Risk Of Developing Acute Kidney Injury Research Articles

Establishment and Diagnostic Value of an Early Prediction Model for Acute Pancreatitis Complicated With Acute Kidney Injury

Objectives To establish an early prediction model for acute pancreatitis (AP) complicated with acute kidney injury (AKI) and evaluate its diagnostic value. Method AP patients were recruited from the Emergency Department at Peking University People's Hospital in 2021 and stratified into AKI and control (no AKI) groups. Their clinical data were analyzed. The risk for AKI development was determined using logistic analyses to establish a risk prediction model, whose diagnostic value was analyzed using a receiver operating characteristic curve. Results There was no significant difference in the basic renal function between the AKI (n = 79) and control (n = 179) groups. The increased triglyceride glucose index (odds ratio [OR], 2.613; 95% confidence interval [CI], 1.324–5.158; P = 0.006), age (OR, 1.076; 95% CI, 1.016–1.140; P = 0.013), and procalcitonin (OR, 1.377; 95% CI, 1.096–1.730, P = 0.006) were associated with AKI development. A model was established for prediction of AKI (sensitivity 79.75%, specificity 96.65%). The area under the receiver operating characteristic curve was 0.856 which was superior to the Ranson, Bedside Index for Severity in AP, and Acute Physiology and Chronic Health Evaluation II scores (0.856 vs 0.691 vs 0.745 vs 0.705). Conclusions The prediction model based on age, triglyceride glucose, and procalcitonin is valuable for the prediction of AP-related AKI.

Predictive value of red blood cell distribution width and platelet-to-lymphocyte ratio for acute kidney injury in critically ill patients.

The purpose of this study was to explore the value of red blood cell distribution width (RDW) and platelet-to-lymphocyte ratio (PLR) in predicting the occurrence of acute kidney injury (AKI) in critically ill patients. Among 1,500 adult patients in the intensive care unit (ICU) between January 2016 and December 2019, we examined the associations of baseline RDW and PLR with the risk of AKI development using logistical analysis. In addition, we explored the value of RDW and PLR in predicting in-hospital mortality. Overall, 615 (41%) patients were diagnosed with AKI. We divided the groups into two subgroups each; the high-RDW (≥14.045%) group had a high risk of developing AKI (OR=5.189, 95% CI: 4.088-6.588), and the high-PLR (≥172.067) group had a risk of developing AKI too (OR=9.11, 95% CI: 7.09-11.71). The areas under the receiver operating characteristic curves (AUCs) for the prediction of AKI incidence based on RDW and PLR were 0.780 (95% CI: 0.755-0.804) and 0.728 (95% CI: 0.702-0.754) (all p < 0.001), with cut-off values of 14.045 and 172.067, respectively. Moreover, a higher RDW was associated with a higher rate of hospital mortality (OR: 2.907, 2.190-3.858), and the risk of in-hospital mortality related to PLR was 1.534 (95% CI: 1.179-1.995). A higher RDW was related to a higher risk of AKI occurrence and in-hospital mortality in the ICU.

ИЗМЕНЕНИЯ ЛИПИДНОГО ОБМЕНА В НАЧАЛЬНЫЕ ПЕРИОДЫ ИНФАРКТА МИОКАРДА, ОСЛОЖНЕННОГО ОСТРЫМ ПОВРЕЖДЕНИЕМ ПОЧЕК, У МУЖЧИН МОЛОДОГО И СРЕДНЕГО ВОЗРАСТА

Relevance. Changes in lipid metabolism during myocardial infarction (MI) complicated by acute kidney injury (AKI) are potentially important for evaluating the effects of therapy and expanding the possibilities of prevention. Aim. To evaluate the changes in lipid metabolism during acute and subacute MI periods and their role in the complication’s development in men under 60 years old (y.o.) with AKI to im-prove prevention and outcomes. Material and methods. The results of inpatient examination and treatment of men aged 20-60 y.o. with MI were studied. Patients were divided into two age-comparable groups: the study group, with AKI - 22 patients and the control group, without it - 141 patients. The parameters of lipid metabolism and their dynamics were compared in the first hours (1) and at the end of the third week of MI (2) in selected groups, their influence was assessed (risk analysis by Pearson's Chi-square test) on the risk of AKI development and complications MI in the study group. Results. In the study group, the following were observed: higher levels of low-density lipo-protein2 (LDL2) (5.53±2.50 mmol/l) compared to the control group (3.33±2.45 mmol/l; p=0.02); an increase in the levels of very low-density lipoproteins, a coefficient and an atherogenic index, a decrease in triglycerides (TG) at the end of the third week of the disease. The risk of AKI development was associated with the concentration of TG1≥1.88 mmol/l (p=0.007). Complicated course of MI in the study group is characterized by levels of LDL1≥4.0 (p=0.02), high-density lipoprotein1 (HDL1)˂1.1 (mmol/l; p=0.02), and their ratio (LDL1/HDL1) ≥4.5 (p =0.02). Conclusions. In AKI, persistent atherogenic changes in lipids are noted both in the acute and at the end of the subacute period of MI. The risk of developing AKI increases at levels of TG1≥1.88 mmol/l, and the complicated course of MI in the study group is associated with lev-els of LDL1≥4.0, HDL1˂1.1 (mmol/l) and LDL1/HDL1≥4.5. It is expedient to use them in predictive modeling.

MAJOR ADVERSE EVENTS WITH THE USE OF FINERENONE IN PATIENTS WITH TYPE 2 DIABETES MELLITUS: A META-ANALYSIS OF CARDIOVASCULAR OUTCOME TRIALS

Type 2 diabetes mellitus (T2DM) is recognized as the main cause of chronic kidney disease (CKD) and end-stage renal disease worldwide, carrying enormous human and financial costs. Mineralocorticoid receptor antagonists (MRAs) have been shown to decrease proteinuria and albuminuria, posing a favorable effect against the progression of CKD. Recently, we welcomed the publication of two large randomized controlled trials (RCTs), namely FIGARO-DKD and FIDELIO-DKD, addressing the cardio-renal efficacy of finerenone, a newer MRA, in patients with T2DM. Herein we sought to assess major adverse events with the use of finerenone in patients with T2DM.We pooled data from the two relevant, published RCTs with finerenone in patients with T2DM, to provide pooled effect estimates for its cardio-renal efficacy and safety. We utilized data from published reports, also searching relevant supplementary appendices for any missing data. We assessed the following safety outcomes: acute kidney injury (AKI), hospitalization due to AKI, hyperkalemia, hospitalization due to hyperkalemia, all-cause death, hospitalization for any cause.We demonstrated that finerenone increased the risk for hyperkalemia by two times compared to placebo (RR = 2.03, 95% CI; 1.82-2.26, I2 = 0%, p < 0.00001), while it also significantly increased the risk for hospitalization due to hyperkalemia (RR = 5.86, 95% CI; 2.99 - 11.47, I2 = 0%, p < 0.00001). We have also documented that finerenone did not significantly affect the risk for development of AKI (p = 0.94) or hospitalization in the context of AKI (p = 0.92). In addition, finerenone resulted in a marginally non-significant reduction in the risk for all-cause death, equal to 10% (p = 0.05).Finerenone appears to provide significant cardiovascular and renal benefits for patients with T2DM. However, extra caution is required, since hyperkalemia appears to be the most important side effect with the use of finerenone, representing also the main cause of hospitalization due to a drug side effect. Large-scale use of potassium-binding drugs, such as patiromer or zirconium, as adjunct to finerenone might be a reasonable treatment combination in high-risk patients for hyperkalemia.

Hydration Interventions Among Agricultural Workers: A Pilot Study.

To estimate the impact of hydration interventions on postworkday hydration status and incidence of acute kidney injury (AKI). Thirty agricultural workers were first monitored on a workday without any interventions. On the intervention workday, the same workers were randomized to one of two groups: 169 ounces (oz) (5 L) of plain water (n = 16) or 169 oz (5L) of water with electrolytes (n = 14). No participants in the electrolyte group had an estimate glomerular filtration rate (eGFR) at the end of the workday of less than 90 mL/min/1.73 m2 or met the criteria for AKI in comparison to the water group (eGFR < 90: 15%; AKI: 23%) or the control group (eGFR < 90: 28%; AKI: 18%). The study showed that drinking water with electrolytes may lower the risk for development of AKI among agricultural workers.

Biomarker Rule-in or Rule-out in Patients With Acute Diseases for Validation of Acute Kidney Injury in the Emergency Department (BRAVA): A Multicenter Study Evaluating Urinary TIMP-2/IGFBP7.

BackgroundUrine tissue inhibitor of metalloproteinases-2/insulin-like growth factor-binding protein 7 (TIMP-2/IGFBP7) (NephroCheck, Ortho Clinical Diagnostics, Raritan, NJ, USA) is a US Food and Drug Administration-approved biomarker for risk assessment of acute kidney injury (AKI) in critically ill adult patients in intensive care units; however, its clinical impact in the emergency department (ED) remains unproven. We evaluated the utility of NephroCheck for predicting AKI development and short-term mortality in the ED.MethodsThis was a prospective, observational, five-center international study. We consecutively enrolled ED patients admitted with ≥30% risk of AKI development (assessed by ED physician ED score) or acute diseases. Serum creatinine was tested on ED arrival (T0), day 1, and day 2 (T48); urine for NephroCheck was collected at T0 and T48. We performed ROC curve and reclassification analyses.ResultsAmong the 529 patients enrolled (213 females; median age, 65 years), AKI developed in 59 (11.2%) patients. The T0 NephroCheck value was higher in the AKI group than in the non-AKI group (median 0.77 vs. 0.29 (ng/m)2/1,000, P=0.001), and better predicted AKI development than the ED score (area under the curve [AUC], 0.64 vs. 0.53; P=0.04). In reclassification analyses, adding NephroCheck to the ED score improved the prediction of AKI development (P<0.05). The T0 NephroCheck value predicted 30-day mortality (AUC, 0.68; P<0.001).ConclusionsNephroCheck can predict both AKI development and short-term mortality in at-risk ED patients. NephroCheck would be a useful biomarker for early ruling-in or ruling-out of AKI in the ED.

Analysis of adherence to therapy and compliance of outpatient treatment with the EURO FORTA system in elderly and senile polymorbid patients with CHF

Abstract Introduction Chronic heart failure (CHF) is one of the main reasons for hospitalization in the elderly. Various scales and algorithms have been proposed to combat polypharmacy. Purpose To assess adherence to therapy and compliance of outpatient treatment with the EURO FORTA system. Methods The study included 313 patients admitted to the city center for the treatment of CHF from February 1, 2019 to October 1, 2020 at the age of 75±8.22 years. In all patients, the Charlson comorbidity index and the number of diseases (1–2, 3–5, &amp;gt;5) were calculated. Outpatient treatment was assessed according to the EURO FORTA system (2018) in patients (over 65 years old – n=274, over 60 years old and ≥6 drugs – n=39) with CHF depending on the level of polymorbidity, age, sex, CHF variant and its severity. Heart failure was diagnosed in 66.77% of patients with preserved ejection fraction (EF), in 19.81% – with intermediate, in 13.42% - with low. Results Depending on the class of drugs according to the EURO FORTA system, 5 groups of patients were identified: 1st (received only class A drugs) – 3.51% of patients; 2nd (A, B)-22.36%; 3rd (A, B and C)-17.25%; 4th (A, B, C and D) – 27.17%; 5th – not taking medications on an outpatient basis 29.71%. In almost all groups at the outpatient stage, patients with&amp;gt;5 diseases (pmg=0.020) prevailed (45.46–70.59%). At the outpatient stage in groups 1, 3 and 4 there were more patients with stage IIB CHF (63.64%, 51.86% and 47.06%) pmg=0.041, and in groups 2 and 5 – patients with stage IIA (58, 57% and 48.39%). Class C: digoxin (n=4, patients with atrial fibrillation (AF) and CHF), amiodarone (n=3, patients with AF), moxonidine (n=1, patient with hypertension), betablockers 3 years after myocardial infarction (MI) (n=2), spironolactone (n=23, CHF). Reception of spironolactone on an outpatient basis was associated with a high risk of developing acute kidney injury (AKI) p=0.01, AKI in CKD p=0.042, and AF p=0.03. Class D: non-steroidal anti-inflammatory drugs (NSAIDs) (n=68), aspirin for AF (n=2), class I-III antiarrhythmics (except amiodarone) (n=8), glibenclamide (n=1), nondihydropyridine calcium antagonists (n=2, patients with hypertension), dihydropyridine antagonists (n=1, with ischemic heart disease 3 years after MI). Taking NSAIDs on an outpatient basis was associated with a high risk of AKI development p=0.033, as well as anemia p=0.036, including grade 3 and 4 anemia (WHO) p=0.042. Conclusion Every second patient with CHF had more than 5 diseases. Every third person did not take drug therapy at the outpatient stage. The frequency of taking drugs of classes C and D was higher in polymorbid patients. With a more severe course of CHF, patients more often took class D drugs. Among class D were NSAIDs (80%) and class I-III antiarrhythmics (except amiodarone) (9.4%) prevailed. The use of spironolactone on an outpatient basis was associated with a high risk of AKI and AF, and NSAIDs-with AKI and anemia. Funding Acknowledgement Type of funding sources: None.

Phenotypes and Baseline Risk Factors of Acute Kidney Injury in Children After Allogeneic Hematopoietic Stem Cell Transplantation.

Background: Acute kidney injury (AKI) is a frequent and widely recognized complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Despite relatively high prevalence, AKI after allo-HSCT and its risk factors in children remain obscure. The aim of this study was to describe the prevalence and course of AKI during the first 100 days after allo-HSCT in children and to investigate its associations with baseline characteristics.Methods: Retrospective single-center chart review of all patients under 18 who underwent allo-HSCT during 2011–2017 was performed. AKI was defined using the pediatric RIFLE criteria and only the patients with pRIFLE stage I (eGFR decrease by 50% or more) or higher were considered for the analysis. Recurrent AKI and acute kidney disease (AKD) were defined according to the Acute Disease Quality Initiative consensus. Demographic, clinical, and procedure-related characteristics were recorded at the day of HSCT.Results: Fifty-one patients (68.6% boys) with a median age of 9 years (range: 0.25–17) were included. During a median follow-up of 82 (IQR, 60–98) days, 27 (52.9%) patients experienced a total of 39 AKI episodes, translating into one AKI episode per 100 patient days. Multiple AKIs occurred in 11 (21.6%) patients and 18 (35.3%) progressed to AKD. Four patients died, all with ongoing or previous AKI. Patients with AKD were, on average, older (10 vs. 6 years; p = 0.03) and had higher baseline body mass index (BMI) [standard deviation score (SDS) 0.83 vs. 0.04, p = 0.05], whereas patients with recurrent AKI had higher baseline estimated glomerular filtration rate (eGFR) (244.1 vs. 193.9 ml/min/1.73 m2, p = 0.02). In the adjusted Cox models (HR; 95% CI), older age (1.10; 1.01–1.20) was associated with higher risk of overall AKI and higher eGFR (1.02; 1.01–1.04) was associated with higher risk of recurrent AKI, while older age (1.17; 1.04–1.31), higher eGFR (HR 1.01; 1.0–1.02), and higher BMI SDS (1.66; 1.01–2.72) were associated with higher risk of AKD.Conclusions: AKI is a frequent early complication of allo-HSCT in children, and approximately one fifth experience AKI recurrence and one third develop AKD. Older age, higher BMI, and higher eGFR at the day of transplant may have an effect on the risk of AKI development and its course.

P1828A PANEL OF URINE BIOMARKERS FOR EARLY KIDNEY INJURY DETECTION IN NEWBORNS

Abstract Background and Aims Neonatal kidney damage is a wide spread pathology, especially among preterm infants. Acute kidney injury (AKI) in newborns remains one of the most important problems because the features of neonatal nephrogenesis and physiology. The current clinical criteria for the diagnosis of AKI, including pediatric scales pRIFLE and nRIFLE, rely on glomerulal filtration rate (GFR), blood urea nitrogen (BUN), and serum creatinine (SCr), which are the late biomarkers detectable only within days or weeks after kidney damage occurred, and therefore have limitations when used within the first days after birth. Therefore, sensitive and specific tests for early diagnostics of kidney injury are extremely needed in neonatology. Urine biomarkers appear to be promising for early diagnosis of AKI. Quite often renal pathologies result in markedly increased (or decreased) urinary excretion of a number of protein biomarkers, indicating subclinical tubular injury while conventional AKI signs are not manifested yet. The aim of this study was to determine clinical value of urine molecular biomarkers for the prediction of acute kidney injury in newborns. Method Urine samples from newborns with congenital malformation were collected on the 1st day after born, and then once a week until the 21th postnatal day. Urine samples were centrifuged, aliquoted and stored at –80°С until testing. The next urinary biomarkers were analyzed: calbindin 1, clusterin, IL-18, KIM-1, GST-π, MCP-1 and NGAL. Quantitative determination was performed with immunoassay kit Bio-Plex Pro™ RBM Human Kidney Toxicity Panel 1 (Bio-Rad Inc., USA) and Human NGAL ELISA kit (Invitrogen, Germany). Control group included five age-matched healthy infants. Results 8 of 20 patients showed a direct correlation of increased NGAL levels in urine (50-fold compared to control group) with high levels of C-reactive protein in the blood (3-10-fold rise above the reference level). NGAL is the most sensitive marker for assessing AKI or tubular damage. These 8 patients were further investigated for other urine biomarkers. The IL-18 level in urine was slightly increased in 4 patients. IL-18 is proposed to be a predictor for AKI severity and mortality in children with critical illness. KIM-1 has low basal expression in the normal kidney but its appearance is highly specific and sensitive sign for nephrotoxicity in proximal tubules. We observed the increase of KIM-1 urinary excretion for 7 patients. However, we discover the equal occurrence of decrease or increase of urine MCP-1 through studied patients. Elevated levels of urine MCP-1 were earlier observed in experimental maleate induced azotemia, LPS injection and in model of unilateral ureteral obstruction (UUO). An increase of KIM-1 and/or MCP-1 urinary excretion is known to be associated with some risk of AKI development. We found 3-fold growth of urine clusterin in 7 children. It is noticed, that clusterin increased in damaged tubular cells during polycystic kidney disease and renal carcinoma. Additionally, we revealed 7-fold decrease of calbindin 1 in urine of 7 patients. Сalbindin 1 exclusively localized in the kidney distal nephron segment, and its decrease was discribed for models of UUO, glomerulonephritis and cisplatin nephropathy. GST-π protein is found in cells lining the lumen of the distal tubules and is elevated in the urine of patients with sepsis, independently of accompanied AKI. We also observed 10- to 20-fold rising of urine GST-π for all 8 NGAL-positive newborns. Conclusion The specificity, rate of increase, and non-invasive detection of urine markers studied in this work, make them indispensable in clinical practice. However, their use in neonatology is still experimental. We showed potential applicability of wide biomarker panel for early detection and prediction of AKI in newborns.

Incidence, Mortality and Predictors of Acute Kidney Injury in Patients with Cirrhosis: A Systematic Review and Meta-analysis.

Background and Aims: Acute kidney injury (AKI) is common in patients with cirrhosis but the incidence is heterogeneous among studies. We performed a meta-analysis to describe the incidence of AKI and its impact on patient mortality in patients with cirrhosis. We also evaluated the admission variables predicting development of AKI.Methods: A systematic search of various databases was performed up to November 2018. Meta-analyses were performed using random effects models.Results: Of 18,474 patients with cirrhosis from 30 selected studies, 5,648 developed AKI, with a pooled incidence of 29% (95% confidence interval [CI]: 28-30%, I2 of 99%). In-hospital mortality assessed in eight studies was six-fold higher among AKI patients, as compared to those without AKI (odds ratio [OR] 6.72, 95% CI: 3.47-13, p<0.0001, I2 of 70%). Three studies on patients admitted to intensive care showed about six-fold higher mortality among AKI patients (OR 5.90, 95% CI: 3.21-10.85, p>0.0001). Mortality remained significantly high, at days 30 and 90 and even at 1-year follow up after development of AKI. Of 12 admission variables analyzed, model for end-stage liver disease score, Child-Pugh-Turcotte stage C, presence of ascites, and presence of sepsis/septic shock were statistically significant risk factors for AKI.Conclusions: AKI occurred in about 29% of patients with cirrhosis and is associated with a six-fold increased risk of in-hospital mortality. Mortality remained high even in long-term follow-up of 1 year. Patients at risk for AKI development can be recognized at admission. Prospective studies are needed to develop strategies for improving outcome of these patients.

Assessment of Acute Kidney Injury in Neurologically Injured Patients Receiving Hypertonic Sodium Chloride: Does Chloride Load Matter?

Background: Increasing evidence suggests that large-volume infusions of 0.9% sodium chloride (NaCl) for resuscitation are associated with hyperchloremic metabolic acidosis, renal vasoconstriction, and increased risk of acute kidney injury (AKI). Patients with neurological injury may require hypertonic NaCl for therapeutic hypernatremia, treatment of cerebral salt wasting, hyponatremia, or elevated intracranial pressure. Consequently, this increased exposure to chloride may result in an increased risk for development of AKI. Objective: The primary aim of this study was to describe the risk for development of AKI in neurologically injured patients receiving large volumes of intravenous hypertonic NaCl. Methods: This single-center, retrospective study looked at neurologically injured patients who received hypertonic NaCl and sodium acetate. Data were collected to assess renal function, hyperchloremia, and acidemia. Receiver operating characteristic (ROC) curve analysis was used to determine the predictive association between the amount of daily and overall chloride exposure and development of AKI. Results: A total of 301 patients were screened, and of those, 142 were included. Of the 142 patients included, 13% developed AKI, and 38% developed hyperchloremia. Additionally, 32% of patients were switched from NaCl to sodium acetate after an average of 3.4 ± 1.5 days of NaCl therapy. The ROC curve demonstrated that if patients received greater than 2055 mEq of chloride over 7 days, they were more likely to develop AKI (sensitivity 72%, specificity 70%; P = 0.002; area under the curve = 0.7). Conclusion and Relevance: Neurologically injured patients receiving hypertonic sodium therapy with a high chloride load are at risk of developing hyperchloremia and AKI.

Elevated admission serum calcium phosphate product as an independent risk factor for acute kidney injury in hospitalized patients

ABSTRACTBackground: Increased serum calcium-phosphate product (CaP) can result in acute kidney injury (AKI) due to tubular and interstitial calcium phosphate deposits. CaP of > 55 mg2/dL2 is also associated with systemic calcification. However, the risk of AKI development among hospitalized patients with different admission calcium-phosphate product levels remains unclear.Methods: All adult hospitalized patients who had both admission serum calcium and phosphate levels available from 2009 through 2013 were enrolled. Admission CaP was categorized based on its distribution into six groups (<22, 22- < 27, 27- < 32, 32- < 37, 37- < 42 and ≥42 mg2/dL2). The odds ratio (OR) of in-hospital mortality by admission CaP, using the CaP category of < 22 mg2/dL2 as the reference group, was obtained by logistic regression analysis.Results: After excluding patients with end-stage renal disease, without serum creatinine measurement, and those who presented with AKI at the time of admission, a total of 9,864 patients were studied. In-hospital AKI occurred in 1,478 patients (15.0%). The incidence of AKI among patients with admission CaP < 22, 22 to < 27, 27 to < 32, 32 to < 37, 37 to < 42, and ≥42 mg2/dL2 was 11.1%, 12.4%, 14.9%, 15.2%, 17.5%, and 19.9%, respectively. After adjusting for potential confounders, a CaP ≥37 mg2/dL2 was associated with an increased risk of developing AKI with OR of 1.53 (CI 1.19–1.96) and 1.63 (CI 1.25–2.14) in patients with admission CaP 37- < 42 and ≥42, respectively. Subgroup analysis based on eGFR consistently demonstrated that CaP ≥37 mg2/dL2 was associated with an increased risk of developing AKI in both chronic kidney disease (CKD) and non-CKD patients.Conclusion: Elevated admission CaP was independently associated with an increased risk for in-hospital AKI.

1EMF Prediction of Acute Kidney Injury in the Emergency Department Using Electronic Health Record Data and Machine Learning Methods

Acute kidney injury (AKI) is strongly associated with adverse clinical outcomes including prolonged hospitalization, progression to CKD, and death. Diagnosis of AKI relies on detection of changes in serum creatinine (sCr) and urine output, both of which lag days behind renal injury and are unreliable at initial presentation. Here, we utilized data mining and machine learning methods to develop a predictive model for AKI with capacity for identifying ED patients at high risk for development of AKI within 7 days of their ED visit. A retrospective cross-sectional cohort of ED visits from 3 hospitals over 2 years was generated and used for model derivation and out-of-sample validation. Clinical data for all adult ED visits where initial sCr measurements were available at index visit and again within 7 days of ED departure were extracted from a relational database that underlies our electronic health record (EHR) by an experienced data user. Primary outcome for prediction was Stage 2 AKI within 7 days of ED visit, defined according to sCr-based Kidney Disease Improving Global Outcomes (KDIGO) criteria (sCr increase to ≥ 2 times baseline). Secondary outcomes included KDIGO Stage 1 AKI (sCr increase of ≥0.3 mg/dl above baseline or ≥1.5 times baseline) and Stage 3 AKI (sCr increase to ≥ 3 times baseline or to ≥ 4.0 mg/dl). Predictor variables extracted from the EHR included vital signs, laboratory results, chief complaints, demographics, past medical history, active problems, home medications and ED medication administrations. Only EHR data available prior to prediction, made at time of first metabolic panel result, was included. Predictor variables were normalized as follows: ED vital signs and laboratory results were processed to minimum and maximum values, nephrotoxic and nephroprotective medications were grouped by pharmacologic class and least absolute shrinkage and selection operator (LASSO) feature selection processing applied to chief complaints and active problems identify variables with predictive value for AKI. Multiple machine learning models (logistic regression, decision tree, linear discriminant analysis, support vector machine, and random forest) were generated and tested in the prediction of our primary outcome. All were developed using a training dataset comprised of 90% of encounters and evaluated in the remaining encounters using 10-fold cross validation. Performance of each model was assessed using binary classification measures and receiver operator curve (ROC) analyses. Our final cohort included 127,183 ED visits by 72,539 unique patients. Median age was 58 years (IQR: 43-71) and most common high-risk comorbidities were hypertension (51.8%) and heart failure (9.8%). Incidence of AKI in our cohort was as follows: Stage 1: 12.4%, Stage 2: 1.5%, Stage 3: 1.0%. Predictive model performance as measured by area under the ROC analysis ranged from 0.661 (95% CI: 0.637 - 0.685) using decision tree to 0.771 (95% CI: 0.759 - 0.783) using random forest. Machine learning methods applied to EHR data identified ED patients at high risk for AKI well before patients met diagnostic criteria. The model developed here, when paired with nephroprotective point-of-care clinical decision support, has potential to improve outcomes for this patient population.

U-shape association of serum albumin level and acute kidney injury risk in hospitalized patients.

BackgroundWhile an association between hypoalbuminemia and increased risk of acute kidney injury (AKI) is well-established, the risk of AKI development and its severity among patients with elevated serum albumin is unclear. The aim of this study was to evaluate the risk of AKI in hospitalized patients stratified by various admission serum albumin levels.MethodsThis single-center retrospective study was conducted at a tertiary referral hospital. All adult hospitalized patients who had admission albumin levels available between January 2009 and December 2013 were enrolled. Admission albumin was categorized based on its distribution into six groups (≤2.4, 2.5–2.9, 3.0–3.4, 3.5–3.9, 4.0–4.4, and ≥4.5 mg/dL). The primary outcome was the incidence of hospital-acquired AKI (HAKI). Logistic regression analysis was performed to obtain the odds ratio of AKI for various admission albumin strata using the albumin 3.5 to 3.9 mg/dL (lowest incidence of AKI) as the reference group.ResultsOf the total 9,552 studied patients, HAKI occurred in 1,556 (16.3%) patients. The incidence of HAKI among patients with admission albumin ≤2.4, 2.5–2.9, 3.0–3.4, 3.5–3.9, 4.0–4.4, and ≥4.5 mg/dL was 18.3%, 14.3%, 15.5%, 14.2%, 16.7%, and 26.0%, respectively. After adjusting for potential confounders, admission serum albumin levels ≤2.4 and ≥4.5 mg/dL were associated with an increased risk of HAKI with odds ratios of 1.52 (95% CI 1.18–1.94) and 2.16 (95% CI 1.74–2.69), respectively. While stage 1 HAKI was significantly more frequent among patients with admission albumin ≥4.5 mg/dL (23.0% vs. 11.6%, P<0.001), incidence of stage 3 HAKI was higher in those with albumin ≤2.4 mg/dL (2.8% vs 0.3%, P<0.001).ConclusionAdmission serum albumin levels ≤2.4 and ≥4.5 mg/dL were associated with an increased risk for HAKI. Patients with admission albumin ≥4.5 mg/dL had HAKI with a lower intensity when compared with those who had admission albumin levels ≤2.4 mg/dL.

Admission calcium levels and risk of acute kidney injury in hospitalised patients.

The risk of acute kidney injury (AKI) development among hospitalised patients with elevated calcium levels on admission remains unclear. The aim of this study was to assess the risk of AKI in hospitalised patients stratified by various admission serum calcium levels. This is a single-centre retrospective study conducted at a tertiary referral hospital. All hospitalised adult patients who had admission calcium levels available between 2009 and 2013 were enrolled. Admission calcium was categorised based on its distribution into six groups (≤7.9, 8.0-8.4, 8.5-8.9, 9.0-9.4, 9.5-9.9, and ≥10.0mg/dL). The primary outcome was hospital-acquired AKI. Logistic regression analysis was performed to obtain the odds ratio of AKI for various admission calcium strata using calcium levels of 8.0-8.4mg/dL (lowest incidence of AKI) as the reference group. A total of 12784 patients were studied. Hospital-acquired AKI occurred in 1779 (13.9%) patients. The incidence of AKI among patients with admission calcium ≤7.9, 8.0-8.4, 8.5-8.9, 9.0-9.4, 9.5-9.9 and ≥10mg/dL was 14.7%, 11.7%, 11.8%, 14.6%, 15.8% and 17.3%, respectively. After adjusting for potential confounders, admission calcium levels ≤7.9, 9.0-9.4, 9.5-9.9 and ≥10mg/dL were associated with increased risk of AKI with odds ratios of 1.36 (95%CI 1.08-1.72), 1.29 (95%CI 1.08-1.56), 1.38 (95%CI 1.14-1.68) and 1.51 (95%CI 1.19-1.91), respectively. Admission hypocalcaemia and hypercalcaemia are associated with an increased risk for hospital acquired AKI. Patients with admission hypercalcaemia (≥10mg/dL) carry a 1.51-fold risk for AKI development during hospitalisation.

Comparison of Acute Kidney Injury During Treatment with Vancomycin and either Piperacillin-Tazobactam or Meropenem

CONTEXTEmpiric antibiotics are often required in hospitalized patients with serious infections who may be septic and at risk for drug resistant organisms. The purpose of this study was to evaluate the observed incidence of acute kidney injury (AKI) in a sample of adult patients receiving either piperacillin-tazobactam and vancomycin or meropenemvancomycin for at least 72 hours.METHODSSingle-center, retrospective matched cohort at a 200-bed Regional Community Medical Center. Adult patients were included in the sample if they were without preexisting renal dysfunction and admitted over an 18-month time period to receive either the combination of piperacillin-tazobactam and vancomycin or meropenem-vancomycin. Sample patients were evaluated for AKI. This condition was defined by the authors as an increase in serum creatinine of 0.5mg/ml or an increase of 50% above baseline during the duration of antibiotic treatment.RESULTSA total of 266 patients receiving either combination of antibiotics were evaluated for AKI. The incidence of AKI was significantly higher in the piperacillin-tazobactam and vancomycin group (n = 74/292, 25%) compared with the meropenem-vancomycin group (n=8/74, 9.5%, p=0.008).CONCLUSIONSThe results of this study suggest that the combination of piperacillin-tazobactam and vancomycin is associated with an increased incidence of AKI. Higher vancomycin trough concentrations were associated with increased risk for development of AKI.

Colistin-induced nephrotoxicity and the role of N-acetylcysteine: a retrospective cohort study.

Colistin is associated with dose-dependent nephrotoxicity. N-acetylcycteine (NAC) may reduce the risk of concomitant acute kidney injury (AKI) due to its antioxidant properties. We report a retrospective cohort study evaluating the role of N-acetylcysteine (NAC) in the development of colistin (COL) associated nephrotoxicity. A single centre retrospective cohort study was conducted in a university hospital between January 2014 and June 2015. Nephrotoxicity was defined and staged per the RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) criteria. We evaluated the association between NAC use and COL-related nephrotoxicity by comparing the incidence of nephrotoxicity in patients receiving colistin with or without adjunctive NAC. Forty-six patients received intravenous (IV) COL and 46 patients received IV NAC+COL. The cumulative COL doses did not differ between the two groups (p = 0.802). The initial creatinine value doubled in 29 (63%) patients undergoing NAC+COL therapy and in 27 (58.7%) patients in the COL group (p = 0.669). The median doubling time of baseline creatinine was 6 and 7 days in the NAC+COL and COL groups, respectively. The mean hospital stay, potentially nephrotoxic agent use, and mortality rates were statistically higher for the patients receiving NAC+COL (p < 0.005). The present study was not able to reveal any beneficial effect of NAC for patients undergoing COL therapy. The NAC+COL group had a higher baseline risk for development of AKI. However, the incidence of AKI was comparable between the groups. The results of the study would not solely exhibit the protective effect of adjunctive NAC therapy.

Urinary neutrophil gelatinase-associated lipocalin identifies critically ill young children with acute kidney injury following intensive care admission: a prospective cohort study.

IntroductionChildren admitted to a pediatric intensive care unit (ICU) are at high risk of developing acute kidney injury (AKI). Although serum creatinine (SCr) levels are used in clinical practice, they are insensitive for early diagnosis of AKI. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) and kidney injury molecule-1 (KIM-1) are novel AKI biomarkers whose performance in pediatric ICU patients is largely unknown. In this study, we aimed to characterize uNGAL and KIM-1 patterns in children following ICU admission and to assess their properties in relation to identifying children at risk for AKI development.MethodsFrom June 2010 until January 2014, we conducted a prospective observational cohort study of term-born children ages 1 day to 1 year on mechanical ventilation. Blood and urine samples were obtained every 6 to 12 hours up to 72 hours post-admission. Blood samples were assayed for SCr, and urine samples were assayed for uNGAL and KIM-1. The RIFLE (risk, injury, failure, loss, end-stage renal disease) classification as 150%, 200% or 300% of median SCr reference values was used to define AKI.ResultsA total of 100 children were included (80 survived). Their median age at admission was 27.7 days (interquartile range (IQR), 1.5 to 85.5). The median duration of mechanical ventilation was 5.8 days (IQR, 3.1 to 11.4). Thirty-five patients had evidence of AKI within the first 48 hours post-admission, of whom 24 (69%) already had AKI when they entered the ICU. uNGAL and KIM-1 concentrations in AKI peaked between 6 to 12 hours and between 12 to 24 hours post-admission, respectively. The maximal area under the receiver operating characteristic curve (AUC) for uNGAL was 0.815 (95% confidence interval (CI), 0.685 to 0.945, P <0.001) at 0 to 6 hours post-admission. The discriminative ability of KIM-1 was moderate, with a largest AUC of 0.737 (95% CI, 0.628 to 0.847; P <0.001) at 12 to 24 hours post-admission. At the optimal cutoff point (126 ng/ml), uNGAL concentration predicted AKI development correctly in 16 (84%) of 19 children, up to 24 hours before a rise in SCr became apparent.ConclusionsLevels of uNGAL and KIM-1 increase in patients with AKI following ICU admission and peak at 6 to 12 hours and 12 to 24 hours post-admission, respectively. uNGAL seems to be a reliable marker for identifying children who will develop AKI 24 hours later.

Association Between the Neutrophil/Lymphocyte Ratio and Acute Kidney Injury After Cardiovascular Surgery: A Retrospective Observational Study.

A high neutrophil-lymphocyte ratio (N/L ratio) was associated with the development of acute kidney injury (AKI) in patients with severe sepsis. We sought to investigate the association between the perioperative N/L ratios and postoperative AKI in patients undergoing high-risk cardiovascular surgery.A retrospective medical chart review was performed of 590 patients who underwent cardiovascular surgeries, including coronary artery bypass, valve replacement, patch closure for atrial or ventricular septal defect and surgery on the thoracic aorta with cardiopulmonary bypass (CPB). Baseline perioperative clinical parameters, including N/L ratios measured before surgery, immediately after surgery, and on postoperative day (POD) one were obtained. Multivariate logistic regression analysis was used to evaluate risk factors.A total of 166 patients (28.1%) developed AKI defined by the KDIGO (kidney disease improving global outcomes) criteria in the first 7 PODs. Independent risk factors for AKI included old age, decreased left ventricular systolic function, preoperative high serum creatinine, low serum albumin and high uric acid levels, intraoperative large transfusion amount, oliguria, hyperglycemia, and elevated N/L ratio measured immediately after surgery and on POD one. The quartiles of immediately postoperative N/L ratio were associated with graded increase in risk of AKI development (fourth quartile [N/L ratio≥10] multivariate odds ratio 5.90, 95% confidence interval [CI] 2.74-12.73; P < 0.001), a longer hospital stay, and a higher in-hospital and 1-year mortality rate (fourth quartile [N/L ratio≥10] adjusted hazard ratio for 1-year mortality [8.40, 95% CI 2.50-28.17]; P < 0.001).In patients undergoing cardiovascular surgery with CPB, elevated N/L ratios in the immediately postoperative period and on POD one were associated with an increased risk of postoperative AKI and 1-year mortality. The N/L ratio, which is easily calculable from routine work-up, can therefore assist with risk stratification of AKI and mortality in high-risk surgical patients.

60 Examining the impact of obesity ≥30 kg/m2 on acute kidney injury following cardiac surgery

Background Postoperative acute kidney injury (AKI) is a frequent and serious consequence of cardiac surgery. A complex and multifactorial issue, improved understanding of its aetiological components will aid development of preventative strategies prospectively. The global prevalence of obesity has reached epidemic proportions and is particularly associated with the pathogenesis of cardiovascular disease. We undertook to investigate the association of obesity and the risk of AKI development following cardiac surgery. Methods 432 patients who underwent cardiac surgery with cardiopulmonary bypass between October 2009 and August 2010 were included in the final retrospective analysis. Obesity was defined as BMI ≥ 30 kg/m 2 . Acute kidney injury (AKI) was defined as a creatinine increase of ≥ 25% from baseline at 48 h post surgery. Results The overall incidence of AKI was 29.9% (n = 129). The incidence of diabetes was significantly higher in the obese cohort (24.3 vs. 10.8% p = 0.0005). There was an increased incidence of post-operative renal impairment in the obese vs. non-obese cohort, however this was not statistically significant (39 vs. 25.9%, p = 0.07). Univariate analysis of independent predictors of postoperative AKI revealed significant associations between obesity (BMI >30 kg/m 2 ) (OR 1.80, 95% CI 1.17–2.79, p = 0.01), cerebrovascular disease (OR 1.83, 95% CI 1.10–2.03, p = 0.02), hyperlipidaemia (OR 0.59, 95% CI 0.39–0.89, p = 0.02) and a history of smoking (OR 2.82, 95% CI 1.79–4.44, p 30 kg/m 2 was independently associated with the development of postoperative AKI (OR 1.81, 95% CI 1.11–2.95, p = 0.02) as were age (OR 0.98 95% CI 0.96–1.0, p = 0.03) and cardiopulmonary bypass time (OR 0.99, 95% CI 0.98–1.0, p = 0.03). Conclusion Obesity ≥ 30 kg/m 2 is independently associated with an increased risk of AKI following cardiac surgery. Further understanding of the molecular basis of this association is critical to the design of preventative strategies.