Incidence, severity, risk factors and outcomes of acute kidney injury in older adults: systematic review and meta-analysis.

OBJECTIVES: Old age was identified as a strong risk factor for acute kidney injury (AKI). Our objectives were to provide estimates of AKI, risk factors and outcomes in patients ≥ 75 years for whom data are scarce. METHODS: Observational studies and randomized controlled trials between 2005 and 2021 with patients of mean or median age ≥ 75 years, reporting AKI according to current definitions. Data on AKI incidence, risk factors and mortality were analyzed separately in unselected (UC) and acute heart failure (AHF) cohorts. RESULTS: Twenty-six observational studies and 4 randomized controlled trials with 51,111 UC and 25,414 AHF patients were included. Ages averaged 79.4 and 79.8 years, respectively. Pooled risk ratios (RRs) of AKI rates were 26.29% (95% confidence intervals (CI) 13.20-41.97) (UC) and 24.21% (95% CI 20.03-28.65) (AHF). In both cohorts, AKI was associated with decreased estimated glomerular filtration rate at baseline, chronic kidney disease (UC: RR 1.80 (95% CI 1.15-2.80), AHF: RR 1.51 (95% CI 1.26-1.95) and hypertension (UC: RR 1.30 (95% CI 1.09-1.56), AHF: RR 1.07 (95% CI 1.05-1.09). RRs of AKI in patients on renin-angiotensin-inhibitors were 0.87 (95% CI 0.78-0.97) and 0.88 (95% CI 0.78-0.98) in UC and AHF, respectively. AKI was consistently associated with increased risk of in-hospital mortality (UC: RR 3.15 (95% CI 2.28-4.35), AHF: RR 4.28 (95% CI 2.53-7.24). CONCLUSION: AKI is frequent in patients ≥ 75 years. While reduced renal function at baseline, CKD and hypertension were associated with AKI development, renin-angiotensin-inhibitors may be protective. Older AKI patients showed higher short-term mortality rates.

Validation of the Clinical Frailty Scale for retrospective use in acute care.

PURPOSE: There is a considerable need to measure frailty retrospectively in clinical practice and research. We assessed agreement, accuracy, precision, and reliability of retrospectively compared with prospectively, and separately attained, retrospective Clinical Frailty Scale (CFS) scoring, respectively. METHODS: We studied 110 hospitalized patients aged ≥ 80 years, consisting of 70.9% females. Agreement was assessed by bias, accuracy by root mean square error (RMSE) and the percentages of one CFS scores within 20% and 30% of each other (P20 and P30), precision by interquartile ranges of the bias, and reliability by weighted Cohen's kappa (κ). RESULTS: Comparison of retrospective and prospective CFS scores demonstrated a modest bias of 0.26. Classification as robust, prefrail, or frail was generally correct in retrospectively compared to prospectively CFS scores. RMSE was low (0.28), while P20 and P30 values were high (90.0% and 96.6%, respectively). Precision of retrospective to predict prospective CFS scores was high with narrow interquartile ranges of 0 and 1. Reliability of retrospective with prospective CFS scores was high (κ = 0.89). Comparing two separately attained retrospective CFS scores demonstrated low bias (0.05) and RMSE (0.24), and a high P30 value (90.0%). Precision and interrater reliability of the comparison of retrospective CFS scores were high with narrow interquartile ranges and κ = 0.85. CONCLUSION: The retrospectively attained CFS score is a valid diagnostic instrument to measure frailty in older hospitalized patients with high agreement, accuracy, precision, and reliability compared to both prospective and separately attained CFS scores.

The initial effectiveness of liposomal amphotericin B (AmBisome) and miltefosine combination for treatment of visceral leishmaniasis in HIV co-infected patients in Ethiopia: A retrospective cohort study.

BACKGROUND: North-west Ethiopia faces the highest burden world-wide of visceral leishmaniasis (VL) and HIV co-infection. VL-HIV co-infected patients have higher (initial) parasitological failure and relapse rates than HIV-negative VL patients. Whereas secondary prophylaxis reduces the relapse rate, parasitological failure rates remain high with the available antileishmanial drugs, especially when administered as monotherapy. We aimed to determine the initial effectiveness (parasitologically-confirmed cure) of a combination of liposomal amphotericin B (AmBisome) and miltefosine for treatment of VL in HIV co-infected patients. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a retrospective cohort study at a Médecins Sans Frontières-supported health center in north-west Ethiopia. We included VL-HIV co-infected adults, treated for VL between January 2011 and August 2014, with AmBisome infusion (30 mg/kg total dose) and miltefosine orally for 28 days (100 mg/day). Proportions of initial treatment outcome categories were calculated. Predictors of initial parasitological failure and of death were determined using multivariable logistic regression. Of the 173 patients included, 170 (98.3%) were male and the median age was 32 years. The proportion of patients with primary VL (48.0%) and relapse VL (52.0%) were similar. The majority had advanced HIV disease (n = 111; 73.5%) and were on antiretroviral therapy prior to VL diagnosis (n = 106; 64.2%). Initial cure rate was 83.8% (95% confidence interval [CI], 77.6-88.6); death rate 12.7% (95% CI, 8.5-18.5) and parasitological failure rate 3.5% (95% CI, 1.6-7.4). Tuberculosis co-infection at VL diagnosis was predictive of parasitological failure (adjusted odds ratio (aOR), 8.14; p = 0.02). Predictors of death were age >40 years (aOR, 5.10; p = 0.009), hemoglobin ≤6.5 g/dL (aOR, 5.20; p = 0.002) and primary VL (aOR, 8.33; p = 0.001). CONCLUSIONS/SIGNIFICANCE: Initial parasitological failure rates were very low with AmBisome and miltefosine combination therapy. This regimen seems a suitable treatment option. Knowledge of predictors of poor outcome may facilitate better management. These findings remain to be confirmed in clinical trials.