Lower Rates Of Acute Kidney Injury Research Articles

Higher intraoperative blood pressure does not reduce acute kidney injury in non-cardiac surgery: what do the results of the POISE-3 trial tell us?

Hypotension is a common cause of acute kidney injury (AKI), with strong associations between the duration and magnitude of hypotension seen across a range of situations including major surgery. However, it is less clear whether targeting higher intraoperative MAP results in lower rates of AKI. In a prespecified analysis of the Perioperative Ischemic Evaluation-3 (POISE-3) randomized controlled trial, this question is addressed for noncardiac major surgery. Despite an increase in cessation of antihypertensive medications and higher intraoperative mean arterial blood pressure in the intervention arm, no differences were seen in the rates of postoperative AKI. This commentary discusses the strengths and weaknesses of the trial, as well as providing some interpretation of results and their relevance to clinical practice.

Impact of mechanical circulatory support on in-hospital outcomes among patients with ventricular tachycardia requiring ablation.

Ventricular tachycardia (VT) ablation is a high-risk procedure, particularly due to the potential for hemodynamic instability. Mechanical circulatory support (MCS) is increasingly utilized to manage these risks. This study investigated the in-hospital outcomes of VT ablation with MCS use, emphasizing its impact on mortality and procedural complications. We retrospectively analyzed patients undergoing VT ablation from 2019 to 2020, using the National Inpatient Sample data. Patients aged 18 years and over were included. MCS includes a percutaneous left ventricular assist device (pLVAD), extracorporeal membrane oxygenation (ECMO), and intraaortic balloon pump (IABP). We also conducted a subgroup analysis for patients experiencing cardiogenic shock (CS). The primary outcome was in-hospital mortality; secondary outcomes included acute kidney injury (AKI), AKI-requiring dialysis, any bleeding events, gastrointestinal bleeding, ischemic stroke, heart transplant, and durable LVAD (dLVAD) utilization. We included 14 450 patients, of whom 6.5% utilized MCS. The MCS group showed a higher in-hospital mortality rate than the non-MCS group (24% vs. 2%, p < 0.01). Secondary outcomes showed statistically higher rates in the MCS group compared to the non-MCS groups. Stratification by MCS modality did not affect outcomes except that pLVAD was associated with lower rates of AKI. In the CS subgroup, the MCS group exhibited significantly higher mortality compared to the non-MCS group (32% vs. 8.4%, p < 0.01). The use of MCS during VT ablation is associated with increased in-hospital mortality, underscoring the severity of cases requiring such support. These findings show the need for careful assessment and optimal usage of MCS to enhance patient outcomes.

A PROMPT Update on Partial REBOA: Initial Clinical Data and Overview of the DoD-Funded Partial REBOA Outcomes Multicenter ProspecTive (PROMPT) Study.

Retrograde Endovascular Balloon Occlusion of the Aorta (REBOA) is an effective management for the transient responder, but the ischemic consequences of complete aortic occlusion currently limit its use. Multiple DoD-funded preclinical studies have clearly demonstrated that partial REBOA reduces distal ischemia to potentially extend safe occlusion times, while still providing effective temporization of noncompressible torso hemorrhage. Early versions of REBOA devices were designed to completely occlude the aorta and had little ability to provide partial occlusion. Recently, a new REBOA device (pREBOA-PRO) was designed specifically to allow for partial occlusion, with the hypothesis that this may reduce the complications of aortic occlusion and extend safe occlusion times while maintaining the benefits on cardiac and cerebrovascular circulation as well as reductions in resuscitation requirements. To ascertain the impact of a new purpose-built partial REBOA device on the extension of safe occlusion time, the Partial REBOA Outcomes Multicenter ProspecTive (PROMPT) trial compared available data from the pREBOA-PRO with existing data from 200 clinical uses of pREBOA-PRO and available data in the AAST AORTA Registry were reviewed to design primary endpoints and clinical evidence for a prospective multi-center trial, the PROMPT Study. Together with the endpoints identified in preclinical studies of partial REBOA, primary endpoints for the PROMPT study were identified and power analyses were conducted to determine the target patient enrollment goals. Results from the clinical implementation of partial REBOA at a single trauma center were used to conduct the initial power analysis for the primary endpoint of Acute Kidney Injury (AKI) after prolonged occlusion. The rate of AKI after complete REBOA was 55% (12/20) compared to 33% (4/12) after partial REBOA (Madurska etal., 2021). With an alpha of 0.05 and power (β) of 0.8, the projected sample size for comparison on a dichotomous outcome is 85 patients for the assessment of AKI. Initial power and endpoint analyses have been confirmed and extended with the ongoing analysis of partial and complete REBOA reported in the AORTA database. These analyses confirm preclinical findings which show that compared to complete REBOA, partial REBOA is associated with extended occlusion time in zone 1 (complete: 31 min vs. partial: 45 min, P = 0.003), lower rates of AKI after zone 1 occlusion (complete: 33% vs. partial: 19%, P = 0.05) and reduced resuscitation requirements (e.g., 25% reduction in pRBC administration: complete: 18 units vs. partial: 13 units, P = 0.02). The DoD-funded PROMPT study of partial REBOA will provide prospective observational clinical data on patients being treated with pREBOA-PRO. Outcomes will be stratified based on partial or complete occlusion to address whether partial REBOA has additional clinical benefits over complete REBOA, such as decreased distal ischemia, extension of safe occlusion time, improved hemodynamics during transition to and from occlusion, and reduced interoperative bleeding and blood product use. The results from this study are expected to confirm previous data demonstrating reduction of ischemic sequalae, improved transition to reperfusion, and reduced resuscitative requirements compared to complete REBOA.

The Babyccino: The Role of Caffeine in the Prevention of Acute Kidney Injury in Neonates-A Literature Review.

Acute kidney injury (AKI) in neonates is associated with increased morbidity and mortality. Theophylline (a methylxanthine) has been shown to prevent neonatal AKI but is seldom used due to its unfavorable profile. Caffeine, another methylxanthine, is utilized ubiquitously to treat apnea of prematurity, but there are no randomized trials evaluating its efficacy in preventing neonatal AKI. This literature review aims to summarize the existing research pertaining to the relationship between caffeine and neonatal AKI. The review was conducted using Pubmed, Embase, Google Scholar, and Cochrane. Inclusion criteria incorporated empirical studies, being published in English, and being available electronically. All eight studies identified were included. Seven studies found caffeine-exposed premature neonates had lower rates of AKI than caffeine-unexposed neonates. Four found reduced AKI severity with caffeine exposure. One study included term neonates and did not find a difference in the AKI rate between caffeine-exposed and non-exposed babies. Limitations include exclusively observational studies, short study periods, heterogenous definitions of prematurity, and a lack of assessment of dose-effect relationships. In conclusion, premature neonates exposed to caffeine appear to have lower rates and potentially less severe AKI. Further research is needed before caffeine can be considered for use in the primary prevention of neonatal AKI.

Acute Kidney Injury Incidence With Bayesian Dosing Software Versus 2-Level First-Order Area Under the Curve-Based Dosing of Vancomycin With Piperacillin-Tazobactam.

Background: Two methods of area under the curve (AUC) dosing are recommended in vancomycin consensus guidelines: first-order calculations utilizing 2 vancomycin concentrations or a Bayesian approach. It is unknown if there is a difference in acute kidney injury (AKI) between the 2 dosing strategies for patients receiving concomitant piperacillin-tazobactam and vancomycin (VPT). Objective: The objective of this study was to compare incidence of AKI in patients being administered VPT with first-order calculations versus model-informed precision dosing (MIPD)/Bayesian dosing. Methods: This was a single-center, retrospective, observational study at a community hospital. Patients who received VPT therapy for at least 48 hours were included. The primary outcome was overall incidence of AKI. Secondary outcomes included percentage target attainment with initial regimen, average serum creatinine increase, time to AKI, usable vancomycin levels, and need for temporary dialysis or intensive care unit admission. Results: There were 100 patients included (50 in the first-order group and 50 in the MIPD/Bayesian group). The overall incidence of AKI was lower in the MIPD/Bayesian group (12% vs 28%, P = 0.046). There was no difference in average serum creatinine increase, time to AKI, need for temporary dialysis, or intensive care unit admission. Patients in the MIPD/Bayesian group had a higher percentage of target attainment (46% vs 18%, P = 0.003) and usable vancomycin levels (98% vs 60%, P < 0.001). Conclusion and Relevance: In patients receiving VPT, model-informed precision dosing with Bayesian modeling resulted in a lower rate of AKI, higher target attainment, and more usable vancomycin levels compared with first-order AUC dosing. The small sample and retrospective nature of this study reinforces the need for additional data.

Implementation of Nephroprotective Measures to Prevent Acute Kidney Injury in Septic Patients: A Retrospective Cohort Study.

Sepsis remains the leading cause of mortality in critically ill patients, and mortality is increased when acute kidney injury (AKI) occurs. The Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommends the implementation of supportive measures in patients at high risk for AKI. However, it remains unclear to what extent these nephroprotective measures are implemented in daily clinical practice in critically ill patients, especially those with high-risk exposures such as sepsis. We analyzed the Medical Information Mart for Intensive Care IV (MIMIC-IV) database to identify septic patients with and without AKI. The primary outcome of interest was the adherence to the KDIGO bundle consisting of avoidance of nephrotoxic agents, implementation of a functional hemodynamic monitoring, optimization of perfusion pressure and volume status, close monitoring of renal function, avoidance of hyperglycemia, and avoidance of radiocontrast agents. Secondary outcomes included the development of AKI, progression of AKI, the use of renal replacement therapy (RRT), mortality, and a composite end point consisting of progression of AKI and mortality within 7 days. Our analysis included 34,679 patients with sepsis with 1.6% receiving the complete bundle (10% received 5, 42.3% 4, 35.4% 3, and 9.8% 2 bundle components). In 56.4%, nephrotoxic agents were avoided, and hemodynamic optimization was reached in 86.5%. Secondary end points were improved in patients with bundle adherence. Avoidance of nephrotoxic drugs and optimization of hemodynamics were significantly associated with lower rates of AKI and improved patient outcomes, including 30-day mortality. Implementation of the KDIGO bundle is poor in patients with sepsis but may be associated with improved outcomes.

Association of Radial Artery Access with Reduced Incidence of Acute Kidney Injury.

To determine if radial artery (RA) access compared with femoral artery (FA) access for percutaneous coronary intervention (PCI) is associated with a lower incidence of acute kidney injury (AKI). AKI results in substantial morbidity and cost following PCI. Prior studies comparing the occurrence of AKI associated with radial artery (RA) versus femoral artery (FA) access have mixed results. Using a large state-wide database, 14,077 patients (8,539 with RA and 5,538 patents with FA access) were retrospectively compared to assess the occurrence of AKI following PCI. To reduce selection bias and balance clinical data across the two groups, a novel machine learning method called a Generalized Boosted Model was conducted on the arterial access site generating a weighted propensity score for each variable. A logistic regression analysis was then performed on the occurrence of AKI following PCI using the weighted propensity scores from the Generalized Boosted Model. As shown in other studies, multiple variables were associated with an increase in AKI after PCI. Only RA access (OR 0.82; 95% CI 0.74-0.91) and male gender (OR 0.80; 95% CI 0.72-0.89) were associated with a lower occurrence of AKI. Based on the calculated Mehran scores, patients were stratified into groups with an increasing risk of AKI. RA access was consistently found to have a lower risk of AKI compared with FA access across these groups of increasing risk. Compared with FA access, RA access is associated with an 18% lower rate of AKI following PCI. This effect was observed among different levels of risk for developing AKI. Although developed from a retrospective analysis, this study supports the use of RA access when technically possible in a diverse group of patients.

Renal outcomes in valve-in-valve transcatheter versus redo surgical aortic valve replacement: A systematic review and meta-analysis.

Postoperative acute kidney injury (AKI) and the requirement for renal replacement therapy (RRT) remain common and significant complications of both transcatheter valve-in-valve aortic valve replacement (ViV-TAVR) and redo surgical aortic valve replacement (SAVR). Nevertheless, the understanding of renal outcomes in the population undergoing either redo SAVR or ViV-TAVR remains controversial. A systematic database search with meta-analysis was conducted of comparative original articles of ViV-TAVR versus redo SAVR in EMBASE, MEDLINE, Cochrane database, and Google Scholar, from inception to September 2021. Primary outcomes were AKI and RRT. Secondary outcomes were stroke, major bleeding, pacemaker implantation rate, operative mortality, and 30-day mortality. Our search yielded 5435 relevant studies. Eighteen studies met the inclusion criteria with a total of 11,198 patients. We found ViV-TAVR to be associated with lower rates of AKI, postoperative RRT, major bleeding, pacemaker implantation, operative mortality, and 30-day mortality. No significant difference was observed in terms of stroke rate. The mean incidence of AKI in ViV-TAVR was 6.95% (±6%) and in redo SAVR was 15.2% (±9.6%). For RRT, our data showed that VIV-TAVR to be 1.48% (±1.46%) and redo SAVR to be 8.54% (±8.06%). Renoprotective strategies should be put into place to prevent and reduce AKI incidence regardless of the treatment modality. Patients undergoing re-intervention for the aortic valve constitute a high-risk and frail population in which ViV-TAVR demonstrated it might be a feasible option for carefully selected patients. Long-term follow-up data and randomized control trials will be needed to evaluate mortality and morbidity outcomes between these 2 treatments.

Balanced forced-diuresis compared to control as a reno-protective approach in cardiac surgery: secondary outcome of a randomized controlled trial, assessment of neutrophil gelatinase-associated lipocalin levels

BackgroundNeutrophil gelatinase-associated lipocalin (NGAL) is a recognised biomarker for acute kidney injury (AKI).This study investigated the impact of balanced forced-diuresis using RenalGuard® system (RG), in reducing acute kidney injury (AKI) rates and the associated NGAL levels (6-h post-CPB plasma level) post adult cardiac surgery with cardiopulmonary bypass (CPB).MethodsPatients included in the study were at high-risk for AKI post cardiac surgery, namely history of diabetes and/or anaemia, e-GFR 20–60 ml/min/1.73 m2, Logistic EuroScore > 5, anticipated CPB time > 120 min. Patients were randomized to either RG (n = 110) or managed as per current practice (control = 110). RIFLE-defined AKI rate (based on serum creatinine level increase) within first 3 days of surgery and 6-h post CPB NGAL levels were the primary and secondary end-points.ResultsPre and intra-operative characteristics between the two groups were similar (p > 0.05) including the pre-op NGAL levels, the oxygen delivery (ecDO2i) and the carbon dioxide production (ecVCO2i) during CPB. Patients in the RG group had a significantly lower post-operative RIFLE-defined AKI rate compared to control (10% (11/110) v/s 20.9% (23/110), p = 0.03). Overall, median 6-h post CPB NGAL levels in patients with AKI were significantly higher than those who did not develop AKI (211 vs 150 ng/ml, p < 0.001). Patients managed by balanced forced-diuresis had lower post-operative NGAL levels (146 vs 178 ng/ml, p = 0.09). Using previously reported NGAL cut-off level for AKI (142 ng/ml), binary logistic regression analysis confirmed a beneficial effect of the RG system, with an increased risk of AKI of 2.2 times in the control group (OR 2.2, 95% CI 1.14–4.27, p = 0.02).ConclusionsOverall, the 6-h post-CPB plasma NGAL levels were significantly higher in patients who developed AKI. Patients managed with the novel approach of balanced forced-diuresis, provided by the RenalGuard® system, had a lower AKI rate and lower NGAL levels indicating a lesser degree of renal tissue injury.Trial registration ClinicalTrials.gov website, NCT02974946, https://clinicaltrials.gov/ct2/show/NCT02974946.

Effect of rapid methicillin-resistant Staphylococcus aureus nasal polymerase chain reaction screening on vancomycin use in the intensive care unit.

PurposeTo determine the impact of a pharmacist-driven methicillin-resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR) screen on vancomycin duration in critically ill patients with suspected pneumonia.MethodsThis was a retrospective, quasi-experimental study at a 613-bed academic medical center with 67 intensive care beds. Adult patients admitted to the intensive care unit (ICU) between 2017 and 2019 for 24 hours or longer and empirically started on intravenous vancomycin for pneumonia were included. The primary intervention was the implementation of a MRSA nasal PCR screen protocol. The primary outcome was duration of empiric vancomycin therapy. Secondary outcomes included the rate of acute kidney injury (AKI), the number of vancomycin levels obtained, the rate of resumption of vancomycin for treatment of pneumonia, ICU length of stay, hospital length of stay, the rate of ICU readmission, and the rate of in-hospital mortality.ResultsA total of 418 patients were included in the final analysis. The median vancomycin duration was 2.59 days in the preprotocol group and 1.44 days in the postprotocol group, a reduction of approximately 1.00 day (P < 0.01). There were significantly fewer vancomycin levels measured in the postprotocol group than in the preprotocol group. Secondary outcomes were similar between the 2 groups, except that there was a lower rate of AKI and fewer vancomycin levels obtained in the postprotocol group (despite implementation of area under the curve–based vancomycin dosing) as compared to the preprotocol group.ConclusionThe implementation of a pharmacist-driven MRSA nasal PCR screen was associated with a decrease in vancomycin duration and the number of vancomycin levels obtained in critically ill patients with suspected pneumonia.

Antenatal Steroids and Acute Kidney Injury in Preterm Infants.

The aim of this study was to identify the effects of antenatal steroids (ANS) on acute kidney injury (AKI) in very low birth weight (VLBW) preterm infants. We performed a retrospective cohort study of VLBW infants admitted to a tertiary-care neonatal intensive care unit between January 2016 and June 2019. Infants were divided into no ANS, partial ANS, and complete ANS groups. Serum creatinine (SCr) levels and rates of AKI during the first 2 weeks of life were compared. During the study period, 335 infants met our inclusion criteria. Among no, partial, and complete ANS groups, there were significant differences in rates of stages 2 and 3 AKI (17, 11, and 6%, respectively). Logistic regression analysis revealed that complete ANS course was associated with lower rates of AKI (odds ratio [OR] = 0.41 95% confidence interval [CI]: 0.20-0.83) and stages 2 and 3 AKI (OR = 0.205 95% CI: 0.075-0.563) compared with no ANS. Infants in complete ANS group had significantly lower SCr at 72 hours of life and at discharge, SCr peak was compared with infants in no ANS group. In VLBW infants, complete ANS exposure may be associated with improved renal function and decreased risk for AKI compared with no ANS. · The effects of antenatal steroid treatment on renal function in preterm infants are not clear.. · A complete course of antenatal steroid decreases the risk for acute kidney injury in preterm infants.. · Infants who are not exposed to antenatal steroids need closer observation of their renal function..

Higher Flow on Cardiopulmonary Bypass in Pediatrics Is Associated With a Lower Incidence of Acute Kidney Injury

Adequate perfusion is of paramount concern during cardiopulmonary bypass (CPB) and different methodologies are employed to optimize oxygen delivery. Temperature, hematocrit, and cardiac index (CI) are all modulated during CPB to ensure appropriate support. This study examines 2 different perfusion strategies and their impact on various outcome measures including acute kidney injury (AKI), urine output on CPB, ICU length of stay, time to extubation, and mortality. Predicated upon surgeon preference, the study institution employs 2 different perfusion strategies (PS) during congenital cardiac surgery requiring CPB. One method utilizes a targeted 2.4 L/min/m2 CI and nadir hematocrit of 28% (PS1), the other a 3.0 L/min/m2 CI with a nadir hematocrit of 25% (PS2). This study retrospectively examines CPB cases during which the 2 perfusion strategies were applied to determine potential differences in packed red blood cell administration, urine output during CPB, AKI post-CPB as defined by the KDIGO criteria, and operative survival as defined by the Society of Thoracic Surgeons. Significant differences were found in urine output while on CPB (P < 0.01) and all combined stages of postoperative AKI (P = 0.01) with the PS2 group faring better in both measures. No significant difference was found between the 2 groups for packed red blood cell administration, mortality, time to extubation, or ICU length of stay. Avoiding a nadir hematocrit less than 25% has been well established but maintaining anything greater than that may not be necessary to achieve adequate oxygen delivery on CPB. Our results indicate that higher CI and oxygen delivery on CPB are associated with a lower rate of AKI and this may be achieved with increased flow rather than increasing the hematocrit thus avoiding unnecessary transfusion.

Comparison of Outcomes of Transfemoral Versus Transapical Approach for Transcatheter Aortic Valve Implantation

Post hoc analyses of clinical trials have shown superior outcomes for a transfemoral (TF) compared with a transapical (TA) approach for transcatheter aortic valve implantation (TAVI). There are few contemporary data on utilization and outcomes of TF versus TA TAVI in real-world patient populations. Using the National Inpatient Sample 2011 to 2014, we identified TF-TAVI and TA-TAVI procedures using ICD-9 procedure codes 35.05 and 35.06, respectively. A propensity-matched cohort of TF and TA TAVI procedures balanced on 23 baseline characteristics was assembled. Outcomes included in-hospital mortality, acute kidney injury (AKI), AKI requiring dialysis (AKI-D) and postoperative stroke. A total of 7,973 TAVI procedures representative of 39,745 procedures nationally were included in the study. Of these, 80.2% were performed using a TF approach while 19.8% used a TA approach. Patients in the TF-TAVI group were older (mean age 81.7 vs 80.4 years, p < 0.001), with a higher prevalence of heart failure (12.7% vs 7.6%, p < 0.001) and lower prevalence of peripheral vascular disease (28.0% vs 35.5%, p < 0.001) compared with the TA-TAVI group. In 1,576 propensity-matched pairs of TF-TAVI and TA-TAVI procedures, TF-TAVI was associated with significantly lower in-hospital mortality (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.42 to 0.88, p = 0.01), lower rates of AKI (0.53, 95% CI 0.44 to 0.63, p < 0.001), similar rates of AKI-D (OR 0.77, 95% CI 0.44 to 1.38, p = 0.38) and postoperative stroke (OR 1.19, 95% CI 0.67 to 2.10, p = 0.56) compared with TA-TAVI. In conclusion, TF-TAVI is associated with lower rates of in-hospital mortality and AKI compared with TA-TAVI. A TF approach should be preferred over a TA approach for TAVI whenever possible.

An assessment of repeat computed tomography utilization in the emergency department in the setting of blunt trauma.

Computed tomography (CT) is a standard imaging modality utilized during the evaluation of trauma patients in the emergency department (ED). However, while it is common to utilize intravenous (IV) contrast as an adjunct, the use of multiple CT scans and how it impacts patient flow can lead to changes in patient management. Our objectives are to assess length of stay (LOS) and rates of acute kidney injury (AKI), when two CT scans of the abdomen/pelvis are performed compared to one CT scan. Data of trauma hospital encounters were retrospectively collected during a 5-year period at a large, level 1 trauma center. Encounters were categorized into patients who received one or two CT scans of the abdomen/pelvis, as well as if they had received IV contrast or not. CT scan reads were extracted from chart records, and groups were compared. Of 5787 patient encounters, 5335 (93.4%) received IV contrast and 75 (1.3%) received two CT scans. Lower rates of AKI were associated with IV contrast (2.5 vs 12.5%). Receiving two CT scans was associated with increased rates of AKI (20.0 vs 3.0%; p < 0.0001), ICU admissions (88.0 vs 25.1%; p < 0.0001), and hospital LOS (21.9 vs 1.4days; p < 0.0001). Of the repeat CT scans, 59.4% demonstrated no significant difference and did not require blood products or the operating room. Two CT scans performed during blunt trauma encounters demonstrated mixed benefit and were associated with an increased hospital LOS. Additionally, IV contrast was associated with lower rates of AKI.

Association Between Early Postoperative Acetaminophen Exposure and Acute Kidney Injury in Pediatric Patients Undergoing Cardiac Surgery

Acute kidney injury (AKI) is a common and serious complication for pediatric cardiac surgery patients associated with increased morbidity, mortality, and length of stay. Current strategies focus on risk reduction and early identification because there are no known preventive or therapeutic agents. Cardiac surgery and cardiopulmonary bypass lyse erythrocytes, releasing free hemoglobin and contributing to oxidative injury. Acetaminophen may prevent AKI by reducing the oxidation state of free hemoglobin. To test the hypothesis that early postoperative acetaminophen exposure is associated with reduced risk of AKI in pediatric patients undergoing cardiac surgery. In this retrospective cohort study, the setting was 2 tertiary referral children's hospitals. The primary and validation cohorts included children older than 28 days admitted for cardiac surgery between July 1, 2008, and June 1, 2016. Exclusion criteria were postoperative extracorporeal membrane oxygenation and inadequate serum creatinine measurements to determine AKI status. Acetaminophen exposure in the first 48 postoperative hours. Acute kidney injury based on Kidney Disease: Improving Global Outcomes serum creatinine criteria (increase by ≥0.3 mg/dL from baseline or at least 1.5-fold more than the baseline [to convert to micromoles per liter, multiply by 88.4]) in the first postoperative week. The primary cohort (n = 666) had a median age of 6.5 (interquartile range [IQR], 3.9-44.7) months, and 341 (51.2%) had AKI. In unadjusted analyses, those with AKI had lower median acetaminophen doses than those without AKI (47 [IQR, 16-88] vs 78 [IQR, 43-104] mg/kg, P < .001). In logistic regression analysis adjusting for age, cardiopulmonary bypass time, red blood cell distribution width, postoperative hypotension, nephrotoxin exposure, and Risk Adjustment for Congenital Heart Surgery score, acetaminophen exposure was protective against postoperative AKI (odds ratio, 0.86 [95% CI, 0.82-0.90] per each additional 10 mg/kg). Findings were replicated in the validation cohort (n = 333), who had a median age of 14.1 (IQR, 3.9-158.2) months, and 162 (48.6%) had AKI. Acetaminophen doses were 60 (95% CI, 40-87) mg/kg in those with AKI vs 70 (95% CI, 45-94) mg/kg in those without AKI (P = .03), with an adjusted odds ratio of 0.91 (95% CI, 0.84-0.99) for each additional 10 mg/kg. These results indicate that early postoperative acetaminophen exposure may be associated with a lower rate of AKI in pediatric patients who undergo cardiac surgery. Further analysis to validate these findings, potentially through a prospective, randomized trial, may establish acetaminophen as a preventive agent for AKI.

A Review of Paracentesis Performance in Ascites Following Simulation-Based Training

Introduction: Guidelines recommend that a diagnostic paracentesis be performed in all patients with cirrhosis and ascites upon hospital admission. Paracentesis is often performed by internal medicine (IM) residents however few institutions have a formal training program. Delays in paracentesis >12 hours have also been linked to increased patient mortality. Methods: We implemented a simulation-based training (ST) course for IM residents to improve resident confidence and competence in paracentesis. 130 IM residents underwent ST which included precourse reading, small group discussions, and task training. We performed a retrospective review of all patients with ascites admitted in two 12-month periods, before and after ST at 2 academic teaching hospitals. The primary outcome was time from admission to paracentesis. Secondary outcomes included in-hospital mortality, hospital length of stay (LOS), and development of acute kidney injury (AKI). Results: A pre-course survey revealed that most residents had never performed a paracentesis, had little prior training and were not confident in performing paracentesis. A total of 678 charts were reviewed, and a total of 89 paracenteses were performed pre-ST and 65 post-ST. IM residents performed more paracenteses following ST (23.6% vs. 33.9%). The remainder were performed by interventional radiology (IR). Mean time to paracentesis decreased for housestaff (49.1h to 39.9h) and increased for IR (57.5h to 82.2h) after ST. IM residents were more likely to perform paracentesis on patients with higher MELD scores and rate of ICU admission (see Table). There was a statistically significant decrease in development of AKI in the resident cohort (47.6% to 18.2%, p= 0.04) and remained unchanged in the IR-cohort (32.4% to 34.9%). Mean hospital LOS and in-hospital mortality decreased in the resident cohort, while they remained unchanged and increased in the IR-cohort (see Table).Table: Table. Results of Paracentesis Performance Following Simulation-Based TrainingConclusion: Our study shows that after implementation of a simulation-based paracentesis course, IM residents performed a greater proportion of procedures, a decreased time to paracentesis, and had improved patient outcomes. ST improved resident confidence in performing paracentesis and this likely explains the increase in procedures performed by them and in higher acuity patients. Increase in clinical knowledge post-ST regarding paracentesis may explain decreased time to procedure, lower rates of AKI, decreased hospital LOS, and in-hospital mortality seen in the post-intervention period.

Circumferential Aortic Endarterectomy Followed with Immediate Infrarenal Clamping Obviates Suprarenal Clamping for Juxtarenal Aortoiliac Occlusion

Traditional open surgery for juxtarenal aortoiliac occlusive disease (AIOD) requires suprarenal aortic cross-clamping (SRCC), which is associated with high incidence of acute kidney injury (AKI). This study was to compare the outcomes of circumferential aortic endarterectomy followed by immediate infrarenal cross-clamping (IRCC) with the traditional approach of SRCC during surgery for juxtarenal AIOD. A 10-year retrospective review of 87 patients who underwent open surgery for AIOD at our University Medical Center was performed. There were 52 males and 35 females (mean age of 52years). Multivariate analysis was performed to assess operative time, blood loss, incidence of AKI, 30-day mortality, and recurrent aneurysm/pseudoaneurysm. Thirty-seven patients were found to have juxtarenal AIOD, which were divided into SRCC (n=25) and IRCC (n=12). Ten patients from the SRCC developed AKI versus 1 from the IRCC (30% vs. 8.3%, P=0.04). SRCC demonstrated increased blood loss (1,681 vs. 591mL, P=0.004). Mean operative time was less in the IRCC group (5 vs. 7hr, P=0.0001). Thirty-day mortality in the SRCC group was 1 and 0 in the IRCC group, respectively. Recurrent aneurysm or pseudoaneurysm was not identified in endarterectomized aorta up to 4-year follow-up. Circumferential aortic endarterectomy followed with immediate IRCC is a feasible, safe, and effective approach for juxtarenal AIOD in properly selected patients. It may be associated with lower rates of AKI, intraoperative bleeding, operating room time, and length of hospital stay, when compared with the traditional SRCC.

PD49-05 COMPARISON OF RENAL FUNCTION DETRIMENTS AFTER LOCAL TUMOR ABLATION OR PARTIAL NEPHRECTOMY FOR RENAL CELL CARCINOMA

You have accessJournal of UrologyKidney Cancer: Surgical Therapy VI1 Apr 2015PD49-05 COMPARISON OF RENAL FUNCTION DETRIMENTS AFTER LOCAL TUMOR ABLATION OR PARTIAL NEPHRECTOMY FOR RENAL CELL CARCINOMA Alessandro Larcher, Malek Meskawi, Katharina Boehm, Roger Valdivieso, Vincent Trudeau, Zhe Tian, Nicola Fossati, Giovanni Lughezzani, Nicolò Buffi, Giorgio Guazzoni, Francesco Montorsi, Maxine Sun, and Pierre Karakiewicz Alessandro LarcherAlessandro Larcher More articles by this author , Malek MeskawiMalek Meskawi More articles by this author , Katharina BoehmKatharina Boehm More articles by this author , Roger ValdiviesoRoger Valdivieso More articles by this author , Vincent TrudeauVincent Trudeau More articles by this author , Zhe TianZhe Tian More articles by this author , Nicola FossatiNicola Fossati More articles by this author , Giovanni LughezzaniGiovanni Lughezzani More articles by this author , Nicolò BuffiNicolò Buffi More articles by this author , Giorgio GuazzoniGiorgio Guazzoni More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , Maxine SunMaxine Sun More articles by this author , and Pierre KarakiewiczPierre Karakiewicz More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2723AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Local tumor ablation (LTA) and partial nephrectomy (PN) represent treatment alternatives for patients diagnosed with small renal mass and both may result in renal function detriments. The aim of the study was to compare renal function detriments after LTA or PN. METHODS A Surveillance Epidemiology and End Results-Medicare-linked retrospective cohort of 2850 T1 kidney cancer patients who underwent LTA or PN between 2000 and 2009 was abstracted. Short-term outcomes consisted of 30-day acute kidney injury (AKI) and 30-day dialysis rates. Long-term outcomes consisted of episodes of AKI, mild (EGFR 90-60) and moderate-severe (EGFR<60) chronic kidney disease (CKD), end-stage renal disease, hemodialysis and anemia in CDK. After propensity score matching to control for measurable selection bias, multivariable models addressing the impact of LTA vs. PN on short-term (logistic regression) and long term (Cox regression) renal function detriments were fitted. RESULTS Median follow-up was 35 months among survivors. Fewer patients (20%; n=561) were treated with LTA, while most (80%; n=2289) were treated with PN. Patients treated with LTA were older, more frequently unmarried, sicker, more frequently diagnosed with T1a stage and more frequently diagnosed with unspecified subtype of renal cell carcinoma (all p<0.05). In patients treated with LTA, approach was open, laparoscopic and percutaneous in 7% (n=38), 53% (n=299), 40% (n=224) of the cohort, respectively. In patients treated with PN, approach was open, laparoscopic and robotic in 72% (n=1663), 23% (n=521) and 5% (n=105) of the cohort, respectively. Following a 1:1 ratio propensity score matching for all covariates, 561 LTA and 561 PN patients remained. The 30-day incidence of AKI was 4.6% after LTA and 9.4% after PN. In multivariable analyses (MVA), LTA was associated with a lower AKI rate (OR 0.42, p=0.001). The 30-day incidence of any dialysis was <2% after either LTA or PN. In MVA, LTA was not associated with a lower rate of any dialysis (OR 0.43, p=0.2). At long-term assessment, both the unadjusted and adjusted rates of all six examined endpoints were not different between LTA and PN (all p>0.5). Similar results were recorded in a sub-analysis of patients with stage T1a. CONCLUSIONS LTA offers short-term protective effect from AKI. The short-term rates of any dialysis treatment are similar after either LTA or PN. At long-term assessment, LTA and PN renal function detriment rates are not different. Concern for long-term functional outcomes should not be a barrier for PN. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e972-e973 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alessandro Larcher More articles by this author Malek Meskawi More articles by this author Katharina Boehm More articles by this author Roger Valdivieso More articles by this author Vincent Trudeau More articles by this author Zhe Tian More articles by this author Nicola Fossati More articles by this author Giovanni Lughezzani More articles by this author Nicolò Buffi More articles by this author Giorgio Guazzoni More articles by this author Francesco Montorsi More articles by this author Maxine Sun More articles by this author Pierre Karakiewicz More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PREDICTORS OF POSTOPERATIVE ACUTE KIDNEY INJURY IN YOUNG ADULTS UNDERGOING CARDIAC SURGERY

Acute kidney injury (AKI) is a frequent complication following cardiac surgery. The purpose of this study was to identify preoperative and perioperative predictors of AKI in young adult patients (≤ 60 years old) undergoing heart surgery. Between August 2010 and December 2013, 649 consecutive patients aged 60 or less underwent cardiac surgery. All patients were prospectively entered in an institutional computerized database. Of these, 601 (93%) received a median sternotomy and 48 (7%) had an alternative approach (thoracotomy, minithoracotomy or robotic interface). Serum creatinine levels were measured prior to surgery and every day following surgery, until hospital discharge. Acute kidney injury was defined according to the maximal change in serum creatinine level and was classified according to the RIFLE criteria into: ≥1.5-fold (risk), ≥2.0-fold (injury), and ≥3.0-fold (failure) increase in serum creatinine. The impact of preoperative and perioperative variables on postoperative AKI was assessed using a multivariate logistic regression model. Mean age was 51.1 ± 8.8 years and 134 patients (21%) were female. Isolated coronary artery bypass graft (CABG) surgery was performed in 303 patients (47%), isolated valvular surgery in 247 (38%), combined CABG and valvular surgery in 57 (9%) and another type of procedure in 42 (6%). Forty-three patients (7%) had undergone previous cardiac surgery. During the postoperative period, a total of 91 patients (14%) suffered from AKI, including 61 (9%), 16 (2%) and 14 (2%) who fell under the risk, injury and failure categories, respectively. On multivariate analysis, body mass index (BMI) [OR 1.11 [1.06-1.15]; p < .001], preoperative use of diuretics [OR 2.24 [1.28-3.94]; p = .005] and long duration of cardiopulmonary bypass (≥ 150 minutes) [OR 8.20 [3.32-20.3]; p < .001] were independent significant predictors of AKI (all severity classes). A higher value of last preoperative haemoglobin [OR 0.96 [0.95-0.98]; p < .001] was associated with lower rates of AKI. In patients aged 60 or less, long cardiopulmonary bypass times, preoperative use of diuretics and a high BMI are independently associated with an increased risk of AKI following cardiac surgery. High preoperative haemoglobin is independently associated with a decreased incidence of AKI.