RIFLE Classification Research Articles

Is there a relationship between hyperchloremia status and the risk of developing acute kidney injury in pediatric patients with diabetic ketoacidosis?

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus (T1DM). Prerenal acute kidney injury (AKI) is associated with profound hypovolemia and reduced renal perfusion. Results regarding hyperchloremia-associated AKI in patients with DKA are conflicting; we therefore investigated the potential relationship between hyperchloremia status and the risk of developing AKI. This single-center cohort study included 113 newly diagnosed T1DM patients with DKA admitted to the pediatric intensive care unit. Laboratory parameters, including Na, K, urea, creatinine, and chloride levels, were retrospectively reviewed at the time of presentation and at 12, 24 and 36h. AKI was defined using the eGFR according to the pediatric RIFLE classification criteria. Twenty-two (19.5%) of the 113 patients were in the AKI group. Two-way repeated-measures ANOVA showed significant (P values ≤ 0.01) time interaction effects within the groups based on the eGFR and the serum chloride, hyperchloremia, and phosphate levels. Serum chloride levels did not differ between the groups during the first 12h (p > 0.05) but were significantly greater in the AKI group than in the non-AKI group at 24h and 36h (p < 0.01). The final DKA resolution time was significantly greater in the AKI group than in the non-AKI group [22.2 (9.5) vs. 17.0 (12.0) h, respectively; p = 0.03]. However, the groups had similar lengths of hospital stay [13.0 (8.0) days vs. 12.0 (4.0) days, respectively; p = 0.17].Conclusions: Hyperchloremia may be iatrogenic rather than causative during treatment. This may worsen renal failure and prolong the recovery and treatment time for DKA patients. What is Known? • Acute kidney injury resulting from severe volume depletion is a common occurrence in diabetic ketoacidosis and typically requires significant volume replacement therapy. • In recent years, hyperchloremia has been associated with increased risks of AKI, morbidity, and mortality in some conditions, such as diabetic ketoacidosis. What is New? • The incidence of hyperchloremia increases over time during the treatment of diabetic ketoacidosis. • Hyperchloremia may be an iatrogenic element rather than a cause of acute kidney injury during the treatment of diabetic ketoacidosis.

#1304 Clinical characteristics of acute kidney injury caused by Phytolaccaceae ingestion

Abstract Background and Aims Phytolaccaceae is a poisonous plant that is associated with cardiac and gastrointestinal toxicity. However, there are limited data about acute kidney injury (AKI) in patients with Phytolaccaceae ingestion. We conducted this study to investigate the clinical characteristics of AKI by Phytolaccaceae overdose. Method From 2010 to 2022, 15 patients with Phytolaccaceae ingestion were enrolled in this study. The incidence, clinical characteristics, and severity of AKI were compared between AKI (N=8) and non-AKI (N=7) groups according to the RIFLE classification. Results Of the 15 patients, 8 patients experienced AKI during hospitalization period. There is no difference in age (54.3 ± 7.2 years vs. 67.1 ± 13.5 years, P=0.057) and comorbidities such as hypertension and diabetes (37.5% vs 28.5%, P=0.563) between two groups. In addition, there is also no difference in total leukocyte count (10.8 × 103/mL vs. 11.4 × 103/mL, P=0.84) and serum albumin level (4.5 ± 2.6 vs 4.3 ± 0.5, P=0.498). Compared to patients without AKI, the estimated glomerular filtration rate was lower in the AKI group (57 ± 12 ml/min/1.73 m2 vs. 77 ± 24 ml/min/1.73 m2, p&amp;lt;0.05) on admission. The AKI group had a significantly longer hospital stay (9.7 ± 6.2 vs 6.1 ± 3.1 days, p&amp;lt;0.001). The overall AKI incidence was 61.5%, of which 46.1% and 15.4% cases were classified as risk and injury, respectively. All patients recovered baseline renal function without renal replacement therapy following antibiotics therapy and supportive care. Conclusion The incidence of AKI in patient with Phytolaccaceae ingestion is 61.5%. Most patients with AKI had a mild type of AKI during admission period. In cases of AKI patients with Phytolaccaceae ingestion, aggressive supportive care including hydration is very important.

INCIDENCE AND MORTALITY RISK OF AKD AND AKI IN THE PRIMARY CARE

Objective: Objective: The aim of the present study was to assess the impact of hypertension in the incidence of Acute Kidney Damage and Acute Kidney Injury episodes in the community, defined by changes in serum creatinine and temporal window. Design and method: The study analyzed the EHR of a community of 1,863,731 adult subjects &gt;23 years of age with serum creatinine before, during and after the AKD episode for a variable period of time. eGFR was calculated using the CKD-EPI formula. AKD and AKI were defined according to the harmonized KDIGO criteria (Lameire 2021). The acute event was defined as having occurred when the blood creatinine was at least 150% of the mean of the previous creatinine measurement. AKD is considered to have ended when the creatinine falls to at least the threshold created by the pre-event mean plus half the increment produced during the episode within three months. AKI was defined as a sudden drop in creatinine within seven days. The RIFLE scale was used to classify episodes. HTN was considered when it was recorded in the EHR (CIE9 and 10). Results: During a mean follow-up of 4.8 years, 56,850 episodes of AKD were identified in 47,670 patients. The incidence was 4.49 and 19.0/1000 patients/year in non-CKD and CKD subjects, respectively. Overall, HTN was present in 62.8% of patients, 49,9% among those without CKD before the event and in 92.6% in CKD patients. In patients without CKD, HTN increases the risk of more severe RIFLE class of AKD (Risk 47.4%, Injury 64.1% and Failure 66.0%). The prevalence of HTN in patients with AKI was 76.6% without differences in the RIFLE class (Risk 76.3%, Injury 77.2% and Failure 76.9%). A higher mortality was recorded among the AKI patients. Conclusions: The data from this study reinforce the concept that acute elevations in serum creatinine occurring and managed in the community may pose a health risk and HTN is an important risk factor. Future work should consider how best eAlerts can be utilized, targeted and implemented.

Increased risk of acute kidney injury in the first part of an ultra-trail-Implications for abandonment.

Acute kidneys injuries (AKIs) have been described in marathon and trail running. The currently available data allows assessment of before/after comparisons but does not allow an analysis of what happens during the race. A multidisciplinary assessment protocol was performed during the first trail of Clécy (Normandy France) in November 2021. This allowed an initial assay to be carried out, then at the end of each of the 6 loops of 26 km, and finally after 24 h of recovery. The race extends over 156 km in hilly terrain and 6000 m of elevation gain (D+). The level of impairment according to the RIFLE classification was defined for each runner at each assay. Fifty-five runners were at the start, and the per protocol analysis involved 36 runners (27 men and 9 women, 26 finishers). Fifteen (41.7%) of the riders presented at least one result corresponding to a "RIFLE risk" level. After 24 h of rest, only one runner still had a "RIFLE Risk". The distance around the marathon seems to be the moment of greatest risk. For the first time, we find an association between this renal risk and the probability of abandonment. Many runners are vulnerable to kidney damage during long-duration exercise, which is why it's important to limit risk situations, such as the use of potentially toxic drugs or hydration disorders. The consumption of NSAIDs (nonsteroidal anti-inflammatory drugs) before or during an ultra-distance race should therefore be prohibited. Attention should be paid to hydration disorders.

Timing and Degree of Acute Kidney Injury in Patients Requiring Non-Surgical Intensive Care.

The degree and timing of acute kidney injury (AKI) on admission and during hospitalization in patients requiring non-surgical intensive care remain unclear. In this study, 3,758 patients requiring intensive care were analyzed retrospectively. AKI was defined based on the ratio of serum creatinine concentrations recorded at each time point (i.e., on admission and during the first 5 days in the intensive care unit and during hospitalization) to those measured at baseline. Patients were grouped by combining AKI severity (RIFLE class) and timing (i.e., from admission to 5 days [A-5D]; from 5 days to hospital discharge [5D-HD]) as follows: No-AKI; New-AKI (no AKI to Class R [risk; ≥1.5-fold increase in serum creatinine], I [injury; ≥2.0-fold increase in serum creatinine], and F [failure; ≥3.0-fold increase in serum creatinine or receiving dialysis during hospitalization]); Stable-AKI (Class R to R; Class I to I); and Worsening-AKI (Class R to I or F; Class I to F). Multivariate logistic regression analysis indicated that 730-day mortality was independently associated with Class R, I, and F on admission; Class I and F during the 5D-H period; and New-AKI and Worsening-AKI during A-5D and 5D-HD. AKI on admission, even Class R, was associated with a poor prognosis. An increase in RIFLE class during hospitalization was identified as an important factor for poor prognosis in patients requiring intensive care.

Neutrophil Gelatinase-Associated Lipocalin Cutoff Value Selection and Acute Kidney Injury Classification System Determine Phenotype Allocation and Associated Outcomes.

We explored the extent to which neutrophil gelatinase-associated lipocalin (NGAL) cutoff value selection and the acute kidney injury (AKI) classification system determine clinical AKI-phenotype allocation and associated outcomes. Cutoff values from ROC curves of data from two independent prospective cardiac surgery study cohorts (Magdeburg and Berlin, Germany) were used to predict Kidney Disease: Improving Global Outcome (KDIGO)- or Risk, Injury, Failure, Loss of kidney function, End-stage (RIFLE)-defined AKI. Statistical methodologies (maximum Youden index, lowest distance to [0, 1] in ROC space, sensitivity≍specificity) and cutoff values from two NGAL meta-analyses were evaluated. Associated risks of adverse outcomes (acute dialysis initiation and in-hospital mortality) were compared. NGAL cutoff concentrations calculated from ROC curves to predict AKI varied according to the statistical methodology and AKI classification system (10.6-159.1 and 16.85-149.3 ng/mL in the Magdeburg and Berlin cohorts, respectively). Proportions of attributed subclinical AKI ranged 2%-33.0% and 10.1%-33.1% in the Magdeburg and Berlin cohorts, respectively. The difference in calculated risk for adverse outcomes (fraction of odds ratios for AKI-phenotype group differences) varied considerably when changing the cutoff concentration within the RIFLE or KDIGO classification (up to 18.33- and 16.11-times risk difference, respectively) and was even greater when comparing cutoff methodologies between RIFLE and KDIGO classifications (up to 25.7-times risk difference). NGAL positivity adds prognostic information regardless of RIFLE or KDIGO classification or cutoff selection methodology. The risk of adverse events depends on the methodology of cutoff selection and AKI classification system.

#5246 RISK FACTORS FOR COMMUNITY-ACQUIRED ACUTE KIDNEY INJURY

Abstract Background and Aims Acute renal injury represents a heterogeneous clinical syndrome with multifactorial etiology rather than a single specific pathology, which is associated with high morbidity and mortality. The disease burden of community-acquired AKI in our country is not well understood. In fact it is known little about it. The aim of this study is to identify and evaluate the risk factors for developing AKI in our community. Method This is a cross-sectional study conducted with a small size sample, 76 adult patients. These patients were identified with AKI at hospital admission. AKI was defined according RIFLE Classifications. This champion was selected among patients hospitalized in the Nephrology Clinic, UHC “Mother Tereza” during 2018. The data was collected through medical files. Results Most of the patients with AKI were males (66%), with the average age of 64 years old. Nephrotoxic drugs were the most frequent precipitating factor (51%) followed by sepsis (47%) and hypovolemia (41%). A total of 40% of patients had acute on chronic kidney disease, 32% were with diabetes, 14% with cardiac failure and 63% with arterial hypertension. Mostly (93%) had more than one precipitating factor for developing AKI. All the patients with the longest hospital stay (16-35days) had a septic condition. Almost 89% of patients were treated in a conservative way . Patients treated with Hemodialysis had a higher number of risk factors (P&amp;lt;0,4). Conclusion The socio-economic factor is also quite important in the development of AKI. It includes lack of access to health care, lack of health insurance, low economic level, poor quality nutrition, etc.The identification of risk factors that predispose to AKI is a crucial aspect of care. It should help primary care and hospital providers identify high risk patients. Comorbit conditions like diabetes, cardiac failure increased the risk for hemodialysis treatment.

STUDY OF CLINICAL PROFILE OF PATIENT WITH ACUTE KIDNEY DISEASE

Introduction: An acute and potentially reversible decline in renal function, which impairs the kidneys ability to eliminate nitrogenous waste products and maintain fluid and electrolyte balance, is the hallmark of acute kidney injury. Depending on the definitions employed, the population being investigated, and the clinical settings, there is a significant difference in the epidemiological statistics of acute kidney injury. Methods: The Institutional Ethics Committee approved this cross-sectional observational study in a semi-urban tertiary-care teaching hospital. All patients with RIFLE-defined acute renal failure were included. Patients under 18 were excluded. The investigation included a detailed history, physical exam, and systemic assessment. Throughout hospitalisation, we categorised patients by RIFLE class (R, I, or F). GFR or urine output determined RIFLE class. Using serum creatinine and urine output, we categorised patients. Results: Amongst the 100 cases of AKI, 46 cases (46%) were females while 54 cases (54%) were males.. The mean age at presentation was 55.22 ± 14.91 years. Sepsis was found to be the major cause of AKI. Out of 100 patients in our study, 64 (64%) cases were attributed to sepsis. Mortality rate seen in this study was 40% (n=40). Conclusion: Acute Kidney Injury is a common complication in ICU patients. Early detection and care reduce AKI-related and all-cause death in critically sick patients.

Maternal and Renal Outcome Of Pregnancy Related Acute Kidney Injury Requiring Dialysis in a Tertiary Care Centre

Introduction: Acute kidney injury (AKI) is a rare complication of pregnancy, but may be associated with significant morbidity and mortality in young and often otherwise healthy women. In a developing countries like Bangladesh due to low resource settings intermittent hemodialysis is the usual mode of renal replacement therapy. It opens up a field of investigation to assess the maternal and renal outcome of pregnancy associated acute kidney injury after getting dialysis. Materials and method: This analytic, descriptive, prospective study was performed over 46 patients with pregnancy associated AKI requiring dialysis during July 2015 to June 2016. Etiology and spectrum of pregnancy related acute kidney injury (PR - AKI) requiring dialysis were assessed and maternal and renal outcome were analyzed. Result : Puerperal sepsis(25, 54.3%) was the most prevalent cause, followed by preeclampsia/ eclampsia, (7,15.2%), septic abortion ( 5 ,10.9%), PPH/APH (5 ,10.9%), sepsis with PPH (2 ,4.3%), HELLP syndrome (1 ,2.2%) and sepsis with HELLP (1 ,2.2%)36 (73.3%) patients remained alive and 10 (22.8%) patients expired. HELLP syndrome and maternal mortality was more commonly observed in dialysis requiring group. Delivery at term was more commonly observed in dialysis requiring group and preterm delidery was more common in dialysis not requiring group. 26(56.5%) patients had delivery at term , 15(32.6%) had preterm delivery and abortion was found in 5(10.9%). Renal out come was better in dialysis not requiring group when compared with dialysis requiring group.Complete recovery was found in 19(52.8%) patient at 3 months follow up, 10(27.8%) had partial recovery seven patients remained dialysis dependent. According to the RIFLE criteria,19 patients were in the Injury category and 27 patients were in the Failure category.Relative risk of mortality in Injury is 0.94 and in Failure is 1.05. Multivariate logistic regression analysis showed that RIFLE classification did not discriminate the prognosis ( p value 0.788) in pregnancy associated AKI requiring dialysis. Conclusion : PR- AKI requiring dialysis is associated with high maternal mortality and poor renal outcome. J Dhaka Med Coll. 2021; 30(2) : 202-207

Acute Kidney Injury Classifications in the Prediction of In-hospital Mortality and Renal Function Non-recovery.

In the last two decades diagnostic criteria for acute kidney injury (AKI) were developed: Risk, Injury, Failure, Loss of Kidney Function, End-Stage Kidney Disease (RIFLE), Acute Kidney Injury Network (AKIN), and Kidney Disease: Improving Global Outcomes (KDIGO) classifications. The study aimed to determine the incidence of AKI based on the RIFLE, AKIN, and KDIGO criteria, as well as analyze their predictive value for mortality and renal function outcome. This was a single-center prospective study of patients diagnosed with AKI. Acute kidney injury was defined and classified according to the RIFLE, AKIN, and KDIGO criteria. The outcomes were renal function outcome and in-hospital mortality. The incidence rates of AKI based on the RIFLE, AKIN, and KDIGO criteria were 13.4%, 14-36%, and 14.64%, respectively. Multiple regression analysis showed that higher stages of AKI according to the KDIGO criteria were independently associated with non-recovery of renal function (p=0.011). However, the predictive ability of RIFLE, AKIN and KDIGO classifications for renal function recovery was poor (Area Under the Receiver Operating Characteristics-AUROC=0.599, AUROC=0.637, AUROC=0.659, respectively). According to the RIFLE and AKIN criteria, in-hospital mortality was statistically significantly higher in stage Failure/3 (p=0.0403 and p=0.0329, respectively) compared to stages Risk/1 and Injury/2. Receiver Operating Characteristics (ROC) analysis showed that all three classifications had poor predictive ability for in-hospital mortality (AUROC=0.675, AUROC=0.66, AUROC=0.681). KDIGO classification is an independent predictor of renal function non-recovery. However, by ROC analysis, all three classifications have poor predictive ability for renal function outcome and mortality.

Assessment of Renal Function in Head and Neck Cancer Patients Treated with Cisplatin: Different Biomarkers and Acute Kidney Injury Classifications.

Cisplatin is associated with dose-limiting nephrotoxicity, and the timely detection of acute kidney injury (AKI) can affect morbimortality. Therefore, this study aimed to investigate the tools for monitoring renal function in AKI. This was a retrospective, cohort study. Cisplatin-treated patients with head and neck cancer were included. Nephrotoxicity was assessed using serum creatinine, estimated creatinine clearance, serum electrolytic alterations, and plasma kidney injury molecule-1 (KIM-1). The toxicity severity was classified according to Common Terminology Criteria for Adverse Events (CTCAE), and AKI was classified by Risk, Injury, Failure, Loss, and End-stage kidney disease (RIFLE) and Acute Kidney Injury Network (AKIN). A total of 81 participants were included, of whom only 32 did not have AKI. Almost 90% of participants had a decreased estimated glomerular filtration rate five (D5) days after chemotherapy. The AKI estimate differs between AKIN and RIFLE; more participants were diagnosed by the RIFLE at D5, 19.5% versus 2.4% by AKIN, and fifteen had a discordance between these classifications. All laboratory markers showed significant changes on D5. KIM-1 appeared a possible biomarker when considering CTCAE or AKIN classifications (p &lt; 0.05 on D5), but not when RIFLE classification was used (p = 0.0780). Further studies may seek to understand the profiles of different biomarkers together.

675. Sulbactam-durlobactam (SUL-DUR) versus colistin therapy in patients with Acinetobacter baumannii-calcoaceticus complex (ABC) infections: A detailed safety review from the pivotal phase 3, global, randomized, active-controlled trial (ATTACK)

Abstract Background SUL-DUR is a β-lactam/β-lactamase inhibitor combination in development for the treatment of ABC, which is a cause of severe infections with substantial mortality. ATTACK evaluated the efficacy and safety of SUL-DUR versus colistin (COL) in patients with serious ABC infections. The primary efficacy endpoint, 28-day all-cause mortality, was achieved. The safety profile of SUL-DUR versus colistin is presented here. Methods ATTACK consisted of two parts. Part A was the randomized, non-inferiority portion in ABC hospital-acquired bacterial pneumonia, ventilator-associated bacterial pneumonia, ventilated pneumonia, or bacteremia; patients were randomized 1:1 to SUL-DUR or colistin for 7 to 14 days. Part B provided open label SUL-DUR for patients intolerant of colistin or with colistin-resistant ABC. Safety data presented here include both Part A and Part B. All patients received imipenem/cilastatin as background therapy. The primary safety objective was nephrotoxicity (RIFLE classification); other safety endpoints included treatment-emergent adverse events (TEAEs) and assessments of laboratory parameters. Results The safety population includes 203 unique patients. TEAEs were common reflecting the critical level of illness. More frequently reported with colistin treatment are severe, serious, and drug-related TEAEs (infections, renal and urinary disorders, and gastrointestinal) (Table 1). Nervous system, infections and renal disorders leading to discontinuation of study drug were more common in the colistin arm (Table 2). During treatment, liver-associated enzymes were similar between arms. Creatinine clearance measures of central tendency showed reduction during the trial in the colistin arm. Nephrotoxicity (RIFLE classification) occurred significantly less often with SUL-DUR: 13.2% (12/91) and 37.6% (32/85), difference -24.4% [p=0.0002]. Conclusion SUL-DUR treated patients had reduced nephrotoxicity, fewer drug-related TEAEs, no safety signals, and fewer TEAEs leading to discontinuation of study drug. If approved, SUL-DUR could be an important therapeutic option for Acinetobacter infections including carbapenem-resistant and multidrug-resistant strains. Disclosures Drew Lewis, MD, MTM&amp;H, Entasis Therapeutics: employee|Entasis Therapeutics: employee|Entasis Therapeutics: Stocks/Bonds|Entasis Therapeutics: Stocks/Bonds Khurram Rana, PharmD, Entasis Therapeutics: Employee|Entasis Therapeutics: Ownership Interest|Entasis Therapeutics: Stocks/Bonds Gabrielle Poirier, BS, Entasis Therapeutics: Ownership Interest|Entasis Therapeutics: Stocks/Bonds David Altarac, MD, MPA, Entasis Therapeutics: Ownership Interest|Entasis Therapeutics: Stocks/Bonds.

IMPACT OF EARLY POSTOPERATIVE IMMUNONUTRITION ON RENAL IMPAIRMENT IN LOW-RISK CARDIAC SURGERY PATIENTS

Rationale Cardiac surgeries with the use of cardiopulmonary bypass (CPB) lead to significant changes in homeostasis and a more or less pronounced immune response (1). Renal impairment is the most common clinically important complication in adult cardiac surgery patients, and is associated with increased mortality and morbidity (2). The aim of the study was to research the efficacy of early postoperative enteral immunonutrition on renal impairment after cardiac surgery. Methods A low operative risk adult patients, who underwent elective cardiac surgery, were included to the study. The patients were randomized into immunonutrition (IN) and control (C) groups. The IN group was supplemented with glutamine and antioxidants for five postoperative days. Creatinine levels were monitored in patients throughout the hospital stay - the worst parameters were recorded, analyzed and compared between the groups. Moreover renal impairment was assessed according to the RIFLE criteria. Student t-test and Mann–Whitney U test was used to compare differences between the groups. A logistic regression model was developed to assess the relationship between immunonutrition and the risk of kidney injury. Results Fifty-five patients were enrolled in the study, the mean age was 69.7±6.3 years, 28(50.9%) males, the median operative risk was 1.75%. Twenty-seven (49.1%) were in the IN group. A statistically significant decrease in postoperative creatinine clearance (worsening of renal function) was detected in the C group, accordingly 77,07 ± 23,90 vs 63,43 ± 23,31 (ml/min), p = 0,037. Based on RIFLE classification, our subjects were at risk of renal impairment in 11 cases (2 cases in the IN group and 9 cases in the C group, p = 0.023) and 5 patients had renal impairment (2 cases in the immunomodulatory group, 3 cases in the control group, p = 0.673). A logistic regression model was developed to assess the relationship between immunonutrition and the risk of kidney injury. The patients without glutamine and antioxidants supplementation had a 4.312-fold increased risk of kidney injury (p = 0,02). Conclusions Early postoperative immunonutrition has a positive effect on reducing risk of renal impairment in low-risk cardiac surgical patients. Cardiac surgeries with the use of cardiopulmonary bypass (CPB) lead to significant changes in homeostasis and a more or less pronounced immune response (1). Renal impairment is the most common clinically important complication in adult cardiac surgery patients, and is associated with increased mortality and morbidity (2). The aim of the study was to research the efficacy of early postoperative enteral immunonutrition on renal impairment after cardiac surgery. A low operative risk adult patients, who underwent elective cardiac surgery, were included to the study. The patients were randomized into immunonutrition (IN) and control (C) groups. The IN group was supplemented with glutamine and antioxidants for five postoperative days. Creatinine levels were monitored in patients throughout the hospital stay - the worst parameters were recorded, analyzed and compared between the groups. Moreover renal impairment was assessed according to the RIFLE criteria. Student t-test and Mann–Whitney U test was used to compare differences between the groups. A logistic regression model was developed to assess the relationship between immunonutrition and the risk of kidney injury. Fifty-five patients were enrolled in the study, the mean age was 69.7±6.3 years, 28(50.9%) males, the median operative risk was 1.75%. Twenty-seven (49.1%) were in the IN group. A statistically significant decrease in postoperative creatinine clearance (worsening of renal function) was detected in the C group, accordingly 77,07 ± 23,90 vs 63,43 ± 23,31 (ml/min), p = 0,037. Based on RIFLE classification, our subjects were at risk of renal impairment in 11 cases (2 cases in the IN group and 9 cases in the C group, p = 0.023) and 5 patients had renal impairment (2 cases in the immunomodulatory group, 3 cases in the control group, p = 0.673). A logistic regression model was developed to assess the relationship between immunonutrition and the risk of kidney injury. The patients without glutamine and antioxidants supplementation had a 4.312-fold increased risk of kidney injury (p = 0,02). Early postoperative immunonutrition has a positive effect on reducing risk of renal impairment in low-risk cardiac surgical patients.

Impact of combining vancomycin with proton pump inhibitors on the incidence of acute kidney injury.

Vancomycin is a potent antibiotic against Gram-positive bacteria; however, its use can be limited by nephrotoxicity. Several reports showed that proton pump inhibitors (PPIs) are associated with renal impairment. Many hospitalized patients are prescribed both drugs. As the literature lacks data on the potential augmentation of acute kidney injury (AKI) risk with this combination, we aimed to assess such risk. This was a retrospective cohort study of hospitalized patients receiving either VAN-PPI or VAN alone for ≥72 h. Patients with a baseline serum creatinine (SCr) of ≥1.5mg/dL were excluded. AKI incidence was assessed 3-5days post VAN-PPI or VAN initiation. Of 300 patients, 186 were in the VAN-PPI group and 114 in the VAN group. The percentage of patients meeting AKI definition was not different between the two groups (11.8% vs. 7.9%; P= 0.277); however, the percentage change in SCr on Days 3-5 was only numerically higher in the VAN-PPI group (1% vs. -2.4%; P= 0.242). The distribution of patients meeting different RIFLE class criteria was not different (P= 0.320). Using VAN with PPI was not associated with augmented AKI risk. However, monitoring kidney function would still be recommended as a standard good clinical practice when either drug is used.

Exposure to lead-free frangible firing emissions containing copper and ultrafine particulates leads to increased oxidative stress in firing range instructors

BackgroundSince the introduction of copper based, lead-free frangible (LFF) ammunition to Air Force small arms firing ranges, instructors have reported symptoms including chest tightness, respiratory irritation, and metallic taste. These symptoms have been reported despite measurements determining that instructor exposure does not exceed established occupational exposure limits (OELs). The disconnect between reported symptoms and exposure limits may be due to a limited understanding of LFF firing byproducts and subsequent health effects. A comprehensive characterization of exposure to instructors was completed, including ventilation system evaluation, personal monitoring, symptom tracking, and biomarker analysis, at both a partially enclosed and fully enclosed range.ResultsInstructors reported symptoms more frequently after M4 rifle classes compared to classes firing only the M9 pistol. Ventilation measurements demonstrated that airflow velocities at the firing line were highly variable and often outside established standards at both ranges. Personal breathing zone air monitoring showed exposure to carbon monoxide, ultrafine particulate, and metals. In general, exposure to instructors was higher at the partially enclosed range compared to the fully enclosed range. Copper measured in the breathing zone of instructors, on rare occasions, approached OELs for copper fume (0.1 mg/m3). Peak carbon monoxide concentrations were 4–5 times higher at the partially enclosed range compared to the enclosed range and occasionally exceeded the ceiling limit (125 ppm). Biological monitoring showed that lung function was maintained in instructors despite respiratory symptoms. However, urinary oxidative stress biomarkers and urinary copper measurements were increased in instructors compared to control groups.ConclusionsConsistent with prior work, this study demonstrates that symptoms still occurred despite exposures below OELs. Routine monitoring of symptoms, urinary metals, and oxidative stress biomarkers can help identify instructors who are particularly affected by exposures. These results can assist in guiding protective measures to reduce exposure and protect instructor health. Further, a longitudinal study is needed to determine the long-term health consequences of LFF firing emissions exposure.

Clinical profile of patients with acute kidney injury admitted in intensive care unit

Background: Acute kidney injury (AKI) is a frequent complication in critically sick patients admitted to the intensive care unit (ICU). The objective of this study was to assess the risk factors and clinical outcomes of AKI in patients admitted to a teaching hospital's intensive care unit.Methods: This prospective observational study was conducted in the department of internal medicine, Janaki Medical College, Janakpur, Nepal from June 2018 till May 2019. Adults (aged 18 years or more) diagnosed with AKI using RIFLE criteria and were either admitted in ICU with diagnosis of AKI or developed AKI after admission to ICU. AKI patients were classified as those who satisfied any of the RIFLE categorization criteria.Results: The most common presenting complaint was fever (77%). The most common etiology of AKI was sepsis (71%). Other causes of AKI were post-operative cases (16%) and alcoholic liver disease (13%). When classified as per RIFLE criteria, we classified 38 cases (31.9%) as ‘risk’, 53 (44.54%) as ‘injury’ and 28 (23.53%) as ‘failure’. The etiological classification of our patients to be significantly associated with RIFLE classification (p&lt;0.01). However, we found the mortality not to be significantly associated with RIFLE classification (p=0.74). Conclusions: AKI classification should be used as a risk assessment tool towards the AKI's influence on the prognosis of ICU patients. Further study should investigate determining the death rate according to the RIFLE criteria in this region of Nepal.

The RIFLE Classification: A Stratification Scheme for Patients of Acute Renal Failure after Coronary Artery Bypass Surgery

Background: Acute renal failure is linked to an increased risk of death and morbidity after cardiac surgery. Because there are no standard criteria for acute renal damage, there is a wide variation in the reports that have been published. The Acute Dialysis Quality Initiative Workgroup has developed new RIFLE criteria for acute renal dysfunction. The goal of current study was to appraise whether this definition of postoperative renal dysfunction after coronary artery bypass surgery (CABG) was accurate. Methods: Fifty patients with critical coronary artery disease &amp; undergoing CABG were enrolled in the study. Out of 50 patients, 25 patients had CABG with cardiopulmonary bypass (CPB) and remaining 25 underwent off pump CABG (OPCAB). Patients were distributed into various groups (based on the severity of renal impairment) using the RIFLE classification: Risk, Injury, Failure, Loss, End-stage kidney disease) depending on either serum creatinine level/ estimated glomerular filtration rate (eGFR) or urine output. The variation with 30 days-mortality, ICU stay and renal replacement therapy after CABG were identified. Results: After CABG, 10% of patients experienced renal impairment, as per definitions of RIFLE classification. In this study, there is no significant difference in ARF (RIFLE classification-normal and risk) with or without use of CPB. However, incidence of RIFLE- injury and failure is higher in CPB group than no CPB group. The postoperative proportions of death and renal failure necessitating renal replacement therapy (RRT) were 2% (number of patients, 1 of 50) and 2% (1 of 50), respectively in RIFLE-failure. For the whole study cohort, the median duration of postoperative ICU stay was 4.0 days, with interquartile ranges of 3.0 to 7.0 days. All the patients of Rifle classification-injury and failure had prolonged ICU stay (5 or more days). Conclusions: The RIFLE criteria are a useful tool for determining renal impairment after CABG. Increased renal replacement treatment, longer ICU stays, and a higher death rate are all linked to the severity of RIFLE classification. Cardiovasc j 2022; 14(2): 150-156

Assessment of the diagnostic ability of RIFLE classification and neutrophil gelatinase-associated lipocalin biomarker in detecting acute kidney injury in newborns at the intensive care unit

Introduction/Objective. This study was designed to demonstrate the association of the RIFLE classification and neutrophil gelatinase-associated lipocalin (NGAL) in predicting of newborns with acute kidney injury (AKI). Methods. This was a prospective study. We included 100 newborns suspected of having a kidney injury. These newborns were admitted to the intensive care unit (ICU) at the University Clinic of Pediatrics from the period of two years. The severity of the disease was determined by RIFLE classification. The biochemical marker NGAL was included in this study because it is an early biomarker of AKI in newborns. The statistical processing of the material was by methods of descriptive statistics. Results. The prevalence rate of AKI was 6.25%, but according to the RIFLE classification the prevalence was 8.7%. According to RIFLE classification, we reported ?risk? in 36%, ?injury? in 50% and ?failure? in 14% of newborns with AKI. In newborns with perinatal asphyxia, kidney injury was seen in 34% and 30%, making perinatal asphyxia the most common predisposing factor. The difference in average value of the score for neonatal acute physiology with perinatal extension in newborns with AKI and the control group without AKI was confirmed significant (p &lt; 0.001). Also, there was a significant difference (p &lt; 0.001) between serum creatinine and urinary NGAL values, on the day they were admitted to the ICU. Conclusion. In newborns hospitalized in the ICU, AKI is a serious condition. We could identify kidney injury and follow up the progression of the disease by using RIFLE classification. The need for early diagnosis of kidney injury, in a period when the disease is not clinically manifest, in the first hours of its occurrence, is provided by NGAL.

Associated Biochemical Changes and Outcome of Acute Kidney Injury in ICU Patients and Impact on Rifle Classes

Background: Acute Kidney Injury (AKI) has an independent impact on outcome, even after correction of all other variables in critically ill patients . AKI in ICU is often associated with different biochemical metabolic derrangements as a result of sepsis and non-renal organ system failure. Adequate informations are essential to develop effective measures to prevent and control morbidity and mortality. This study was done to detect AKI with their associated biochemical abnormalities and outcome among admitted patients in intensive care unit of BSMMU.&#x0D; Materials and methods: This prospective observational study was carried out in the Department of Nephrology, Bangabandhu Sheikh Mujib Medical University (BSMMU) Dhaka, during the period of September 2015 to October 2016. A total of 105 patients who were admitted in the Department of Anesthesia, Analgesia and intensive care medicine, BSMMU were included in this study. Patients who had pre-existing CKD, those on maintenance dialysis, with history of renal transplantation, Feature suggestive of chronic kidney disease were excluded. Baseline data were recorded accordingly. The study population was divided initially into two group (No AKI and AKI) then sub groups into risk, injury, failure and followed up till discharge or death.&#x0D; Results: Incidence of AKI was 37.14%. Mean increase in Serum creatinine was 64.53%, 132.87% and 375.01% from baseline for risk, injury and failure respectively. Subgroup analysis revealed risk (20%) injury (6.67%) and failure (10.47%). Associated acid base disorder, electrolytes imbalance, hepatic dysfunction, haemotogical disorder and hypoalbuminemia were found statistically significant between two groups. Logistic regression analysis showed that associated haematological abnormalities were positively correlated to the development of AKI. But among these no variables showed significant effect on RIFLE class population. Our study revealed overall morality is (53.8%). Mortality was highest in Failure class and most patients from risk class achieved renal recovery.&#x0D; Conclusion: The incidence of AKI in critically ill patient is high. Associated biochemical changes should be addressed properly to minimize fatality. RIFLE classification for AKI might help in recruitment of patients for predicting prognosis.&#x0D; JCMCTA 2021 ; 32 (2) : 53-58

47-Year-Old Woman With Bilateral Flank Pain

47-Year-Old Woman With Bilateral Flank Pain