Epidemiological profile of acute kidney injury in critically ill patients admitted to intensive care units: A Prospective Brazilian Cohort / Perfil epidemiológico de injúria renal aguda em pacientes críticos admitidos em unidades de terapia intensiva: uma coorte brasileira prospectiva

Abstract Introduction Acute kidney injury (AKI) is a frequent syndrome affecting patients admitted to intensive care units (ICU), and it is associated with poor clinical outcomes. The aim of the present study was to understand the epidemiological profile of patients with AKI admitted to ICUs. Methods Prospective cohort study, carried out in three ICUs in the Federal District, Brazil. Between October/2017 and December/2018, 8,131 patients were included in the cohort. AKI was defined according to the KDIGO criteria. The main outcomes assessed were AKI development and mortality within 28 days of hospitalization. Results Of the 8,131 patients followed up, 1,728 developed AKI (21.3%). Of the 1,728 patients with AKI, 1,060 (61.3%) developed stage 1, while stages 2 and 3 represented 154 (8.9%) and 514 (29.7%), respectively. Of these, 459 (26.6%) underwent renal replacement therapy. The mortality was 25.7% for those with AKI, and 4.9% for those without AKI. Discussion Patients with AKI had higher mortality rates when compared to those without AKI. Likewise, among patients with AKI, higher disease stages were associated with higher death occurrences. AKI incidence (21.3%) and mortality (25.7%) in our study is in line with the largest meta-analysis ever conducted, in which incidence and mortality of 21.6 and 23.9% were observed, respectively. These findings confirm the importance of establishing the KDIGO guideline for the definition and management of AKI in Brazilian ICUs.

Resumo Introdução A injúria renal aguda (IRA) é uma síndrome frequente em pacientes admitidos em unidades de terapia intensiva (UTI) e está associada a negativos desfechos clínicos. O objetivo do presente estudo foi conhecer o perfil epidemiológico de pacientes com IRA admitidos em UTIs. Métodos Estudo de coorte prospectiva, realizado em três UTIs do Distrito Federal, Brasil. Entre o período de outubro/2017 e dezembro/2018, 8.131 pacientes foram incluídos na coorte. A IRA foi definida de acordo com o critério KDIGO. Os principais desfechos avaliados foram o desenvolvimento de IRA e mortalidade dentro de 28 dias de internação. Resultados Dos 8.131 pacientes acompanhados, 1.728 desenvolveram IRA (21,3%). Dos 1.728 pacientes com IRA, 1.060 (61,3%) desenvolveram o estágio 1, já os estágios 2 e 3 representaram 154 (8,9%) e 514 (29,7%), respectivamente. Destes, um total de 459 (26,6%) realizou terapia renal substitutiva. A mortalidade observada foi de 25,7% para aqueles com IRA e 4,9% para os não IRA. Discussão Os pacientes com IRA, comparados aos não IRA, apresentaram maior mortalidade. Da mesma forma, entre os pacientes com IRA, os estágios superiores estiveram associados à maior ocorrência de óbito. A incidência de IRA (21,3%) e mortalidade (25,7%) em nosso estudo está em consonância com a maior meta-análise já conduzida, na qual foram observadas incidência e mortalidade de 21,6 e 23,9%, respectivamente. Esses achados confirmam a importância de se estabelecer a diretriz KDIGO para definição e manejo da IRA em UTIs brasileiras.

Epidemiological profile of acute kidney injury in critically ill patients admitted to intensive care units: A Prospective Brazilian Cohort.

INTRODUCTION: Acute kidney injury (AKI) is a frequent syndrome affecting patients admitted to intensive care units (ICU), and it is associated with poor clinical outcomes. The aim of the present study was to understand the epidemiological profile of patients with AKI admitted to ICUs. METHODS: Prospective cohort study, carried out in three ICUs in the Federal District, Brazil. Between October/2017 and December/2018, 8,131 patients were included in the cohort. AKI was defined according to the KDIGO criteria. The main outcomes assessed were AKI development and mortality within 28 days of hospitalization. RESULTS: Of the 8,131 patients followed up, 1,728 developed AKI (21.3%). Of the 1,728 patients with AKI, 1,060 (61.3%) developed stage 1, while stages 2 and 3 represented 154 (8.9%) and 514 (29.7%), respectively. Of these, 459 (26.6%) underwent renal replacement therapy. The mortality was 25.7% for those with AKI, and 4.9% for those without AKI. DISCUSSION: Patients with AKI had higher mortality rates when compared to those without AKI. Likewise, among patients with AKI, higher disease stages were associated with higher death occurrences. AKI incidence (21.3%) and mortality (25.7%) in our study is in line with the largest meta-analysis ever conducted, in which incidence and mortality of 21.6 and 23.9% were observed, respectively. These findings confirm the importance of establishing the KDIGO guideline for the definition and management of AKI in Brazilian ICUs.

Do intravenous N-acetylcysteine and sodium bicarbonate prevent high osmolal contrast-induced acute kidney injury? A randomized controlled trial.

BACKGROUND: N-acetylcysteine (NAC) or sodium bicarbonate (NaHCO3), singly or combined, inconsistently prevent patients exposed to radiographic contrast media from developing contrast-induced acute kidney injury (CI-AKI). OBJECTIVE: We asked whether intravenous isotonic saline and either NaHCO3 in 5% dextrose or else a high dose of NAC in 5% dextrose prevent CI-AKI in outpatients exposed to high-osmolal iodinated contrast medium more than does saline alone. METHODS: This completed prospective, parallel, superiority, open-label, controlled, computer-randomized, single-center, Brazilian trial (NCT01612013) hydrated 500 adult outpatients (214 at high risk of developing CI-AKI) exposed to ioxitalamate during elective coronary angiography and ventriculography. From 1 hour before through 6 hours after exposure, 126 patients (group 1) received a high dose of NAC and saline, 125 (group 2) received NaHCO3 and saline, 124 (group 3) received both treatments, and 125 (group 4) received only saline. RESULTS: Groups were similar with respect to age, gender, weight, pre-existing renal dysfunction, hypertension, medication, and baseline serum creatinine and serum cystatin C, but diabetes mellitus was significantly less prevalent in group 1. CI-AKI incidence 72 hours after exposure to contrast medium was 51.4% (257/500), measured as serum creatinine > (baseline+0.3 mg/dL) and/or serum cystatin C > (1.1 · baseline), and 7.6% (38/500), measured as both serum creatinine and serum cystatin C > (baseline+0.3 mg/dL) or > (1.25 · baseline). CI-AKI incidence measured less sensitively was similar among groups. Measured more sensitively, incidence in group 1 was significantly (p<0.05) lower than in groups 2 and 3 but not group 4; adjustment for confounding by infused volume equalized incidence in groups 1 and 3. CONCLUSION: We found no evidence that intravenous isotonic saline and either NaHCO3 or else a high dose of NAC prevent CI-AKI in outpatients exposed to high osmolal iodinated contrast medium more than does saline alone. TRIAL REGISTRATION: ClinicalTrials.gov NCT01612013.

Vitamin D and Kidney disease: what we know and what we do not know / Vitamina D e doença renal: o que nós sabemos e o que nós não sabemos

Vitamin D deficiency is common in the chronic kidney disease (CKD) population. CKD has been recognized as a significant public health problem and CKD patients are at increased risk of total and cardiovascular morbidity and mortality. There are increasing epidemiological data suggesting that vitamin D deficiency may play a role in overall morbidity and mortality associated with CKD. The vitamin D hormonal system is classically implicated in the regulation of calcium homeostasis and bone metabolism but there is ample evidence to support the claim that extra renal conversion of 25(OH)D to 1.25(OH)2 has significant biological roles beyond those traditionally ascribed to vitamin D. Based on the current state of evidence this review intends to give an update on novel biological and clinical insights with relevance to the steroid hormone vitamin D specifically in patients with kidney disease.

A deficiência de vitamina D é um achado comum em pacientes com doença renal crônica (DRC). A DRC é reconhecida como um problema de saúde pública importante, com elevado risco de morbimortalidade total e cardiovascular. Inúmeras publicações epidemiológicas sugerem que a morbimortalidade nesses pacientes pode estar associada à deficiência de vitamina D. O sistema hormonal da vitamina D é classicamente implicado na regulação do metabolismo ósseo e da homeostase do cálcio; entretanto, há uma grande evidência de que a conversão de 25(OH)D para 1.25(OH)2 tem um papel biológico significante além daquele tradicionalmente descrito. Baseada em atual evidência, esta revisão pretende ressaltar os aspectos clínicos e biológicos relevantes no sistema hormonal da vitamina D especificamente em pacientes com doença renal.

Vitamin D and kidney disease: what we know and what we do not know.

Vitamin D deficiency is common in the chronic kidney disease (CKD) population. CKD has been recognized as a significant public health problem and CKD patients are at increased risk of total and cardiovascular morbidity and mortality. There are increasing epidemiological data suggesting that vitamin D deficiency may play a role in overall morbidity and mortality associated with CKD. The vitamin D hormonal system is classically implicated in the regulation of calcium homeostasis and bone metabolism but there is ample evidence to support the claim that extra renal conversion of 25(OH)D to 1.25(OH)2 has significant biological roles beyond those traditionally ascribed to vitamin D. Based on the current state of evidence this review intends to give an update on novel biological and clinical insights with relevance to the steroid hormone vitamin D specifically in patients with kidney disease.