the highest mortality and require a specific treatment for each type.

Identificação de lesão renal aguda em unidade de terapia intensiva: parâmetros para avaliação clínica de enfermagem

Este estudo teve como objetivo identificar a prevalência de lesão renal aguda em pacientes de unidade de terapia intensiva por meio da avaliação isolada da elevação da creatinina sérica e da aplicação clínica da classificação de disfunção renal Acute Kidney Injury Network. Trata-se de um estudo de coorte prospectivo realizado em unidade de terapia intensiva de um hospital especializado em cardiologia. Foram obtidas informações a partir dos registros de prontuário clínico e laboratorial. Para definição da lesão renal aguda foram adotados os critérios de elevação nos valores de creatinina sérica e critérios de classificação Acute Kidney Injury Network. A amostra final envolveu 79 pacientes, com média de idade de 59,8 (DP=13,5) anos, tendo como principais comorbidades hipertensão arterial sistêmica, insuficiência cardíaca congestiva, diabetes mellitus e doença de chagas. A prevalência de lesão renal aguda foi de 63,3% na avaliação da creatinina sérica isolada, enquanto que, pelos critérios Acute Kidney Injury Network identificou-se 77,2%. Conclui-se que o critério Acute Kidney Injury Network apresenta melhor estratificação de lesão renal aguda do que a creatinina isolada e pode servir como instrumento de avaliação em pacientes críticos. Por se tratar de um método composto por parâmetros de avaliação usuais em unidade de terapia intensiva, o mesmo pode ser incorporado pelo enfermeiro em sua avaliação clínica.

Abstract 132: Acute Kidney Injury in Acute Ischemic Stroke Patients: Pooled Analysis of ALIAS I and II and IMS III Trials

Background: Acute ischemic stroke patients are at risk of acute kidney injury (AKI) due to volume depletion, contrast exposure and pre-existing co-morbid diseases. We determined the incidence and identified predictors associated with AKI in acute ischemic stroke patients. Methods: Data from the Albumin in Acute Ischemic Stroke trial (ALIAS) - I and II and Interventional Management of Stroke (IMS) - III clinical trials were pooled and analyzed in which acute ischemic stroke patients were randomized into either IV albumin, placebo, endovascular or IV thrombolytic treatment groups. Serum creatinine levels from baseline and within day 5 or discharge along with the demographic and comorbidity information was collected. AKI classification was used to ascertain severity of renal dysfunction and based on increase in serum creatinine levels from baseline, stage 1 ≥ 0.3 mg/dl (≥ 26.4umol/L) or (&gt;1.5 to 2-fold), stage 2 (&gt;2 to 3-fold) and stage 3 (&gt;3-fold) were identified. We analyzed the relationship between AKI and mortality at 3 months post randomization. Results: A total of 1931 acute ischemic stroke patients (mean age 66± 13 (SD) years; 1024 were men) were analyzed. Any increase in serum creatinine was seen in 691 (35.8%, 95% CI 30%-40%) and AKI was seen in 68 (3.5%, 95% CI 3%-4%) of 1931 patients. Severity of AKI was grade I, II, III in 2.1 %, 0.4%, and 0.1% patients, respectively. The risk of AKI was not higher between those who either underwent CT angiography (2% compared with 4.2%, RR 0.5, 95% CI 0.3-0.8, p=0.02) or endovascular treatment (1.9% compared with 4.1%, RR 0.4, 95% CI 0.2-0.8, p=0.0096). Patients with preexisting hypertension (4.3% compared to 1.5%, RR 2.8, 95% CI 1.3-5.7, p=0.006) and preexisting renal disease (9.1% compared to 3.0%, RR 3.1, 95% CI 1.8-5.3, p=0.006) had higher risk of AKI. Mortality at 3 months was significantly higher among patients with AKI (27% compared with 15%, RR 1.8, 95% CI 1.2-2.7, p=0.0083). Conclusions: The incidence of AKI in acute ischemic stroke patients was low and was not higher in patients who underwent CT angiogram or those who received endovascular treatment. Occurrence of AKI increased mortality at 3 months among acute ischemic stroke patients.

Assessment of the Independent and Synergistic Effects of Fluid Overload and Acute Kidney Injury on Outcomes of Critically Ill Children.

Evaluate the independent and synergistic associations of fluid overload and acute kidney injury with outcome in critically ill pediatric patients. Secondary analysis of the Acute Kidney Injury in Children Expected by Renal Angina and Urinary Biomarkers (NCT01735162) prospective observational study. Single-center quaternary level PICU. One-hundred forty-nine children 3 months to 25 years old with predicted PICU length of stay greater than 48 hours, and an indwelling urinary catheter enrolled (September 2012 to March 2014). Acute kidney injury (defined by creatinine or urine output on day 3) and fluid overload (≥ 20% on day 3) were used as outcome variables and risk factors for ICU endpoints assessed at 28 days. None. Acute kidney injury and fluid overload occurred in 19.4% and 24.2% respectively. Both acute kidney injury and fluid overload were associated with longer ICU length of stay but neither maintained significance after multivariate regression. Delineation into unique fluid overload/acute kidney injury classifications demonstrated that fluid overload patients experienced a longer ICU and hospital length of stay and higher rate of mortality compared with fluid overload patients, regardless of acute kidney injury status. Fluid overload/acute kidney injury patients had increased odds of death (p = 0.013). After correction for severity of illness, ICU length of stay remained significantly longer in fluid overload/acute kidney injury patients compared with patients without both classifications (17.4; 95% CI, 11.0-23.7 vs 8.8; 95% CI, 7.3-10.9; p = 0.05). Correction of acute kidney injury classification for net fluid balance led to acute kidney injury class switching in 29 patients and strengthened the association with increased mechanical ventilation and ICU length of stay on bivariate analysis, but reduced the increased risk conferred by fluid overload for mortality. The current study suggests the effects of significant fluid accumulation may be delineable from the effects of acute kidney injury. Concurrent fluid overload and acute kidney injury significantly worsen outcome. Correction of acute kidney injury assessment for net fluid balance may refine diagnosis and unmask acute kidney injury associated with deleterious downstream sequelae. The unique effects of fluid overload and acute kidney injury on outcome in critically ill patients warrant further study.

Long-term predictive value of acute kidney injury classification in diffuse proliferative lupus nephritis with acute kidney injury

BackgroundThe long-term predictive ability of acute kidney injury (AKI) classification based on “Kidney Disease: Improving Global Outcomes”(KDIGO) AKI diagnosis criteria has not been clinically validated in diffuse proliferative lupus nephritis (DPLN) patients with AKI. Our objective was to assess the long-term predictive value of KDIGO AKI classification in DPLN patients with AKI.MethodsRetrospective cohort study was conducted by reviewing medical records of biopsy-proven DPLN patients with AKI from the First Affiliated Hospital of Wenzhou Medical University between Jan 1, 2000 and Dec 31, 2014. Multivariate Cox regression and survival analysis were performed.ResultsOne hundred sixty-seven DPLN patients were enrolled,82(49%) patients were normal renal function (No AKI), 40(24%) patients entered AKI-1 stage (AKI-1), 26(16%) patients entered AKI-2 stage (AKI-2) and 19(16%) patients entered AKI-3 stage (AKI-3). The mean follow-up of all patients was 5.1 ± 3.8 years. The patient survival without ESRD of all patients was 86% at 5 years and 79% at 10 years. The patient survival rate without ESRD at 10 yr was 94.5% for No AKI patients, 81.8% for AKI-1 patients, 44.9% for AKI-2 patients and 14.6% for AKI-3 patients. The area under the ROC curve for KDIGO AKI classification to predict the primary end point was 0.83 (95% CI: 0.73–0.93) (P < 0.001). In Cox regression analysis, AKI stage was independently associated with primary endpoint, with an adjusted hazard ratio (HR) of 3.8(95% CI 2.1–6.7, P < 0.001).ConclusionSeverity of AKI based on KDIGO AKI category was associated with progression to ESRD in DPLN patients. Analytical data also confirmed the good discriminative power of the KDIGO AKI classification system for predicting long-term prognosis of DPLN patients with AKI.

Hepatorenal syndrome: A review into changing definition, diagnostic criteria, pathophysiology, and management

Hepatorenal syndrome (HRS) is a form of kidney function impairment that characteristically occurs in patients with cirrhosis. The diagnostic criteria for this syndrome have been revised throughout the years, with recent revisions aimed at improving earlier diagnosis and treatment. HRS definition has been updated recently by the International Club of Ascites in accordance with Kidney Disease Improving Global Outcomes acute kidney injury (AKI) classification. Recent changes in terminology have led to acute or Type I HRS being referred to as AKI-HRS and chronic or Type II HRS as chronic kidney disease (CKD)-HRS. The contribution of systemic inflammation, a key feature of cirrhosis, in the development of HRS has been highlighted in recent years. The current standard of care for the management of HRS involves the use of vasoconstrictor therapy and volume expansion with albumin. All patients do not respond to treatment, and even in those who respond, early mortality rates are very high in the absence of liver transplantation (LT). LT is the only curative treatment of HRS.