Increased Incidence Of Acute Kidney Injury Research Articles

505 Risk Stratification by TBSA for Acute Kidney Injury in Burn Patients Following Combination Antibiotic Therapy

Abstract Introduction Burn patients are susceptible to infections and are often treated with broad-spectrum antibiotics. Vancomycin is a common antibiotic administered alone, or in combination with piperacillin-tazobactam (Pip/Tazo). This combination therapy was associated with increased rates of acute kidney injury (AKI) in burn patients when compared to Vancomycin alone or in combination with other antibiotics. However, recent studies failed to demonstrate these findings. We sought to determine the degree of nephrotoxicity of Vancomycin, Pip/Tazo, and their combination, with burn severity. Methods A retrospective, multi-institutional study was performed utilizing TriNetX Global Health Research Network that encompasses de-identified patient records from 55 health care organization across the US. We identified the population of burn patients between 2000-2020 and stratified them into 3 groups by TBSA < 10%, 10-39%, or 40%+. Patients were further stratified into cohorts by administration of broad-spectrum antibiotics within 3 months of their burn: Vancomycin, Pip/Tazo alone, in combination (Combo), or neither. Cohorts were propensity score matched for age at index, gender, race, ethnicity, and pre-existing conditions that predispose to AKI. We explored patient distribution and conducted a comparative outcome analysis to determine the risk of developing AKI in 7- and 90-day outcome windows. Results Vancomycin and Pip/Tazo were compared to control groups and showed increased risk of AKI in all TBSA groups and time outcomes(p< 0.0001). Before stratifying by TBSA, all burn patients administered combination antibiotics showed increased risk of AKI when compared to control, Vancomycin alone, and Pip/Tazo. In patients under < 10% TBSA, combo antibiotics increased AKI incidence in both 7- and 90-days when compared to all other groups. In the 10-39% TBSA group, combination therapy increased the risk of AKI when compared to Pip/Tazo at 7-days. Increased risk of AKI occurred in the combo group when compared to both Vancomycin and Pip/Tazo in 90-days. In the 40%+ TBSA cohort, combination antibiotics did not increase the incidence of AKI in either time period or when compared to Vancomycin and Pip/Tazo. The results of the comparative analysis are included in Table 1. Conclusions Broad-spectrum antibiotics use in burn patients is associated with increased risk of AKI, this risk is higher with Vancomycin and Piperacillin/Tazobactam combination. Combo therapy increased AKI in < 10% and 10-39% but not 40%+ TBSA. These findings can be used to monitor for early manifestations of AKI when using broad-spectrum antibiotics. Applicability of Research to Practice The decision to initiate antimicrobial therapy is crucial in burn patients as they are already at risk for AKI. TBSA can be a useful tool for guiding risk stratification.

Cystatin C and derived measures of renal function as risk factors for mortality and acute kidney injury in sepsis – A post-hoc analysis of the FINNAKI cohort

PurposeTo assess the association between cystatin C-derived estimates of kidney function and mortality and acute kidney injury (AKI) in sepsis. Materials and methodsPost-hoc analysis of sepsis patients in the FINNAKI-cohort (n = 802). Primary outcome was 90-day mortality. We measured plasma cystatin C and creatinine at intensive care unit (ICU) admission and estimated glomerular filtration rates (eGFRcys, eGFRcrea) and shrunken pore syndrome (SPS; defined as eGFRcys/eGFRcrea ratio < 0.7). Associations were assessed using Cox- or logistic regression. ResultsIncreased cystatin C and decreased eGFRcys were associated with mortality in unadjusted analyses and in analyses adjusted for illness severity and creatinine. Hazard ratios (HRs) in unadjusted analyses were 3.30 (95% CI; 2.12–5.13, p < 0.001) and 3.26 (95% CI; 2.12–5.02, p < 0.001) respectively. SPS was associated with mortality in an unadjusted- (HR 1.78, 95% CI; 1.33–2.37, p < 0.001) and in an adjusted analysis (HR 1.54, 95% CI; 1.07–2.22, p = 0.021). All cystatin C-derived measures were associated with mortality also after adjustment for AKI development. Cystatin C was associated with AKI in unadjusted analyses but not in analyses adjusted for creatinine. ConclusionCystatin C and derived measures of kidney function at ICU admission are associated with an increased 90-day mortality. Increased AKI incidence does not fully explain this association.

Interaction of hemoglobin, transfusion, and acute kidney injury in patients undergoing cardiopulmonary bypass: a group-based trajectory analysis

Anemia is a risk factor for acute kidney injury (AKI) following cardiopulmonary bypass (CPB). Whether red blood cell (RBC) transfusion-enhanced hemoglobin levels contribute to low AKI rates remains unclear. We investigated the interaction between hemoglobin, RBC transfusion, and AKI after CPB. Hemoglobin trajectories within 72 h were analyzed using group-based trajectory analysis. Multivariable logistic analysis and inverse probability-weighted regression were adopted to evaluate the associations between hemoglobin and AKI in RBC and non-RBC transfusion subgroups. We analyzed 6226 patients’ data. In the transfusion subgroup, three hemoglobin trajectories were identified. The AKI incidence was lowest in the trajectory with the lowest hemoglobin level (trajectory 1, less transfusion), and it was comparable in trajectories 2 and 3 (20.7% vs. 32.7% vs. 29.4%, p < 0.001, respectively). In four logistic models, the odds ratio for AKI with trajectory 1 as the reference ranged from 1.44 to 1.85 for trajectory 2 (p < 0.001) and 1.45 to 1.66 for trajectory 3 (p < 0.050). The average treatment effect on AKI was 5.6% (p = 0.009) for trajectory 2 and 7.5% (p = 0.041) for trajectory 3, with trajectory 1 as the reference. In the non-RBC transfusion subgroup, three approximately linear hemoglobin trajectories (9, 10, and 12 g/dL) were observed; however, both the crude and adjusted AKI incidence were similar within the three trajectories. In patients undergoing CPB, hemoglobin level >9 g/dL was not associated with decreased AKI incidence in the subgroup without RBC transfusion. However, in patients with RBC transfusion, maintaining hemoglobin level >9 g/dL by RBC transfusion was associated with increased AKI incidence.

Ultrafiltration and cardiopulmonary bypass associated acute kidney injury: A systematic review and meta-analysis.

BackgroundCardiopulmonary bypass is known to raise the risk of acute kidney injury (AKI). Previous studies have identified numerous risk factors of cardiopulmonary bypass including the possible impact of perioperative ultrafiltration. However, the association between ultrafiltration (UF) and AKI remains conflicting. Thus, we conducted a meta‐analysis to further examine the relationship between UF and AKI.HypothesisUltrafiltration during cardiac surgery increases the risk of developping Acute kidney Injury.MethodsWe searched PubMed, Web of Science, EBSCO, and SCOPUS through July 2021. The RevMan (version 5.4) software was used to calculate the pooled risk ratios (RRs) and mean differences along with their associated confidence intervals (95% CI).ResultsWe identified 12 studies with a total of 8005 patients. There was no statistically significant difference in the incidence of AKI between the group who underwent UF and the control group who did not (RR = 0.90, 95% CI = 0.64−1). Subgroup analysis on patients with previous renal insufficiency also yielded nonsignificant difference (RR = 0.84, 95% CI = 0.53 −1.33, p = .47). Subgroup analysis based on volume of ultrafiltrate removed (> or <2900 ml) was not significant and did not increase the AKI risk as predicted (RR = 0.82, 95% CI = 0.63 −1.07, p = .15). We also did subgroup analysis according to the type of UF and again no significant difference in AKI incidence between UF groups and controls was observed in either the conventional ultrafiltration (CUF), modified ultrafiltration (MUF), zero‐balanced ultrafiltration (ZBUF), or combined MUF and CUF subgroups.ConclusionUF in cardiac surgery is not associated with increased AKI incidence and may be safely used even in baseline chronic injury patients.

Incidence of acute kidney injury and its association with mortality in patients with COVID-19: a meta-analysis

Acute kidney injury (AKI) is a complication of COVID-19. However, the incidence of AKI in COVID-19 varies among studies. Thus, we aimed to evaluate the pooled incidence of AKI and...

2292. Incidence of Acute Kidney Injury Associated with Duration of Vancomycin and Piperacillin/tazobactam Combination Therapy

BackgroundEmpiric antibiotic therapy for serious and healthcare-acquired infections often requires coverage for resistant pathogens, including methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. These regimens commonly consist of vancomycin plus an antipseudomonal β-lactam. Recent studies have reported increased acute kidney injury (AKI) risk associated with concomitant vancomycin and piperacillin/tazobactam therapy compared with each agent alone. The objective of this study was to determine whether vancomycin with piperacillin/tazobactam had an increased AKI incidence compared with vancomycin plus cefepime or meropenem. Furthermore, data were analyzed to determine whether a specific duration was associated with an increased AKI incidence.MethodsA retrospective cohort study was conducted analyzing patients who received vancomycin in combination with piperacillin/tazobactam (V+PT), cefepime (V+C), or meropenem (V+M) between January 1, 2018 through June 30, 2018. Adult patients with normal baseline renal function and receipt of at least 48 hours of combination therapy, with the two antibiotics initiated within 24 hours of one another, were included. AKI events, evaluated using the Acute Kidney Injury Network (AKIN) criteria, during antibiotic therapy and up to 72 hours after antibiotic discontinuation were recorded. This data were used to calculate the AKI incidence with each regimen and AKI incidence associated with each day of therapy.ResultsA total of 181 patients were included in the study. The incidence of AKI in the V+PT group was 22.8% vs. 5.6% and 16.7% in the V+C and V+M groups, respectively (P = 0.237). Median duration of therapy when AKI occurred was 3 days for V+PT, 4 days for V+C, and 2 days for V+M (P = 0.015). Patients in the V+M group received more nephrotoxic agents compared with V+PT and V+C (P = 0.004). Statistical analysis did not find a specific day of V+PT therapy predictive of AKI. However, a time to event analysis demonstrated a steady increase in AKI risk with V+PT from day 2 through 6.ConclusionAlthough not statistically significant, V+PT therapy was associated with a higher incidence of AKI compared with V+C or V+M. Future studies are needed to further assess the impact of duration of therapy on AKI incidence.Disclosures All authors: No reported disclosures.

Acute Kidney Injury in Non-Intensive Care and Intensive Care Patients Treated with Vancomycin and Piperacillin-Tazobactam.

We investigated the incidence of acute kidney injury (AKI) and risk factors associated with vancomycin (VAN) and piperacillin-tazobactam (TZP) combination therapy in non-intensive care unit (ICU) and ICU settings. In this single-center retrospective cohort study, adults who received VAN for ≥48 h during the period from 1 January 2016 through 31 December 2017 were included. The primary endpoint was incidence of AKI. Data from 593 adults were analyzed. The incidence of AKI was 10.6% overall, 8.0% in the non-TZP group, and 19.8% in the TZP group. In univariate analysis, the odds ratio (OR) for AKI was higher in the TZP group than in the non-TZP group (2.84, 95% CI = 1.64-4.90). In both the non-ICU and ICU settings, the OR for AKI was higher in the TZP group than in the non-TZP group (non-ICU: OR = 3.04, 95% CI = 1.52-6.09; ICU: OR = 2.51, 95% CI = 1.03-6.08). Furthermore, in propensity score analysis, the OR for AKI was higher in the TZP group than in the non-TZP group (OR = 2.81, 95% CI = 1.52-5.17). In both the non-ICU and ICU settings, the OR for AKI was higher in the TZP group than in the non-TZP group (non-ICU: OR = 2.57, 95% CI = 1.17-5.64; ICU: OR = 3.51, 95% CI = 1.05-11.6). Combined use of TZP in patients receiving VAN increased AKI incidence in non-ICU and ICU settings.

Effect of mean arterial pressure on acute kidney injury in patients with septic shock

Objective To study the effect of mean arterial pressure (MAP) level on acute kidney injury (AKI) in patients with septic shock, and to determine the best resuscitation target MAP to prevent the occurrence or progression of sepsis- associated AKI. Methods The study subjects included 168 adult patients with septic shock (age≥65 years) who were admitted to the Department of Intensive Care Unit (ICU) of the First Hospital of Jilin University from January 2016 to January 2019. The clinical data of all enrolled patients were retrospectively analyzed. The baseline data were compared between the AKI group (n=111) and non-AKI group (n=57). Multivariate logistic regression analysis was used to determine the risk factors of AKI in patients with septic shock. Results ① The first, second, third, and forth quartile of ΔMAP (pre-resuscitation MAP minus post-resuscitation MAP) were -24.3-3.9 mmHg, 4.0-12.3 mmHg, 12.4-19.8 mmHg, and 19.9-43.5 mmHg, respectively. The second to fourth quartile interval wasΔMAP ≥4 mmHg.② There were no significant differences in age, body mass index, sex, pre-resuscitation MAP, MAP at first hour, SOFA score, positive culture ratio, negative culture ratio, hypertension, peripheral vascular disease, cerebrovascular accident, chronic obstructive pulmonary disease, gastrointestinal ulcer, liver cirrhosis, and tumor between the two groups (P>0.05). There were significant differences in post-resuscitation MAP (P=0.01), APACHEⅡ score (P=0.02), diabetes mellitus (P=0.01), fluid balance (P=0.01), and ΔMAP from the second to fourth quartile (P=0.03) between the two groups.③ ΔMAP ≥4 mmHg (OR=0.26, 95%CI: 0.12-0.57, P=0.01), diabetes (OR=6.03, 95%CI: 1.35-44.16, P=0.04), and high APACHE Ⅱ score (OR=0.96, 95%CI: 0.84-0.97, P=0.02) were closely related to the increased incidence of AKI in patients with septic shock. Post-resuscitation MAP and fluid balance had no significant effect on the incidence of AKI in patients with septic shock. Conclusions ΔMAP ≥4 mmHg, APACHE Ⅱ score and diabetes were independent risk factors for the incidence of AKI in patients with septic shock. The incidence of AKI in septic shock patients with post-resuscitation MAP 4 mmHg or more lower than pre-resuscitation MAP is significantly increased. Key words: Septic shock; Mean arterial pressure; Acute kidney injury; Risk factors

Ureteral stents increase risk of postoperative acute kidney injury following colorectal surgery.

Ureteral stents are commonly placed before colorectal resection to assist in identification of ureters and prevent injury. Acute kidney injury (AKI) is a common cause of morbidity and increased cost following colorectal surgery. Although previously associated with reflex anuria, prophylactic stents have not been found to increase AKI. We sought to determine the impact of ureteral stents on the incidence of AKI following colorectal surgery. All patients undergoing colon or rectal resection at a single institution between 2005 and 2015 were reviewed using American College of Surgeons National Surgical Quality Improvement Program dataset. AKI was defined as a rise in serum creatinine to ≥ 1.5 times the preoperative value. Univariate and multivariate regression analyses were performed to identify independent predictors of AKI. 2910 patients underwent colorectal resection. Prophylactic ureteral stents were placed in 129 patients (4.6%). Postoperative AKI occurred in 335 (11.5%) patients during their hospitalization. The stent group demonstrated increased AKI incidence (32.6% vs. 10.5%; p < 0.0001) with bilateral having a higher rate than unilateral stents. Hospital costs were higher in the stent group ($23,629 vs. $16,091; p < 0.0001), and patients with bilateral stents had the highest costs. Multivariable logistic regression identified predictors of AKI after colorectal surgery including age, procedure duration, and ureteral stent placement. Prophylactic ureteral stents independently increased AKI risk when placed prior to colorectal surgery. These data demonstrate increased morbidity and hospital costs related to usage of stents in colorectal surgery, indicating that placement should be limited to patients with highest potential benefit.

Relation between national changes in prescription of angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers and admissions with acute kidney injury

BackgroundGuidelines advise prescription of angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) for several disorders, such as chronic kidney disease. Yet, treatment with these drugs is associated with acute kidney injury (AKI) during episodes of intercurrent illness. Frequency of AKI admission is increasing. Whether increased AKI admissions are associated with increased prescription of ACE inhibitors and ARBs is unknown. MethodsEnglish National Health Service (NHS) dispensing data (ePACT) for numbers of ACE inhibitors and ARBs dispensed per general practice were matched by practice to numbers of hospital admissions (Hospital Episode Statistics) for AKI (primary diagnosis ICD 10 code N17). Prescription rates are expressed per Age Sex Temporary Resident Originated Prescribing Unit (ASTRO-PU), which is a weighted measure of practice size based on patients' age, sex, and temporary resident status (mean 4·3 ASTRO-PU per person across 8028 practices in England). A mixed effect Poisson regression was done to model the number of admissions for AKI occurring in each practice for each of 4 years from April 1, 2007. This model included prescription rates and year as categorical variables, a random intercept for practice, and random slopes for year by practice. Practices with prescribing rates greater than 0·5 items per ASTRO-PU per year were deemed to be unusual and excluded. FindingsFrom 2007–08 to 2010–11, crude AKI admission rates increased from 0·38 to 0·57 per 1000 patients (52% increase), and national annual prescription rates of ACE inhibitors and ARBs increased by 0·032 (SD 0·035) from 0·202 to 0·234 per ASTRO-PU (15·8% increase). The results of the model provide strong evidence (p<0·0001) that within-practice increases in prescription of ACE inhibitors and ARBs are associated with increased AKI admissions. The typical within-practice increases in prescription during the study period are associated with a rise in AKI admission rates of about 5·4% (rate ratio 1·054 [95% CI 1·049–1·058] for a 0·032 per ASTRO-PU increase in annual prescription rate. InterpretationIn England, a 5·4% increase in AKI admissions in 4 years is potentially attributable to prescription of ACE inhibitors and ARBs, which might account for roughly a tenth of the total increase in AKI admissions. Whether the benefits of these drugs outweigh the increased AKI incidence at the population level is unknown. This study was an ecological analysis and therefore might not relate to individual risk of AKI with respect to prescription of ACE inhibitors and ARBs. Quality of the prescribing data (exposure) might have changed and coding practice (outcome) could have altered with time and by hospital. This analysis assumes that the practice population profile remains largely unchanged, but temporal changes in prevalence of comorbidities in the population related to AKI and for which treatment with ACE inhibitors and ARBs is recommended could confound our findings. FundingCambridge Biomedical Research Centre; British Heart Foundation.