Median Blood Urea Nitrogen Research Articles

Machine Learning to Detect Disparities in ICU Mortality Among Patients Receiving Direct Oral Anticoagulants

INTRODUCTION The current prescribing practices of direct oral anticoagulants (DOACs) in intensive care unit (ICU) patients and the associated clinical outcomes, including the incidence of major bleeding episodes and mortality, are significant clinical challenges. There is a need for early detection and intervention among patients taking DOACs to prevent adverse clinical outcomes. We hypothesized that machine-learning algorithms could be used to create a more precise and user-friendly diagnostic tool that incorporates a variety of clinical and laboratory data and takes complex interactions into account. METHODS This was an observational, retrospective study using routine clinical practice data from MIMIC-IV, a freely accessible electronic health record database. The study included patients who were admitted to the ICU with a DOAC (apixaban, rivaroxaban, dabigatran, or edoxaban) listed as one of the active medications at the time of hospital admission. ICD-9 and ICD-10 codes were utilized to identify cases (Z7901, V5861). Descriptive statistics were reported for all variables of interest. Various machine-learning models were utilized to predict the outcome variable of ICU mortality after accounting for variables from the demographic, laboratory, comorbidity, etc. domains. Model performance was evaluated by comparing the accuracy and Area Under the Receiver Operating Characteristic Curve (AUROC) values. RESULTS Overall, there were 3597 cases that met the inclusion criteria. Among these, 1517 (42.2%) were female. The majority of the sample was White (70.5%), and 2093 (58.2%) cases had Medicare insurance. The median [Q1, Q3] age of the sample was 74 [65, 83] years. ICU mortality was reported in 297 cases (8.2%). The mean ( SD) ICU length of stay was 3.5 (4.6) days among those cases who were discharged alive and 4.2 (4.7) days among those who expired (p < 0.012). The median blood urea nitrogen among those discharged alive and expired was 20.0 and 29.5 (p<0.001), respectively. Intracranial hemorrhage was reported in 186 (5.6%) and 59 (19.9%) of those discharged alive and expired, respectively (p<0.001). The machine learning model results showed that the Random forest classifier performed best in predicting mortality in the ICU, with an AUROC value of 85.3%. The top ten variables associated with ICU mortality by feature importance were pH, WBC count, platelet count, blood urea nitrogen, heart rate, anion gap, partial pressure of carbon dioxide, oxygen saturation, age, and respiratory rate. CONCLUSION The Random forest classifier algorithm improved discrimination and calibration compared to other ML models for predicting mortality in the ICU among patients taking DOACs. It has the potential to reduce delayed diagnosis and overtreatment in clinical practice. Future studies will validate this model in broader clinical settings.

Efficacy and safety of tolvaptan for refractory fluid collection and edema in the terminal cancer patients.

Tolvaptan, a vasopressin V2 receptor antagonist, is an oral diuretic. Patients with terminal cancer develop marked fluid retention, and oral diuretics other than tolvaptan have been used as treatments without clear therapeutic effects. Herein, we aimed to study the efficacy and safety of tolvaptan in patients with terminal cancer. Tolvaptan was administered at a dose of 7.5mg/day to 29 patients (median, 72 years) between August 2017 and February 2020. The duration of tolvaptan treatment ranged from 1 to 85 days (mean, 18.5 days). Median albumin (Alb) and transthyretin (TTR) levels on admission were 2.3g/dL (1.2-4.2g/dL) and 8.9mg/dL (2.1-38.2g/dL), respectively. Median Alb and TTR levels 1 month after treatment initiation remained at 2.3g/dL (0.8-2.9g/dL) and 8.6mg/dL (0.8-23.7mg/dL), respectively. Regarding renal function indicators, median blood urea nitrogen (BUN) and creatinine levels on admission were 19.9mg/dL (8.6-49.3mg/dL) and 0.81mg/dL (0.38-2.25mg/dL), respectively. Median BUN and creatinine levels 1 month after treatment initiation were 23.4mg/dL (13.5-34.0mg/dL) and 0.91mg/dL (0.39-2.41mg/dL), respectively. No patients had hypernatremia on admission, and no effects of tolvaptan on the blood sodium level were found 1 month after treatment initiation. The median potassium level on admission was 4.2mEq/dL (2.9-5.0mEq/dL); tolvaptan treatment had no effects on blood potassium level. Tolvaptan is effective and safe for treating fluid retention refractory to conventional diuretics in patients with terminal cancer.

Effect of withdrawal of thyroid hormones versus administration of recombinant human thyroid-stimulating hormone on renal function in thyroid cancer patients

This study was conducted to investigate the effects of thyroid hormone withdrawal (THW) and recombinant human thyroid-stimulating hormone (rhTSH) administration on renal function in patients with thyroid cancer after total thyroidectomy. This study included 202 patients who discontinued thyroid hormone therapy and/or received rhTSH after total thyroidectomy. Creatinine (Cr), blood urea nitrogen (BUN) levels, and estimated glomerular filtration rate (eGFR) were assessed at the following three time points: before thyroidectomy, at least 3 weeks after THW, and 1 day after the second injection of rhTSH. The median serum Cr level was significantly higher following THW compared to that before thyroidectomy (0.95 versus 0.70). In contrast, the median BUN level was significantly lower after THW compared to that before thyroidectomy (9.8 versus 11.3). Over a fifth (22.2%) of patients had abnormal eGFR values after THW, which was significantly greater than that before thyroidectomy. In contrast, renal parameter values after rhTSH administration were not significantly different than those before thyroidectomy. In conclusion, THW affects renal function in patients with thyroid cancer who have undergone total thyroidectomy. However, renal function in such patients is not affected by rhTSH administration.

Blood Urea Nitrogen/Albumin Ratio and Mortality Risk in Patients with COVID-19

IntroductionWe researched blood urea nitrogen (BUN), albumin and their ratio (BAR), and compared them with C-reactive protein (CRP), D-dimer, and computed tomography severity scores (CT-SS), to predict in-hospital mortality.MethodsOne-hundred and thirty-one coronavirus disease-2019 (COVID-19) confirmed patients brought to the emergency department (ED) were dispensed to the survivor or non-survivor group, in light of in-hospital mortality. Information on age, gender, complaints, comorbidities, laboratory parameters, and outcome were gathered from the patient's record files.ResultsThe median BUN, mean total protein, mean albumin, median BAR, median creatinine, median CRP, and median D-dimer were recorded. CT-SS were utilized in categorizing the patient as mild, moderate, and severe. In-hospital mortality occurred in 42 (32.06%) patients (non-survivor group) and did not occur in 89 (67.94%) patients (survivor group). The median BUN (mg/dL) and BAR (mg/gm) values were significantly raised in the non-survivor group than in the survivor group [BUN: 23.48 (7.51–62.75) and 20.66 (4.07–74.67), respectively (p = 0.009); BAR: 8.33 mg/g (2.07–21.86) and 6.11 mg/g (1.26–23.33); (p = 0.0003)]. The mean albumin levels (gm/dL) in the non-survivor group were significantly lower than in the survivor group [2.96 ± 0.35 and 3.27 ± 0.35, respectively (p <0.0001)]. Albumin with an odd's ratio of 6.14 performed the best in predicting in-hospital mortality, followed by D-dimer (4.98). BAR and CRP had similar outcome of 3.75; BUN showed an OR of 3.13 at the selected cutoff value.ConclusionThe BUN, albumin, and BAR were found to be dependable predictors of in-hospital mortality in COVID-19 patients, with albumin (hypoalbuminemia) performing even better.How to cite this articleSingh S, Singh K. Blood Urea Nitrogen/Albumin Ratio and Mortality Risk in Patients with COVID-19. Indian J Crit Care Med 2022;26(5):626–631.

Neurological Complications of Veno-Arterial Extracorporeal Membrane Oxygenation: A Retrospective Case-Control Study.

Background: To explore the epidemiology, clinical features, risk indicators, and long-term outcomes of neurological complications caused by veno-arterial extracorporeal membrane oxygenation (V-A ECMO).Methods: We retrospectively analyzed 60 adult patients who underwent V-A ECMO support in our unit from February 2012 to August 2020. These patients were separated into the neurological complications group (NC group) and the non-neurological complications group (nNC group). The differences in basic data and ECMO data between the two groups were compared. The data of long-term neurological prognosis were collected by telephone follow-up.Results: Thirty-nine patients (65.0%) had neurological complications. There were significant differences between the two groups in terms of median age, hypertension, median blood urea nitrogen, median troponin I (TNI), median lactic acid, pre-ECMO percutaneous coronary intervention, continuous renal replacement therapy (CRRT), median Sequential Organ Failure Assessment score, median Acute Physiology and Chronic Health Evaluation II score, median peak inspiratory pressure, median positive end expiratory pressure, and median fresh frozen plasma (P < 0.05). The median Intensive Care Unit length of stay (ICU LOS), 28-day mortality, median post-ECMO vasoactive inotropic score, non-pulsate perfusion (NP), and median ECMO duration of the NC group were significantly higher than those of the nNC group (P < 0.05). Furthermore, multiple logistic regression analysis revealed that TNI (P = 0.043), CRRT (P = 0.047), and continuous NP > 12 h (P = 0.043) were independent risk indicators for neurological complications in patients undergoing ECMO. Forty-four patients (73.3%) survived after discharge, and 38 patients (63.3%) had Cerebral Performance Category score of 1–2. And there were significant differences between the two groups in long-term neurological outcomes after discharge for 6 months (P < 0.05).Conclusion: The incidence of neurological complications was higher in patients undergoing V-A ECMO and was closely related to adverse outcomes (including ICU LOS and 28-day mortality). TNI, CRRT, and continuous NP > 12 h were independent risk indicators for predicting neurological complications in ECMO supporting patients. And the neurological complications of patients during ECMO support had significant adverse effect on long-term surviving and neurological outcomes of patients after discharge for 6 months.

Sacubitril/valsartan improves cardiac function in Chinese patients with heart failure: a real-world study.

AimsSacubitril/valsartan significantly reduced heart failure (HF) hospitalization and cardiovascular mortality in a randomized controlled trial. However, little is known about real‐world efficacy and safety of sacubitril/valsartan in Chinese patients with HF with reduced ejection fraction (HFrEF). We aimed to evaluate whether sacubitril/valsartan could improve cardiac function in Chinese patients with HFrEF in a tertiary hospital in China.Methods and resultsPatients with HFrEF receiving sacubitril/valsartan in our hospital between January 2018 and January 2020 were recruited in the present study. We retrospectively collected and analysed all clinical parameters at baseline and during follow‐up. A total of 100 consecutive patients (73% male) with HFrEF were recruited in the present study. During a median follow‐up period of 365 days [interquartile range (IQR), 346–378], a pronounced improvement of cardiac function was achieved. New York Heart Association classification was significantly improved (P < 0.001), and median N‐terminal pro‐B‐type natriuretic peptides level significantly decreased from 3003 pg/mL (IQR, 1513–5404) to 2039 pg/mL (IQR, 921–3955) (P = 0.010). Mean left ventricular ejection fraction increased from 31 ± 6% to 38 ± 10% (P < 0.001) and median left ventricular end‐diastolic diameter reduced from 63 mm (IQR, 59–67) to 60 mm (IQR, 55–68) (P = 0.001). Mean pulmonary arterial systolic pressure decreased significantly from 49 ± 13 mmHg to 44 ± 12 mmHg (P < 0.001) and median right ventricular end‐diastolic diameter reduced from 23 mm (IQR, 21–26) to 22 mm (IQR, 20–25) (P = 0.030). After treatment with sacubitril/valsartan, mean estimated glomerular filtration rate significantly decreased (from 88.8 ± 22.4 mL/min to 71.8 ± 27.3 mL/min, P < 0.001). Median serum creatinine and median blood urea nitrogen levels significantly increased [from 0.9 mg/dL (IQR, 0.8–1.0) to 1.1 mg/dL (IQR, 0.9–1.3), P < 0.001, and from 6.8 mmol/L (IQR, 5.5–8.9) to 8.0 mmol/L (IQR, 6.6–10.3), P = 0.002, respectively]. The proportion of patients with chronic kidney disease Stage 3/4 increased significantly from 8% to 39% (P < 0.001).ConclusionsIn Chinese patients with HFrEF, sacubitril/valsartan treatment was associated with a pronounced improvement of cardiac function, but might be prone to a decrease in blood pressure and deterioration in renal function.

Age- and sex-specific reference intervals for blood urea nitrogen in Chinese general population

Blood urea nitrogen (BUN) is a nitrogenous end product of protein metabolism. This study aims to explore the age- and sex-specific distribution of BUN among healthy Chinese adults. A total of 24,006 BUN values from healthy adults (14,148 males and 9858 females) were included in the cross-sectional study. Males had a higher median BUN value compared to females (4.6 mmol/L vs. 4.1 mmol/L). BUN values showed a positive correlation with body mass index (BMI), cholesterol, and blood sugar (P < 0.0001). However, eGFR showed a negative correlation with the BUN reference value (P < 0.0001) in both sexes. Multiple linear regression analysis confirmed that the positive associations of BUN levels and age were statistically significant after adjusting confounding factors (P < 0.001). Thus, the serum BUN values increased by 0.21 mmol/L for males and 0.282 mmol/L for females per 10 years. The BUN values corresponding to the 1st, 2.5th, 50th, 97.5th, and 99th percentiles for any specific age in both sex were also calculated. These results indicate that the serum BUN reference value is significantly affected by age and gender, and thus, its interpretation is age- and sex-dependent.

The role of the BUN/albumin ratio in predicting mortality in COVID-19 patients in the emergency department.

IntroductionDue to the high mortality and spread rates of coronavirus disease 2019 (COVID-19), there are currently serious challenges in emergency department management. As such, we investigated whether the blood urea nitrogen (BUN)/albumin ratio (BAR) predicts mortality in the COVID-19 patients in the emergency department.MethodsA total of 602 COVID-19 patients who were brought to the emergency department within the period from March to September 2020 were included in the study. The BUN level, albumin level, BAR, age, gender, and in-hospital mortality status of the patients were recorded. The patients were grouped by in-hospital mortality. Statistical comparison was conducted between the groups.ResultsOf the patients who were included in the study, 312(51.8%) were male, and their median age was 63 years (49–73). There was in-hospital mortality in 96(15.9%) patients. The median BUN and BAR values of the patients in the non-survivor group were significantly higher than those in the survivor group (BUN: 24.76 [17.38–38.31] and 14.43 [10.84–20.42], respectively [p < 0.001]; BAR: 6.7 [4.7–10.1] and 3.4 [2.5–5.2], respectively [p < 0.001]). The mean albumin value in the non-survivor group was significantly lower than that in the survivor group (3.60 ± 0.58 and 4.13 ± 0.51, respectively; p < 0.001). The area-under-the-curve (AUC) and odds ratio values obtained by BAR to predict in-hospital COVID-19 mortality were higher than the values obtained by BUN and albumin (AUC of BAR, BUN, and albumin: 0.809, 0.771, and 0.765, respectively; odds ratio of BAR>3.9, BUN>16.05, and albumin<4.01: 10.448, 7.048, and 6.482, respectively).ConclusionThe BUN, albumin, and BAR levels were found to be reliable predictors of in-hospital mortality in COVID-19 patients, but BAR was found to be a more reliable predictor than the BUN and albumin levels.

Aerococcus-Related Infections and their Significance: A 9-Year Retrospective Study.

Introduction:Aerococcus spp. is a Gram-positive, catalase- and oxidase-negative, microaerophilic, nonmotile bacteria species rarely associated with human infections such as arthritis, bacteremia, endocarditis, and meningitis. The bacteria are also often confused with streptococci species or treated as a contaminant.Patients and Methodology:We conducted a retrospective, observational cohort study on all patients with Aerococcus spp. isolates in blood samples from July 2010 to June 2019. All categorical data were presented as counts and proportions, whereas continuous data were presented as median and interquartile ranges.Results:A total of 20 Aerococcus spp. isolates were identified over the study period of 9 years. Of these, Aerococcus urinae was isolated in 10 (50%), Aerococcus viridans in 6 (30%), and Aerococcus spp. (not speciated) in 4 (20%). The median age was 74.3 years (12 males and 8 females). The two most frequent presentations were fever (15 of 20) and altered mentation (6 of 15). Most of the patients (11 of 15) had at least one predisposing comorbidity related to the urinary tract system (8 with recurrent urinary tract infection, 7 with urinary incontinence, 3 with an indwelling catheter, 2 with renal stones, and 1 each with benign prostatic hyperplasia and a recent cystoscopy). The median white blood cell count was 18,426 cells/mL, median hemoglobin 10.96 g/dL, median platelet count 191,000 cells/μL, median blood urea nitrogen 28.6 mg/dL, and median creatinine 1.54 mg/dL. The urinary tract was the most likely source of bacteremia (10 of 20) based on either imaging findings (5 cases), positive urine culture for Aerococcus spp. (4 cases), or instrumentation history (1 case). In the rest, the cause of bacteremia could not be found. Endocarditis was suspected in 9 out of 20 patients. Transthoracic echocardiography/transesophageal echocardiography (TEE) confirmed 3 cases (2 aortic valves, 1 mitral valve and pacemaker). Interestingly, one case had septic emboli causing a right frontal stroke with a normal TEE and normal Doppler study for deep venous thrombosis. Blood cultures were positive in 35% (7 of 20) with polymicrobial growth, 3 with coagulase-negative staphylococci, 2 with Enterococcus faecalis, and the other 2 each with Diphtheroids spp. and Proteus mirabilis. Of the 20 cases, 9 and 10 required intensive care unit level care and vasopressor support, respectively. Most of the patients were treated for 5–14 days except the 3 cases with infective endocarditis (IE). The median hospital stay duration was 6.55 days with 2 fatalities (2 out of 20 patients).Conclusion:Old age and underlying urologic conditions are the best-known risk factors for Aerococcus spp. infection. Recent advances in diagnostic technology have led to an increase in detection of Aerococcus spp.-related infections. The rare occurrence of Aerococcus spp. in human infections and resultant lack of randomized control trials have resulted in a significant degree of clinical uncertainty in the management of Aerococcus spp. IE.

Correlation of Measured and Estimated Creatinine Clearance in Hospitalized Elderly Patients: A Retrospective Cohort Study.

Background: Accurate assessment of renal function is essential in hospitalized elderly patients. Few studies have examined the accuracy of Cockcroft-Gault (C-G) estimates of creatinine clearance (CrCl) compared with measured clearance in these patients. Objective: The objective of this study was to determine the correlation between C-G estimates of CrCl and measured CrCl in hospitalized elderly patients. Methods: This Institutional Review Board-approved, single-center retrospective observational cohort study included all patients who were 65 years and older admitted to our medical center in January to September 2018 with either an 8- or 24-hour urine collected during admission. The primary outcome was correlation, bias, and precision of C-G estimates of CrCl versus measured CrCl using Pearson correlation, Spearman linear regression, and Bland-Altman analysis. Outliers were determined using a cut-off of ±20%. Data are presented as median (interquartile range) or percentages. Results: A total of 108 urine collections from 90 unique patients were included in the study. The patients were 51% female, median age was 71 (68-77) years, and median body mass index was 26.6 (22.8-31) kg/m2. Most collections were over 24 hours (66.7%), and 38% were performed while patients were in an intensive care unit. Median blood urea nitrogen (BUN) was 24.5 (17-36) mg/dL and median serum creatinine was 0.71 (0.55-1.09) mg/dL. The median C-G estimation was 75.4 (48.2-110.6) mL/min, and the median measured CrCl was 79.1 (38.1-99.5) mL/min, r 2 = .56 (P < .001). Bland-Altman analysis showed large limits of agreement (-75.5-57.7 mL/min), with a bias of -8.9 and precision (standard deviation of bias) of 34 mL/min. Outliers were common, with 38% of C-G estimation values >120% of measured CrCl, and 18% of C-G estimates <80% of measured CrCl. Conclusions: Measured CrCl varied significantly from C-G estimates in hospitalized elderly patients. It is important to recognize characteristics of patients who may benefit from measurement of CrCl. Future studies should examine the impact of this variance on clinical outcomes.

Prognostic factors for patients with multiple myeloma admitted to the intensive care unit

ABSTRACT Objectives: This study aimed to analyze clinical characteristics and outcomes of critically ill patients with multiple myeloma (MM) admitted to the intensive care unit (ICU) and identify predictors of poor short-term prognosis. Methods: Data for patients with MM admitted to the ICU were extracted from the Medical Information Mart for Intensive Care III database. The risk factors leading to the ICU and hospital mortality were evaluated using logistic regression analysis. Results: Of 126 patients identified, 17 (13.5%) and 37 (29.4%) died in the ICU and hospital, respectively. Patients with ICU mortality showed higher median blood urea nitrogen (57.0 vs. 29.0) and poorer Acute Physiology Scores (APS, 70.0 vs. 46.0) than did surviving patients on the day of ICU admission. In-ICU deceased patients had higher proportion of mechanical ventilation (64.7% vs. 26.6%) and vasopressor use (64.7% vs. 17.4%) at admission and positive pathogenic culture during ICU stay (58.8% vs. 19.3%). The APS and positive pathogenic culture were independent prognostic factors for ICU mortality, while risk factors for hospital mortality included higher APS and relapsed/refractory disease. Conclusion: The short-term prognoses for patients with MM admitted to the ICU were mainly determined by the severity of organ failure, infection, and disease status.

The possibility of serum and urine cystatin C and NGAL as discriminative biomarkers for early stage AKI and CKD among hospitalized and renal outpatients

Although some studies have found that early initiation of continuous renal replacement therapy (CRRT) is associated with better prognosis, no consensus exists on the best timing to start CRRT. We investigated whether the timing of CRRT initiation was relevant to overall mortality and explored which factors at the time of CRRT initiation were associated with better outcomes in critically ill patients with acute kidney injury (AKI).A total of 361 patients who received CRRT for AKI between 2009 and 2011 were collected and divided into 2 groups based on the median blood urea nitrogen (BUN) levels or 6-hour urine output immediately before CRRT was started. The impact of the timing of CRRT initiation stratified by BUN concentration or urine output on 28-day all-cause mortality was compared between groups.When the timing of CRRT initiation was stratified by 6-hour urine output, 28-day all-cause mortality rates were significantly lower in the nonoliguric group compared with the oliguric group (P = .02). In contrast, clinical outcomes were not different between the low-BUN and the high-BUN groups (P = .30). Cox regression analysis revealed that 28-day all-cause mortality risk was significantly lower in the nonoliguric group stratified by 6-hour urine output, even after adjusting for age, sex, mean arterial pressure, Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, and serum biomarkers (hazard ratio, 0.85; 95% confidence interval, 0.65-0.99; P = .04).Urine output but not BUN concentration was significantly associated with a better prognosis in critically ill patients with AKI requiring CRRT.

Hepatic and renal toxicity and associated factors among HIV-infected children on antiretroviral therapy: a prospective cohort study.

The aim of the study was to investigate the prevalence of renal function and liver enzyme abnormalities among HIV-infected children, changes in prevalence with time on combination antiretroviral therapy (cART), and the factors associated with these abnormalities. A prospective cohort study was conducted among HIV-infected children < 18 years old (n = 705) who were on first-line cART. Liver enzymes, renal function, haematology, immunology and virological response were assessed at enrolment and followed bi-annually for 18 months. Liver fibrosis and cirrhosis were assessed using noninvasive markers including the aspartate aminotransferase (AST) to platelet ratio index (APRI) and fibrosis score (FIB-4). The median age was 12 [interquartile range (IQR) 8-14] years; 53.3% of patients were male. At enrolment, the median cART duration was 3.3 (IQR 1.1-6.1) years; 177 (25.1%) and 83 (11.8%) patients had elevated AST and alanine aminotransferase (ALT), respectively. A tenth of the children had an APRI score > 0.5, suggesting liver fibrosis. Being on a zidovudine (ZDV)- or nevirapine (NVP)-based regimen and having a viral load > 1000 HIV-1 RNA copies/mL were significantly associated with elevated ALT. Twenty-four (3.4%) and 84 (12.1%) patients had elevated creatinine and blood urea nitrogen (BUN), respectively. As cART duration increased by 6 months, median BUN increased by 1.6 [95% confidence interval (CI) 0.4-2.7] mg/dL (P = 0.01); the glomerular filtration rate (GFR) decreased by 35.6 (95% CI 17.7-53.4) mL/min/1.73 m2 (P < 0.0001); and AST and ALT decreased by 1.4 (95% CI 0.4-2.5) IU/L (P = 0.01) and 1.4 (95% CI 0.2-2.6) IU/L (P = 0.01), respectively. A high prevalence of liver enzyme and renal function abnormalities was observed at enrolment. Decreasing liver enzyme levels during follow-up are possibly reassuring, while the progressive reduction in GFR and the increase in BUN are worrisome and require further study.

Real-time Application of an Inpatient Heart Failure Mortality Model to Predict 30-Day Mortality

Background A CART model using admission systolic blood pressure (SBP), blood urea nitrogen (BUN), and serum creatinine (SCr) is proven to discern HF in-patient mortality risk. However, this model was not able to evaluate post-discharge outcomes. Objective We sought to 1) investigate an established HF in-patient mortality CART model's ability to discern 30-day all-cause mortality risk at an academic medical center and 2) investigate the potential to implement it in a real-time HF dashboard within the EMR Methods We have previously derived and validated a region-specific risk tool using CMS data on Medicare beneficiaries, age >65 years admitted to Vanderbilt University Medical Center with a primary diagnosis of acute HF from July 2009 to June 2016. We then applied the pre-specified threshold values from the aforementioned CART model for admission SBP, BUN, and SCr to evaluate 30-day all-cause mortality across the 5 resultant risk groups. We explored the presence of the model's data points at admission, the ability to automatically extract the data, and the ability to present a risk score in a real-time HF dashboard within the EMR. We utilized the CMS mortality report to identify death occurring within 30 days of hospital discharge. Results There were 2065 patients in the study population with 192 deaths occurring from July 2009-June 2016. The total population mean age was 77 ± 7.6 years with 54% male, 48% HFrEF, and 77% ischemic cardiomyopathy, not significantly different from the patients who died, 78 ± 7.6 years with 58% male, 57% HFrEF, and 77% ischemic cardiomyopathy. At admission, the median BUN was 28 (19,44) mg/dl, SCr was 1.4 (1.1, 2.0) mg/dl, and SBP was 122 (107,138) mmHg. The three data points were available within 24 hours of admission in all patients and the risk score was able to be presented in the EMR in real-time. In-patient mortality occurred in 2.5% of the population and the 30-day mortality rate was 9.3% at a median of 6 (0,15) days from discharge. The Highest Risk cohort in our CMS regional-specific model had increased 30-day mortality compared to the Low (OR 9.4; 95% CI 5.5-15.9), Intermediate Risk 3 (OR 6.5; 95% CI 3.7-11.4), and Intermediate Risk 2 (OR 3.5, 95% CI 2.0-6.2) cohorts but not the Intermediate Risk 1 (OR 1.60; 95% CI 0.9-2.8) cohort. Conclusion The high mortality risk stratification tool is capable of discerning 30-day mortality risk among hospitalized HF patients upon admission. This could be utilized to identify patients who may benefit from palliative care referral.

Blood urea nitrogen (BUN) independently predicts mortality in critically ill patients admitted to ICU: A multicenter study.

The Microcirculatory Shock Occurrence in Acutely Ill Patients (micro-SOAP) study investigated associations of microcirculation and mortality. Risk stratification in critically ill patients is of utmost interest. Established score such as APACHE2 (Acute Physiology And Chronic Health Evaluation 2) are relatively complex and might therefore be of limited use. Blood urea nitrogen (BUN) was described to be associated with mortality in various diseases. We therefore aimed (i) to evaluate BUN for prediction of mortality in a cohort of critically ill patients and (ii) to investigate associations of BUN with microcirculation. 412 patients were included in our post-hoc analysis of the prospective multicenter microSOAP study. Assesment of the sublingual microcirculation (Sidestream Dark Field (SDF) imaging) and collection of laboratory values were performed on the same day in this point prevalence study. Evaluation of associations with mortality was done by logistic regression analysis. An optimal BUN cut-off was calculated by means of the Youden Index. Median BUN was 9.0 mmol/L. BUN was associated with in-hospital-mortality in a logistic regression analysis (HR 1.03; 95% CI 1.01-1.05; p < 0.001). Per quartile (BUN 0-5.4 mmol/L, 5.4-9.0 mmol/L, 9.0-15.9 mmol/L and above 15.9 mmol/L) in-hospital mortality increased by as much as 51% (HR 1.51; 95% CI 1.23-1.85; p < 0.001). ROC analysis was done (AUC 0.63 95% CI 0.58-0.67) and the statistically optimal cut-off calculated by means of the Youden Index: 9.7 mmol/L. This cut-off was associated with a significant 3-fold increase in mortality (HR 2.97 95% CI 1.88-4.70; p < 0.001) and remained robustly associated with adverse outcome after correction for APACHE2 (HR 2.71 95% CI 1.61-4.59; p < 0.001), renal function as expressed by creatinine (HR 2.63 95% CI 1.59-4.33; p = 0.001), as well in an integrative model (MAP<60 mmHg, tachycardia (heart rate >90/min), lactate above 1.5 mmol/L, age above 80 years; HR 2.43 95% CI 1.50-3.92; p < 0.001). Parameters of microvascular perfusion were associated neither with BUN nor mortality. BUN is associated with hospital mortality and a combination of BUN and clinical signs might constitute a powerful but easy-to-use tool for risk stratification in critically ill patients and help improve their outcome. BUN was not associated with parameters of microcirculation which were not associated with mortality.

Abdominal Ultrasound Examination Findings in 534 Hyperthyroid Cats Referred for Radioiodine Treatment Between 2007-2010.

BackgroundThe prevalence of concurrent disease in hyperthyroid cats is unknown.ObjectivesTo identify the prevalence of concurrent intra‐abdominal disease using abdominal ultrasound examination (AUS) in hyperthyroid cats referred for radioactive iodine treatment (RIT) and to determine whether the requirement for pretreatment AUS is justified.AnimalsFive hundred and thirty‐four client‐owned cats diagnosed with hyperthyroidism and referred for RIT.MethodsRetrospective study. Age, breed, sex, body weight, clinical signs, total serum T4 concentration, blood urea nitrogen (BUN) concentration, serum creatinine concentration, urine specific gravity (USG), AUS results, and biopsy or cytology results, or both (if obtained) were collected from the medical records.ResultsThe prevalence of concurrent disease identified using AUS in hyperthyroid cats referred for RIT was 36.1%; 22.8% of the cats in the study had renal disease and 2.4% had confirmed neoplasia. Significant differences in median USG (P value 0.032) and median BUN (P value 0.028) were found between cats that had abnormal kidneys on AUS compared to those with normal‐appearing kidneys. Only 2.2% of the cats were not treated with RIT as a result of changes identified on AUS and subsequently obtained cytology or biopsy results.Conclusions and Clinical ImportanceThe results indicate that pretreatment AUS in hyperthyroid cats referred for RIT is unnecessary in most patients.

Urine output is associated with prognosis in patients with acute kidney injury requiring continuous renal replacement therapy

PurposeAlthough some studies have found that early initiation of continuous renal replacement therapy (CRRT) is associated with better prognosis, no consensus exists on the best timing to start CRRT. We investigated whether the timing of CRRT initiation was relevant to overall mortality and explored which factors at the time of CRRT initiation were associated with better outcomes in critically ill patients with acute kidney injury (AKI). Materials and MethodsA total of 361 patients who received CRRT for AKI between 2009 and 2011 were collected and divided into 2 groups based on the median blood urea nitrogen (BUN) levels or 6-hour urine output immediately before CRRT was started. The impact of the timing of CRRT initiation stratified by BUN concentration or urine output on 28-day all-cause mortality was compared between groups. ResultsWhen the timing of CRRT initiation was stratified by 6-hour urine output, 28-day all-cause mortality rates were significantly lower in the nonoliguric group compared with the oliguric group (P = .02). In contrast, clinical outcomes were not different between the low-BUN and the high-BUN groups (P = .30). Cox regression analysis revealed that 28-day all-cause mortality risk was significantly lower in the nonoliguric group stratified by 6-hour urine output, even after adjusting for age, sex, mean arterial pressure, Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, and serum biomarkers (hazard ratio, 0.85; 95% confidence interval, 0.65-0.99; P = .04). ConclusionsUrine output but not BUN concentration was significantly associated with a better prognosis in critically ill patients with AKI requiring CRRT.

Relation of Blood Urea Nitrogen to Long-Term Mortality in Patients With Heart Failure

Patients with chronic kidney disease and heart failure (HF) have been shown to be at higher risk for major adverse cardiovascular events and death. Recent studies have demonstrated that blood urea nitrogen (BUN) might serve as a powerful predictor of mortality in acutely decompensated HF. The goal of this study was to determine the impact of BUN on long-term mortality in patients with stage B and C HF. Our retrospective analysis included patients undergoing percutaneous intervention with a calculated left ventricular ejection fraction < or =50%. Patients on dialysis or with technically inadequate left ventriculograms were excluded. Chart review was performed and mortality data were obtained. Our population included 444 patients with a mean ejection fraction of 38 +/- 10%, mean age of 59 +/- 11 years, median BUN of 14 mg/dl, and median glomerular filtration rate (GFR) of 81 ml/min/1.73 m(2); 31% had stage C HF, and 33% died during follow-up. Patients with increased BUN (> or =17 mg/dl) and decreased GFR (< or =69 ml/min/1.73 m(2)) had significantly increased long-term mortality on Kaplan-Meier analysis (8-year mortalities of 57% and 55%, respectively). In patients with stage C HF, mortalities at 8 years were 69% and 73% with abnormal BUN and GFR, respectively. Proportional hazard regression analysis demonstrated that BUN and stage C HF were independently associated with increased mortality, whereas GFR was not. In conclusion, we demonstrated that BUN is strongly associated with mortality in patients with stage B and C HF and may serve as a better biomarker than GFR for prognostication.

Subcutaneous administration of desoxycorticosterone pivalate for the treatment of canine hypoadrenocorticism.

Twelve dogs with hypoadrenocorticism were treated with subcutaneous desoxycorticosterone pivalate (DOCP). Eight of these dogs were recently diagnosed and had not yet been treated. Four dogs previously had been diagnosed and treated (three with intramuscular DOCP, one with oral fludrocortisone acetate). History, physical examination, serum electrolytes, and blood urea nitrogen (BUN) were evaluated. Desoxycorticosterone pivalate (2.2 mg/kg body weight) was administered every 25 days. On day 0, recently diagnosed dogs had a median serum sodium concentration of 131.5 mEq/L, median serum potassium concentration of 6.6 mEq/L, and median BUN of 41.5 mg/dl. All subsequent median serum electrolyte and BUN concentrations were normal. All previously treated dogs had normal blood values which were maintained throughout the study.

EXACERBATION OF CYCLOSPORINE TOXICITY BY CONCOMITANT ADMINISTRATION OF ERYTHROMYCIN

Cyclosporine (CsA), an immunosuppressive drug widely used in clinical organ transplantation, causes a variety of side effects, including parenchymal complications of nephrotoxicity and hepatotoxicity. Erythromycin ethinylsuccinate (EES), a macrolide antibiotic frequently administered to transplant patients afflicted with pneumonias caused by Mycoplasma pneumoniae and Legionella pneumophila, markedly potentiated parenchymal drug toxicity in nine (three renal and six cardiac) CsA-treated allograft recipients. The mean and median blood urea nitrogen (BUN), creatinine, and total bilirubin increased upon initiation of EES treatment: in the renal recipients from 27, 1.7, and 0.5 mg/dl, respectively, before, to a mean and median of 81/101, 8.3/3.9, and 2.1/1.2 mg/dl during, and to 72/22, 1.9/1.7, and 0.6/0.5 mg/dl after cessation of EES treatment. The median serum radioimmunoassay (RIA)-determined CsA trough value of 147 ng/ml prior, rose to a zenith of 1125 ng/ml during, EES therapy. In the six cardiac recipients, the mean and median BUN, creatinine, and total bilirubin of 51/45, 1.5/1.3, 1.2/1.3 mg/dl, respectively, before, rose to 100/91, 3.7/3.6, and 2.3/2.1 mg/dl during, and fell to 49/44, 1.8/2.1, and 1.0/0.8 mg/dl after, cessation of EES. The mean serum CsA trough value of 185 ng/ml rose to 815 ng/ml during EES administration. Since EES and CsA are both metabolized by the hepatic cytochrome P450 mixed-function oxidase system, simultaneous use of these two drugs may decrease CsA metabolism, with consequent elevation of blood levels and induction of CsA toxicity. Therefore, blood level monitoring and careful regulation of CsA dose are necessary, in order to achieve the safe use of EES in transplant recipients.