Acute kidney injury: the experience of a tertiary center of Pediatric Nephrology / Insuficiência renal aguda: experiência de um centro terciário de Nefrologia Pediátrica

ABSTRACT Introduction: Acute kidney injury (AKI) is an abrupt deterioration of kidney function. The incidence of pediatric AKI is increasing worldwide, both in critically and non-critically ill settings. We aimed to characterize the presentation, etiology, evolution, and outcome of AKI in pediatric patients admitted to a tertiary care center. Methods: We performed a retrospective observational single-center study of patients aged 29 days to 17 years and 365 days admitted to our Pediatric Nephrology Unit from January 2012 to December 2021, with the diagnosis of AKI. AKI severity was categorized according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. The outcomes considered were death or sequelae (proteinuria, hypertension, or changes in renal function at 3 to 6 months follow-up assessments). Results: Forty-six patients with a median age of 13.0 (3.5-15.5) years were included. About half of the patients (n = 24, 52.2%) had an identifiable risk factor for the development of AKI. Thirteen patients (28.3%) were anuric, and all of those were categorized as AKI KDIGO stage 3 (p < 0.001). Almost one quarter (n = 10, 21.7%) of patients required renal replacement therapy. Approximately 60% of patients (n = 26) had at least one sequelae, with proteinuria being the most common (n = 15, 38.5%; median (P25-75) urinary protein-to-creatinine ratio 0.30 (0.27-0.44) mg/mg), followed by reduced glomerular filtration rate (GFR) (n = 11, 27.5%; median (P25-75) GFR 75 (62-83) mL/min/1.73 m2). Conclusions: Pediatric AKI is associated with substantial morbidity, with potential for proteinuria development and renal function impairment and a relevant impact on long-term prognosis.

RESUMO Introdução: Insuficiência renal aguda (IRA) é uma deterioração abrupta da função renal. A incidência de IRA pediátrica está aumentando em todo o mundo, em ambientes críticos e não críticos. Nosso objetivo foi caracterizar apresentação, etiologia, evolução e desfechos da IRA em pacientes pediátricos internados em um centro de atendimento terciário. Métodos: Realizamos estudo retrospectivo observacional de centro único de pacientes com idade entre 29 dias a 17 anos e 365 dias internados em nossa Unidade de Nefrologia Pediátrica, de janeiro de 2012 a dezembro de 2021, com diagnóstico de IRA. A gravidade da IRA foi categorizada de acordo com os critérios do Kidney Disease Improving Global Outcomes (KDIGO). Os desfechos considerados foram óbito ou sequelas (proteinúria, hipertensão ou alterações na função renal em avaliações de acompanhamento de 3 a 6 meses). Resultados: Incluímos 46 pacientes com idade mediana de 13,0 (3,5-15,5) anos. Cerca de metade (n = 24; 52,2%) apresentou um fator de risco identificável para o desenvolvimento de IRA. Treze pacientes (28,3%) eram anúricos; todos foram classificados como IRA KDIGO 3 (p < 0,001). Quase um quarto (n = 10; 21,7%) dos pacientes necessitaram de terapia renal substitutiva. Aproximadamente 60% (n = 26) apresentou pelo menos uma sequela, sendo proteinúria a mais comum (n = 15; 38,5%; mediana (P25-75) da relação proteína/creatinina urinária 0,30 (0,27-0,44) mg/mg), seguida de taxa de filtração glomerular (TFG) reduzida (n = 11; 27,5%; mediana (P25-75) da TFG 75 (62-83) mL/min/1,73 m2). Conclusões: A IRA pediátrica está associada à morbidade substancial, com potencial para desenvolvimento de proteinúria e comprometimento da função renal e impacto relevante no prognóstico de longo prazo.

Acute kidney injury in nonagenarians: clinical characteristics and mortality / Injúria renal aguda em nonagenários: características clínicas e mortalidade

Abstract Introduction: Nonagenarians constitute a rising percentage of inpatients, with acute kidney injury (AKI) being frequent in this population. Thus, it is important to analyze the clinical characteristics of this demographic and their impact on mortality. Methods: Retrospective study of nonagenarian patients with AKI at a tertiary hospital between 2013 and 2022. Only the latest hospital admission was considered, and patients with incomplete data were excluded. A logistic regression analysis was conducted to define risk factors for mortality. A p-value < 0.05 was considered statistically significant. Results: A total of 150 patients were included, with a median age of 93.0 years (91.2-95.0), and males accounting for 42.7% of the sample. Sepsis was the most common cause of AKI (53.3%), followed by dehydration/hypovolemia (17.7%), and heart failure (17.7%). ICU admission occurred in 39.3% of patients, mechanical ventilation in 14.7%, vasopressors use in 22.7% and renal replacement therapy (RRT) in 6.7%. Death occurred in 56.7% of patients. Dehydration/hypovolemia as an etiology of AKI was associated with a lower risk of mortality (OR 0.18; 95% CI 0.04-0.77, p = 0.020). KDIGO stage 3 (OR 3.15; 95% CI 1.17-8.47, p = 0.023), ICU admission (OR 12.27; 95% CI 3.03-49.74, p < 0.001), and oliguria (OR 5.77; 95% CI 1.98-16.85, p = 0.001) were associated with mortality. Conclusion: AKI nonagenarians had a high mortality rate, with AKI KDIGO stage 3, oliguria, and ICU admission being associated with death.

Resumo Introdução: Nonagenários constituem um percentual de pacientes internados em ascensão, sendo a injúria renal aguda (IRA) frequente nesses pacientes. Sendo assim, é importante analisar as características clínicas dessa população e seu impacto na mortalidade. Métodos: Estudo retrospectivo de pacientes nonagenários com IRA entre 2013 e 2022 em um hospital terciário. Apenas o último internamento foi considerado e pacientes com dados incompletos foram excluídos. Uma análise por regressão logística foi realizada para definir fatores de risco para mortalidade. Um valor de p < 0,05 foi considerado significativo. Resultados: Foram incluídos 150 pacientes com mediana de idade 93,0 anos (91,2-95,0) e sexo masculino em 42,7%. Sepse foi a causa mais comum de IRA (53,3%), seguida de desidratação/hipovolemia (17,7%) e insuficiência cardíaca (17,7%). Admissão na UTI ocorreu em 39,3% dos pacientes, ventilação mecânica em 14,7%, uso de vasopressores em 22,7% e realização de terapia renal substitutiva (TRS) em 6,7%. Óbito ocorreu em 56,7% dos pacientes. Desidratação/hipovolemia como etiologia da IRA foi associado a menor risco de mortalidade (OR 0,18; IC 95% 0,04-0,77, p = 0,020). Estágio KDIGO 3 (OR 3,15; IC 95% 1,17-8,47, p = 0,023), admissão na UTI (OR 12,27; IC 95% 3,03-49,74, p < 0,001) e oligúria (OR 5,77; IC 95% 1,98-16,85, p = 0,001) foram associados à mortalidade. Conclusão: Nonagenários com IRA apresentaram alta mortalidade e IRA KDIGO 3, oligúria e admissão na UTI foram associadas ao óbito.

Incidence of contrast-associated acute kidney injury: a prospective cohort / Incidência de lesão renal aguda associada ao contraste: uma coorte prospectiva

ABSTRACT Introduction: Contrast-associated acute kidney injury (CA-AKI) is a deterioration of kidney function that occurs after the administration of a iodinated contrast medium (ICM). Most studies that defined this phenomenon used older ICMs that were more prone of causing CA-AKI. In the past decade, several articles questioned the true incidence of CA-AKI. However, there is still a paucity of a data about the safety of newer ICM. Objective: To assess the incidence of CA-AKI in hospitalized patients that were exposed to computed tomography (CT) with and without ICM. Methods: Prospective cohort study with 1003 patients who underwent CT in a tertiary hospital from December 2020 through March 2021. All inpatients aged > 18 years who had a CT scan during this period were screened for the study. CA-AKI was defined as a relative increase of serum creatinine of ≥ 50% from baseline or an absolute increase of ≥ 0.3 mg/dL within 18 to 48 hours after the CT. Chi-squared test, Kruskal-Wallis test, and linear regression model with restricted cubic splines were used for statistical analyses. Results: The incidence of CA-AKI was 10.1% in the ICM-exposed group and 12.4% in the control group when using the absolute increase criterion. The creatinine variation from baseline was not significantly different between groups. After adjusting for baseline factors, contrast use did not correlate with worse renal function. Conclusion: The rate of CA-AKI is very low, if present at all, with newer ICMs, and excessive caution regarding contrast use is probably unwarranted.

RESUMO Introdução: Lesão renal aguda associada ao contraste (LRA-AC) é uma deterioração da função renal que ocorre após a administração de meio de contraste iodado (MCI). A maioria dos estudos que definiram esse fenômeno utilizaram MCI mais antigos, mais propensos a causar LRA-AC. Na última década, diversos artigos questionaram a verdadeira incidência de LRA-AC. Entretanto, ainda há escassez de dados sobre a segurança dos MCI mais novos. Objetivo: Avaliar a incidência de LRA-AC em pacientes hospitalizados expostos à tomografia computadorizada (TC) com e sem MCI. Métodos: Estudo de coorte prospectivo com 1.003 pacientes submetidos a TC em hospital terciário, de dezembro/2020 a março/2021. Todos os pacientes internados com idade ≥ 18 anos que realizaram TC nesse período foram selecionados. A LRA-AC foi definida como aumento relativo de creatinina sérica de ≥ 50% em relação ao valor basal ou aumento absoluto de ≥ 0,3 mg/dL dentro de 18 a 48 horas após a TC. Utilizamos o teste qui-quadrado, teste de Kruskal-Wallis e modelo de regressão linear com splines cúbicos restritos para análises estatísticas. Resultados: A incidência de LRA-AC foi 10,1% no grupo exposto ao MCI e 12,4% no grupo controle ao usar o critério de aumento absoluto. A variação da creatinina em relação ao valor basal não foi significativamente diferente entre os grupos. Após ajuste para fatores basais, o uso de contraste não se correlacionou com pior função renal. Conclusão: A taxa de LRA-AC é muito baixa, caso exista, com MCIs mais novos, e a cautela excessiva quanto ao uso de contraste provavelmente não se justifica.

Risk factors for acute kidney injury in patients hospitalized with COVID-19 / Fatores de risco para lesão renal aguda em pacientes hospitalizados com COVID-19

Abstract Introduction: Acute kidney injury (AKI) occurs frequently in COVID-19 patients and is associated with greater morbidity and mortality. Knowing the risks of AKI allows for identification, prevention, and timely treatment. This study aimed to identify the risk factors associated with AKI in hospitalized patients. Methods: A descriptive, retrospective, cross-sectional, and analytical component study of adult patients hospitalized with COVID-19 from March 1 to December 31, 2020 was carried out. AKI was defined by the creatinine criteria of the KDIGO-AKI guidelines. Information, regarding risk factors, was obtained from electronic medical records. Results: Out of the 934 patients, 42.93% developed AKI, 60.59% KDIGO-1, and 9.9% required renal replacement therapy. Patients with AKI had longer hospital stay, higher mortality, and required more intensive care unit (ICU) admission, mechanical ventilation, and vasopressor support. Multivariate analysis showed that age (OR 1.03; 95% CI 1.02-1.04), male sex (OR 2.13; 95% CI 1.49-3.04), diabetes mellitus (DM) (OR 1.55; 95% CI 1.04-2.32), chronic kidney disease (CKD) (OR 2.07; 95% CI 1.06-4.04), C-reactive protein (CRP) (OR 1.02; 95% CI 1.00-1.03), ICU admission (OR 1.81; 95% CI 1.04-3.16), and vasopressor support (OR 7.46; 95% CI 3.34-16.64) were risk factors for AKI, and that bicarbonate (OR 0.89; 95% CI 0.84-0.94) and partial pressure arterial oxygen/inspired oxygen fraction index (OR 0.99; 95% CI 0.98-0.99) could be protective factors. Conclusions: A high frequency of AKI was documented in COVID-19 patients, with several predictors: age, male sex, DM, CKD, CRP, ICU admission, and vasopressor support. AKI occurred more frequently in patients with higher disease severity and was associated with higher mortality and worse outcomes.

RESUMO Introdução: Lesão renal aguda (LRA) ocorre frequentemente em pacientes com COVID-19 e associa-se a maior morbidade e mortalidade. Conhecer riscos da LRA permite a identificação, prevenção e tratamento oportuno. Este estudo teve como objetivo identificar fatores de risco associados à LRA em pacientes hospitalizados. Métodos: Realizou-se estudo descritivo, retrospectivo, transversal e de componente analítico de pacientes adultos hospitalizados com COVID-19 de 1º de março a 31 de dezembro, 2020. Definiu-se a LRA pelos critérios de creatinina das diretrizes KDIGO-LRA. Informações sobre fatores de risco foram obtidas de prontuários eletrônicos. Resultados: Dos 934 pacientes, 42,93% desenvolveram LRA, 60,59% KDIGO-1 e 9,9% necessitaram de terapia renal substitutiva. Pacientes com LRA apresentaram maior tempo de internação, maior mortalidade e necessitaram de mais internações em UTIs, ventilação mecânica e suporte vasopressor. A análise multivariada mostrou que idade (OR 1,03; IC 95% 1,02-1,04), sexo masculino (OR 2,13; IC 95% 1,49-3,04), diabetes mellitus (DM) (OR 1,55; IC 95% 1,04-2,32), doença renal crônica (DRC) (OR 2,07; IC 95% 1,06-4,04), proteína C reativa (PCR) (OR 1,02; IC 95% 1,00-1,03), admissão em UTI (OR 1,81; IC 95% 1,04-3,16) e suporte vasopressor (OR 7,46; IC 95% 3,34-16,64) foram fatores de risco para LRA, e que bicarbonato (OR 0,89; IC 95% 0,84-0,94) e índice de pressão parcial de oxigênio arterial/fração inspirada de oxigênio (OR 0,99; IC 95% 0,98-0,99) poderiam ser fatores de proteção. Conclusões: Documentou-se alta frequência de LRA em pacientes com COVID-19, com diversos preditores: idade, sexo masculino, DM, DRC, PCR, admissão em UTI e suporte vasopressor. LRA ocorreu mais frequentemente em pacientes com maior gravidade da doença e associou-se a maior mortalidade e piores desfechos.

Acidosis láctica en un paciente usuario de metformina / Metformin-associated lactic acidosis

Metformin is a hypoglycemic agent used as the first line for the treatment of non-insulin dependent Diabetes Mellitus. While it is a generally safe drug, it has an infrequent adverse reaction called lactic acidosis. We report a 49 year-old patient with non-insulin-requiring type 2diabetes who developed an acute kidney failure injury along with severe metabolic acidosis secondary to pneumonia during treatment.

La metformina es un agente hipoglucemiante que se ocupa de primera línea para el tratamiento de la Diabetes Mellitus no insulino dependiente. Si bien es un medicamento bien tolerado, tiene una reacción adversa bastante infrecuente que es la acidosis láctica. Reportamos el caso de una paciente de 49 años insulino no dependiente que desarrolló una injuria renal aguda junto con acidosis metabólica severa secundaria a una neumonía en tratamiento.

Pediatric nephrologist-intensivist interaction in acute kidney injury / Interação nefro-intensivista pediátrica na lesão renal aguda

ABSTRACT Introduction: Acute Kidney Injury (AKI) in the Intensive Care Unit (ICU) have concepts of diagnosis and management have water balance as their main point of evaluation. In our ICU, from 2004 to 2012, the nephrologist's participation was on demand only; and as of 2013 their participation became continuous in meetings to case discussion. The aim of this study was to establish how an intense nephrologist/intensivist interaction influenced the frequency of dialysis indication, fluid balance and pRIFLE classification during these two observation periods. Methods: Retrospective study, longitudinal evaluation of all children with AKI undergoing dialysis (2004 to 2016). Parameters studied: frequency of indication, duration and volume of infusion in the 24 hours preceding dialysis; diuresis and water balance every 8 hours. Non-parametric statistics, p ≤ 0.05. Results: 53 patients (47 before and 6 after 2013). There were no significant differences in the number of hospitalizations or cardiac surgeries between the periods. After 2013, there was a significant decrease in the number of indications for dialysis/year (5.85 vs. 1.5; p = 0.000); infusion volume (p = 0.02), increase in the duration of dialysis (p = 0.002) and improvement in the discrimination of the pRIFLE diuresis component in the AKI development. Conclusion: Integration between the ICU and pediatric nephrology teams in the routine discussion of cases, critically approaching water balance, was decisive to improve the management of AKI in the ICU.

RESUMO Introdução: Os conceitos sobre diagnóstico e conduta da Lesão Renal Aguda (LRA) na Unidade de Terapia Intensiva (UTI) tem como ponto primordial a avaliação do balanço hídrico. Em nossa UTI, de 2004 a 2012, a participação do nefrologista era sob demanda. A partir de 2013, a participação passou a ser contínua em reunião de discussão de casos. O objetivo deste estudo foi determinar como a maior interação nefrologista/intensivista influenciou a frequência de indicação de diálise, no balanço hídrico e na classificação pRIFLE durante esses dois períodos de observação. Método: Estudo retrospectivo, avaliação longitudinal de todas as crianças com LRA em diálise (2004 a 2016). Parâmetros estudados: frequência de indicação, tempo de duração e volume de infusão nas 24 horas precedendo a diálise; diurese e balanço hídrico a cada 8 horas. Estatística não paramétrica, p ≤ 0,05. Resultado: 53 pacientes (47 antes e 6 após 2013). Sem diferença significativa no número de internações e nem de cirurgias cardíacas entre os períodos. Após 2013, houve diminuição significativa no número de indicação de diálise/ano (5,85 vs. 1,5; p = 0,000); no volume de infusão (p = 0,02), aumento do tempo de duração da diálise (p = 0,002) e melhora da discriminação do componente diurese do pRIFLE na indicação de LRA. Conclusão: Integração entre equipes de UTI e nefrologia pediátrica na discussão rotineira de casos, abordando criticamente o balanço hídrico, foi determinante para a melhora na conduta da LRA na UTI.

Case fatality rate among COVID-19 patients treated with acute kidney replacement therapy / Letalidade entre pacientes com injúria renal aguda por COVID-19 tratados com suporte renal artificial

Abstract Introduction: Acute kidney injury (AKI) is a frequent complication of severe COVID-19 and is associated with high case fatality rate (CFR). However, there is scarcity of data referring to the CFR of AKI patients that underwent kidney replacement therapy (KRT) in Brazil. The main objective of this study was to describe the CFR of critically ill COVID-19 patients treated with acute kidney replacement therapy (AKRT). Methods: Retrospective descriptive cohort study. We included all patients treated with AKRT at an intensive care unit in a single tertiary hospital over a 15-month period. We excluded patients under the age of 18 years, patients with chronic kidney disease on maintenance dialysis, and cases in which AKI preceded COVID-19 infection. Results: A total of 100 out of 1479 (6.7%) hospitalized COVID-19 patients were enrolled in this study. The median age was 74.5 years (IQR 64 - 82) and 59% were male. Hypertension (76%) and diabetes mellitus (56%) were common. At the first KRT prescription, 85% of the patients were on invasive mechanical ventilation and 71% were using vasoactive drugs. Continuous veno-venous hemodiafiltration (CVVHDF) was the preferred KRT modality (82%). CFR was 93% and 81 out of 93 deaths (87%) occurred within the first 10 days of KRT onset. Conclusion: AKRT in hospitalized COVID-19 patients resulted in a CFR of 93%. Patients treated with AKRT were typically older, critically ill, and most died within 10 days of diagnosis. Better strategies to address this issue are urgently needed.

Resumo Introdução: Injúria renal aguda (IRA) é uma complicação frequente da COVID-19 grave e está associada a alta taxa de letalidade (TL). Entretanto, há escassez de dados referentes à TL de pacientes com IRA submetidos a suporte renal artificial (SRA) no Brasil. O objetivo principal deste estudo foi descrever a TL de pacientes graves com IRA por COVID-19 tratados com SRA. Métodos: Estudo de coorte descritivo retrospectivo. Incluímos todos os pacientes tratados com SRA em unidade de terapia intensiva de um único hospital terciário por 15 meses. Excluímos pacientes menores de 18 anos, pacientes com doença renal crônica em diálise de manutenção e casos nos quais a IRA precedeu a infeção por COVID-19. Resultados: Incluímos neste estudo um total de 100 dos 1479 (6,7%) pacientes hospitalizados com COVID-19. A mediana de idade foi 74,5 anos (IIQ 64 - 82) e 59% eram homens. Hipertensão (76%) e diabetes mellitus (56%) foram comuns. Na primeira prescrição de SRA, 85% dos pacientes estavam em ventilação mecânica invasiva e 71% em uso de drogas vasoativas. A hemodiafiltração contínua foi a modalidade de SRA preferida (82%). A TL foi de 93% e 81 dos 93 óbitos (87%) ocorreram nos primeiros 10 dias do início da SRA. Conclusão: O SRA em pacientes hospi­talizados com IRA por COVID-19 resultou em TL de 93%. Os pacientes tratados com SRA eram geralmente idosos, gravemente enfermos e a maioria foi a óbito em até 10 dias após o diagnóstico. Estratégias melhores para abordar esse problema são urgentemente necessárias.

Acute kidney injury and hypercalcemia associated with veterinary supplements applications in adult man / Injúria renal aguda e hipercalcemia associadas a aplicações de suplementos veterinários em homem adulto

The compound "ADE" is an injectable oil for veterinary use which contains large amounts of vitamins A, D and E. The parenteral application in humans leads to a granuloma reaction which triggers hypercalcemia. A 42-year-old man was admitted with lower limb pain, nephrolithiasis and nephrocalcinosis. Laboratory tests revealed creatinine 4.59 mg/dl, calcium 13.3 mg/dl and parathormone 13.8 pg/ml. He underwent an ureterolithotripsy, stent placement, intravenous crystalloid fluids, and corticosteroid. He improved symptoms, kidney function and normalized serum calcium. The "ADE"-induced hypercalcemia diagnosis can be challenging. The early diagnosis may avoid negative outcomes.

O composto "ADE'' é um óleo veterinário injetável que contém grandes quantidades de vitaminas A, D e E. A aplicação parenteral causa reação granulomatosa e hipercalcemia. Um homem de 42 anos foi admitido com dor no membro inferior, nódulos musculares endurecidos, nefrolitíase e nefrocalcinose. O laboratório revelou creatinina 4,59 mg/dl, cálcio 13,3 mg/dl e paratormônio 13,8 pg/ml. Foi tratado com ureterolitotripsia, cateter duplo-J, cristaloide intravenoso e corticoterapia. Ele apresentou melhora dos sintomas, função renal e normalizou cálcio. O diagnóstico da hipercalcemia pelo "ADE'' pode ser desafiador. O diagnóstico precoce pode evitar desfechos negativos.

Therapeutic Drug Monitoring of 1 106 Cases of Vancomycin Therapy and Analysis of Risk Factors / 医药导报

Objective To analyze the achievement of target vancomycin concentration and the risk factors affecting the concentration to reach the target,providing a reference for the rational use of vancomycin and the implementation of therapeutic drug monitoring(TDM).Methods Patients who were hospitalized and received vancomycin TDM from January 2016 to June 2019 at Zhongshan Hospital,Fudan University were selected.Clinical data,vancomycin blood concentrations,and occurrences of acute kidney injury(AKI)during the hospitalization were collected.Factors affecting the attainment of target vancomycin concentrations were analyzed using logistic regression and grouped according to whether the target concentrations were attained.The correlation between drug concentration and the occurrence of AKI was analyzed.Results A total of 1 106 patients were included,with 70.7％being males and a median age of 60.0(IQR=20)years.Surgical departments accounted for 76.4％of the distribution.The median duration of vancomycin therapy was 10.8 d(IQR=9.0).A total of 21.6％of patients had their first concentration monitored before administration of doses 4 and 5.The drug concentration monitoring results of 46.8％(518/1 106)of patients were in the range between 10-20 μg·mL-1,reaching the target concentration range.The incidence of vancomycin-associated AKI was 25.9％.The incidence of AKI varied among patients with different vancomycin concentrations:when the concentrations are＜10,10-＜15,15-20,and＞20 μg·mL-1,the AKI rates are 15.8％,20.5％,25.8％,and 39.4％,respectively.Multivariate logistic regression analysis showed that target concentrations were more likely to be reached with a dosing course of＞7-14 d(OR=1.688,P=0.001)and＞14 d(OR=1.744,P=0.002)than with a dosing course of ≤7 d.Patients receiving conventional daily doses were more likely to achieve target concentrations than those receiving the non-conventional daily dose(OR=1.540,P=0.003).Conclusion The current status of vancomycin TDM in China still suffers from deficiencies,such as delayed timing of monitoring and low rate of target concentration attainment.Higher vancomycin concentrations are significantly associated with AKI,and the factors affecting the vancomycin concentration to reach the target mainly include treatment duration and the complexity of the dosing regimen.

Study and validation of biomarkers in serum of patients with acute and chronic kidney injury / 中国病理生理杂志

AIM:The aim of this study is to investigate the clinical utility of neutrophil gelatinase-associated lipocalin(NGAL)and other biomarkers in serum for patients with acute and chronic kidney injury.METHODS:A total of 171 patients with acute kidney injury(AKI)and 209 patients with chronic kidney disease(CKD)who sought medical care at the Third Affiliated Hospital of Sun Yat-sen University in Guangzhou between January 2022 and July 2023 were in-cluded in this study.Data on potassium(K),sodium(Na),chloride(Cl),carbon dioxide(CO2),urea(Urea),and glu-cose(GLU)were collected from each group of participants.A total of 94 individuals who were deemed healthy and had un-dergone physical examinations within the same time frame were chosen as the control group.The serum NGAL levels of all three groups were measured using latex immunoturbidimetry.The diagnostic effectiveness of serum NGAL and other bio-markers in identifying acute and chronic kidney injury was analyzed.Multiple logistic regression equations were employed to examine the factors influencing the occurrence of AKI and CKD in patients.Additionally,receiver operating characteris-tic(ROC)curves were constructed to evaluate the clinical significance of these biomarkers in patients with kidney injury.RESULTS:Through bioinformatic analysis,it was suggested that NGAL may be a detection marker of kidney injury.Ac-cording to general data,in the AKI and the CKD groups,K,Na,CO2,Urea,GLU and NGAL levels were higher than those in the healthy control group(P＜0.05).Multivariate logistic regression equation analysis showed that Na,Urea,GLU and NGAL levels were all independent risk factors for AKI or CKD disease occurrence(P＜0.05).The ROC curve analysis showed that in the AKI group,the area under the curve(AUC)for Na,Urea,GLU and NGAL were 0.711,0.960,0.793 and 0.841,respectively(P＜0.01).In the CKD group,the AUC for Na,Urea,GLU and NGAL were 0.681,0.990,0.703 and 0.930,respectively(P＜0.01).The sensitivity and specificity of NGAL and Urea combined diagnosis for AKI were 81.9%and 61.1%,respectively,and those for CKD were 62.7%and 80.0%,respectively.CONCLUSION:Serum NGAL can serve as an indicator of acute and chronic kidney injury,and its combination with other biomarkers also has certain clinical application value in acute and chronic kidney injury.

Efficacy of plasma exchange in the treatment of renal injury associated with autoimmune diseases / 中国基层医药

Objective:To investigate the effectiveness and safety of plasma exchange for thrombotic microangiopathy and anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, which require renal replacement therapy.Methods:This is a retrospective study. The clinical data of four patients who underwent plasma exchange at the Blood Purification Center, North Branch of the First Affiliated Hospital of Anhui Medical University, from June 2021 to February 2022 were collected and analyzed. The records included a total of 19 treatments performed, including 15 treatments with a single plasma exchange regimen used in 3 patients and 4 treatments with double filtration plasmapheresis used in 1 patient. Changes in condition before and after treatment, as well as corresponding biochemical test results, were recorded.Results:In four patients, clinical symptoms and biochemical indicators improved. Three patients required maintenance hemodialysis, while one patient showed remarkable clinical efficacy. After treatment, hemoglobin level increased from 76 g/L to 83 g/L, blood creatinine level decreased from 703.6 μmol/L to 526.2 μmol/L, anti-SM antibody decreased from > 400 RU/mL to < 2 RU/mL, anti-myeloperoxidase antibody decreased from 255.49 RU/mL to 15.64 RU/mL, and perinuclear anti-neutrophil cytoplasmic antibody turned negative. During treatment, there were two cases of allergic reactions, which were significantly alleviated after treatment.Conclusion:Plasma exchange is safe and effective against thrombotic microangiopathy and anti-neutrophil cytoplasmic antibody-associated vasculitis, which require renal replacement therapy.

Establishment and analysis of an early prognosis model of patients with acute kidney injury in intensive care unit / 中华危重病急救医学

Objective:To establish a predictive model for the progression of acute kidney injury (AKI) to stage 3 AKI (renal failure) in the intensive care unit (ICU), so as to assist physicians to make early and timely decisions on whether to intervene in advance.Methods:A retrospective analysis was conducted. Thirty-eight patients with AKI admitted to the intensive care medicine of the Third People's Hospital of Henan Province from January 2018 to May 2023 were enrolled. Patient data including acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) upon admission, serum creatinine (SCr), blood urea nitrogen (BUN), daily urine output during hospitalization, and the timing of continuous renal replacement therapy (CRRT) intervention were recorded. Based on clinically collected pathological data, standardized creatinine value ratio mean polynomial fitting models were established as the first criterion for judging the progression to stage 3 AKI after data cleansing, screening, and normalization. Additionally, standardized creatinine value ratio index fitting models were established as the second criterion for predicting progression to stage 3 AKI.Results:A total of 38 AKI patients were included, including 25 males and 13 females. The average age was (58.45±12.94) years old. The APACHEⅡ score was 24.13±4.17 at admission. The intervention node was (4.42±0.95) days. Using a dual regression model approach, statistical modeling was performed with a relatively small sample size of statistical data samples, yielding a scatter index non-linear regression model for standardized creatinine value ratio data relative to day " n", with y = 1.246?2 x1.164?9 and an R2 of 0.860?1, indicating reasonable statistical fitting. Additionally, a quadratic non-linear regression model was obtained for the mean standardized creatinine value ratio relative to day " n", with y = -0.260?6 x2+3.010?7 x-1.612 and an R2 of 0.998?9, indicating an excellent statistical fit. For example, using a baseline SCr value of 66 μmol/L for a healthy individual, the dual regression model predicted that the patient would progress to stage 3 AKI within 3-5 days. This prediction was consistent when applied to other early intervention renal injury patients. Conclusion:The established model effectively predicts the time interval of the progression of AKI to stage 3 AKI (renal failure), which assist intensive care physicians to intervene AKI as early as possible to prevent disease progression.

Correlation between serum calcium level and prognosis of acute kidney injury patients with hypercalcemia / 中国综合临床

Objective:To analyze the correlation between serum calcium levels and the prognosis of survival and renal recovery in patients with acute kidney injury (AKI) accompanied by hypercalcemia.Methods:This retrospective study analyzed the clinical data of patients with AKI accompanied by hypercalcemia admitted to Shanghai General Hospital from December 2015 to August 2022. There were 157 patients included in the study. The observation endpoint was set at discharge, focusing on the patients' survival and renal recovery during this period. Based on their status at discharge, patients were divided into a survival group (116 cases) and a death group (41 cases); and among the survivors, into a renal recovery group (63 cases) and a non-recovery group (53 cases). Continuous variables conforming to normal distribution were expressed as xˉ± s, and the mean comparison between the two groups was performed using an independent sample t-test. Continuous variables not conforming to normal distribution were represented by median (interquartile range) and compared between groups using the Mann-Whitney U test. Categorical variables were expressed as frequency (percentage), and comparisons were made using the chi-squared (χ 2) test or Fisher's exact test, as applicable. The correlation between serum calcium levels and patient outcomes was analyzed using univariate and multivariate Logistic regression. Results:The average age of the study subjects was (68.37±16.28) years, with 97 males (61.78%). The ages in the survival and death groups were (65.39±16.13) years and (76.80±13.67) years, respectively, with 66 males in the survival group and 31 in the death group. The history of malignancy (excluding multiple myeloma) was 37 cases and 23 cases, respectively, and serum albumin levels were (35.41±6.84) g/L and (30.82±5.75) g/L, respectively. Significant Statistical differences were observed in age, gender, history of malignancy (excluding multiple myeloma), and serum albumin were found between the survival and death groups (statistical values: t=4.04, χ 2=4.49, χ 2=7.51, t=3.85; all P<0.05). AIK 1 stage were 33.33%(21/63) and 64.15%(34/53), 2 stage were 36.51%(23/63) and 24.53%(13/34), 3 stage were 30.16%(23/63) and 11.32%(6/34) in the renal recovery and non-recovery groupsrespectively. Serum calcium at discharge in the renal recovery and non-recovery groups were (2.50±0.38) mmol/L and (2.70±0.58) mmol/L, respectively, with mean serum calcium levels of (2.60±0.29) mmol/L and (2.78±0.39) mmol/L, and lowest serum calcium levels of (2.28±0.36) mmol/L and (2.50±0.51) mmol/L, respectively. BNP levels were 118 (64, 283) ng/L and 248 (69, 1 383) ng/L, respectively. Significant differences in AKI stage, serum calcium at discharge, mean serum calcium, lowest serum calcium, and BNP were observed between the two groups (statistical values: χ 2=11.84, t=2.26, t=2.75, t=2.73, U=2.62, all P<0.05). Multivariate logistic regression analysis showed that age ( OR=1.062, 95% CI 1.027-1.098, P<0.001), history of malignancy (excluding multiple myeloma) ( OR=3.811, 95% CI 1.623-8.951, P=0.002), and serum albumin ( OR=0.889, 95% CI 0.829-0.953, P=0.001) were independent risk factors for in-hospital mortality of patients; severity of AKI(AKI2 OR=2.984, 95% CI 1.281-6.954, P=0.011, AKI3 OR=5.280, 95% CI 1.863-14.963, P=0.002) and serum calcium level at discharge ( OR=0.813, 95% CI 0.666-0.992, P=0.041) were independent risk factors affecting early renal recovery of patients. Conclusion:Serum calcium level is not associated with the risk of in-hospital mortality in patients with AKI accompanied by hypercalcemia but is related to the prognosis of early renal recovery. Proactively managing serum calcium, along with treatment of the primary malignancy and correction of hypoalbuminemia can help improve the prognosis of these patients.

Predictive value of systemic immune-inflammation index and NT-proBNP for contrast-induced acute kidney injury in elderly STEMI patients / 中华老年心脑血管病杂志

Objective To investigate the predictive value of systemic immune-inflammation index(SII)and N-terminal pro-brain natriuretic peptide(NT-proBNP)level in elderly patients with acute ST-segment elevation myocardial infarction(STEMI)developing contrast-induced acute kidney injury(CIAKI)after PCI.Methods A total of 1085 elderly STEMI patients undergoing emergency PCI in the Affiliated Hospital of Xuzhou Medical University from January 2018 to March 2023 were consecutively recruited as a training set,and another 287 elderly STEMI pa-tients receiving emergency PCI in the East Branch of the Affiliated Hospital from January 2021 to June 2023 were included as a verification set.According to the diagnostic criteria of CIAKI,they were divided into CIAKI group(n=95)and non-CIAKI group(n=990).Based on the results of restricted cubic spline(RCS)analysis,the patients from the training set were assigned into low-risk subgroup(n=292),moderate-risk group(n=515)and high-risk group(n=278).Multivari-ate logistic regression analysis was used to analyze the independent risk factors of CIAKI in elder-ly STEMI patients after PCI,and ROC curve was plotted to analyze the predictive value of combi-nation of SII and NT-proBNP.The risk of CIAKI was compared among the patients at different risk grades.Results Age,SII,baseline serum creatinine,NT-proBNP,fasting blood glucose and use of diuretics were independent risk factors for CIAKI after primary PCI in elderly STEMI patients(P＜0.05,P＜0.01).The AUC value of SII combined with NT-proBNP in predicting CIAKI was 0.801(95％CI:0.761-0.842,P＜0.01),with a sensitivity of 83.2％and a specificity of 67.5％,both superior to that of SII or NT-proBNP alone.RCS analysis revealed an increased risk of CIAKI at SII ≥1084.97 × 109/L and NT-proBNP ≥296.12 ng/L.The incidence of CIAKI was increased with the increase of risk grades(1.71％vs 6.41％vs 20.50％).Conclusion SII and NT-proBNP are independent risk factors for CIAKI after emergency PCI in elderly STEMI pa-tients.And their combination has better predictive value for CIAKI.

Clinical study of ulinastatin in prevention and treatment of CIAKI in elderly coronary heart disease patients with CKD / 中华老年心脑血管病杂志

Objective To investigate the protective and treatment role of ulinastatin(UTI)on con-trast-induced acute kidney injury(CIAKI)in the elderly with coronary heart disease(CHD)and chronic kidney diseases(CKD).Methods A total of 321 elderly CHD inpatients complicated with CKD undergoing coronary angiography admitted in the First Medical Center of Chinese PLA Gen-eral Hospital from November 2021 to November 2022 were enrolled consecutively and then divid-ed into UTI group(n=161)and hydration group(n=160).Their cardiac and renal function pa-rameters were collected and analyzed before and 2 d after intervention.The changes in above pa-rameters and incidence of CIAK were observed and compared between the two groups.Results In 2 d after intervention,the UTI group had significantly lower Scr,urea,CysC,homocysteine and NT-proBNP,but higher eGFR than the hydration group(P＜0.01).There were 62 patients(62/321,19.3％)developing CIAKI,including 17 from the UTI group and 45 from the hydration group,and statistical difference was observed in the incidence(10.6％vs 28.1％,P＜0.01).For the patients with comorbidities of hypertension,diabetes,hyperlipidemia and hyperuricemia,the incidence of CIAKI was obviously lower in the UTI group than the hydration group(P＜0.01).Multivariate logistic regression analysis showed that UTI was an independent protective factor for occurrence of CIAKI(OR=0.348,95％CI:0.180-0.673,P=0.001).Conclusion UTI can im-prove renal function and reduce the risk of CIAKI in elderly CHD patients with CKD.

Effect of goal-directed fluid therapy on postoperative acute kidney injury in elderly patients undergoing long-time abdominal surgery / 中华麻醉学杂志

Objective:To evaluate the effect of goal-directed fluid therapy (GDFT) on postoperative acute kidney injury (AKI) in elderly patients undergoing long-time abdominal surgery.Methods:The medical records from elderly patients of both sexes, aged ≥ 65 yr, with a duration of operation ≥ 8 h and American Society of Anesthesiologists Physical Status classification Ⅱ or Ⅲ, undergoing elective first abdominal surgery for gastrointestinal tumors at the Shanxi Provincial People′s Hospital from October 1, 2016 to June 30, 2022, were collected from the electronic medical record database. Patients were divided into conventional fluid therapy group (group C) and GDFT group (group G) according to whether GDFT was employed during operation. In group C, blood pressure was maintained ≥90/60 mmHg or mean arterial pressure≥65 mmHg, and urine output more than 30 ml/h. In group G, the stroke volume variation was maintained ≤13%, and cardiac index ≥2.5 L·min -1·m -2. The patient general characteristics, requirement for fluid, urine output, blood loss, requirement for vasoactive agents and abdominal hyperthermic perfusion, and operation time were recorded during operation. The development of AKI within 72 h after operation and development of other complications (pneumonia, anastomotic leakage, surgical site infection, septic shock, arrhythmia) after operation were recorded. The length of hospital stay and 30-day mortality after operation were recorded. Results:A total of 125 patients were included in this study, with 41 patients in group C and 84 patients in group G. Postoperative AKI occurred in 19 patients, with an incidence of 15.2%. Compared with group C, the requirement for colloid, total volume of fluid infused and urine volume were significantly decreased during operation, the requirement for vasoactive agents was increased during operation ( P<0.05), the risk of postoperative AKI was reduced ( OR=0.23, P<0.05), and no significant change was found in the incidence of other postoperative complications, 30-day mortality, and length of hospital stay in group G ( P>0.05). Conclusions:GDFT can reduce the risk of AKI in the elderly patients undergoing long-time abdominal surgery.

Effect of losartan on acute kidney injury and the relationship with mitochondrial fusion-fission in septic mice / 中华麻醉学杂志

Objective:To evaluate the effect of losartan on acute kidney injury (AKI) and the relationship with mitochondrial fusion-fission in septic mice.Methods:One hundred and twenty-eight SPF male C57BL/6J mice, aged 6-8 weeks, weighing 20-25 g, were divided into 4 groups ( n=32 each) using a random number table method: sham operation group (Sham group), sham operation+ losartan group (Sham+ LOS group), sepsis-associated AKI group (SA-AKI group), and sepsis-associated AKI+ losartan group (SA-AKI+ LOS group). Sepsis was induced by cecal ligation and puncture in anesthetized mice. Sham+ LOS group and SA-AKI+ LOS group received intraperitoneal injection of losartan 5 mg/kg, once a day, for 3 consecutive days, starting from 3 days before sham operation or developing the model. The equal volume of solvent was given instead in Sham group and SA-AKI group. Twenty mice were randomly selected to observe the survival 7 days after surgery. At 24 h after sham operation or establishing the model, serum blood urea nitrogen (BUN) and creatinine (Cr) concentrations were determined by the colorimetric method, and serum concentrations of tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and high-mobility group box 1 protein (HMGB1) were measured using enzyme-linked immunosorbent assay. Renal tissues were obtained for microscopic examination of pathological changes which were scored and for determination of mitochondrial membrane potential (using JC-1 method) and expression of dynamin-related protein 1 (Drp1) and mitofusin-2 (Mfn2) (using Western blot). Results:Compared with Sham group, the survival rate was significantly decreased, the serum BUN, Cr, TNF-α, IL-6 and HMGB1 concentrations and renal tubular injury score were increased, the ATP content and MMP were decreased, the expression of Drp1 was up-regulated, the expression of Mfn2 was down-regulated ( P<0.05), and pathological changes were found in renal tissues in SA-AKI group and SA-AKI+ LOS group. Compared with SA-AKI group, the survival rate was significantly increased, serum concentrations of BUN, Cr, TNF-α, IL-6 and HMGB1 and renal tubular injury score were decreased, the ATP content and MMP were increased, the expression of Drp1 was down-regulated, the expression of Mfn2 was up-regulated ( P<0.05), and the pathological changes of renal tissues were significantly attenuated in SA-AKI+ LOS group. Conclusions:Losartan can alleviate AKI in septic mice, and the mechanism may be related to promoting mitochondrial fusion and inhibiting mitochondrial fission.

Clinical progress in the diagnosis and treatment of end-stage liver disease complicated with acute kidney injury / 中华全科医师杂志

Acute kidney injury (AKI) is a devastating complications of end-stage of liver disease (ESLD), seriously affecting the prognosis of patients. With the deepening understanding of the pathogenesis, the definition, staging, diagnosis and treatment of ESLD with AKI have been gradually optimized. This article reviews the evolution of definition, pathogenesis, diagnosis and treatment of ESLD with AKI, to provide reference for early recognition, precise diagnosis and standardized treatment of this condition.

Establishment of machine learning-based risk prediction model for acute kidney injury in acute myocardial infarction patients and compared with traditional model / 中华肾脏病杂志

Objective:To establish a predictive risk model for acute kidney injury (AKI) in acute myocardial infarction (AMI) patients based on machine learning algorithm and compare with a traditional logistic regression model.Methods:It was a retrospective study. The demographic data, laboratory examination, treatment regimen and medication of AMI patients from July 2011 to December 2016 in Beijing Anzhen Hospital, Capital Medical University were collected. The diagnostic criteria of AKI were based on the AKI diagnosis and treatment guidelines published by Kidney Diseases: Improving Global Outcomes in 2012. The selected AMI patients were randomly divided into training set (70%) and internal test set (30%) by simple random sampling. SelectFromModel and Lasso regression models were used to extract clinical parameters as predictors of AKI in AMI patients. Logistic regression model (model A) and machine learning algorithm (model B) were used to establish the risk prediction model of AKI in AMI patients. DeLong method was used to compare the area under the receiver-operating characteristic (ROC) curve ( AUC) between model A and model B for selecting the best model. Results:A total of 6 014 AMI patients were included in the study, with age of (58.4±11.7) years old and 3 414 males (80.5%). There were 674 patients (11.2%) with AKI. There were 4 252 patients (70.7%) in the training set and 1 762 patients (29.3%) in the test set. The selected twelve clinical parameters by the SelectFromModel and Lasso regression models included the number of myocardial infarctions, ST-segment elevation myocardial infarction, ventricular tachycardia, third degree atrioventricular block, decompensated heart failure at admission, admission serum creatinine, admission blood urea nitrogen, admission peak creatine kinase isoenzyme, diuretics, maximum daily dose of diuretics, days of diuretic use and statins. Logistic regression prediction model showed that AUC for the test set was 0.80 (95% CI 0.76-0.84). The machine learning algorithm model obtained AUC in the test set with 0.82 (95% CI 0.78-0.85).There was no significant difference in AUC between the two models ( Z=0.858, P=0.363), and AUC of the machine learning algorithm predictive model was slightly higher than that of the traditional logistic regression model. Conclusions:The prediction effect of AKI risk in AMI patients based on machine learning algorithm is similar to that of traditional logistic regression model, and the prediction accuracy of machine learning algorithm is better. The introduction of machine learning algorithm model may improve the ability to predict AKI risk.

Establishment of nomogram model of acute kidney injury risk prediction based on clinical database / 中华肾脏病杂志

Objective:To construct the risk prediction nomogram model of acute kidney injury (AKI) with R language and traditional statistical methods based on the large sample clinical database, and verify the accuracy of the model.Methods:It was a a retrospective case control study. The patients who met the diagnostic criteria of AKI in Tongji Hospital of Tongji University from January 1 to December 31, 2021 were screened in the clinical database, and the patients with monitored serum creatinine within 48 hours but without AKI were included as the control group. The demographic data, disease history, surgical history, medication history and laboratory test data were collected to screen the risk factors of AKI in clinic.Firstly, based on multivariate logistic regression analysis and forward stepwise logistic regression analysis, the selected risk factors were included to construct the nomogram model. At the same time, cross validation, bootstrap validation and randomly split sample validation were used for internal verification, and clinical data of patients in the sane hospital after one year (January to December, 2022) were collected for external verification. The receiver-operating characteristic curve was used to determine the discrimination of the model, and calibration curve and decision curve analysis were carried out to evaluate the accuracy and clinical net benefit, respectively.Results:A total of 5 671 patients were enrolled in the study, with 1 884 AKI patients (33.2%) and 3 787 non-AKI patients (66.7%). Compared with non-AKI group, age, and proportions of surgical history, renal replacement therapy, hypertension, diabetes, cerebrovascular accident,chronic kidney disease, drug use histories and mortality in AKI group were all higher (all P<0.05). Multivariate logistic regression analysis showed that the independent influencing factors of AKI were surgical history, hypertension, cerebrovascular accident, diabetes, chronic kidney disease, diuretics, nitroglycerin, antidiuretic hormones, body temperature, serum creatinine, C-reactive protein, red blood cells, white blood cells, D-dimer, myoglobin, hemoglobin, blood urea nitrogen, brain natriuretic peptide, aspartate aminotransferase, alanine aminotransferase, triacylglycerol, lactate dehydrogenase, total bilirubin, activated partial thromboplastin time, blood uric acid and potassium ion (all P<0.05). Finally, the predictive factors in the nomogram were determined by forward stepwise logistic regression analysis, including chronic kidney disease, hypertension, myoglobin, serum creatinine and blood urea nitrogen, and the area under the curve of the prediction nomogram model was 0.926 [95% CI 0.918-0.933, P<0.001]. The calibration curve showed that the calibration effect of nomogram was good ( P>0.05). The decision curve showed that when the risk threshold of nomogram model was more than 0.04, the model construction was useful in clinic. In addition, the area under the curve of receiver-operating characteristic curve predicted by nomograph model in external validation set was 0.876 (95% CI 0.865-0.886), which indicated that nomograph model had a high discrimination degree. Conclusion:A nomogram model for predicting the occurrence of AKI is established successfully, which is helpful for clinicians to find high-risk AKI patients early, intervene in time and improve the prognosis.