Peak Increase In Serum Creatinine Research Articles

A Novel Hemodynamic Index of Post-operative Right Heart Dysfunction Predicts Mortality in Cardiac Surgical Patients.

This study aimed to investigate whether mortality following cardiac surgery was associated with the pulmonary artery pulsatility index (PAPi): pulmonary artery pulse pressure divided by central venous pressure (CVP), and a novel index: mean pulmonary artery pressure (mPAP) minus CVP. This retrospective analysis investigated all cardiac surgery patients in the Society of Thoracic Surgeons registry at a single academic medical center from January 2017 through March 2020 (n = 1510). The primary and secondary outcomes were mortality at 1 year and serum creatinine increase during index surgical admission, respectively. CVP, mPAP, PAPi, mPAP-CVP gradient, mean arterial pressure (MAP), and cardiac index (CI) were sampled continually from invasive hemodynamic monitors post-operatively. Associations with mortality were tested with univariate and multivariate analyses. The relationship with serum creatinine was investigated with Pearson's correlation at alpha = .05. One-year mortality was observed in 44/1200 patients (3.7%). On univariate analysis, mortality was associated with minimums for mPAP, MAP, and CI and maximums for CVP, mPAP, PAPi, mPAP-CVP gradient, and CI (all P < .10). Model selection revealed that the only independently predictive parameters were minimum MAP (AOR = .880 [.819-.944]), maximum mPAP-CVP gradient (AOR = 1.082 [1.031-1.133]), and maximum CI (AOR = 1.421 [.928-2.068]), with model c-statistic = .770. A maximum mPAP-CVP gradient >20.5 predicted mortality with 54.5% sensitivity and 79.30% specificity, maintaining significance on survival analysis (P < .001). Peak increase in serum creatinine from baseline demonstrated a weak association with all parameters (max |r| = .33). Mortality was not predicted by the post-operative PAPi; rather, it was independently predicted by the mPAP-CVP gradient, MAP, and CI.

The effect of admission and pre-admission serum creatinine as baseline to assess incidence and outcomes of acute kidney injury in acute medical admissions.

Acute kidney injury (AKI) in hospital-admitted patients is a common complication associated with increased mortality. The diagnosis of AKI relies on the ascertainment of peak increase in serum creatinine (SCr). This study evaluated the incidence of AKI using the increase from mean 7-365 days pre-admission (AKIpre) and admission (AKIadm) SCr levels, and examined the associations of AKI and changes in SCr levels with all-cause mortality. A total of 2436 patients admitted to a tertiary hospital were recruited and followed-up for a median of 47.70 (interquartile range 18.20) months. AKI incidence and severity were defined according to the Kidney Disease: Improving Global Outcomes-AKI Guidelines. Follow-up data were collected from the Hospital Episode Statistics and Office of National Statistics. Mortality was evaluated during a short- (30 days), mid- (1 year) and long-term (4 years) period. No difference in the AKI rates using AKIpre and AKIadm (12.5% versus 12.2%; P = 0.695) or in the AKI severity (P = 0.261) was evident. Agreement between the two definitions was modest (Kappa-statistic = 0.596, P < 0.001). Patients with AKIpre or AKIadm had increased all-cause mortality compared with those without AKI during all follow-up periods. In fully adjusted regression analysis, AKIpre [hazard ratio (HR) = 2.226, 95% confidence interval (CI) 1.140-4.347; P = 0.027] and AKIadm (HR = 2.105, 95% CI 1.090-4.064; P = 0.027) remained associated with 30-day mortality. Results for the 1- and 4-year periods were similar. Increases of >4.00 μmol/L and >6.06% from pre-admission or >6.00 μmol/L and >17.24% from admission SCr levels presented increased mortality risk during follow-up. Use of admission or pre-admission SCr provides similar incidence rates, but they diagnose different sets of patients. Even minor increases in SCr, below those required for the classification of AKI, were associated with increased mortality. These findings can help the clinicians to identify patients at higher risk for adverse outcomes.

The prognostic importance of duration of AKI: a systematic review and meta-analysis

BackgroundAcute kidney injury (AKI), as defined by peak increase in serum creatinine, is independently associated with increased risk of mortality and length of stay. Studies have suggested that the duration of AKI may be an important additional or independent prognostic marker of increased mortality in patients with AKI across clinical settings. We performed a systematic review and meta-analysis of published studies to assess the impact of duration of AKI on outcomes.MethodsVarious bibliographic databases (MEDLINE, Embase, Cochrane Library, CINAHL and Web of Science) were searched through database inception to December 2015. Human, longitudinal studies with patients aged 18 or above describing outcomes of duration of AKI were included. Duration of AKI categorized as “Short” if AKI duration was ≤2 days or labeled as “transient AKI”; “Medium” for AKI durations 3–6 days and “Long” for AKI duration of ≥7 days or “non-recovered”. Various outcomes looked at were Long term mortality, cardiovascular events, chronic kidney disease (CKD).ResultsEighteen studies were deemed eligible for the systematic review. The outcome of long-term mortality with duration of AKI was reported in 8 studies. The pooled Risk Ratio (RR) for long-term mortality generally was higher for longer duration of AKI: short duration of AKI (n = 8 studies, RR 1.42, 95% CI 1.21–1.66), medium duration (n = 4 studies, RR 1.92, 95% CI 1.34–2.75), and long duration (n = 8 studies, RR 2.28, 95% CI 1.77–2.94) duration of AKI. Further, Duration of AKI was independently associated with higher risk of cardiovascular outcomes and incident CKD Stage 3 when stratified within each stage of AKI.ConclusionDuration of AKI was independently associated with long term mortality, cardiovascular(CV) events, and development of incident CKD Stage 3.

Nephrotoxicity of iodixanol versus iohexol inpatients with chronic kidney disease and diabetes mellitus undergoing coronary angiographic procedures

Background: The choice of radiographic contrast media for use in patients at increased risk of contrast-induced nephropathy is of ongoing interest. Materials and Methods: The current study is a prospective, randomized in which comparison of nonionic, isoosmolal agent, iodixanol, versus the nonionic, low-osmolal agent, iohexol, on the renal effects was carried out. A total of 526 subjects with impaired baseline renal functionand diabetes mellitus underwent diagnostic and/or therapeutic coronary angiographic procedures. The coprimary end points were the peak increase in serum creatinine and the incidence of contrast-induced nephropathy, that is, ≥0.5 mg/dl in serum creatinine from baseline within 72 h of receiving contrast media. Results: Of the 129 patients, 97 received iodixanol and 97 received iohexol randomly. The median peak increase in serum creatinine in the iodixanol arm was 0.10 mg/dl; whereas in the Iohexol arm, the median peak increase was 0.09 mg/dl (P = 0.13). The overall contrast-induced nephropathy incidence was 10.5% in the iodixanol arm and 9.8% in the iohexol arm (P = 0.7). The volume of contrast media, volume of saline administered, frequency of coronary interventional procedures, and severity of baseline kidney disease and of diabetes mellitus were similar between treatments. Conclusions: In the present study, the overall rate of contrast-induced nephropathy in patients with chronic kidney disease and diabetes mellitus undergoing coronary angiographic procedures was 10.5%. There was no significant difference between iodixanol and iohexol in either peak increase in serum creatinine or risk of contrast-induced nephropathy.

PREVENTION OF CONTRAST-INDUCED NEPHROPATHY WITH ASCORBIC ACID

ObjectivesA single-center prospective randomised controlled trials was performed, 149 patients were divided randomly into control group (n=78, receiving only 0.9% sodium chloride solution for routine hydration) and intervention group (n=71,...

Prevention of Contrast-Induced Nephropathy with Ascorbic Acid

Some studies have shown that antioxidant ascorbic acid has renal protective effects, but the beneficial effects of contrast-induced nephropathy prevention remain to be clearly shown. Therefore, we aimed to determine whether ascorbic acid pretreatment reduces the risk of contrast-induced nephropathy in a high-risk population of patients with renal insufficiency undergoing coronary angiography. We conducted a prospective, randomized, controlled trial, involving 156 consecutive patients with chronic renal insufficiency (calculated estimated glomerular filtration rate<60 mL/min/1.73 m(2) and/or serum creatinine≥1.1 mg/dL) undergoing coronary angiography. Patients were randomized to ascorbic acid (n=74, 3 g intravenous injection before the procedure and oral 1 g per day for 2 days after the procedure, ascorbic acid group) or sodium chloride alone (n=82, control group). All patients received pre-and postprocedure hydration. There was no difference between the ascorbic acid group and control group in mean peak increase in serum creatinine measured within 48 hours after coronary angiography, the primary study end point (0.012±0.146 vs 0.022±0.212 mg/dL respectively, p=0.216). The incidence of contrast-induced nephropathy, a secondary end point defined as increase of either≥25% or ≥0.5 mg/dL in serum creatinine, was 5.4% in ascorbic acid-treated patients (4/74) and 6.3% in control group patients (6/82), a nonsignificant difference (p=0.690). There were also no differences between the 2 groups in the inhospital clinical outcomes or length of hospital stay. Ascorbic acid pretreatment for short-term at high dose do not prevent renal function deterioration after administration of contrast medium in patients with baseline renal insufficiency undergoing coronary angiography.

Comparison of Contrast-Induced Nephrotoxicity of Iodixanol and Iopromide in Patients With Renal Insufficiency Undergoing Coronary Angiography

This prospective, randomized, double-blind study was performed to compare the incidence of contrast-induced nephropathy (CIN) after the administration of the iso-osmolar contrast medium iodixanol to the low-osmolar contrast medium iopromide during coronary angiography in patients with impaired renal function. Patients with creatinine clearance (CrCl) <60 ml/min who underwent coronary angiography and/or percutaneous coronary intervention were randomized to receive either iodixanol (n = 215) or iopromide (n = 205). The primary study end point was the incidence of CIN, which was defined as an absolute increase in serum creatinine (SCr) ≥0.5 mg/dl (44.2 mol/L) or a relative increase ≥25% compared to baseline SCr. The secondary end points were the proportion of patients with increases in SCr ≥0.5 mg/dl, the proportion with SCr increases ≥1.0 mg/dl (88.4 mol/L), and the peak increase in SCr. Age, the presence of diabetes mellitus, mean baseline SCr, CrCl, the use of N-acetylcysteine, contrast volume, and the predicted risk score for CIN were similar in the 2 groups. CIN developed in 39 patients (9.3%); there was no significant difference between the iodixanol and iopromide groups (10.7% and 7.8%, respectively; absolute difference 2.9%, 95% confidence interval -3.1% to 8.9%, p = 0.394). The proportions of patients with SCr increases ≥0.5 mg/dl (6.5% vs 6.3%) and ≥1.0 mg/dl (2.8% vs 2.9%) were similar in the 2 groups. There was a tendency for more patients with relative increases ≥25% (10.2% vs 6.8%) and greater peak increases in SCr (0.037 ± 0.375 vs 0.029 ± 0.351 mg/dl) to be in the iodixanol group, but these differences were not statistically significant. In conclusion, the incidences of CIN after coronary angiography did not significantly differ between the iodixanol and iopromide groups in patients with impaired renal function.

E0539 B-type natriuretic peptide on preventing of contrast-induced nephropathy in patients with heart failure undergoing primary percutaneous coronary intervention

BackgroundContrast-induced nephropathy (CIN) is one of the leading causes of hospital-acquired renal failure and increase in the mortality and length of hospital stay after percutaneous coronary intervention (PCI).PurposeTo evaluate the...

B-type natriuretic peptide for prevention of contrast-induced nephropathy in patients with heart failure undergoing primary percutaneous coronary intervention

Contrast-induced nephropathy (CIN) is one of the leading causes of hospital-acquired renal failure and increase in the mortality and length of hospital stay after percutaneous coronary intervention (PCI). To evaluate the protective effect of B-type natriuretic peptide (BNP) on CIN in patients with heart failure undergoing PCI. In the prospective, placebo-controlled, randomized trial, 149 consecutive acute myocardial infarction (AMI) patients with heart failure undergoing primary PCI received recombinant human BNP (rhBNP) or placebo from the time of admission to 24 h after PCI. Serum creatinine (SCr) levels were measured to evaluate the protective effect of rhBNP on renal function. Estimated glomerular filtration rate (eGFR) was calculated by the simplified modification of diet in renal disease study equation. CIN was defined as a postprocedure peak increase in SCr of >0.5 mg/dl or >25% from baseline. The baseline characteristics were similar in the two groups. The SCr significantly increased after PCI, with the peak value at 48 h, and then began to decrease. At day 7 after PCI, the SCr had lowered to the baseline level in the BNP group, but it failed to do so in the control group. At 24, 48, and 72 h and 7 days after PCI, the SCr was lower in the BNP group than that in the control group. The eGFR decreased significantly after PCI, with the lowest value at 48 h, and then it began to increase. The eGFR after PCI was higher in the rhBNP group than that in the control group. The occurrence of CIN was significantly lower in the rhBNP group than in the control group. Periprocedural use of BNP could further promote the recovery of renal function and decrease the occurrence of CIN compared with routine treatment alone in patients with heart failure undergoing primary PCI.

Nephrotoxicity of iodixanol versus iopamidol in patients with chronic kidney disease and diabetes mellitus undergoing coronary angiographic procedures

The choice of radiographic contrast media for use in patients at increased risk of contrast-induced nephropathy (CIN) is of ongoing interest. The current study is a prospective, multicenter, randomized, double-blind design comparing the renal effects of the non-ionic, iso-osmolal agent, iodixanol, versus the non-ionic, low-osmolal agent, iopamidol, in 526 subjects with impaired baseline renal function (chronic kidney disease) and diabetes mellitus undergoing diagnostic and/or therapeutic coronary angiographic procedures. The co-primary end points were the peak increase in serum creatinine (SCr) and the incidence of CIN (increase > or =0.5 mg/dL) in SCr from baseline within 3 days of receiving contrast media. In 418 evaluable subjects with complete postcontrast media SCr data, the median peak increase in SCr in the iodixanol arm was 0.10 mg/dL, whereas in the iopamidol arm, the median peak increase was 0.09 mg/dL (P = .13). The overall CIN incidence was 10.5% (11.2% % in the iodixanol arm and 9.8% in the iopamidol arm, P = .7). The volume of contrast media, volume of saline administered, frequency of coronary interventional procedures, and severity of baseline kidney disease and of diabetes mellitus were similar between treatments. In the present study, the overall rate of CIN in patients with chronic kidney disease and DM undergoing coronary angiographic procedures was 10.5%. There was no significant difference between iodixanol and iopamidol in either peak increase in SCr or risk of CIN.

Nephrotoxic effects of iodixanol and iopromide in patients with abnormal renal function receiving N‐acetylcysteine and hydration before coronary angiography and intervention: a randomized trial

The use of contrast agents during coronary intervention can result in nephropathy, particularly in patients with renal dysfunction. We aimed to determine whether the use of iso-osmolar iodixanol is less nephrotoxic than that of low-osmolar iopromide when patients are adequately prehydrated and have received N-acetylcysteine. We conducted a randomized, double-blind, multicentre study of patients with impaired renal function undergoing a coronary interventional procedure. Primary end-point was the incidence of contrast-induced nephropathy (CIN) on day 2, defined as an increase in serum creatinine concentration of > or =44 micromol/L (0.5 mg/dL) or by a relative increase of > or =25% from baseline. Secondary end-points included peak increase in serum creatinine between baseline and day 7. Of 191 patients recruited, 15% (95% CI: 8-22) of the patients receiving iopromide and 12% (95% CI: 5-19) of the patients receiving iodixanol developed CIN (95% CI of the difference: 13 to -7, P = 0.56). When including peak serum creatinine on day 7, CIN developed in 23% of patients receiving iopromide and in 27% of patients receiving iodixanol (95% CI of the difference: 8 to -16, P = 0.48). The peak increase in serum creatinine concentration at day 7 was similar in both groups (patients receiving iopromide, 18.4 +/- 24.4 micromol/L, vs patients receiving iodixanol, 21.9 +/- 24.2 micromol/L; P = 0.33). There remains a high incidence of CIN despite prehydration and routine use of N-acetylcysteine in patients with pre-existing renal dysfunction undergoing coronary interventional procedures. Although our study is underpowered, iodixanol was not associated with a statistically significant lower incidence of CIN when compared with iopromide.

Safety of HES 130/0.4 (Voluven®) in patients with preoperative renal dysfunction undergoing abdominal aortic surgery

Patients with impaired renal function are at risk of developing renal dysfunction after abdominal aortic surgery. This study investigated the safety profile of a recent medium-molecular-weight hydroxyethyl starch (HES) preparation with a low molar substitution (HES 130/0.4) in this sensitive patient group. Sixty-five patients were randomly allocated to receive either 6% hydroxyethyl starch (Voluven); n = 32) or 3% gelatin (Plasmion); n = 33) for perioperative volume substitution. At baseline, renal function was impaired in all study patients as indicated by a measured creatinine clearance < 80 mL min(-1). The main renal safety parameter was the peak increase in serum creatinine up to day 6 after surgery. Both treatment groups were compared for non-inferiority (pre-defined non-inferiority range hydroxyethyl starch < gelatin + 17.68 micromol L(-1) or 0.2 mg dL(-1). Other renal safety parameters included minimum postoperative creatinine clearance, incidence of oliguria and adverse events of the renal system. Baseline characteristics, surgical procedures and the mean total infusion volume were comparable. Non-inferiority of hydroxyethyl starch vs. gelatin could be shown by means of the appropriate non-parametric one-sided 95% CI for the difference hydroxyethyl starch-gelatin [-infinity, 11 micromol L(-1)]. Oliguria was encountered in three patients of the hydroxyethyl starch and four of the gelatin treatment group. One patient receiving gelatin required dialysis secondary to surgical complications. Two patients of each treatment group died. As we found no drug-related adverse effects of hydroxyethyl starch on renal function, we conclude that the choice of the colloid had no impact on renal safety parameters and outcome in patients with decreased renal function undergoing elective abdominal aortic surgery.

Prevention of radiocontrast medium–induced nephropathy using short-term high-dose simvastatin in patients with renal insufficiency undergoing coronary angiography (PROMISS) trial—a randomized controlled study

Contrast media cause oxidative stress, which has been suggested as one possible mechanism responsible for contrast-induced nephropathy. Statins appear to have pleiotropic effects, including antioxidant properties. We investigated to determine whether simvastatin pretreatment reduces the risk of contrast-induced nephropathy in a high-risk population of patients with renal insufficiency undergoing coronary angiography. We conducted a prospective, randomized, double-blind, placebo-controlled, 2-center trial, involving 247 consecutive patients with chronic renal insufficiency (calculated creatinine clearance < or = 60 mL/min and/or serum creatinine > or = 1.1 mg/dL) undergoing coronary angiography. Patients were randomized to simvastatin (n = 124; 160 mg total, 40 mg orally every 12 hours starting the evening before and ending the morning after the procedure) or placebo (n = 123). All patients received pre - and postprocedure hydration. The iso-osmolar contrast agent iodixanol was used for coronary angiography in all patients. There was no difference between simvastatin and placebo in mean peak increase in serum creatinine measured within 48 hours after coronary angiography, the primary study end point (0.002 +/- 0.164 vs 0.017 +/- 0.230 mg/mL respectively, P = .559). The incidence of contrast-induced nephropathy, a secondary end point defined as increase of either > or = 25% or > or = 0.5 mg/dL in serum creatinine, was 2.5% in simvastatin-treated patients (3/118) and 3.4% in placebo-treated patients (4/118), a nonsignificant difference (P = 1.00). There were also no differences between the 2 groups in length of hospital stay or 1- and 6-month clinical outcomes. Simvastatin pretreatment for short-term at high dose do not prevent renal function deterioration after administration of contrast medium in patients with baseline renal insufficiency undergoing coronary angiography.

Risk for Acute Renal Failure in Patients Hospitalized for Decompensated Congestive Heart Failure

Introduction: Congestive heart failure (CHF) is an important cause of hospital admissions and is associated with an increased risk for development of acute renal failure (ARF). The purpose of this study was to describe the incidence of ARF, to ascertain risk factors for its development, and to determine whether ARF impacts hospital outcomes. Methods: Review was conducted of 509 hospital medical records of patients hospitalized with a principal diagnosis of CHF during 2004. ARF was defined as an increase in serum creatinine of 0.5 mg/dl compared to the admission value. Multivariable analysis was used to identify independent predictors of ARF. Results: Most patients had reduced renal function at the time of admission with mean serum creatinine of 1.45 ± 0.72 and calculated creatinine clearance of 43.1 ml/min. ARF developed during the hospitalization in 21% of patients, with a peak increase in serum creatinine of 0.5–3.3 mg/dl. Most cases occurred on hospital days 4–6 (69.5% of cases). ARF was associated with increased risk for in-hospital mortality and increased length of hospital stay. Risk factors for ARF included diabetes, elevated admission serum creatinine and reduced serum sodium and echocardiographic demonstration of diastolic dysfunction. Neither diuretic nor ACEI/ARB treatment was associated with increased risk. Conclusion: ARF is a common complication among patients hospitalized for CHF, and is associated with increased risk for adverse outcomes. Certain clinical characteristics present at the time of admission help identify patients at increased risk.

Effects of Perioperative Nesiritide in Patients With Left Ventricular Dysfunction Undergoing Cardiac Surgery: The NAPA Trial

The purpose of this study was to determine the role nesiritide might play in patients with left ventricular dysfunction undergoing coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB). Given the hemodynamic, neurohormonal, and renal effects of natriuretic peptides, nesiritide might be useful in the management of patients undergoing cardiac surgery. This prospective, double-blind, exploratory evaluation randomly assigned patients with ejection fraction </=40% who were undergoing CABG with anticipated use of CPB to receive either nesiritide or placebo, in addition to usual care, for 24 to 96 h after induction of anesthesia. Postoperative renal function, hemodynamics, and drug use (primary end points) were assessed in patients who underwent CABG using CPB; mortality and safety (secondary end points) were assessed in all patients who received the study drug. Of 303 randomized patients, 279 received the study drug and 272 underwent CABG using CPB. Compared with placebo, nesiritide was associated with a significantly attenuated peak increase in serum creatinine (0.15 +/- 0.29 mg/dl vs. 0.34 +/- 0.48 mg/dl; p < 0.001) and a smaller fall in glomerular filtration rate (-10.8 +/- 19.3 ml/min/1.73 m(2) vs. -17.2 +/- 21.9 ml/min/1.73 m(2); p = 0.001) during hospital stay or by study day 14, and a greater urine output (2,926 +/- 1,179 ml vs. 2,350 +/- 1,066 ml; p < 0.001) during the initial 24 h after surgery. In addition, nesiritide-treated patients had a shorter hospital stay (p = 0.043) and lower 180-day mortality (p = 0.046). Nesiritide in the setting of CABG with CPB is associated with improved postoperative renal function and possibly enhanced survival. (The NAPA Trial; ; ).

Does volume substitution with HES 130/0.4 affect renal safety in abdominal aortic surgery?

Abdominal aortic surgery patients are at risk for renal dysfunction, notably if preoperatively the renal function is impaired. This sensitive patient population was chosen to prove that the recent hydroxyethyl starch (HES) 130/0.4 has no adverse renal effects as asserted for less metabolisable HES preparations. After IRB approval and signed informed consent, 65 adult patients scheduled for abdominal aortic surgery were randomly allocated to receive either 6% HES 1300.4 (Voluven, n = 32) or 3% gelatin solution (Plasmion, n = 33) for perioperative volume substitution. The daily dose limitation for HES was 50 ml/kg body weight Baseline renal function was impaired in all patients (creatinine clearance (CrCl) <80 ml/min). The primary renal safety parameter was the peak increase in serum creatinine through day 6 after surgery. Both groups were compared for non-inferiority of HES (predefined non-inferiority range HES < gelatin + 17.68 mol/l or 0.2 mg/dl). Other renal safety parameters were minimum postoperative CrCl, incidence of oliguria (urine output <500 ml/day), and adverse events (AEs) related to the renal system until hospital discharge. Baseline characteristics, surgical procedures, and the mean total infused colloid volumes were similar between both groups. Postoperatively, the mean peak increase in creatinine was slightly higher in gelatin patients. Non-inferiority of HES was statistically proven by means of the appropriate nonparametric one-sided 95% CI for the difference HES-gelatin (-∞, 11 μmol/l). The minimum postoperative CrCl was lower for gelatin (see Table ​Table1,1, mean values ± SD). Oliguria occurred in a few patients only (three HES vs four gelatin patients). One patient of the gelatin group required dialysis treatment following a cascade of AEs related to surgical complications. Mortality in both groups was 6% (two deaths/ group). No drug-related unfavourable effects on renal function were found for volume substitution with HES 130/0.4 compared with gelatin in patients with mild to severe renal insufficiency undergoing infrarenal abdominal aortic surgery. Table 1