Peak Serum Creatinine Values Research Articles

MO334: Incidence of AKI Among Hospitalized COVID-19 Patients During the First and Sixth Waves of the Pandemic

BACKGROUND AND AIMSDuring the last 2 years, we have witnessed several waves of the COVID-19 pandemic characterized by massive infections among the general population, sudden increases in the number of hospitalizations and variable rates of complications and mortality among patients.Acute kidney injury (AKI) has been described as a common and serious complication of COVID-19. However, multiple factors that are involved in the development of this complication have been modified throughout these months, including the appearance of new variants of the virus, the modification of treatment protocols or the advancement of vaccination among the general population.In this study, we aimed to compare the rates of AKI among patients who required admission due to COVID-19 in the first and current (sixth) waves of the pandemic.METHODConsecutive patients that required admission due to COVID-19 in a tertiary referral hospital during the first (March to May 2020) and current (December 2021) waves of the pandemic were enrolled in the study. Patient characteristics, rates of AKI incidence, 28-day mortality and in-hospital length of stay were compared between groups. Viral infection was confirmed by real-time RT-qPCR in all cases. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines using peak serum creatinine and acute dialysis criteria. Multivariate logistic regression was performed to define potential predictors of AKI.RESULTSTable 1 summarizes demographic and clinical characteristics among enrolled patients. Compared with the current wave, patients admitted during the first wave were older, had higher baseline serum creatinine and lower baseline eGFR. During the first wave, patients presented higher peak serum creatinine values and a higher incidence of in-hospital AKI. Age, male sex, hypertension, diabetes, CKD and pandemic wave were included in multivariate logistic regression analysis as potential predictors of AKI. Only past history of hypertension [OR 2.867; 95% confidence interval (95% CI) 1.279–6.424; P-value: .011] and CKD (OR 2.418; 95% CI 1.237–4.73; P-value: .01) independently predicted AKI in the sample.Table 1.Comparison of patient characteristics between pandemic waves CONCLUSIONDespite multiple changes that have occurred throughout the pandemic, including new treatment protocols, the appearance of new variants of the virus with different clinical profiles or the extensive application of vaccines, these changes have not translated into a significant decrease in the risk of AKI among patients admitted due to COVID-19, which appears to still be conditioned mainly by comorbidities of each patient, including past history of CKD.

POS-204 TELENEPHROLOGY IN MANAGING ACUTE KIDNEY INJURY IN RURAL RWANDA

Telenephrology provides clinical nephrology support to overcome geographical barriers, connecting users who are not in the same physical location. Strategies to minimize access disparities between urban and remotely located Acute Kidney Injury (AKI) were used, telephone calls, and email-based consultation between the general practitioners and physicians of Gisenyi and Gihundwe district hospitals and the nephrologist based in the city of Kigali. The purpose of this study was to determine whether telenephrology can be implemented in remote areas to improve the clinical outcomes of patients with AKI. A retrospective study design was adopted to evaluate the effect of telenephrology on AKI patient care. We collected data on patients admitted in Gisenyi and Gihundwe district hospitals in western province, Rwanda between August 2019 to October 2020. The patient history was captured by a dialysis nurse or general practitioner using a pre-established patient follow up datasheet. The filled template was shared with the nephrologist remotely for more assessment and testing. The nephrologists advised the team on additional investigations and diagnosis. Urgent clarifications were done telephonically. Additionaly, a daily evening e-mail based clinical reporting system was completed by nurses to inform the whole team of nephrologists as a second check mechanism. Once a month visit was conducted by the nephrologist to each of the sites for follow-up of all patients. Clinical outcomes included renal functions and urinary output. All admitted patients with suspected AKI from two hospitals were enrolled in the telenephrology program (n = 105), Gisenyi hospital (n=64), and Gihundwe hospital (n=41) during the study period. The mean age of patients admitted with suspected AKI was 42.73 years, 55.55% (n=61) being male. The etiological breakup of AKI was sepsis 66.67% (n=70), malaria 31.4% (n=33), indigenous drug toxicity32%(n=33), and unknown causes in 1.8%(n=2). Hypertension (n=32) and diabetes (n=18) were co-morbidities found in 50 patients. The mean initial, and peak serum creatinine values were 739.2umols/l and 2578.6umols/l respectively. Hemodialysis (HD) was required in 53.7% (n=57) patients and the total HD and mean HD being 322 and 5.45 sessions, respectively. Of the patients admitted 74 (69.8%) recovered completely. Mortality occurred in 15 (14.2%) patients; two patients (1.8%) were referred out for further management at a higher center. Fifteen patients (14.2%) showed only partial recovery hence deemed to have Chronic Kidney Disease (CKD) and were enlisted for long-term follow-up. With the telenephrology-based patient consultation, the findings of this study evidenced the effective care of patients with AKI by local general physicians in patients who reside in underserved areas. This being an initial feasibility evaluation, a larger study is planned for further investigation of the impact of telenephrology based AKI management in these underserved areas to improve clinical outcomes.

Urinary Neutrophil Gelatinase-Associated Lipocalin as Predictor of Short- or Long-Term Outcomes in Cardiac Surgery Patients.

To determine the ability of urinary neutrophil gelatinase-associated lipocalin (uNGAL) to predict cardiac surgery-associated acute kidney injury (CSA-AKI), continuous renal replacement therapy (CRRT), mortality, and a composite outcome of major adverse kidney events at 365 days (MAKE365), and to investigate the influence of cardiopulmonary bypass (CPB) on NGAL release. A prospective observational study. A single-center university hospital. A cohort of 288 adult cardiac surgery patients. uNGAL was measured at baseline, immediately after surgery, and on days 1 and 2 postoperatively. The authors used the recent Kidney Disease Improving Global Outcomes consensus criteria to define CSA-AKI. CSA-AKI occurred in 36.1% of patients. uNGAL rapidly became significantly higher in patients who developed AKI, with peak value immediately after surgery (349.9 [76.6-1446.6] v 90.1 [20.8-328] ng/mg creatinine; p<0.001). No measure of uNGAL (peak, postsurgery, day 1 or 2 postsurgery) accurately predicted CSA-AKI, CRRT, mortality, or MAKE365. However, immediately after surgery, CPB induced greater uNGAL release compared with off-pump surgery (265.5 µmol/L [71-989.6] v 48.7 ng/mg creatinine [17-129.8]; p<0.001). Moreover, such early uNGAL release correlated with CPB duration (r = 0.505; p<0.001) but not with peak serum creatinine values on day 3 or 7 after surgery. uNGAL had a limited predictive ability for CSA-AKI or other relevant clinical outcomes after cardiac surgery and appeared to be more closely related to the use and duration of CPB. Thus, its levels may represent the aggregate effect of an inflammatory response to CPB as well as a renal response to cardiac surgery and inflammation.

Opioid Use After Cardiac Surgery in Children With Down Syndrome*

To determine the cumulative opioid doses administered to patients with Down syndrome after cardiac surgery and compare them with patients without Down syndrome. Retrospective observational comparative study. PICU in a university-affiliated freestanding pediatric teaching hospital. Infants and children who presented to our institution for heart surgery after July 1, 2008, and met the following criteria: 1) no opioid medications for 48 hours prior to surgery, 2) sternotomy approach with primary closure, and 3) no additional operative procedures in the 5 days after surgery. All patients with Down syndrome were included, and patients without Down syndrome with similar age, type of cardiac lesion, and length of surgical procedure were selected in a ~2:1 ratio, blinded to opioid exposure. None. Clinical and demographic data were extracted from electronic medical record data. Univariate analyses and multivariate linear regression modeling were performed to determine the influence of Down syndrome, patient characteristics, and clinical covariates on weight-adjusted opioid dose. The differences in median cumulative opioid doses between those with Down syndrome (n = 44) and those without Down syndrome (n = 77) were not significant in the first 24 hours (+0.39 mg/kg [95% CI, -0.45 to +1.39 mg/kg]) or 96 hours (+0.54 mg/kg [95% CI, -0.59 to +2.07 mg/kg]) after surgery. Age, cardiac bypass time, benzodiazepines, and neuromuscular blocking agents were significantly correlated with opioid dose, but Down syndrome, gender, pain score, creatinine, acetaminophen, nonsteroidal anti-inflammatory drugs, and steroid medications were not. Patients with Down syndrome had longer hospital stays; in multivariate analysis, higher opioid exposures in the first 96 hours after surgery and higher peak serum creatinine values correlated with longer hospitalization. This cohort did not provide evidence for opioid resistance in patients with Down syndrome. Younger age, longer cardiac bypass time, exposure to benzodiazepines, and neuromuscular blockade did correlate with increased opioid doses after cardiac surgery.

Perioperative fluid balance and acute kidney injury

Positive fluid balance (FB) has been linked to adverse clinical outcomes. We performed this study to explore the relationship between perioperative fluid balance and acute kidney injury (AKI). The relationships between FB and AKI were explored using a prospective, observational design. Patients were divided into quartiles based on FB status in the first 24 h from initiation of surgery in order to further explore this relationship. One hundred adult patients undergoing cardiovascular surgery were included in the analysis. The major finding of the study was that positive FB occurred early in the intraoperative period and progressed into the postoperative period and that fluid administration was not clearly associated with any identifiable volume-sensitive event. The evolution of positive FB preceded the rise in serum creatinine. Progressive severity of positive FB was associated with increased incidence of AKI. The highest quartile FB group had a five-fold increased risk for AKI (adjusted odds ratio 4.98, 95 % confidence interval 1.38-24.10, p = 0.046) compared to the lowest quartile group, higher postoperative peak serum creatinine values (p < 0.001), surgery-related complications (p < 0.001) and intensive care unit (p < 0.001) and hospital length of stay (p = 0.048). Positive FB was associated with increased incidence of AKI.

Acute kidney injury in patients with influenza A (H1N1) 2009

We aim to evaluate the incidence and outcome of acute kidney injury (AKI) among critically ill adult patients with H1N1 2009 infection. From a prospectively collected influenzaA (H1N1) 2009 bi-national, we identified 671 adult patients admitted to intensive care unit (ICU) from June 1 to August 31, 2009. Of these, 628 (93.6%) had admission and/or peak serum creatinine values during ICU stay. We defined AKI according to the creatinine criteria of the RIFLE classification. Of 628 adult patients, 211 [33.6%, 95% confidence interval (CI) 29.8-37.4%] had AKI: 41 (6.5%) risk, 56 (8.9%) injury and 114 (18.2%) failure. Of all 211 AKI patients, 76 [36.0% (29.4-42.6%)] died in hospital (36.6% in risk, 25.0% in injury and 41.3% in failure group) compared with 33 of 408 (8.1%) patients without AKI. Among the 33 AKI patients treated with renal replacement therapy, 13 died (39.4%). Mechanical ventilation [odds ratio (OR) 3.62 (2.07-6.34)], any severe co-morbidity (OR 2.36, 95% CI 1.15-3.71), age (OR 1.02, 95% CI 1.01-1.03 per 1 year increase), and AKI (OR 6.69, 95% CI 4.25-10.55) were independently associated with hospital mortality. Acute kidney injury appears common in H1N1 2009 infected patients and is independently associated with an increased risk of hospital mortality.

One-Year Mortality in Critically Ill Patients by Severity of Kidney Dysfunction: A Population-Based Assessment

Kidney dysfunction in the intensive care unit (ICU) results in increased morbidity, mortality, and health care costs; however, long-term mortality has not been described across strata of severity in kidney dysfunction. The primary objective is to describe and assess factors associated with 1-year mortality in critically ill patients stratified by severity of kidney dysfunction during admission to the ICU. Kidney dysfunction is defined by peak serum creatinine values and stratified by: (1) no dysfunction (creatinine < 1.7 mg/dL [<150 micromol/L]), (2) mild dysfunction (creatinine, 1.7 to 3.4 mg/dL [150 to 299 micromol/L]), (3) moderate dysfunction (creatinine >or= 3.4 mg/dL [>or= 300 micromol/L]), (4) severe acute dysfunction requiring renal replacement therapy (acute renal failure), or (5) preexisting end-stage kidney disease. Population-based surveillance was of adult residents of the Calgary Health Region (population, 1 million) admitted to any multidisciplinary ICU and a cardiovascular surgery ICU from May 1, 1999, to April 30, 2002. Of 5,693 admissions, 62% were men, median age was 64.9 years (interquartile range, 50.6 to 74.5 years), and mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 24.9 +/- 8.7 (SD). Case fatality rates stratified by renal dysfunction were 17% (763 of 4,411), 47% (370 of 790), 48% (77 of 160), 64% (153 of 240), and 40% (37 of 92) for no, mild, and moderate dysfunction; severe acute renal failure; and end-stage kidney disease, respectively. By means of multivariate analysis, 1-year mortality was associated independently with advancing age, medical diagnosis, higher APACHE II score, and presence and severity of kidney dysfunction, although no difference was evident comparing those with mild to moderate dysfunction. End-stage kidney disease was not associated independently with 1-year mortality. Severity of kidney dysfunction in patients in the ICU is associated with an incremental increase in long-term mortality. Although patients classified with either mild or moderate kidney dysfunction had an increased risk for death, use of serum creatinine level alone was poor at discriminating long-term outcome, suggesting this measure alone should not be used for defining long-term prognosis.

Successful Six‐Day Kidney Preservation Using Trophic Factor Supplemented Media and Simple Cold Storage

This study examined the effect of trophic factor supplementation [TFS; bovine neutrophil peptide-1 (bactenecin), 1 mg/L; substance P, 2.5 mg/L; nerve growth factor, 20 microg/L; epidermal growth factor, 10 microg/L; insulin-like growth factor-1, 10 microg/L] during cold storage with UW lactobionate solution. Dogs transplanted with kidneys stored for 4days in TFS-UW had significantly lower peak serum creatinine values (mean 2.9 +/- 0.2mg/dL) and returned to normal values faster (6 days) than kidneys stored for 3days in unmodified UW solution (4.2 +/- 0.3 mg/dL and 14 days, respectively). Kidneys stored for 5days in TFS-UW (mean peak creatinine 3.7 +/- 0.3) functioned equivalently to kidneys stored for 3days and better than kidneys stored for 4 days in UW alone. Dogs with kidneys stored for 6days in TFS-UW had mean peak creatinines of 5.7 +/- 0.4 mg/dL. These returned to normal creatinine values in 14 days, equal to 3-day stored and significantly better than kidneys stored for 4days in UW alone (20days recovery time). This study shows trophic factor deprivation appears to be a critical mechanism of injury in organ preservation with current synthetic storage media, and marks the initial development of a synthetic biologically active preservation solution, the next generation of preservation media.

The association of epsilon-aminocaproic acid with postoperative decrease in creatinine clearance in 1502 coronary bypass patients.

Renal dysfunction is a common serious complication after cardiac surgery. Reports of proteinuria and hyperkalemia after cardiac surgery with epsilon-aminocaproic acid (EACA) have therefore raised concerns for renal safety. Since EACA renders these markers unreliable, we used perioperative change in creatinine clearance (DCrCl) to test the hypothesis that EACA is associated with greater reductions in creatinine clearance after heart surgery, particularly for patients with renal disease. We evaluated data from all elective primary coronary bypass patients during EACA introduction at our institution (July 1, 1991-December 31, 1992; 10 g iv bolus pre-cardiopulmonary bypass, then 1 g/h for 5 h). DCrCl was calculated using preoperative (CrPre) and postoperative peak serum creatinine values, using the Cockroft-Gault equation. Patients with CrPre > or = 133 micromol/L were also separately analyzed. Evaluated patients (n = 1502, +/-EACA; 581/905, 16 exclusions) included 233 with CrPre > or = 133 micromol/L (+/-EACA; 98/135). Multivariate analyses confirmed several known risk factors, but no association between DCrCl and EACA in all patients (P: = 0.66), and the subgroup with CrPre > or = 133 micromol/L (P: = 0.42). In a large population of primary Coronary Artery Bypass Graft including a subset with preoperative renal dysfunction, there were no postoperative reductions in creatinine clearance attributable to epsilon-aminocaproic (EACA) administration. This retrospective study suggests that moderate epsilon-aminocaproic acid dosing during cardiac surgery is safe for the kidney; however, this inference is based on a single marker of renal dysfunction and requires prospective confirmation using a variety of tests of renal function.

The Association of ε-Aminocaproic Acid with Postoperative Decrease in Creatinine Clearance in 1502 Coronary Bypass Patients

Renal dysfunction is a common serious complication after cardiac surgery. Reports of proteinuria and hyperkalemia after cardiac surgery with ε-aminocaproic acid (EACA) have therefore raised concerns for renal safety. Since EACA renders these markers unreliable, we used perioperative change in creatinine clearance (DCrCl) to test the hypothesis that EACA is associated with greater reductions in creatinine clearance after heart surgery, particularly for patients with renal disease. We evaluated data from all elective primary coronary bypass patients during EACA introduction at our institution (July 1, 1991–December 31, 1992; 10 g iv bolus pre-cardiopulmonary bypass, then 1 g/h for 5 h). DCrCl was calculated using preoperative (CrPre) and postoperative peak serum creatinine values, using the Cockroft-Gault equation. Patients with CrPre ≥ 133 μmol/L were also separately analyzed. Evaluated patients (n = 1502, ±EACA; 581/905, 16 exclusions) included 233 with CrPre ≥ 133 μmol/L (±EACA; 98/135). Multivariate analyses confirmed several known risk factors, but no association between DCrCl and EACA in all patients (P = 0.66), and the subgroup with CrPre ≥ 133 μmol/L (P = 0.42). Implications In a large population of primary Coronary Artery Bypass Graft including a subset with preoperative renal dysfunction, there were no postoperative reductions in creatinine clearance attributable to δ-aminocaproic (EACA) administration. This retrospective study suggests that moderate δ-aminocaproic acid dosing during cardiac surgery is safe for the kidney; however, this inference is based on a single marker of renal dysfunction and requires prospective confirmation using a variety of tests of renal function.

Prognostic markers in patients with antineutrophil cytoplasmic autoantibody-associated microscopic polyangiitis and glomerulonephritis.

The purpose of this study was to determine the prognostic value of clinical, laboratory, and pathologic features at the time of presentation on patient and renal survival in patients with antineutrophil cytoplasmic autoantibody (ANCA)-associated microscopic polyangiitis and glomerulonephritis (excluding Wegener's granulomatosis). One hundred seven ANCA-positive patients with necrotizing and crescentic glomerulonephritis, including 69 with evidence for microscopic polyangiitis, were evaluated for this study. The relative risk of death was calculated for the following potential prognostic indicators: (1) ANCA pattern; (2) pulmonary hemorrhage at onset; (3) presence of extrarenal manifestations versus renal limited disease; and (4) treatment with corticosteroids and cyclophosphamide (intravenous or oral), compared with corticosteroids alone. Cox's proportional hazard model was used to assess the predictive value of the following variables on renal survival: (1) age; (2) race; (3) pulmonary symptoms at onset of disease; (4) renal pathology; (5) ANCA pattern; and (6) peak serum creatinine values obtained near the time of renal biopsy. Patients were followed prospectively for 2.5 yr (range, 5 days to 12 yr 2 months). There were 12 disease-related deaths and 46 patients who reached ESRD. The relative risk (and 95% confidence interval) of patient death was 8.65 (3.36, 22.2) times greater in patients who presented with pulmonary hemorrhage, and 3.78 (1.22, 11.70) times greater in patients with cytoplasmic ANCA compared to those with perinuclear ANCA. The relative risk of pulmonary hemorrhage was no different by ANCA pattern. The risk of death was 5.56 times lower in the cyclophosphamide-treated patients versus those treated with corticosteroids alone. The predictors of renal survival were entry serum creatinine value (P = 0.0002), race (African Americans having a worse outcome compared with Caucasians, P = 0.0008), and the presence of arterial sclerosis on kidney biopsy (P = 0.0076) when controlling for age, ANCA pattern, microscopic polyangiitis versus glomerulonephritis alone, and pulmonary involvement. Pathology indices such as glomerular necrosis, glomerular crescents, glomerular sclerosis, and interstitial sclerosis were not predictive of renal survival when controlling for entry serum creatinine value, race, and arterial sclerosis. However, in the subgroup of patients with a peak creatinine value of < or = 3.0 mg/dL (N = 29), increased interstitial sclerosis was a predictor of a poor renal outcome (P = 0.04).

Renal Toxicity of Interleukin-2 Administration in Patients With Metastatic Renal Cell Cancer: Effect of Pre-therapy Nephrectomy

Systemic administration of interleukin-2 and lymphokine-activated killer cells is a new approach to the immunotherapy of advanced cancer. Metastatic renal cell cancer is one of the histological types of tumors particularly susceptible to this treatment approach although renal toxicity often is a dose-limiting side effect. We compared the renal functional changes observed during interleukin-2 therapy in 52 consecutive patients with advanced renal cancer to that of 83 consecutive patients with metastatic nonrenal cancer. Of the 52 patients with renal cancer 41 had recently undergone nephrectomy. The over-all peak serum creatinine values and the percentage increase of serum creatinine over baseline for all patients studied were significantly higher in cycle 2 of interleukin-2 therapy than in cycle 1: 3.8 ± 0.2 versus 2.6 ± 0.1mg. per dl. and 241.7 ± 16.5 versus 140.3 ± 11.0 per cent, respectively. In patients with pre-therapy serum creatinine values of 0.4 to 0.9mg. per dl. there were no significant differences in the mean peak serum creatinine nor in the percentage increase over baseline between renal and nonrenal cancer patients during cycle 1. In cycle 2 of therapy these values were higher in the renal cancer group (3.6 ± 0.8 versus 2.4 ± 0.2mg. per dl. and 310.4 ± 103.5 versus 214 ± 30.4 per cent, respectively) but they did not reach statistical significance (P2 = 0.08 and 0.25, respectively). Renal and nonrenal cancer patients with pre-therapy serum creatinine levels of 1.0 to 1.4mg. per dl. achieved similar high values in cycle 2 of interleukin-2 therapy (3.9 ± 0.3 versus 3.9 ± 0.4mg. per dl. and 222.7 ± 23.2 versus 248.7 ± 33.5 per cent, respectively), although the initial increase (cycle 1) was higher in the renal cancer patients (3.3 ± 0.3 versus 2.4 ± 0.2mg. per dl. and 172.3 ± 25.9 versus 116.1 ± 18.0 per cent, respectively). Baseline serum creatinine greater than or equal to 1.5mg. per dl. was associated with an over-all higher peak serum creatinine and higher percentage increase of serum creatinine over baseline than that below 1.5mg. per dl. baseline: 4.4mg. per dl. and 171.1 ± 36.3 per cent in cycle 1 and 6.5 ± 0.7mg. per dl. and 296.1 ± 44.0 per cent in cycle 2, respectively (p less than 0.01). There was no association between peak serum creatinine and interval from nephrectomy to interleukin-2 therapy. Over-all, patients with a recent pre-therapy nephrectomy did not have significantly more severe renal insufficiency compared to patients with renal cancer who did not undergo nephrectomy before interleukin-2 therapy.Administration of additional rounds of interleukin-2 therapy to patients who showed partial regression of tumor after the first round of therapy was not associated with a higher degree of renal dysfunction. There was no statistical difference in the mean peak serum creatinine with intervals of less than 6, 6 to 12 or more than 12 weeks between rounds (p greater than 0.05). Pre-therapy baseline serum creatinine is a predictor of the degree of renal insufficiency in patients following systemic administration of interleukin-2.

Acute renal failure complicating viral hepatitis in the absence of severe hepatic insufficiency.

Four patients (2 were HBsAg positive) with acute icteric viral hepatitis (VH) developed acute renal failure (ARF) in the course of their illness and in the absence of other complications. Their peak serum creatinine values (4.7-10, mean 7 mg/dl) were reached either before or simultaneously with their maximum serum aminotransferase values (1,390-2730, mean 2,032 mU/ml). Apart from VH no other factors responsible for precipitating ARF could be identified. In the HBsAg-negative patients, serological investigations for infectious mononucleosis, cytomegalovirus infection, and leptospirosis were negative. In 2 patients liver biopsy showed changes consistent with VH. Proteinuria was absent in all cases, making glomerulonephritis unlikely. The urinary sodium excretion was uniformly high (57-104, mean 78 mmol/l in random samples). Two patients required short courses of dialysis. All cases recovered completely with return of serum creatinine to normal values after a mean duration of 25 days. After a normal serum creatinine level had been achieved, 1 case was lost to follow-up, and the other 3 cases maintain normal renal and liver function tests 9 months (mean) after the initial episode. Otherwise uncomplicated VH is a potential cause of ARF, even in the absence of severe hepatic insufficiency. The mechanism of ARF in VH is unknown, but vasoconstriction phenomena induced by endotoxemia might contribute.