Laboratory Test Surveillance following Acute Kidney Injury

Background

Patients with hospitalized acute kidney injury (AKI) are at increased risk for accelerated loss of kidney function, morbidity, and mortality. We sought to inform efforts at improving post-AKI outcomes by describing the receipt of renal-specific laboratory test surveillance among a large high-risk cohort.

Methods

We acquired clinical data from the Electronic health record (EHR) of 5 Veterans Affairs (VA) hospitals to identify patients hospitalized with AKI from January 1^st, 2002 to December 31^st, 2009, and followed these patients for 1 year or until death, enrollment in palliative care, or improvement in renal function to estimated GFR (eGFR) ≥60 L/min/1.73 m². Using demographic data, administrative codes, and laboratory test data, we evaluated the receipt and timing of outpatient testing for serum concentrations of creatinine and any as well as quantitative proteinuria recommended for CKD risk stratification. Additionally, we reported the rate of phosphorus and parathyroid hormone (PTH) monitoring recommended for chronic kidney disease (CKD) patients.

Results

A total of 10,955 patients admitted with AKI were discharged with an eGFR<60 mL/min/1.73 m². During outpatient follow-up at 90 and 365 days, respectively, creatinine was measured on 69% and 85% of patients, quantitative proteinuria was measured on 6% and 12% of patients, PTH or phosphorus was measured on 10% and 15% of patients.

Conclusions

Measurement of creatinine was common among all patients following AKI. However, patients with AKI were infrequently monitored with assessments of quantitative proteinuria or mineral metabolism disorder, even for patients with baseline kidney disease.     

The Real Importance of Pre-Existing Comorbidities on Long-Term Mortality after Acute Kidney Injury

Background

The causes of death on long-term mortality after acute kidney injury (AKI) have not been well studied. The purpose of the study was to evaluate the role of comorbidities and the causes of death on the long-term mortality after AKI.

Methodology/Principal Findings

We retrospectively studied 507 patients who experienced AKI in 2005–2006 and were discharged free from dialysis. In June 2008 (median: 21 months after AKI), we found that 193 (38%) patients had died. This mortality is much higher than the mortality of the population of São Paulo City, even after adjustment for age. A multiple survival analysis was performed using Cox proportional hazards regression model and showed that death was associated with Khan’s index indicating high risk [adjusted hazard ratio 2.54 (1.38–4.66)], chronic liver disease [1.93 (1.15–3.22)], admission to non-surgical ward [1.85 (1.30–2.61)] and a second AKI episode during the same hospitalization [1.74 (1.12–2.71)]. The AKI severity evaluated either by the worst stage reached during AKI (P = 0.20) or by the need for dialysis (P = 0.12) was not associated with death. The causes of death were identified by a death certificate in 85% of the non-survivors. Among those who died from circulatory system diseases (the main cause of death), 59% had already suffered from hypertension, 34% from diabetes, 47% from heart failure, 38% from coronary disease, and 66% had a glomerular filtration rate <60 previous to the AKI episode. Among those who died from neoplasms, 79% already had the disease previously.

Conclusions

Among AKI survivors who were discharged free from dialysis the increased long-term mortality was associated with their pre-existing chronic conditions and not with the severity of the AKI episode. These findings suggest that these survivors should have a medical follow-up after hospital discharge and that all efforts should be made to control their comorbidities.     

Prognostic Value of Acute Kidney Injury after Cardiac Surgery according to Kidney Disease: Improving Global Outcomes Definition and Staging (KDIGO) Criteria

Objectives

The definition of acute renal failure has been recently reviewed, and the term acute kidney injury (AKI) was proposed to cover the entire spectrum of the syndrome, ranging from small changes in renal function markers to dialysis needs. This study was aimed to evaluate the incidence, morbidity and mortality associated with AKI (based on KDIGO criteria) in patients after cardiac surgery (coronary artery bypass grafting or cardiac valve surgery) and to determine the value of this feature as a predictor of hospital mortality (30 days).

Methods

From January 2003 to June 2013, a total of 2,804 patients underwent cardiac surgery in our service. Cox proportional hazard models were used to determine the association between the development of AKI and 30-day mortality.

Results

A total of 1,175 (42%) patients met the diagnostic criteria for AKI based on KDIGO classification during the first 7 postoperative days: 978 (35%) patients met the diagnostic criteria for stage 1 while 100 (4%) patients met the diagnostic criteria for stage 2 and 97 (3%) patients met the diagnostic criteria for stage 3. A total of 63 (2%) patients required dialysis treatment. Overall, the 30-day mortality was 7.1% (2.2%) for patients without AKI and 8.2%, 31% and 55% for patients with AKI at stages 1, 2 and 3, respectively. The KDIGO stage 3 patients who did not require dialysis had a mortality rate of 41%, while the mortality of dialysis patients was 62%. The adjusted Cox regression analysis revealed that AKI based on KDIGO criteria (stages 1–3) was an independent predictor of 30-day mortality (P<0.001 for all. Hazard ratio = 3.35, 11.94 and 24.85).

Conclusion

In the population evaluated in the present study, even slight changes in the renal function based on KDIGO criteria were considered as independent predictors of 30-day mortality after cardiac surgery.     

Paediatric Acute Kidney Injury in a Tertiary Hospital in Nigeria: Prevalence,Causes and Mortality Rate

Background

The modest decline in child mortality in Africa raises the question whether the pattern of diseases associated with acute kidney injury (AKI) in children in Nigeria has changed.

Methods

A database of children, aged between one month and 16 years, with AKI (using modified pediatric RIFLE criteria) was reviewed. The cause of AKI was defined as the major underlying disease. The clinical and laboratory features of children with AKI who survived were compared to those who died.

Results

Of the 4 015 children admitted into Lagos University Teaching Hospital between July 2010 and July 2012, 70 episodes of AKI were recorded equalling 17.4 cases per 1000 children. The median age of the children with AKI was 4.8 (range 0.1–14.4) years and 68.6% were males. Acute kidney injury was present in 58 (82.9%) children at admission with 70% in ‘failure’ category. Primary kidney disease (38.6%), sepsis (25.7%) and malaria (11.4%) were the commonest causes. The primary kidney diseases were acute glomerulonephritis (11) and nephrotic syndrome (8). Nineteen (28.4%) children with AKI died. Need for dialysis [odds ratio: 10.04 (2.94–34.33)], white cell >15 000/mm³ [odds ratio: 5.72 (1.65–19.89)] and platelet <100 000/mm³ [odds ratio: 9.56 (2.63–34.77)] were associated with death.

Conclusion

Acute kidney injury is common in children admitted to hospitals. The common causes remain primary kidney diseases, sepsis and malaria but the contribution of sepsis is rising while malaria and gastroenteritis are declining. Acute kidney injury-related mortality remains high.     

Renal function at hospital admission and mortality due to acute kidney injury after myocardial infarction

Background

The role of an impaired estimated glomerular filtration rate (eGFR) at hospital admission in the outcome of acute kidney injury (AKI) after acute myocardial infarction (AMI) has been underreported. The aim of this study was to assess the influence of an admission eGFR<60 mL/min/1.73 m² on the incidence and early and late mortality of AMI-associated AKI.

Methods

A prospective study of 828 AMI patients was performed. AKI was defined as a serum creatinine increase of ≥50% from the time of admission (RIFLE criteria) in the first 7 days of hospitalization. Patients were divided into subgroups according to their eGFR upon hospital admission (MDRD formula, mL/min/1.73 m²) and the development of AKI: eGFR≥60 without AKI, eGFR<60 without AKI, eGFR≥60 with AKI and eGFR<60 with AKI.

Results

Overall, 14.6% of the patients in this study developed AKI. The admission eGFR had no impact on the incidence of AKI. However, the admission eGFR was associated with the outcome of AMI-associated AKI. The adjusted hazard ratios (AHR, Cox multivariate analysis) for 30-day mortality were 2.00 (95% CI 1.11–3.61) for eGFR<60 without AKI, 4.76 (95% CI 2.45–9.26) for eGFR≥60 with AKI and 6.27 (95% CI 3.20–12.29) for eGFR<60 with AKI. Only an admission eGFR of <60 with AKI was significantly associated with a 30-day to 1-year mortality hazard (AHR 3.05, 95% CI 1.50–6.19).

Conclusions

AKI development was associated with an increased early mortality hazard in AMI patients with either preserved or impaired admission eGFR. Only the association of impaired admission eGFR and AKI was associated with an increased hazard for late mortality among these patients.     

Measuring Unsafe Abortion-Related Mortality: A Systematic Review of the Existing Methods

Background

The WHO estimates that 13% of maternal mortality is due to unsafe abortion, but challenges with measurement and data quality persist. To our knowledge, no systematic assessment of the validity of studies reporting estimates of abortion-related mortality exists.

Study Design

To be included in this study, articles had to meet the following criteria: (1) published between September 1^st, 2000-December 1^st, 2011; (2) utilized data from a country where abortion is “considered unsafe”; (3) specified and enumerated causes of maternal death including “abortion”; (4) enumerated ≥100 maternal deaths; (5) a quantitative research study; (6) published in a peer-reviewed journal.

Results

7,438 articles were initially identified. Thirty-six studies were ultimately included. Overall, studies rated “Very Good” found the highest estimates of abortion related mortality (median 16%, range 1–27.4%). Studies rated “Very Poor” found the lowest overall proportion of abortion related deaths (median: 2%, range 1.3–9.4%).

Conclusions

Improvements in the quality of data collection would facilitate better understanding global abortion-related mortality. Until improved data exist, better reporting of study procedures and standardization of the definition of abortion and abortion-related mortality should be encouraged.     

Acute Kidney Injury in Patients with Newly Diagnosed High-Grade Hematological Malignancies: Impact on Remission and Survival

Background

Optimal chemotherapy with minimal toxicity is the main determinant of complete remission in patients with newly diagnosed hematological malignancies. Acute organ dysfunctions may impair the patient’s ability to receive optimal chemotherapy.

Design and Methods

To compare 6-month complete remission rates in patients with and without acute kidney injury (AKI), we collected prospective data on 200 patients with newly diagnosed high-grade malignancies (non-Hodgkin lymphoma, 53.5%; acute myeloid leukemia, 29%; acute lymphoblastic leukemia, 11.5%; and Hodgkin disease, 6%).

Results

According to RIFLE criteria, 137 (68.5%) patients had AKI. Five causes of AKI accounted for 91.4% of cases: hypoperfusion, tumor lysis syndrome, tubular necrosis, nephrotoxic agents, and hemophagocytic lymphohistiocytosis. Half of the AKI patients received renal replacement therapy and 14.6% received suboptimal chemotherapy. AKI was associated with a lower 6-month complete remission rate (39.4% vs. 68.3%, P<0.01) and a higher mortality rate (47.4% vs. 30.2%, P<0.01) than patients without AKI. By multivariate analysis, independent determinants of 6-month complete remission were older age, poor performance status, number of organ dysfunctions, and AKI.

Conclusion

AKI is common in patients with newly diagnosed high-grade malignancies and is associated with lower complete remission rates and higher mortality.     

Incidence,Predictive Factors,and Clinical Outcomes of Acute Kidney Injury after Gastric Surgery for Gastric Cancer

Background

Postoperative acute kidney injury (AKI), a serious surgical complication, is common after cardiac surgery; however, reports on AKI after noncardiac surgery are limited. We sought to determine the incidence and predictive factors of AKI after gastric surgery for gastric cancer and its effects on the clinical outcomes.

Methods

We conducted a retrospective study of 4718 patients with normal renal function who underwent partial or total gastrectomy for gastric cancer between June 2002 and December 2011. Postoperative AKI was defined by serum creatinine change, as per the Kidney Disease Improving Global Outcomes guideline.

Results

Of the 4718 patients, 679 (14.4%) developed AKI. Length of hospital stay, intensive care unit admission rates, and in-hospital mortality rate (3.5% versus 0.2%) were significantly higher in patients with AKI than in those without. AKI was also associated with requirement of renal replacement therapy. Multivariate analysis revealed that male gender; hypertension; chronic obstructive pulmonary disease; hypoalbuminemia (<4 g/dl); use of diuretics, vasopressors, and contrast agents; and packed red blood cell transfusion were independent predictors for AKI after gastric surgery. Postoperative AKI and vasopressor use entailed a high risk of 3-month mortality after multiple adjustments.

Conclusions

AKI was common after gastric surgery for gastric cancer and associated with adverse outcomes. We identified several factors associated with postoperative AKI; recognition of these predictive factors may help reduce the incidence of AKI after gastric surgery. Furthermore, postoperative AKI in patients with gastric cancer is an important risk factor for short-term mortality.     

Identification and Predicting Short-Term Prognosis of Early Cardiorenal Syndrome Type 1: KDIGO Is Superior to RIFLE or AKIN

Objective

Acute kidney injury (AKI) in patients hospitalized for acute heart failure (AHF) is usually type 1 of the cardiorenal syndrome (CRS) and has been associated with increased morbidity and mortality. Early recognition of AKI is critical. This study was to determine if the new KDIGO criteria (Kidney Disease: Improving Global Outcomes) for identification and short-term prognosis of early CRS type 1 was superior to the previous RIFLE and AKIN criteria.

Methods

The association between AKI diagnosed by KDIGO but not by RIFLE or AKIN and in-hospital mortality was retrospectively evaluated in 1005 Chinese adult patients with AHF between July 2008 and May 2012. AKI was defined as RIFLE, AKIN and KDIGO criteria, respectively. Cox regression was used for multivariate analysis of in-hospital mortality.

Results

Within 7 days on admission, the incidence of CRS type 1 was 38.9% by KDIGO criteria, 34.7% by AKIN, and 32.1% by RIFLE. A total of 110 (10.9%) cases were additional diagnosed by KDIGO criteria but not by RIFLE or AKIN. 89.1% of them were in Stage 1 (AKIN) or Stage Risk (RIFLE). They accounted for 18.4% (25 cases) of the overall death. After adjustment, this proportion remained an independent risk factor for in-hospital mortality [odds ratios (OR)3.24, 95% confidence interval(95%CI) 1.97–5.35]. Kaplan-Meier curve showed AKI patients by RIFLE, AKIN, KDIGO and [K(+)R(−)+K(+)A(−)] had lower hospital survival than non-AKI patients (Log Rank P<0.001).

Conclusion

KDIGO criteria identified significantly more CRS type 1 episodes than RIFLE or AKIN. AKI missed diagnosed by RIFLE or AKIN criteria was an independent risk factor for in-hospital mortality, indicating the new KDIGO criteria was superior to RIFLE and AKIN in predicting short-term outcomes in early CRS type 1.     

Incidence and Mortality of Acute Kidney Injury after Myocardial Infarction: A Comparison between KDIGO and RIFLE Criteria

Background

Acute kidney injury (AKI) increases the risk of death after acute myocardial infarction (AMI). Recently, a new AKI definition was proposed by the Kidney Disease Improving Global Outcomes (KDIGO) organization. The aim of the current study was to compare the incidence and the early and late mortality of AKI diagnosed by RIFLE and KDIGO criteria in the first 7 days of hospitalization due to an AMI.

Methods and Results

In total, 1,050 AMI patients were prospectively studied. AKI defined by RIFLE and KDIGO occurred in 14.8% and 36.6% of patients, respectively. By applying multivariate Cox analysis, AKI was associated with an increased adjusted hazard ratio (AHR) for 30-day death of 3.51 (95% confidence interval [CI] 2.35–5.25, p<0.001) by RIFLE and 3.99 (CI 2.59–6.15, p<0.001) by KDIGO and with an AHR for 1-year mortality of 1.84 (CI 1.12–3.01, p = 0.016) by RIFLE and 2.43 (CI 1.62–3.62, p<0.001) by KDIGO. The subgroup of patients diagnosed as non-AKI by RIFLE but as AKI by KDIGO criteria had also an increased AHR for death of 2.55 (1.52–4.28) at 30 days and 2.28 (CI 1.46–3.54) at 1 year (p<0.001).

Conclusions

KDIGO criteria detected substantially more AKI patients than RIFLE among AMI patients. Patients diagnosed as AKI by KDIGO but not RIFLE criteria had a significantly higher early and late mortality. In this study KDIGO criteria were more suitable for AKI diagnosis in AMI patients than RIFLE criteria.     

Nitrotyrosine Level Was Associated with Mortality in Patients with Acute Kidney Injury

Background

To examine the characteristics of oxidative stress in patients with acute kidney injury (AKI) and investigate the association between plasma nitrotyrosine levels and 90-day mortality in patients with AKI.

Methodology/Principal Findings

158 patients with hospital-acquired AKI were recruited to this prospective cohort study according to RIFLE (Risk, Injury, Failure, Lost or End Stage Kidney) criteria. Twelve critically ill patients without AKI and 15 age and gender-matched healthy subjects served as control. Plasma 3-nitrotyrosine was analyzed in relation to 90-day all cause mortality of patients with AKI. The patients with AKI were followed up for 90 days and grouped according to median plasma 3-nitrotyrosine concentrations. Highest 3-NT/Tyr was detected in patients with AKI compared with healthy subjects, and critically ill patients without AKI (ANOVA p<0.001). The 90-day survival curves of patients with high 3-NT/Tyr showed significant differences compared with the curves of individuals with low 3-NT/Tyr (p = 0.001 by log rank test). Multivariate analysis (Cox regression) revealed that 3-NT/Tyr (p = 0.025) was independently associated with mortality after adjustment for age, gender, sepsis and Acute Physiology and Chronic Health Evaluation (APACHE) II score.

Conclusions/Significance

There is excess plasma protein oxidation in patients with AKI, as evidenced by increased nitrotyrosine content. 3-NT/Tyr level was associated with mortality of AKI patients independent of the severity of illness.     

Prevalence of Acute Kidney Injury and Prognostic Significance in Patients with Acute Myocarditis

Objective

Myocarditis is an inflammation of the myocardium. The condition is commonly associated with rapid disease progression and often results in profound shock. Impaired renal function is the result of impairment in end-organ perfusion and is highly prevalent among critically ill patients. The aim of this study was to evaluate the incidence of acute kidney injury (AKI) and identify the relationship between AKI and the prognosis of patients with acute myocarditis.

Design, Measurements and Main Results

This retrospective study reviewed the medical records of 101 patients suffering from acute myocarditis between 1996 and 2011. Sixty of these patients (59%) developed AKI within 48 hours of being hospitalized. AKI defined as AKIN stage 3 (p = 0.007) and SOFA score (p = 0.03) were identified as predictors of in-hospital mortality in multivariate analysis. The conditional effect plot of the estimated risk against SOFA score upon admission categorized according to the AKIN stages showed that the risk of in-hospital mortality was highest among patients in AKIN stage 3 with a high SOFA score.

Conclusions

Among patients with acute myocarditis, AKI defined as AKIN stage 3 and elevated SOFA score were associated with unfavorable outcomes. AKIN classification is a simple, reproducible, and easily applied evaluation tool capable of providing objective information related to the clinical prognosis of patients with acute myocarditis.     

Scrub Typhus Is an Under-recognized Cause of Acute Febrile Illness with Acute Kidney Injury in India

Background

Infection-related acute kidney injury (AKI) is an important preventable cause of morbidity and mortality in the tropical region. The prevalence and outcome of kidney involvement, especially AKI, in scrub typhus is not known. We investigated all patients with undiagnosed fever and multisystem involvement for scrub typhus and present the pattern of renal involvement seen.

Methods

From September 2011 to November 2012, blood samples of all the patients with unexplained acute febrile illness and/or varying organ involvement were evaluated for evidence of scrub typhus. A confirmed case of scrub typhus was defined as one with detectable Orientia tsutsugamushi deoxyribonucleic acid (DNA) in patient''s blood sample by nested polymerase chain reaction (PCR) targeting the gene encoding 56-kDa antigen and without any alternative etiological diagnosis. Renal involvement was defined by demonstration of abnormal urinalysis and/or reduced glomerular filtration rate. AKI was defined as per Kidney Disease: Improving Global Outcomes (KDIGO) definition.

Results

Out of 201 patients tested during this period, 49 were positive by nested PCR for scrub typhus. Mean age of study population was 34.1±14.4 (range 11–65) years. Majority were males and a seasonal trend was evident with most cases following the rainy season. Overall, renal abnormalities were seen in 82% patients, 53% of patients had AKI (stage 1, 2 and 3 in 10%, 8% and 35%, respectively). The urinalysis was abnormal in 61%, with dipstick positive albuminuria (55%) and microscopic hematuria (16%) being most common. Acute respiratory distress syndrome (ARDS) and shock were seen in 57% and 16% of patients, respectively. Hyperbilirubinemia was associated with AKI (p = 0.013). A total of 8 patients (including three with dialysis dependent AKI) expired whereas rest all made uneventful recovery. Jaundice, oliguria, ARDS and AKI were associated with mortality. However, after multivariate analysis, only oliguric AKI remained a significant predictor of mortality (p = 0.002).

Conclusions

Scrub typhus was diagnosed in 24% of patients presenting with unexplained febrile illness according to a strict case definition not previously used in this region. Renal abnormalities were seen in almost 82% of all patients with evidence of AKI in 53%. Our finding is contrary to current perception that scrub typhus rarely causes renal dysfunction. We suggest that all patients with unexplained febrile illness be investigated for scrub typhus and AKI looked for in scrub typhus patients.     

Risk Models and Scoring Systems for Predicting the Prognosis in Critically Ill Cirrhotic Patients with Acute Kidney Injury: A Prospective Validation Study

Background

Cirrhotic patients with acute kidney injury (AKI) admitted to intensive care units (ICUs) show extremely high mortality rates. We have proposed the MBRS scoring system, which can be used for assessing patients on the day of admission to the ICU; this new system involves determination of mean arterial pressure (MAP) and bilirubin level and assessment of respiratory failure and sepsis. We had used this scoring system to analyze the prognosis of ICU cirrhotic patients with AKI in 2008, and the current study was an external validation of this scoring system.

Methods

A total of 190 cirrhotic patients with AKI were admitted to the ICU between March 2008 and February 2011. We prospectively analyzed and recorded the data for 31 demographic parameters and some clinical characteristic variables on day 1 of admission to the ICU; these variables were considered as predictors of mortality.

Results

The overall in-hospital mortality rate was 73.2% (139/190), and the 6-month mortality rate was 83.2% (158/190). Hepatitis B viral infection (43%) was observed to be the cause of liver disease in most of the patients. Multiple logistic regression analysis indicated that the MBRS and Acute Physiology and Chronic Health Evaluation III (ACPACHE III) scores determined on the first day of admission to the ICU were independent predictors of in-hospital mortality in patients. In the analysis of the area under the receiver operating characteristic (AUROC) curves, the MBRS scores showed good discrimination (AUROC: 0.863±0.032, p<0.001) in predicting in-hospital mortality.

Conclusion

On the basis of the results of this external validation, we conclude that the MBRS scoring system is a reproducible, simple, easy-to-apply evaluation tool that can increase the prediction accuracy of short-term prognosis in critically ill cirrhotic patients with AKI.     

Association of Body Mass Index with Cause Specific Deaths in Chinese Elderly Hypertensive Patients: Minhang Community Study

Background

Most studies have suggested that elevated body mass index (BMI) was associated with the risk of death from all cause and from specific causes. However, there was little evidence illustrating the effect of BMI on the mortality in elderly hypertensive patients in Chinese population.

Methods

The information of 10,957 hypertensive patients at baseline not less than 60 years were from Xinzhuang, a town in Minhang district of Shanghai, was extracted from the Electronic Health Record (EHR) system. All study participants were divided into eight categories of baseline BMI (with cut-points at 18, 20, 22, 24, 26, 28 and 30 kg/m²). Relative hazard ratio of death from all cause, cardiovascular and non-cardiovascular cause by baseline BMI groups were calculated, standardized for sex, age, smoking, drinking, physical activity, systolic blood pressure, history of cardiovascular disorders, serum lipid disturbance, diabetes mellitus and antihypertensive drug treatment.

Results

During follow up (median: 3.7 years), 561 deaths occurred. Underweight (BMI<18 kg/m²) was associated with significantly increased mortality from all cause mortality (OR: 2.00; 95% CI: 1.43–2.79) and non cardiovascular mortality (OR: 2.76; 95% CI: 1.87–4.07), but not with cardiovascular mortality. For the cause specific analysis, the underweight was associated significantly with neoplasms (OR: 2.15; 95% CI: 1.16–4.00) and respiratory disorders (OR: 3.41; 95% CI: 1.64–7.06). The results for total mortality and specific cause mortality were not influenced by sex, age and smoking status.

Conclusion

Our study revealed an association between underweight and increased mortality from non-cardiovascular disorders in elderly hypertensive patients in Chinese community. Overweight and obesity were not associated with all cause or cause specific death.     

Should We Still Focus That Much on Cardiovascular Mortality in End Stage Renal Disease Patients? The CONvective TRAnsport STudy

Background

We studied the distribution of causes of death in the CONTRAST cohort and compared the proportion of cardiovascular deaths with other populations to answer the question whether cardiovascular mortality is still the principal cause of death in end stage renal disease. In addition, we compared patients who died from the three most common death causes. Finally, we aimed to study factors related to dialysis withdrawal.

Methods

We used data from CONTRAST, a randomized controlled trial in 714 chronic hemodialysis patients comparing the effects of online hemodiafiltration versus low-flux hemodialysis. Causes of death were adjudicated. The distribution of causes of death was compared to that of the Dutch dialysis registry and of the Dutch general population.

Results

In CONTRAST, 231 patients died on treatment. 32% died from cardiovascular disease, 22% due to infection and 23% because of dialysis withdrawal. These proportions were similar to those in the Dutch dialysis registry and the proportional cardiovascular mortality was similar to that of the Dutch general population. cardiovascular death was more common in patients <60 years. Patients who withdrew were older, had more co-morbidity and a lower mental quality of life at baseline. Patients who withdrew had much co-morbidity. 46% died within 5 days after the last dialysis session.

Conclusions

Although the absolute risk of death is much higher, the proportion of cardiovascular deaths in a prevalent end stage renal disease population is similar to that of the general population. In older hemodialysis patients cardiovascular and non-cardiovascular death risk are equally important. Particularly the registration of dialysis withdrawal deserves attention. These findings may be partly limited to the Dutch population.     

Extended Daily Dialysis in Acute Kidney Injury Patients: Metabolic and Fluid Control and Risk Factors for Death

Intermittent hemodialysis (IHD) and continuous renal replacement therapies (CRRT) are used as Acute Kidney Injury (AKI) therapy and have certain advantages and disadvantages. Extended daily dialysis (EDD) has emerged as an alternative to CRRT in the management of hemodynamically unstable AKI patients, mainly in developed countries.

Objectives

We hypothesized that EDD is a safe option for AKI treatment and aimed to describe metabolic and fluid control of AKI patients undergoing EDD and identify complications and risk factors associated with death.

Study Selection

This is an observational and retrospective study describing introduction of EDD at our institution. A total of 231 hemodynamically unstable AKI patients (noradrenalin dose between 0.3 and 1.0 ucg/kg/min) were assigned to 1367 EDD session. EDD consisted of 6–8 h of HD 6 days a week, with blood flow of 200 ml/min, dialysate flows of 300 ml/min.

Data Synthesis

Mean age was 60.6±15.8 years, 97.4% of patients were in the intensive care unit, and sepsis was the main etiology of AKI (76.2). BUN and creatinine levels stabilized after four sessions at around 38 and 2.4 mg/dl, respectively. Fluid balance decreased progressively and stabilized around zero after five sessions. Weekly delivered Kt/V was 5.94±0.7. Hypotension and filter clotting occurred in 47.5 and 12.4% of treatment session, respectively. Regarding AKI outcome, 22.5% of patients presented renal function recovery, 5.6% of patients remained on dialysis after 30 days, and 71.9% of patients died. Age and focus abdominal sepsis were identified as risk factors for death. Urine output and negative fluid balance were identified as protective factors.

Conclusions

EDD is effective for AKI patients, allowing adequate metabolic and fluid control. Age, focus abdominal sepsis, and lower urine output as well as positive fluid balance after two EDD sessions were associated significantly with death.     

Procalcitonin Levels Predict Acute Kidney Injury and Prognosis in Acute Pancreatitis: A Prospective Study

Background

Acute kidney injury (AKI) has been proposed as a leading cause of mortality for acute pancreatitis (AP) patients admitted to the intensive care unit (ICU). This study investigated the predictive value of procalcitonin (PCT) for AKI development and relevant prognosis in patients with AP, and compared PCT’s predictive power with that of other inflammation-related variables.

Methods

Between January 2011 and March 2013, we enrolled 305 cases with acute pancreatitis admitted to ICU. Serum levels of PCT, serum amyloid A (SAA), interleukin-6 (IL-6), and C reactive protein (CRP) were determined on admission. Serum PCT was tested in patients who developed AKI on the day of AKI occurrence and on either day 28 after occurrence (for survivors) or on the day of death (for those who died within 28 days).

Results

Serum PCT levels were 100-fold higher in the AKI group than in the non-AKI group on the day of ICU admission (p<0.05). The area under the receiver-operating characteristic (ROC) curve of PCT for predicting AKI was 0.986, which was superior to SAA, CRP, and IL-6 (p<0.05). ROC analysis revealed all variables tested had lower predictive performance for AKI prognosis. The average serum PCT level on day 28 (2.67 (0.89, 7.99) ng/ml) was significantly (p<0.0001) lower than on the day of AKI occurrence (43.71 (19.24,65.69) ng/ml) in survivors, but the serum PCT level on death (63.73 (34.22,94.30) ng/ml) was higher than on the day of AKI occurrence (37.55 (18.70,74.12) ng/ml) in non-survivors, although there was no significant difference between the two days in the latter group (p = 0.1365).

Conclusion

Serum PCT is superior to CRP, IL-6, and SAA for predicting the development of AKI in patients with AP, and also can be used for dynamic evaluation of AKI prognosis.     

Prevention of Acute Kidney Injury by Tauroursodeoxycholic Acid in Rat and Cell Culture Models

Background

Acute kidney injury (AKI) has grave short- and long-term consequences. Often the onset of AKI is predictable, such as following surgery that compromises blood flow to the kidney. Even in such situations, present therapies cannot prevent AKI. As apoptosis is a major form of cell death following AKI, we determined the efficacy and mechanisms of action of tauroursodeoxycholic acid (TUDCA), a molecule with potent anti-apoptotic and pro-survival properties, in prevention of AKI in rat and cell culture models. TUDCA is particularly attractive from a translational standpoint, as it has a proven safety record in animals and humans.

Methodology/Principal Findings

We chose an ischemia-reperfusion model in rats to simulate AKI in native kidneys, and a human kidney cell culture model to simulate AKI associated with cryopreservation in transplanted kidneys. TUDCA significantly ameliorated AKI in the test models due to inhibition of the mitochondrial pathway of apoptosis and upregulation of survival pathways.

Conclusions

This study sets the stage for testing TUDCA in future clinical trials for prevention of AKI, an area that needs urgent attention due to lack of effective therapies.     

The Impact of Dialysis-Requiring Acute Kidney Injury on Long-Term Prognosis of Patients Requiring Prolonged Mechanical Ventilation: Nationwide Population-Based Study

Background

Prolonged mechanical ventilation (PMV) is increasingly common worldwide, consuming enormous healthcare resources. Factors that modify PMV outcome are still obscure.

Methods

We selected patients without preceding mechanical ventilation within the one past year and who developed PMV during index admission in Taiwan''s National Health Insurance (NHI) system during 1998–2007 for comparison of mortality and resource use. They were divided into three groups: (1) patients with end-stage renal diseases (ESRD) before the index admission for PMV onset; (2) patients with dialysis-requiring acute kidney injury (AKI-dialysis) during the hospitalization course; and (3) patients without AKI or with non dialysis-requiring AKI during the hospitalization course (non-AKI). We used a random-effects logistic regression model to identify factors associated with mortality.

Results

Compared with the other two groups, patients with AKI-dialysis had significantly longer mechanical ventilation, more frequent use of vasopressors, longer intensive care unit/hospital stay and higher inpatient expenditures during the index admission. Relative to non-AKI patients, patients with AKI-dialysis had an elevated mortality hazard; the adjusted relative risk ratios were 1.51 (95% confidence interval [CI]:1.46–1.56), 1.27 (95% CI: 1.23–1.32), and 1.10 (95% CI: 1.08–1.12) for mortality rates at discharge, 3 months, and 4 years after PMV, respectively. Patients with AKI-dialysis also consumed significantly higher total in-patient expenditure than the other two patient groups (p<0.001).

Conclusions

Among patients that need PMV care during an admission, the presence of de novo AKI requiring dialysis significantly increased short and long term mortality, and demand for health care resources.