Acute Kidney Injury In Hospital Research Articles

0.9% sodium chloride versus dextrose 5% in water safety as medication's diluents in critically ill patients: Meta-analysis of observational studies

Adverse drug effects such as electrolyte abnormalities and acid-base disturbances are commonly associated with intravenous (IV) fluids administered in the intensive care units (ICUs). Although several studies have addressed the risk associated with resuscitative fluids in ICU patients, limited data evaluating the safety of IV medications diluents and their association with clinical outcomes in critical care settings. We conducted a systematic review and meta-analysis to compare the safety of 0.9% sodium chloride (0.9% NaCl) and dextrose 5% in water (D5W) as drug diluents in ICU settings. We searched PubMed, MEDLINE, Cochrane Library bibliographic databases, and conference abstracts for studies comparing medication diluents in adult critically ill patients. Our primary outcome was the risk of hypernatremia. The secondary outcomes included hyperchloremia, acute kidney injury (AKI) rate, ICU length of stay (LOS), ICU mortality, and hospital mortality. Three observational studies were included (1549 patients), all received 0.9% NaCl as standard diluents and D5W was the comparison. Our results shows that hypernatremia and hyperchloremia were significantly higher in 0.9% NaCl group (risk ratio [RR], 1.84; 95% confidence interval [CI], 1.38–2.47; P ≤ 0.001; I = 0%), (RR, 1.78; 95% CI, 1.38–2.31; P < 0.001, I2 = 0%), respectively. There was no significant difference in AKI risk, hyperglycemia, and hospital mortality between the groups. However, the 0.9% NaCl group has a longer ICU LOS (mean difference 0·407, 0·062–0·752; P = 0.021). The utilization of D5W as medication diluent in critical care settings was associated with a lower incidence of hypernatremia and hyperchloremia, In addition, may be associated with shorter ICU LOS.

SGLT2 Inhibitors and the Risk of Acute Kidney Injury in Older Adults With Type 2 Diabetes

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been found to have many benefits for patients with type 2 diabetes. However, whether SGLT2 inhibitors increase the risk of acute kidney injury (AKI) remains unknown. We examined the association of AKI hospitalization with prior initiation of an SGLT2 inhibitor compared with initiation of a dipeptidyl peptidase 4 (DPP-4) inhibitor or a glucagon-like peptide 1 receptor agonist (GLP-1RA) among older adults with type 2 diabetes in routine practice. Population-based cohort study. Older adults aged at least 66 years with type 2 diabetes enrolled in Medicare fee-for-service and who were new users of SGLT2 inhibitor, DPP-4 inhibitor, or GLP-1RA agents in the interval from March 2013 to December2017. New use of an SGLT2 inhibitor versus new use of a DPP-4 inhibitor or GLP-1RA. The primary outcome was hospitalization for AKI, defined as a discharge diagnosis of AKI in the primary or secondary position. New users of SGLT2 inhibitors were matched at a 1:1 ratio to new users of DPP-4 inhibitors or GLP-1RAs using propensity scores in 2 pairwise comparisons. Cox proportional hazards regression models generated hazard ratios (HRs) with 95% CIs in propensity score-matched groups. Totals of 68,130 and 71,477 new users of SGLT2 inhibitors were matched to new users of DPP-4 inhibitors or GLP-1RAs, respectively. Overall, the mean age of study participants was 72 years. The risk of AKI was lower in the SGLT2 inhibitor group than in the DPP-4 inhibitor group (HR, 0.71 [95% CI, 0.65-0.76]) or the GLP-1RA group (HR, 0.81 [95% CI, 0.75-0.87]). Residual confounding and lack of laboratory data. Among older adults with type 2 diabetes, initiation of an SGLT2 inhibitor was associated with a reduced risk of AKI compared with initiation of a DPP-4 inhibitor or a GLP-1RA.

Adverse outcomes after partner bereavement in people with reduced kidney function: Parallel cohort studies in England and Denmark.

To investigate whether partner bereavement is associated with adverse cardiovascular and kidney-related events in people with reduced kidney function. Two parallel matched cohort studies using linked routinely collected health data. England (general practices and hospitals using linked Clinical Practice Research Datalink, Hospital Episode Statistics, and Office of National Statistics) and Denmark (hospitals and community pharmacies using the Danish National Patient, Prescription and Education Registries and the Civil Registration System). Bereaved people with reduced kidney function (estimated glomerular filtration rate (eGFR) <60mL/min/1.73m2 (England) or hospital-coded chronic kidney disease (Denmark)) and non-bereaved people with reduced kidney function similarly defined, matched on age, sex, general practice (England), and county of residence (Denmark) and followed-up from the bereavement date of the exposed person. Cardiovascular disease (CVD) or acute kidney injury (AKI) hospitalization, or death. In people with reduced kidney function, we identified 19,820 (England) and 5,408 (Denmark) bereaved individuals and matched them with 134,828 (England) and 35,741 (Denmark) non-bereaved individuals. Among the bereaved, the rates of hospitalizations (per 1000 person-years) with CVD were 31.7 (95%-CI: 30.5-32.9) in England and 78.8 (95%-CI: 74.9-82.9) in Denmark; the rates of hospitalizations with AKI were 13.2 (95%-CI: 12.5-14.0) in England and 11.2 (95%-CI: 9.9-12.7) in Denmark; and the rates of death were 70.2 (95%-CI: 68.5-72.0) in England and 126.4 (95%-CI: 121.8-131.1) in Denmark. After adjusting for confounders, we found increased rates of CVD (England, HR 1.06 [95%-CI: 1.01-1.12]; Denmark, HR 1.10 [95%-CI: 1.04-1.17]), of AKI (England, HR 1.20 [95%-CI: 1.10-1.31]; Denmark HR 1.36 [95%-CI: 1.17-1.58]), and of death (England, HR 1.10 [95%-CI: 1.05-1.14]; Denmark HR 1.20 [95%-CI: 1.15-1.25]) in bereaved compared with non-bereaved people. Partner bereavement is associated with an increased rate of CVD and AKI hospitalization, and death in people with reduced kidney function. Additional supportive care for this at-risk population may help prevent serious adverse events.

Ambient temperature and hospitalizations for acute kidney injury in Queensland, Australia, 1995–2016

To examine the associations between ambient temperature and hospitalizations for acute kidney injury (AKI) in Queensland, Australia, 1995–2016. Data were collected on a total of 34 379 hospitalizations for AKI from Queensland between 1 January 1995 and 31 December 2016. Meteorological data were downloaded from the Queensland Government’s Department of Environment and Science. We assessed the temperature-AKI relationship using a time-stratified case-crossover design fitted with conditional quasi-Poisson regression model and time-varying distributed lag non-linear model. Stratified analyses were performed by age, sex, climate zone and socioeconomic group. Both cold and hot temperatures were associated with hospitalizations for AKI. There were stronger temperature-AKI associations among women than men. Cold effects were only positive in the ⩾70 years age group. Hot effects were stronger in the ⩽59 years age group than in the >60 years age group. In different climate zone areas, cold effects decreased with increasing local mean temperatures, while hot effects increased. In different socio-economic status groups, hot effects were stronger in the poor areas than the affluent areas. From 1995 to 2016, the magnitude of associations between cold temperature and hospitalizations for AKI decreased, while the hot effect increased. The associations between hot temperature and hospitalizations for AKI become stronger, while the magnitude of cold effect decreased from 1995 to 2016. This trend may accelerate over the coming decades, which warrants further research. More attention is needed toward susceptible population including women, people ⩾70 years, and the people living in hot climate zones and in low socioeconomic status areas.

792-P: Comparative Safety of Empagliflozin in Routine Care Patients: Interim Results from the Empagliflozin Comparative Effectiveness and Safety (EMPRISE) Study

In the EMPA-REG OUTCOME trial empagliflozin (EMPA) reduced the risk of cardiovascular death, all-cause mortality, and hospitalization for heart failure in patients with type 2 diabetes (T2D) and established cardiovascular disease. The comparative safety of EMPA in routine care is yet to be established. EMPRISE studies the effectiveness, safety and healthcare utilization of EMPA, based on data from Medicare and 2 U.S. commercial claims datasets (2014-2019). In an interim analysis using data from 2014-2018 (2014-2017 in Medicare), we identified 55,580 pairs of 1:1 propensity score-matched patients ≥18 years with T2D initiating EMPA or a DPP4 inhibitor (DPP4i). Safety outcomes of interest included lower-limb amputations (LLA), bone fractures, diabetic ketoacidosis hospitalization (DKA), and acute kidney injury hospitalization (AKI). We estimated pooled HR and RD/1000 PY with their 95% CI adjusting for >140 baseline covariates. Over a mean follow up of 6.3 months, EMPA initiators had similar risk of LLA and fractures, an increased risk of DKA [HR, 2.01 (1.37-2.95); RD, 1.44 (0.72,2.17) per 1000 PY], and a decreased risk of AKI [HR, 0.66 (0.59-0.74); RD, -8.59 (-10.93,-6.25) per 1000 PY], compared with DPP4i (Table). In routine care, the initiation of EMPA was associated with a safety profile in line with documented information.View largeDownload slideView largeDownload slide DisclosureE. Patorno: Research Support; Self; Boehringer Ingelheim International GmbH, National Institutes of Health. S. Schneeweiss: Other Relationship; Self; Aetion. H. Tesfaye: None. D. J. Wexler: Board Member; Self; Novo Nordisk. R. Glynn: Research Support; Self; AstraZeneca, Kowa Research Institute, Inc., Novartis AG, Pfizer Inc. M. Najafzadeh: None. L. G. Bessette: Consultant; Self; Aetion, Inc. H. Zakoul: None. L. Koeneman: Employee; Self; Eli Lilly and Company, Stock/Shareholder; Self; Eli Lilly and Company. A. Deruaz-luyet: Employee; Self; Boehringer Ingelheim (Canada) Ltd., Employee; Spouse/Partner; Sanofi-Aventis Deutschland GmbH.

69-Year-Old Man With Nasal Congestion and Pre-Syncope

69-Year-Old Man With Nasal Congestion and Pre-Syncope

Alarming rates of psychological problems among caregivers of pediatric kidney patients admitted during the COVID-19 pandemic lockdown.

Introduction:Caregivers of children with comorbidities suffer from various psychological problems. We envisage more such complications during this COVID-19 pandemic.Methodology:A cross-sectional study to assess psychological issues in caregivers of children with kidney diseases, admitted during lockdown period in India was done. Psychological tools including Peritraumatic Distress Inventory (PDI), Insomnia Severity Index, Depression Anxiety Stress Scale (DASS II), Positive and Negative Affect Schedule (PANAS) and a new “COVID Stress Survey Questionnaire” were used. Standard statistical analysis using SPSS Statistic 23 (IBM SPSS Statistics, New York, United States) was done.Results:Forty-seven caregivers (33 mothers; 14 fathers) were included. Of these, 33 (70.2%) experienced psychological distress. On PANAS, 45 (95.7%) scored below cut off on a positive affect and 42 (89.4%) scored above cut off on a negative effect. The DASS II score revealed that 38 (80.9%) reported mild stress, 23 (48.9%) severe anxiety, and 37 (78.7%) had moderate depression. Upper middle socioeconomic status caregivers reported more insomnia. Further, parents of children with acute kidney injury (AKI) or prolonged hospital stay scored higher on subjective distress and aversive feelings.Conclusion:We observed an alarming level of distress, insomnia, and anxiety among caregivers, more so in upper middle socioeconomic status, children with AKI and prolonged hospital stay. We suggest due counseling should be done.

Cost–benefit analysis comparing trough, two-level AUC and Bayesian AUC dosing for vancomycin

ObjectivesArea under the time–concentration curve (AUC) -guided dosing provides better estimates of exposure than vancomycin trough concentrations. Though clinical benefits have been reported, the costs of AUC-guided dosing are uncertain. The objective of this study was to quantify the costs of single-sample Bayesian or two-sample AUC strategies versus trough-guided dosing. MethodsA cost–benefit analysis from the institutional perspective was conducted using a decision tree to model the probabilities and costs of acute kidney injury (AKI) associated with vancomycin administered over 48 hours up to 21+ days. Costs included vancomycin concentrations, Bayesian software and AKI hospitalization costs, and probabilities were obtained from primary literature. Robustness was assessed via both one-way and probabilistic sensitivity analyses. ResultsIn the base-case model, two-sample AUC versus trough dosing saved an average of US$ 846 per patient encounter, and single-sample Bayesian AUC versus trough dosing saved an average of US$ 2065 per patient encounter. This translates into annual cost-savings of US$ 846 810 and US$ 2 065 720 for two-sample and single-sample Bayesian methods versus trough dosing, respectively, assuming 1000 vancomycin-treated patients per year. Assuming a budget of US$ 100 000 per year for Bayesian software, an institution would need to treat ≥41 patients with vancomycin for at least 48 hours to break even. ConclusionsThere are significant institutional cost benefits using two-sample AUC or single-sample Bayesian methods over trough dosing, even after accounting for the annual costs of Bayesian programs. The potential to decrease rates of AKI, improve clinical outcomes and reduce costs to the institution strongly warrants consideration of improved dosing methods for vancomycin.

Community-Based Epidemiology of Hospitalized Acute Kidney Injury.

Acute kidney injury (AKI) may lead to short- and long-term consequences in children, but its epidemiology has not been well described at a population level and outside of ICU settings. In a large, diverse pediatric population receiving care within an integrated health care delivery system between 2008 and 2016, we calculated age- and sex-adjusted incidences of hospitalized AKI using consensus serum creatinine (SCr)-based diagnostic criteria. We also investigated the proportion of AKI detected in non-ICU settings and the rates of follow-up outpatient SCr testing after AKI hospitalization. Among 1 500 546 children, the mean age was 9.8 years, 49.0% were female, and 33.1% were minorities. Age- and sex-adjusted incidence of hospitalized AKI among the entire pediatric population did not change significantly across the study period, averaging 0.70 (95% confidence interval: 0.68-0.73) cases per 1000 person-years. Among the subset of hospitalized children, the adjusted incidence of AKI increased from 6.0% of hospitalizations in 2008 to 8.8% in 2016. Approximately 66.7% of AKI episodes were not associated with an ICU stay, and 54.3% of confirmed, unresolved Stage 2 or 3 AKI episodes did not have outpatient follow-up SCr testing within 30 days postdischarge. Community-based pediatric AKI incidence was ∼1 per 1000 per year, with two-thirds of cases not associated with an ICU stay and more than one-half not receiving early outpatient follow-up kidney function testing. Further efforts are needed to increase the systematic recognition of AKI in all inpatient settings with appropriate, targeted postdischarge kidney function monitoring and associated management.

Malaria in HIV-infected patients in a nonendemic setting.

The impact of HIV infection on malaria is unclear in nonendemic areas. In endemic territories, HIV has been reported to be a risk factor for higher morbidity. Nowadays, as HIV-infected patients travel more, it is important to assess the impact of HIV at the individual level on imported malaria. This retrospective case-control study collected data on HIV-infected patients diagnosed with malaria (2000-2017) and matched them with two controls based on age, sex and ethnicity. Clinical and biological parameters were collected and compared. We identified 47 cases and matched them with 94 controls. Comparing each of the WHO 2014 severity criteria, hyperparasitemia above 10% (P = 0.006; 12.8 versus 1.1%), icterus (P = 0.042; 14.9 versus 4.3%), acute renal failure (P = 0.022; 25.5 versus 9.6%) and bacteraemia (P = 0.014; 6.4 versus 0%) were significantly more present in HIV-infected patients with a trend to more cerebral malaria (12.8 versus 6.4%). HIV- infected patients were hospitalized more frequently and for longer periods. We observed a higher number of severity criteria when CD4 T-cell count was lower, especially below 200 cells/μl. The difference in occurrence of severe malaria disappeared when patients with CD4 T-cell count more than 500 cells/μl and undetectable viral load (n = 9) were compared with controls. De-novo HIV diagnosis was made during the malaria episode in 17% of cases. HIV infection has an impact on the imported malaria profile, although it is unclear whether well controlled HIV-infected patients have a higher risk of severe malaria. HIV-infected patients should be particularly targeted for pretravel advice.

Thrombocytopenia After Cardiopulmonary Bypass Is Associated With Increased Morbidity and Mortality

Thrombocytopenia is a risk factor for morbidity and mortality in critically ill patients, and is common after cardiopulmonary bypass (CPB). In this study, we evaluate whether thrombocytopenia after CPB is an independent risk factor for postoperative morbidity and mortality. We retrospectively evaluated 1364 patients requiring CPB at the University of Colorado Hospital between January 2011 and May 2016. Platelet nadir, absolute change in platelets, and percent change in platelets were modeled as continuous variables. Patients with postoperative thrombocytopenia (defined a nadir <75× 103/μL within 72 hours) were also compared with patients without thrombocytopenia in a propensity-matched model. The primary outcome was in-hospital mortality, and secondary outcomes included postoperative infection, postoperative acute kidney injury (AKI), postoperative stroke, and prolonged intensive care unit (ICU) and hospital lengths of stay (LOS). Postoperative thrombocytopenia occurred in 356 (26.0%) patients. In multivariable analysis, platelet nadir was significantly inversely associated with mortality (odds ratio [OR], 0.955; 95% confidence interval [CI], 0.934-0.975; P < .001), postoperative infection (OR, 0.992; 95% CI, 0.986-0.999; P= .03), AKI (all stage) (OR, 0.993; 95% CI, 0.988-0.998; P= .01), AKI (stage 3) (OR, 0.966; 95% CI, 0.951-0.982; P < .001), postoperative stroke (OR, 0.974; 95% CI, 0.956-0.992; P= .006), prolonged ICU stay (OR, 0.986; 95% CI, 0.981-0.991; P < .001), and hospital LOS (OR, 0.998; 95% CI, 0.997-0.999; P= .001). Percent change in platelets from baseline was also significantly associated with all primary and secondary outcomes. Postoperative thrombocytopenia is independently associated with postoperative mortality, AKI, infection, stroke, and prolonged ICU and hospital LOS. Serial platelet monitoring may help identify patients at higher risk of postoperative complications. Further studies investigating strategies to reduce postoperative thrombocytopenia, including reducing CPB time, are needed.

Outcomes of fractional flow reserve-guided percutaneous coronary interventions in patients with acute coronary syndrome.

Fractional flow reserve (FFR) assessment has been validated as an effective tool to guide revascularization of stable coronary artery disease. The role of utilizing FFR in acute coronary syndrome (ACS) is less established. The study population was extracted from the National Readmissions Data (NRD) 2014 using International Classification of Diseases, ninth edition, clinical modification (ICD-9-CM) codes for ACS, percutaneous coronary intervention (PCI), FFR, and periprocedural complications. Study endpoints included all-cause of in-hospital mortality, length of index hospital stay (LOS), acute kidney injury (AKI), bleeding, coronary dissection, total number of stents used, stroke, vascular complications (VCs), and the total charges of index hospitalization. A total of 304,548 discharges that had the diagnosis of ACS and treated invasively within the same index hospitalization (average age 65.1 years; 64% male) were identified. Among these, 7,832 had FFR guided invasive treatment (2.6%) which was associated with significantly lower in-hospital all-cause mortality (1.1 vs. 3.1%, p < .01), shorter LOS (4.6 vs. 5.3 days, p < .01), less AKI (12.5 vs. 14.6%, p < .01), less bleeding (7.0 vs. 8.5%, p < .01), and lower total charges ($99,805 vs. $105,736). There was no significant difference between both groups in terms of stroke (2.2 vs. 2.3%, p = .41), coronary dissection (0.7 vs. 0.8%, p = .34), VC (1.3 vs. 1.0% p = .01) or the total number of stents used (55.5 vs. 54.5% p = .34). In patients presenting with an ACS FFR- guided PCI, as compared to angiography guided PCI, was associated with lower rates of in-hospital mortality, shorter LOS, less AKI, bleeding and lower hospital charges. There was no significant difference in terms of the incidence of stroke, coronary dissection, VC or the total number of stents used.

Acute kidney injury in hospitalized patients frequency of various etiologies.

Objectives: To identify magnitude of various etiologies causing acute kidney injury (AKI) in hospital admitted patients at Nishtar hospital, Multan. Study Design: Cross sectional observational study. Setting: Medical Unit-IV, Nishtar Hospital and Medical University, Multan. Period: The study span was six month extending from February 2018 to July 2018. Material and Methods: In our setting, we took a sample of 383 patients admitted to medical unit- IV for variety of medical conditions using non-probability purposive sampling technique. Patients having an age range of 30-70 years and either gender were taken. Those patients who had previously deranged kidney functions, Reno grafting, snake envenomation and kalapathar (PPD) poisoning were not considered for study. Results: The age of patients ranged from 36 years to 62 years and had a mean of 47.94±8.14 years. There were54% male and 46% female patients in our setting. The most common presenting medical disorders requiring indoor admission were pulmonary diseases seen in 38.9% patients then hepatobiliary disorders 27.4%, infections 24% and diabetes 9.6%. Out of 383 patients, 107(27.9%) patients had AKI. It was more prevalent (p=0.000) diabetic patients 46%, hepatobiliary disorders 36.1%, infectious diseases 27.1% and then respiratory tract diseases 18.1%. While working on etiological causes of AKI, we found drugs were frequent inciting factor, present in 39.3% patients then was sepsis 19.6%, volume loss 17.7% and hypotension 8.5%. Combined fluid depletion plus sepsis was noted in 6.5% patients followed by sepsis plus drugs in 4.6% and sepsis plus drugs plus hypotension seen in 3.7% patients. However, drugs were major contributory factor of AKI in patients having hepatobiliary diseases 65.8% and diabetes 35.3%. In patients of respiratory tract diseases having AKI, fluid loss 36.0% and sepsis 28.6% were recurring findings. Among patients of infectious diseases, sepsis 40% and drugs 28% were more common. Conclusion: Occurrence of Acute kidney injury among hospitalized patients was statistically significant (p=0.000) in patients with diabetes mellitus and hepatobiliary disease at the time of admission. While noting etiological factors, it was seen that drugs were the most prevalent followed by septicemia, then hypovolemia among the factors responsible for AKI.

Hospitalization Trends for Acute Kidney Injury in Kidney Transplant Recipients in the United States, 2004-2014.

The incidence of acute kidney injury (AKI) and AKI requiring dialysis (AKI-D) in the general population is increasing. However, there is limited information on the epidemiology of AKI-related hospitalizations in the prevalent US kidney transplant population. We analyzed trends in the incidence of hospitalizations with primary diagnosis of AKI and secondary diagnosis of AKI and AKI-D using data from the National Inpatient Sample 2004-2014. Co-primary endpoints were in-hospital mortality, length of stay (LOS), and cost. Survey analysis techniques were used to compute national estimates. Linear trends in outcomes were evaluated using linear regression. There were a total of 37 562 hospitalizations for primary AKI, 136 628 for secondary AKI, and 10 731 for AKI-D during the study period. We found an increase in hospitalizations for all 3 diagnoses over time (13.7-24.7 per thousand kidney transplant recipients [KTRs] for primary AKI, 37.4-108.0 per thousand KTRs for secondary AKI, and 4.2-6.0 per thousand KTRs for AKI-D; all P trend < 0.01). This was accompanied by significant improvements in in-hospital mortality (3.2%-0.5% for primary and 6.1%-4.4% for secondary AKI; both P trend < 0.01), average LOS (5.3-4.6 days for primary and 8.4-7.2 days for secondary AKI; both P trend < 0.001), and cost ($11 635-$8234 for primary and $21 373-$17 470 for secondary AKI; P trend < 0.001 for both). The incidence of hospitalizations for AKI and AKI-D among KTRs is rapidly rising. This has been accompanied by significant improvements in in-hospital mortality, LOS, and cost.

Predictors of 90-Days Readmissions for New Onset Heart Failure after Acute Coronary Syndrome

Background Coronary heart disease is one of the leading risk factors for the development of heart failure (HF). Despite major improvements in the management of acute coronary syndromes (ACS), HF remains the most common cause of readmission after ACS, followed by myocardial re-infarction. We sought to evaluate the risks and predictors for HF admission after ACS. Methods Using the national readmission database (NRD), we examined discharge data from 2010 until 2015 and identified all patients age 18 years and older with ACS recorded as the primary discharge diagnosis; we then excluded all patients with a prior diagnosis of HF. Chi-square test and Wilcoxon rank-sum test were used to compare proportions and continuous variables, respectively. We used logistic regression modeling to estimate the unadjusted odds of readmission for the covariates of interest. Results We identified 1,322,335 patients discharged after an ACS (36.2% STEMI). Of these, 56,345 (4.2%) were readmitted within 90-days with a new primary diagnosis of HF. The most common individual risk factors associated with HF admission were the presence of atrial fibrillation (OR 1.71), diabetes (OR 1.62) and lung disease (OR 1.49). The most common predictors for HF admission were STEMI (OR 1.28), development of acute kidney injury (AKI) (OR 1.49), length of stay > 5 days (OR 1.77) and discharge against medical advice (OR 1.88). Revascularization during index admission for ACS was a strong predictor against HF admission (OR of 0.61 and 0.49 for PCI and CABG respectively). Self-pay or private insurance were also associated with lower rates of HF admissions (OR 0.68 and 0.57, respectively). Conclusions Readmission for new-onset HF occurs in close to 5% of patients after ACS. The presence of atrial fibrillation, diabetes, development of AKI or prolonged hospitalization identifies a higher risk cohort at the time of discharge.

Identifying on admission patients likely to develop acute kidney injury in hospital

BackgroundThe incidence of Acute Kidney Injury (AKI) continues to increase in the UK, with associated mortality rates remaining significant. Approximately one fifth of hospital admissions are associated with AKI and approximately a third of patients with AKI in hospital develop AKI during their time in hospital. A fifth of these cases are considered avoidable. Early risk detection remains key to decreasing AKI in hospitals, where sub-optimal care was noted for half of patients who developed AKI.MethodsElectronic anonymised data for adults admitted into the Royal Cornwall Hospitals Trust (RCHT) between 18th March and 31st December 2015 was trimmed to that collected within the first 24 h of hospitalisation. These datasets were split according to three separate time periods: data used for training the Takagi-Sugeno Fuzzy Logic Systems (FLS) and the multivariable logistic regression (MLR) models; data used for testing; and data from a later patient spell used for validation.Three fuzzy logic models and three MLR models were developed to link characteristics of patients diagnosed with a maximum stage AKI within 7 days of admission: the first models to identify any AKI Stage (FLS I, MLR I), the second for patterns of AKI Stage 2 or 3 (FLS II, MLR II), and the third to identify AKI Stage 3 (FLS III, MLR III). Model accuracy is expressed by area under the curve (AUC).ResultsAccuracy for each model during internal validation was: FLS I and MLR I (AUC 0.70, 95% CI: 0.64–0.77); FLS II (AUC 0.77, 95% CI: 0.69–0.85) and MLR II (AUC 0.74, 95% CI: 0.65–0.83); FLS III and MLR III (AUC 0.95, 95% CI: 0.92–0.98).ConclusionsFLS II and FLS III (and the respective MLR models) can identify with a high level of accuracy patients at high risk of developing AKI in hospital. These two models cannot be properly assessed against prior studies as this is the first attempt at quantifying the risk of developing specific Stages of AKI for a broad cohort of both medical and surgical inpatients. FLS I and MLR I performance is comparable to other existing models.

Role of elevated red cell distribution width on acute kidney injury patients after cardiac surgery

BackgroundThe aim of the study was to explore associations between elevated red cell distribution width (RDW) and acute kidney injury (AKI) in patients undergoing cardiac surgery (CS-AKI).MethodsPreoperative, intraoperative and postoperative data of 10,274 patients undergoing cardiac surgery, including demographic data, were prospectively collected from January 2009 to December 2014. Propensity score matching was used on the basis of clinical characteristics and preoperative variables. An elevated RDW was defined as the difference between RDW 24 h after cardiac surgery and the latest RDW before cardiac surgery.ResultsA total of 10,274 patients were included in the unmatched cohort, and 3146 patients in the propensity-matched cohort. In the unmatched cohort, the overall CS-AKI incidence was 32.8% (n = 3365) with a hospital mortality of 5.5% (n = 185). In the propensity-matched cohort, the elevated RDW in AKI patients was higher than in patients without AKI (0.3% (0.0%, 0.7%) vs 0.5% (0.1, 1.1%), P < 0.001) and the elevated RDW incidences were 0.4% (0.1%, 0.9%), 0.6% (0.2%, 1.1%) and 1.1% (0.3%, 2.1%) in stage 1, 2 and 3 AKI patients (P < 0.001). Among propensity-matched patients with CS-AKI, the level of elevated RDW in non-survivors was higher than in survivors [1.2% (0.5%, 2.3%) vs 0.5% (0.1%, 1.0%), P < 0.001] and a 0.1% increase in elevated RDW was associated with a 0.24% higher risk of within-hospital mortality in patients with CS-AKI. Estimating the receiver-operating characteristic (ROC) area under the curve (AUC) showed that an elevated RDW had moderate discriminative power for AKI development (AUC = 0.605, 95% CI, 0.586–0.625; P < 0.001) and hospital mortality (AUC = 0.716, 95% CI, 0.640–0.764; P < 0.001) in the propensity-matched cohort.ConclusionsAn elevated RDW might be an independent prognostic factor for the severity and poor prognosis of CS-AKI.

Quality measures in acute kidney injury

Quality measure assessment and reporting is evolving in end-stage renal disease care and is inchoate in ambulatory nephrology clinic care. Acute kidney injury (AKI) quality measures have not received sufficient attention, yet deserve consideration in view of the substantial proportion of effort nephrology providers devote to AKI care. Accumulating literature permits consideration of timing of nephrology consultation, follow-up after AKI hospitalization, early detection, medication dosing, hospital readmissions and length of stay, cost, and mortality as potential AKI quality measures. We review candidate AKI quality measures and assess the strength of evidence supporting the use of each measure as a standard for AKI care.

Comparative Risk of Acute Kidney Injury with Oral Anticoagulant Use Among Patients with Nonvalvular Atrial Fibrillation

Background: Acute kidney injury (AKI) is common in patients with nonvalvular atrial fibrillation (NVAF) taking oral anticoagulants (OAC), especially in those with underlying chronic kidney disease (CKD). However, little is known on the comparative risk of AKI with the use of different OAC, including the direct acting oral anticoagulants (DOACs).Methods: We conducted a population-based cohort study using the administrative healthcare databases of Quebec, Canada. Patients with NVAF who were new users of oral anticoagulants between 2011 and 2014 were followed for hospitalized AKI, stratified by CKD status. Hazard ratios (HR) and corresponding 95% CI for hospitalized AKI with the use of dabigatran, rivaroxaban, and apixaban versus warfarin and versus each other in pairwise analyses, were assessed using Cox proportional hazards models. Estimates were stratified by the deciles of a disease risk score for AKI obtained from a historic cohort of 25,513 warfarin users with NVAF. The disease risk score included important demographic and clinical covariates weighted by their association with AKI.Results: Our cohort of 26,357 patients with NVAF included 22,084 without, and 4273 with CKD. The rates of AKI hospitalization were 3.2 (95% CI 2.9-3.4) and 16.5 (95% CI 15.3-17.9) per 100 person-years, respectively. Among patients without CKD, apixaban (HR, 0.25; 95% CI, 0.14-0.44), rivaroxaban (HR, 0.50; 95% CI, 0.40-0.64), and dabigatran (HR, 0.68; 95% CI 0.57-0.81) were associated with a decreased risk of AKI compared with warfarin (Table 1). Similar findings were observed in the CKD cohort (Table 2). Compared with apixaban, dabigatran was associated with increased AKI risk in patients without (HR, 2.58; 95% CI, 1.42-4.67) and with (HR, 2.08; 95% CI, 1.01-4.26) CKD, as was rivaroxaban (without CKD - HR, 2.29 [95% CI, 1.24-4.20]; with CKD - HR, 1.98 [95% CI, 0.95-4.11]). Rivaroxaban was associated with decreased risk of AKI in patients without CKD (HR, 0.76; 95% CI, 0.58-0.99), compared with dabigatran.Conclusions: Use of all DOACs was associated with decreased risk of AKI compared with warfarin. Apixaban was associated with the lowest comparative risk of AKI among DOACs, and rivaroxaban was suggested to be more protective than dabigatran in patients without CKD. While these findings await further confirmation, worsening renal function while on DOAC treatment has been associated with increased risk of major bleeding. Thus, suggested differences in the renal safety of DOACs should be incorporated in informed prescription and monitoring of these drugs. [Display omitted] DisclosuresRenoux:Bayer Pharmaceuticals: Research Funding; Canadian Foundation for Innovation: Research Funding.

Postauthorization safety study of the DPP-4 inhibitor saxagliptin: a large-scale multinational family of cohort studies of five outcomes

ObjectiveTo evaluate the risk of serious adverse events among patients with type 2 diabetes mellitus initiating saxagliptin compared with oral antidiabetic drugs (OADs) in classes other than dipeptidyl peptidase-4 (DPP-4)...