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1.
Eur J Intern Med ; 2020 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-32616340

RESUMO

BACKGROUND: Acute kidney injury (AKI) is independently associated with increased morbidity and mortality. Quality improvement has been identified as an important goal in the care of patients with AKI. Different settings can be targeted to improve AKI care, broadly classified these include the inpatient and outpatient environments. In this paper, we will emphasize quality indicators associated with the management and secondary prevention of AKI in hospitalized patients to limit the severity, duration, and complications. METHODS: During the 22nd Acute Disease Quality Initiative (ADQI) consensus conference, a multidisciplinary group of experts discussed the evidence and used a modified Delphi process to achieve consensus on recommendations for AKI-related quality indicators (QIs) and care processes to improve patient outcomes. The management and secondary prevention of AKI in hospitalized patients were discussed, and recommendations were summarized. RESULTS: The first step in optimizing the quality of AKI management is the determination of baseline performance. Data regarding each institution's/center's performance can provide a reference point from which to benchmark quality efforts. Quality program initiatives should prioritize achievable goals likely to have the highest impact according to the setting and context. Key AKI quality metrics should include improvement in timely recognition, appropriate diagnostic workup, and implementation of known interventions that limit progression and severity, facilitating recovery, and mitigating AKI-associated complications. We propose the Recognition-Action-Results framework to plan, measure, and report the progress toward improving AKI management quality. CONCLUSIONS: These recommendations identified and outlined an approach to define and evaluate the quality of AKI management in hospitalized patients.

2.
BMJ Glob Health ; 5(5)2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32371573

RESUMO

BACKGROUND: Kidney disease is prevalent in low-resource settings worldwide, but tests for its diagnosis are often unavailable. The saliva urea nitrogen (SUN) dipstick is a laboratory and electricity independent tool, which may be used for the detection of kidney disease. We investigated the feasibility and performance of its use in diagnosing kidney disease in community settings in Africa. METHODS: Adult patients at increased risk of kidney disease presenting to three community health centres, a rural district hospital and a central hospital in Malawi were recruited between October 2016 and September 2017. Patients underwent concurrent SUN and creatinine testing at enrolment, and at 1 week, 1 month, 3 months and 6 months thereafter. RESULTS: Of 710 patients who presented at increased risk of kidney disease, 655 (92.3%) underwent SUN testing at enrolment, and were included (aged 38 (29-52) years, 367 (56%) female and 333 (50.8%) with HIV). Kidney disease was present in 482 (73.6%) patients and 1479 SUN measurements were made overall. Estimated glomerular filtration rate (eGFR) correlated with SUN (r=-0.39; p<0.0001). The area under the receiver operating characteristics curve was 0.61 for presenting SUN to detect acute or chronic kidney disease, and 0.87 to detect severe (eGFR <15 mL/min/1.73 m2) kidney disease (p<0.0001; sensitivity 82.3%, specificity 81.8%, test accuracy 81.8%). In-hospital mortality was greater if enrolment SUN was elevated (>test pad #1) compared with patients with non-elevated SUN (p<0.0001; HR 3.3 (95% CI 1.7 to 6.1). CONCLUSIONS: SUN, measured by dipstick, is feasible and may be used to screen for kidney disease in low resource settings where creatinine tests are unavailable.

3.
BMC Nephrol ; 21(1): 87, 2020 Mar 06.
Artigo em Inglês | MEDLINE | ID: mdl-32143585

RESUMO

BACKGROUND: Interstitial fibrosis (IF) on kidney biopsy is one of the most potent risk factors for kidney disease progression. The furosemide stress test (FST) is a validated tool that predicts the severity of acute kidney injury (especially at 2 h) in critically ill patients. Since furosemide is secreted through the kidney tubules, the response to FST represents the tubular secretory capacity. To our knowledge there is no data on the correlation between functional tubular capacity assessed by the FST with IF on kidney biopsies from patients with chronic kidney disease (CKD). The aim of this study was to determine the association between urine output (UO), Furosemide Excreted Mass (FEM) and IF on kidney biopsies after a FST. METHODS: This study included 84 patients who underwent kidney biopsy for clinical indications and a FST. The percentage of fibrosis was determined by morphometry technique and reviewed by a nephropathologist. All patients underwent a FST prior to the biopsy. Urine volume and urinary sodium were measured in addition to urine concentrations of furosemide at different times (2, 4 and 6 h). We used an established equation to determine the FEM. Values were expressed as mean, standard deviation or percentage and Pearson Correlation. RESULTS: The mean age of the participants was 38 years and 44% were male. The prevalence of diabetes mellitus, hypertension and diuretic use was significantly higher with more advanced degree of fibrosis. Nephrotic syndrome and acute kidney graft dysfunction were the most frequent indications for biopsy. eGFR was inversely related to the degree of fibrosis. Subjects with the highest degree of fibrosis (grade 3) showed a significant lower UO at first hour of the FST when compared to lower degrees of fibrosis (p = 0.015). Likewise, the total UO and the FEM was progressively lower with higher degrees of fibrosis. An inversely linear correlation between FEM and the degree of fibrosis (r = - 0.245, p = 0.02) was observed. CONCLUSIONS: Our findings indicate that interstitial fibrosis correlates with total urine output and FEM. Further studies are needed to determine if UO and FST could be a non-invasive tool to evaluate interstitial fibrosis. TRIAL REGISTRATION: ClinicalTrials.gov NCT02417883.

4.
Clin Ther ; 42(4): 625-633, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32199609

RESUMO

PURPOSE: Antibiotic dosing is challenge in critically ill patients undergoing renal replacement therapy. Our aim was to evaluate the pharmacokinetic and pharmacodynamic (PK/PD) characteristics of meropenem and vancomycin in patients undergoing SLED. METHODS: Consecutive ICU patients undergoing SLED and receiving meropenem and/or vancomycin were prospectively evaluated. Serial blood samples were collected before, during, and at the end of SLED sessions. Antimicrobial concentrations were determined using a validated HPLC method. Noncompartmental PK analysis was performed. AUC was determined for vancomycin. For meropenem, time above MIC was calculated. FINDINGS: A total of 24 patients receiving vancomycin and 21 receiving meropenem were included; 170 plasma samples were obtained. Median serum vancomycin and meropenem concentrations before SLED were 24.5 and 28.0 µg/mL, respectively; after SLED, 14 and 6 µg/mL. Mean removal was 42% with vancomycin and 78% with meropenem. With vancomycin, 19 (83%), 16 (70%), and 15 (65%) patients would have achieved the target (AUC0-24 >400) considering MICs of 1, 2, and 4 mg/L, respectively. With meropenem, 17 (85%), 14 (70%), and 10 (50%) patients would have achieved the target (100% of time above MIC) if infected with isolates with MICs of 1, 4, and 8 mg/L, respectively. IMPLICATIONS: SLED clearances of meropenem and vancomycin were 3-fold higher than the clearance described by continuous methods. Despite this finding, overall high PK/PD target attainments were obtained, except for at higher MICs. We suggest a maintenance dose of 1 g TID or BID of meropenem. With vancomycin, a more individualized approach using therapeutic drug monitoring should be used, as commercial assays are available.

5.
BMC Nephrol ; 21(1): 36, 2020 Jan 30.
Artigo em Inglês | MEDLINE | ID: mdl-32000713

RESUMO

BACKGROUND: Hypothyroidism is highly prevalent in patients with chronic kidney disease (CKD) and has been associated with poorer clinical outcomes, including faster decline of kidney function. However, there is no consensus whether low free thyroxin (LFT) affects the rate of estimated glomerular filtration rate (eGFR) decline and how the presence of proteinuria influences the progression of renal dysfunction in hypothyroidism. METHODS: We assessed thyroid status, proteinuria, and progression of eGFR by Modification of Diet in Renal Disease equation and CKD-EPI equation in a cohort of CKD patients followed in general nephrology clinics. We estimated the association of LFT levels, and the degree of proteinuria on progression of eGFR. We adjusted for other covariables: age, gender, body mass index, diabetes, hypertension, HbA1c, uric acid, cholesterol, and triglycerides levels.. RESULTS: One thousand six hundred ten patients (64 ± 15 years, 46.8% men, 25.3% diabetic) were included. At beggnining of follow up eGFR was between 45 and 60, 30-45 and 15-30 ml/min/1.73m2 in 479 (29.8%), 551(34.2%), and 580(36.0%) patients, respectively. LFT levels were available at initial evaluation in 288(17.9%) patients and 735(48.5%) had assessment of proteinuria (19.6% with LFT vs. 15.4% without LFT, p = 0.032). Median follow-up time was of 21 months, and 1223(76%) had at least 1 year of follow up. Overall, eGFR decline per month was - 0.05(- 0.26, 0.23) ml/min/1.73m2, reaching 1.7(1.3, 2.4) ml/min/1.73m2 by the end of study period. Similar results were obtained using CKD-EPI. Multivariable mixed linear analysis showed that proteinuria and age were independently associated with eGFR decline, with no effect of LFT, and no interaction between proteinuria and LFT. In patients without proteinuria, there was an improvement of eGFR despite the presence of LFT. CONCLUSIONS: We confirmed a faster rate of eGFR declined in patients with proteinuria. However, despite the pathophysiological rational that hypothyroidism can lead to increased rate of CKD progression, we failed to demonstrate an association between LFT and rate of CKD progression. We conclude that the benefit of hypothyroidism treatment in CKD patients needs to be evaluate in prospective studies.

6.
PLoS One ; 15(1): e0226325, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31951618

RESUMO

OBJECTIVES: Although the majority of the global population lives in developing countries, most of the epidemiological data related to intensive care unit (ICU) acute kidney injury (AKI) comes from developed countries. This systematic review aims to ascertain the methodology of studies on ICU AKI patients in developing and developed countries, to determine whether epidemiological comparisons between these two settings are possible, and to present a summary estimate of AKI incidence. METHODS: A systematic review of published studies reporting AKI in intensive care units (2005-2015) identified in PubMed, LILACS, and IBECs databases was conducted. We compared developed and developing countries by evaluating study methodology, AKI reference serum creatinine definitions, population characteristics, AKI incidence and mortality. AKI incidence was calculated with a random-effects model. RESULTS: Ninety-two studies were included, one of which reported data from both country categories: 60 from developed countries (1,057,332 patients) and 33 from developing countries (34,539 patients). In 78% of the studies, AKI was defined by the RIFLE, AKIN or KDIGO criteria. Oliguria had 11 different definitions and reference creatinine 23 different values. For the meta-analysis, 38 studies from developed and 18 from developing countries were selected, with similar AKI incidence: 39.3% and 35.1%, respectively. The need for dialysis, length of ICU stay and mortality were higher in developing countries. CONCLUSION: Although patient characteristics and AKI incidence were similar in developed and developing countries, main outcomes were worse in developing country studies. There are significant caveats when comparing AKI epidemiology in developed and developing countries, including lack of standardization of reference serum creatinine, oliguria and the timeframe for AKI assessment. Larger, prospective, multicenter studies from developing countries are urgently needed to capture AKI data from the overall population without ICU access.


Assuntos
Lesão Renal Aguda/epidemiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Países Desenvolvidos , Países em Desenvolvimento , Humanos , Incidência
7.
J Hypertens ; 38(3): 456-466, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31714338

RESUMO

BACKGROUND: Chromogranin A (CHGA) is an index granin protein critical for biogenesis and exocytotic release of catecholamine storage granules. It is elevated in plasma of patients with sympathetic over-activity and kidney dysfunction. Several CHGA polymorphisms are associated with hypertensive kidney disease. Previously, we unraveled the molecular mechanism by which CHGA expression is regulated in African Americans carrying a genetic variation associated with hypertensive chronic kidney disease (CKD). METHOD: Experimental CKD mouse model were created by 5/6th nephrectomy (Npx) using wild-type and Chga-/- knockout mouse strains to delineate the role of CHGA in CKD. RESULT: Wild-type-Npx mice expressing Chga developed exacerbated azotemia and fibrosis as compared with their knockout-Npx counterparts. Gene expression profiling revealed downregulation of mitochondrial respiratory complexes genes consistent with maladaptive mitochondria in wild-type-Npx mice, contrasted to knockout-Npx. In healthy individuals, an inverse relationship between circulating CHGA levels and glomerular function was observed. In vitro, mesangial cells treated with CHGA-triggered nitric oxide release by a signaling mechanism involving scavenger receptor SR-A. The CHGA-treated and untreated mesangial cells displayed differential expression of cytokine, chemokine, complement, acute phase inflammatory and apoptotic pathway genes. Thus, build-up of plasma CHGA because of kidney injury served as an insult to the mesangial cells resulting in expression of genes promoting inflammation, fibrosis, and progression of CKD. CONCLUSION: These findings improve understanding of the role of elevated CHGA in the progression of CKD and reveal novel pathways that could be exploited for therapeutic strategies in hypertensive kidney disease.

8.
Crit Care ; 23(1): 389, 2019 Dec 02.
Artigo em Inglês | MEDLINE | ID: mdl-31791373

RESUMO

BACKGROUND: Intradialytic hypotension, a complication of intermittent hemodialysis, decreases the efficacy of dialysis and increases long-term mortality. This study was aimed to determine whether different predialysis ultrasound cardiopulmonary profiles could predict intradialytic hypotension. METHODS: This prospective observational single-center study was performed in 248 critically ill patients with acute kidney injury undergoing intermittent hemodialysis. Immediately before hemodialysis, vena cava collapsibility was measured by vena cava ultrasound and pulmonary congestion by lung ultrasound. Factors predicting intradialytic hypotension were identified by multiple logistic regression analysis. RESULTS: Intradialytic hypotension was observed in 31.9% (n = 79) of the patients, interruption of dialysis because of intradialytic hypotension occurred in 6.8% (n = 31) of the sessions, and overall 28-day mortality was 20.1% (n = 50). Patients were classified in four ultrasound profiles: (A) 108 with B lines > 14 and vena cava collapsibility > 11.5 mm m-2, (B) 38 with B lines < 14 and vena cava collapsibility ≤ 11.5 mm m-2, (C) 36 with B lines > 14 and vena cava collapsibility Di ≤ 11.5 mm m-2, and (D) 66 with B lines < 14 and vena cava collapsibility > 11.5 mm m-2. There was an increased risk of intradialytic hypotension in patients receiving norepinephrine (odds ratios = 15, p = 0.001) and with profiles B (odds ratios = 12, p = 0.001) and C (odds ratios = 17, p = 0.001). CONCLUSION: In critically ill patients on intermittent hemodialysis, the absence of hypervolemia as assessed by lung and vena cava ultrasound predisposes to intradialytic hypotension and suggests alternative techniques of hemodialysis to provide better hemodynamic stability.


Assuntos
Diálise/efeitos adversos , Hipotensão/etiologia , Ultrassonografia/classificação , APACHE , Lesão Renal Aguda/terapia , Idoso , Diálise/métodos , Feminino , Humanos , Hipotensão/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Estudos Prospectivos , Estatísticas não Paramétricas , Ultrassonografia/métodos
9.
Sci Transl Med ; 11(512)2019 10 02.
Artigo em Inglês | MEDLINE | ID: mdl-31578243

RESUMO

High serum concentrations of kidney-derived protein uromodulin [Tamm-Horsfall protein (THP)] have recently been shown to be independently associated with low mortality in both older adults and cardiac patients, but the underlying mechanism remains unclear. Here, we show that THP inhibits the generation of reactive oxygen species (ROS) both in the kidney and systemically. Consistent with this experimental data, the concentration of circulating THP in patients with surgery-induced acute kidney injury (AKI) correlated with systemic oxidative damage. THP in the serum dropped after AKI and was associated with an increase in systemic ROS. The increase in oxidant injury correlated with postsurgical mortality and need for dialysis. Mechanistically, THP inhibited the activation of the transient receptor potential cation channel, subfamily M, member 2 (TRPM2) channel. Furthermore, inhibition of TRPM2 in vivo in a mouse model mitigated the systemic increase in ROS during AKI and THP deficiency. Our results suggest that THP is a key regulator of systemic oxidative stress by suppressing TRPM2 activity, and our findings might help explain how circulating THP deficiency is linked with poor outcomes and increased mortality.

10.
BMC Nephrol ; 20(1): 367, 2019 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-31615452

RESUMO

BACKGROUND: Acute kidney injury (AKI) is a common complication in patients undergoing liver transplant (LT) and is associated with high morbidity and mortality. We aim to evaluate the pattern of urine and plasma neutrophil gelatinase-associated lipocalin (NGAL) elevation during the perioperative period of LT and to assess it as a prognostic marker for AKI progression, need for dialysis and mortality. METHODS: We assessed NGAL levels before induction of anesthesia, after portal reperfusion and at 6, 18, 24, and 48 h after surgery. Patients were monitored daily during the first week after LT. RESULTS: Of 100 enrolled patients undergoing liver transplant, 59 developed severe AKI based on the KDIGO serum creatinine (sCr) criterion; 34 were dialysed, and 21 died within 60 days after LT. Applying a cut-off value of 136 ng/ml, UNGAL values 6 h after surgery was a good predictor of AKI development within 7 days after surgery, having a positive predictive value (PPV) of 80% with an AUC of 0.76 (95% CI 0.67-0.86). PNGAL at 18 h after LT was also a good predictor of AKI in the first week, having a PPV of 81% and AUC of 0.74 (95% CI 0.60-0.88). Based on PNGAL and UNGAL cut-off criteria levels, time to AKI diagnosis was 28 and 23 h earlier than by sCr, respectively. The best times to assess the need for dialysis were 18 h after LT by PNGAL and 06 h after LT by UNGAL. CONCLUSION: In conclusion, the plasma and urine NGAL elevation pattern in the perioperative period of the liver transplant can predict AKI diagnosis earlier. UNGAL was an early independent predictor of AKI development and need for dialysis. Further studies are needed to assess whether the clinical use of biomarkers can improve patient outcomes. TRIAL REGISTRATION: Registered at Clinical Trials ( clinicaltrials.gov ) in March 24th, 2014 by title "Acute Kidney Injury Biomarkers: Diagnosis and Application in Pre-operative Period of Liver Transplantation (AKIB)" and identifier NCT02095431, retrospectively registered.

11.
Rev Assoc Med Bras (1992) ; 65(8): 1094-1101, 2019 Sep 12.
Artigo em Inglês | MEDLINE | ID: mdl-31531608

RESUMO

INTRODUCTION: Acute kidney injury (AKI) is a frequent event among critically ill patients hospitalized in intensive care units (ICU) and represents a global public health problem, being imperative an interdisciplinary approach. OBJECTIV: To investigate, through literature review, the AKI epidemiology in ICUs. METHODS: Online research in Medline, Scientific Electronic Library Online, and Latin American and Caribbean Literature in Health Sciences databases, with analysis of the most relevant 47 studies published between 2010 and 2017. RESULTS: Data of the 67,033 patients from more than 300 ICUs from different regions of the world were analyzed. The overall incidence of AKI ranged from 2.5% to 92.2%, and the mortality from 5% to 80%. The length of ICU stay ranged from five to twenty-one days, and the need for renal replacement therapy from 0.8% to 59.2%. AKI patients had substantially higher mortality rates and longer hospital stays than patients without AKI. CONCLUSION: AKI incidence presented high variability among the studies. One of the reasons for that were the different criteria used to define the cases. Availability of local resources, renal replacement therapy needs, serum creatinine at ICU admission, volume overload, and sepsis, among others, influence mortality rates in AKI patients.


Assuntos
Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/mortalidade , Lesão Renal Aguda/terapia , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação , Fatores de Risco
12.
Nephron ; 143(3): 188-192, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31533119

RESUMO

Acute kidney injury (AKI) is a frequent event in hospitalized patients, with an incidence that continues to rise, reaching as high as 70-80% in intensive care settings. The need for dialysis and progression to end-stage kidney disease (ESKD) after an episode of AKI is relatively low, from 5 to 20%. However, it is now recognized that patients with AKI may have very different kidney outcomes, varying from complete recovery, incipient chronic kidney disease (CKD), to progression to ESKD. Recent studies have shown that even mild AKI episodes can be associated with a 90% increased risk of developing CKD during long-term follow-up. There is a significant need to focus our efforts on factors that could mitigate the progression of kidney dysfunction and ultimately improve outcomes from AKI. The first step toward this goal encompasses a better understanding of tubular and glomerular alterations during and following an AKI episode. Our current approach, based solely on glomerular filtration rate (GFR), is flawed, since the loss of kidney function does not correspond to the degree of decline in estimated GFR (eGFR), and eGFR does not reflect tubular function. Changes in tubular concentration, reabsorptive and secretory capacity are recognized in AKI; however, they have not been incorporated in clinical assessments of overall kidney function. Here we review a few candidates to assess glomerular filtration/permeability, tubular dysfunction, and injury and how we expect these markers to alter during the development and recovery phase of AKI.

13.
Am J Physiol Gastrointest Liver Physiol ; 317(4): G447-G452, 2019 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-31411505

RESUMO

Acute kidney injury (AKI) is a common complication in hospitalized patients with cirrhosis. Uromodulin, a protein uniquely produced by the kidney and released both in the urine and circulation, has been shown to regulate AKI and is linked to tubular reserve. Although low levels of urine uromodulin are associated with AKI after cardiac surgery, it is unclear whether circulating uromodulin can stratify the risk of AKI, particularly in a susceptible population such as hospitalized patients with cirrhosis. Thus, we investigated whether plasma uromodulin measured at the time of admission is associated with subsequent hospital-acquired AKI (defined by a rise in serum creatinine >0.3mg/dL within 48 h or ≥ 1.5 times baseline) in patients with cirrhosis. A total of 98 patients [mean age 54 yr, Model for Endstage Liver Disease Sodium (MELD-Na) score 19, and baseline creatinine of 0.95 mg/dL] were included, of which 13% (n = 13) developed AKI. Median uromodulin levels were significantly lower in patients who developed AKI compared with patients who did not (9.30 vs. 13.35 ng/mL, P = 0.02). After adjusting for age, sex, diabetes, hypertension, albumin, and MELD-Na score as covariates on multivariable logistic regression, uromodulin was independently associated with AKI [odd ratios of 1.19 (95% confidence interval 1.02, 1.37; P = 0.02)]. Lower uromodulin levels on admission are associated with increased odds of subsequent AKI in hospitalized patients with cirrhosis. Further studies are needed to better understand the role of uromodulin in the pathogenesis and as a predictive biomarker of AKI in this population.NEW & NOTEWORTHY In this study, we found that admission plasma uromodulin levels are significantly lower in patients who developed subsequent acute kidney injury (AKI) during their hospital stay compared with patients who did not. Additionally, uromodulin is independently associated with AKI development after adjusting for clinically relevant parameters such as age, sex, diabetes, hypertension, severity of cirrhosis, and kidney function. To our knowledge, this is the first study linking plasma uromodulin with AKI development in patients with cirrhosis.


Assuntos
Lesão Renal Aguda/sangue , Lesão Renal Aguda/etiologia , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Uromodulina/sangue , Lesão Renal Aguda/epidemiologia , Biomarcadores/sangue , Citocinas/sangue , Doença Hepática Terminal/sangue , Feminino , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Fatores de Risco
14.
Rev. Assoc. Med. Bras. (1992) ; 65(8): 1094-1101, Aug. 2019. tab, graf
Artigo em Inglês | LILACS-Express | ID: biblio-1041055

RESUMO

SUMMARY INTRODUCTION Acute kidney injury (AKI) is a frequent event among critically ill patients hospitalized in intensive care units (ICU) and represents a global public health problem, being imperative an interdisciplinary approach. OBJECTIV To investigate, through literature review, the AKI epidemiology in ICUs. METHODS: Online research in Medline, Scientific Electronic Library Online, and Latin American and Caribbean Literature in Health Sciences databases, with analysis of the most relevant 47 studies published between 2010 and 2017. RESULTS Data of the 67,033 patients from more than 300 ICUs from different regions of the world were analyzed. The overall incidence of AKI ranged from 2.5% to 92.2%, and the mortality from 5% to 80%. The length of ICU stay ranged from five to twenty-one days, and the need for renal replacement therapy from 0.8% to 59.2%. AKI patients had substantially higher mortality rates and longer hospital stays than patients without AKI. CONCLUSION AKI incidence presented high variability among the studies. One of the reasons for that were the different criteria used to define the cases. Availability of local resources, renal replacement therapy needs, serum creatinine at ICU admission, volume overload, and sepsis, among others, influence mortality rates in AKI patients.


RESUMO INTRODUÇÃO Injúria renal aguda (IRA) é um evento frequente entre pacientes criticamente enfermos internados em unidade de terapia intensiva (UTI) e representa um problema de saúde pública global, sendo imperativa uma abordagem interdisciplinar. OBJETIVO Investigar, por meio de revisão de literatura, a epidemiologia da IRA em UTIs. MÉTODOS Pesquisa on-line nas bases de dados Medline, Scientific Electronic Library Online e Literatura Latino-americana e do Caribe em Ciências da Saúde, com análise dos 47 estudos de maior relevância publicados entre 2010 e 2017. RESULTADOS Foram analisados dados de 67.033 pacientes, internados em mais de 300 UTIs de diferentes regiões do mundo. A incidência global de IRA variou de 2,5% a 92,2% e a mortalidade, entre 5% e 80%. O tempo de internação em UTI variou de cinco a 21 dias, enquanto que a necessidade de terapia renal substitutiva, de 0,8% a 59,2%. Pacientes com IRA apresentam índice de mortalidade substancialmente maior e tempo de internação mais elevado, em comparação com pacientes sem IRA. CONCLUSÃO: A incidência de IRA apresentou alta variabilidade entre os estudos e, dentre os motivos, estão os diferentes critérios utilizados para definição dos casos. Disponibilidade de recursos locais, necessidade de terapia renal substitutiva, creatinina na admissão na UTI, sobrecarga volêmica e sepse, dentre outros, influenciam as taxas de mortalidade entre os pacientes com IRA.

15.
Ann Nutr Metab ; 74 Suppl 3: 45-50, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31203299

RESUMO

Acute kidney injury (AKI) is a common disorder with a high risk of mortality and development of chronic kidney disease. With the validation of the recent classification systems, RIFLE in 2004 and KDIGO, in use today, our understanding of AKI has evolved. We now know that community-acquired AKI is also associated with an increased risk of worse outcomes. In addition, several epidemiological studies, including cohorts from low-income and low-middle income countries, have confirmed common risk factors for community-acquired AKI. In 2013, the International Society of Nephrology launched the 0 by 25 campaign with the goal that no patient should die from preventable or untreated AKI in low-resource areas by 2025 [Mehta et al.: Lancet 2015;385:2616-43]. The initial effort of the initiative was a meta-analysis of AKI epidemiology around the world. The second project of the 0 by 25 initiative, the Global AKI Snapshot (GSN) study, provided insights into the recognition, treatment, and outcomes of AKI worldwide [Mehta et al.: Lancet 2016;387:2017-25]. Following the GSN, a Pilot Project was designed to test whether education and a simple protocol-based approach can improve outcomes in patients at risk of community-acquired AKI in low-resource settings [Macedo: J Am Soc Nephrol 2017]. In this review, we will comment on the main findings and lessons learned from the 0 by 25 initiative.

16.
Ann Nutr Metab ; 74 Suppl 3: 51-56, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31203300

RESUMO

Few studies have assessed kidney function in patients with gastrointestinal infections in low-resource settings. Although dehydration is a frequent complication of acute diarrhea, we do not know the frequency and severity of acute kidney injury (AKI) in this context. A high prevalence of chronic kidney disease (CKD) has been reported among the inhabitants of poor communities in Poncitlan, Mexico. Polluted drinking water has been implicated as a probable cause. These communities report a high mortality associated with gastrointestinal infection. It is possible that a high incidence of waterborne disease and consequent more episodes of AKI might contribute to the high prevalence of CKD in this population. In this study, we aim to determine the association between the use of unsafe water and the incidence of acute diarrhea and AKI, and to determine if the provision of clean water decreases these complications. The study will be conducted in 3 communities of the municipality of Poncitlan. Initially, we will determine the water, sanitation, and hygiene (WASH) characteristics in the population and evaluate the incidence of diarrheal disease. In the observation phase, outcomes will be assessed after families receive training in WASH techniques, but before they are provided with clean water. In the intervention phase, outcomes will be assessed after clean water is provided.

17.
Clin J Am Soc Nephrol ; 14(6): 941-953, 2019 06 07.
Artigo em Inglês | MEDLINE | ID: mdl-31101671

RESUMO

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.

20.
J Clin Med ; 7(8)2018 Aug 11.
Artigo em Inglês | MEDLINE | ID: mdl-30103503

RESUMO

Acute kidney injury (AKI) can potentially lead to the accumulation of antimicrobial drugs with significant renal clearance. Drug dosing adjustments are commonly made using the Cockcroft-Gault estimate of creatinine clearance (CLcr). The Modified Jelliffe equation is significantly better at estimating kidney function than the Cockcroft-Gault equation in the setting of AKI. The objective of this study is to assess the degree of antimicrobial dosing discordance using different glomerular filtration rate (GFR) estimating equations. This is a retrospective evaluation of antimicrobial dosing using different estimating equations for kidney function in AKI and comparison to Cockcroft-Gault estimation as a reference. Considering the Cockcroft-Gault estimate as the criterion standard, antimicrobials were appropriately adjusted at most 80.7% of the time. On average, kidney function changed by 30 mL/min over the course of an AKI episode. The median clearance at the peak serum creatinine was 27.4 (9.3⁻66.3) mL/min for Cockcroft Gault, 19.8 (9.8⁻47.0) mL/min/1.73 m² for MDRD and 20.5 (4.9⁻49.6) mL/min for the Modified Jelliffe equations. The discordance rate for antimicrobial dosing ranged from a minimum of 8.6% to a maximum of 16.4%. In the event of discordance, the dose administered was supra-therapeutic 100% of the time using the Modified Jelliffe equation. Use of estimating equations other than the Cockcroft Gault equation may significantly alter dosing of antimicrobials in AKI.

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