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1.
Crit Care ; 23(1): 225, 2019 06 20.
Artículo en Inglés | MEDLINE | ID: mdl-31221200

RESUMEN

BACKGROUND: The first FDA-approved test to assess risk for acute kidney injury (AKI), [TIMP-2]•[IGFBP7], is clinically available in many parts of the world, including the USA and Europe. We sought to understand how the test is currently being used clinically. METHODS: We invited a group of experts knowledgeable on the utility of this test for kidney injury to a panel discussion regarding the appropriate use of the test. Specifically, we wanted to identify which patients would be appropriate for testing, how the results are interpreted, and what actions would be taken based on the results of the test. We used a modified Delphi method to prioritize specific populations for testing and actions based on biomarker test results. No attempt was made to evaluate the evidence in support of various actions however. RESULTS: Our results indicate that clinical experts have developed similar practice patterns for use of the [TIMP-2]•[IGFBP7] test in Europe and North America. Patients undergoing major surgery (both cardiac and non-cardiac), those who were hemodynamically unstable, or those with sepsis appear to be priority patient populations for testing kidney stress. It was agreed that, in patients who tested positive, management of potentially nephrotoxic drugs and fluids would be a priority. Patients who tested negative may be candidates for "fast-track" protocols. CONCLUSION: In the experience of our expert panel, biomarker testing has been a priority after major surgery, hemodynamic instability, or sepsis. Our panel members reported that a positive test prompts management of nephrotoxic drugs as well as fluids, while patients with negative results are considered to be excellent candidates for "fast-track" protocols.

2.
Clin J Am Soc Nephrol ; 14(6): 941-953, 2019 Jun 07.
Artículo en Inglés | MEDLINE | ID: mdl-31101671

RESUMEN

AKI is a global concern with a high incidence among patients across acute care settings. AKI is associated with significant clinical consequences and increased health care costs. Preventive measures, as well as rapid identification of AKI, have been shown to improve outcomes in small studies. Providing high-quality care for patients with AKI or those at risk of AKI occurs across a continuum that starts at the community level and continues in the emergency department, hospital setting, and after discharge from inpatient care. Improving the quality of care provided to these patients, plausibly mitigating the cost of care and improving short- and long-term outcomes, are goals that have not been universally achieved. Therefore, understanding how the management of AKI may be amenable to quality improvement programs is needed. Recognizing this gap in knowledge, the 22nd Acute Disease Quality Initiative meeting was convened to discuss the evidence, provide recommendations, and highlight future directions for AKI-related quality measures and care processes. Using a modified Delphi process, an international group of experts including physicians, a nurse practitioner, and pharmacists provided a framework for current and future quality improvement projects in the area of AKI. Where possible, best practices in the prevention, identification, and care of the patient with AKI were identified and highlighted. This article provides a summary of the key messages and recommendations of the group, with an aim to equip and encourage health care providers to establish quality care delivery for patients with AKI and to measure key quality indicators.

3.
Am J Kidney Dis ; 74(1): 36-46, 2019 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-30955944

RESUMEN

RATIONALE & OBJECTIVE: The process of angiogenesis after kidney injury may determine recovery and long-term outcomes. We evaluated the association of angiogenesis markers with acute kidney injury (AKI) and mortality after cardiac surgery. STUDY DESIGN: Prospective cohort. SETTING & PARTICIPANTS: 1,444 adults undergoing cardiac surgery in the TRIBE-AKI (Translational Research Investigating Biomarker Endpoints for Acute Kidney Injury) cohort. EXPOSURES: Plasma concentrations of 2 proangiogenic markers (vascular endothelial growth factor A [VEGF] and placental growth factor [PGF]) and 1 antiangiogenic marker (soluble VEGF receptor 1 [VEGFR1]), measured pre- and postoperatively within 6 hours after surgery. OUTCOMES: AKI, long AKI duration (≥7 days), and 1-year all-cause mortality. ANALYTICAL APPROACH: Multivariable logistic regression. RESULTS: Following cardiac surgery, plasma VEGF concentrations decreased 2-fold, and PGF and VEGFR1 concentrations increased 1.5- and 8-fold, respectively. There were no meaningful associations of preoperative concentrations of angiogenic markers with outcomes of AKI and mortality. Higher postoperative VEGF and PGF concentrations were independently associated with lower odds of AKI (adjusted ORs of 0.89 [95% CI, 0.82-0.98] and 0.69 [95% CI, 0.55-0.87], respectively), long AKI duration (0.65 [95% CI, 0.49-0.87] and 0.48 [95% CI, 0.28-0.82], respectively), and mortality (0.74 [95% CI, 0.62-0.89] and 0.46 [95% CI, 0.31-0.68], respectively). In contrast, higher postoperative VEGFR1 concentrations were independently associated with higher odds of AKI (1.56; 95% CI, 1.31-1.87), long AKI duration (1.75; 95% CI, 1.09-2.82), and mortality (2.28; 95% CI, 1.61-3.22). LIMITATIONS: Angiogenesis markers were not measured after hospital discharge, so we were unable to determine long-term trajectories of angiogenesis marker levels during recovery and follow-up. CONCLUSIONS: Higher levels of postoperative proangiogenic markers, VEGF and PGF, were associated with lower AKI and mortality risk, whereas higher postoperative antiangiogenic VEGFR1 levels were associated with higher risk for AKI and mortality.

4.
Pharmacogenomics J ; 2019 Feb 11.
Artículo en Inglés | MEDLINE | ID: mdl-30713337

RESUMEN

Effective doctor-patient communication is critical for disease management, especially when considering genetic information. We studied patient-provider communications after implementing a point-of-care pharmacogenomic results delivery system to understand whether pharmacogenomic results are discussed and whether medication recall is impacted. Outpatients undergoing preemptive pharmacogenomic testing (cases), non-genotyped controls, and study providers were surveyed from October 2012-May 2017. Patient responses were compared between visits where pharmacogenomic results guided prescribing versus visits where pharmacogenomics did not guide prescribing. Provider knowledge of pharmacogenomics, before and during study participation, was also analyzed. Both providers and case patients frequently reported discussions of genetic results after visits where pharmacogenomic information guided prescribing. Importantly, medication changes from visits where pharmacogenomics influenced prescribing were more often recalled than non-pharmacogenomic guided medication changes (OR = 3.3 [1.6-6.7], p = 0.001). Case patients who had separate visits where pharmacogenomics did and did not, respectively, influence prescribing more often remembered medication changes from visits where genomic-based guidance was used (OR = 3.4 [1.2-9.3], p = 0.02). Providers also displayed dramatic increases in personal genomic understanding through program participation (94% felt at least somewhat informed about pharmacogenomics post-participation, compared to 61% at baseline, p = 0.04). Using genomic information during prescribing increases patient-provider communications, patient medication recall, and provider understanding of genomics, important ancillary benefits to clinical use of pharmacogenomics.

5.
BMJ ; 364: k4891, 2019 Jan 09.
Artículo en Inglés | MEDLINE | ID: mdl-30626586

RESUMEN

Sepsis is defined as organ dysfunction resulting from the host's deleterious response to infection. One of the most common organs affected is the kidneys, resulting in sepsis associated acute kidney injury (SA-AKI) that contributes to the morbidity and mortality of sepsis. A growing body of knowledge has illuminated the clinical risk factors, pathobiology, response to treatment, and elements of renal recovery that have advanced our ability to prevent, detect, and treat SA-AKI. Despite these advances, SA-AKI remains an important concern and clinical burden, and further study is needed to reduce the acute and chronic consequences. This review summarizes the relevant evidence, with a focus on the risk factors, early recognition and diagnosis, treatment, and long term consequences of SA-AKI. In addition to literature pertaining to SA-AKI specifically, pertinent sepsis and acute kidney injury literature relevant to SA-AKI was included.


Asunto(s)
Lesión Renal Aguda/epidemiología , Riñón/lesiones , Sepsis/complicaciones , Lesión Renal Aguda/clasificación , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/tratamiento farmacológico , Biomarcadores/sangre , Cuidados Críticos/normas , Diagnóstico Precoz , Humanos , Riñón/microbiología , Riñón/patología , Masculino , Persona de Mediana Edad , Evaluación de Resultado (Atención de Salud) , Guías de Práctica Clínica como Asunto/normas , Factores de Riesgo , Sepsis/epidemiología , Sepsis/mortalidad , Sepsis/prevención & control
6.
Pharmacogenet Genomics ; 29(2): 31-38, 2019 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-30531377

RESUMEN

OBJECTIVE: The objective of this study was to study provider attitudes of and perceived barriers to the clinical use of pharmacogenomics before and during participation in an implementation program. PARTICIPANTS AND METHODS: From 2012 to 2017, providers were recruited. After completing semistructured interviews (SSIs) about pharmacogenomics, providers received training on and access to a clinical decision support tool housing patient-specific pharmacogenomic results. Thematic analysis of SSI was conducted (inter-rater reliability κ≥0.75). Providers also completed surveys before and during study participation, and provider-perceived barriers to pharmacogenomic implementation were analyzed. RESULTS: Seven themes emerged from the SSI (listed from most frequent to least): decision-making, concerns with pharmacogenomic adoption, outcome expectancy, provider knowledge of pharmacogenomics, patient attitudes, individualized treatment, and provider interest in pharmacogenomics. Although there was prestudy enthusiasm among all providers, concerns with clinical utility, time, results accession, and knowledge of pharmacogenomics were frequently stated at baseline. Despite this, adoption of pharmacogenomics was robust, as patient-specific results were accessed at 64% of visits, and medication changes were influenced by provided pharmacogenomic information 42% of the time. Providers reported they had enough time to evaluate the information and the results were easily understood on 74 and 98% of surveys, respectively. Nevertheless, providers consistently felt there was insufficient pharmacogenomic information for most drugs they prescribed and clear guidelines for using pharmacogenomic information were lacking. CONCLUSION: Despite initial concerns about adequate time and knowledge for adoption, providers frequently utilized pharmacogenomic results. Provider-perceived barriers to wider use included lack of clear guidelines and evidence for most drugs, highlighting important considerations for the field of pharmacogenomics.

7.
Blood Purif ; 46(4): 315-322, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-30107381

RESUMEN

BACKGROUND/AIMS: We sought to quantify any differences in cytokine clearance between continuous venovenous hemofiltration (CVVH-convective) compared to continuous venovenous hemodialysis (CVVHD-diffusive). METHODS: We conducted a 20 patient, multicenter, prospective, open-label randomized trial (CVVH or CVVHD) at continuous renal -replacement therapy (CRRT) initiation. Blood, urine, and effluent were collected at 0, 4, 24, and 48 h after initiation of CRRT. Serum electrolytes, cytokines levels, and clearances were measured. Cytokines studies included IL-1ß, IL-1RA, IL-6, IL-10, and TNFα. RESULTS: We randomized 20 patients to receive CRRT. After 4 h of CRRT there was no difference in total cytokine levels or change in cytokine concentrations across the 2 groups. With the exception of IL-1 RA, all cytokines levels decreased across patient groups regardless of modality. There was no significant difference in cytokine concentration across CRRT modality for any time point. CONCLUSION: Within the first 4 h of CRRT initiation, there is no significant difference between cytokine or solute clearance between CVVH and CVVHD.

8.
Anesth Analg ; 127(5): 1236-1245, 2018 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-30138176

RESUMEN

Acute kidney injury (AKI) in the perioperative period is a common complication and is associated with increased morbidity and mortality. A standard definition and staging system for AKI has been developed, incorporating a reduction of the urine output and/or an increase of serum creatinine. Novel biomarkers may detect kidney damage in the absence of a change in function and can also predict the development of AKI. Several specific considerations for AKI risk are important in surgical patients. The surgery, especially major and emergency procedures in critically ill patients, may cause AKI. In addition, certain comorbidities, such as chronic kidney disease and chronic heart failure, are important risk factors for AKI. Diuretics, contrast agents, and nephrotoxic drugs are commonly used in the perioperative period and may result in a significant amount of in-hospital AKI. Before and during surgery, anesthetists are supposed to optimize the patient, including preventing and treating a hypovolemia and correcting an anemia. Intraoperative episodes of hypotension have to be avoided because even short periods of hypotension are associated with an increased risk of AKI. During the intraoperative period, urine output might be reduced in the absence of kidney injury or the presence of kidney injury with or without fluid responsiveness. Therefore, fluids should be used carefully to avoid hypovolemia and hypervolemia. The Kidney Disease: Improving Global Outcomes guidelines suggest implementing preventive strategies in high-risk patients, which include optimization of hemodynamics, restoration of the circulating volume, institution of functional hemodynamic monitoring, and avoidance of nephrotoxic agents and hyperglycemia. Two recently published studies found that implementing this bundle in high-risk patients reduced the occurrence of AKI in the perioperative period. In addition, the application of remote ischemic preconditioning has been studied to potentially reduce the incidence of perioperative AKI. This review discusses the epidemiology and pathophysiology of surgery-associated AKI, highlights the importance of intraoperative oliguria, and emphasizes potential preventive strategies.

10.
Clin Transl Sci ; 11(4): 420-427, 2018 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-29691991

RESUMEN

Acute kidney injury (AKI) limits cisplatin use. We tested whether urine cystatin C (uCyC) and neutrophil gelatinase-associated lipocalin (uNGAL) can preidentify patients at risk for AKI. Patients initiating cisplatin-based chemotherapy were prospectively enrolled. uNGAL/uCyC were measured pre/post-cisplatin administration and compared with serum creatinine (sCr). AKI was defined as sCr increase ≥50% or ≥0.3 mg/dL above baseline. In all, 102 patients were enrolled; 95 provided evaluable data. Twenty-five patients developed AKI. Median baseline and pre-cisplatin uNGAL levels were significantly higher in AKI patients. Although immediate changes in uNGAL/uCyC 2 h after cisplatin were not detectable, post-cisplatin peak values over the course of therapy were markedly and significantly elevated in AKI patients. In multivariate modeling with age, baseline glomerular filtration rate, and histology, maximum uCyC was a significant independent AKI predictor. These findings suggest pre-cisplatin uNGAL and peak uCyC levels can identify patients with increased AKI risk, potentially allowing for tailored modification of cisplatin-based treatment regimens.

11.
Crit Care Med ; 46(7): 1070-1077, 2018 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-29596073

RESUMEN

OBJECTIVES: To develop an acute kidney injury risk prediction model using electronic health record data for longitudinal use in hospitalized patients. DESIGN: Observational cohort study. SETTING: Tertiary, urban, academic medical center from November 2008 to January 2016. PATIENTS: All adult inpatients without pre-existing renal failure at admission, defined as first serum creatinine greater than or equal to 3.0 mg/dL, International Classification of Diseases, 9th Edition, code for chronic kidney disease stage 4 or higher or having received renal replacement therapy within 48 hours of first serum creatinine measurement. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographics, vital signs, diagnostics, and interventions were used in a Gradient Boosting Machine algorithm to predict serum creatinine-based Kidney Disease Improving Global Outcomes stage 2 acute kidney injury, with 60% of the data used for derivation and 40% for validation. Area under the receiver operator characteristic curve (AUC) was calculated in the validation cohort, and subgroup analyses were conducted across admission serum creatinine, acute kidney injury severity, and hospital location. Among the 121,158 included patients, 17,482 (14.4%) developed any Kidney Disease Improving Global Outcomes acute kidney injury, with 4,251 (3.5%) developing stage 2. The AUC (95% CI) was 0.90 (0.90-0.90) for predicting stage 2 acute kidney injury within 24 hours and 0.87 (0.87-0.87) within 48 hours. The AUC was 0.96 (0.96-0.96) for receipt of renal replacement therapy (n = 821) in the next 48 hours. Accuracy was similar across hospital settings (ICU, wards, and emergency department) and admitting serum creatinine groupings. At a probability threshold of greater than or equal to 0.022, the algorithm had a sensitivity of 84% and a specificity of 85% for stage 2 acute kidney injury and predicted the development of stage 2 a median of 41 hours (interquartile range, 12-141 hr) prior to the development of stage 2 acute kidney injury. CONCLUSIONS: Readily available electronic health record data can be used to predict impending acute kidney injury prior to changes in serum creatinine with excellent accuracy across different patient locations and admission serum creatinine. Real-time use of this model would allow early interventions for those at high risk of acute kidney injury.

12.
Biomarkers ; 23(1): 61-69, 2018 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-29034718

RESUMEN

OBJECTIVES AND METHODS: The Furosemide Stress Test (FST) is a novel dynamic assessment of tubular function that has been shown in preliminary studies to predict patients who will progress to advanced stage acute kidney injury, including those who receive renal replacement therapy (RRT). The aim of this study is to investigate if the urinary response to a single intraoperative dose of intravenous furosemide predicts delayed graft function (DGF) in patients undergoing deceased donor kidney transplant. RESULTS: On an adjusted multiple logistic regression, a single 100 mg dose of intraoperative furosemide after the anastomosis of the renal vessels (FST) predicted the need for RRT at 2 and 6 h post kidney transplantation (KT). Recipient urinary output was measured at 2 and 6 h post furosemide administration. In receiver-operating characteristic (ROC) analysis, the FST predicted DGF with an area-under-the curve of 0.85 at an optimal urinary output cut-off of <600 mls at 6 h with a sensitivity of and a specificity of 83% and 74%, respectively. CONCLUSIONS: The FST is a predictor of DGF post kidney transplant and has the potential to identify patients requiring RRT early after KT.


Asunto(s)
Funcionamiento Retardado del Injerto/diagnóstico , Furosemida/administración & dosificación , Trasplante de Riñón/métodos , Donantes de Tejidos , Adulto , Funcionamiento Retardado del Injerto/fisiopatología , Diuréticos/administración & dosificación , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Curva ROC , Estudios Retrospectivos
13.
J Am Soc Nephrol ; 28(12): 3699-3707, 2017 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-28808078

RESUMEN

Clinical AKI, measured by serum creatinine elevation, is associated with long-term risks of adverse cardiovascular (CV) events and mortality in patients after cardiac surgery. To evaluate the relative contributions of urine kidney injury biomarkers and plasma cardiac injury biomarkers in adverse events, we conducted a multicenter prospective cohort study of 968 adults undergoing cardiac surgery. On postoperative days 1-3, we measured five urine biomarkers of kidney injury (IL-18, NGAL, KIM-1, L-FABP, and albumin) and five plasma biomarkers of cardiac injury (NT-proBNP, H-FABP, hs-cTnT, cTnI, and CK-MB). The primary outcome was a composite of long-term CV events or death, which was assessed via national health care databases. During a median 3.8 years of follow-up, 219 (22.6%) patients experienced the primary outcome (136 CV events and 83 additional deaths). Compared with patients without postsurgical AKI, patients who experienced AKI Network stage 2 or 3 had an adjusted hazard ratio for the primary composite outcome of 3.52 (95% confidence interval, 2.17 to 5.71). However, none of the five urinary kidney injury biomarkers were significantly associated with the primary outcome. In contrast, four out of five postoperative cardiac injury biomarkers (NT-proBNP, H-FABP, hs-cTnT, and cTnI) strongly associated with the primary outcome. Mediation analyses demonstrated that cardiac biomarkers explained 49% (95% confidence interval, 1% to 97%) of the association between AKI and the primary outcome. These results suggest that clinical AKI at the time of cardiac surgery is indicative of concurrent CV stress rather than an independent renal pathway for long-term adverse CV outcomes.


Asunto(s)
Biomarcadores/metabolismo , Enfermedades Cardiovasculares/complicaciones , Enfermedades Cardiovasculares/cirugía , Riñón/lesiones , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos , Femenino , Humanos , Enfermedades Renales/diagnóstico , Enfermedades Renales/etiología , Masculino , Resultado del Tratamiento
15.
BMC Nephrol ; 18(1): 218, 2017 Jul 06.
Artículo en Inglés | MEDLINE | ID: mdl-28683730

RESUMEN

INTRODUCTION: Urinary biomarkers of kidney injury are presumed to reflect renal tubular damage. However, their concentrations may be influenced by other factors, such as hematuria or pyuria. We sought to examine what non-injury related urinalysis factors are associated with urinary biomarker levels. METHODS: We examined 714 adults who underwent cardiac surgery in the TRIBE-AKI cohort that did not experience post-operative clinical AKI (patients with serum creatinine change of ≥ 20% were excluded). We examined the association between urinalysis findings and the pre- and first post-operative urinary concentrations of 4 urinary biomarkers: neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18), kidney injury molecule-1 (KIM-1), and liver fatty acid binding protein (L-FABP). RESULTS: The presence of leukocyte esterase and nitrites on urinalysis was associated with increased urinary NGAL (R2 0.16, p < 0.001 and R2 0.07, p < 0.001, respectively) in pre-operative samples. Hematuria was associated with increased levels of all 4 biomarkers, with a much stronger association seen in post-operative samples (R2 between 0.02 and 0.21). Dipstick proteinuria concentrations correlated with levels of all 4 urinary biomarkers in pre-operative and post-operative samples (R2 between 0.113 and 0.194 in pre-operative and between 0.122 and 0.322 in post-operative samples). Adjusting the AUC of post-operative AKI for dipstick proteinuria lowered the AUC for all 4 biomarkers at the pre-operative time point and for 2 of the 4 biomarkers at the post-operative time point. CONCLUSIONS: Several factors available through urine dipstick testing are associated with increased urinary biomarker concentrations that are independent of clinical kidney injury. Future studies should explore the impact of these factors on the prognostic and diagnostic performance of these AKI biomarkers.


Asunto(s)
Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/orina , Urinálisis , Anciano , Anciano de 80 o más Años , Biomarcadores/orina , Estudios de Cohortes , Femenino , Humanos , Internacionalidad , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Proteinuria/diagnóstico , Proteinuria/orina , Urinálisis/métodos
16.
Artículo en Inglés | MEDLINE | ID: mdl-28729381
18.
Blood Purif ; 43(1-3): 68-77, 2017.
Artículo en Inglés | MEDLINE | ID: mdl-27923227

RESUMEN

As advances in Critical Care Medicine continue, critically ill patients are surviving despite the severity of their illness. The incidence of acute kidney injury (AKI) has increased, and its impact on clinical outcomes as well as medical expenditures has been established. The role, indications and technological advancements of renal replacement therapy (RRT) have evolved, allowing more effective therapies with less complications. With these changes, Critical Care Nephrology has become an established specialty, and ongoing collaborations between critical care physicians and nephrologist have improved education of multi-disciplinary team members and patient care in the ICU. Multidisciplinary programs to support these changes have been stablished in some hospitals to maximize the delivery of care, while other programs have continue to struggle in their ability to acquire the necessary resources to maximize outcomes, educate their staff, and develop quality initiatives to evaluate and drive improvements. Clearly, the role of the nephrologist in the ICU has evolved, and varies widely among institutions. This special article will provide insights that will hopefully optimize the role of the nephrologist as the leader of the acute care nephrology program, as clinician for critically ill patients, and as teacher for all members of the health care team.


Asunto(s)
Unidades de Cuidados Intensivos/organización & administración , Nefrólogos/organización & administración , Nefrología/organización & administración , Guías de Práctica Clínica como Asunto/normas , Lesión Renal Aguda/terapia , Cuidados Críticos/métodos , Cuidados Críticos/normas , Humanos , Relaciones Interprofesionales
19.
Curr Opin Nephrol Hypertens ; 26(1): 31-35, 2017 01.
Artículo en Inglés | MEDLINE | ID: mdl-27820705

RESUMEN

PURPOSE OF REVIEW: The kidney, like most other organs, has a reserve capacity that can be utilized in times of increased physiologic demand. The ability to quantify this renal reserve function across various parts of the nephron (glomerular and tubular) has been an area of increased investigation over the past several years. In this review, we discuss several techniques that have been developed to interrogate the maximal physiologic capacity of the injured kidney. RECENT FINDINGS: Although protein loading has been established as an ideal method to investigate glomerular filtration capacity in healthy kidneys, other methods such as the antagonism of the renin-angiotensin-aldosterone system have demonstrated promise as a method to determine underlying glomerular disease in those with acute kidney injury and other comorbidities (e.g., congestive heart failure and chronic kidney disease). The furosemide stress test has been demonstrated to be a useful clinical tool to ascertain tubular integrity in the setting of acute kidney injury. SUMMARY: Although various methods to interrogate the reserve capacity of the several nephron segments (glomerulus and tubules) have been investigated, none of these techniques have had wide-spread clinical implementation. Further research into acute kidney injury stress testing is warranted.


Asunto(s)
Lesión Renal Aguda/fisiopatología , Pruebas de Función Renal , Glomérulos Renales/fisiopatología , Túbulos Renales/fisiopatología , Insuficiencia Renal Crónica/fisiopatología , Lesión Renal Aguda/metabolismo , Furosemida , Tasa de Filtración Glomerular , Humanos , Glomérulos Renales/metabolismo , Sistema Renina-Angiotensina
20.
Clin J Am Soc Nephrol ; 11(11): 1935-1943, 2016 11 07.
Artículo en Inglés | MEDLINE | ID: mdl-27633727

RESUMEN

BACKGROUND AND OBJECTIVES: Identification of patients at risk for AKI on the general wards before increases in serum creatinine would enable preemptive evaluation and intervention to minimize risk and AKI severity. We developed an AKI risk prediction algorithm using electronic health record data on ward patients (Electronic Signal to Prevent AKI). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: All hospitalized ward patients from November of 2008 to January of 2013 who had serum creatinine measured in five hospitals were included. Patients with an initial ward serum creatinine >3.0 mg/dl or who developed AKI before ward admission were excluded. Using a discrete time survival model, demographics, vital signs, and routine laboratory data were used to predict the development of serum creatinine-based Kidney Disease Improving Global Outcomes AKI. The final model, which contained all variables, was derived in 60% of the cohort and prospectively validated in the remaining 40%. Areas under the receiver operating characteristic curves were calculated for the prediction of AKI within 24 hours for each unique observation for all patients across their inpatient admission. We performed time to AKI analyses for specific predicted probability cutoffs from the developed score. RESULTS: Among 202,961 patients, 17,541 (8.6%) developed AKI, with 1242 (0.6%) progressing to stage 3. The areas under the receiver operating characteristic curve of the final model in the validation cohort were 0.74 (95% confidence interval, 0.74 to 0.74) for stage 1 and 0.83 (95% confidence interval, 0.83 to 0.84) for stage 3. Patients who reached a cutoff of ≥0.010 did so a median of 42 (interquartile range, 14-107) hours before developing stage 1 AKI. This same cutoff provided sensitivity and specificity of 82% and 65%, respectively, for stage 3 and was reached a median of 35 (interquartile range, 14-97) hours before AKI. CONCLUSIONS: Readily available electronic health record data can be used to improve AKI risk stratification with good to excellent accuracy. Real time use of Electronic Signal to Prevent AKI would allow early interventions before changes in serum creatinine and may improve costs and outcomes.


Asunto(s)
Lesión Renal Aguda/diagnóstico , Algoritmos , Registros Electrónicos de Salud , Modelos Biológicos , Adulto , Anciano , Anciano de 80 o más Años , Área Bajo la Curva , Nitrógeno de la Urea Sanguínea , Creatinina/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Habitaciones de Pacientes , Probabilidad , Curva ROC , Medición de Riesgo/métodos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo
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