Serum Creatinine Monitoring Research Articles

Protocol description and initial experience in kidney graft perfusion using infrared thermography.

Protocol description for renal perfusion study using thermographic technology and description of the thermographic and clinical behavior of the transplanted kidneys before and after unclamping. Infrared thermographic images of renal grafts are obtained before kidney reperfusion, 10min after and just before closing the surgical wound. Thermographic data is evaluated together with the type of graft and donor, cold ischemia time, hypovascularized areas determined by the surgeon during surgical intervention, alterations in vascular flow in postoperative echo-Doppler, time at the beginning of graft function and serum creatinine monitoring during postoperative follow-up. 17 grafts were studied. The mean temperature of the grafts before reperfusion, 10min after and at the end of the surgery were 18.7°C (SD 6.27), 32.36°C (SD1.47) and 32.07°C (SD1.78) respectively. 4 grafts presented hypoperfused areas after reperfusion. These areas presented a lower temperature compared to the well perfused parenchyma surface using thermographic images. The study of the usefulness and applicability of thermography can allow the development of tools that provide additional objective information on organ perfusion in real time and non-invasive manner. Our protocol and initial results can contribute to provide new evidence. Further analyses should be developed to shed light on the role of this technology.

#2710 The importance of monitoring creatinine, hematuria, and proteinuria in relation to kidney outcomes in patients with ANCA-associated vasculitis

Abstract Background and Aims Patients with ANCA-associated vasculitis (AAV) often a have kidney involvement and it has been shown that a decreased glomerular filtration rate at entry is associated with a worse outcome both for patient and kidney survival. However, some patients present with a low kidney function at entry, but recover during treatment. Thus, it may be interesting to see if the kidney function after starting treatment is more accurate predicting outcome than the one at entry. The aim of our study was to determine the prognostic significance of proteinuria, hematuria and serum creatinine monitoring in patients with AAV Method The dataset included 848 patients with newly diagnosed AAV who participated in 7 RCTs (1995-2012), and median follow-up time of the entire cohort was 8 years (IQR: 2.9-13.6). Creatinine, hematuria, and proteinuria was recorded at baseline, 3, 6, 9, 12, and 18 months after randomization. Kidney outcome was defined as permanent dialysis dependency during follow-up or kidney transplantation. Receiver operating characteristic curves (ROC) were calculated and screening performance of cut-off scores was evaluated using the Youden Index. A multivariate Cox regression model was performed to examine the factors associated with the kidney outcome. Results Median baseline Creatinine was 176 µmol/L (IQR: 97-388.5), 114 µmol/L (IQR: 88-171) at 3 months, 110 µmol/L (IQR: 89-160) at 6 months, 110 µmol/L (IQR: 89-155) at 12 months, and 102 µmol/L (IQR: 84-132.6) at 18 months. Within 12 months, the AUC of Creatinine was the highest at 0.87 (95% CI: 0.79-0.95; SE: 0.05; p-value: 0.04) to predict kidney outcome. For the cut-off point of 135 µmol/L, 12-month-Creatinine achieved a sensitivity of 83% and specificity of 76% (LR+: 3.35, LR-: 0.23). The ROC curves for hematuria, showed that the highest AUC was found at 9 months (AUC: 0.71; SE: 0.04; 95% CI: 0.64-0.78; p = 0.032) (Fig. 1). Examination of the ROC curve of proteinuria > 0.5/24 h, revealed that the highest AUC corresponded to the baseline determination (AUC: 0.64; SE: 0.08; 95% CI: 0.48-0.80), but there was no statistically significant difference observed among the AUC values of proteinuria across the monitored periods. In the multivariable Cox regression model, MPA diagnosis, creatinine at 12 months, and age > 65 years old were independent prognostic factors for the kidney outcome. The model including Creatinine at 12 months was more robust than the model including baseline Creatinine (Harrell's C: 0.84 and 0.76, respectively) Conclusion The best diagnostic accuracy for ESKD in ROC curves was shown by serum creatinine at 12 months (AUC: 0.87; SE: 0.05; 95% CI 0.79-0.95; p-value: 0.04). Hematuria was a predictor of the kidney outcome of moderate quality (AUC 0.71; SE 0.04; 95% CI: 0.64-0.78), while proteinuria > 0. 5 g/24 h had a modest and non-significant AUC (AUC 0.64; SE 0.08; 95% CI 0.48-0.80). Serum creatinine at 12 months was found to be an independent prognostic factor for kidney outcome, while haematuria and albuminuria during follow up within the first 18 months did not seem to add any impact on outcome. Reevaluation of renal prognosis at 12 months might be useful to reassess treatment in patients with AAV. Taken together, these findings suggest than incorporating biomarker monitoring into clinical-analytical predictive models can provide a more nuanced and accurate method for predicting renal outcomes as the disease progresses.

Gentamicin concentration and acute kidney injury in term neonates treated for neonatal sepsis with gentamicin and ampicillin-cloxacillin combination.

Gentamicin is widely used to treat neonatal infections caused by both Gram-negative and Gram-positive bacteria, and the WHO recommends its use while monitoring serum creatinine and gentamicin concentrations to avoid drug-induced nephrotoxicity and ototoxicity. Yet in some resource-limited settings, the drug is used without monitoring. A population pharmacokinetics study involving term neonates with neonatal infection admitted to a neonatal unit. Participants were started on intravenous gentamicin 5 mg/kg once a day in combination with ampicilin-cloxacillin. Blood samples for serum gentamicin concentration were taken at 0.25, 0.5, 1, 2, 3, 5, 6, 8, 10, 12, 14, 16, 18, 20, 23, and 24 hours after the initial dose, each participant contributing two samples to the 24 hour sampling schedule. An additional sample for trough concentration was taken from each participant just before the third gentamicin dose while serum creatinine concentration was measured before and after treatment. Twenty-four participants were enrolled into the study and included in the final analysis. Mean (SD) peak and trough serum gentamicin concentrations were 16.66 (0.64) µg/mL and 3.28 (0.70) µg/mL, respectively. Gentamicin clearance (CL) was 0.40 mL min-1 kg-1 and volume of distribution (VD) was 0.31 L kg-1. Mean (SD) serum creatinine level after treatment was 209.7 (70.4) µmol/L compared to 103.3 (23.6) µmol/L before treatment [mean difference (106.4 ± 67.1; 95% confidence interval (CI): 78.1; 134.7 µmol/L; t (23) = 7.77; P < 0.001]. All participants fulfilled the Kidney Disease Improving Global Outcomes (KDIGO) criteria for acute kidney injury after treatment. Treatment of neonatal infection with antimicrobial regimen containing gentamicin, without renal function and gentamicin concentration monitoring, carries a significant risk for drug-induced acute kidney injury.

Use of urine neutrophil gelatinase-associated lipocalin for nephrotoxic medication acute kidney injury screening in neonates.

Daily serum creatinine monitoring protocols for acute kidney injury (AKI) are invasive and may lead to surveillance resistance. We aimed to understand if use of urine neutrophil gelatinase-associated lipocalin (uNGAL) could increase high-risk nephrotoxic medication (NTMx) associated AKI screening adherence in neonates. Statistical process control methods prior to and post implementation were trended. The primary outcome, screening adherence, was defined as either daily serum creatinine or uNGAL assessment through 2 days post high-risk NTMx exposure. 1291 monitoring days from the pre-implementation era (4/2020-6/2021) were compared to1377 monitoring days from the post-era (6/2021-10/2022). AKI screening adherence increased (81 to 92%) following implementation of optional uNGAL screening. Urine NGAL accounted for 35% of screening obtained. Use of uNGAL resulted in a 40% reduction in blood sampling for serum creatinine. Incorporation of uNGAL as a complementary screening tool to serum creatinine demonstrated sustained increased AKI surveillance in our Baby NINJA monitoring program.

Clinical profile and outcome of acute kidney injury in preterm neonates in a level three neonatal intensive care unit

Background: Acute kidney injury is an important cause of neonatal mortality and morbidity. Preterm neonates, in particular are a vulnerable population as they are associated with various risk factors, predisposing them to multi-organ injury. Data on AKI in preterm neonates in India are limited. There are several gaps including the risk factors, demographic profile and associations with other comorbidities which remain unanswered. The objectives of this study were to study the clinical profile, outcomes and various associated risk factors of AKI in preterm neonates. Methods: It is a prospective observational study conducted in neonatal intensive care unit of a government medical college hospital in Rajkot, Gujarat, India. 300 preterm neonates with AKI were selected and demographic details, risk factors associated with AKI and outcomes were studied. Results: It was found that among 300 newborns under study, 82% were males, 92% had sepsis, 65% had respiratory distress syndrome, 32% had birth asphyxia, 29% had shock, 30% had exposure to nephrotoxic drugs, 54% had requirement for mechanical ventilation, 94% patients were discharged and 6% patients expired. Conclusions: The most common risk factor associated with AKI was sepsis. The other important risk factors are birth asphyxia, respiratory distress syndrome, and shock. Monitoring of serum creatinine can help in early detection of acute kidney injury.

Efficacy and Safety of Pre-Exposure Prophylaxis to Control HIV and Sexually Transmitted Infection Among Men Who Have Sex With Men: Protocol for a Single-Arm Interventional Study.

Pre-exposure prophylaxis (PrEP) against HIV infection is a new approach that involves the prophylactic use of the anti-HIV drug Truvada (tenofovir disoproxil fumarate [TDF] and emtricitabine [FTC]) by people not infected with HIV. The objective of this investigator-initiated clinical study of PrEP was to evaluate the incidence of HIV and sexually transmitted infection (STI), safety and efficacy of PrEP in PrEP users, and their compliance with PrEP medication. The social, medical, and economic benefits of PrEP in Japan was assessed. This single-center feasibility study of PrEP was conducted at the National Center for Global Health and Medicine, Tokyo, Japan, where a cohort of men who have sex with men without HIV was established in January 2017. This single-arm interventional study compared the efficacy and safety of PrEP in a single group of men who have sex with men who participated in PrEP cohort studies. For reference, the cohort study participants who did not participate in the PrEP study were included for comparison. Blood samples were collected for storage at baseline and clinic visits at 1, 3, and 6 months after starting PrEP and every 3 months thereafter. The participants were administered with 1 tablet of Truvada once daily as PrEP. They underwent blood and anal swab tests 1 and 3 months after starting PrEP and then HIV and STI infection assessments at 3-month intervals. Blood samples were centrifuged at the AIDS Clinical Center Laboratory. PrEP safety was evaluated by monitoring serum creatinine levels for symptoms of renal function disorders. The primary end point was the incidence of HIV in PrEP users (100 person-years). The secondary end points were the incidence of STI in PrEP users (100 person-years), incidence of adverse events caused by Truvada, frequency of high-risk sexual activity, and adherence to periodic visits and medication. The study protocol was reviewed and approved by the certified review board of the National Center for Global Health and Medicine (NCGM-C-003129-03) on April 20, 2020. Changes to the study plan were submitted for review by the certified review board and approved before implementation. Recruitment was completed on March 28, 2019, and the study was completed (last adult participant and last time point) on March 31, 2021. The data were analyzed, and the main results of the study have been published in a peer-reviewed journal. The findings indicated that PrEP is a highly effective and feasible strategy against HIV infection in terms of prophylactic response, retention, and compliance. UMIN Clinical Trials Registry UMIN000031040; https://tinyurl.com/3msdkeb8 and Japan Registry of Clinical Trials jRCTs031180134; https://tinyurl.com/2p88mhyr. RR1-10.2196/50919.

Comparative analysis of Basiliximab and Alemtuzumab induction therapies in blood type A2-to-B kidney transplantation: Impact on kidney function and de novo donor-specific HLA antibodies

PurposeBlood group B kidney transplant candidates have lower transplantation rates and longer waiting times compared to other blood groups. Kidney transplantation from blood group A2-to-B has offered a solution for these patients. This study aimed to investigate the impact of Basiliximab and Alemtuzumab induction therapies on kidney function and de novo donor-specific antibodies (DSA) in blood type A2-to-B kidney transplant recipients within the first 12 months of post-transplant. MethodsA retrospective analysis was conducted on 110 consecutive A2-to-B kidney transplant recipients between January 2015 and December 2022. Of these, 46 (41.8%) received Basiliximab, while 64 (58.2%) received Alemtuzumab as induction therapy. Demographics and comorbidities data were collected and compared between the two groups. Serum samples collected at 4- and 12-month intervals post-transplant were used to assess the presence of de novo DSA. Kidney allograft function was evaluated by monitoring serum creatinine levels and assessing Creatinine Clearance based on 24-h urine collection at various time points. ResultsDuring the follow-up period, 20.00% of patients who received Alemtuzumab developed de novo DSA, whereas none of the patients induced with Basiliximab developed de novo DSA (p = 0.038). Recipients who received Basiliximab were older (mean age = 72.00) and received higher Kidney Donor Profile Index (KDPI) kidneys (mean = 75) compared to those induced with Alemtuzumab (mean age = 58.00, mean KDPI = 49) (p < 0.001), with no significant difference observed in the last follow-up creatinine clearance or creatinine levels between the two groups (p = 0.28). ConclusionThe use of Basiliximab as induction immunosuppression in A2-to-B kidney transplant recipients is associated with a lower incidence of de novo HLA DSA formation without significant differences in overall renal function compared to Alemtuzumab.

Abstract 12153: Prevalence and Prognostic Implications of Worsening Renal Function After Acute Myocardial Infarction

Introduction: Limited data exist on the association between longitudinal changes in renal function and long-term clinical outcomes in patients who survive acute myocardial infarction (AMI) events. Hypothesis: We sought to investigate the relationship between worsening renal function (WRF) at one-year follow-up and clinical outcomes at three years after AMI. Methods: We analyzed data from 13,104 patients enrolled in the national AMI registry from November 2011 to December 2015. Patients with all-cause death, recurrent myocardial infarction (re-MI), and re-hospitalization for heart failure (rHHF) at one-year follow-up after AMI were excluded. A total of 6,235 patients were extracted and divided into WRF and non-WRF groups. WRF was defined as a ≥25% decrease in estimated glomerular filtration rate (eGFR) from baseline to one-year follow-up. The primary outcome was three-year major adverse cardiac events (MACE), a composite of all-cause death, re-MI, and rHHF. Results: On average, a -1.5 ml/min/1.73 m 2 /year rate of decline in eGFR was exhibited, and 575 (9.2%) patients exhibited WRF at one-year follow-up. After multiple adjustments, WRF at one-year follow-up was independently associated with increased risks of MACEs (adjusted hazard ratio: 1.498, 95% confidence interval: 1.113-2.016, P =0.01), all-cause death, and re-MI at three-year follow-up (Figure 1). Older age, female, diabetes, hypertension, non-ST segment elevation AMI, anterior AMI, anemia, left ventricular ejection fraction &lt;35%, and baseline eGFR &lt;30 ml/min/1.73 m 2 were identified as independent predictors of WRF after AMI. Conclusions: WRF at one-year follow-up after AMI intuitively seems like a risk marker indicating multiple comorbidities. Monitoring serum creatinine in patients at one-year follow-up after AMI may help to identify those who are at the highest risk and guide effective long-term therapeutics.

Follow-up biopsies identify high rates of persistent rejection inpediatric kidney transplant recipients after treatment of T cell-mediated rejection.

Incomplete resolution of T cell-mediated rejection (TCMR) after treatment may not be detected with serum creatinine monitoring and is associated with donor-specific antibodies and chronic rejection. We evaluate the utility of follow-up biopsies (FUB) to identify and characterize rates of persistent TCMR after treatment in pediatric kidney transplant patients. Patients from two pediatric transplant centers performing standard of care FUB at 1.5-2 months after treatment for TCMR were included. FUB were evaluated for extent of rejection resolution (complete vs. incomplete) and grade. Clinical data at time of FUB and later were reported, where available. Fifty-eight patients underwent FUB, at mean of 1.7 months (SD 0.7) post-index biopsy. Rejection grade on index biopsy was Banff borderline (≥i1t1 and <i2t2) in 59% and Banff ≥1A (≥i2t2) in 41%. Acute rejection was persistent in 32 (55%) of FUB. Borderline rejection had higher rates of complete resolution of rejection compared to grade ≥1A (53% vs. 33%, p = .033). Incomplete resolution of rejection on FUB was re-treated in 25 (78%) of cases. Change in eGFR from index to FUB did not differ between those with complete and incomplete resolution (5.7 ± 32.2 vs. 13.1 ± 51.3, p = .28) and was not a sensitive marker of identifying persistent rejection. FUB were effective at detecting persistent rejection, which was common among pediatric transplant patients after standard TCMR treatment. Until more effective rejection treatments or sensitive biomarkers are available, FUB may be effectively utilized to identify patients with ongoing rejection who would benefit from further treatment.

A Rare Case Series on Cefoperazone Sulbactam Induced Uremia: A Matter of Concern and Awareness

Uraemia is a clinical syndrome marked by elevated concentrations of urea in the blood and is associated with fluid, electrolyte, hormone imbalances and metabolic abnormalities. Cefoperazone + sulbactam is a combination of two medicines: cefoperazone and sulbactam. Cefoperazone is an antibiotic that works by preventing the formation of the bacterial protective covering, which is essential for the survival of bacteria [1]. Sulbactam is a beta-lactamase inhibitor that reduces resistance and enhances the activity of cefoperazone against bacteria [2].&#x0D; Pharmaceutical agents play a central role in diagnostic and therapeutic activities for patient care. However, all agents carry the risk of adverse drug effects. While most of these are clinically insignificant, some drugs may cause unacceptable toxicity that negatively impacts patient morbidity and mortality [3]. Recognizing adverse effects is important for administering appropriate drug doses, implementing preventive strategies, and discontinuing the offending agent when toxicity occurs [2]. In most cases, nephrotoxicity leads to discontinuation of the causative drug, thereby limiting treatment options.&#x0D; One of the biggest challenges lies in our ability to identify nephrotoxicity in its early stages. Monitoring serum creatinine and blood urea nitrogen (BUN) levels is an effective method for identifying renal diseases [4]. In this study, the authors report three cases of isolated cefoperazone-sulbactam-induced uraemia in patients without chronic kidney disease (CKD). A Naranjo assessment score of 5 was obtained for the three case scenarios, indicating a probable relationship between the patient’s uraemia and use of the suspected drug.

Longitudinal Estimated Glomerular Filtration Rate Trajectories in Children with Type 1 Diabetes

Although children with type 1 diabetes (T1D) are at risk for developing diabetic kidney disease (DKD), clinical practice guidelines do not uniformly recommend routine serum creatinine (SCr) monitoring, and data describing changes in renal function from diagnosis are lacking. As part of a quality improvement initiative, the Diabetes Clinic at British Columbia Children’s Hospital in Vancouver, Canada, implemented routine serum SCr monitoring. This study describes estimated glomerular filtration rate (eGFR) trajectories and prevalence of decreased eGFR, hypertension, and albuminuria and their relationship to patterns of nephrology referral in a cohort of children aged ≤18 years (n = 307) with T1D recruited between December 2016 and February 2019. Annualized eGFR (ml/min/1.73 m2 per year) was calculated using the CKiD U25 formula and categorized as declining (&lt;−3), stable (−3 to +3), and inclining (&gt;+3). eGFR was categorized as normal (≥90), mildly decreased (60 to &lt;90), and chronic kidney disease (CKD, &lt;60). In this cohort, 54% were male; the median age at diagnosis and duration of T1D was 6.2 years and 6.9 years, respectively. Over a median follow-up of 2.3 years, declining, stable, and inclining trajectories were observed in 33%, 32%, and 35%, respectively. During their follow-up, 32% had mildly decreased eGFR, elevated blood pressures (≥90th percentile), and/or abnormal urine albumin-creatinine ratios (≥2 mg/mmol), with &lt;10% referred for nephrology assessment. Twenty-three percent of subjects had an eGFR &lt;90; this subgroup was more highly represented in the declining trajectory group (vs. stable and inclining). Logistic regression analysis found female sex and higher baseline eGFR to be associated with a declining eGFR trajectory. In conclusion, these data challenge the commonly held paradigm that renal function remains stable in childhood T1D and supports systematic monitoring of renal function in children with T1D, as well as collaboration across disciplines, particularly endocrinology and nephrology, to provide evidence-based individualized care.

Prevalence and Prognostic Implications of Worsening Renal Function After Acute Myocardial Infarction

We sought to investigate the relation between worsening renal function (WRF) at 1-year follow-up and clinical outcomes at 3 years after acute myocardial infarction (AMI). We analyzed data from 13,104 patients enrolled in the national AMI registry from November 2011 to December 2015. Patients with all-cause death, recurrent myocardial infarction (re-MI), and rehospitalization for heart failure at 1-year follow-up after AMI were excluded. A total of 6,235 patients were extracted and divided into WRF and non-WRF groups. WRF was defined as a ≥25% decrease in estimated glomerular filtration rate (eGFR) from baseline to 1-year follow-up. The primary outcome was 3-year major adverse cardiac events, a composite of all-cause death, re-MI, and rehospitalization for heart failure. On average, a -1.5 ml/min/1.73 m2/y rate of decrease in eGFR was exhibited, and 575 patients (9.2%) exhibited WRF at 1-year follow-up. After multiple adjustments, WRF at 1-year follow-up was independently associated with increased risks of major adverse cardiac events (adjusted hazard ratio 1.498, 95% confidence interval 1.113 to 2.016, p = 0.01), all-cause death, and re-MI at 3-year follow-up. Older age, female, diabetes mellitus, hypertension, non-ST-segment elevation AMI, anterior AMI, anemia, left ventricular ejection fraction <35%, and baseline eGFR <30 ml/min/1.73 m2 were identified as independent predictors of WRF after AMI. In conclusion, WRF at 1-year follow-up after AMI intuitively seems like a risk marker indicating multiple co-morbidities. Monitoring serum creatinine in patients at 1-year follow-up after AMI may help to identify those who are at the highest risk and guide effective long-term therapeutics.

Postoperative Acute Kidney Injury in Geriatric Gynecologic Oncology Patients After Major Open Abdominal Surgery: A Retrospective Cohort Study

Introduction: This investigation’s purpose was to determine the incidence of acute kidney injury, the associated risk factors, and the 90-day outcomes and kidney function of geriatric patients who underwent major open abdominal gynecologic oncologic surgery. Materials and Method: This retrospective cohort study involved patients aged ≥ 65 years who underwent major open abdominal gynecologic oncologic surgery. Results: The postoperative incidence of acute kidney injury in gynecologic oncologic surgical procedures was 22.1%, with a transient nature observed in 72% of patients. The in-hospital mortality rate was 4 %. Kidney function on the 90th day after acute kidney injury development revealed that estimated glomerular filtration rate regressed by over 25% in 6 patients (24%). Acute kidney injury development was associated with surgical time, intraoperative bleeding volume, bowel procedures, the presence of ascites, intraoperative hypotension, vasopressor use, postoperative diuretic use, postoperative hypoalbuminemia, prolonged post-anesthesia care unit, and hospital stay (p &lt; 0.05). A logistic regression analysis of the risk factors for acute kidney injury revealed that surgery duration was a significant one (p &lt; 0.05). Conclusion: Postoperative acute kidney injury is an important postoperative complication associated with the development or progression of chronic kidney disease. This leads to a prolonged stay in the post-anesthesia care unit and in the hospital. Although acute kidney injury is frequently transient in geriatric patients following major open abdominal gynecologic oncologic surgery, developing preventive measures, encouraging team collaboration, and monitoring serum creatinine concentration in the early postoperative period are critical in complex surgical procedures. Keywords: Postoperative Complications; Acute Kidney Injury; Geriatrics.

Impact of care bundles on the occurrence and outcomes of acute kidney injury among patients withST-segment elevation myocardial infarction.

Several reports suggested that compliance with acute kidney injury care bundles among hospitalized patients resulted in improved kidney and patient outcomes. We investigated the effect of acute kidney injury care bundle utilization on the incidence of acute kidney injury and renal outcomes in a large cohort of myocardial infarction patients treated with percutaneous coronary intervention. We included patients withmyocardial infarction admitted following percutaneous coronary intervention between January 2008 and December 2020. From January 2016, acute kidney injury care bundle was implemented in our cardiac intensive care unit. Acute kidney injury care bundle consisted of simple standardized investigations and interventions, including strict monitoring of serum creatinine and urine analysis, planning investigations, treatment, and guidance about seeking nephrologist advice. Patients' records were evaluated for the occurrence of acute kidney injury, its severity, and recovery, before and after the implementation of acute kidney injury care bundle. We included2646 patients (1941 patients in the years 2008-2015 and 705 patients in the years 2016-2020). Implementation of care bundles resulted in a significant decrease in the occurrence of acute kidney injury from 190/1945 to 42/705 (10-6%; p < 0.001), with a trend for lower acute kidney injury score > 1 (20% vs. 25%; p = 0.07) and higher acute kidney injury recovery (62% vs. 45%, p = 0.001). Using a multivariable regression model, the use of care bundles resulted in a 45% decrease in the relative risk for acute kidney injury (HR 0.55, 95% CI 0.37-0.82, p < 0.001). Among patients withST-elevation myocardial infarction, treated with percutaneous coronary intervention and admitted to our cardiac intensive care unit over the period January 2008-December 2020, compliance with acute kidney injury care bundle was independently associated with a significant decrease in occurrence ofacute kidney injury and withbetter renal outcomes following acute kidney injury. Further interventions, such ase-alert systems for acute kidney injury, could improve utilization of the acute kidney injury care bundle and optimize its clinical benefits.

Comprehensive Acute Kidney Injury Survivor Care: Protocol for the Randomized Acute Kidney Injury in Care Transitions Pilot Trial.

Innovative care models are needed to address gaps in kidney care follow-up among acute kidney injury (AKI) survivors. We developed the multidisciplinary AKI in Care Transitions (ACT) program, which embeds post-AKI care in patients' primary care clinic. The objective of this randomized pilot trial is to test the feasibility and acceptability of the ACT program and study protocol, including recruitment and retention, procedures, and outcome measures. The study will be conducted at Mayo Clinic in Rochester, Minnesota, a tertiary care center with a local primary care practice. Individuals who are included have stage 3 AKI during their hospitalization, do not require dialysis at discharge, have a local primary care provider, and are discharged to their home. Patients unable or unwilling to provide informed consent and recipients of any transplant within 100 days of enrollment are excluded. Consented patients are randomized to receive the intervention (ie, ACT program) or usual care. The ACT program intervention includes predischarge kidney health education from nurses and coordinated postdischarge laboratory monitoring (serum creatinine and urine protein assessment) and follow-up with a primary care provider and pharmacist within 14 days. The usual care group receives no specific study-related intervention, and any aspects of AKI care are at the direction of the treating team. This study will examine the feasibility of the ACT program, including recruitment, randomization and retention in a trial setting, and intervention fidelity. The feasibility and acceptability of participating in the ACT program will also be examined in qualitative interviews with patients and staff and through surveys. Qualitative interviews will be deductively and inductively coded and themes compared across data types. Observations of clinical encounters will be examined for discussion and care plans related to kidney health. Descriptive analyses will summarize quantitative measures of the feasibility and acceptability of ACT. Participants' knowledge about kidney health, quality of life, and process outcomes (eg, type and timing of laboratory assessments) will be described for both groups. Clinical outcomes (eg, unplanned rehospitalization) up to 12 months will be compared with Cox proportional hazards models. This study received funding from the Agency for Health Care Research and Quality on April 21, 2021, and was approved by the Institutional Review Board on December 14, 2021. As of March 14, 2023, seventeen participants each have been enrolled in the intervention and usual care groups. Feasible and generalizable AKI survivor care delivery models are needed to improve care processes and health outcomes. This pilot trial will test the ACT program, which uses a multidisciplinary model focused on primary care to address this gap. ClinicalTrials.gov NCT05184894; https://www.clinicaltrials.gov/ct2/show/NCT05184894. DERR1-10.2196/48109.

Impact of care bundles on the occurrence and outcomes of acute kidney injury among myocardial infarction patients

Abstract Funding Acknowledgements Type of funding sources: None. Background Among Patients with myocardial infarction hospitalized patients, deterioration of renal function resulting in acute kidney injury (AKI) is an important complication, associated with increased length of hospital stay, morbidity and mortality. Given large variation in care for AKI patients and poor outcomes of AKI, the interest in implementing care bundles for AKI is growing. Several reports suggested that compliance with AKI bundles among hospitalized patients resulted in better kidney and patient outcomes non, however, included acute cardiac patients. Purpose We investigated the effect of AKI care bundle (AKI-CB ) utilization on the incidence and renal outcomes of AKI in a large cohort of myocardial infarction patients treated percutaneous coronary intervention (PCI). Methods We Included ST elevation myocardial infarction (STEMI) patients admitted to the cardiac intensive care unit following PCI between January 2008- December 2020. From January 2016 AKI- CB was implemented in our cardiac intensive care unit. AKI-CB consisted of simple standardized investigations and interventions, reminding clinicians of the importance of early AKI detection, management, via strict monitoring of serum creatinine and urine analysis, planning investigations and treatment and guidance about seeking nephrologist advice. .Patients' records were evaluated for the occurrence of AKI, its severity, AKI recovery, length of hospital stay and long term mortality before and after the implementation of AKI-CB. Results 2646 patients were included (1945 patients in the years 2008-2015 and 705 patients in the years 2016-2020). Overall, 232 AKI episodes occurred within the study period (232/2646, 8.7%). Implementation of care bundles resulted in a decrease in the occurrence of AKI from 190/1945 ( 10%) to 42/705 (6%); P&amp;lt;0.001, with a trend for lower AKI score&amp;gt;1 (20% vs. 25% ; p=0.07), higher AKI recovery ( 62% vs. 45% , p=0.001) and reduction in the length of hospital stay ( 5.2± 6 days vs. 5.9 ± 5 days ; p=0.02). Over a median follow up period of 48 month, mortality was significantly lower following implementation of AKI-CB ( 3.7% vs. 5.8%,p=0.002,figure 1). Using a multivariable regression model, the use of care bundles resulted in a 45% decrease in the relative risk for AKI (HR 0.55, 95% CI 0.37-0.82, p=0.003; figure 2). Conclusion Among STEMI patients, compliance with AKI-CB was independently associated with a decrease in AKI occurrence and better renal outcomes following an AKI event. Further interventions are required to improve utilization of the AKI-CB.

Acute supratherapeutic vancomycin serum concentration in a premature neonate: a case report

Vancomycin, a glycopeptide, is a first-line agent in the neonatal population for the treatment of suspected or confirmed Gram-positive infections, including methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative Staphylococci (CoNS).1,2 Vancomycin dosing strategies vary greatly and are generally based on factors such as post-menstrual age (PMA), post-natal age (PNA), and serum creatinine (SCr). Recommended starting doses can range from 10 to 15 mg/kg/dose every 6 to 48 hours, depending upon infection site, suspected organism, desired serum vancomycin trough concentration/area under the curve (AUC), and/or minimal inhibitory concentration (MIC) to vancomycin. Nephrotoxicity in patients receiving vancomycin has been systematically documented in adults and less often in neonates, with a reported occurrence of 1-9% when receiving recommended dosing.1 Risk of toxicity can be minimized through dosage modifications and close monitoring of SCr and urine output at baseline and throughout therapy.2 This case report describes the use of vancomycin, dosed at 10 mg/kg, in a premature infant born at 26 weeks and 4 days gestation for CoNS pneumonia. The infant showed signs of renal dysfunction, prompting a pre-steady state vancomycin serum concentration lab draw, resulting in a concentration of 102.2 µg/mL. Serial repeat vancomycin serum concentrations showed a linear excretion pattern and an ARCHITECT iVancomycin assay completed by medical laboratory scientists confirmed the concentration of the vancomycin aliquot prepared by the inpatient pharmacy department. Renal ultrasound established return to normal renal function; however, the infant failed routine newborn hearing screening upon NICU (neonatal intensive care unit) discharge due to suspected vancomycin-induced ototoxicity.

Acute kidney injury among preterm infants receiving nonsteroidal anti-inflammatory drugs: A pilot study.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a frequently prescribed class of medications in the neonatal intensive care unit (NICU). We aimed to reveal acute kidney injury (AKI) epidemiology in NSAID-exposed premature infants admitted to the NICU using a standardized definition and determine the percentage of NSAID-exposed patients with adequate serum creatinine (SCr) monitoring. This retrospective study compared infants born at ≤34 weeks gestational age who received NSAID for intraventricular hemorrhage prophylaxis (prophylaxis group) or symptomatic treatment for patent ductus arteriosus (PDA; treatment group) between January and December 2014at a tertiary NICU. All available SCr and 12-h urine output (UO) values were recorded from admission until day seven post-NSAID exposure. AKI incidence was determined using the neonatal modified Kidney Disease Improving Global Outcomes classification, defined as an increase in SCr (i.e., 1.5 fold rise from previous SCr measurement within seven days or 26.5mmol/L increase within 48h) or UO<1mL/kg/hour, excluding the first 24h of life. We identified 70 eligible subjects; 32 received prophylactic NSAIDs, and 38 received indomethacin or ibuprofen for treating symptomatic PDA. AKI incidence for the entire cohort was 23% (16/70). The prophylaxis group had a significantly lower AKI rate than the treatment group (9% vs. 34%; p=0.014). The treatment group had a higher proportion of infants with adequate SCr monitoring during NSAID treatment than the prophylaxis group (87% vs. 13%, p<0.001). NSAID-associated AKI occurred in approximately one-quarter of premature infants overall, and the AKI incidence was higher in infants treated with NSAIDs for the symptomatic treatment of PDA than in those receiving prophylactic treatment during the first day of life. Standardized protocols for monitoring daily SCr and UO after exposure should be implemented for all neonates with NSAID exposure to improve early AKI recognition and management.

Acute kidney injury post-abdominal surgery in infants: implications for prevention and management.

Acute kidney injury (AKI) is common in critically ill infants and is associated with long-term sequelae including hypertension and chronic kidney disease. The etiology of AKI in infants is multifactorial. There is robust literature highlighting the risk of AKI after cardiothoracic surgery in infants. However, risk factors and outcomes for AKI in infants after abdominal surgery remains limited. This article reviews the epidemiology and association of abdominal surgery with postoperative AKI and suggests methods for AKI management and prevention. Postoperative AKI may result from hemodynamic shifts, hypoxia, exposure to nephrotoxic medications, and inflammation. Infants in the intensive care unit after intraabdominal surgeries have a unique set of risk factors that predispose them to AKI development. Prematurity, sepsis, prolonged operation time, emergent nature of the procedure, and diagnosis of necrotizing enterocolitis increase risk of AKI after intrabdominal surgeries. Prevention, early diagnosis, and management of AKI post-abdominal surgery is imperative to clinical practice. Close monitoring of urine output, serum creatinine, and fluid status is necessary in infants after abdominal surgery. A recent study suggests elevated levels of a urinary biomarker, neutrophil gelatinase-associated lipocalin (NGAL), 24 h after an abdominal procedure may improve early prediction of AKI. Identification of risk factors, avoidance of nephrotoxic medications, careful fluid balance, early detection of AKI, and maintenance of hemodynamic stability is imperative to potentially prevent and/or mitigate AKI.

Implementation of the Kidney Disease Improving Global Outcomes guidelines for the prevention of acute kidney injury after cardiac surgery: An international cohort survey.

Increasing evidence from randomised controlled trials supports the implementation of a six-measure care bundle proposed by the Kidney Disease Improving Global Outcomes (KDIGO) guidelines in patients at high risk for acute kidney injury (AKI) to reduce its incidence after cardiac surgery. To assess compliance with the KDIGO bundle in clinical practice. Prospective observational multinational study. Six international tertiary care centres, from February 2021 to November 2021. Five hundred and thirty-seven consecutive patients undergoing cardiac surgery during a 1-month observational period. All patients were assessed for the postoperative implementation of the following measures: avoidance of nephrotoxic medication and radiocontrast agents whenever possible, strict glycaemic control, close monitoring of renal function, optimisation of haemodynamic and volume status and functional monitoring of haemodynamic status. The primary endpoint was the proportion of patients receiving fully compliant care. Secondary outcomes were occurrence of AKI and major adverse kidney event rate at day 30. The full care bundle was applied to 0.4% of patients. There was avoidance of nephrotoxic drugs in 15.6%, radiocontrast agents in 95.3% and hyperglycaemia in 39.6%. Close monitoring of urine output and serum creatinine was achieved in 6.3%, 57.4% underwent optimisation of volume and haemodynamic status, and 43.9% received functional haemodynamic monitoring. 27.2% developed AKI within 72 h after surgery. The average number of implemented measures was 2.6 ± 1.0 and did not differ between AKI or non-AKI patients ( P = 0.854). Adherence with the KDIGO bundle was very low in cardiac surgery patients. Initiatives to improve guideline compliance might provide a strategy to mitigate the burden of AKI. www.drks.de DRKS00024204.