A risk prediction score for acute kidney injury in the intensive care unit.

BACKGROUND: Acute kidney injury (AKI) is common in critically ill patients and is associated with high morbidity and mortality. Early identification of high-risk patients provides an opportunity to develop strategies for prevention, early diagnosis and treatment of AKI. METHODS: We undertook this multicenter prospective cohort study to develop and validate a risk score for predicting AKI in patients admitted to an intensive care unit (ICU). Patients were screened for predictor variables within 48 h of ICU admission. Baseline and acute risk factors were recorded at the time of screening and serum creatinine was measured daily for up to 7 days. A risk score model for AKI was developed with multivariate regression analysis combining baseline and acute risk factors in the development cohort (573 patients) and the model was further evaluated on a test cohort (144 patients). Validation was performed on an independent prospective cohort of 1300 patients. The discriminative ability of the risk model was assessed by the area under the receiver operating characteristic curve (AUROC) and model calibration was evaluated by Hosmer-Lemeshow statistic. AKI was defined by the Kidney Disease: Improving Global Outcomes criteria (absolute change of 0.3 mg/dL or relative change of 50% from baseline serum creatinine in 48 h to 7 days, respectively). RESULTS: AKI developed in 754 (37.2%) patients. In the multivariate model, chronic kidney disease, chronic liver disease, congestive heart failure, hypertension, atherosclerotic coronary vascular disease, pH ≤ 7.30, nephrotoxin exposure, sepsis, mechanical ventilation and anemia were identified as independent predictors of AKI and the AUROC for the model in the test cohort was 0.79 [95% confidence interval (CI) 0.70-0.89]. On the external validation cohort, the AUROC value was 0.81 (95% CI 0.78-0.83). The risk model demonstrated good calibration in both cohorts. Positive and negative predictive values for the optimal cutoff value of ≥ 5 points in test and validation cohorts were 22.7 and 96.1% and 31.8 and 95.4%, respectively. CONCLUSIONS: A risk score model integrating chronic comorbidities and acute events at ICU admission can identify patients at high risk to develop AKI. This risk assessment tool could help clinicians to stratify patients for primary prevention, surveillance and early therapeutic intervention to improve care and outcomes of ICU patients.

Oliguria is an early predictor of higher mortality in critically ill patients.

Oliguria is a valuable marker of kidney function and a criterion for diagnosing and staging acute kidney injury (AKI). However, the utility of urine output as a specific metric for renal dysfunction is somewhat controversial. To study this issue further we tested whether urine output is a sensitive, specific, and early measure for diagnosing and staging AKI in 317 critically ill patients in a prospective observational study. Urine output was assessed every hour and serum creatinine every 12 to 24 h. The sensitivity and specificity of different definitions of oliguria for the diagnosis of AKI were compared with the Acute Kidney Injury Network serum creatinine criterion. The incidence of AKI increased from 24%, based solely on serum creatinine, to 52% by adding the urine output as a diagnostic criterion. Oliguric patients without a change in serum creatinine had an intensive care unit mortality rate (8.8%) significantly higher than patients without AKI (1.3%), and similar to oliguric patients with an increase in serum creatinine (10.4%). The diagnosis of AKI occurred earlier in oliguric than in non-oliguric patients. Oliguria of more than 12 h and oliguria of 3 or more episodes were associated with an increased mortality rate. Thus, urine output is a sensitive and early marker for AKI and is associated with adverse outcomes in intensive care unit patients.

Exploiting Technology to Popularize Goals-of-Care Conversations and Advance Care Planning.

BACKGROUND: Goals-of-care conversations are a central component of high-quality patient-centered care. However, clinicians may not engage in such conversations until patients are critically ill. OBJECTIVE: To assess the frequency and quality of goals-of-care conversation documentation among patients who died in an intensive care unit, and then to develop and implement mechanisms to improve the quantity and quality of such conversations. METHODS: A baseline retrospective medical records review of intensive care unit deaths that occurred within 1 year was conducted to assess the barriers to high-quality goals-of-care conversations. A nurse-led inter-professional task force was formed to address possible solutions. INTERVENTIONS: A new electronic health record tab, note type, and preformatted template known as a SmartPhrase for goals-of-care conversations were created. Nurses and physicians were educated and encouraged to perform and document goals-of-care conversations. RESULTS: Before implementation of the initiative, the electronic health record lacked a consistent place to document goals-of-care conversations, and such conversations were not occurring until patients required intensive care. Moreover, the content of documentation of the conversations was inconsistent. Three years after implementation of the initiative, the goals-of-care conversation documentation tab was used for 75% of hospital deaths, and 67% of goals-of-care conversation notes included use of the SmartPhrase template. CONCLUSIONS: Electronic health record platforms can be used to improve the frequency, consistency of documentation, and quality of goals-of-care conversations. A standardized process coupled with effective work tools can foster a culture of advance care planning.

Redefining renal dysfunction in trauma: implementation of the Acute Kidney Injury Network staging system.

BACKGROUND: Acute renal failure (ARF) in trauma patients is associated with high mortality rates. There is currently no consensus definition for renal failure, however, the American College of Surgeons' Committee on Trauma (ACSCOT) defines ARF as a serum creatinine > or =3.5, blood urea nitrogen > 100, or renal replacement therapy. We hypothesize that by using the Acute Kidney Injury Network (AKIN) staging system we would identify smaller changes in renal function that may impact outcome, and may serve as a marker for mortality and other organ dysfunction. METHODS: We retrospectively identified all trauma patients admitted to the surgical intensive care unit (SICU) for >48 hours during a 3-year period ending December 2007. Hourly urine output, serum creatinine, demographic data, trauma scores, admission vital signs, ICU and hospital length of stay, need for renal replacement therapy, organ failure, and death were collected and were stratified according to AKIN and ACSCOT renal dysfunction criteria. Trauma patients admitted to the SICU who did not develop renal dysfunction were used as controls. RESULTS: A total of 571 patients were studied. Of those, only 17 patients (3.0%) were classified as having ARF by the ACSCOT criteria, whereas 170 (29.8%) had kidney injury using the AKIN criteria (146, stage 1; 15, stage 2; 9, stage 3). Compared with patients admitted to the ICU for > or =48 hours with normal renal function, patients meeting AKIN criteria had longer hospital and ICU length of stay (p < 0.001). Patients meeting AKIN criteria also had an increased incidence of multiple organ failure and death (p < 0.03). CONCLUSIONS: Stratification using the AKIN criteria for acute kidney injury identifies an increased number of patients with renal dysfunction compared with the current ACSCOT criteria. Importantly, these patients have an increased risk of multiple organ failure and death. Inclusion into the AKIN criteria may be a marker for later morbidity and mortality.

Prevalence of asymptomatic urinary tract infections in morbidly obese dogs.

Background. Obesity has reached epidemic proportions in dogs and, as in humans, cost of care has increased due to associated comorbidities. In humans, asymptomatic urinary tract infections (UTI) may be more prevalent in the obese. Asymptomatic bacteriuria (AB) is the term used when UTI are asymptomatic. We hypothesized that morbidly obese dogs are similarly more likely to have asymptomatic bacteriuria than lean, overweight, and moderately obese dogs. Methods. A retrospective study was undertaken to explore a possible association between obesity and asymptomatic bacteriuria. Records from lean, overweight, and obese dogs receiving both a dual energy absorptiometry (DXA) scan and urine culture were included. Results. Six positive urine cultures were identified among 46 dogs fulfilling search criteria. All six positive cultures were found in dogs with body fat percentage of >45%. In dogs with body fat percentage of <45%, there were no positive urine cultures. Discussion. There was an increased prevalence of asymptomatic bacteriuria in the morbidly obese dogs in this study compared to those that were lean, overweight, or moderately obese. Whether antibiotic therapy is necessary in such cases is still being debated, but because asymptomatic bacteriuria may be associated with ascending infections, uroliths, or other complications, the data reported herein support the screening of obese patients for bacteriuria.

Pharmacognosy: phytomedicines and their mechanisms.

The more a critical look at the medicinal properties of plants is undertaken, the more it will be realized that nature does not make it easy to find all there is to know about them and the complexities of their interactions. An illustration of this can be found in one of the earlier scientific studies on phytomedicines, the Nobel laureate Albert Szent-Györgyi and his colleagues [170] found that flavanone extracts from the Capsicum spp contain an ascorbate-protective factor. It has now been repeatedly shown that the electron-donating properties of the phytochemical flavonoids, providing both nutritive and chemotherapeutic benefits, are the basis of their antioxidant action [171-175]. Studies by zoologists have demonstrated that animals, by selectively choosing specific plants, soils, and clays, maintain their health and treat themselves in times of ill health. The term zoopharmacognosy, now well researched, has been coined to describe the study of this recognized phenomenon. Long ago, Isaac Newton stated that for every action, there is an equal and opposite reaction. The same may be seen in plants and plant material. The same may be said of life in general. At the most basic concept, we are talking of electrons and their activities.

Cellular effects of common nutraceuticals and natural food substances.

Tabular information of proposed cellular effects regarding the use of certain nutraceuticals (including antioxidants, phytonutrients, and other biological therapies) and herbs, compiled from scientific sources and experimental research, is provided.

Cellular effects of various herbs and botanicals.

Tabular information of proposed cellular effects regarding the use of certain nutraceuticals (including antioxidants, phytonutrients, and other biologic therapies) and herbs, compiled from scientific sources and experimental research, is provided.

Is contrast exposure safe among the highest risk trauma patients?

BACKGROUND: Despite improvements in the diagnosis and management of acute kidney injury (AKI), posttraumatic renal dysfunction continues to be associated with increased morbidity and mortality. Intravenous (IV) contrast is known to induce AKI in high-risk groups including the elderly and critically ill. We sought to determine whether IV contrast exposure among high-risk trauma patients resulted in renal dysfunction as defined by the Acute Kidney Injury Network criteria. METHODS: We performed a 3-year retrospective analysis of all patients admitted to our Level I trauma center surgical intensive care unit for >48 hours. Patients with preexisting chronic renal dysfunction were excluded. We performed univariate and bivariate analyses to identify risk factors for AKI. Multivariable logistic regression analysis identified independent predictors for AKI. Subgroup analysis was undertaken among high-risk groups to include elderly patients (aged ≥65 years) with admission hypotension (systolic blood pressure <90 mm Hg) and an Injury Severity Score (ISS) ≥25. RESULTS: Of the 6,317 patients, 571 (9.0%) patients met the inclusion criteria; 170 (29.8%) patients developed AKI. Age ≥65 years (odds ratio [OR] 2.26, 95% confidence interval [CI] = 1.06-4.80, p <0.034) and ISS ≥25 (OR 1.86, 95% CI = 1.12-3.07, p <0.015) were determined to be independent predictors of AKI. IV contrast was not identified to be a predictor of AKI. Upon subgroup analysis, IV contrast exposure was not a predictor of AKI among the elderly, hypotensive, or severely injured patients (ISS ≥25). CONCLUSION: A complete trauma workup including studies requiring IV contrast exposure should be considered safe even among high-risk trauma patients.

Azodyl, a synbiotic, fails to alter azotemia in cats with chronic kidney disease when sprinkled onto food.

The effect of probiotic therapy in chronic kidney disease (CKD) in cats is poorly defined, but gaining in popularity. However, cat owners often prefer to administer probiotics by combining them with food, rather than administering capsules intact, as is prescribed by the manufacturer. The efficacy of such non-recommended administration is unknown. In this double-blinded, controlled clinical trial, 10 cats with naturally-occurring CKD were randomized to receive either a probiotic-prebiotic combination (synbiotic) or psyllium husk (prebiotic only) for 2 months. Medications were sprinkled and mixed into food or given as a slurry. Blood urea nitrogen (BUN) and creatinine were measured twice prior to administration of medication, and then monthly for 2 months during the medication administration. Owners and clinicians were masked as to treatment. The maximal percentage change in BUN and creatinine was calculated for each cat. No differences in percentage change were detected between groups (P=0.8 for both BUN and creatinine). The synbiotic supplement used in this study, when applied to food or administered as a slurry fails to reduce azotemia in cats with CKD. Therefore, owners should not administer this synbiotic in this manner.

Hacia un consenso en termilogia y semantica / Toward a consensus in terminology and semantics

Este proyecto pretende describir una terminologia homeopatica comun que permita la comunicacion eficaz con el gremio medico y en ciencias naturales. Se envio un cuestionario por correo electronico a un grupo internacional de expertos en homeopatia. Como resultado de un proceso iterativo propusimos... (AU)

Hacia un consenso en termilogia y semantica / Toward a consensus in terminology and semantics

Este proyecto pretende describir una terminologia homeopatica comun que permita la comunicacion eficaz con el gremio medico y en ciencias naturales. Se envio un cuestionario por correo electronico a un grupo internacional de expertos en homeopatia. Como resultado de un proceso iterativo propusimos...