Higher Baseline Serum Creatinine Research Articles

Acute Kidney Injury in Cirrhosis: Baseline Serum Creatinine Predicts Patient Outcomes.

The International Ascites Club (IAC) recently defined Stage 1 acute kidney injury (AKI) for cirrhosis as an acute increase in serum creatinine (SCr) by ≥0.3 mg/dl or by ≥50% in <48 h from a stable value within 3 months. The baseline SCr may influence AKI risk and patient outcomes. The objective of this study is to determine in cirrhosis whether the baseline SCr has any effect on the in-hospital AKI course and patient survival. North American Consortium for the Study of End-Stage Liver Disease is a consortium of tertiary-care hepatology centers prospectively enroling non-elective cirrhotic inpatients. Patients with different baseline SCr levels (≤0.5, 0.51-1.0, 1.01-1.5, >1.5 mg/dl) were evaluated for the development of AKI, and compared for AKI outcomes and 30-day survival. 653 hospitalized cirrhotics (56.7±10years, 64% men, 30% with infection) were included. The incidence of AKI was 47% of enrolled patients. Patients with higher baseline SCr were more likely to develop AKI, with significantly higher delta and peak SCr (P<0.001) than the other groups, more likely to have a progressive AKI course (P<0.0001), associated with a significantly reduced 30-day survival (P<0.0001). Multivariate logistic regression showed that the delta SCr during an AKI episode to be the strongest factor impacting AKI outcomes and survival (P<0.001), with a delta SCr of 0.70 mg/dl having a 68% sensitivity and 80% specificity for predicting 30-day mortality. Admitted cirrhotic patients with higher baseline SCr are at higher risk for in-hospital development of AKI, and more likely to have AKI progression with reduced survival. Therefore, such patients should be closely monitored and treated promptly for their AKI.

Acute Kidney Injury in Patients Continued on Renin-Angiotensin System Blockers During Hospitalization

BackgroundAcute kidney injury (AKI) is common in hospitalized patients and is associated with adverse outcomes. This study aimed to evaluate patient characteristics and interventions during hospitalization associated with the development of AKI in patients continued on renin-angiotensin system (RAS) blockers during hospitalization. MethodsA retrospective study of 184 adult patients admitted between January 2012 and September 2014 and continued on RAS blockers was conducted. Risk factors for AKI were compared between AKI (n = 92) and non-AKI (n = 92) groups. ResultsPatients who developed hospital-acquired AKI had a higher baseline serum creatinine (1.2 ± 0.4 versus 1 ± 0.3mg/dL, P < 0.001) and lower estimated glomerular filtration rate (54 ± 10 versus 57 ± 7mL/minute/1.73m2, P = 0.03) compared with patients who did not develop AKI. Patients who developed AKI were also more likely to be admitted to the intensive care unit, have surgical procedures, have hypotension and be prescribed loop diuretics. The presence of chronic kidney disease and hypotension were risk factors associated with AKI development. In addition, the AKI group had a significantly longer length of stay (14 days versus 8 days, P < 0.0001) and had a higher rate of all-cause hospital mortality (9% versus 1%, P = 0.03). ConclusionsPatients with chronic kidney disease, hypotension and those undergoing surgeries were more likely to develop AKI while receiving RAS blockers. During hospitalization, temporary discontinuation of these medications may be warranted in patients with these characteristics.

Renal dysfunction following bone marrow transplantation.

Acute kidney injury and long-term renal dysfunction are common problems following bone morrow transplantation (BMT) and highly related to mortality. The frequency and risk of renal dysfunction are directly related to the method of BMT, with myeloablative allogeneic BMT being associated to the highest risk followed by non-myeloablative allogeneic and myeloablative autologous BMT. The type of BMT is, thus, more important than co-factors such as advanced age, comorbidities, or high baseline serum creatinine. The causes for renal failure are multiple and include chemotherapy and high-dose radiation with fluid loss by diarrhea or vomiting, sepsis or nephrotoxic drugs such as calcineurin inhibitors and antimicrobials. Additionally, there are BMT-specific reasons for renal dysfunction including marrow infusion toxicity, hepatic veno-occlusive disease, thrombotic microangiopathy (TMA) and graft versus host disease (GvHD). Once the kidney has been damaged, the therapy depends on the underlying disease. Particularly in cases of TMA and GvHD, immunosuppressive therapy is essential. In TMA, plasma exchange therapy or eculizumab should be additionally considered if the complement system is affected. Hence, patients with these causes should preferably be referred to tertiary centers to allow early diagnosis and appropriate treatment.

PP.25.19

Objective: Contrast-induced acute kidney injury (CI-AKI) is a well-known serious complication of percutaneous coronary intervention (PCI) associated with increased morbidity and mortality. The aim of the study was to evaluate the incidence, predictors and outcomes of CI-AKI in patients with unstable angina pectoris/non-STEMI (UAP/NSTEMI) and delayed PCI. Design and method: 236 patients with UAP/NSTEMI and delayed PCI (158 male, 69 ± 14 years (M ± SD), arterial hypertension 94%, previous myocardial infarction 36%, diabetes mellitus (DM) 22%, known chronic kidney disease 15%, anemia 15%, heart failure 58%, left ventricular ejection fraction (LV EF) 44 ± 6%) were examined. CI-AKI was defined using 2012 KDIGO Guidelines. Mann-Whitney test was performed. P < 0.05 was considered statistically significant. Results: 15% of patients developed CI-AKI. Stages 1 and 2 of CI-AKI were found in 71 and 29% of cases accordingly. CI-AKI developed in 61% of cases in first 48 hours after PCI. Patients with versus without CI-AKI had higher baseline serum creatinine (104 ± 32 vs 98 ± 24 μmol/l, p < 0.05), plasma glucose (8,4 ± 3,9 vs 6,7 ± 2,7 mmol/l, p < 0.05), higher rate of DM (39 vs 19,5%, p < 0.05), anemia (28 vs 12,5%, p < 0.05), stroke (44 vs 20%, p < 0.05), higher rate of therapy with nephrotoxic antibiotics (11 vs 3.5%, p < 0.05), lower rate of postprocedural TIMI3 (83 vs 96 %, p < 0.05), higher rate of main left coronary artery disease (59 vs 30%, p < 0.001). Patients with CI-AKI had higher risk of hospital mortality (11 vs 1.5%, p < 0.001), 30-days mortality (12 vs 4%, p < 0.05) and similar rate of 6 months rehospitalizations (74 vs 58%, p > 0.05). Conclusions: CI-AKI in patients with UAP/NSTEMI and delayed PCI developed in 15% of cases, predominantly in first 48 hours after PCI. CI-AKI was associated with higher rate of comorbidities (DM, anemia, stroke), therapy with nephrotoxic drugs, higher baseline serum creatinine and plasma glucose, main left coronary artery disease, lower rate of postprocedural TIMI3. CI-AKI had negative impact on hospital mortality, 30-days mortality.

PP.22.17

Objective: The impact of acute decompensated heart failure (ADHF) on hepatic function has been described as cardio-hepatic syndrome. The aim of the study was to evaluate prevalence of liver transaminases (TA) increase in patients with ADHF. Design and method: In 200 patients with ADHF (84 male, 72.9 ± 10.7 years (M ± SD), arterial hypertension 79%, myocardial infarction 43%, atrial fibrillation (AF) 62%, diabetes mellitus 36.5%, chronic kidney disease (CKD) 38%, anaemia 23.5%, chronic obstructive lung disease 23.5%, ejection fraction (EF)45 ± 12%, EF < 35% 25%, chronic hepatic diseases 9.5%) alanine transaminase (ALT) and aspartate transaminase (AST) were measured at admission and further according routine clinical practice. TA were considered abnormal when exceeded 50U/L (local upper normal limit). Mann-Whitney test was performed. P < 0.05 was considered statistically significant. Results: Increase of ALT and/or AST occurred in 29(14.5%) patients (alone ALT/alone AST/both TA – in 42.3, 19.2, 38.5% respectively). Mean baseline ALT and AST values in patients with versus without increase of TA were 95 ± 36 vs 21 ± 14 U/l and 87 ± 26 vs 25 ± 11 U/l respectively (p < 0.001). Increase of ALT and AST more than 1, 2 and 3 UNL was found in 85.7%, 9.5% and 4.8% and 93%, 7%, 0% cases respectively. Increase of TA higher than 4UNL was not observed. Transient increase of TA was observed in 80% cases, persistent - in 20% cases. Patients with vs without increased TA had lower weight (76 ± 15 vs 87 ± 11 kg, p < 0.05), higher baseline serum creatinine (152 ± 44 vs 114 ± 44 μmol/l, p < 0.001), lower eGRF(34 ± 11 vs 53 ± 18 ml/min/1.73m2, p < 0.001), higher heart rate (115 ± 25 vs 92 ± 25 per minute, p < 0.001), left ventricular mass index (LVMI) (194 ± 40 vs 174 ± 48 g/m2, p < 0.01), lower EF (40 ± 11 vs 45 ± 12%, p < 0.05), higher rate of CKD (11 vs 2.8%, p < 0.05), anaemia (83 vs 24%, p < 0.05), AF (11 vs 1%, p < 0.001). Conclusions: Increase of TA in patients with ADHF occurred in 14.5%, predominantly was mild and transient. Cardiohepatic syndrome was associated with lower weight, higher baseline serum creatinine, lower eGRF, higher heart rate, LVMI, lower EF, higher rate of comorbidities (CKD, chronic anaemia, AF). There was no impact of chronic hepatic diseases on incidence of cardio-hepatic syndrome in patients with ADHF.

Balloon dilation atrial septostomy for advanced pulmonary hypertension in patients on prostanoid therapy.

Prostanoid therapy improves quality of life and may increase survival in patients with advanced pulmonary hypertension (PH). Balloon dilated atrial septostomy (BDAS) can palliate or bridge to transplantation for patients resistant to medical therapy. The safety and efficacy of BDAS in the prostanoid era has not previously been reported. All patients had progressive symptoms despite prostanoid therapy at the time of their first BDAS. Sixteen patients who underwent a total of 23 septostomies between 2004 and 2014 were included in this retrospective case series. Patients were aged 47.6 years ± 11.3 with 12/16 women. Etiologies included idiopathic (7), methamphetamine (6), scleroderma (1), and anorexigen (2). One patient died within 24 hr post-procedure. Thirty-day and 1-year survival were 75% and 64%, respectively. Six of the septostomies were revisions, including two which were ultimately stented. Three subjects were successfully bridged to transplant. Pulmonary capillary wedge pressure (PCWP) increased from a mean of 13 to 17 mm Hg, cardiac index increased from 2.1 to 2.4 L/min/m(2) , and arterial saturation decreased from 90.7 ± 4.3 to 82.5 ± 5.6%. All non-survivors at 30 days were male and had higher baseline serum creatinine, mean RAP, right ventricular end diastolic pressure (RVEDP), and left ventricle (LV) filling pressures, and lower right ventricle (RV) ejection fraction. Mortality was associated with unchanged post-septostomy cardiac output despite an increase in left ventricular end diastolic pressure (LVEDP). BDAS may be an alternate therapy for select PH patients who have symptomatic progression despite prostanoid therapy. Survival is comparable to prior reports of BDAS in the pre-prostanoid era.

Heart transplantation with or without prior mechanical circulatory support in adults with congenital heart disease

Recent analyses establish that heart transplantation is increasing among adults with congenital heart disease (ACHD), but the effects of pretransplant mechanical circulatory support (MCS) on perioperative and post-transplant outcomes have not been examined in the ACHD population. Scientific Registry of Transplant Recipients data on all adult heart transplants from September 1987 to September 2012 (n = 47 160) were classified based on primary diagnosis codes as CHD or non-CHD and MCS or non-MCS. Demographic, procedural, outcome and survival variables were compared between MCS and non-MCS ACHD patient groups. MCS was used in 83 (6.8%) ACHD patients compared with 8625 (18.8%) patients without CHD (P < 0.001). MCS as a fraction of ACHD transplants increased over time (P = 0.002). MCS patients spent more time on the wait list, had a higher baseline serum creatinine and were more likely to be male, status 1A, hospitalized, in the ICU and/or on a ventilator prior to transplant. However, MCS patients experienced equivalent short-term survival (30-day mortality = 10.8% in MCS vs 13.5% in non-MCS, P = 0.62) and overall survival by Kaplan-Meier analysis (P = 0.57). MCS patients had a longer post-transplant length of stay and were more likely to be transfused, but otherwise had no significant differences in adverse outcomes. MCS is less commonly used in adult CHD patients compared with all patients undergoing heart transplant, but has been increasing over time. Within the ACHD population, patients with MCS have a higher risk profile, but except for increased transfusion rate and longer length of stay, do not experience less favourable post-transplant outcomes.

Blood pressure changes after renal denervation at 10 European expert centers

We did a subject-level meta-analysis of the changes (Δ) in blood pressure (BP) observed 3 and 6 months after renal denervation (RDN) at 10 European centers. Recruited patients (n=109; 46.8% women; mean age 58.2 years) had essential hypertension confirmed by ambulatory BP. From baseline to 6 months, treatment score declined slightly from 4.7 to 4.4 drugs per day. Systolic/diastolic BP fell by 17.6/7.1 mm Hg for office BP, and by 5.9/3.5, 6.2/3.4, and 4.4/2.5 mm Hg for 24-h, daytime and nighttime BP (P⩽0.03 for all). In 47 patients with 3- and 6-month ambulatory measurements, systolic BP did not change between these two time points (P⩾0.08). Normalization was a systolic BP of <140 mm Hg on office measurement or <130 mm Hg on 24-h monitoring and improvement was a fall of ⩾10 mm Hg, irrespective of measurement technique. For office BP, at 6 months, normalization, improvement or no decrease occurred in 22.9, 59.6 and 22.9% of patients, respectively; for 24-h BP, these proportions were 14.7, 31.2 and 34.9%, respectively. Higher baseline BP predicted greater BP fall at follow-up; higher baseline serum creatinine was associated with lower probability of improvement of 24-h BP (odds ratio for 20-μmol l−1 increase, 0.60; P=0.05) and higher probability of experiencing no BP decrease (OR, 1.66; P=0.01). In conclusion, BP responses to RDN include regression-to-the-mean and remain to be consolidated in randomized trials based on ambulatory BP monitoring. For now, RDN should remain the last resort in patients in whom all other ways to control BP failed, and it must be cautiously used in patients with renal impairment.

Impact of Periprocedural Atrial Fibrillation on Short-Term Clinical Outcomes Following Percutaneous Coronary Intervention

There are few data on the incidence and clinical outcomes of patients with atrial fibrillation (AF) treated in the era of percutaneous coronary intervention (PCI). We analyzed 30-day clinical outcomes in 3,307 consecutive patients with and without AF (sinus rhythm) undergoing PCI from January 2007 through December 2008 enrolled in a multicenter Australian registry. Periprocedural AF was present in 162 patients (4.9%). AF was associated with older age (74.1 ± 8.9 vs 63.9 ± 11.9 years, p <0.001), higher baseline serum creatinine (0.13 ± 0.14 vs 0.10 ± 0.13 mmol/L, p = 0.01), and lower left ventricular ejection fraction (49.5 ± 13.2% vs 53.4% ± 11.6%, p <0.001). Significantly more patients with AF had a history of heart failure and cerebrovascular and peripheral arterial diseases (p ≤0.01 for all comparisons). Periprocedural glycoprotein IIb/IIIa inhibitor (31.5% vs 31.4%, p = 0.98) and antithrombin use were not different between groups, but in-hospital bleeding complications were higher in patients with AF (5.0% vs 2.1%, p = 0.015). Fewer patients with AF received drug-eluting stents (p = 0.004). AF was associated with a greater than fourfold increase in 30-day mortality (9.9% vs 2.2%, p <0.0001) and readmission rates at 30 days (p = 0.01). Fewer patients with AF were on dual antiplatelet therapy at 30 days (86.3% vs 94.3%, p <0.0001), although 28.1% of patients with AF were on triple therapy (dual antiplatelet therapy plus oral anticoagulation). In conclusion, patients with periprocedural AF represent a very high-risk group. Excess 30-day morbidity and mortality after PCI may be due to the higher incidence of co-morbidities, bleeding complications, and suboptimal antiplatelet therapy.

Abstract 17001: Safety and Efficacy of Balloon Atrial Septostomy for Advanced Pulmonary Hypertension in Patients Failing Prostanoid Therapy

Background: Prostanoid therapy improves quality of life and may increase survival in patients with advanced pulmonary hypertension (PH). Balloon atrial septostomy (BAS) can palliate or a serve as a bridge to transplantation for patients resistant to medical therapy. The safety and efficacy of BAS in the era of prostanoid therapy has not previously been reported. Methods: All patients had progressive symptoms despite prostanoid therapy at the time of their first BAS. Eleven patients who underwent a total of 16 septostomies between 2004-11 were included in this retrospective analysis. Results: Baseline demographics are shown in Table 1. Survival at a mean of 739 days was 73%. No patient died within 24 hours post-procedure. Thirty-day and 1-year survival were both 82%. 4 subjects required repeat BAS due to shunt closure; 3 subjects were successfully bridged to transplant. 9 of 11 patients had improvement by one functional class. Hemodynamic and echocardiographic measurements are presented in Table 2. All non-survivors were male and had higher baseline serum creatinine, mean right atrial pressure, right ventricular (RV) end diastolic pressure and left ventricular filling pressures, and lower RV ejection fraction. Mortality was associated with unchanged post-septostomy cardiac output despite an increase in LVEDP. Tricuspid annular plane systolic excursion (TAPSE) and serum BNP were not different between the two groups. Conclusions: BAS appears to be a promising therapy for select PH patients who have symptomatic progression despite prostanoid therapy. Survival is comparable to prior reports of patients undergoing BAS in the pre-prostanoid era.

Predictors of outcome for renal artery stenting performed for salvage of renal function

To identify preoperative clinical features that predict a durable improvement in renal function with renal artery stenting (RAS). Sixty-one patients with renal insufficiency (serum creatinine ≥ 1.5 mg/dL) underwent RAS for renal salvage. Patients were categorized as "responders" if estimated glomerular filtration rate (eGFR) at last follow-up was improved 20% or more over baseline. Patients with stable or worse renal function after RAS were labeled "non-responders." For the purpose of calculating changes in eGFR, patients on dialysis were represented by an eGFR of 10 ml/min/1.73 m(2). Renal volume was estimated as kidney length × width × depth/2. The median age of the cohort was 66 years (interquartile range [IQR], 60-73 years). Median preoperative serum creatinine was 1.8 mg/dL (IQR, 1.6-2.3), and median estimated glomerular filtration rate (eGFR) was 34 mL/min/1.73 m(2) (IQR, 24-45). With stenting, 17 of 61 patients (27.9%) derived a durable improvement in renal function at a median follow-up of 24 months (IQR, 16-33 months). The largest proportion of stented patients (44.3%) had no improvement in renal function after stenting, while a subset (27.9%) experienced a decline in renal function. Responders enjoyed a 47% improvement in renal function from baseline, while non-responders had a 13% decrement in renal function (P < .0001). Responders had a higher baseline serum creatinine, lower eGFR, and a steeper decline in renal function prior to RAS, compared with non-responders. Kidney length, width, depth, and volume were not significantly different between responders and non-responders. Logistic regression analysis identified the rate of decline of renal function prior to stenting as the only independent preoperative predictor of improved renal function after RAS (odds ratio, 3.4; 95% confidence interval, 1.6 to 7.5; P = .0019). The rate of decline in eGFR per week was more than 20-fold greater for responders than non-responders (2.1% vs 0% decline in eGFR per week; P < .0001). No predictors of renal function deterioration after stenting were identified. The current study found that a steep decline in preoperative renal function portends a higher likelihood of renal salvage from RAS among patients with renal insufficiency. Incorporating this finding into patient selection may improve outcomes for RAS.

Persistent renal enhancement after intra-arterial versus intravenous iodixanol administration

To examine the clinical significance of persistent renal enhancement after iodixanol administration. We retrospectively studied 166 consecutive patients who underwent non-enhanced abdominopelvic CT within 7 days after receiving intra-arterial (n=99) or intravenous (n=67) iodixanol. Renal attenuation was measured for each non-enhanced CT scan. Persistent renal enhancement was defined as CT attenuation>55 Hounsfield units (HU). Contrast-induced nephropathy (CIN) was defined as a rise in serum creatinine>0.5 mg/dL within 5 days after contrast administration. While the intensity and frequency of persistent renal enhancement was higher after intra-arterial (mean CT attenuation of 73.7 HU, seen in 54 of 99 patients, or 55%) than intravenous contrast material administration (51.8 HU, seen in 21 of 67, or 31%, p<0.005), a multivariate regression model showed that the independent predictors of persistent renal enhancement were a shorter time interval until the subsequent non-enhanced CT (p<0.001); higher contrast dose (p<0.001); higher baseline serum creatinine (p<0.01); and older age (p<0.05). The route of contrast administration was not a predictor of persistent renal enhancement in this model. Contrast-induced nephropathy was noted in 9 patients who received intra-arterial (9%) versus 3 who received intravenous iodixanol (4%), and was more common in patients with persistent renal enhancement (p<0.01). Persistent renal enhancement at follow-up non-contrast CT suggests a greater risk for contrast-induced nephropathy, but the increased frequency of striking renal enhancement in patients who received intra-arterial rather than intravenous contrast material also reflects the larger doses of contrast and shorter time to subsequent follow-up CT scanning for such patients.

Renal Artery Stenting for Salvage of Renal Function: Preoperative Predictors of Outcome Guide Patient Selection

Improved renal function after renal artery bypass surgery has been associated with improved dialysis-free survival. Unfortunately, renal artery bypass in patients with ischemic nephropathy carries a 4% to 7% operative mortality rate. Renal artery stenting (RAS) offers a lower risk of mortality, but the clinical response rates for RAS have been disappointing. We surmise that the poor results for RAS are related to inadequate patient selection. The purpose of this study was to identify preoperative clinical features that predict a durable improvement in renal function with RAS. The study cohort consisted of 43 patients with renal insufficiency (serum creatinine ≥ 1.5 mg/dL) who underwent RAS for renal salvage. Patients were categorized as “responders” if estimated glomerular filtration rate (eGFR) at last follow-up was improved 20% or more over baseline. Patients with stable or worse renal function after RAS were labeled “nonresponders.” For the purpose of calculating changes in eGFR, patients on dialysis were represented by an eGFR of 10 mL/min/1.73 m2. Renal volume was estimated as kidney length × width × depth/2. The median age of the cohort was 69 years (interquartile range, IQR, 61-73 years). Median preoperative serum creatinine was 1.8 mg/dL (IQR 1.6-2.3), and median eGFR was 39 mL/min/1.73 m2 (IQR 21-46). With stenting, 11 of 43 patients (25.6%) derived a durable improvement in renal function at a median follow-up of 26 months (IQR 16-36 months). Responders enjoyed a 54% improvement in renal function from baseline, while nonresponders had a 7% decrement in renal function (P < .0001). Responders had a higher diastolic blood pressure, higher baseline serum creatinine, lower eGFR, and a steeper decline in renal function prior to RAS (Table). Kidney length, width, depth, and volume were not significantly different between responders and nonresponders (Table). Logistic regression analysis identified the rate of decline of renal function prior to stenting as the only independent predictor of improved renal function after RAS (odds ratio 16.7, 95% confidence interval 1.9-147.0; P = .011). Indeed, the rate of decline in eGFR per week was more than 18-fold greater for responders than nonresponders (3.4% vs 0.18% decline in eGFR per week; P < .0001).Tabled 1VariablesRespondersNonrespondersP valueAge71 years68 years.62Gender55% male66% male.43Systolic blood pressure172 mm Hg145 mm Hg.15Diastolic blood pressure86 mm Hg73 mm Hg.015Serum creatinine2.4 mg/dL1.7 mg/dL.025eGFR21 ml/min/1.72m242 ml/min/1.72 m2.027Percent decline in preop eGFR per week3.4 % / week0.18 % / week< .0001Proportion with solitary kidneys18%13%.64Kidney Length9.6 cm9.8 cm.72Kidney Width5.3 cm5.4 cm.20Kidney Depth5.0 cm5.1 cm.70Kidney Volume123 cm3129 cm3.53 Open table in a new tab The current study found that a steep decline in preoperative renal function portends a higher likelihood of renal salvage from RAS among patients with renal insufficiency. Incorporating this finding into patient selection may improve outcomes for RAS.

Race and renal function early after live kidney donation: an analysis of the United States Organ Procurement and Transplantation Network Database.

Among Americans, the risk for kidney disease is higher in individuals of African descent (AA) when compared with Caucasians. We considered whether there are similar racial differences in kidney function soon after donor nephrectomy. Of the 31,928 live kidney donors that donated between the years 2000 and 2005, 16,996 (53%) had post-donation serum creatinine recorded at a mean follow-up of 156 d (range 1-1410 d). A total of 14,525 (85%) were Caucasians and 2471 (15%) were AA. When compared with Caucasians, AA donors were more likely to be younger, heavier, and male, had a higher baseline serum creatinine and a shorter duration of follow-up. After accounting for these differences, the serum creatinine after donation and fractional rise in serum creatinine after donation were similar between the two groups (AA vs. Caucasian donors, 1.3 ± 0.3 vs. 1.2 ± 0.3 mg/dL; 53% vs. 45%) and the post-donation estimated glomerular filtration rate was also similar (57.2 ± 0.6 vs. 56.0 ± 0.2 mL/min per 1.73 m(2)). We observed no major clinical difference in glomerular filtration rate and ability to compensate for loss of renal mass soon after live kidney donation between Caucasian and AA donors.

Prevalence and Risk Factors for Acute Kidney Injury Associated with Parenteral Polymyxin B Use

The main adverse effect of polymyxin B is nephrotoxicity. There are few data on polymyxin-associated renal injury. To assess the prevalence of and risk factors for acute kidney injury (AKI) in patients treated with polymyxin B. The studied population included 114 patients who received at least 3 consecutive days of intravenous polymyxin B and had baseline serum creatinine (SCr) and at least one further SCr measurement during treatment. AKI was defined as an SCr increase to 1.8 mg/dL or greater in patients with baseline SCr less than 1.5 mg/dL, or an increase greater than or equal to 50% in baseline SCr when it was already greater than or equal to 1.5 mg/dL, or need for dialysis. AKI developed in 22% of the patients. They were older, had a higher baseline SCr, had a higher frequency of baseline SCr greater than or equal to 1.5 mg/dL, used other nephrotoxic drugs and furosemide more often, and required vasoactive drugs and mechanical ventilation more frequently. Progression to renal failure was significantly more probable when the bacteria were isolated in the abdomen, catheter, or blood. AKI patients had a higher mortality rate (92% vs 53%; p < 0.001). Logistic regression identified abnormal baseline SCr (odds ratio [OR] 3.51); need for vasoactive drugs (OR 3.03); and abdomen, blood, or catheter as the infection site (OR 3.82) as independent risk factors for AKI. Patients who developed AKI had a strikingly elevated mortality rate. Polymyxin B should be used with extreme caution in patients who have an abnormal baseline SCr; use vasoactive drugs; or have abdomen, blood, or catheter as the infection site.

Gentamicin-associated acute kidney injury

The incidence of gentamicin-associated acute kidney injury (AKI) as defined by the RIFLE criteria is unknown. We performed a retrospective observational study to examine this and the predictive value of RIFLE stage on patient outcome in this setting. We included all patients who were treated with gentamicin at our centre over a 1-month period. Data on 228 patients across all specialities were collected by manual searching of hospital notes and electronic pathology reporting systems. Information collected included baseline and peak serum creatinine results, gentamicin dose and serum levels, the presence of additional renal insults and the Stoke co-morbidity index. AKI occurred in 51 (24.4%) patients; 37 (17.7%) 'Risk', 9 (4.3%) 'Injury', 5 (2.4%) 'Failure'. Independent predictors of gentamicin associated AKI were number of gentamicin levels >2 mg/l (OR 1.845, 95% CI 1.22 to 2.79) and higher baseline serum creatinine (OR 1.014, 95% CI 1.001-1.028). There was a greatly increased risk of in-hospital mortality in the AKI group as compared to those without AKI (45.1% vs. 19.1%, OR 3.48, 95% CI 1.8-6.9, P = 0.0004). Risk of in hospital mortality increased with each RIFLE stage (P < 0.0001). This study shows that gentamicin-associated AKI remains a common and potentially serious clinical problem. There is a strong correlation between RIFLE class and in-hospital mortality.

Prevention of contrast-induced nephropathy by chronic pravastatin treatment in patients with cardiovascular disease and renal insufficiency

Contrast-induced nephropathy (CIN) is known to increase morbidity and mortality of cardiovascular disease. Recent studies have shown statins prevented CIN after contrast media exposure, but optimal statin type and dosage are still unknown. The aims of the present study were to evaluate whether chronic pravastatin treatment before scheduled coronary angiography or percutaneous coronary intervention could reduce the incidence of CIN and to elucidate the factors related to CIN in patients with renal insufficiency. We studied 431 consecutive patients with renal insufficiency. One hundred ninety-four patients were receiving pravastatin treatment as standard chronic treatment of hypercholesterolemia. Serum creatinine levels were measured at baseline (pre-procedure) and within 48 h after contrast media exposure (peak post-procedure). CIN was defined as an increase in the serum creatinine values of > or = 25% or > or = 0.5 mg/dl after contrast media exposure. Logistic regression analysis was performed to evaluate the important factors related to CIN using four variables: age, pravastatin, pre-procedure serum creatinine, and contrast volume. CIN was observed in 36 patients (8.4%). Patients without pravastatin (p<0.01), high level pre-procedure serum creatinine (p<0.01), and high contrast volume (p=0.034) had a significantly higher incidence of CIN. Logistic regression analysis revealed that pravastatin treatment (chi(2)=6.549, p=0.011, odds ratio=0.34), pre-procedure serum creatinine (chi(2)=6.294, p=0.009, odds ratio=2.78), and contrast volume (chi(2)=4.484, p=0.034, odds ratio=1.01) were independently related to the decreased risk of CIN. Chronic pravastatin treatment before contrast media exposure was important for preventing CIN in patients with renal insufficiency. Also, reducing the dose of contrast media was important for preventing CIN in patients with high-baseline serum creatinine levels.

Factors Associated with the Use of Preventive Care for Contrast-Induced Acute Kidney Injury

The factors that affect the implementation of preventive care for contrast-induced acute kidney injury (CIAKI) are unknown. To assess patient and provider factors associated with the use of preventive care for CIAKI. Prospective cohort study. Patients with kidney disease undergoing procedures with intravascular iodinated radiocontrast. We recorded the use of preventive care defined as the administration of: (1) pre- and post-procedure isotonic intravenous (IV) fluid, (2) N-acetylcysteine, and (3) iso-osmolal radiocontrast. We surveyed patients' providers to assess their knowledge, experience, and training on CIAKI and used multiple logistic regression to assess the independent associations of patient and provider factors with the use of these preventive interventions. We enrolled 660 patients and 87 providers. Patient factors associated with use of IV fluid and N-acetylcysteine were higher baseline serum creatinine (OR 1.5 and 5.0, p < 0.05) and inpatient status (OR 3.0 and 6.3, p < 0.05), while higher baseline serum creatinine was associated with the use of iso-osmolal contrast (OR = 13.4, p < 0.01). The primary provider characteristics associated with the use of IV fluid and N-acetylcysteine were a greater degree of prior training on CIAKI (OR 1.9 and 2.8, p < 0.05) and higher number of prior patients with CIAKI (OR 2.7 and 2.6, p < 0.05). Patient baseline kidney function and provider training and experience with CIAKI are independently associated with the use of preventive care. Efforts to increase and intensify the training providers receive on CIAKI may help decrease the incidence of this costly iatrogenic condition.

Sodium Bicarbonate versus Normal Saline for Protection against Contrast Nephropathy

Contrast-induced nephropathy (CIN) is a form of acute kidney injury and a significant source of morbidity and mortality. We defined CIN as an increase in serum creatinine (SCr) of 25% or more within 48 hours of receiving contrast. We retrospectively compared sodium bicarbonate with normal saline for prevention of CIN. One hundred and eighty-seven patients exposed to contrast during cardiac angiography, treated prophylactically either with sodium bicarbonate (n = 89) or with normal saline (n = 98), were studied. Baseline characteristics of both groups were similar in terms of age, amount of contrast, presence of diabetes mellitus, and use of furosemide and angiotensin-converting enzyme inhibitor. Patients in bicarbonate group had more severe renal disease with higher baseline SCr (1.58 ± 0.5 mg/dL vs. 1.28 ± 0.3 mg/dL, p = 0.001) and lower estimated glomerular filtration rate (eGFR, 51.06 ± 14.0 mL/min vs. 62.3±13.5 mL/min, p = 0.001) compared to the normal saline group. After the contrast exposure, there was significant drop in eGFR (6.4%) and increase in SCr (11.3%) in the normal saline group and no significant change in the bicarbonate group. Three patients (3.4%) in the bicarbonate group as opposed to 14 patients (14.3%) in the normal saline group developed CIN (p = 0.011). Two patients in the normal saline group and none in the bicarbonate group needed dialysis. There was no significant difference in serum creatinine at three-month follow-up in either group. The above findings suggest that hydration with intravenous sodium bicarbonate is more effective than normal saline in preventing contrast-induced nephropathy.

Impact of Variability of Sirolimus Trough Level on Chronic Allograft Nephropathy

The efficacy of sirolimus is strictly dose-dependent; an inappropriate exposure may cause either rejection episodes or drug toxicity. The variability of sirolimus trough levels (C 0) may also have an impact on renal allograft function. We prospectively evaluated the impact of the dose-normalized C 0 of sirolimus and the intrapatient coefficient of variation (% CV) on renal allograft function at 6 months after the administration of sirolimus to kidney transplant recipients with chronic allograft nephropathy (CAN). We enrolled 51 recipients with CAN who were treated with sirolimus. The dose-normalized C 0 of sirolimus was 3.8 ± 1.9 ng/mL/mg. The intra- and interpatient variabilities of sirolimus C 0 were 26.1% and 51.9%, respectively. Based on receiver operating characteristic analysis, patients were divided into 2 groups: group I, sirolimus % CV <22.9% (n = 36) versus group II, sirolimus % CV >22.9% (n = 15). Patients in group II experienced significantly greater risk for progressive deterioration of allograft function (group I vs group II: 11.1% vs 73.3%; P < .05). Multiple logistic regression analysis revealed that higher baseline serum creatinine, but not age, gender, or concomitant immunosuppressants, positively correlated with the sirolimus % CV. In conclusion, both higher baseline serum creatinine and higher intraindividual variability of sirolimus C 0 impact the outcome of renal allograft function in CAN. Thus, we suggest that close monitoring of sirolimus C 0 is necessary for recipients treated with sirolimus, especially for patients with CAN.