Acute Kidney Injury Complications Research Articles

Indications and Timing of Continuous Renal Replacement Therapy Application.

Renal replacement therapy (RRT) is increasingly utilized to support critically ill patients with severe acute kidney injury (AKI). The clinical dilemma of when to ideally start RRT in these patients has been a longstanding issue that is in need of higher quality evidence to guide clinical practice. When clinicians are confronted with patients with life-threatening complications of AKI, the decision to start RRT is straightforward. However, in the absence of clear indications, the ideal circumstances and timing that balance the perceived benefits and risks of early versus delayed RRT remain uncertain. Survey data have confirmed substantial practice variation in the timing of RRT initiation. Most observational data and small clinical trials have limitations related to confounding by indication, heterogeneity in case-mix and illness severity, and variation in defining timing thresholds for starting RRT. Recently published trials have further added to the clinical uncertainty. This concise review provides an overview of prevailing and evolving evidence on the optimal time to start RRT in critically ill patients with AKI.

The Burden of Acute Kidney Injury and Related Financial Issues.

Acute kidney injury (AKI) is one of the most common complications in acutely ill patients. The epidemiology, clinical presentation, and outcome vary between patients and countries. Patients with AKI often exhibit multiple organ dysfunction that is caused, in part, by marked cross-talk between the kidney and other organs and tissues. These deleterious interactions arise, at least in part, from systemic inflammatory changes, an increased cytokine load, increases in leukocyte trafficking and activation of neurohormonal processes. Typical short-term complications of AKI include acute lung injury, liver dysfunction, cardio-renal syndrome, brain dysfunction, systemic inflammation, and increased mortality. Survivors of AKI are at risk of chronic kidney disease, cardiovascular morbidity, strokes, infections, bone fractures and increased mortality. AKI is associated with high healthcare costs as a result of a longer stay in hospital, increased costs for investigations and interventions and the development of long-term complications including dialysis dependence, chronic comorbidities and re-hospitalisations. The outcomes and financial implications are worse in low-income countries compared to high-income countries. Key Message: AKI is common among hospitalised patients and associated with serious short- and long-term complications, increased mortality, and high health care costs. There are important differences in epidemiology and outcomes between low- and high-income countries.

Is knowledge and practice of oral rehydration therapy suboptimal? Assessment at Federal Medical Center, Asaba, South-South Nigeria

Background: Oral rehydration therapy (ORT) is a core component of the childhood survival strategies to reduce child mortality and morbidity due to diarrhoeal disease with its fatal dehydrating complication of acute kidney injury. This strategy is indispensable to the attainment of the International Society of Nephrology’s (ISN) aim to eliminate preventable deaths from acute kidney injury (AKI) by year 2025. Diarrheal disease is the second most common cause of morbidity and mortality in children at our centre. This interventional study assessed the knowledge and the practice of ORT among caregivers, educated and trained them on the management of diarrhoeal diseases and practice of ORT. Oral rehydration salt (ORS) and zinc tablets were also distributed. Methods: An interviewer-administered questionnaire was used following informed consent. Consented care givers of wards attendees of FMC Asaba were assessed on their knowledge and their practice of ORT, educated on childhood diarrheal diseases, trained on practice of ORT and had ORS and zinc tablets distributed to them. These assessments were done on the spot and 6 weeks after the health talk, from July 2015 to December 2015. Results: There were 266 respondents and 231 were mothers. The immediate impact of the health talk on the knowledge and the practice of ORT was laudable, p≤0.0001 and educational attainment of the respondent influenced the immediate post health talk knowledge of ORT, p=0.009. The age of the respondent predicted the long term impact of health talk on practice of ORT, p=0.020. Conclusions: Knowledge and practice of ORT are not optimal but can be improved by regular education.

Acute Kidney Injury in Critically Ill Patients

Acute kidney injury is a common disease that affects critically ill patients and increases morbidity and mortality. Even though there have been extensive efforts to prevent this disease, the incidence has steadily increased over the last decade. This could be attributed to better recognition or to overestimation of the disease based on the most recent consensus criteria. Complications of acute kidney injury have a significant effect on quality of life, morbidity, and mortality. Despite advances in the field, this disease continues to be a challenge, and decreasing the mortality associated with it remains difficult. Plenty of literature has been published about the appropriate definition, diagnosis, and treatment of the disease. One of the topics of ongoing discussion deals with the lack of consensus about the exact timing for initiation of renal replacement therapy (RRT). Even though RRT adds more complexity to the treatment, recent publications suggest that early versus late initiation of RRT is related to reduced mortality in critically ill patients. Further high-level studies of this intervention are warranted to standardize treatment. This review contains 5 figures, 7 tables, and 77 references. Key words: Acute Kidney Injury Network (AKIN), acute kidney injury, chronic kidney disease, Kidney Disease: Improving Global Outcomes (KDIGO), renal biomarkers, replacement therapy, Risk, Injury, Failure, Loss of kidney function and End-stage kidney disease (RIFLE)

The effect of dexmedetomidine on renal function in patients undergoing cardiac valve replacement under cardiopulmonary bypass: A double-blind randomized controlled trial

Study objectiveWe attempted to explore the effect of Dex on renal function in patients with cardiac valve replacement under cardiopulmonary bypass (CPB). DesignWe designed a prospective, randomized, placebo-controlled, single-center, parallel-arm double-blind trial. SettingOperating room. PatientsSeven-two eligible patients were randomly divided into Dex group and placebo group. InterventionsDexmedetomidine (Dex) (0.6μg·kg−1) was administered in patients of Dex group at 15min before anesthesia induction, followed by a treatment of 0.2μg·kg−1·h−1 Dex until the end of operation. Patients in placebo group were treated with normal saline equally. MeasurementsThe levels of serum urea nitrogen (BUN), creatinine (Cr), neutrophil gelatinase-associated lipocalin (NGAL), urine interleukin-8 (IL-18) and superoxide dismutase (SOD) activity were tested before anesthesia induction (T1) and after operation at 0, 12h, 24h and 72h (T2–5). The urine output during operation and the post-operative complication of acute kidney injury (AKI) were recorded. Main resultsThe levels of BUN and Cr were significantly increased at T5, and similar findings were found in the levels of NGAL and urine IL-18 at T3 and T4. The SOD activity was significantly declined at T2 and T3 in the two groups. The levels of BUN and Cr at T5 and the NGAL level at T3 and T4 were significantly lower in Dex group, comparable to placebo group. The intraoperative urine output was significantly increased and the postoperative incidence of AKI was significantly lower in Dex group. ConclusionsDex may attenuate the renal injury and decrease the incidence of AKI in patients undergoing cardiac valve replacement under CPB.

Analysis of prognostic factors for acute kidney injury with continuous renal replacement therapy in severely burned patients

Acute kidney injury (AKI) is a critical complications in severely burned patients associated with high morbidity and mortality. The purpose of this study was to investigate the impact of severity of AKI at the time of continuous renal replacement therapy (CRRT) start on patient outcome and to identify the prognostic factors in severely burned patients with CRRT application. From January 2007 to June 2010, 84 burn patients with more than 40% of total body surface area (TBSA) burned who treated with continuous renal replacement therapy for acute kidney injury were analyzed retrospectively. There was no significant difference of mortality by the severity of AKI at the time of CRRT start. However, the mean TBSA burned, abbreviated burn severity index, arterial pH, partial pressure of carbon dioxide (PaCO2) and blood urea nitrogen (BUN)/creatinine (Cr) ratio had a statistical significance to predict mortality in receiver operation characteristic curve. In a multivariate logistic regression analysis, only sepsis had an independent association with mortality. The severity of the AKI at the time of CRRT start did not have significant relationship with patient outcome. CRRT can be applied to minimize the complication of AKI including electrolyte imbalance and volume overload. Because only the presence of sepsis was independently associated with mortality, treatment for sepsis should be focused to improve the survival of the severely burned patients with CRRT.

Early peritoneal dialysis reduces lung inflammation in mice with ischemic acute kidney injury

Although dialysis has been used in the care of patients with acute kidney injury (AKI) for over 50 years, very little is known about the potential benefits of uremic control on systemic complications of AKI. Since the mortality of AKI requiring renal replacement therapy (RRT) is greater than half in the intensive care unit, a better understanding of the potential of RRT to improve outcomes is urgently needed. Therefore, we sought to develop a technically feasible and reproducible model of RRT in a mouse model of AKI. Models of low- and high-dose peritoneal dialysis (PD) were developed and their effect on AKI, systemic inflammation, and lung injury after ischemic AKI was examined. High-dose PD had no effect on AKI, but effectively cleared serum IL-6, and dramatically reduced lung inflammation, while low-dose PD had no effect on any of these three outcomes. Both models of RRT using PD in AKI in mice reliably lowered urea in a dose-dependent fashion. Thus, use of these models of PD in mice with AKI has great potential to unravel the mechanisms by which RRT may improve the systemic complications that have led to increased mortality in AKI. In light of recent data demonstrating reduced serum IL-6 and improved outcomes with prophylactic PD in children, we believe that our results are highly clinically relevant.

The Complexity of Pulmonary Complications in Acute Kidney Injury.

Background: Pulmonary complications often occur in patients with acute kidney injury, and represent an important cause of death.Objective: To analyze the complexity of lung disorders in patients with RIFLE class III acute kidney injury undergoing hemodialysis and the physiopathological mechanisms that cause the various pulmonary complications.Methods: Our study included 74 clinical cases of acute kidney injury of various etiologies (severe sepsis, trauma, post-surgery, toxic, etc.). The respiratory function of these patients was monitored from the clinical and radiological points of view. Deceased patients underwent autopsy.Results: Pulmonary complications occurred in 47.24% of cases. Most pulmonary complications (over 50%) occurred in sepsis-induced acute kidney injury.Regarding the clinical aspects of pulmonary complications, the most frequent were ARDS, atelectasisand bronchopneumopathies, determined by the etiological factors that had caused the acute kidney injury in the first place, and by the acute kidney injury-induced physiological effects.Conclusions: 1. The frequency of pulmonary complications in acute kidney injury is very high and has a negative impact on the evolution and prognosis. 2. The etiology of the pulmonary complications is complex, as these are caused by the agents that induced the acute kidney injury in the first place, most frequently by septic shock. 3. Along with clinical and radiological evidence of pulmonary damage, severe pulmonary histological lesions were found in deceased patients, with a high contribution to the increased mortality rate.

The Fatal Outcome of a Child with a Delayed Posterior Urethral Valve Diagnosis in a Low Income Country: A Case Report and Take Home Messages

Introduction: When faced with early urinary tract infections in infants, there is a need to do diagnostic imaging to exclude urinary tract malformations. Delayed diagnosis of this condition could lead to serious complications. Case presentation: We received a 2 months old male infant referred for better management of an acute kidney injury (AKI) with septicemia. He had a past medical history of febrile urinary tract infection. Our diagnosis was that of acute kidney injury and septicemia associated to a posterior urethral valve. The initial treatment included broad spectrum antibiotics, management of AKI complications and vesicostomy to relief the urinary obstruction prior to valve ablation. We unfortunately lost the infant on day 3 following surgery from severe refractory hyperkalemia and a uremic syndrome. Conclusion: This case is a call to clinicians' attention in low income countries to always check for urinary tract malformations when confronted with an infant presenting a febrile urinary tract infection.

Indoxyl Sulfate as a Mediator Involved in Dysregulation of Pulmonary Aquaporin-5 in Acute Lung Injury Caused by Acute Kidney Injury.

High mortality of acute kidney injury (AKI) is associated with acute lung injury (ALI), which is a typical complication of AKI. Although it is suggested that dysregulation of lung salt and water channels following AKI plays a pivotal role in ALI, the mechanism of its dysregulation has not been elucidated. Here, we examined the involvement of a typical oxidative stress-inducing uremic toxin, indoxyl sulfate (IS), in the dysregulation of the pulmonary predominant water channel, aquaporin 5 (AQP-5), in bilateral nephrectomy (BNx)-induced AKI model rats. BNx evoked AKI with the increases in serum creatinine (SCr), blood urea nitrogen (BUN) and serum IS levels and exhibited thickening of interstitial tissue in the lung. Administration of AST-120, clinically-used oral spherical adsorptive carbon beads, resulted in a significant decrease in serum IS level and thickening of interstitial tissue, which was accompanied with the decreases in IS accumulation in various tissues, especially lung. Interestingly, a significant decrease in AQP-5 expression of lung was observed in BNx rats. Moreover, the BNx-induced decrease in pulmonary AQP-5 protein expression was markedly restored by oral administration of AST-120. These results suggest that BNx-induced AKI causes dysregulation of pulmonary AQP-5 expression, in which IS could play a toxico-physiological role as a mediator involved in renopulmonary crosstalk.

Delayed Nephrology Consultation and High Mortality on Acute Kidney Injury: A Meta-Analysis

Background: Acute kidney injury (AKI) is a complex syndrome associated with substantial morbidity, mortality and costs. Despite advancements in diagnosis and care practice, AKI remains a disorder usually under/late-recognized with high mortality. One of the hidden reasons for poor outcome might be delayed nephrology consultation, with the involvement of the specialist only in severe stages of AKI when renal replacement therapy (RRT) is required. Methods: We searched PubMed, EMBASE and Cochrane central register for related work on the subject. Six studies were identified for the meta-analysis, correlating time of nephrology consultation and mortality in AKI. Results: We found that delayed nephrology consultation is associated with higher mortality in AKI, with an OR 0.79 (95% CI 0.48-1.10, p < 0.05). Conclusion: Delayed nephrology consultation contributes to higher mortality in AKI. The early involvement of nephrologist may present an advantage in terms of early recognition, prevention and effective treatment of AKI. An early involvement of multidisciplinary task force may contribute to better treatment, before the preventable complications of AKI occur or an emergency RRT is required.

Admission Characteristics and Outcomes of ED Patients With Rhabdomyolysis

Objective: Rhabdomyolysis is a potentially life-threatening syndrome characterized by muscle necrosis and the release of potentially toxic intracellular muscle constituents into the circulation. Acute kidney injury (AKI) is the most important complication of rhabdomyolysis and is associated with increased risk of all-cause mortality. The main objectives of this study were (1) to characterize the most common etiologies of rhabdomyolysis and (2) to determine the complications and outcomes (rhabdomyolysis-induced AKI, need for renal replacement therapy [RRT] and, 28-day mortality) in our sample. Material and Methods: This retrospective, cross sectional, and single-center study was conducted in the ED of university hospital between January 1, 2013, and December 31, 2013. We analyzed the clinical spectrum and evaluated the complications and outcomes for each patient. Results: Forty-three eligible cases were enrolled in the study. The mean age was 52.0±21.9 years (range 16 to 92), and 81.4% were men. The two most common causes of rhabdomyolysis in this sample were trauma and infections (n=16; 37.2% and n=12; 27.9%, respectively). AKI occurred in 23 patients (53.4%), 13 of whom (30.2%) required RRT. All-cause 28-day mortality rate was 44.2% (n=19). The nonsurvival group had significantly increased peak creatinine level, increased phosphate level, and prolonged aPTT ( P <.001, P =.003, and P =.001, respectively). Conclusion: A substantial proportion of patients with rhabdomyolysis developed the complications of AKI and required RRT. Early recognition and aggressive fluid replacement should be considered for ED patients with rhabdomyolysis.

Acute kidney injury (AKI) outcome, a predictor of long-term major adverse cardiovascular events (MACE).

The incidence of acute kidney injury (AKI) in hospitalized patients is increasing. Many of these patients survive the immediate post-AKI period and may be prone to developing long-term complications of AKI. This study aimed to determine whether complete recovery following an episode of AKI is associated with a lower risk of long-term major adverse cardiovascular events (MACE). Retrospective cohort study. Adults admitted to the University of Virginia Medical Center between January 1, 2002 and December 31, 2012 who developed hospital-acquired AKI. AKI was defined as an increase in serum creatinine (SCr) by ≥ 0.3 mg/dL from the baseline and or requirement for acute dialysis during index hospitalization. Complete recovery was defined as a return of SCr to less than 1.25 times the baseline value and not dialysis dependent. Outcome and measurement: MACE was defined as subsequent admission for myocardial infarction, stroke or transient ischemic attach and heart failure using ICD- 9-CM codes. Overall, 11,538 patients survived beyond 90 days of AKI and had data available for analysis. Of the 9,673 survivors of AKI in whom recovery could be assessed, 7170 (74.12%) had complete renal recovery. MACE occurred in 27.28% of our study population over a median follow-up period of 399 days. 28.19% of patients who completely recovered renal function developed MACE, while only 32.48% did in those who did not recover completely. Patients who had complete recovery had a lower risk of long-term MACE when compared with those without complete recovery (adjusted hazard ratio 95% confidence interval (CI): 0.774 (0.713, 0.842)). Measurement of albuminuria was not available. Complete renal recovery after an episode of AKI in patients with normal baseline kidney function is associated with a lower risk of long-term MACE when compared with those who did not fully recover.

Timing of Renal Replacement Therapy in Acute Kidney Injury.

Renal replacement therapy (RRT) is commonly and increasingly utilized in critically ill patients with severe acute kidney injury (AKI). The issue of when to start RRT in a critically ill patient with AKI has long troubled clinicians. Currently, there is a paucity of high-quality evidence to guide clinician decision-making on the optimal time to start RRT. This lack of evidence has translated into wide variation in treatment patterns and practices. In patients developing life-threatening complications of AKI, the decision to start RRT is largely indisputable; however, in the absence of such complications, the optimal thresholds to start RRT that translates into improved outcomes for patients are unknown. Available evidence from observational studies and clinical trials have considerable limitations for translation to clinical practice due to their retrospective, post hoc secondary design, their small sample sizes, heterogeneity in study populations and illness severity, variation in the definitions of AKI and in the timing of or thresholds for starting RRT and the risk of residual confounding and bias related to the association between the timing of RRT and outcome. Several large randomized trials are planned or ongoing, and the results of these trials will greatly inform best clinical practice and will help reduce unnecessary variation in the practice of RRT prescription. For now, the decision on the appropriate time to start RRT is naturally complex, integrating numerous variables, and should largely be individualized.

αKlotho deficiency in acute kidney injury contributes to lung damage.

αKlotho is a circulating protein that originates predominantly from the kidney and exerts cytoprotective effects in distant sites. We previously showed in rodents that the lung is particularly vulnerable to αKlotho deficiency. Because acute lung injury is a common and serious complication of acute kidney injury (AKI), we hypothesized that αKlotho deficiency in AKI contributes to lung injury. To test the hypothesis, we created AKI by renal artery ischemia-reperfusion in rats and observed the development of alveolar interstitial edema and increased pulmonary oxidative damage to DNA, protein, and lipids. Administration of αKlotho-containing conditioned media 6 h post-AKI did not alter plasma creatinine but improved recovery of endogenous αKlotho production 3 days post-AKI, reduced lung edema and oxidative damage, and increased endogenous antioxidative capacity in the lung. Intravenously injected αKlotho rapidly exits alveolar capillaries as a macromolecule, suggesting transcytosis and direct access to the epithelium. To explore the epithelial action of αKlotho, we simulated oxidative stress in vitro by adding hydrogen peroxide to cultured A549 lung epithelial cells. Purified recombinant αKlotho directly protected cells at 20 pM with half-maximal effects at 40-50 pM, which is compatible with circulating αKlotho levels. Addition of recombinant αKlotho activated an antioxidant response element reporter and increased the levels of target proteins of the nuclear factor erythroid-derived 2 related factor system. In summary, αKlotho deficiency in AKI contributes to acute lung injury by reducing endogenous antioxidative capacity and increasing oxidative damage in the lung. αKlotho replacement partially reversed these abnormalities and mitigated pulmonary complications in AKI.

Retroperitoneal lymph node dissection (RPLND) for malignant phenotype Leydig cell tumours of the testis: a 10-year experience

Retroperitoneal lymph node dissection (RPLND) is a prognostic, palliative, and potentially therapeutic procedure for patients with malignant phenotype Leydig cell tumours of the testis. We reviewed the records of patients diagnosed with malignant phenotype Leydig cell tumours of the testis treated by RPLND. Modified template dissection was performed in all cases with extra-template excision of tumour mass in Stage II disease. Routine clinico-radiological follow-up was performed. Six open RPLNDs (1 re-do procedure) were performed on 5 patients diagnosed with Stage I (n = 3) and Stage II (n = 2) malignant phenotype Leydig cell tumour of the testis. Median age = 63 years (range = 55-72). Median peri-operative blood loss = 1500 ml (range = 500-1500 ml). Median operating time = 6 h (range = 4.5-6.5). Two patients with Stage II disease developed post-operative complications of acute kidney injury (n = 1) and pneumonia (n = 1). Median length of stay was 8 days (range = 6-11). RPLND specimens from patients with Stage I were tumour-free, whilst patients with Stage II disease had evidence of metastatic tumour. At latest follow-up (median = 13 months, range = 7-22), no patient with Stage I disease had radiological evidence of recurrence, however the two patients with Stage II disease had died due to tumour recurrence at 13 months and 36 months. RPLND for malignant phenotype Leydig cell testicular tumours appears to be well tolerated. Despite surgery, overall outcomes for Stage II appear to be poor due to the disease phenotype. Larger prospective multi-centre studies are required to determine the definitive criteria for surgery in Stage I disease.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-014-0781-x) contains supplementary material, which is available to authorized users.

Prevalence and Associated Complication of Acute Kidney Injury Among Dengue Patients.

Prevalence and Associated Complication of Acute Kidney Injury Among Dengue Patients.

Brain-kidney crosstalk.

Encephalopathy and altered higher mental functions are common clinical complications of acute kidney injury. Although sepsis is a major triggering factor, acute kidney injury predisposes to confusion by causing generalised inflammation, leading to increased permeability of the blood–brain barrier, exacerbated by hyperosmolarity and metabolic acidosis due to the retention of products of nitrogen metabolism potentially resulting in increased brain water content. Downregulation of cell membrane transporters predisposes to alterations in neurotransmitter secretion and uptake, coupled with drug accumulation increasing the risk of encephalopathy. On the other hand, acute brain injury can induce a variety of changes in renal function ranging from altered function and electrolyte imbalances to inflammatory changes in brain death kidney donors.

Acute Kidney Injury

Acute Kidney Injury

Acute Kidney Injury

1. David T. Selewski, MD* 2. Jordan M. Symons, MD† 1. *Department of Pediatrics and Communicable Diseases, Division of Nephrology, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI. 2. †Department of Pediatrics, Division of Nephrology, University of Washington School of Medicine, Seattle, WA. * Abbreviations: ACE: : angiotensin-converting enzyme AKI: : acute kidney injury AKIN: : Acute Kidney Injury Network ANCA: : antineutrophil cytoplasmic antibody ATN: : acute tubular necrosis ECG: : electrocardiogram FEurea: : fractional excretion of urea FENa: : fractional excretion of sodium KDIGO: : Kidney Disease: Improving Global Outcomes NSAID: : nonsteroidal anti-inflammatory drug RIFLE: : Risk, Injury, Failure, Loss, and End-stage The term acute kidney injury has replaced acute renal failure and represents a spectrum of clinically meaningful kidney damage. After completing this article, readers should be able to: 1. Recognize and define the spectrum of acute kidney injury (AKI). 2. Understand the diagnostic approach and be able to differentiate the main causes of AKI. 3. Understand the complications of AKI and the treatment of a child with AKI. Acute kidney injury (AKI), formerly called acute renal failure, is characterized by multiple abnormalities, including increases in serum creatinine and blood urea nitrogen, electrolyte abnormalities, acidosis, and difficulties with fluid management. We have come to realize that what was previously thought to be relatively minor damage to the kidney can have significant short-term effects on morbidity and mortality and potential long-term implications for the development of chronic kidney disease. Thus, the term acute kidney injury has replaced acute renal failure , suggesting the spectrum of kidney damage that can occur. ### Definition AKI is classically defined as an acute decrease in glomerular filtration rate, which results in an increase in serum creatinine. It is important to recognize the limitations of creatinine as a marker of AKI because an increase in creatinine can be delayed by as much as 48 hours after damage to the kidney has occurred. Despite this limitation, change in creatinine remains the gold standard for the diagnosis of AKI. An evolution in the definition of AKI to better understand, characterize, and study the disease spectrum, has occurred, which has sought to capture the clinical importance of even small variations in kidney function. In addition, previous definitions used in the literature were widely disparate; this …