Urine Output Rate Research Articles

Effect of Midodrine in Non-azotemic Liver Cirrhosis Patients with Refractory or Recurrent Ascites

Objectives To study the effectiveness of midodrine in treatment of refractory, recurrent ascites in nonazotemic liver cirrhosis patients. Material and Methods This is a facility-based open-label parallel design randomized controlled trial conducted at the Regional Institute of Medical Sciences (RIMS), Imphal. All patients above the age of 18 with non-azotemic liver cirrhosis with refractory or recurrent ascites patients attending medicine out patient department (OPD), liver clinic, and those admitted to the medicine ward, RIMS, Imphal, were enrolled. After getting informed consent, the patients were allocated to standard medical therapy (SMT) with the midodrine group (group A) and the SMT group (group B). Since there were two treatment options involved, a block size of four was used. Possible treatment allocation within each block was (1) AABB, (2) BBAA, (3) ABAB, (4) BABA, (5) ABBA and (6) BAAB. Both the study participants and the investigator were double-blinded. Mean arterial blood pressure, weight, frequency and volume of indicated large volume paracentesis (LVP), volume of urine in 24-hour, Estimated glomerular filtration rate (eGFR) by Cockcroft-Gault equation, and Child-Pugh classification score were calculated and recorded. Complete blood counts (CBC), liver function test (LFT), coagulation profile (prothrombin time (PT) and international normalized ratio (INR)), kidney function test (KFT), serum lipid profile, serology (HbsAg, Anti-hepatitis C virus (HCV) Ab, human immunodeficiency virus (HIV) 1&2), antinuclear antibody (ANA), ascitic fluid study, urine analysis, chest X-ray, Electrocardiogram (ECG) and echocardiography (patients with coronary artery disease, valvular heart disease with left ventricular (LV) systolic dysfunction or cardiomyopathy were excluded) were also done. computed tomography (CT) abdomen and upper gastrointestinal (GI) endoscopy (if indicated) were considered. The analysis was done using SPSS (trial version 23) software. A p-value < 0.05 was considered statistically significant. Results The present study enrolled 40 non-azotemic liver cirrhosis with refractory or recurrent ascites patients. In this study, after one month of treatment, there was a significant increase in urine output in the midodrine group compared with the SMT group (p-value 0.006). There was no statistical difference in model for end stage liver disease (MELD) scores after treatment among the groups. Mean arterial pressure (MAP), urine output, and glomerular filtration rate (GFR) were significantly higher in the midodrine group compared to the standard medical therapy (SMT) group after one month of treatment and were statistically significant and different. Conclusion The results of this randomized controlled trial (RCT) suggest that adding midodrine drug to the SMT group improves the systemic hemodynamics in non-azotemic cirrhotic patients with ascites, and it is also effective in lowering the body weights of the patients by decreasing the fluid accumulation. More clinical trials need to be conducted among a large number of patients before midodrine can be recommended for use in the patients.

Development and Validation of an Interpretable Machine Learning Model for Early Prognosis Prediction in ICU Patients with Malignant Tumors and Hyperkalemia.

This study aims to develop and validate a machine learning (ML) predictive model for assessing mortality in patients with malignant tumors and hyperkalemia (MTH). We extracted data on patients with MTH from the Medical Information Mart for Intensive Care-IV, version 2.2 (MIMIC-IV v2.2) database. The dataset was split into a training set (75%) and a validation set (25%). We used the Least Absolute Shrinkage and Selection Operator (LASSO) regression to identify potential predictors, which included clinical laboratory indicators and vital signs. Pearson correlation analysis tested the correlation between predictors. In-hospital death was the prediction target. The Area Under the Curve (AUC) and accuracy of the training and validation sets of 7 ML algorithms were compared, and the optimal 1 was selected to develop the model. The calibration curve was used to evaluate the prediction accuracy of the model further. SHapley Additive exPlanations (SHAP) and Local Interpretable Model-agnostic Explanations (LIME) enhanced model interpretability. 496 patients with MTH in the Intensive Care Unit (ICU) were included. After screening, 17 clinical features were included in the construction of the ML model, and the Pearson correlation coefficient was <0.8, indicating that the correlation between the clinical features was small. eXtreme Gradient Boosting (XGBoost) outperformed other algorithms, achieving perfect scores in the training set (accuracy: 1.000, AUC: 1.000) and high scores in the validation set (accuracy: 0.734, AUC: 0.733). The calibration curves indicated good predictive calibration of the model. SHAP analysis identified the top 8 predictive factors: urine output, mean heart rate, maximum urea nitrogen, minimum oxygen saturation, minimum mean blood pressure, maximum total bilirubin, mean respiratory rate, and minimum pH. In addition, SHAP and LIME performed in-depth individual case analyses. This study demonstrates the effectiveness of ML methods in predicting mortality risk in ICU patients with MTH. It highlights the importance of predictors like urine output and mean heart rate. SHAP and LIME significantly enhanced the model's interpretability.

Fluid balance during physical work in the heat is not modified by the menstrual cycle when fluids are freely available.

We tested the hypothesis that women may be more at risk of becoming dehydrated during physical work in the heat in the early follicular phase (EF), compared with the late follicular (LF) and mid-luteal (ML) phases of the menstrual cycle when allowed free access to drink. Twelve healthy, eumenorrheic, unacclimated women (26 ± 5 yr) completed three trials (EF, LF, and ML phases) involving 4 h of exposure to 33.8 ± 0.8 °C, 54 ± 1% relative humidity. Each hour, participants walked on a treadmill for 30 min at a rate of metabolic heat production of 338 ± 9 W. Participants drank a cool, flavor-preferred non-caloric sport drink ad libitum. Nude body weight was measured pre- and post-exposure, and percent changes in body weight loss were interpreted as an index of changes in total body water. Total fluid intake and urine output were measured and sweat rate was estimated from changes in body mass corrected for fluid intake and urine output. Fluid intake was not different between phases (EF: 1,609 ± 919 mL; LF: 1,902 ± 799 mL; ML: 1,913 ± 671; P = 0.202). Total urine output (P = 0.543) nor sweat rate (P = 0.907) differed between phases. Percent changes in body mass were not different between phases (EF: -0.5 ± 0.9%; LF: -0.3 ± 0.9%; ML: -0.3 ± 0.7%; P = 0.417). This study demonstrates that the normal hormonal fluctuations that occur throughout the menstrual cycle do not alter fluid balance during physical work in the heat.NEW & NOTEWORTHY The effect of the menstrual cycle on fluid balance during physical work in the heat when fluids are freely available is unknown. This study demonstrates that fluid balance is not modified in women across three distinct phases of the menstrual cycle during physical work in the heat These results indicate that when women have free access to cool fluid during physical work in the heat, they respond similarly across all three phases to maintain fluid homeostasis across the menstrual cycle.

MP24-08 THE CLINICAL FEATURE AND SIGNIFICANCE OF VESICAL ADAPTATION RESPONSE TO DIURESIS IN MALE LUTS PATIENTS

You have accessJournal of UrologyCME1 Apr 2023MP24-08 THE CLINICAL FEATURE AND SIGNIFICANCE OF VESICAL ADAPTATION RESPONSE TO DIURESIS IN MALE LUTS PATIENTS Kanako Matsuoka, Kei Yaginuma, Yu Endo, Yuki Harigane, Yuta Matsuoka, Yuki Yoshida, Hitomi Imai, Akifumi Onagi, Seiji Hoshi, Tomoyuki Koguchi, Junya Hata, Yuichi Sato, Hidenori Akaihata, Masao Kataoka, and Yoshiyuki Kojima Kanako MatsuokaKanako Matsuoka More articles by this author , Kei YaginumaKei Yaginuma More articles by this author , Yu EndoYu Endo More articles by this author , Yuki HariganeYuki Harigane More articles by this author , Yuta MatsuokaYuta Matsuoka More articles by this author , Yuki YoshidaYuki Yoshida More articles by this author , Hitomi ImaiHitomi Imai More articles by this author , Akifumi OnagiAkifumi Onagi More articles by this author , Seiji HoshiSeiji Hoshi More articles by this author , Tomoyuki KoguchiTomoyuki Koguchi More articles by this author , Junya HataJunya Hata More articles by this author , Yuichi SatoYuichi Sato More articles by this author , Hidenori AkaihataHidenori Akaihata More articles by this author , Masao KataokaMasao Kataoka More articles by this author , and Yoshiyuki KojimaYoshiyuki Kojima More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003249.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The bladder storage function has a homeostatic system that continuously varies voided volume at each void in response to changes in bladder filling rate. Specifically, high diuresis increases the voided volume at each voiding, and low diuresis decreases the voided volume at each voiding. Attention has recently focused on this system named vesical adaptation response to diuresis (VARD). We have reported that patients with lower urinary tract symptoms (LUTS) lacked VARD (Haga et al. PLoS One, 2016). Although VARD seems to be important to maintain lower urinary tract function, the clinical feature and significance of VARD remains unknown. Therefore, the aim of this study is to determine what factors influence VARD in male patients with LUTS. METHODS: Ninety-four male patients older than 60 years old (age 76.5±6.6 years) with LUTS who attended our hospital between 2017 and 2019 were included in this study. Overactive Bladder Symptom Score (OABSS), 24-h frequency-volume charts (FVCs), uroflowmetry, and ultrasonography to measure prostate volume were evaluated. Exclusion criteria were apparent neurogenic lower urinary tract dysfunction, acute urinary tract infection, and needed urethral catheterization. VARD was defined by the presence of a significant correlation coefficient (γ) between urine output rate and voided volume at each voiding on FVCs (γ>0.4, p<0.05). According to the presence or absence of VARD, patients were divided into two groups: VARD presence (n=48) and VARD absence groups (n=46). The patient characteristics and parameters of lower urinary tract functions were compared between two groups, with p<0.05 considered significant. RESULTS: The number of OAB patients was significantly higher in the VARD absence group than in the VARD presence group (p=0.04). The prostate volume tended to be higher in VARD absence group. The multivariate analysis revealed that OAB and prostate enlargement (BPE) were significantly related to the VARD absence group (OAB: aOR 3.76, 95%CI: 1.34-10.6, p=0.01, BPE: aOR = 1.04, 95% CI: 1.01-1.07, p=0.02). CONCLUSIONS: The OAB and BPE were independent risk factors for the lack of VARD in male LUTS patients. Increased afferent nerve activity from the lower urinary tract associated with OAB and BPE might lack VARD, resulting in increased urinary frequency during a high-diuretic phase. The VARD could be more a useful objective marker to measure the bladder storage function than the symptom questionnaire for LUTS. Source of Funding: Nothing © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e320 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kanako Matsuoka More articles by this author Kei Yaginuma More articles by this author Yu Endo More articles by this author Yuki Harigane More articles by this author Yuta Matsuoka More articles by this author Yuki Yoshida More articles by this author Hitomi Imai More articles by this author Akifumi Onagi More articles by this author Seiji Hoshi More articles by this author Tomoyuki Koguchi More articles by this author Junya Hata More articles by this author Yuichi Sato More articles by this author Hidenori Akaihata More articles by this author Masao Kataoka More articles by this author Yoshiyuki Kojima More articles by this author Expand All Advertisement PDF downloadLoading ...

Acute Kidney Injury: Medical Causes and Pathogenesis.

Acute kidney injury (AKI) is a common clinical syndrome characterized by a sudden decline in or loss of kidney function. AKI is not only associated with substantial morbidity and mortality but also with increased risk of chronic kidney disease (CKD). AKI is classically defined and staged based on serum creatinine concentration and urine output rates. The etiology of AKI is conceptually classified into three general categories: prerenal, intrarenal, and postrenal. Although this classification may be useful for establishing a differential diagnosis, AKI has mostly multifactorial, and pathophysiologic features that can be divided into different categories. Acute tubular necrosis, caused by either ischemia or nephrotoxicity, is common in the setting of AKI. The timely and accurate identification of AKI and a better understanding of the pathophysiological mechanisms that cause kidney dysfunction are essential. In this review, we consider various medical causes of AKI and summarize the most recent updates in the pathogenesis of AKI.

Could melatonin prevent Vancomycin-induced nephrotoxicity in critically ill patients? A randomized, double-blinded controlled trial.

Previous research showed some clinical benefits regarding the nephroprotective effect of melatonin. So, this study aimed to evaluate the beneficial effect of oral melatonin on preventing acute kidney injury (AKI) in patients who received vancomycin therapy in the intensive care unit (ICU). We performed a randomized, double-blinded, placebo-controlled pilot study in an academic hospital. Adult patients admitted to the ICU who received vancomycin with normal gastrointestinal and kidney function were randomized into treatment or placebo groups. After that, enrolled patients received a tablet of melatonin (3 mg) or placebo twice daily for seven consecutive days. The occurrence of AKI was assessed by RIFLE criteria (by measurement of serum creatinine (SCr)) and plasma neutrophil gelatinase-associated lipocalin (NGAL) concentration. Moreover, other data related to renal functions and SOFA were also compared between groups. A total of 90 patients were included in the study, while 21patients in the placebo group and 20 in the intervention group completed the study. There were no significant differences between groups regarding baseline SCr, BUN, urine output, NGAL, SOFA, and glomerular filtration rate (GFR). Our results showed that these differences remained insignificant after a 7-day follow-up between groups. However, the incidence of AKI was significantly lower in the melatonin group based on the NGAL cutoff (> 150 ng/mL). We detected a significant decrease in vancomycin-induced nephrotoxicity incidence in patients receiving melatonin compared to placebo. However, more clinical trials in a larger population were required to confirm this result.

Abstract P107: Adam 10 &amp; 17 Double-knockout Impairs Renal And Vascular Functions And Induces Hypertension By Altering The Renal Proteomic Profiles

Background: ADAM 10 &amp; 17, the two most well-known members of disintegrin and metalloproteinases (ADAMs), are responsible for the cleavage of diverse transmembrane proteins into bioactive molecules in the renal tubular cells. Objective: The purpose of this study is to understand the effects of ADAM 10 &amp; 17 double-knockout (DKO) on renal and vascular functions using the renal tubular cell-specific ADAM 10 &amp; 17 DKO mice. Results: We tested the renal and vascular functions in three groups (n=10-15 per group) of male and female wild-type (WT), vehicle, and DKO mice. The urine output ( P &lt; 0.05) and glomerular filtration rate ( P &lt; 0.01) of DKO mice were significantly lower than those of WT and vehicle control groups. The urinary sodium ( P &lt; 0.0001) and potassium ( P &lt; 0.01) excretion in DKO mice were also significantly reduced. Consistently, we found a significant decrease in urea ( P &lt; 0.0001) and creatinine ( P &lt; 0.0001) clearance in DKO mice, suggesting that the renal function is impaired when both ADAM 10 &amp; 17 are depleted. In addition, the pulse wave velocity ( P &lt; 0.0001), and blood pressure including systolic blood pressure ( P -value &lt; 0.0001), diastolic blood pressure ( P &lt; 0.0001), and mean blood pressure ( P &lt; 0.0001) levels of DKO mice were significantly higher than those of WT and vehicle controls, indicating that ADAM 10 &amp; 17 depletion impairs renal and vascular functions and causes hypertension. This phenomenon is further supported by the evidence that DKO mice showed a slower relaxation response to acetylcholine, compared to WTs. Next, to understand the changes in proteomic profiles in DKO kidneys, we performed proteomic analysis of WT and DKO kidney tissues and identified ~100 differentially expressed proteins (DEPs). These DEPs are highly enriched in drug metabolism, metabolic pathways, and TGF-beta signaling, PPAR-signaling and AGE-RAGE signaling pathways, suggesting that ADAM 10 &amp; 17 may play a role in renal cellular metabolism, cell growth, differentiation, and apoptosis. Conclusions: The depletion of ADAM 10 &amp; 17 impairs the renal and vascular functions likely via disrupting the cellular metabolism and homeostasis.

8 Less Is More: Reconsidering Hourly Urine Output Goals in Burn Resuscitation

IntroductionSignificant morbidity and mortality is seen with high volume burn resuscitations. Surpassing the Ivy Index, defined as 250 milliliters/kilogram (ml/kg), has been correlated with increased incidence of complications such as abdominal compartment syndrome. Cognizance of factors contributing to over-resuscitation can help optimize fluid administration strategies to minimize associated morbidity.MethodsA single-center Quality Improvement review was performed of all adult (age ≧ 18 years) burn-injured patients presenting to a major metropolitan burn center with burns ≧ 20% total body surface area (TBSA) between 12/2020-8/2021. Those not surviving the first 24 hours were excluded. Patient demographics and injury characteristics were collected, and resuscitation volumes and timing were recorded prospectively. Patients were categorized by whether their initial 24-hour intake exceeded their Ivy Index, and groups were compared to assess factors associated with over-resuscitation.ResultsDuring the study period 11 patients met inclusion criteria, and one early mortality was excluded. Patients were predominantly male (70.0%), with mean age 49.9±17.4 years. Burns were primarily due to flame injury, with mean TBSA 41.4±18.6%. Patients required resuscitation volumes of 5.9±1.7 ml/kg/TBSA%, with half surpassing their Ivy Index in the first 24 hours. These patients had larger burns (55.1±17.0% v. 27.7±5.1%) with a significantly higher third degree component (41.4±15.8% v. 15.4±15.2%, p = 0.029). None had diagnosed inhalation injury, and none required abdominal decompression for resuscitation-related compartment syndrome. Observed mortality rate was 30.0%. Patients resuscitating beyond their Ivy Index had significantly higher hourly urine output rates (0.96 v. 0.52 ml/kg, p = 0.024), and hourly urine output was significantly higher among non-survivors as compared to survivors (1.10 v. 0.60 ml/kg, p = 0.033).ConclusionsPatients with severe burn injury are at high risk for over-resuscitation and associated complications. While traditional teaching instructs a goal of hourly urine output of 0.5-1.0 ml/kg, our study shows that patients resuscitated on the higher end of this range were significantly more likely to surpass their Ivy Index and less likely to survive.

Contrast Induced Nephropathy: Efficacy of matched hydration and forced diuresis for prevention in patients with impaired renal function undergoing coronary procedures-CINEMA trial.

BackgroundMatched hydration and forced diuresis (MHFD) using the RenalGuard device has been shown to reduce contrast induced nephropathy (CIN) following coronary interventions.AimTo evaluate the potential benefits of a non-automated MHFD protocol compared to current hydration protocol in prevention of CIN in patients with CKD.MethodsA total of 1,205 patients were randomized to either non-automated MHFD group (n = 799) or intravenous hydration control group (n = 406). The MHFD group received 250 ml IV normal saline over 30 min before the coronary procedure followed by 0.5 mg/kg IV furosemide. Hydration infusion rate was manually adjusted to replace the patient's urine output. When urine output rate reached > 300 ml/h, patients underwent coronary procedure. Matched fluid replacement was maintained during the procedure and for 4-hour post-treatment. CIN was defined conventionally as ≥ 25% or ≥ 0.5 mg/dl rise in serum creatinine over baseline.ResultsCIN occurred in 121 of 1,205 (10.0%) patients in our study. With respect to the primary outcome, 64 (8.01%) of the MHFD patients developed CIN compared with 57 (14.04%) of the control group (p < 0.001).ConclusionsA non-automated MHFD protocol is an effective and safe method for the prevention of CIN in patients with CKD.

SAFETY OF PROPOFOL ANESTHESIA DURING NEUROSURGICAL OPERATIONS.

The aim: The purpose of this study was to assess the safety of propofol use during neurosurgical operations of different durations. Materials and methods: 72 patients were divided into three groups depending on the type of operations; it were group 1 (ventriculostomy), group 2 (hematoma removal), and group 3 (tumor removal), the anesthesia durations in these groups were 65±5 min, 145±7 min and 225±10 min, respectively. Total propofol doses in patients of groups 1, 2, and 3 were 452±22 mg, 710±42 mg, and 966±51 mg, respectively. Before intervention and 1 h post operation, blood gas composition, serum levels of transaminase, triglycerides, creatine phosphokinase, and potassium, rate of urine output, level of mean arterial pressure, and heart rhythm rate were determined. Results: No significant deviations concerning hemodynamic indicators, blood gas composition, changes of creatine kinase activity were found for any group patients during the perioperative period. The rate of urine output in all patients reached above 0.5 ml/kg/h without saluretics use. The deviated transaminase values returned to their normal ones during 24 h post intervention. The triglycerides levels were in normal range proving the absence of propofol doses used on the lipid metabolism. Conclusions: Anesthetic protection of neurosurgical interventions using propofol in doses 2.5-3 mg/kg and 3.60.3 mg/kg/h for induction anesthesia and for anesthesia support, respectively, is safe and does not lead to dangerous undesired consequences. However, the propofol use for prolonged patient sedation and his/her adaptation for prolonged lung ventilation needs further studies.

Acute kidney injury after cardiac surgery in children

Acute kidney injury (AKI) after cardiac surgery in children remains a common clinical concern. The approaches developed recently and applied in clinical practice have sufficiently helped in clarifying the epidemiology, risk factors and pathophysiology of AKI in paediatric cardiac surgery. Pediatric Risk, Injury, Failure, Loss, End-Stage Renal Disease criteria (pRIFLE), Acute Kidney Injury Network (AKIN) and Kidney Disease: Improving Global Outcomes (KDIGO), which are based on changes in serum creatinine levels and urine output rate, enable the identification and ranking of AKI according to severity. However, the diagnostic strategies for AKI have developed beyond creatinine levels and recommend the use of markers of renal tissue damage. Currently, two markers, neutrophil gelatinase-associated lipocalin and TIMP-2/IGFBP-7 (tissue inhibitor of metalloproteinase 2 and protein that binds insulin-like growth factor-7), can be used for the early diagnosis of AKI in paediatric cardiac surgery. Various risk factors, both renal and extrarenal, can predict AKI after cardiac surgery, among which age, the duration of cardiopulmonary bypass and the need for mechanical ventilation and inotropic support before surgery, are the most significant. Strategies for addressing modifiable risk factors (maintaining appropriate perfusion pressure during cardiopulmonary bypass and avoiding nephrotoxic drugs and fluid overload) will reduce the risk of developing AKI. There has been a significant increase in survival rates due to the introduction of ultrafiltration techniques and the early initiation of renal replacement therapy in the postoperative period. The purpose of this review is to analyse the current literature data on AKI in paediatric cardiac surgery. The review results demonstrate the differences in the incidence of AKI associated with cardiac surgery and the effectiveness of certain methods for prevention and treatment of this complication. Further comprehensive research on the issue of AKI in children, creation of medical electronic databases on patients, minimisation of the influence of possible risk factors and timely prevention and treatment of complications would prevent the development of AKI and reduce the possibility of complication progression to a more severe stage. Received 12 April 2021. Revised 24 June 2021. Accepted 25 June 2021. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Contribution of the authors: The authors contributed equally to this article.

Insights into the development of a new index, vesical adaptation response to diuresis, for understanding lower urinary tract dysfunction.

To clarify how vesical adaptation response, the homeostatic system that constantly changes voided volume to adapt to diuresis, is involved in male lower urinary tract symptoms and bladder storage function. We included male patients older than 65 years with lower urinary tract symptoms. Vesical adaptation response to diuresis was defined as a positive correlation between urine output rate and voided volume on 3-day sensory-related frequency volume charts. Patients were divided into two groups according to the presence or absence of vesical adaptation response to diuresis, and characteristics were compared between groups. Ninety-four male patients were finally analyzed. Vesical adaptation response to diuresis was found in 48 patients (51%) and was lacking in 46 patients (49%). Patients without vesical adaptation response to diuresis were significantly more often diagnosed with overactive bladder (P = 0.04). After adjusting for confounders, absence of vesical adaptation response to diuresis was significantly associated with overactive bladder (adjusted odds ratio 3.76, 95% confidence interval 1.34-10.55; P = 0.01) and benign prostatic enlargement (adjusted odds ratio 1.04, 95% confidence interval 1.01-1.07; P = 0.02). The absence of vesical adaptation response to diuresis, characterized by decreased voided volume during a diuretic phase, can be interpreted as a form of bladder storage dysfunction. Assessment of vesical adaptation response to diuresis may provide a new index of bladder storage function and contribute to a better understanding of the pathophysiology underlying bladder storage dysfunction in patients with lower urinary tract symptoms.

Does Artificial Intelligence Make Clinical Decision Better? A Review of Artificial Intelligence and Machine Learning in Acute Kidney Injury Prediction.

Acute kidney injury (AKI) is a common complication of hospitalization that greatly and negatively affects the short-term and long-term outcomes of patients. Current guidelines use serum creatinine level and urine output rate for defining AKI and as the staging criteria of AKI. However, because they are not sensitive or specific markers of AKI, clinicians find it difficult to predict the occurrence of AKI and prescribe timely treatment. Advances in computing technology have led to the recent use of machine learning and artificial intelligence in AKI prediction, recent research reported that by using electronic health records (EHR) the AKI prediction via machine-learning models can reach AUROC over 0.80, in some studies even reach 0.93. Our review begins with the background and history of the definition of AKI, and the evolution of AKI risk factors and prediction models is also appraised. Then, we summarize the current evidence regarding the application of e-alert systems and machine-learning models in AKI prediction.

Goal-directed fluid therapy in autologous breast reconstruction results in less fluid and more vasopressor administration without outcome compromise

Aggressive or restricted perioperative fluid management has been shown to increase complications in patients undergoing microsurgery. Goal-directed fluid therapy (GDFT) aims to administer fluid, vasoactive agents, and inotropes according to each patient's hemodynamic indices. This study assesses GDFT impact on perioperative outcomes of autologous breast reconstruction (ABR) patients, as there remains a gap in management understanding. We hypothesize that GDFT will have lower fluid administration and equivocal outcomes compared to patients not on GDFT.A single-center retrospective review was conducted on ABR patients from January 2010-April 2017. An enhanced recovery after surgery (ERAS) using GDFT was implemented in April 2015. With GDFT, patients were administered intraoperative fluids and vasoactive agents according to hemodynamic indices. Patients prior to April 2015 were included in the pre-ERAS cohort. Primary outcomes included the amount and rate of fluid delivery, urine output (UOP), vasopressor administration, major (i.e., flap failure) and minor (i.e., seroma) complications, and length of stay (LOS).Overall, 777 patients underwent ABR (ERAS: 312 and pre-ERAS: 465). ERAS patients received significantly less total fluid volume (ERAS median: 3750 mL [IQR: 3000-4500 mL]; pre-ERAS median: 5000 mL [IQR 4000-6400 mL]; and p<0.001), had lower UOP, were more likely to receive vasopressor agents (47% vs 35% and p<0.001), and had lower LOS (ERAS: 4 days [4-5]; pre-ERAS: 5 [4-6]; and p<0.001) as compared to pre-ERAS patients. Complications did not differ between cohorts.GDFT, as part of ERAS, and the prudent use of vasopressors were found to be safe and did not increase morbidity in ABR patients. GDFT provides individualized perioperative care to the ABR patient.

Avoiding the night terrors: the effect of circadian rhythm on post-operative urine output and blood pressure in free flap patients

Multiple studies demonstrate the importance of goal-directed fluid regimens in avoiding complications. These regimens do not take account of circadian fluctuations in urine output (UO), MAP (mean arterial pressure) and pulse rate (PR). This is the first study that aims to demonstrate the effect of circadian rhythm on these haemodynamic parameters in post-operative patients with free flaps, as well as analysing clinicians’ response to these variations. Retrospective analysis of 116 patients with free flaps. Records were assessed for UO, MAP, IV fluid infusion rate, oral fluid intake. Parameters were measured from 8 am to 8 pm (diurnal) and from 8 pm to 8 am (nocturnal) in the first 48 h post operatively. Patients with diabetes or hypertension were excluded. Mean diurnal UO rate (1.7 ml/kg/hr) was higher than nocturnal UO rate (0.7 ml/kg/hr); and mean diurnal MAP (93) was higher than nocturnal MAP (73.8). Mean diurnal IV infusion rate was 1.25 ml/kg/hr (lower) and mean nocturnal infusion rate 1.81 ml/kg/hr (higher). These differences were all statistically significant by paired student t-test (p < 0.05). This study demonstrates that circadian rhythm has a statistically significant impact on UO, MAP and PR. UO, MAP and PR are expected to dip overnight. This dip is normal and does not necessarily need to be treated by increasing IV fluids to avoid over filling of free flap patients.

ФУНКЦИЯ ПОЧЕК У НОВОРОЖДЕННЫХ ДЕТЕЙ

Objective. The article discusses the problem of assessing renal function of the kidneys in premature babies born as a result of prematurely premature births with extremely low birth weight. Materials and methods. The functional state of the kidneys was evaluated in 148 children with ELBW and VLBW in the period from 1 to 90 days of postnatal age. The urine output rate, serum creatinine level, GFR calculation according to the Schwartz formula. Results. The results of the study showed that premature babies with ELBW are characterized by elevated serum creatinine levels and a low glomerular filtration rate, starting from the 4th day of life. An increase in GFR from the 3rd week of postnatal life significantly increases the likelihood of survival of premature babies with ELBW. The decrease in glomerular filtration rate in this contingent of children is associated not so much with kidney damage, but rather due to a more pronounced immaturity of nephrons Conclusion: Kidney function in preterm infants with ENMT is much lower than even in more mature children with ONHT. This is confirmed by high persistent levels of creatinine in serum and low SCF values throughout the neonatal period of life.

P0250COLD DIURESIS DURING TARGETED TEMPERATURE MANAGEMENT AFTER CARDIAC ARREST, MYTH OR FACT?

Abstract Background and Aims Therapeutic hypothermia or targeted temperature management (TTM) has been standard treatment for cardiac arrest survivors with suspected hypoxic ischemic brain injury for improvement in both survival and neurological outcomes. TTM is consisted of an induction phase of quickly lowering the temperature to target temperature (ranging from 32°C -36°C) as soon as possible, a hypothermia maintenance phase of keeping the body temperature at target temperature for at least 24 hours, a rewarming phase of slowly rewarming the temperature to normothermia, and a normothermia phase of keeping the body temperature at normothermia. During the dynamic changes in body temperature, cold-diuresis is a commonly described phenomenon. However, limited studies have characterized cold-induced diuresis during TTM. In this study, we sought to determine urine output changes during post cardiac arrest therapeutic hypothermia. Method This retrospective cohort study included adult patients who underwent TTM after out-of-hospital cardiac arrest and were admitted to the intensive care unit for post cardiac arrest care between January 2012 and August 2018. The exclusion criteria of this study were as follows: 1) deceased status before the completion of all phase of TTM; 2) previous end stage kidney disease patients, 3) undergoing renal replacement therapy due to AKI within 48 hours of TTM termination; 4) terminal cancer less than 6 months of life expectancy or previously cerebral performance category (CPC) 3 or more. The neurologic outcome was assessed using the CPC score after 1 month. Good neurologic outcome was defined as a CPC score of 1, 2 and poor neurologic outcome as a CPC score of 3 to 5. The post cardiac arrest protocol recommends a target temperature of 33°C unless the patient is hemodynamically unstable or has a bleeding tendency or severe infection. Rewarming rate was 0.15°C/hr or 0.25°C/hr. TTM was conducted with the use of temperature managing devices with a feedback loop system (Artic Sun Energy Transfer Pads, Medivance Corp., Louisville, CO, USA; Cool Guard Alsius Icy Heat Exchange Catheter, Alsius Corporation, Irvine, CA, USA). We calculated the hourly IV fluid input and urine output rates for each TTM phase. To compare the mean of urine volume between each TTM phase, we used repeated measure analysis of variance (ANOVA). Results 178 Patients included in the analysis. We observed a increase in urine output rates during hypothermia induction. This effect persisted even after adjustment for variable clinical confounders, including intravenous fluid input rate, mean arterial pressure (MAP), initial shockable rhythm, SOFA score, body mass index, and IV furosemide use. However, we did not detect any evidence of urine output increases or decreases during the hypothermia maintenance or rewarming phases. By repeating measures ANOVA and a linear mixed model, it was confirmed that there is a difference in urine output for each TTM phase. Even after the post hoc analysis was calibrated with several variables, only the hypotheria induction phase differed significantly from the urine output of the phase. Conclusion Although our results are some limitations, the findings support the potential presence of cold-induced dieresis, but not rewarm anti-diuresis during TTM. Our study may not fully capture the extent of renal impairment in post cardiac arrest undergoing TTM. However, our objective was to characterize urine output during TTM in post cardiac arrest patients. This has important implications for fluid management in patients undergoing TTM.

SAT-238 Congenital Nephrogenic Diabetes Insipidus with First Presentation as an Adult: A Case Report

Congenital Nephrogenic Diabetes Insipidus with First Presentation as an Adult: A Case ReportBackground:Congenital nephrogenic diabetes insipidus (NDI) is a rare inherited condition, usually presenting during the first year of life. It is characterized by a renal insensitivity to arginine vasopressin. About 90% of patients are males with X-linked NDI who have mutations in the vasopressin V2 receptor (AVPR2) gene encoding the vasopressin V2 receptor. Females are typically asymptomatic. Here, we report female case of NDI initially presenting and diagnosed in an adult woman.Clinical Case:A previously well 47-year-old woman of Italian descent underwent an elective laparoscopic repair of an abdominal hernia. Her medical history included obesity and migraine headaches. She was not taking any medications prior to admission. She had a bowel perforation 6 days after surgery, necessitating an emergency right hemicolectomy and small bowel resection. Upon instituting bowel rest with nil per os (NPO), she developed severe hypernatremia (Na+ 163 mmol/L) with polyuria (>6 L/day) and dilute urine (osmolality 174 mmol/kg). Further inquiry revealed that the patient routinely drank at least 10 L/day of fluids throughout her entire adult life. Her family history was remarkable for polydipsia affecting at least additional six people across three generations (including her son, her mother, 3 maternal uncles and 1 nephew). Following administration of desmopressin 1 ug subcutaneously, her urine remained inappropriately dilute (osmolality 160 mmol/kg) with no significant change in urine output (rate 350 mL/h for 3 hours). Her arginine vasopressin level was detectable (3.2 pmol/L, reference range 0.8–3.5 pmol/L), consistent with nephrogenic diabetes insipidus. Subsequent molecular analysis of the AVPR2 gene, located on chromosome Xq28, confirmed a pathogenic mutation (c.253G>A), consistent with a p.Asp85Asn substitution resulting in decreased binding affinity between the V2 receptor and arginine vasopressin. Thus, X-linked NDI was diagnosed according to the patient’s presentation, compatible family history, and genetic analysis. When she was able to eat and drink ad lib again, a low-salt, low-protein diet along with a trial of a thiazide diuretic were recommended. The patient remained well with 3 years of follow-up.Conclusion:The diagnosis of congenital NDI may be delayed until adulthood because of a relatively mild phenotype and compensatory drinking behavior, so that the disorder will not be clinically apparent until a person is deprived of free water. Men and women alike can be affected by this X-linked dominant condition which should be considered in any polyuric, hypernatremic hospitalized patient.

MiR-185-3p downregulates advanced glycosylation end product receptor expression and improves renal function in diabetic nephropathy mice.

To investigate the effects of the downregulation of AGER by miRNA-185-3p on renal function in diabetic nephropathy (DN) mice. Mice were divided into normal, model, NC, miR-185-3p mimic, si-AGER, and miR-185-3p mimic + si-AGER groups. Eight weeks following the establishment of the model, various indicators were assessed. Compared to control groups, miR-185-3p expression, body weight, superoxide dismutase (SOD) content, catalase (CAT) content, proliferation, S-phase ratios, and proliferating cell nuclear antigen (PCNA) expression were significantly lower in all experimental groups, whilst AGER expression, water intake, food intake, urine volume, urine protein content, serum creatinine (Scr), Blood Urea Nitrogen (BUN), MDA content, G0/G1 status, and rates of apoptosis were significantly higher (all p<0.05). Compared to the model group, miR-185-3p mimics, si-AGER, and miR-185-3p mimic + si-AGER groups had a significantly higher SOD content, CAT content, proliferation, S phase ratios, PCNA expression and lower AGER expression, water intake, food intake, urine output, urine protein, Scr, BUN, MDA content, G0/G1 ratios, and apoptosis rates (all p<0.05). In addition, the effects of the miR-185-3p mimics + si-AGER were superior to miR-185-3p mimics and si-AGER monotherapy groups (both p<0.05). MiR-185-3p inhibits AGER, downregulates AGER expression, and improves renal function in DN mice.

Urine Recirculation Improves Hemodynamics and Enhances Function in Normothermic Kidney Perfusion.

Kidney pairs were recovered uninjured (as live-donor nephrectomy) and perfused consecutively. Pig kidneys (n = 10) were allocated to either NMP with URC (n = 5) or NMP with volume replacement (n = 5). Cold ischemia time was either 2 or 27 hours for the first or second perfusion (URC or UR) of a kidney pair. An autologous blood-based perfusate, leukocyte-filtered, was used and NMP performed up to 24 hours. Perfusion parameters, biochemistry/metabolic parameters were monitored and samples collected. Physiological mean arterial pressures and flows were achieved in both groups but were sustainable only with URC. Significantly higher arterial flow was observed with URC (326.7 ± 1.8 versus 242.5 ± 14.3 mL/min, P = 0.001). Perfusate sodium levels were lower with URC, 129.6 ± 0.7 versus 170.3±2.7 mmol/L, P < 0.001). Stable physiological pH levels were only observed with URC. Perfusate lactate levels were lower with URC (2.2 ± 0.1 versus 7.2 ± 0.5 mmol/L, P < 0.001). Furthermore, the hourly rate of urine output was lower with URC and closer to physiological levels (150 versus 548 mL/h, P = 0.008). Normothermic kidney perfusion with URC was associated with longer achievable durations of perfusion: the objective in all experiments was a 24-hour perfusion, but this was not achieved in every case. The mean perfusions were 17.3 ± 9.2 hours with URC versus 5.3 ± 1.3 hours NMP with UR; P = 0.02. There appeared to be no differences in baseline tubular condition with and without URC. URC facilitates long-term kidney NMP in a porcine model. Perfusate homeostasis and stability of renal arterial flow throughout the perfusion period was only achievable with URC, independent of cold ischemia time duration.