Predictive value of urine interleukin-18 in the evolution and outcome of acute kidney injury in critically ill adult patients.

BACKGROUND: Interleukin-18 (IL-18) is a pro-inflammatory protein, which mediates ischaemic tubular injury, and has been suggested to be a sensitive and specific biomarker for acute kidney injury (AKI). The predictive value of IL-18 in the diagnosis, evolution, and outcome of AKI in critically ill patients is still unclear. METHODS: We measured urine IL-18 from critically ill patients at intensive care unit (ICU) admission and 24 h. We evaluated the association of IL-18 with developing new AKI, renal replacement therapy (RRT), and 90-day mortality. We calculated areas under receiver operating characteristics curves (AUCs), best cut-off values, and positive likelihood ratios (LR+) for IL-18 concerning these endpoints. Additionally, we compared the predictive value of IL-18 at ICU admission to that of urine neutrophil gelatinase-associated lipocalin (NGAL). RESULTS: In this study population of 1439 patients the highest urine IL-18 during the first 24 h in the ICU associated with the development of AKI with an AUC [95% confidence interval (CI)] of 0.586 (0.546-0.627) and with the development of Stage 3 AKI with an AUC (95% CI) of 0.667 (0.591-0.774). IL-18 predicted the initiation of RRT with an AUC (95% CI) of 0.655 (0.572-0.739), and 90-day mortality with an AUC (95% CI) of 0.536 (0.497-0.574). CONCLUSIONS: IL-18 had poor-to-moderate ability to predict AKI, RRT, or 90-day mortality in this large cohort of critically ill patients. Thus, it should be used with caution for diagnostic or predictive purposes in the critically ill.

Comorbidities and survival of patients with type 1 diabetes on renal replacement therapy.

AIMS/HYPOTHESIS: Comorbidities are frequent among type 1 diabetes patients on renal replacement therapy, yet the effect of comorbidities on survival is unknown. Our aim was to estimate this effect. METHODS: An incident cohort of all patients with type 1 diabetes entering chronic renal replacement therapy (n = 656) in Finland between 2000 and 2008 was followed until death or the end of follow-up on 31 December 2008. All data were obtained from the Finnish Registry for Kidney Diseases, which collects information on comorbidities at the start of renal replacement therapy. The main outcome measure was relative risk of death according to comorbidities. RESULTS: At start of renal replacement therapy, 22% of the patients with type 1 diabetes had coronary artery disease, 19% peripheral vascular disease, 11% cerebrovascular disease, 33% left ventricular hypertrophy and 7% heart failure. All these comorbidities were significant predictors of death in univariate analyses (RR 1.6-4.9). The 5 year survival probability of patients without comorbidities was 74%, while it was 56% and 37%, respectively, for those with one or more than one comorbidity. When the comorbidities were studied in a multivariate model, adjusting for age and sex, peripheral vascular disease (RR 1.9), left ventricular hypertrophy (RR 1.7) and heart failure (RR 2.5) remained independent risk factors for death. Calculations indicated that one-third of deaths in the study population could be attributed to comorbidities. CONCLUSIONS/INTERPRETATION: Among patients with type 1 diabetes entering renal replacement therapy, comorbidities are common and strong predictors of death. Therefore, it is essential to identify and adequately treat comorbidities.

ADQI 7: the clinical management of the Cardio-Renal syndromes: work group statements from the 7th ADQI consensus conference.

Many patients with heart failure have underlying renal dysfunction, and similarly, patients with kidney failure are prone to cardiac failure. This has led to the concept of cardio-renal syndromes, which can be an acute or chronic cardio-renal syndrome, when cardiac failure causes deterioration in renal function, or acute and/or chronic Reno-Cardiac syndrome, when renal dysfunction leads to cardiac failure. Patients who develop these syndromes have increased risk of hospital admission and mortality. Although there are clinical guidelines for managing both heart failure and chronic kidney disease, there are no agreed guidelines for managing patients with cardio-renal and/or Reno-Cardiac syndromes, as these patients have typically been excluded from clinical trials. We have therefore reviewed the currently available published literature to outline a consensus of current best clinical practice for these patients.