Kidney Disease Improving Global Outcomes Research Articles

Epidemiological study of hospital acquired acute kidney injury in critically ill and its effect on the survival.

In the intensive care unit (ICU), acute kidney injury (AKI) is the most common cause of morbidity and mortality. Hospital-acquired acute kidney injury (HAAKI) is AKI developing after 48h. We aimed to study the development of AKI and its associated risk factors. We conducted a longitudinal observational study. Inclusion criteria were patients > 18 years of age admitted to ICU. The primary outcome was the development of AKI as defined by Kidney Disease Improving Global Outcomes (KDIGO) criteria. A total of 273 patients were included in the study. Out of 273, 44(16.11%) patients developed AKI. The mean age was 45.80(17.39) years, and 60.81% were males. The median acute physiology and chronic health evaluation (APACHE II) and sequential organ failure assessment (SOFA) scores were 12(8-18) and 5(3-7), respectively. Diabetes mellitus (23.44%) and hypertension (23.81%) were predominant comorbidities. The risk factors associated with AKI were serum chloride level, colistin, invasive ventilation, positive end-expiratory pressure (PEEP), and fluid balance. The hospital mortality was significantly higher in patients with AKI (43.18%) as compared with no AKI (14.41%). Among the secondary outcomes, 7 (15.90%) patients required renal replacement therapy (RRT) during hospitalisation. The length of ICU stay was higher in patients with AKI 8(5-13) compared to no AKI 5(3-8). A total of 16.11% developed HAAKI, and mortality was 43.18%. Post 6 months follow-up of AKI patients, mortality was 23%. Among survivors none of the patients were on RRT.Patients admitted with normal kidney function can develop AKI. Hence, careful monitoring of ICU patients is necessary.

Abstract 4138714: Implementation of the KDIGO Guidelines to Prevent Cardiac Surgery Associated Acute Kidney Injury in Patients with Heart Failure With Preserved Ejection Fraction Undergoing Coronary Artery Bypass Grafting

Backgrounds: The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommended the initiation of multiple supportive measures in patients at high risk for cardiac surgery associated acute kidney injury (CSA-AKI). Heart failure with preserved ejection fraction (HFpEF) was known as a critical risk factor for CSA-AKI. Purpose: Our study was designed to assess the effectiveness of KDIGO guidelines and the risk of CSA-AKI following coronary artery bypass grafting (CABG) among patients with HFpEF. Methods: This retrospective cohort study included 7420 patients undergoing CABG from 2019 to 2022, including 1960 patients with pre-operative HFpEF and 5460 patients without pre-operative HF as comparison. Implementation of the KDIGO guidelines consists of 6 measures in the first 72 hours after surgery, including avoidance of nephrotoxic agents, discontinuation of ACEi and ARB, implementation of advanced hemodynamic monitoring, avoidance of hyperglycemia, optimization of hemodynamics, and intensified monitoring of renal function. The primary outcome was in-hospital postoperative AKI according to the KDIGO criteria. Results: Among the included patients with HFpEF, 125 (6.4%) patients were classified as fully implementing the KDIGO guidelines. For the primary outcome, implementation of guidelines was associated with a significantly decreased risk of CSA-AKI (46.4% vs. 62.0%; OR, 0.591 [95% CI, 0.407-0.857]; p = 0.006). Meanwhile, implementation of guidelines had a greater preventive effect on CSA-AKI for HFpEF patients compared with non-HF patients (OR, 0.921 [95% CI, 0.759-1.118]; p = 0.405). Noticeably, we found that avoidance of hyperglycemia (OR, 0.737 [95% CI, 0.591-0.920]; p = 0.007) and optimization of hemodynamics (OR, 0.638 [95% CI, 0.508-0.802]; p < 0.001) were associated with lower incidence of CSA-AKI. Conclusions: Despite a lack of adherence to the KDIGO guidelines in patients undergoing CABG, implementation of the guidelines was found to be associated with a significantly lower risk of CSA-AKI for patients with HFpEF. Among the measures in the guidelines, avoidance of hyperglycemia and optimization of hemodynamics had stronger preventive effects for CSA-AKI.

Abstract 4138719: Effect of Recombinant Human Brain Natriuretic Peptide on Cardiac Surgery Associated Acute Kidney Injury in Patients Undergoing Coronary Artery Bypass Grafting

Backgrounds: Cardiac surgery associated acute kidney injury (CSA-AKI) is a prevalent and detrimental complication following cardiac surgery, with significant effects on both in-hospital and long-term morbidity and mortality. The effect on renal prognosis of recombinant human brain natriuretic peptide (rhBNP) for patients undergoing cardiac surgery remains unclear. Purpose: This study aims to evaluate the association between postoperative rhBNP and the risk of CSA-AKI following coronary artery bypass grafting (CABG). Methods: This retrospective cohort study included 16096 consecutive patients undergoing CABG between 2017 and 2022. The primary outcome was in-hospital postoperative AKI according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The secondary outcome was the amplitude of postoperative NT-proBNP reduction, defined as a difference value between the highest and last results during hospitalization. Multivariate Cox proportional hazards regression models and linear regression models were constructed to assess the association between perioperative statin and pre-defined outcomes. Results: A total of 9392 (58.3%) patients received postoperative rhBNP therapy, with a total of 1474 (9.2%) patients developing CSA-AKI. For the primary outcome, postoperative rhBNP was associated with a significantly increased risk of CSA-AKI (83.0% vs. 55.9%; adjusted Odds Ratio [OR], 3.615 [95% CI, 3.136-4.166]; p < 0.001). Noticeably, we found that postoperative rhBNP was also related to increased amplitude of postoperative NT-proBNP reduction, with an average of 3193.98 versus 1040.21 pg/mL (p for linear < 0.001). For the subgroup analysis, the association between postoperative rhBNP and reduced CSA-AKI risk was greater among patients with HFpEF (p for interaction = 0.087). Conclusions: Postoperative rhBNP therapy was associated with a significantly higher risk of CSA-AKI following CABG. Meanwhile, rhBNP contributed to NT-proBNP reduction postoperatively, with a more pronounced effect in patients with HFpEF.

Abstract 4136654: Urine Output Response to a Furosemide Infusion is Associated with Acute Kidney Injury in Infants Following Cardiac Surgery

Background: Acute kidney injury (AKI) following cardiac surgery in infants is common and associated with longer mechanical ventilation times and length of stay. Prior studies have shown that a lack of responsiveness to bolus dose furosemide has been associated with increased incidence of AKI. However, these studies have excluded patients on continuous furosemide infusions who are often younger, more hemodynamically unstable, and at higher risk for AKI. Hypothesis: Decreased urine output after initiation of a furosemide infusion predicts development of AKI. Methods: A retrospective cohort study of infants (<1 year of age) was conducted who underwent cardiac surgery requiring cardiopulmonary bypass from 2020-2023 and were on a furosemide infusion post-operatively. The primary outcome was post-operative AKI as defined using KDIGO (Kidney Disease: Improving Global Outcomes) guidelines. A furosemide response score (FRS) was calculated using the total urine output divided by the total dose of furosemide administered over a given time. Univariate and multivariate analyses were performed, and receiver operating characteristic curves used to determine the discriminatory ability of the FRS with regards to the primary outcome. Results: A total of 155 infants (median age at surgery 9 days) were included. Overall, 77% of infants met definition for the primary outcome of AKI; 32% stage 1, 30% stage 2, and 15% stage 3. Lower FRS at 4, 10, and 24 hours after infusion initiation were associated with AKI development (p<0.0001). Younger age, smaller weight at surgery, lack of pre-operative feedings, pre-operative inotropic use and higher surgical complexity were also associated with a higher risk of AKI. An FRS (mL/mg/kg) cutoff of <11.3 at 4 hours, <25.5 at 10 hours, and <55.3 at 24 hours had good discriminatory ability (area under the curve 0.7-0.75) in predicting AKI stage 2 or 3 (p<0.001). Controlling for the significant univariate variables listed above, the FRS cutoffs remained an independent risk factor for the development of AKI stage 2 or 3, (p<0.01) and were significantly associated with longer mechanical ventilation days and length of stay. Conclusion: Lack of responsiveness to a furosemide infusion (as measured by urine output corrected for dose of furosemide) is associated with the development of AKI in a high-risk cohort of infants. These novel findings may be helpful to predict those at risk and allow for further investigations for modifiable risk factors.

Can Radiological Renal Artery Parameters Predict Acute Kidney Injury in Infective Endocarditis Surgery?—From Imaging to Outcomes

Background: Infective endocarditis (IE) poses significant challenges in cardiovascular medicine, often necessitating valvular surgery to manage severe complications. Postoperative acute kidney injury (AKI) is a notable complication affecting patient outcomes. While clinical and procedural factors have been well studied, the role of radiological renal artery parameters in AKI risk remains underexplored. Methods: This retrospective study analyzed 80 patients with IE who underwent valvular surgery from 2013 to 2021, focusing on postoperative AKI as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Radiological parameters, including renal artery calcification, renal ostial calcification, the presence of renal infarctions, and additional arteries, were assessed using preoperative computed tomography (CT). Statistical analyses included binary logistic and linear regression models, Kaplan–Meier survival curves, and Cox proportional hazard regression to explore associations between these parameters and AKI incidence, creatinine levels, and mortality. Results: Out of 80 patients, 31 (38.8%) developed AKI. No significant differences were found in baseline characteristics or radiological parameters between the AKI+ and AKI− groups. Binary logistic and linear regression analyses revealed no substantial relationship between anatomical factors and AKI risk or creatinine levels. However, Cox regression identified “additional renal artery” as a significant predictor of 1-month mortality (HR: 1.747, 95% CI: 1.024–2.979, p = 0.041) but not for 6- or 12-month mortality. Conclusions: Radiological anatomical factors, including calcifications and additional arteries, did not significantly impact AKI risk in IE patients undergoing valvular surgery. However, the presence of additional arteries was associated with increased short-term mortality. These findings suggest the need for further research to elucidate factors contributing to AKI and mortality in this context.

Abstract 4138635: The Association of Perioperative Statins and Cardiac Surgery Associated Acute Kidney Injury in Patients Undergoing Coronary Artery Bypass Grafting

Backgrounds: Cardiac surgery associated acute kidney injury (CSA-AKI) is a prevalent and detrimental complication following cardiac surgery, with significant effects on both in-hospital and long-term morbidity and mortality. The renal protective effect of statins for patients undergoing cardiac surgery remains unclear. Purpose: This study aims to evaluate the association between perioperative statin therapy and the risk of CSA-AKI following coronary artery bypass grafting (CABG). Methods: This retrospective cohort study included consecutive patients undergoing CABG between 2013 and 2022, with one year follow-up after hospital discharge. Any usage of statin initiated from admission to 72 hours after surgery was defined as perioperative statin therapy. The primary outcome was in-hospital postoperative AKI according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The secondary outcomes were composite measures including all-cause mortality and dialysis at 30 days and one year. Multivariate Cox proportional hazards regression models were constructed to assess the association between perioperative statin and pre-defined outcomes. Results: Among the included 36288 patients, 22272 (61.3%) patients received perioperative statin therapy, with a total of 19683 (54.2%) patients developing CSA-AKI. For the primary outcome, perioperative statin was associated with a significantly decreased risk of CSA-AKI (52.8% vs. 56.5%; adjusted Odds Ratio [OR], 0.865 [95% CI, 0.829-0.904]; p < 0.001). Additionally, the occurrence of a composite measure including all-cause mortality and dialysis was statistically lower in patients who underwent perioperative statin therapy at 30 days (0.7% vs. 1.6%; OR, 0.485 [95% CI, 0.394-0.597]; p < 0.001), as well as at one year (adjusted Hazard Ratio [HR], 0.632 [95% CI, 0.543-0.737], p < 0.001). For the subgroup analysis, the association between perioperative statin and reduced CSA-AKI risk was greater among patients with chronic heart failure and undergoing on-pump CABG. Conclusions: Perioperative statin therapy was associated with significantly lower risks of CSA-AKI following CABG, and a composite measure including all-cause mortality and dialysis at both 30 days and one year. The preventive effect of perioperative statin was more pronounced in patients with chronic heart failure and undergoing on-pump CABG.

Sepsis-Associated Acute Kidney Injury in Critically Ill Children: Incidence and Outcomes

Background: Acute kidney injury (AKI) is a major concern in pediatric critical care, often occurring in conjunction with sepsis. This study aimed to identify the incidence, outcomes, and risk factors for AKI in the context of pediatric sepsis. Methods: This was a bicentric retrospective cohort study conducted at two university hospitals in Saudi Arabia. All patients aged 1 month to 14 years admitted to pediatric intensive care units (PICUs) with evidence of sepsis between January 2021 and December 2022 were included. AKI was defined and staged according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Demographic, clinical, and laboratory data were collected from electronic medical records. Results: 309 patients were included, 38 (12.3%) developed stage 1 AKI, 64 (20.7%) developed stage 2 AKI, and 183 (59.2%) developed stage 3 AKI. Patients with sepsis-associated AKI had significantly longer PICU stays and higher mortality rates than those without AKI (p < 0.01). Inflammatory markers and certain medications were associated with increased AKI risk. Factors independently associated with stage 3 AKI include younger age, positive blood culture, gentamycin use, and higher SOFA score. Conclusions: Sepsis-associated AKI is a common and serious complication in critically ill children, contributing to increased morbidity and mortality. Identification of specific risk factors may facilitate early recognition and targeted interventions to mitigate the impact of AKI in this vulnerable population.

What is confirmed in the treatment of metabolic acidosis in chronic kidney disease?

Precise regulation of the acid-base balance is essential for the functioning of various organs and physiological processes. Acid retention and metabolic acidosis (MA) are frequent complications of chronic kidney disease (CKD) and can also occur following kidney transplantation. In addition to dietary modifications, pharmacological interventions, most notably sodium bicarbonate, are employed to correct MA. While several studies have reported abeneficial effect of MA correction on the progression of CKD, the results remain inconsistent and the magnitude of the treatment effect may be limited. Importantly, no beneficial effect on graft function has been demonstrated after kidney transplantation. The MA is associated with impaired bone quality and although alkali treatment has generally shown positive effects on markers of bone metabolism, consistent changes in bone density have not been observed. Additionally, MA is linked to an increased incidence of cardiovascular events but so far there is alack of interventional studies with definitive cardiovascular endpoints. Sodium bicarbonate may lead to sodium retention, potentially increasing blood pressure, although the data on this are inconclusive. One interventional study with notable limitations reported apositive effect of alkali treatment on mortality. Correction of MA has been suggested to positively impact protein and muscle catabolism, although no improvement in physical performance was observed in ageriatric population. Limited studies exist on the endocrinological effects of alkali treatment but these indicate afavorable impact on glucose metabolism and potential benefits for thyroid function in predialysis CKD patients. Given the overall low to moderate level of evidence supporting the benefits of alkali treatment, the current guidelines from Kidney Disease: Improving Global Outcomes (KDIGO) propose alkali treatment to prevent serum bicarbonate levels < 18 mmol/l (prior < 22 mmol/l) in adults and the resulting complications.

Effects of ertugliflozin on uric acid and gout-related outcomes in persons with type 2 diabetes and cardiovascular disease: Post hoc analyses from VERTIS CV.

To conduct post hoc analyses of the VERTIS CV (NCT01986881) trial to explore the effects of ertugliflozin on serum uric acid (UA) and gout-related outcomes. Participants with type 2 diabetes and atherosclerotic cardiovascular disease were randomised (1:1:1) to placebo, ertugliflozin 5 mg or ertugliflozin 15 mg. Mean UA over time (260 weeks) was evaluated for pooled ertugliflozin versus placebo overall, and by baseline quintile of UA (≤4.3 mg/dL [≤255.8 µmol/L], >4.3-5.1 mg/dL [>255.8-303.4 µmol/L], >5.1-5.8 mg/dL [>303.4-345.0 µmol/L], >5.8-6.9 mg/dL [>345.0-410.4 µmol/L] and >6.9 mg/dL [>410.4 µmol/L]), glycated haemoglobin level, albuminuria status, estimated glomerular filtration rate and KDIGO (Kidney Disease: Improving Global Outcomes in Chronic Kidney Disease) risk category. The effect of ertugliflozin on a composite of gout onset or initiation of anti-gout medication was assessed. The mean UA levels at baseline were 5.67 and 5.62 mg/dL in the placebo and ertugliflozin groups, respectively. Ertugliflozin reduced UA over Weeks 6-260 compared with placebo, with least squares mean (LSM) changes (95% confidence interval [CI]) from baseline at Week 260 of 0.07 mg/dL (-0.02, 0.15) and -0.19 mg/dL (-0.25, -0.13) in the placebo and pooled ertugliflozin groups, respectively. At Week 260, placebo-adjusted LSM change (95% CI) from baseline in UA was -0.26 mg/dL (-0.36, -0.16) with ertugliflozin. Ertugliflozin was associated with reductions in UA across baseline UA quintiles compared with placebo. The incidence of the composite of gout-related outcomes was 84/2539 (3.3%) for placebo and 133/5091 (2.6%) for ertugliflozin (hazard ratio for the composite 0.76 [95% CI 0.580, 1.002]). Ertugliflozin was generally associated with lowering UA overall and across subgroups compared with placebo, and numerically reduced rates of gout-related outcome events.

Association between perioperative platelet distribution width changes and postoperative acute kidney injury in patients with renal insufficiency: a retrospective study

BackgroundAcute kidney injury (AKI) is a major complication following cardiac surgery with a high incidence in those with existing kidney dysfunction. Platelet distribution width (PDW) reflects variability in platelet size and serves as an indicator of platelet activation. Recent investigations linked PDW changes to kidney pathology, suggesting its utility in identifying individuals at risk for AKI, thus necessitating exploration of its predictive value.MethodsPatients with preoperative renal dysfunction [15 ≤ estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2] who underwent cardiac surgery from January 2018 to December 2021 were retrospectively enrolled. PDW values were measured preoperatively and again upon admission to the ICU immediately after cardiac surgery, with the change in PDW (dPDW) defined as the difference between these two measurements. The primary outcome was postoperative AKI, defined base on the Kidney Disease: Improving Global Outcomes (KDIGO) definition and staging criteria. Multivariate regression models were performed to identify the association between dPDW and AKI and its potential trend. Restricted cubic spline analysis assessed non-linear associations between dPDW and AKI. The Youden index identified an optimal dPDW cut-off for AKI prediction. Subgroup analysis was performed to elucidate the consistency of these associations across the various subgroups.ResultsAKI occurred in 53.10% (513/966) of patients, accompanied by significant PDW increases in cases of AKI (P < 0.001). After adjusting confounders, dPDW was identified as a significant risk factor for AKI [odds ratio (OR) = 1.09, 95% confidence interval (CI): (1.02 ~ 1.16), P = 0.012]. Patients in the highest dPDW quartile (Q4) had a 195% higher AKI risk compared to those in the lowest quartile (Q1) (OR = 2.95, 95% CI:1.78 ∼ 4.90, P < 0.001). Trend analysis indicates that the risk of AKI increased with higher dPDW quartiles (P for trend < 0.001). Youden index showed that dRDW = 1.1 was identified as the optimal diagnostic cut-off value for AKI. Subgroup analyses and interaction tests showed a robust association between dPDW and AKI in all subgroups (P for interaction > 0.05).ConclusionsThis study underscored perioperative PDW changes as a significant predictor of postoperative AKI in patients with renal insufficiency, highlighting its potential in refining risk stratification and management strategies.Clinical trial numberNot applicable for this observational retrospective study.

Does serum neutrophil gelatinase–associated lipocalin level predict acute kidney injury in patients with acute rhabdomyolysis in the emergency department? A multicentre prospective study

ObjectivesThe major complication of rhabdomyolysis is acute kidney injury (AKI), which requires prompt treatment. Currently, few biomarkers are available for the early detection of AKI. Serum neutrophil gelatinase–associated lipocalin (NGAL) has been suggested as an early biomarker for renal ischemia. However, its capacity to predict AKI in patients presenting with rhabdomyolysis in the emergency department (ED) remains unclear. The aim of this study was to evaluate the ability of NGAL to predict 48-hour AKI.DesignProspective, multicentre study.SettingFive adult EDs in France from August 2013 to December 2015.ParticipantsNGAL levels were measured on ED admission in patients with rhabdomyolysis. A total of 197 patients were enrolled, and 189 (96%) were analysed, of whom 89 (47%) were women. Patients were included if they presented to the ED with rhabdomyolysis and a creatine phosphokinase (CPK) level above 1000 IU/L. Exclusion criteria were pregnancy, presentation with acute coronary syndrome, the need for iodinated contrast, chronic dialysis or recent use of nephrotoxic drugs (within 72 hours prior to the ED visit). Patients who withdrew consent or had AKI due to other causes were also excluded.Primary and secondary outcome measuresThe primary outcome was AKI at 48 hours, defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary outcomes included in-hospital mortality, length of hospital stay, admission to intensive care and the need for renal replacement therapy.ResultsOverall, 54 (29%) patients developed AKI by day 2. The area under the ROC curve (AUC-ROC) for NGAL in predicting AKI on day 2 was 0.60 (95% CI 0.51 to 0.70), with an optimal cut-off of 129 ng/mL. The sensitivity was 0.65, and specificity was 0.50. After adjustment for CPK levels, age, sex and oxygen saturation, the AUC-ROC for predicting AKI on day 2 increased slightly to 0.64 (95% CI 0.54 to 0.74).ConclusionNGAL has limited ability to predict day 2 AKI in patients presenting with acute rhabdomyolysis in the ED.Trail registration numberNCT01544231.Comité de Protection des Personnes Sud Méditerranée III n°2011-A01059-32.

Neuropsychiatric complications in chronic kidney disease: Role of gender, clinical, and sociodemographic factors

ABSTRACT Introduction: Patients with chronic kidney disease (CKD) frequently experience neuropsychiatric conditions, such as depression, anxiety, and cognitive impairment, which not only significantly diminish their quality of life, but also contribute to longer hospitalizations, poor treatment adherence, and increased mortality. This hospital-based cross-sectional study aimed to investigate neuropsychiatric complications in CKD patients, focusing on gender differences, and clinical and other sociodemographic factors. Materials and Methods: Diagnosis of CKD was based on the Kidney Disease: Improving Global Outcomes (KDIGO) criteria, and patients aged 18 years or above were included. Delirium was assessed using the Confusion Assessment Method (CAM) Scale. Those without delirium underwent evaluation using the Hindi Mental Status Examination (HMSE), Brief Psychiatric Rating Scale (BPRS), and Hospital Anxiety and Depression Scale (HADS) to identify cognitive and psychiatric symptoms. Results: Among the 104 participants, 50% were male, with a predominant age group over 45 years (61.5%). A majority portion of the cohort was married (72.1%), employed (57.7%), and identified as Christian (56.7%). The majority of CKD cases were diagnosed as stage 5 (87.5%) and on dialysis treatment. Delirium was present in 19.2% of participants. In those without delirium, anxiety affected 46.3%, depression impacted 50.0%, and cognitive dysfunction was present in 11.1%. A gender-based analysis revealed no significant differences in age or illness duration; however, males exhibited a higher level of education (P &lt; 0.02). While females tended to display more severe psychiatric symptoms (P &lt; 0.06), males had more cognitive dysfunction (P &lt; 0.08); however, these differences did not reach statistical significance. Socioeconomic status (SES) comparisons demonstrated that lower SES correlated with a reduced number of years of education (P &lt; 0.00). Conclusion: Anxiety and depression were prevalent in nearly half of CKD patients, without gender or socioeconomic disparities. This underscores the imperative need for holistic, multidisciplinary interventions to effectively manage these conditions and enhance overall quality of life.

An early HMGB1 rise 12 hours before creatinine predicts acute kidney injury and multiple organ failure in a smoke inhalation and burn swine model.

Acute kidney injury (AKI) and multiple organ failure (MOF) are leading causes of mortality in trauma injuries. Early diagnosis of AKI and MOF is vital to improve outcomes, but current diagnostic criteria rely on laboratory markers that are delayed or unreliable. In this study, we investigated whether damage associated molecular patterns such as high-mobility group box 1 (HMGB1), syndecan-1 (SDC-1) and C3a correlate with the development of trauma-induced AKI and MOF. Thirty-nine swine underwent smoke inhalation and severe burns, then received critical care for 72 hours or until death. AKI was defined by the KDIGO (Kidney Disease: Improving Global Outcomes) criteria, which labels AKI when a 1.5-fold increase in blood creatinine levels from baseline or a urine output < 0.5 mL/kg/h for 6 hours or more occurs. MOF was defined by the presence of both AKI and acute respiratory distress syndrome (PaO2/FiO2<300 for 4 hours). Eight of 39 pigs developed AKI and seven of those developed MOF. Pathological analysis revealed that polytrauma induces significantly higher kidney injury scores compared to sham controls. The average time from injury to KDIGO AKI was 24 hours (interquartile range: 22.50-32.25). Twelve hours after injury, HMGB1 levels were significantly increased in animals that went on to develop AKI compared to those that did not (73.07 ± 18.66 ng/mL vs. 31.64 ± 4.15 ng/mL, p<0.01), as well as in animals that developed MOF compared to those that did not (81.52±19.68 ng/mL vs. 31.19 ± 3.972 ng/mL, p<0.05). SDC-1 and C3a levels were not significantly different at any time point between groups. ROC analysis revealed that HMGB1 levels at 12 hours post-injury were predictive of both AKI and MOF development (AKI: AUROC=0.81, cut-off value=36.41 ng/mL; MOF: AUROC=0.89, cut-off value=36.41 ng/mL). Spearman's correlation revealed that HMGB1 levels at 12 hours correlated with multiple parameters of AKI, including blood urea nitrogen, blood creatinine, and blood myoglobin. Twelve-hour post-injury HMGB1 levels predict AKI and MOF in a smoke inhalation and burn swine model. Further research is needed to validate this result in other polytrauma models and in critical combat causalities.

Acute kidney injury (AKI) in cardiac intensive care unit patients: a real challenge to overcome

Abstract Introduction Acute kidney injury (AKI) is a major cause of morbidity and mortality in intensive care units (ICUs), but in cardiac intensive care unit (CICU), despite the evidence of a causal link between cardiac illness and AKI, few data are available (1). Purpose We analyzed the predictive factors of AKI in CICU, as well as the impact of AKI on the long-term prognosis of patients admitted to CICU. Methods We reviewed the medical data of patients admitted to our CICU over a 2-year period. We excluded patients with chronic kidney disease prior to admission. We defined AKI according to the KDIGO (Kidney Disease Improving Global Outcomes) classification based on serum creatinine and urine output. To determine the predictive factors, we performed a logistic regression analysis, and to determine the prognostic impact of AKI, we performed a Cox proportional hazards regression, taking all-cause mortality at 30 months as the main study outcome. p-values less than 0.05 were considered statistically significant Results We included in our study 1581 patients hospitalized in our unit over a 2-year period, 70.4% of whom were men and 29.6% women. Among these patients, 291 presented with AKI (18.4%), 35.5% classified as KDIGO 1, 42% as KDIGO 2, and 22.5% as KDIGO 3. For the admission diagnosis of patients with AKI, STEMI came first at 56.3%, followed by NSTEMI at 17.3%, acute heart failure at 9.3%, pulmonary embolism at 2.1%, severe arrhythmias at 7.9%, and valvular disease at 1.1%. Among patients in the KDIGO 3 group, 54% benefited from a renal replacement strategy. La morta For factors predictive of AKI, and after adjustment for variables significant in univariate analysis, we objectified the following factors: arterial hypertension (OR=1.92, p&amp;lt;0.001), Diabetes (OR=1.50, p=0.007), KILLIP&amp;gt;2 at admission (OR=1.75, p=0.003), Ejection fraction&amp;lt;40% at admission (OR=1. 93, p&amp;lt;0.001), right ventricular systolic dysfunction (OR=2.95, p&amp;lt;0.001), anemia with Hb&amp;lt;10g/dl (OR=2.95, p&amp;lt;0.001), cardiogenic shock (OR=3.02, p&amp;lt;0.001), high-grade conduction disorder (OR=2.7, p=0.003) and bleeding events (OR=5.93, p&amp;lt;0.001) (Table 1-figure 1). For all-cause mortality at 30 months, 204 events were observed, 104 in the AKI group (35%), and 100 in the non-AKI group (7.75%) (p&amp;lt;0.001), and AKI was independently associated with the outcome studied for all KDIGO classes with for stage 1 (HR = 1.33; p=0.03), stage 2 (HR = 2.28; p&amp;lt;0. 001), and stage 3 (HR = 5.71; p&amp;lt;0.001), adding to this diabetes (HR = 1.96; p&amp;lt;0.001), cardiogenic shock (HR = 2.27; p&amp;lt;0.001) and finally EF&amp;lt;35% at discharge (HR = 1.53; p=0.001) (Table 2-figure 1). The Kaplein-Meier survival analysis showed a significant difference between the rates of mortality between the different KDIGO at 30-months, with a log-rank test p&amp;lt;0.001 (Figure 2). Conclusion We can conclude that AKI remains a real challenge for admitted patients, since long-term mortality in this group is very high.Figure 1.Figure 2.

Chronic kidney disease in patients with heart failure in German primary care practices: the InspeCKD study

Abstract Background Chronic kidney disease (CKD) is, alongside type 2 diabetes mellitus, the most common comorbidity in patients with heart failure (HF), with a prevalence of 40-50%. HF patients should therefore be screened, monitored, and treated according to international Kidney Disease Improving Global Outcomes (KDIGO) conclusions for early identification and intervention of CKD, with annual determination of eGFR to monitor kidney function and annual urine albumin-to-creatinine ratio (UACR) testing as appropriate. Early diagnosis is important as therapeutic options can be offered to slow the progression of CKD and reduce the risk of cardiovascular complications and mortality. Purpose Currently, there are only limited data available regarding screening, diagnosis and treatment of CKD for HF patients in German primary care physician (PCP) practices. Therefore, this analysis of the InspeCKD study was designed to examine the frequency of use of CKD-specific laboratory diagnostics in HF patients in routine PCP care. Methods In the current data analysis, fully anonymized patient data from German PCP practices were evaluated. In accordance with the screening recommendation of the KDIGO guideline, adult patients with diabetes, hypertension and/or cardiovascular disease, including HF, with at least one year of observation period were included in the analysis. Results The overall patient cohort comprised 448.837 patients from 1.244 German PCP practices. Of the 7.9% HF patients, 6.1% participated in a disease management program (DMP) for coronary heart disease. The average age of HF patients was 74 years. The prevalence of diagnosed CKD in HF patients during the observational period (mean: 1.7 years) was 26.8%. Within the subgroup of patients with HF, serum creatinine to estimate GFR was measured at least once in 48.5% of patients. Urine dipstick testing for albuminuria was performed in 7.4% of patients and UACR was measured at least once in 0.3% of patients. In patients with at least one documented measurement, eGFR and UACR were checked 2.2 and 0.9 times, respectively, per patient and year. Of the HF patients with laboratory-confirmed CKD according to KDIGO criteria, 81.8% were not diagnosed with CKD. Conclusion The analysis shows that, given the high prevalence of CKD in HF patients and the current KDIGO recommendations for early identification and intervention of CKD, a substantial proportion of HF patients in German PCP practices did not receive adequate laboratory diagnostics for early diagnosis of CKD. In addition, the majority of patients with laboratory-confirmed CKD were not diagnosed. Early detection of CKD and the use of evidence-based therapeutic options can significantly reduce the risk of CKD progression. In conclusion, there is an urgent need to raise awareness among PCPs about secondary and tertiary prevention of CKD in patients with HF and to include coordinated CKD screening recommendations in HF guidelines.

Association of a history of acute kidney injury with major adverse cardiovascular events in chronic kidney disease patients

Abstract Background/introduction Acute kidney injury (AKI) is strongly associated with major adverse cardiovascular events (MACE), particularly heart failure, in both general and critically ill populations. A recent study questioned whether this association holds true only for patients without chronic kidney disease (CKD). Purpose To evaluate the association of a history of AKI with MACE in a large real-world CKD population defined using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Methods A retrospective cohort study was conducted using Merative® Explorys electronic health records (&amp;gt;54 million patients) from Jan 2010 to Dec 2019. Six cohorts of CKD patients (diagnosed or not) were created, one for each stage (1-5). Patients were required to have two consecutive abnormal eGFR, uACR/uPCR results within 3-18 months to determine CKD stage, to have at least a 12-months lookback period, and no history of end-stage kidney disease. CKD classification was not mutually exclusive (individual patients could contribute to multiple stages). Index date was the date of the second abnormal test. History of AKI was defined using ICD diagnosis codes, not through biological changes. We followed each patient until the occurrence of a composite of MACE including death, coronary events [acute coronary syndrome + coronary revascularization], any stroke, hospitalization for heart failure, or loss to follow-up, or for up to 5 years. We used multivariable Cox proportional hazards regression to estimate associations between the history of AKI and the risk of MACE during follow-up, adjusted for the following confounders: age, sex, ethnicity, systolic blood pressure, eGFR, BMI, CV history, diabetes, and any CKD diagnosis at baseline. Results Most of the 969,394 patients included in at least one CKD stage cohort were in stage 3a (see table) and Caucasian. Mean ages were 57-75y and 42%-64% were females across the 5 CKD stages. The prevalence of pre-existing CV disease increased from 24% in stage 1 to 57% in stage 4. The proportion of patients with a history of AKI increased from 4% in stage 1 to 36% in stage 4, as well as, the proportion of patients with a ICD code for CKD diagnosis at baseline (3% to 44%). The 5-year incidence of the composite of MACE increased from 25.1% in stage 1 to 65.8% in stage 5. Death was the most frequent event across all stages. In multivariable analysis, a history of AKI was associated with increased risk of MACE (hazard ratios, HR 1.19 to 1.32), all-cause death (HR 1.12 to 1.86), and hospitalization for Heart Failure (HR 1.59 to 1.98) for all CKD stages, and coronary events for stage 2 to 5 (HR 1.14 to 1.22), but not stroke. Conclusion Patients with CKD and a history of AKI are at higher risk of adverse CV outcomes, especially hospitalization for heart failure. This study suggest that these patients should receive cardio -protective intervention.

Increased Body Mass Index is Independently Associated with Chronic Kidney Disease among People with Type 2 Diabetes

Background The alarming increase in the prevalence of obesity has implications for chronic kidney disease (CKD) progression in type 2 diabetes (T2D). This study aimed to assess if increased body mass index (BMI) can be an independent risk factor for CKD and T2D in the Indian context. Materials and Methods In this cross-sectional study, 602 (M:F = 378:224) participants were screened using Kidney Disease Improving Global Outcomes (KDIGO) from January to October 2023 in Chennai. Demographic, anthropometric, biochemical, clinical details, and comorbidities were recorded. T2D with CKD low risk was taken as control group, and CKD moderate and high risks were the study groups. BMI was classified based on the Asian criteria into normal (18.5–22.9), overweight (23–24.9), and obese (≥25 kg/m2). Results Majority of participants in moderate and high risk categories were obese compared to the low risk category (60.5% and 66.4% vs. 39.1%; p &lt; 0.001). A higher proportion of participants was on antihypertensive drugs in the high risk group and in the obese category (p &lt; 0.001). Comorbidities and diabetic complications were higher in the high risk group (p &lt; 0.001). Multivariate logistic regression revealed that age of ≥ 60 years [OR(95% CI); 6.3(2.2–18); p = 0.009]; increased BMI as overweight [3.6(2.1–6.3); p &lt; 0.001] and obese [5.2(3.3–8.3); p &lt; 0.001]; smoking [4.2(1.7–10.2); p = 0.002]; increased duration of diabetes of 5–15 years [2.3(1.2–4.5); p = 0.013], 16–25 years [4.8(2.2–10.4); p &lt; 0.001], and &gt;25 years [4.2(1.4–13); p = 0.011]; systolic blood pressure [1.01(1.0–1.03); p = 0.02]; and hemoglobin A1c [1.2(1.1–1.3); p &lt; 0.001] were independent risk factors for the progression of CKD. Conclusion Increased BMI was independently associated with CKD in T2D. Overweight and obese individuals are four to five times at risk for CKD progression. Early identification, lifestyle intervention, and weight-lowering drugs may reduce the complications of obesity in T2D and CKD.

Incidence and Risk Factors of Postoperative Acute Kidney Injury in Non-Cardiovascular Surgery: A Retrospective Cohort Study

Objective: To identify the incidence, risk factors, and outcome of postoperative acute kidney injury (AKI) in non-cardiovascular surgery. Materials and Methods: A single-center retrospective cohort study included patients who underwent non-cardiovascular surgeries such as general, orthopedics, gynecology, neurosurgery, ENT, plastic, and endoscopy, between January 1, 2019 and December 31, 2020. The primary outcome was the incidence of AKI within seven days after surgery, as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The secondary outcomes were risk factors and the outcome of AKI. Results: From 2,898 cases, the incidence of postoperative AKI was 2% (57 cases). Twenty-two out of 57 cases (38.6%) had diagnosis of acute renal failure in the discharge summary. Independent risk factors of postoperative AKI by multivariate logistic regression analysis were the American Society of Anesthesiologists (ASA) classification of 3 or greater, emergency surgery, atrial fibrillation, preoperative use of a mechanical ventilator, eGFR of less than 60 mL/minute/1.73 m², hypoalbuminemia, intraoperative urine output of less than 0.5 mL/kg/hour, vasopressor infusion, and intraoperative blood transfusion. Patients with postoperative AKI had higher mortality rates and postoperative complications included pneumonia, surgical site infection, sepsis, respiratory failure, and severe arrhythmia. Conclusion: Postoperative renal function should be monitored in patients with risk factors associated with postoperative AKI to improve patient outcomes.

Advancing Community Care and Access to Follow-Up after Acute Kidney Injury Hospitalization: A Randomized Clinical Trial.

Key Points A risk-guided intervention improved adherence to processes of care for AKI survivors.Further supports are necessary to improve uptake of processes of care for AKI survivors in primary care. Background AKI is associated with development and progression of CKD. Gaps in recommended care for CKD are common after AKI. Methods In this randomized controlled trial conducted in Alberta, Canada, we allocated adults hospitalized with Kidney Disease Improving Global Outcomes (KDIGO) stage 2 or greater AKI to a risk-guided, transition of care intervention versus usual practices at the time of hospital discharge. For people in the intervention group, we used a validated risk index to predict risk of severe CKD after AKI. People at low risk (&lt;1%) received patient education alone. People at medium risk received additional clinical guidance, provided to their primary care physician. People at high risk (&gt;10%) were referred to nephrology. The primary outcome was the proportion of patients who received treatment with an angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB), statin, and nephrology specialist follow-up within 90 days of discharge. Results One hundred fifty-five patients were recruited; the mean (SD) age was 60 (15) years, 91 (60%) were male, and 96 (62%) had eGFR &lt;60 ml/min per 1.73 m2 or urine albumin-creatinine ratio &gt;30 mg/g at discharge. The proportion of participants who received ACE-I/ARB, statin treatment, and nephrologist follow-up was 28% in the intervention group versus 3% in the usual care group (absolute risk difference [RD], 25%; 95% confidence interval [CI], 15% to 36%). The use of ACE-I or ARB in participants with urine albumin-creatinine ratio &gt;300 mg/g or diabetes was greater in the high-risk group with the intervention versus usual care (RD, 37%; 95% CI, 6% to 67%), as was statin use among those with CKD (RD, 30%; 95% CI, 5% to 56%) and nephrologist follow-up for those with sustained eGFR &lt;30 ml/min per 1.73 m2 at discharge (RD, 78%; 95% CI, 56% to 100%). Hyperkalemia was more frequent in the intervention group (RD, 10%; 95% CI, 9% to 19%). Conclusions A risk-guided intervention for patients hospitalized with AKI increased recommended processes of care for CKD for high-risk patients after hospital discharge. Clinical Trial registry name and registration number: Improving Post Discharge Care after Acute Kidney Injury (AFTER AKI), NCT02915575.

Comprehensive comparative evaluation of the eight pediatric estimated glomerular filtration rate equations in a large Korean pediatric patient cohort

IntroductionAlthough estimated glomerular filtration rate (eGFR) are continuously developed for pediatric population, impact of height measurement is often neglected due to variable dynamic growth changes in children. This study aimed to compare differential impacts of eGFR values calculated by six equations that do not use height information. Materials and methods3503 Korean pediatric patients with creatinine/cystatin C assay-based laboratory results from 2008 to 2021 were analyzed for clinical course using a total of 8113 laboratory test results. Baseline eGFR was calculated by eight different equations including two widely used equations incorporating height parameter. Along with the agreement of CKD (chronic kidney disease) stage categorization by different equations, clinical outcome of incident CKD diagnosis in 13 years of study period were compared. ResultsAmong a total of 28 pairwise comparisons among eight equations, only 4 combinations of comparisons revealed optimal P15 values (≥80 % concordance), with FAS-age equation being both concordant with two equations using height parameter. Clustering of eight equations by incident CKD diagnosis in subsequent tests also highlighted FAS-age as candidate equation within the same cluster with Schwartz-bedside and FAS-height equations. When the equation values were classified into Kidney Disease Improving Global Outcomes (KDIGO) CKD stages, the distribution patterns for stage 1 and 5 were significantly different among eGFR equations. FAS-age equation revealed the highest agreement with Schwartz-bedside and FAS-height equations that incorporate the height data. ConclusionsThe eGFR equation type should be considered to establish the eGFR intervals for CKD stage classification, particularly in the pediatric patient population. Cautious interpretation is required for eGFR value along with clinical context.