Recognition and management of community-acquired acute kidney injury in low-resource settings in the ISN 0by25 trial: A multi-country feasibility study.

BACKGROUND: Acute kidney injury (AKI) is increasingly encountered in community settings and contributes to morbidity, mortality, and increased resource utilization worldwide. In low-resource settings, lack of awareness of and limited access to diagnostic and therapeutic interventions likely influence patient management. We evaluated the feasibility of the use of point-of-care (POC) serum creatinine and urine dipstick testing with an education and training program to optimize the identification and management of AKI in the community in 3 low-resource countries. METHODS AND FINDINGS: Patients presenting to healthcare centers (HCCs) from 1 October 2016 to 29 September 2017 in the cities Cochabamba, Bolivia; Dharan, Nepal; and Blantyre, Malawi, were assessed utilizing a symptom-based risk score to identify patients at moderate to high AKI risk. POC testing for serum creatinine and urine dipstick at enrollment were utilized to classify these patients as having chronic kidney disease (CKD), acute kidney disease (AKD), or no kidney disease (NKD). Patients were followed for a maximum of 6 months with repeat POC testing. AKI development was assessed at 7 days, kidney recovery at 1 month, and progression to CKD and mortality at 3 and 6 months. Following an observation phase to establish baseline data, care providers and physicians in the HCCs were trained with a standardized protocol utilizing POC tests to evaluate and manage patients, guided by physicians in referral hospitals connected via mobile digital technology. We evaluated 3,577 patients, and 2,101 were enrolled: 978 in the observation phase and 1,123 in the intervention phase. Due to the high number of patients attending the centers daily, it was not feasible to screen all patients to assess the actual incidence of AKI. Of enrolled patients, 1,825/2,101 (87%) were adults, 1,117/2,101 (53%) were females, 399/2,101 (19%) were from Bolivia, 813/2,101 (39%) were from Malawi, and 889/2,101 (42%) were from Nepal. The age of enrolled patients ranged from 1 month to 96 years, with a mean of 43 years (SD 21) and a median of 43 years (IQR 27-62). Hypertension was the most common comorbidity (418/2,101; 20%). At enrollment, 197/2,101 (9.4%) had CKD, and 1,199/2,101 (57%) had AKD. AKI developed in 30% within 7 days. By 1 month, 268/978 (27%) patients in the observation phase and 203/1,123 (18%) in the intervention phase were lost to follow-up. In the intervention phase, more patients received fluids (observation 714/978 [73%] versus intervention 874/1,123 [78%]; 95% CI 0.63, 0.94; p = 0.012), hospitalization was reduced (observation 578/978 [59%] versus intervention 548/1,123 [49%]; 95% CI 0.55, 0.79; p < 0.001), and admitted patients with severe AKI did not show a significantly lower mortality during follow-up (observation 27/135 [20%] versus intervention 21/178 [11.8%]; 95% CI 0.98, 3.52; p = 0.057). Of 504 patients with kidney function assessed during the 6-month follow-up, de novo CKD arose in 79/484 (16.3%), with no difference between the observation and intervention phase (95% CI 0.91, 2.47; p = 0.101). Overall mortality was 273/2,101 (13%) and was highest in those who had CKD (24/106; 23%), followed by those with AKD (128/760; 17%), AKI (85/628; 14%), and NKD (36/607; 6%). The main limitation of our study was the inability to determine the actual incidence of kidney dysfunction in the health centers as it was not feasible to screen all the patients due to the high numbers seen daily. CONCLUSIONS: This multicenter, non-randomized feasibility study in low-resource settings demonstrates that it is feasible to implement a comprehensive program utilizing POC testing and protocol-based management to improve the recognition and management of AKI and AKD in high-risk patients in primary care.

[Epidemiología y desenlaces de la lesión renal aguda en Latinoamérica].

La lesión renal aguda (LRA) o injuria renal aguda, como se describe en Sudamérica, está sobreestimada por estudios epidemiológicos de países de alto nivel económico. En Latinoamérica (LA) existe un vacío de información sobre la epidemiología de la LRA. Se realizó una búsqueda de artículos publicados en LA referentes a la LRA y se hallaron 61 estudios, que representan a 10,670 pacientes latinoamericanos, en los cuales se distingue entre población adulta y pediátrica, LRA adquirida en la comunidad (LRA-AC) y adquirida en el hospital (LRA-AH), y se describen sus etiologías y desenlaces. El conocimiento de la incidencia y características de los pacientes con LRA en LA nos permitirá el desarrollo de estrategias preventivas y mejor acceso a un tratamiento de apoyo adecuado.Acute kidney injury (AKI) is over represented by epidemiological studies of high-income countries. In Latin America there is a lack of information on the epidemiology of AKI. We conducted a search of articles on AKI published in Latin America, finding 61 studies that represent 10,670 Latin American patients. Data were segmented by adult and pediatric populations, and community-acquired AKI and hospital-acquired AKI. Finally, etiology and outcomes are described. The knowledge of the incidence and characteristics of patients with AKI in Latin America will allow us to develop preventive strategies and better access to adequate support treatment.

Recognition and management of acute kidney injury in the International Society of Nephrology 0by25 Global Snapshot: a multinational cross-sectional study.

BACKGROUND: Epidemiological data for acute kidney injury are scarce, especially in low-income countries (LICs) and lower-middle-income countries (LMICs). We aimed to assess regional differences in acute kidney injury recognition, management, and outcomes. METHODS: In this multinational cross-sectional study, 322 physicians from 289 centres in 72 countries collected prospective data for paediatric and adult patients with confirmed acute kidney injury in hospital and non-hospital settings who met criteria for acute kidney injury. Signs and symptoms at presentation, comorbidities, risk factors for acute kidney injury, and process-of-care data were obtained at the start of acute kidney injury, and need for dialysis, renal recovery, and mortality recorded at 7 days, and at hospital discharge or death, whichever came earlier. We classified countries into high-income countries (HICs), upper-middle-income countries (UMICs), and combined LICs and LMICs (LLMICs) according to their 2014 gross national income per person. FINDINGS: Between Sept 29 and Dec 7, 2014, data were collected from 4018 patients. 2337 (58%) patients developed community-acquired acute kidney injury, with 889 (80%) of 1118 patients in LLMICs, 815 (51%) of 1594 in UMICs, and 663 (51%) of 1241 in HICs (for HICs vs UMICs p=0.33; p<0.0001 for all other comparisons). Hypotension (1615 [40%] patients) and dehydration (1536 [38%] patients) were the most common causes of acute kidney injury. Dehydration was the most frequent cause of acute kidney injury in LLMICs (526 [46%] of 1153 vs 518 [32%] of 1605 in UMICs vs 492 [39%] of 1260 in HICs) and hypotension in HICs (564 [45%] of 1260 vs 611 [38%%] of 1605 in UMICs vs 440 [38%] of 1153 LLMICs). Mortality at 7 days was 423 (11%) of 3855, and was higher in LLMICs (129 [12%] of 1076) than in HICs (125 [10%] of 1230) and UMICs (169 [11%] of 1549). INTERPRETATION: We identified common aetiological factors across all countries, which might be amenable to a standardised approach for early recognition and treatment of acute kidney injury. Study limitations include a small number of patients from outpatient settings and LICs, potentially under-representing the true burden of acute kidney injury in these areas. Additional strategies are needed to raise awareness of acute kidney injury in community health-care settings, especially in LICs. FUNDING: International Society of Nephrology.

Acute kidney injury in Latin America: a view on renal replacement therapy resources.

BACKGROUND: Acute kidney injury (AKI) has increasingly been recognized as an important public health issue due to its rising frequency, its associations with early and late adverse outcomes and its economic burden. METHODS: Given the importance of determining the available resources to address this serious issue, the AKI Committee of SLANH conducted a survey to obtain information about infrastructure, human resources and equipment devoted to the treatment of AKI in Latin America RESULTS: A total of 246 units from 14 countries participated in the survey, the majority of them pertaining to nephrology divisions in teaching hospitals. Intermittent hemodialysis was universally performed by all of the units, and less frequently, slow extended dialysis (40%) and continuous renal replacement therapy (23%) were performed. Seventy-nine units (30%) perform peritoneal dialysis, but only 51 (19%) of them reported having treated at least 1 patient with this technique in the last 3 months pre-survey. The vast majority of the units reported adequate water treatment and use of modern filter membranes. Most of the patients received renal replacement therapy (RRT) in the intensive care unit. Specific causes of AKI were reported in different frequencies, with a heterogeneous pattern among the countries. Septic abortion, hemolytic-uremic syndrome, community-acquired diarrhea and leptospirosis were the etiologies most frequently associated with AKI. CONCLUSIONS: To our knowledge, this report was the first available study of the equipment and human resources utilized for RRT in AKI patients in Latin America.

Latin American registry of renal involvement in COVID-19 disease. The relevance of assessing proteinuria throughout the clinical course.

The Latin American Society of Nephrology and Hypertension conducted a prospective cohort, multinational registry of Latin American patients with kidney impairment associated to COVID-19 infection with the objective to describe the characteristics of acute kidney disease under these circumstances. The study was carried out through open invitation in order to describe the characteristics of the disease in the region. Eight-hundred and seventy patients from 12 countries were included. Median age was 63 years (54-74), most of patients were male (68.4%) and with diverse comorbidities (87.2%). Acute kidney injury (AKI) was hospital-acquired in 64.7% and non-oliguric in 59.9%. Multiorgan dysfunction syndrome (MODS) due to COVID-19 and volume depletion were the main factors contributing to AKI (59.2% and 35.7% respectively). Kidney replacement therapy was started in 46.2%. Non-recovery of renal function was observed in 65.3%. 71.5% of patients were admitted to ICU and 72.2% underwent mechanical ventilation. Proteinuria at admission was present in 62.4% of patients and proteinuria during hospital-stay occurred in 37.5%. Those patients with proteinuria at admission had higher burden of comorbidities, higher baseline sCr, and MODS was severe. On the other hand, patients with de novo proteinuria had lower incidence of comorbidities and near normal sCr at admission, but showed adverse course of disease. COVID-19 MODS was the main cause of AKI in both groups. All-cause mortality of the general population was 57.4%, and it was associated to age, sepsis as cause of AKI, severity of condition at admission, oliguria, mechanical ventilation, non-recovery of renal function, in-hospital complications and hospital stay. In conclusion, our study contributes to a better knowledge of this condition and highlights the relevance of the detection of proteinuria throughout the clinical course.

Development of a prediction score for in-hospital mortality in COVID-19 patients with acute kidney injury: a machine learning approach.

Acute kidney injury (AKI) is frequently associated with COVID-19 and it is considered an indicator of disease severity. This study aimed to develop a prognostic score for predicting in-hospital mortality in COVID-19 patients with AKI (AKI-COV score). This was a cross-sectional multicentre prospective cohort study in the Latin America AKI COVID-19 Registry. A total of 870 COVID-19 patients with AKI defined according to the KDIGO were included between 1 May 2020 and 31 December 2020. We evaluated four categories of predictor variables that were available at the time of the diagnosis of AKI: (1) demographic data; (2) comorbidities and conditions at admission; (3) laboratory exams within 24 h; and (4) characteristics and causes of AKI. We used a machine learning approach to fit models in the training set using tenfold cross-validation and validated the accuracy using the area under the receiver operating characteristic curve (AUC-ROC). The coefficients of the best model (Elastic Net) were used to build the predictive AKI-COV score. The AKI-COV score had an AUC-ROC of 0.823 (95% CI 0.761-0.885) in the validation cohort. The use of the AKI-COV score may assist healthcare workers in identifying hospitalized COVID-19 patients with AKI that may require more intensive monitoring and can be used for resource allocation.

EPILAT-IRA Study: A contribution to the understanding of the epidemiology of acute kidney injury in Latin America.

INTRODUCTION: Epidemiology of acute kidney injury (AKI) is highly dependent on patient characteristics, context and geography. Considering the limited information in Latin America and the Caribbean, we performed a study with the aim to contribute to improve its better understanding. METHODS: Observational, prospective, longitudinal, multinational cohort study addressed to determine risk factors, clinical profile, process of care and outcomes of AKI in the region. Patients meeting KDIGO AKI definition were included over a 9-month period and designated community or hospital-acquired. De-identified clinical and lab data were entered in a specifically designed on-line platform. Co-variables potentially linked to AKI onset, in-hospital and 90-days mortality, were recorded and correlated using a multiple logistic regression model. RESULTS: Fifty-seven physicians from 15 countries provided data on 905 patients, most with acceptable basic needs coverage. Median age 64 (50-74) yrs; most of them were male (61%) and mestizos (42%). Comorbidities were present in 77%. AKI was community-acquired in 62%. Dehydration, shock and nephrotoxic drugs were the commonest causes. During their process of care, 77% of patients were assessed by nephrologists. Kidney replacement therapy (KRT) was performed in 29% of cases. In-hospital mortality was 26.5% and independently associated to older age, chronic liver disease, hypotension, shock, cardiac disturbances, hospital-acquired sepsis, KRT and mechanical ventilation. At 90-days follow up partial or complete renal recovery was 81% and mortality 24%. CONCLUSIONS: AKI was mainly community-acquired, in patients with comorbidities and linked to fluid loss and nephrotoxic drugs. Mortality was high and long-term follow up poor. Notwithstanding, the study shows partially the situation in the participant countries rather than the actual epidemiology of AKI in Latin America and Caribbean, a pending and needed task.

Epidemiology of acute kidney injury in Latin America.

There is little reliable information on the epidemiology of acute kidney injury (AKI) in Latin America. It is generally assumed that AKI in the developing world affects mainly young and previously healthy people, with an etiologic spectrum relying on particular socioeconomic and environmental conditions. Transmissible diseases such as leptospirosis, malaria, dengue, diarrhea, among others, are recognized as important causes of AKI in these areas. On the other hand, in large cities and university hospitals in Latin American, the AKI spectrum is similar to that seen in developed countries. Large studies are needed to improve our knowledge to design preventive strategies for this potentially lethal disease that affects all population subgroups, from the socially and economically vulnerable to the wealthy. In this article the available information regarding AKI epidemiology in Latin America is reviewed. Data obtained by the Latin American Acute Renal Failure Commission from the Latin American Society of Nephrology through surveys performed in 1997, 2000, and 2004 are reported. Finally, 3 particular medical conditions frequently associated with AKI in Latin America are reviewed.

Risk factors profile for acute kidney injury after cardiac surgery is different according to the level of baseline renal function.

Acute kidney injury (AKI) occurs frequently after cardiac surgery. Although numerous variables were identified as predictors for AKI, there is a lack of information about possible differences in risk factors according to the level of preoperative renal function. Preoperative, intraoperative, and postoperative data from 4118 adult patients submitted to cardiac surgery from January 1, 2000, to December 31, 2005, were included in the study. AKI was defined by an increase in serum creatinine (S(Cr)) >/= 0.3 mg/dL after surgery. Patients were stratified into two groups: group 1, C(Cr) >/= 60 mL/min/1.73 m(2) BSA; group 2, C(Cr) < 60 mL/min/1.73 m(2) BSA. Risk factors were assessed using a multiple logistic regression model. In all, 749 patients (42.5%) developed AKI. The mortality rate of the entire population was a 5.2%. In patients of group 1 (n = 2678), the variables independently associated with the onset of AKI were age, diabetes, preoperative use of diuretics, non-scheduled surgery, cardiopulmonary by-pass (CPB) time, CPB mean arterial pressure, hemodilution, and postoperative use of norepinephrine. Baseline S(Cr) was associated with AKI only in patients of group 2 (n = 1440). Age, EuroSCORE, non-coronary surgery, hemodilution, and postoperative use of vasoactive drugs were also predictors of AKI in this group of patients. The mortality rate was significantly higher in group 2 than group 1 (8.5% vs. 3.6%, p = 0.000). In conclusion, the present study demonstrated a difference in variables associated with postoperative AKI, according to baseline renal function. The degree of preoperative renal function was a predictor of AKI only in patients with CKD stages 3-4, as well as other risk factors. In addition to other well known risk factors for AKI in this setting, the use of diuretics in patients of group 1 and the level of hemodilution during CPB in both groups should be emphasized, as they are potentially modifiable.

Raising Awareness of Acute Kidney Injury: A Latin American Experience.

INTRODUCTION: Raising awareness of acute kidney injury (AKI) is an essential strategy for minimizing the burden of this lethal syndrome. The AKI Commission of the Latin American Society of Nephrology and Hypertension conducted an educational program based on networked learning. METHODS: Two online courses with similar methodologies were developed, 1 course for nephrologists and the other for primary care physicians (PCP). The courses were developed as a distance education, asynchronous online modality with multiple educational strategies: written lessons, videos, e-rounds, and clinical simulation. Knowledge gain was explored through a 10-question test before and after course completion. RESULTS: The course for nephrologists had 779 participants from 21 countries; 52% were male, and 46% were <35 years of age. Mean qualification increased from 5.87 to 8.01 (36% gain of knowledge). The course for PCPs had 2011 participants, 81% of whom were physicians. The time from graduation was <5 years in 52%. In both courses, clinical simulation was considered the best part and lack of time the main limitation for learning. Because 48% of the nephrologist course attendees were interested in AKI activities, a Latin American AKI Network site (RedIRA) composed of a brief review, a clinical forum, a self-assessment, and a bibliography on AKI was launched on a monthly basis in November 2016. To date there are 335 users from 18 countries. CONCLUSIONS: Distance education techniques were effective for learning about AKI and are a potential tool for the development of a sustainable structure for communication, exchange, and integration of physicians involved in the care of patients with AKI.

Acute kidney injury after cardiac surgery is associated with mid-term but not long-term mortality: A cohort-based study.

Acute kidney injury (AKI) in cardiac surgery is associated with complications, early and late mortality and increased health care expenditures. The overall dynamic comorbidity-adjusted contributions of an episode of AKI on mortality during long-term follow-up have not been fully explored. A longitudinal cohort of 7075 adult patients admitted for cardiac surgery were enrolled in the study. Follow-up data were obtained through telephonic survey after 1, 5, 10, and 15 years or from the National Mortality Registry. All-cause mortality was assessed at five time intervals: I) 30 days after surgery to 1 year; II) 1 to 3 years; III) 3 to 5 years; IV) 5 to 10 years; and V) 10 to 15 years. For the adjustment of mortality for comorbidity and pre-, intra- and postoperative variables, Cox proportional hazard regression models were conducted within each period. The overall incidence of AKI was 36.1%. AKI was an independent predictor of death only during the first five years after surgery (30 days to 1 year: HR 1.834, 95% CI 1.459 to 2.306; 1 to 3 years: HR 1.285, 95% CI 1.023 to 1.610; and 3 to five years: HR 1.330, 95% CI 1.123 to 1.750). Only age, diabetes mellitus and CHF were associated with increased risk of death over the entire follow-up period. Our study demonstrates a transient association of AKI with long-term mortality that progressively decreases and vanishes five years after surgery. The knowledge of this dynamic is crucial to understanding this complex association, planning health care and allocating resources.

Acute Kidney Injury in Mechanically Ventilated Patients: The Risk Factor Profile Depends on the Timing of Aki Onset.

BACKGROUND: Acute kidney injury (AKI) is a frequent complication in patients under mechanical ventilation (MV). We aimed to assess the risk factors for AKI with particular emphasis on those potentially preventable. STUDY DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of a large, multinational database of MV patients with >24 h of MV and normal renal function at admission. AKI was defined according to creatinine-based KDIGO criteria. Risk factors were analyzed according to the time point at which AKI occurred: early (≤48 h after ICU admission, AKIE) and late (day 3 to day 7 of ICU stay, AKIL). A conditional logistic regression model was used to identify variables independently associated with AKI. RESULTS: Three thousand two hundred six patients were included. Seven hundred patients had AKI (22%), the majority of them AKIE (547/704). The risk factor profile was highly dependent upon the timing of AKI onset. In AKIE risk factors were older age; SAPS II score; postoperative and cardiac arrest as the reasons for MV; worse cardiovascular SOFA, pH, serum creatinine, and platelet count; higher level of peak pressure and Vt/kg; and fluid overload at admission. In contrast, AKIL was linked mostly to events that occurred after admission (lower platelet count and pH; ICU-acquired sepsis; and fluid overload). None ventilation-associated parameters were identify as risk factors for AKIL. CONCLUSIONS: In the first 48 h, risk factors are associated with the primary disease and the patient's condition at admission. Subsequently, emergent events like sepsis and organ dysfunction appear to be predictive factors making prevention a challenge.

Genetic characterization and phylogeography of the wild boar Sus scrofa introduced into Uruguay.

The European wild boar Sus scrofa was first introduced into Uruguay, in southern South America during the early decades of the last century. Subsequently, and starting from founder populations, its range spread throughout the country and into the neighbouring Brazilian state Rio Grande do Sul. Due to the subsequent negative impact, it was officially declared a national pest. The main aim in the present study was to provide a more comprehensive scenario of wild boar differentiation in Uruguay, by using mtDNA markers to access the genetic characterization of populations at present undergoing rapid expansion. A high level of haplotype diversity, intermediate levels of nucleotide diversity and considerable population differentiation, were detected among sampled localities throughout major watercourses and catchment dams countrywide. Phylogenetic analysis revealed the existence of two different phylogroups, thereby reflecting two deliberate introduction events forming distantly genetic lineages in local wild boar populations. Our analysis lends support to the hypothesis that the invasive potential of populations emerge from introgressive hybridization with domestic pigs. On taking into account the appreciable differentiation and reduced migration between locales in wild boar populations, management strategies could be effective if each population were to be considered as a single management unit.

An assessment of the Acute Kidney Injury Network creatinine-based criteria in patients submitted to mechanical ventilation.

BACKGROUND AND OBJECTIVES: The aim of our study was to assess the new diagnostic criteria of acute kidney injury (AKI) proposed by the Acute Kidney Injury Network (AKIN) in a large cohort of mechanically ventilated patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This is a prospective observational cohort study enrolling 2783 adult intensive care unit patients under mechanical ventilation (MV) with data on serum creatinine concentration (SCr) in the first 48 hours. The absolute and the relative AKIN diagnostic criteria (changes in SCr ≥ 0.3 mg/dl or ≥ 50% over the first 48 hours of MV, respectively) were analyzed separately. In addition, patients were classified into three groups according to their change in SCr (ΔSCr) over the first day on MV (ΔSCr): group 1, ΔSCr ≤ -0.3 mg/dl; group 2, ΔSCr between -0.3 and +0.29 mg/dl; and group 3, ΔSCr ≥ +0.3 mg/dl). The primary end point was in-hospital mortality, and secondary end points were intensive care unit and hospital length of stay, and duration of MV. RESULTS: Of 2783 patients, 803 (28.8%) had AKI according to both criteria: 431 only absolute (AKI(A)), 362 both relative and absolute (AKI(R+A)), and 10 only relative. The relative criterion identified more patients when baseline SCr (SCr0) was <0.9 mg/dl and the absolute when SCr0 was >1.5 mg/dl. The diagnosis of AKI was associated with mortality. CONCLUSIONS: Our study confirms the validity of the AKIN criteria in a population of mechanically patients and the criteria's relationship with the baseline SCr.