Postoperative Blood Urea Nitrogen-to-Albumin Ratio Predicts 90-Day Mortality Following Burn Surgery.

Recanalisation of renal artery bridging stent graft thrombosis in patients with delayed ischemia lasting more than 24h could potentially save some residual renal function. This study evaluates the technical success and short-term clinical outcomes of delayed recanalisation of bilateral or single-functioning kidneys with renal artery occlusion after endovascular repair of complex aortic aneurysms. We retrospectively analysed 11 patients treated between October 2019 and November 2024 who developed occlusion of a single functioning kidney or bilateral renal stent-graft thrombosis. Technical success was defined as recanalisation of at least one occluded renal bridging stent with restoration of blood flow to the kidney.. Clinical success was, defined by the improvement or stabilisation of residual renal function (eGFR) and delaying the need for dialysis. Delayed endovascular repair was performed for fifteen renal artery stent-graft thromboses in eleven patients.. Mean age was 68.7 ± 5years; nine patients (81%) were male. Six patients (54%) had contained aortic rupture or aneurysms > 8cm and were treated acutely/subacutely with off-the-shelf stent grafts; four (36%) received custom-made devices, and one a fenestrated cuff. Main symptoms included anuria (81%), nausea, diarrhoea, and flank pain (100%). Time from symptom onset to treatment ranged 24-96h (mean 27.2h), and mean time from index procedure to thrombosis was 10.4months. Clinical success was achieved in 72% of cases. Nine patients required dialysis post-intervention; six were temporary, and three permanent. Perioperative complications occurred in 2/11 patients. In 55%, the cause of occlusion was undetermined. Median follow-up was 18.5months (IQR 0-33). Delayed renal stent graft recanalisation is safe and effective, preserving renal function and avoiding dialysis in single-functioning or bilateral renal artery occlusions. Recanalisation should be considered aggressively when renal perfusion remains, regardless of occlusion duration.

BackgroundAccurate prediction of short-term mortality in sepsis patients is critical for timely clinical decision-making. However, existing deep learning models often focus on static physiological parameters while neglecting the dynamic response to medical interventions, leading to risk underestimation due to the "masking effect" of therapeutic measures.MethodsWe propose a lightweight hybrid deep learning framework that integrates dynamic intervention responses to predict 24-h all-cause mortality. Utilizing the MIMIC-IV v3.1 database, we included 13,788 adult sepsis patients. The model employs a dual-branch architecture: a Bidirectional LSTM to capture local temporal trends and a Transformer Encoder to extract global long-range dependencies. Crucially, we constructed a high-resolution feature set that includes vasopressor infusion rates and hourly urine output to quantify physiological feedback to resuscitation.ResultsThe proposed model achieved an Area Under the Receiver Operating Characteristic Curve (AUROC) of 0.8139, significantly outperforming seven mainstream baselines, including LightGBM (0.8015), Bi-LSTM (0.7870), and pure Transformer models (0.7704). Feature importance analysis revealed that indicators of treatment response, specifically urine output and norepinephrine dosage, were among the top predictive features, validating the clinical hypothesis that drug dependency and renal perfusion are sensitive markers of prognosis. Furthermore, external validation on the independent multi-center eICU Collaborative Research Database demonstrated robust generalizability: a zero-shot transfer yielded an AUROC of 0.6620, which improved to 0.7347 after lightweight domain adaptation fine-tuning, with a Negative Predictive Value (NPV) of 90.04%, confirming the model's cross-institutional applicability as a reliable rule-out tool.ConclusionOur LSTM-Transformer Fusion architecture effectively captures the complex "drug-physiology" interactions with low computational cost. By explicitly modeling the dynamic response to treatment and demonstrating cross-institutional generalizability through external validation on the eICU database, this lightweight model offers a robust and interpretable tool for early warning systems in resource-constrained intensive care environments.

Low cardiac index during periods of arterial hypotension and risk of acute kidney injury in cardiac surgery.

BACKGROUND Crossed fused renal ectopia (CFRE) is an uncommon congenital renal anomaly in which 1 kidney crosses the midline and fuses with the contralateral kidney. Although CFRE is often asymptomatic, its rare association with renal malignancy poses substantial diagnostic and surgical challenges due to abnormal anatomy and vascular supply. This report describes clear cell renal cell carcinoma (RCC) arising in CFRE with direct invasion into the contralateral, normally positioned kidney. CASE REPORT A 60-year-old man presented with a 2-month history of mild left loin pain without urinary or systemic symptoms. Initial laboratory findings were unremarkable. Imaging studies, including contrast-enhanced computed tomography, demonstrated a congenitally ectopic right kidney fused to the left kidney, consistent with CFRE, and a large heterogeneously enhancing mass replacing most of the ectopic kidney and extending into the lower pole of the normally located left kidney. Positron emission tomography showed no evidence of distant metastasis. The patient underwent radical nephrectomy of the ectopic right kidney combined with partial nephrectomy of the invaded segment of the left kidney, with preservation of renal perfusion. Histopathologic examination confirmed clear cell RCC, World Health Organization/International Society of Urological Pathology grade 3, staged as pT3a, with negative surgical margins. The postoperative course was uneventful, and renal function was preserved. CONCLUSIONS This is the first documented report of RCC arising in CFRE with invasion into the contralateral normal kidney. It emphasizes the importance of detailed preoperative imaging, individualized surgical planning, and nephron-sparing strategies in the management of complex renal anomalies with malignancy.

Early postoperative mortality remains a major challenge in elderly patients with intertrochanteric hip fractures. Identifying simple and reliable preoperative biomarkers is essential for short-term risk stratification. The blood urea nitrogen-to-albumin ratio (BAR) integrates metabolic stress, renal perfusion, and nutritional status; however, its prognostic value in orthopedic trauma has not been fully clarified. This retrospective cohort study included 514 patients aged ≥ 65 years who underwent surgical treatment for intertrochanteric femur fractures. Preoperative BAR and other inflammatory biomarkers-including CRP-to-albumin ratio (CAR), fibrinogen-to-albumin ratio (FAR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR)-were analyzed. Thirty-day mortality was evaluated using receiver operating characteristic (ROC) analysis and multivariable logistic regression. Thirty-day mortality occurred in 54 patients (10.5%). Non-survivors had significantly higher inflammatory and metabolic biomarker levels and lower albumin levels compared with survivors (all p < 0.05). BAR demonstrated the highest discriminative ability for predicting 30-day mortality (AUC = 0.82), with an optimal cut-off value of 9.0 (sensitivity 79%, specificity 72%). In multivariable analysis, BAR ≥ 9.0 remained the only independent predictor of mortality (adjusted OR 2.68; 95% CI 1.34-5.34; p = 0.006). Preoperative BAR is an independent biomarker for predicting early mortality in elderly patients with intertrochanteric hip fractures. Its simplicity and routine clinical availability support its potential use in preoperative risk stratification. Prospective multicenter studies are needed to confirm these findings.

With increasing interest in renal normothermic machine perfusion (NMP), a deeper understanding of exvivo renal physiology is essential to establish NMP as a robust pre-transplant assessment platform. This study utilized magnetic resonance imaging (MRI) to compare invivo renal physiology in healthy volunteers with exvivo renal function of human donor kidneys during NMP. Multiparametric MRI maps assessing water diffusion, oxygenation, tissue characteristics, and perfusion were obtained from 11 healthy volunteers to define an invivo renal reference frame. For exvivo evaluation, 25 discarded human donor kidneys underwent 4 h of oxygenated hypothermic machine perfusion, followed by 6 h of NMP in an MRI-compatible setup. The kidneys were assessed hourly using comparable MRI modalities as invivo. Ex vivo renal physiology was substantially different from invivo physiology in terms of MRI-based diffusion patterns, oxygenation, tissue characteristics, and tissue perfusion. Most MRI measurements did not correlate well with conventional parameters such as flow, renal function, and injury markers during NMP. Our findings highlight distinct differences between invivo and exvivo MRI-based renal characteristics in a human cohort, suggesting that parameters beyond conventional invivo functional markers may warrant consideration when evaluating organ viability during NMP.

Introduction Pediatric poisoning is a major global public health concern, with plant-derived intoxications constituting a substantial proportion of cases. Hyoscyamus niger (henbane) contains tropane alkaloids responsible for antimuscarinic toxicity. This study aims to evaluate the clinical characteristics, management, and outcomes of pediatric henbane poisoning cases and to highlight prevention strategies. Methods This retrospective observational study was conducted in the pediatric intensive care unit of Ağrı Training and Research Hospital between January 2018 and April 2023. Patients aged one month to 18 years diagnosed with henbane poisoning were included. Poisoning severity was classified according to the International Programme of Chemical Safety/European Association of Poison Control Centres and Clinical Toxicologists, Poisoning Severity Score. Demographics, clinical features, laboratory data, interventions, and outcomes were analyzed. Statistical analyses were performed, with P <0.05 considered significant. Results A total of 68 patients (35 males, 51.5%; median age 63.5 months) were included. Severe cases had significantly higher rates of seizures (10/28, 35.7% versus 0/40, 0%; P <0.001), sedation requirement (14/28, 50.0% versus 0/40, 0%; P <0.001), and acute kidney injury (19/28, 67.9% versus 4/40, 10.0%; OR: 8.44, 95% CI: 2.79–25.59; P <0.001). Agitation (55/68, 80.9%) and mydriasis (58/68, 85.3%) were the most common symptoms and clinical findings. Tachycardia was significantly associated with acute kidney injury (25/54, 46.3% versus 2/14, 14.3%; OR: 5.17, 95% CI: 1.06–5.25, P = 0.031). No patients received physostigmine therapy. All patients recovered fully. Discussion Henbane poisoning in children causes neuropsychiatric and systemic signs of antimuscarinic toxicity, mainly agitation, hallucinations, and sinus tachycardia. Severe cases may lead to seizures and acute kidney injury, possibly due to reduced renal perfusion. Conclusion Severe henbane poisoning in children requires sedation, can cause seizures, and may lead to acute kidney injury. Tachycardia is a potential indicator of renal injury.

BackgroundThoracoabdominal aortic aneurysm (TAAA) repair is associated with significant risks of blood loss and organ ischemia. This study evaluates the efficacy of a novel, modified Extracorporeal Circulation (mECC) circuit system designed to enhance blood conservation and selective organ perfusion during open TAAA repair.MethodsIn this retrospective analysis, 7 patients underwent open thoracoabdominal aortic repair between January 2022 and October 2024 using a modified extracorporeal circulation system. The system incorporated integrated roller pumps for selective visceral and renal perfusion, a centrifugal pump, and an integrated autotransfusion system reservoir to optimize hemodynamic control and minimize allogeneic blood transfusion. Demographic data, intraoperative parameters, transfusion requirements, and postoperative outcomes were assessed.ResultsThe cohort consisted of 7 patients (57.1% male; mean age 54.4 ± 15.0years). Crawford type I repair was performed in 71.4% of cases. The mean ECC duration was 104.4 ± 16.8min, and mean aortic clamp time was 72.0 ± 18.5min. The use of the integrated autotransfusion system resulted in reduced postoperative transfusion requirements and helped maintain hemoglobin levels. Postoperative complications included gastrointestinal events (42.9%), wound infections (42.9%), and spinal cord deficit (14.3%). Early in-hospital mortality was 14.3% (one patient, postoperative day 5). Kaplan-Meier analysis showed a 1-week survival rate of 85.7%, with all surviving patients remaining alive throughout the follow-up period.ConclusionThe modified ECC system with integrated roller pumps and cell-saver technology demonstrated favorable short-term outcomes and effective blood conservation in open TAAA repair. This reservoirless, isothermic, centrifugal circuit with peripheral cannulation may offer a safe and efficient alternative for complex aortic surgery. Larger, prospective studies with extended follow-up are warranted to confirm these findings and evaluate long-term durability.

ABSTRACT Background Acute kidney injury (AKI) remains one of the most frequent and prognostically relevant complications following cardiac surgery, even in the era of modern cardiopulmonary bypass (CPB) management and goal‐directed perfusion. Cardiac surgery–associated AKI (CSA‐AKI) is associated with increased postoperative morbidity, prolonged hospitalization, neurocognitive complications, and reduced early as well as long‐term survival. Although optimization of macrocirculatory parameters and oxygen delivery has demonstrated benefits, renal injury often occurs despite apparently adequate perfusion and oxygenation. Recent evidence suggests that CPB‐related metabolic stress and protein catabolism contribute to renal vulnerability. Indeed, intravenous amino acid administration has emerged as a novel metabolic strategy for renal protection. Materials and Methods This narrative review was informed by a structured literature search of PubMed/MEDLINE, Embase, and the Cochrane Library, covering publications from database inception through March 2025. Search terms included combinations of “acute kidney injury,” “cardiac surgery,” “cardiopulmonary bypass,” “amino acids,” “intravenous amino acid infusion,” “renal protection,” and “goal‐directed perfusion”. Randomized controlled trials, meta‐analyses, systematic reviews, secondary analyses, and relevant narrative reviews published in English were considered. Particular emphasis was placed on high‐quality evidence, including the PROTECTION randomized trial, contemporary meta‐analyses, and consensus or expert reviews addressing cardiac surgery–associated acute kidney injury and perioperative metabolic interventions. Results The literature search identified 124 records; 18 articles were included in the final narrative synthesis after title, abstract, and full‐text evaluation. The selected literature comprised a multicenter randomized controlled trial, secondary analyses of randomized data, meta‐analyses/systematic reviews, narrative or expert reviews, and observational or mechanistic studies addressing CSA‐AKI. The evidence indicates that CSA‐AKI results from an interaction between altered renal perfusion, inflammation, ischemia–reperfusion injury, and CPB‐induced metabolic derangement. Intravenous amino acid infusion was consistently associated with reduced postoperative AKI incidence, particularly in patients with preexisting chronic kidney disease, without significant safety concerns. These findings support amino acid administration as a metabolic adjunct to goal‐directed perfusion rather than a standalone intervention. Conclusions Intravenous amino acid infusion is a recent strategy to reduce AKI in cardiac surgery. By targeting the CPB‐induced metabolic stress, amino acid administration complements goal‐directed perfusion and expands current AKI prevention paradigms beyond hemodynamic optimization alone. Future research should focus on CPB‐specific timing, dosing strategies, and integration of metabolic support into multimodal AKI prevention bundles.

Background/Objectives: Sepsis-associated acute kidney injury (SA-AKI) involves complex disturbances in renal microcirculation that may precede overt biochemical evidence of renal dysfunction. This study aimed to characterize early renal perfusion patterns during the emergency department (ED) phase of sepsis, as assessed by the renal resistive index (RRI) and the semiquantitative power Doppler ultrasonography score (SPDUS), and to explore their relationship with subsequent SA-AKI trajectories. Methods: In this prospective observational study, adult ED patients who met the Sepsis-3 criteria were enrolled. Renal perfusion was evaluated using the RRI and SPDUS at ED admission and repeated at the fourth hour. SA-AKI was classified as transient or non-transient based on renal recovery patterns. Trajectory comparisons were performed to identify early physiological differences. Receiver operating characteristic (ROC) analyses were conducted for descriptive and exploratory assessment of perfusion pattern separation between injury trajectories. Results: Fifty-four patients were included, with 35 classified as transient and 19 as non-transient SA-AKI. Patients with non-transient injury exhibited lower baseline SPDUS0 grades and higher RRI0 values compared with those with transient injury. These differences were evident at ED presentation, prior to the initiation of advanced organ support, and persisted at the fourth hour, with the non-transient group continuing to show lower SPDUS4 and higher RRI4 values than the transient group. These findings reflect distinct early renal microcirculatory perfusion patterns across SA-AKI trajectories. Sensitivity, specificity, and cut-off values are reported for descriptive and exploratory purposes only and should not be interpreted as validated clinical thresholds. Conclusions: Early alterations in renal microcirculatory perfusion are detectable during the ED phase of sepsis and differ between transient and non-transient SA-AKI trajectories. Baseline RRI and SPDUS values provide physiological insight into early renal perfusion abnormalities and evolving microcirculatory dysfunction in sepsis, but should not be interpreted as predictive tools.

In patients with acute heart failure (HF), both hypotension and hypertension may compromise renal perfusion, yet the association between systolic blood pressure (SBP) and acute kidney injury (AKI) risk is controversial and poorly quantified. This study aimed to define this relationship. In this retrospective cohort analysis of 19,604 HF patients from the MIMIC-IV database, individuals were categorized into three SBP strata based on their mean SBP during the first 24 hours of intensive care unit admission: strict (<110 mmHg), standard (110-139 mmHg), and lenient (≥140 mmHg). We employed multivariable logistic regression, propensity score weighting, and restricted cubic spline (RCS) analysis to evaluate associations. To further address confounding, we incorporated standardized ICU severity scores (OASIS, SAPS II, APACHE III) into the models. Sensitivity analyses were performed using alternative SBP cutoffs and in a subcohort with available BNP measurements. A predictive model was developed and internally validated via bootstrapping. The overall incidence of AKI was 36.6%. After multivariable adjustment, compared with the lenient SBP stratum (≥140 mmHg), both strict (<110 mmHg; aOR 0.74, 95% CI 0.67-0.82) and standard (110-139 mmHg; aOR 0.77, 95% CI 0.69-0.86) SBP strata were associated with significantly lower odds of AKI. These associations remained robust after adjustment for OASIS (strict: aOR 0.71, 0.64-0.79; standard: aOR 0.75, 0.68-0.84), SAPS II (strict: aOR 0.67, 0.60-0.75; standard: aOR 0.75, 0.67-0.83), and APACHE III (strict: aOR 0.69, 0.62-0.77; standard: aOR 0.76, 0.68-0.85). RCS analysis revealed a significant non-linear relationship, with the lowest predicted AKI risk at an SBP of approximately 120 mmHg. Key independent risk factors included chronic kidney disease (aOR 2.64) and elevated 48-hour creatinine ratio (aOR 2.07 per unit). The full prediction model demonstrated moderate discrimination (area under the curve [AUC] = 0.726, 95% CI: 0.718-0.733) but significant calibration issues (Hosmer-Lemeshow P < 0.001). Internal validation yielded an optimism-corrected AUC of 0.726. Notably, in sensitivity analyses focusing on severe AKI, both standard and lenient strategies were associated with significantly lower risk compared to strict control. The simplified model (6 variables) showed poor calibration (Hosmer-Lemeshow P < 0.001, Brier 0.205) but provided positive net benefit in decision curve analysis across thresholds 0-0.7; however, its poor calibration limits clinical application, and the net benefit estimates should be interpreted with caution. Compared with the lenient SBP stratum, both strict and standard SBP strata were associated with significantly lower odds of overall acute kidney injury in heart failure patients. However, the relationship is non-linear, with the lowest predicted risk observed at approximately 120 mmHg. These findings suggest that an observed SBP of approximately 120 mmHg was associated with the lowest risk of AKI in this population, warranting prospective validation.

Changes in sympathetic outflow, and the associated cardiovascular effects, are well known to occur during refractory intracranial hypertension, uncal herniation and brainstem death. However, sympathetically mediated changes in renal perfusion and the cortical microcirculation, although hypothesised to occur, are not well documented. Using contrast enhanced ultrasound, the presented case demonstrates a dramatic improvement in, previously abnormal, renal blood flow following uncal herniation. These findings potentially illustrate the effect of sympathetic tone on organ perfusion and the microcirculation in critical illness. Future study in this area may have important implications on vasopressor and organ transplantation practices.

Renal arteriovenous fistula (RAVF) is a rare vascular anomaly, and it becomes exceedingly uncommon when accompanied by a renal vein aneurysm (RVA). While several cases of renal artery aneurysm (RAA) accompanied by RAVF have been sporadically reported, progression from RAA to RAVF and then to RVA has not been previously documented. We present a unique case of a 75-year-old man with chronic kidney disease and hypertension who had a huge RAA and RVA connected by a RAVF. Contrast-enhanced computed tomography revealed an aneurysmal dilation of both the renal artery and renal vein, connected by a high-flow fistulous tract. Given the high risk of rupture and the patient's frailty and comorbidities, endovascular treatment was selected as the initial management strategy. Coil embolization of the renal artery aneurysm was successfully performed, and an aortic extender was deployed using a chimney technique to preserve contralateral renal perfusion. Postoperative imaging demonstrated successful occlusion of the RAA and significant reduction in blood flow through the fistula. During the 3-year follow-up, no enhancement was observed in the RAA, and slight reductions in the size of both the RAA and RVA were noted. To our knowledge, this is the first reported case of a huge RAA and RVA connected by a non-aneurysmal RAVF successfully treated with endovascular therapy, with documented long-term outcomes. This case underscores the feasibility and safety of endovascular intervention in select high-risk patients, even in anatomically complex lesions with high-flow dynamics. As device technology continues to evolve, endovascular repair may increasingly become a first-line option for managing such rare and challenging vascular anomalies.

The pharmacokinetics of tolfenamic acid in Himalayan Griffon vultures. A better understanding for the safety of the drug in old world vultures.

Trajectories in renal perfusion pressure during hemodynamically guided therapy are associated with worsening renal function and patient outcomes.

Background/Objectives: The renal resistive index (RRI) has emerged as an early marker of renal vascular resistance. The purpose of this study was to investigate the association between RRI on intensive care unit (ICU) admission and the development of acute kidney injury (AKI) in a general ICU population, and to assess its predictive accuracy. Methods: This prospective observational study was conducted in a multidisciplinary ICU. Consecutive mechanically ventilated adults were enrolled; RRI was measured within 24 h of admission after hemodynamic stabilization. AKI was defined by Kidney Disease: Improving Global Outcomes (KDIGO) criteria within seven days. Multivariable regression, receiver operating characteristic (ROC), reclassification, and mediation analyses were performed. Results: A total of 181 patients were included. AKI occurred in 36%. Median RRI was 0.73 (0.65-0.80). RRI correlated with age, acute physiology and chronic health evaluation (APACHE) II and sequential organ failure assessment (SOFA) scores, lactate, and glomerular filtration rate (GFR) (all p < 0.001). In multivariable analysis, RRI was the only independent predictor of AKI (OR 2.86 per 0.05 increase, 95% CI 1.64-4.98, p = 0.001). It was also associated with an increased likelihood of presenting with a more severe AKI stage. RRI showed high discriminative ability (AUC = 0.89, 95% CI 0.84-0.94); the optimal cut-off was 0.77 (sensitivity 0.83, specificity 0.82). Adding RRI to a clinical model improved prediction (ΔAUC p = 0.049; net reclassification index (NRI) = 0.52, p < 0.001). Mediation analyses showed that RRI significantly mediated the effects of hypertension and low baseline GFR on AKI risk. Subgroup analyses confirmed consistent predictive performance across age, lactate, and sepsis categories. Conclusions: RRI is an independent early predictor of AKI and its severity, as well as a mediator of both hypertension and low GFR, regarding their effect on AKI development in ICU patients. RRI could serve as an early bedside marker of renal perfusion impairment in critically ill patients, guiding strategies aimed at reducing the risk of AKI.

Abstract Background Open thoracoabdominal aortic aneurysm (TAAA)repair carries high risk of organ ischaemia.We assessed mortality, survival, and the effect of standardised organ and spinal cord protection bundle in high-risk single-centre cohort. Methods Analysis of 124 consecutive repairs (2017–2021): open 98, endovascular 26; non-elective 26; Extent II 69; redo 51. Risk factors were analysed. The bundle comprised left-heart bypass (LHB), selective coeliac and renal perfusion (Custodiol/cold blood), cerebrospinal fluid drainage (CSFD), paraspinal NIRS, cMEP, selective intercostal reimplantation. In a feasibility subset, lactate, pyruvate, and glucose CSF/MD were measured serially;lactate-pyruvate-ratio(LPR &amp;gt; 25) was pre-specified as a metabolic ischaemia threshold. Results In-hospital mortality was 17.7% (open 16.9%; endovascular 0.8%). Stroke 6.5%; SCI 11.3% (permanent 8.9%). Haemofiltration was required in 41.9% (permanent 4.0%). Five-year survival was 79.8%. Bundle delivery: LHB &amp;gt; 90%, CSFD 79.8%, coeliac/SMA perfusion 88%, renal perfusion 82%, CSFD/MD 5% (feasibility). Haemofiltration (HR 14.89, P = 0.020) and paraplegia (HR 4.30, P = 0.027) predicted in-hospital death, whereas SMA perfusion was protective (HR 0.023, P = 0.036). Serial MD showed metabolic derangement during ischaemia (rising lactate, falling glucose, LPR &amp;gt; 25), normalising with reperfusion. Lactate rose fivefold, peaking six hours postoperatively (P = 0.001). Intraoperative SCI (two patients with &amp;gt;50% cMEP reduction) was associated with 200% LPR increase. Conclusions In this high-risk Extent II, non-elective/redo cohort,multimodal protection achieved acceptable survival. Mortality was driven by renal replacement therapy and SCI, underscoring the need for rigorous spinal protocols and standardised bundles. CSF microdialysis offers actionable real-time metabolic surveillance with potential to improve outcomes.

Abstract Background In deceased donor kidney transplantation, the process of donation, transportation and transplantation exposes grafts to ischemia-reperfusion injury (IRI). Machine perfusion (MP) has increased in popularity to ameliorate IRI compared to conventional static cold storage (SCS). Perfusion preservation can be performed at different temperatures (hypothermic versus normothermia), with or without oxygen, either during transport plus at the recipient centre (continuous) or only at the recipient centre (end-ischemic). This study assessed the effectiveness of various MP strategies on kidney transplant outcomes. Methods This Bayesian network meta-analysis (NMA) included randomised trials from our recent Cochrane review that specified the MP type and timing (continuous versus end-ischemic). NMA allows comparisons across multiple interventions even without direct head-to-head trials. Rankograms were used to obtain the probability of each intervention occupying specific ranks. Results Oxygenated continuous hypothermic MP (cHMPO2) was the top-ranked technique for 1-year graft survival (probability of cHMPO2 being rank 1 = 92%; probability of cHMP being rank 2 = 80%), delayed graft function and acute rejection, followed by non-oxygenated cHMP. Results for patient survival and primary non-function were less certain due to small number of events and resulting imprecision. In contrast, oxygenated end-ischemic HMP (eiHMPO2) and end-ischemic normothermic MP (eiNMP) showed no clear benefit over SCS for any outcome. Conclusions cHMPO2 was consistently ranked as the most effective renal ex-situ machine perfusion strategy across multiple outcomes. However, head-to-head trials comparing cHMPO2 and cHMP in DBD and younger DCD transplants are needed, as current randomised evidence is limited to older DCD transplants.

Time-to-peak of renal blood flow (TTPr), derived from Tc-99m diethylenetriaminepentaacetic acid (DTPA) renal scintigraphy, is a novel parameter for assessing renal perfusion. To evaluate the prognostic significance of TTPr in patients with heart failure (HF). Retrospective, observational cohort study. We analyzed 304 patients with HF who underwent Tc-99m DTPA renal scintigraphy to assess TTPr. TTPr values were compared between deceased and surviving patients. Cox regression analyses evaluated the prognostic value of TTPr. Model performance was assessed using the C-index, net reclassification improvement (NRI), and integrated discrimination improvement (IDI). Bootstrap internal validation (200 repetitions) generated optimism-corrected estimates, and the Holm-Bonferroni correction accounted for multiple testing in secondary analyses. During a median follow-up of 790 days, 79 patients (26.0%) died. For short-term outcomes (3-month mortality, n = 7), deceased patients showed a trend toward prolonged TTPr compared with survivors (59 s vs. 27 s, p = 0.008); multivariable analysis was not performed due to limited events. For long-term prognosis, TTPr was an independent predictor, demonstrating the highest corrected C-index among individual predictors (p < 0.001). After bootstrap correction, models incorporating TTPr [BM + TTPr and Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) + TTPr] showed modest but significant C-index improvements for all-cause and cardiovascular mortality (BM + TTPr: corrected ΔC-index = +0.018 and +0.020, both p < 0.01; MAGGIC + TTPr: corrected ΔC-index = +0.040 and +0.062, both p < 0.001), with reduced AIC. After Holm-Bonferroni correction, MAGGIC + TTPr significantly improved IDI at 1, 3, and 5 years for both endpoints (all adjusted p = 0.012), whereas NRI improvements were not statistically significant. Survival analysis using exploratory cut-offs (35 s for all-cause mortality, 33 s for cardiovascular mortality) revealed lower cumulative survival in the prolonged TTPr group (p < 0.05); these cut-offs require external validation. Time-to-peak of renal blood predicted long-term outcomes in this HF cohort, showing potential incremental value. Prospective validation in broader populations is warranted before clinical implementation.