Performance of the renal resistive index and usual clinical indicators in predicting persistent AKI.

BACKGROUND: Early recognition of persistent acute kidney injury (AKI) could optimize management and prevent deterioration of kidney function. The Doppler-based renal resistive index (RI) has shown promising results for predicting persistent AKI in preliminary studies. Here, we aimed to evaluate the performance of renal RI, clinical indicators, and their combinations to predict short-term kidney prognosis in septic shock patients. METHOD: We performed a retrospective study based on data from a prospective study in a single-center general ICU between November 2017 and October 2018. Patients with septic shock were included. Clinical indicators were evaluated immediately at inclusion, and renal RI was measured within the first 12 h of ICU admission after hemodynamic stabilization. Persistent AKI was defined as AKI without recovery within 72 h. A multivariable logistic regression was used to select significant variables associated with persistent AKI. The discriminative power was evaluated by a receiver operating characteristic curve analysis. RESULT: Overall, 102 patients were included, 39 of whom had persistent AKI. Renal RI was higher in the persistent AKI patients than in those without persistent AKI: 0.70 ± 0.05 vs. 0.66 ± 0.05; p = 0.001. The performance of RI to predict persistent AKI was poor, with an area under the receiver operating characteristic curve (AUROC) of 0.699 [95% confidence interval (CI) 0.600-0.786]. A clinical prediction model combining serum creatinine at inclusion and the nonrenal SOFA score showed a better prediction ability for nonrecovery, with an AUROC of 0.877 (95% CI 0.797-0.933, p = 0.0012). The addition of renal RI to this model did not improve the predictive performance. CONCLUSION: The Doppler-based renal resistive index performed poorly in predicting persistent AKI and did not improve the clinical prediction provided by a combination of serum creatinine at inclusion and the nonrenal SOFA score in patients with septic shock.

VV-ECMO combined with prone position ventilation in the treatment of Pneumocystis jirovecii pneumonia: A case report.

INTRODUCTION: Pneumocystis jirovecii pneumonia (PJP) occurs in immunocompromised hosts. It is classified as PJP with human immunodeficiency virus (HIV) infection (HIV-PJP) and PJP without HIV infection (non-HIV PJP). Compared with HIV-PJP, non-HIV PJP is more likely to develop rapidly into respiratory failure, with difficult diagnosis and high mortality. PATIENT CONCERNS: A 46-year-old male with membranous nephropathy was treated with oral corticosteroids and tacrolimus. He was admitted to our hospital for fever and dyspnea which developed 4 days ago. Laboratory data revealed that leukocytes were 10.99 × 109/L, neutrophils 87.7%, lymphocytes 9.6%, C-reactive protein 252.92 mg/L, New coronavirus nucleic acid detection negative. CT scan of chest revealed ground-glass opacity in both lungs. He was admitted to the respiratory department of our hospital, and then transferred to ICU because of his critical condition. DIAGNOSIS: High throughput gene detection of pathogenic microorganisms in alveolar lavage fluid showed that the detection sequence of Pneumocystis yersiniae increased significantly. The serum HIV-antibody was negative. Therefore, the patient was diagnosed as non-HIV PJP. INTERVENTIONS: After admission, the patient was assisted by noninvasive ventilator and treated with compound trimethoprim-sulfamethoxazole (SMX-TMP) and caspofungin. The patient's condition continued to deteriorate, and then underwent endotracheal intubation and veno-venous extracorporeal membrane oxygenation (VV-ECMO) combined with prone position ventilation until the lung lesion improved. OUTCOMES: VV-ECMO was stopped on day 12, tracheal intubation was removed after 2 days. The patient was transferred to the respiratory department on day 15, discharged after 12 days without complications. Two months later, the follow-up showed that the patient was in good condition. CONCLUSION: VV-ECMO combined with prone position ventilation could be a useful choice for respiratory assistance in non-HIV PJP patients.

A case report of early application of veno-arterial extracorporeal membrane oxygenation in amniotic fluid embolism.

RATIONALE: Amniotic fluid embolism (AFE) is a rare obstetrical complication and is a leading cause of maternal death in developed countries. Despite the development of supportive therapeutic measures, the mortality rate remains high. PATIENT CONCERNS: A 38-year-old nulliparous pregnant woman, who underwent in vitro fertilization-embryo transfer, was admitted for labor at 37 weeks' gestation. Approximately 30 minutes after delivery of the placenta, the puerpera developed postpartum hemorrhage with uterine atony. Soon after, the patient experienced hypotension, repeated cardiac arrest, refectory hypoxia, and disseminated intravascular coagulopathy. DIAGNOSIS: AFE is diagnosed clinically. The pregnant woman in this case fulfilled the diagnostic criteria for AFE: acute hypotension, cardiac arrest, acute hypoxia, and coagulation disorders within approximately 30 minutes after delivery of the placenta. INTERVENTIONS: The patient was intubated, connected to a ventilator, and was administered a high dose of vasoactive drugs to maintain blood pressure and underwent an emergency hysterectomy. Considering the risk for recurrent cardiac arrest and severe refractory hypoxia, venoarterial extracorporeal membrane oxygenation was initiated and discontinued as soon as cardiac function was restored based on serial bedside ultrasound assessment. OUTCOMES: The patient stabilized on day 7 in the intensive care unit and was transferred to the obstetrics ward and, 1 week later, was discharged with no complications. Two months later, follow-up revealed that the patient was in good condition. LESSON: Serial bedside ultrasound was crucial for assessing cardiac function and optimal weaning. Timely application of venoarterial extracorporeal membrane oxygenation and weaning was significant to avoid the occurrence of complications and improve long-term outcomes.

[Value of the combination of renal resistive index and central venous pressure to predict septic shock induced acute kidney injury].

OBJECTIVE: To explore a better indicator that can predict septic shock induced acute kidney injury (AKI) by combining renal resistive index (RRI) and central venous pressure (CVP). METHODS: A prospective observational study was conducted. Patients with septic shock admitted to department of critical care medicine of Hebei General Hospital from November 2017 to October 2018 were enrolled. Baseline characteristics such as age, gender, underlying diseases, infection sites, acute physiology and chronic health evaluation II (APACHE II) in the first 24-hour, sequential organ failure assessment (SOFA) were recorded; Doppler-based RRI was obtained on the first day when hemodynamics was relatively stable, meanwhile the dose of norepinephrine and hemodynamic parameters were assessed. Urine output per hour, the total duration of mechanical ventilation, the length of intensive care unit (ICU) stay and 28-day mortality were also collected. Observational end point was death at discharge or the 28th day after ICU admission, whenever which came first. The patients were divided into AKI and non-AKI groups according to the 2012 Kidney Disease: Improving Global Organization (KDIGO) clinical practice guideline. The baseline and prognostic indicators, variables potentially associated with AKI were compared between the two groups. The variables independently associated with septic shock induced AKI were identified using multivariable Logistic regression. The predictive value of RRI and RRI combining CVP for AKI were analyzed by the receiver operating characteristic (ROC) curve. RESULTS: A total of 107 patients were enrolled, with 59 patients in AKI group and 48 patients in non-AKI group. There was significant difference in RRI, CVP, percentage of norepinephrine dosage ≥ 0.5 µg×kg-1×min-1, procalcitonin (PCT), lactate (Lac), and serum creatinine (SCr) between the two groups. Logistic regression analysis showed that high CVP, RRI, Lac and PCT were independent risk factors for septic shock induced AKI [CVP: odds ratio (OR) = 1.20, 95% confidence interval (95%CI) was 1.03-1.40, P = 0.022; RRI: OR = 3.02, 95%CI was 2.64-3.48, P = 0.006; Lac: OR = 2.43, 95%CI was 1.32-4.50, P = 0.005; PCT: OR = 1.20, 95%CI was 1.05-1.38, P = 0.009]. ROC curve analysis showed that the area under ROC curve (AUC) values of CVP ≥ 9.5 mmHg (1 mmHg = 0.133 kPa) and RRI ≥ 0.695 for predicting septic shock induced AKI were 0.656 and 0.662 respectively. The AUC value of the combination of RRI and CVP was greater compared with either RRI or CVP alone in predicting septic shock induced AKI, which AUC value was 0.712, 95%CI was 0.615-0.809, the sensitivity was 59% and the specificity was 75%. CONCLUSIONS: High CVP and RRI were independent risk factors for septic shock induced AKI. The combination of RRI and CVP performs poorly in predicting septic shock induced AKI. Further studies are needed to describe factors influencing Doppler-based assessment of RRI, which may help clinicians to prevent AKI early.