Risk of Hospital-Acquired Acute Kidney Injury among Adult Opioid Analgesic Users: A Multicenter Real-World Data Analysis.

Introduction: Comprehensive data on the risk of hospital-acquired (HA) acute kidney injury (AKI) among adult users of opioid analgesics are lacking. This study aimed to systematically compare the risk of HA-AKI among the users of various opioid analgesics. Methods: This multicenter, retrospective real-world study analyzed 255,265 adult hospitalized patients who received at least one prescription of opioid analgesic during the first 30 days of hospitalization. The primary outcome was the time from the first opioid analgesic prescription to HA-AKI occurrence. 12 subtypes of opioid analgesics were analyzed, including 9 for treating moderate-to-severe pain and 3 for mild-to-moderate pain. We examined the association between the exposure to each subtype of opioid analgesic and the risk of HA-AKI using Cox proportional hazards models, using the most commonly used opioid analgesic as the reference group. Results: As compared to dezocine, the most commonly used opioid analgesic for treating moderate-to-severe pain, exposure to morphine, but not the other 7 types of opioid analgesics, was associated with a significantly increased risk of HA-AKI (adjusted hazard ratio: 1.56, 95% confidence interval: 1.40-1.78). The association was consistent in stratified analyses and in a propensity-matched cohort. There were no significant differences in the risk of HA-AKI among the opioid analgesic users with mild-to-moderate pain after adjusting for confounders. Conclusion: The use of morphine was associated with an increased risk of HA-AKI in adult patients with moderate-to-severe pain. Opioid analgesics other than morphine should be chosen preferentially in adult patients with high risk of HA-AKI when treating moderate-to-severe pain.

Epidemiology and outcomes of post-AKI proteinuria.

Background: Acute kidney injury (AKI) has been associated with increased risks of new-onset and worsening proteinuria. However, epidemiologic data for post-AKI proteinuria was still lacking. This study aimed to determine the incidence, risk factors and clinical correlations of post-AKI proteinuria among hospitalized patients. Methods: This study was conducted in a multicenter cohort including patients aged 18-100 years with hospital-acquired AKI (HA-AKI) hospitalized at 19 medical centers throughout China. The primary outcome was the incidence of post-AKI proteinuria. Secondary outcomes included AKI recovery and kidney disease progression. The results of both quantitative and qualitative urinary protein tests were used to define post-AKI proteinuria. Cox proportional hazard model with stepwise regression was used to determine the risk factors for post-AKI proteinuria. Results: Of 6206 HA-AKI patients without proteinuria at baseline, 2102 (33.9%) had new-onset proteinuria, whereas of 5137 HA-AKI with baseline proteinuria, 894 (17.4%) had worsening proteinuria after AKI. Higher AKI stage and preexisting CKD diagnosis were risk factors for new-onset proteinuria and worsening proteinuria, whereas treatment with renin-angiotensin system inhibitors was associated with an 11% lower risk of incident proteinuria. About 60% and 75% of patients with post-AKI new-onset and worsening proteinuria, respectively, recovered within 3 months. Worsening proteinuria was associated with a lower incidence of AKI recovery and a higher risk of kidney disease progression. Conclusions: Post-AKI proteinuria is common and usually transient among hospitalized patients. The risk profiles for new-onset and worsening post-AKI proteinuria differed markedly. Worsening proteinuria after AKI was associated with adverse kidney outcomes, which emphasized the need for close monitoring of proteinuria after AKI.

[Down-regulation of PTEN expression in kidney and its role in development of diabetic nephropathy in rats].

Transforming growth factor-ß1 (TGF-ß1)-activated phosphoinositide-3-kinase (PI3K)-protein kinase B (PKB/Akt) pathway is intimately related to the development of diabetic nephropathy (DN), which is negatively regulated by phosphatase and tensin homolog deleted on chromosome ten (PTEN). The present study was to investigate the expression of PTEN in the renal tissue of diabetic mellitus (DM) rats and explore its possible effect on development of DN. Sixteen Sprague-Dawley rats were divided into normal control group (n = 8) and diabetic group (n = 8) at random. Streptozotocin injection was used to establish diabetic model. After 12 weeks, the rats were sacrificed to detect relative biochemical parameters and renal index, and to observe the changes of pathomorphology by HE staining as well. In addition, immunohistochemistry staining and Western blotting were employed to detect the protein expression of PTEN, TGF-ß1, PI3Kp110α, Akt1, p-Akt1 (Ser(473)), fibronectin (FN) and Collagen IV, respectively. Furthermore, the expression of PTEN mRNA was also examined by RT-PCR. The results indicated that the levels of blood glucose, serum creatinine and urine protein (24 h) were increased remarkably in the diabetic group (P < 0.05) compared with those in the control group. Compared with those in the control group, the protein expressions of TGF-ß1, PI3Kp110α, Akt1 in renal tubular epithelium and the expressions of FN and CollagenIV in renal interstitium were increased in the diabetic group (P < 0.05). The expression of PTEN in the diabetic group was significantly reduced than that in the control group (P < 0.05), and the expression of p-Akt1 (Ser(473)) increased remarkably in the diabetic group which had the similar trend to Akt1 (P < 0.05). PTEN mainly located in renal tubular epithelial cells. The expression of PTEN had negative correlation to that of p-Akt1 (Ser(473)). Compared with that in the control group, the expression of PTEN mRNA was decreased remarkably in the diabetic group (P < 0.05). The data suggest that the down-regulation of PTEN in renal tissue of DM rats may promote the PI3K-PKB/Akt pathway over-activated by TGF-ß1, which facilitates the initiation and development of DN.

Effects of Carvedilol on Cardiovascular Events and Mortality in Hemodialysis Patients, A Systematic Review and Meta-Analysis.

Carvedilol, the third generation of vasodilators; serves as the blocker of non-selective beta-adrenergic receptor and alpha1 adrenergic receptor. It could protect the cardiovascular system of patients receiving dialysis treatment. However, current clinical trials discussing the therapeutic benefit of carvedilol on patients receiving dialysis treatment remain inconsistent. Consequently, we decided to perform a meta-analysis to evaluate the clinical efficacy of carvedilol on patients receiving dialysis treatment. A search was conducted using EMBASE, Pubmed, Cochrane Central Register of Controlled Trials, Wanfang database, Chinese National Knowledge Infrastructure (CNKI), and VIP information database up to February 2020. We research publications (include English and Chinese language) that discuss the effects of carvedilol on cardiovascular events, all-cause mortality, hospitalizations or left ventricular ejection fraction (LVEF) in dialysis population. Our analysis included 4 randomized control trials and 2 observational studies. We discussed the therapeutical effects of carvedilol on all-cause mortality, cardiovascular events, hospitalizations, and LVEF of patients receiving dialysis treatment. Totally, this analysis reported 2998 hemodialysis (HD) patients. We found a significant association between carvedilol and reduced incidence of all-cause mortality, cardiovascular events and hospitalizations in HD patients. In addition, carvedilol significantly improves LVEF (n = 241; WMD = 6.95; 95% CI, 0.54 to 13.36; I2 = 90%) in HD population. Our systematic review and meta-analysis demonstrates that carvedilol is associated with a reduced incidence of cardiovascular events, all-cause mortality and hospitalizations in patients on HD. Besides; carvedilol significantly improves LVEF in HD population. Nevertheless, high-quality and well-powered evidence is still needed, so as to further confirm the impacts of carvedilol on HD patients.

Proton pump inhibitors and the risk of hospital-acquired acute kidney injury in children.

BACKGROUND: To evaluate the association between use of proton pump inhibitor (PPI) and the risk of hospital-acquired acute kidney injury (HA-AKI) in hospitalized children. METHODS: We conducted a multicenter retrospective cohort study in hospitalized children aged 1 month to 18 years from 25 tertiary hospitals across China from 2013 to 2015. Patient-level data were obtained from the electronic hospitalization databases. AKI was defined and staged using the serum creatinine (SCr) data according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. RESULTS: Among 42,232 children analyzed, 11,496 (27.2%) used PPI, 1,760 (4.2%) used histamine 2 receptor antagonist (H2RA), and 3,514 (8.3%) had HA-AKI during hospitalization. Over 85% of PPIs were prescribed for prophylaxis of gastro-duodenal lesions in children. The use of PPI was associated with a significantly increased risk of HA-AKI compared with both non-users [odds ratio (OR), 1.37; 95% confidence interval (CI), 1.23-1.53)] and H2RA users (OR, 1.24; 95% CI, 1.01-1.52). The associations were consistent across children of different age range, gender, subtypes of PPIs and methods of administration. A larger effect was observed in children with chronic kidney disease (OR, 3.37; 95% CI, 2.46-4.62) and those needed intensive care (OR, 1.54; 95% CI, 1.33-1.78). The risk of HA-AKI was increased even within the recommended dosage range of PPI. CONCLUSIONS: PPIs were widely used and associated with an increased risk of HA-AKI in hospitalized children in China.

Application of mini-clinical evaluation exercise for assessing the integrated-based learning during physical diagnostic course.

Medical education paradigm has been questioned for the requirements of improving the quality and quantity of medical students. This study was to explore the efficiency of integrated-based learning (IBL) used mini-clinical evaluation exercise (mini-CEX) during physical diagnostics course. One hundred and eleven volunteered students were randomly divided into three groups: lecture-based learning (LBL), case-based learning (CBL), and IBL. Nephrotic syndrome was the teaching content. In the IBL group, students were provided the guideline and additional interpretation from the instructor about the basic knowledge related to disease as vertical integration curriculum. Their performance was evaluated by mini-CEX and theoretical examination, respectively. All subjects have completed the study. The difference of five factors (medical interview, physical examination, clinical judgment, organizational effectiveness, and competence) in mini-CEX between IBL, CBL, and LBL were statistically significant (p <0.05). Sample sizes of below, meets, and above the expectations of mini-CEX in different instructional groups were statistically significant (X2 =17.842, p =0.001). The final exam scores in IBL group and the CBL group were significantly higher than that of LBL group (F =41.553, p =0.000). And the relationship of final exam score only in the IBL group was positive existed with medical interview (R =0.466, p =0.004), physical examination (R =0.328, p =0.048), professional attitude (R =0.366, p =0.026), and communication skill (R =0.412, p =0.011). Therefore, our study revealed the effect of IBL on the medical students' skills. It highlights IBL could improve the physical examination, organizational effectiveness, and competence and the application of basic knowledge. © 2018 International Union of Biochemistry and Molecular Biology, 46(5):417-423, 2018.

[Down-regulation of p38 MAPK and collagen by 1, 25-(OH)2-VD3 in rat models of diabetic nephropathy].

Objective To investigate the effect of 1, 25-(OH)2-VD3 on collagen type III (Col3), collagen type IV (Col4) and p38 mitogen-activated protein kinase (p38 MAPK) in rat models of type 2 diabetic nephropathy, and explore the relationships of p38MAPK with Col3 and Col4. Methods Rat models of type 2 diabetic nephropathy were induced by streptozocin (STZ, 30 mg/kg) combined with high-glucose-and-fat diet. Sixty rats were randomly divided into control group, model group, 1, 25-(OH)2-VD3 treatment group [given 1, 25-(OH)2-VD3 6 ng/(100 g.d) after modeling] and insulin group (given 2-3 U insulin after modeling). After 8 weeks' intervention, serum creatinine (Scr), blood urea nitrogen (BUN) and 24-hour proteinuria were detected in all groups. Periodic acid-Schiff (PAS) staining was used to observe the kidney pathological changes, and immunohistochemical staining and Western blotting were performed to determine p38 MAPK Col3 and Col4 expressions in rat renal interstitium. Spearman method was applied to the correlation analysis. Results Compared with the model group, blood glucose, Scr, BUN, 24-hour proteinuria and impaired renal interstitial area were all reduced in the 1, 25-(OH)2-VD3 treatment group and the insulin group. Compared with the control group, the expressions of Col3, Col4 and p38 MAPK were higher in the model group, and lower in the 1, 25-(OH)2-VD3 treatment group and the insulin group. Correlation analysis showed that 24-hour proteinuria was positively related with p38 MAPK, Col3, Col4 and immunohistochemical results; p38MAPK was positively correlated with Col3 and Col4 expressions. Conclusion Col3, Col4 and p38MAPK are up-regulated in rat models of type 2 diabetic nephropathy. The 1, 25-(OH)2-VD3 might attenuates the progression of renal interstitial fibrosis via down-regulating p38 MAPK, Col3 and Col4.