Global Outcomes Clinical Practice Guideline Research Articles

The Effects of Early-Phase, Low- or Standard-Intensity Continuous Renal Replacement Therapy on Acid-Base Control and Clinical Outcomes: An Observational Study

Introduction: The Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guideline recommends administering an effluent volume of 20–25 mL/kg/h during continuous renal replacement therapy (CRRT) for acute kidney injury. Recent evidence on CRRT initiation showed that less intervention might be beneficial for renal recovery. This study aimed to explore the association between early-phase low CRRT intensity and acid-base balance corrections and clinical outcomes. Methods: This was a single-centre, retrospective, observational study at a tertiary intensive care unit (ICU) in Japan. All adult patients requiring CRRT in the ICU were included. Eligible patients were classified into the Low group (dialysate flow rate [QD] 10.0–19.9 mL/kg/h) and the Standard group (QD ≥20 mL/kg/h) by the intensity of CRRT at the beginning. The primary outcomes were acid-base parameters 6 h after CRRT initiation. We used an inverse probability of treatment weighting analysis to estimate the association between the intensity group and the outcomes. Results: Overall, 194 patients were classified into the Low group (n = 144) and the Standard group (n = 50). The Standard group presented with more severe acid-base disturbances, including lower pH and base excess (BE) at baseline. At 6 h after CRRT initiation, pH, BE, and strong ion difference values were comparable, even after adjusting for baseline severity. Despite the efficient correction, no evident differences were observed in clinical outcomes between the two groups. Conclusions: The initial standard intensity appeared to be efficient in correcting acid-base imbalance at the early phase of CRRT; however, further studies are needed to assess the impact on clinical outcomes.

Effects of Balanced Versus Saline-based Solutions on Acute Kidney Injury in Off-pump Coronary Artery Bypass Surgery: A Randomized Controlled Trial

To determine whether balanced solutions can reduce the incidence of acute kidney injury after off-pump coronary artery bypass surgery compared with saline. Randomized controlled trial. Single tertiary care center. Patients who underwent off-pump coronary artery bypass surgery between June 2014 and July 2020. Balanced solution-based chloride-restrictive intravenous fluid strategy. The primary outcome was acute kidney injury within 7 postoperative days, as defined by the 2012 Kidney Disease: Improving Global Outcomes Clinical Practice Guideline. The incidence of acute kidney injury was 4.4% (8/180) in the balanced group and 7.3% (13/178) in the saline group. The difference was not statistically significant (risk difference, -2.86%; 95% confidence interval [CI], -7.72% to 2.01%; risk ratio, 0.61, 95% CI, 0.26 to 1.43; p = 0.35). Compared with the balanced group, the saline group had higher levels of intraoperative serum chloride and lower base excess, which resulted in a lower pH. In patients undergoing off-pump bypass surgery with a normal estimated glomerular filtration rate, the intraoperative balanced solution-based chloride-restrictive intravenous fluid administration strategy did not decrease the rate of postoperative acute kidney injury compared with the saline-based chloride-liberal intravenous fluid administration strategy.

Epidemiology of Diabetic Kidney Disease among US Veterans.

With a large number of patients and high mortality, diabetic kidney disease (DKD) imposes a significant burden on US health care. Although diabetes is the leading cause of chronic kidney disease and complications, the epidemiology of DKD in the contemporary US veteran population is generally unknown. We aimed to estimate the rate of DKD progression and to measure the general epidemiology of DKD in the United States veteran population. We performed a retrospective observational research using electronic health-care records and administrative databases. The DKD patient cohort was abstracted from the Veterans Health Administration health-record data from January 2016 to March 2022. We defined DKD patients using the laboratory test data based on Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines. Summary statistics include the five-year cumulative incidence of progression to an advanced stage from the DKD stage at the cohort entry date and prevalence at a series of single time points. A total of 685,288 patients (male [96%], mean age 62 years, Caucasian [64%], non-Hispanic [87%]) met our eligibility criteria. The 5-year cumulative incidence of progression to an advanced DKD stage or all-cause death from DKD stages G1 A2/A3, G2 A2/A3, G3a, and G3b were 52.0%, 47.4%, 50.5%, and 60.9%, respectively. In sum, 594,082 patients were classified as moderate or high risk as per KDIGO guidelines in 2021, and stages G3a and G3b accounted for 51.2% and 25.3%, respectively, of cases. More than half of DKD patients underwent a stage progression or death within 5 years. A substantial number of DKD patients at an earlier stage might be left undetermined. The study findings warrant a revision of DKD patient identification and management in US veterans.

Acute kidney injury, the present on admission (POA) indicator and sex disparities: observational study of inpatient real-world data in a Swiss tertiary healthcare system. Explorative analysis

BackgroundRegarding kidney disease (KD), sex differences in epidemiology and clinical relevance have been reported. Related to absolute and relative changes of baseline creatinine, different criteria for staging may induce underdiagnosis...

Dyslipidemia in Patients with Chronic Kidney Disease: An Updated Overview.

Dyslipidemia is a potentially modifiable cardiovascular risk factor. Whereas the recommendations for the treatment target of dyslipidemia in the general population are being more and more rigorous, the 2013 Kidney Disease: Improving Global Outcomes clinical practice guideline for lipid management in chronic kidney disease (CKD) presented a relatively conservative approach with respect to the indication of lipid lowering therapy and therapeutic monitoring among the patients with CKD. This may be largely attributed to the lack of high-quality evidence derived from CKD population, among whom the overall feature of dyslipidemia is considerably distinctive to that of general population. In this review article, we cover the characteristic features of dyslipidemia and impact of dyslipidemia on cardiovascular outcomes in patients with CKD. We also review the current evidence on lipid lowering therapy to modify the risk of cardiovascular events in this population. We finally discuss the association between dyslipidemia and CKD progression and the potential strategy to delay the progression of CKD in relation to lipid lowering therapy.

Sex as a biological variable in acute kidney injury.

The purpose of this review is to provide an overview of the preclinical and clinical studies investigating sex as a biological variable, as well as the impact of gender, on the development of and progression of acute kidney injury (AKI). Despite a matched degree of ischemia-reperfusion AKI based on measured glomerular filtration rates, male and female mice demonstrated important sex biases in cardiorenal outcomes (1). Although the 2012 Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guideline for AKI reported that female sex is associated with increased rates of hospital acquired AKI, subsequent meta-analyses do not show increased risk of AKI in women. Recent large scale, multicenter epidemiologic studies suggest males have higher rates of hospital acquired AKI. However, women have been consistently shown to have worse renal outcomes after AKI. There may be also be gender-based differences in presentation to care and management. Sex is an important biological variable in animal models of acute kidney injury. The impact of sex on AKI likely varies based on the etiology of AKI. Preclinical studies demonstrate the nuances of sex chromosomes, sex hormones and epigenetic factors on AKI, however these have not been well studied in humans. Gender may also impact processes of care, treatment and clinical outcomes related to AKI. The scientific rigor and reproducibility of translational studies benefit from the consideration of sex and gender.

The 2021 KDIGO blood pressure target and the progression of chronic kidney disease: Findings from KNOW-CKD.

The 2021 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline for the management of blood pressure (BP) in chronic kidney disease (CKD) recommends a target systolic BP of <120mmHg as this target can provide cardiovascular benefits. However, it remains unclear whether implementing the new BP target could improve kidney outcomes. The association between the 2021 KDIGO BP target and CKD progression was examined and compared with the 2012 KDIGO BP target among 1724 participants included in the KoreaN Cohort Study for Outcomes in Patients With CKD. The main exposure was the BP status categorized according to the 2012 or 2021 KDIGO guideline: (1) controlled within the 2021 target, (2) controlled within the 2012 target only, and (3) above both targets. The primary outcome was a composite kidney outcome of ≥50% decline in the estimated glomerular filtration rate from baseline or the initiation of kidney replacement therapy during the follow-up period. Composite kidney outcomes occurred in 650 (37.7%) participants during the 8078 person-years of follow-up (median, 4.9 years). The incidence rates of this outcome were 55, 66.5, and 116.4 per 1000 person-years in BP controlled within the 2021 and 2012 KDIGO targets, and BP above both targets, respectively. In the multivariable cause-specific hazard model, hazard ratios for the composite outcome were 0.76 (95% confidence interval (CI), 0.60-0.95) for BP controlled within the 2021 target and 1.36 (95% CI, 1.13-1.64) for BP above both targets, compared with BP controlled within 2012 target only. The newly lowered BP target by the 2021 KDIGO guideline was associated with improved kidney outcome compared with BP target by the 2012 KDIGO guideline.

#4483 THE 2021 KDIGO BLOOD PRESSURE TARGET AND THE PROGRESSION OF CHRONIC KIDNEY DISEASE: FINDINGS FROM THE KNOW-CKD

Abstract Background and Aims The 2021 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline for management of blood pressure (BP) in chronic kidney disease (CKD) recommends a target systolic BP of &amp;lt;120 mmHg because this lower target can provide cardiovascular benefits. However, whether implementing the new BP target could improve kidney outcome remains unknown. Method We examined the association of the 2021 KDIGO BP target with CKD progression compared with the 2012 KDIGO BP target among 1724 participants from the Korean Cohort Study for Outcomes in Patients With CKD. The main exposure was BP status categorized according to the 2012 or 2021 KDIGO guideline: 1) controlled within 2021 target; 2) controlled within 2012 target only; and 3) above both targets. The primary outcome was a composite kidney outcome of ≥50% decline in estimated glomerular filtration rate from baseline measurement or the initiation of kidney replacement therapy during the follow-up. Results During 8,078 person-years of follow-up (median, 4.9 years), the composite kidney outcome occurred in 650 (37.7%) participants. The incidence rates of this outcome were 55, 66.5, and 116.4 per 1,000 person-years in BP controlled within the 2021 and 2012 KDIGO targets, and BP above both targets, respectively. In the multivariable cause-specific hazard model, hazard ratios for the composite outcome were 0.76 (95% confidence interval, 0.60-0.95) for BP controlled within the 2021 target and 1.36 (95% confidence interval, 1.13-1.64) for BP above both targets, compared with BP controlled within 2012 target only. Conclusion The newly lowered BP target by the 2021 KDIGO guideline was associated with improved kidney outcome compared with BP target by the 2012 KDIGO guideline.

New guideline on diabetes management in chronic kidney disease

In autumn 2022, an update of the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on diabetes management in chronic kidney disease (CKD) was published. This article presents in aclear manner and discusses the new aspects compared to the 2020 guideline. Innovations are seen in the area of general and all-encompassing treatment as well as in relation to blood glucose-lowering and organ-protective treatments with sodium-glucose cotransporter2 inhibitors, non-steroidal mineralocorticoid receptor antagonists, and glucagon-like peptide‑1 receptor agonists. Anew feature is also the top 10 recommendations on diabetes management in CKD for both patients and physicians. The KDIGO guideline on diabetes management in CKD represents the current evidence-based standard of care for patients with diabetes mellitus and CKD. It is now important to implement the guideline in order to provide patients with the benefits of the treatments and thus improve their lives.

Use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers increases the risk of postoperative acute kidney injury after elective endovascular abdominal aortic aneurysm repair.

Endovascular abdominal aortic aneurysm repair (EVAR) is the major treatment for abdominal aortic aneurysm (AAA); however, EVAR still carries a considerable risk of acute kidney injury (AKI). The present study aimed to investigate the risk factors for AKI after elective EVAR procedures. This was a retrospective observational study. Eligible patients who underwent EVAR from September 2011 to March 2019 in West China Hospital were included. The primary outcome was the occurrence of AKI within two days after EVAR, which was defined by the Kidney Disease Improving Global Outcomes Clinical Practice Guideline. Demographics, comorbidities, medications, laboratory tests, anatomical parameters of AAA, and relative operative details were collected as variables. Univariable and multivariable logistic regression analyses were applied to identify the risk factors among variables, and covariate interactions were further assessed. A total of 679 eligible patients were included. The incidence of postoperative AKI was 8.2% (56/679) in the whole cohort, and it was associated with a lower 5-year survival rate (63.5% vs . 80.9%; χ 2 = 4.10; P = 0.043). The multivariable logistic regression showed that chronic kidney disease (OR, 5.06; 95% CI: 1.43-17.95; P = 0.012), angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) (OR, 2.60; 95% CI: 1.17-5.76; P = 0.019), and short neck (OR, 2.85; 95% CI: 1.08-7.52; P = 0.035) were independent risk factors for postoperative AKI. In the covariate interaction analysis, the effect of ACEIs/ARBs use on postoperative AKI was similar across all subgroups ( P > 0.05), thereby suggesting a robust effect of ACEIs/ARBs use in all patients undergoing elective endovascular abdominal aortic aneurysm repair. Postoperative AKI was associated with lower survival rate, and the use of ACEIs/ARBs was the only adjustable independent risk factor. Clinicians should consider withdrawing ACEIs/ARBs in high-risk patients undergoing elective endovascular abdominal aortic aneurysm repair to prevent postoperative AKI.

Aetiology and Outcome of Acute Kidney Injury Patients at the Nephrology Unit of Pak Emirats Military Hospital Rawalpindi

Objective: To assess the aetiology and outcome of patients admitted with acute kidney injury at the Nephrology Unit of Pak Emirates Military Hospital (PEMH).&#x0D; Study Design: Cross-sectional analytical study.&#x0D; Place and Duration of Study: Nephrology Unit, Pak Emirates Military Hospital, Rawalpindi Pakistan, from Jun 2019 to Jun 2020.&#x0D; Methodology: Patients admitted with AKI were included in the study. The Kidney Disease: Improving Global Outcomes(KDIGO) clinical practice guidelines were used to diagnose acute renal injury based on creatinine level or urine output. &#x0D; Results: A total of 300 patients were admitted to the Nephrology Unit with AKI during the study period. Sepsis was the commonest aetiology for acute kidney injury among the target population, followed by injury. 155(51.4%) patients were discharged, 53(17.7%) were stable in the ward, 70(23.4%) patients were shifted to the Critical Care Unit, and 22(7.3%) died.Long duration of hospital stay and the presence of multiorgan failure had a statistically significant relationship with poor outcomes in our study.&#x0D; Conclusion: This study gives an insight into the aetiology and outcome of acute kidney injury among acute kidney injury patients admitted to the nephrology ward. Sepsis and injury were the commonest causes affecting renal function. Most of the patients had a good outcome. Patients with long hospital stays and multiorgan failure should be given special attention as they were more at risk of poor outcomes in our study.

Albuminuria testing and nephrology care among insured US adults with chronic kidney disease: a missed opportunity

BackgroundIn chronic kidney disease (CKD), assessment of both estimated glomerular filtration rate (eGFR) and albuminuria are necessary for stratifying risk and determining the need for nephrology referral. The Kidney Disease: Improving Global Outcomes clinical practice guidelines for CKD recommend nephrology referral for eGFR < 30 ml/min/1.73m2 or for urinary albumin/creatinine ratio ≥ 300 mg/g.MethodsUsing a national claims database of US patients covered by commercial insurance or Medicare Advantage, we identified patients with CKD who were actively followed in primary care. We examined receipt of nephrology care within 1 year among these patients according to their stage of CKD, classified using eGFR and albuminuria categories. Multivariable logistic regression was used to examine odds of receiving nephrology care by CKD category, adjusting for age, sex, race/ethnicity, diabetes, heart failure, and coronary artery disease.ResultsAmong 291,155 patients with CKD, 55% who met guideline-recommended referral criteria had seen a nephrologist. Receipt of guideline-recommended nephrology care was higher among those with eGFR < 30 (64%; 11,330/17738) compared with UACR ≥300 mg/g (51%; 8789/17290). 59% did not have albuminuria testing. Those patients without albuminuria testing had substantially lower adjusted odds of recommended nephrology care (aOR 0.47 [0.43, 0.52] for eGFR < 30 ml/min/1.73m2). Similar patterns were observed in analyses stratified by diabetes status.ConclusionsOnly half of patients meeting laboratory criteria for nephrology referral were seen by a nephrologist. Underutilization of albuminuria testing may be a barrier to identifying primary care patients at elevated kidney failure risk who may warrant nephrology referral.

Machine Learning Predicts Acute Kidney Injury in Hospitalized Patients with Sickle Cell Disease

Introduction Acute kidney injury (AKI) in hospitalized patients is associated with a high morbidity and mortality. Individuals with sickle cell disease (SCD) frequently experience organ dysfunction, including AKI, during hospitalization for episodes of vaso-occlusive crisis (VOC). AKI can lead to progressive kidney disease and chronic kidney disease (CKD), which is associated with further increased morbidity and mortality. Identifying AKI early during hospitalizations can lessen the risk of progressive CKD and renal replacement therapy. Utilizing machine learning techniques, we hypothesized that risk of AKI can be identified in SCD patients before the onset of kidney injury, leading to earlier recognition of AKI. Methods This is a single-site, retrospective IRB-approved study of 6,278 patient encounters with SCD admitted across five regional hospitals in Memphis, TN, from July 2017 to December 2020. Of these, 1,178 patient encounters were selected for analysis by including encounters with continuous minute-by-minute physiological data availability and excluding dialysis-dependent patient encounters. Each patient admission was considered a separate patient encounter if the interval between admissions was at least 1 month. AKI was defined based on the 2012 Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guideline. Physiomarkers, a set of signal processing features, derived from five physiological data streams from bedside monitors, including heart rate, respiratory rate, and blood pressure (systolic, diastolic, and mean), were used, along with clinical laboratory and demographic data. Missing laboratory values and vital sign measurements were first imputed using the last-one carry forward imputation. The remaining missing values were imputed by the global median of the associated variable in the training dataset. Logistic regression, support vector machine, random forest, and eXtream Gradient Boosting (XGBoost) classifiers were used for classification. Case (AKI) and control records were divided into 12 non-overlapping but consecutive 6-hour analysis time-windows (Figure 1). Prediction horizons (the time in advance each model bundle was asked to predict the AKI event) were increased by 6-hour until the beginning of the record. Controls were balanced with cases using a bootstrap method and randomized across each unique iteration to minimize selection bias. Statistical features were derived from the 6-hour analysis window immediately prior to each prediction horizon. Explainability of models generated at each time window was assessed using averaged Shapley Additive Explanations (SHAP) scores. Results A total of 82 (7%) patient encounters were identified as AKI cases based on the 2012 KDIGO guidelines. The other 1096 SCD patient encounters served as controls (Figure 1). Overall, there were more females (64.6%) than males among AKI cases (Table 1). A history of hypertension, pulmonary hypertension, CKD, and pneumonia were higher in AKI cases than in controls (Table 1). The XGBoost model most accurately predicted AKI up to 60 hours before AKI onset, with an average test sensitivity, specificity, and area under the receiver operating characteristics curve of 0.86, 0.72, and 0.80, respectively. Conclusions In this proof-of-concept study, we found that physio/biomarkers derived from continuous bedside monitoring and laboratory data are temporally and differentially expressed in SCD patients with AKI. A minimalistic artificial intelligence model can be developed using this information to predict AKI earlier in hospitalized SCD patients and may enable the development of innovative prevention strategies. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Assessment of level of care of diabetic patients with nephropathy in predialysis stage 4 in Tanta

Background Stage 4 chronic kidney disease (CKD) in comparison with earlier stages of CKD is associated with higher morbidity, mortality, and costs, and current guidelines recommend greater intensity of care for patients with stage 4 disease. Aim Our study assessed the level of care of patients with diabetic nephropathy (DN) in predialysis stage (CKD stage 4) in Tanta. Patients and methods A total of 257 patients experiencing DN stage 4 from Tanta were subjected to a questionnaire sheet that included age; duration of diabetes; time of diagnosis of DN; treatment of hypertension; patient diet; antidiabetic drugs; level of serum creatinine; estimated glomerular filtration rate; hemoglobin level; serum levels of Ca, Ph, parathyroid hormone, Na, K, and HCO3; lipid profile; statin therapy; and hemoglobin A1c. The data collected were compared with Kidney Disease: Improving Global Outcomes clinical practice guideline for the evaluation and management of CKD. Results Of the 257 patients, 27.6% were type 1 diabetics and 72.4% were type 2. The mean duration of diabetes was 12.43 years (±6.388). Overall, 29.9% had uncontrolled elevated blood pressure, of whom 27.2% were on no antihypertensive drugs. Renin-angiotensin-aldosterone system blockage agents were used in 52.1% of patients. Overall, 57.2% had good control of diabetes. Dyslipidemia was found in 49.4% patients of them 62.2% patients were on no statin therapy. Hypocalcemia was found in 5.4% patients, hyperphosphatemia was found in 12.4% patients, 4.7% had secondary hyperparathyroidism, 79.8% had bicarbonate level below normal range, 9.7% had mild elevate potassium level, and 20.4% had anemia. Conclusion Our patients reached stage 4 early after few years of diabetes, and parameters that need more level of care include hypertension, diabetes, treatment used for diabetes, dyslipidemia, and acidosis.

Statin use before and after the KDIGO Lipids in chronic kidney disease guideline: A population-based interrupted time series analysis.

In November 2013, the Kidney Disease: Improving Global Outcomes Clinical Practice Guideline for Lipid Management in Chronic Kidney Disease was published, recommending statins for all individuals 50 years or older with an estimated glomerular filtration rate below 60 ml/min/1.73 m2 to lower the risk of major cardiovascular events. We quantified the prevalence of statin use among the target population before and after the guideline publication in a large Danish cohort of individuals with an estimated glomerular filtration rate below 60 ml/min/1.73 m2 , to investigate the effect of the guideline, but found no difference in the prevalence of statin use prior to and after the guideline publication.

Plasma presepsin level predicts acute kidney injury in patients with sepsis in the emergency department.

Acute kidney injury (AKI) is a common complication in patients with sepsis. We evaluated the potential prognostic value of plasma presepsin to predict AKI in patients with sepsis in the emergency department. A total of 193 patients diagnosed with sepsis based on the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) were included in this observational study. AKI was defined according to the Kidney Disease Improving Global Outcomes clinical practice guideline. Plasma presepsin levels were measured on admission to the emergency department. We compared plasma presepsin levels between patients who did and those who did not develop AKI. AKI occurred in 100 (51.8%) patients. The median plasma presepsin level was significantly higher in patients with AKI than in those without AKI (1061 pg/mL vs 495 pg/mL, P <.001). Plasma presepsin levels were significantly increased in patients with AKI stage 3 compared with those with AKI stages 1 and 2 (P =.001). The area under the curve of presepsin for predicting AKI was 0.793 (95% confidence interval: 0.729-0.848). The optimal presepsin cutoff value for predicting AKI was >572 pg/mL, with a sensitivity of 77.0% and specificity of 81.7%. Plasma presepsin level is a valuable biomarker for the prediction of AKI in patients with sepsis in the emergency department.

Predictive Values of Procalcitonin and Presepsin for Acute Kidney Injury and 30-Day Hospital Mortality in Patients with COVID-19.

Background and Objectives: Acute kidney injury (AKI) is a common complication in patients with coronavirus disease 2019 (COVID-19). We investigated the values of procalcitonin (PCT) and presepsin (PSS) for predicting AKI and 30-day hospital mortality in patients with COVID-19. Materials and Methods: We retrospectively evaluated 151 patients with COVID-19 who were admitted to the hospital via the emergency department. The diagnosis of AKI was based on the Kidney Disease: Improving Global Outcomes clinical practice guidelines. Results: The median patient age was 77 years, and 86 patients (57%) were male. Fifty-six patients (37.1%) developed AKI, and 19 patients (12.6%) died within 30 days of hospital admission. PCT and PSS levels were significantly higher in patients with AKI and non-survivors. The cutoff values of PCT levels for predicting AKI and mortality were 2.26 ng/mL (sensitivity, 64.3%; specificity, 89.5%) and 2.67 ng/mL (sensitivity, 68.4%; specificity, 77.3%), respectively. The cutoff values of PSS levels for predicting AKI and mortality were 572 pg/mL (sensitivity, 66.0%; specificity, 69.1%) and 865 pg/mL (sensitivity, 84.6%; specificity, 76.0%), respectively. Conclusion: PCT and PSS are valuable biomarkers for predicting AKI and 30-day hospital mortality in patients with COVID-19.

FC 127: Acute Kidney Injury and Exposure to Nephrotoxic Drugs in Critically Ill Patients: A Report From the Multicenter Rescue Project in the Netherlands

Abstract BACKGROUND AND AIMS Acute kidney injury (AKI) is a common problem in patients admitted to the intensive care unit (ICU). Nephrotoxic drugs play a causal role in 14–28% of the ICU AKI cases and are one of the few preventable AKI causes. The Dutch multicenter project ‘Towards a leaRning mEdication Safety system in a national network of Intensive Care Units—timely detection of adverse drug Events’ (RESCUE) aims to improve medication safety in ICU patients with respect to drug-induced AKI. This requires knowledge on which drugs may cause AKI and the strength of their effects. Obtaining such knowledge is challenging due to confounding. Especially in the ICU, where patients often have multiple comorbidities, AKI risk factors may also be indications or contraindications for drugs. We aimed to estimate the independent associations between nephrotoxic drug groups and AKI in ICU patients by adjusting for drug group-specific confounders. METHOD We used a detailed electronic health record database of ICU patients admitted to 13 different ICUs between 2010 and 2019 in the Netherlands. The database contains admission characteristics, (chronic) comorbidities, physiology measurements, Acute Physiology and Chronic Health Evaluation IV admission diagnoses and predicted mortality probabilities, serum creatinine (SCr), drug administrations, arterial blood pressure and renal replacement therapy (RRT) treatments. We included admissions with at least two SCr values and excluded admissions with one or more missing AKI risk factor values. Using the Kidney Disease: Improving Global Outcomes Clinical Practice Guideline for Acute Kidney Injury, we diagnosed and staged AKI according to the SCr and RRT criteria. We recorded exposure to eight drug groups widely regarded as acutely nephrotoxic [1] until AKI onset, discharge or death. Multilevel logistic regression models were applied to estimate the independent association between each drug group and AKI. The estimates were adjusted for drug group-specific confounders: we registered which AKI risk factors were indications or contraindications for each drug group. RESULTS We included 98 391 ICU admissions, of which 14 074 (14%) were diagnosed with AKI, ranging between 6 and 21% across the ICUs. Of all admissions with AKI, 8962 (64%), 1283 (9%) and 3829 (27%) developed AKI stage 1, stage 2 or stage 3, respectively (Figure 1). The percentage of admissions exposed to nephrotoxic drug groups was 7% for aminoglycosides, 6% for nonsteroidal anti-inflammatory drugs (NSAIDs), 6% for penicillin combinations, 5% for glycopeptide antibiotics, 2% for sulfonamides, 2% for antivirals for herpes infections, 1% for immunosuppressants and 1% for antimycotic antibiotics. All drug groups were associated with a higher odds of AKI except NSAIDs and penicillin combinations (Table 1). While penicillin combinations were not associated with AKI, NSAIDs were associated with a lower odds of AKI. The drug groups with the highest odds of AKI were immunosuppressants [odds ratio (OR) 2.26, 95% confidence interval (95% CI) 1.97–2.60; P &amp;lt; 0.001), sulfonamides (OR 1.84, 95% CI 1.65–2.04; P &amp;lt; 0.001) and aminoglycosides (OR 1.70, 95% CI 1.59–1.81; P &amp;lt; 0.001). The NSAID group was the only group that showed a higher OR after adjustment. CONCLUSION We estimated the independent associations between nephrotoxic drug groups and AKI by adjusting for drug-group specific confounders. Our results provide new estimates of the strengths of the associations. Surprisingly, NSAIDs were associated with a lower odds of AKI. This association might be biased due to residual confounding by contraindication. Future studies may investigate strategies to avoid drug-induced AKI.

Fasting during Ramadan and acute kidney injury (AKI): a retrospective, propensity matched cohort study

BackgroundDuring the month of Ramadan, Muslims abstain from daytime consumption of fluids and foods, although some high-risk individuals are exempt. Because fasting's effects on the risk of acute kidney injury (AKI) have not been established, this study assesses the relationship between fasting and risk of AKI and identifies patients at high risk.MethodsA single-center, retrospective, propensity-score matched, cohort study was conducted with data collected from adult patients admitted to the emergency room during Ramadan and the following month over two consecutive years (2016 and 2017). AKI was diagnosed based on the 2012 definition from the Kidney Disease: Improving Global Outcomes clinical practice guideline. Multivariable logistic regression analyses were used to examine the correlation and measure the effect of fasting on the incidence of AKI, and assess the effect of different variables on the incidence of AKI between the matching cohorts.ResultsA total of 1199 patients were included; after matching, each cohort had 499 patients. In the fasting cohort, the incidence of AKI and the risk of developing AKI were significantly lower (adjusted odds ratio (AOR) 0.65;95% confidence interval (CI) 0.44–0.98). The most indicative risk factors for AKI were hypertension (AOR 2.17; 95% CI 1.48–3.18), history of AKI (AOR 5.05; 95% CI 3.46–7.39), and liver cirrhosis (AOR 3.01; 95% CI 1.04–8.70). Patients with these factors or most other comorbidities in the fasting cohort had a lower risk of AKI as compared with their nonfasting counterparts.ConclusionThe data show a strong reduction in the risk of developing AKI as a benefit of fasting, particularly in patients with comorbid conditions. Therefore, most patients with comorbid conditions are not harmed from fasting during Ramadan. However, larger prospective studies are needed to investigate the benefit of fasting in reducing the risk of developing AKI.

Impact of central venous pressure on the mortality of patients with sepsis-related acute kidney injury: a propensity score-matched analysis based on the MIMIC IV database.

BackgroundSepsis has long been a life-threatening organ dysfunction. Sepsis associated acute kidney injury (SA-AKI) is an important complication of sepsis, as an important hemodynamic index, the impact of central venous pressure (CVP) on sepsis patients needs to be explored. Thus this study aimed to investigate the relationship between CVP and the mortality of SA-AKI.MethodsClinical data of adult patients with sepsis-related acute kidney injury, defined as met both the Sepsis 3.0 criteria and the Kidney Disease Improving Global Outcomes Clinical Practice Guideline (KDIGO) criteria, were obtained from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database. The included cohort was divided into a high CVP and a low CVP group were determined based on the cuf-off value from receiver operating characteristic curve, with propensity score-matched analysis of the 28-day mortality for both groups and sensitivity analysis using inverse the probability-weighting model, multifactorial regression, and doubly robust estimation, patients acquired chronic coronary syndrome (CCS) and diabetes were also taken into consideration.ResultsOf 1,377 patients with sepsis-related acute kidney injury, low CVP group (<13 mmHg) was 67.4% (n=928) and high CVP group (≥13 mmHg) was 32.6% (n=449). The two groups were matched 1:1 by propensity score to obtain a matched cohort (n=288). The mortality rates in the low versus high CVP group (19.4% vs. 34.7%) were statistically difference (odds ratio OR: 0.454; 95% confidence interval 0.263, 0.771). Moreover, the bistable analysis of logistic regression of the matched cohort (OR: 0.434; 95% CI: 0.244, 0.757), propensity score inverse probability weighting (IPW) (OR: 0.547; 95% CI: 0.454, 0.658), and multifactorial logistic regression (OR: 0.352; 95% CI: 0.127, 0.932) all yielded the same results.ConclusionsIn patients with sepsis-related acute kidney injury, a lower CVP level (<13 mmHg) is an independent variable associated with decreased mortality. The threshold of CVP needs to be controlled in clinical work to improve the prognosis of patients with SA-AKI.