Cardiac surgery-associated acute kidney injury (CSA-AKI) in adults and pediatrics; prevention is the optimal management.

Background Cardiac surgery-associated acute kidney injury (CSA-AKI) is an important and serious complication that affects morbidity and mortality. We studied both pediatric and adults using the definition of the Acute Kidney Injury Network (AKIN). Methods This is an observational retrospective cohort study done at King Abdulaziz University Hospital in Jeddah, Saudi Arabia approved by ethical committee. The exclusion criteria were baseline serum creatinine (SCr) ≥ 4 mg/dL or preexisting renal failure requiring dialysis, reoperation, death within 24 hours postoperatively, and operative mortality or missing data. 941 patients were included in the analysis using the statistical software SPSS, version 15.0. Results 28.68% in the adult group and 20.07% in the pediatric group developed CSA-AKI. Adult risk factors included age group of 60-69 years, cardiopulmonary bypass (CPB), number of grafts and hypertension. In the pediatric group, CPB, aortic cross-clamping (ACX) and the lower preoperative SCr are the main risk factors Conclusion Conventional conservative management and preoperative Identification of predictor risk factors are essential for prevention of CSA-AKI which constitute the main strategy for optimal management.

Elevated Levels of Urinary Biomarkers TIMP-2 and IGFBP-7 Predict Acute Kidney Injury in Neonates after Congenital Heart Surgery

Objectives: This article investigated the utility of urine biomarkers tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein-7 (IGFBP-7) in identifying acute kidney injury (AKI) in neonates after congenital heart surgery (CHS). TIMP-2 and IGFBP-7 are cell cycle arrest proteins detected in urine during periods of kidney stress/injury. Methods: We conducted a single-center, prospective study between September 2017 and May 2019 with neonates undergoing CHS requiring cardiopulmonary bypass (CPB). Urine samples were analyzed using NephroCheck prior to surgery and 6, 12, 24, and 96 hours post-CPB. All patients were evaluated using the Acute Kidney Injury Network (AKIN) criteria. Wilcoxon rank sum tests were used to compare the medians of the [TIMP-2*IGFBP-7] values in the AKIN negative and positive groups at each time point. Receiver operating characteristic curves were used to measure how well the [TIMP-2*IGFBP-7] values predict AKIN status. Results: Thirty-six patients were included. No patients met the AKIN criteria for AKI preoperatively. Postoperatively, 19 patients (53%) met the AKIN criteria for AKI diagnosis: 13 (36%) stage 1, 5 (14%) stage 2, and 1 (3%) stage 3. None required renal replacement therapy. At the 24-hour time points, patients who met the AKIN criteria for AKI had a statistically significantly higher [TIMP-2*IGFBP7] values than the patients without AKI (1.1 vs. 0.27 [ng/mL]2/1,000) at 24 hours (adj-p = 0.0019). Conclusion: AKI is a serious complication associated with adverse outcomes in patients undergoing cardiac surgery. [TIMP-2*IGFBP-7] urinary level 24 hours after CPB is a good predictor of AKI in this population.

Relation between Prolonged Cardiopulmonary Bypass Time in Cardiac Surgery in Adult Patients and Post-Operative Acute Kidney Injury

Background Cardiac-surgery associated acute kidney injury (CSA-AKI) remains an important and frequent complication in patients undergoing cardiac surgery and is associated with a poor short- and long-term prognosis. The incidence for CSA-AKI according to Acute Kidney Injury Network criteria (AKIN) varies between 3% and 50%. CSA-AKI requiring temporary renal replacement therapy (RRT) occurs in 5% to 20% of these patients and is associated with a high mortality rate. Objective To detect the relation between prolonged cardiopulmonary bypass time in cardiac surgery and the incidence of post-operative acute kidney injury. Patients and Methods This is an observational retrospective study conducted on (80) adult patients who underwent elective cardiac surgery at Aswan Heart Centre (Magdi Yacoub Foundation) after the approval of the Ethical Medical Committee of Aswan Heart Centre. Results Results of the statistical analysis of the present study showed that mean CPB duration was prolonged in the AKI group of patients (155 min) than the non-AKI group of patients (129 min). Conclusion Prolonged cardiopulmonary bypass duration may be an independent risk factor for acute kidney injury post cardiac surgery in adult patients.

Preoperative Serum GDF-15, Endothelin-1 Levels, and Intraoperative Factors as Short-Term Operative Risks for Patients Undergoing Cardiovascular Surgery

Objectives: The Society of Thoracic Surgeons (STS) risk score is widely used for the risk assessment of cardiac surgery. Serum biomarkers such as growth differentiation factor-15 (GDF-15) and endothelin-1 (ET-1) are also used to evaluate risk. We investigated the relationships between preoperative serum GDF-15, ET-1 levels, and intraoperative factors and short-term operative risks including acute kidney injury (AKI) for patients undergoing cardiovascular surgery. Methods: In total, 145 patients were included in this study (92 males and 53 females, age 68.4 ± 13.2 years). The preoperative STS score was determined, and the serum GDF-15 and ET-1 levels were measured by ELISA. These were related to postoperative risks, including AKI, defined according to the Acute Kidney Injury Network (AKIN) classification criteria. Results: AKI developed in 23% of patients. The GDF-15 and ET-1 levels correlated with the STS score. The STS score and GDF-15 and ET-1 levels all correlated with preoperative eGFR, Alb, Hb, and BNP levels; perioperative data (urine output); ICU stay period; and postoperative admission days. Patients with AKI had longer circulatory pulmonary bypass (CPB) time, and male patients with AKI had higher ET-1 levels than those without AKI. In multivariable logistic regression analysis, the preoperative ET-1 level and CPB time were the independent determinants of AKI, even adjusted by age, sex, and BMI. The preoperative GDF-15 level, CPB time, and RCC transfusion were independent determinants of 30-day mortality plus morbidity. Conclusion: Preoperative GDF-15 and ET-1 levels as well as intraoperative factors such as CPB time may be helpful to identify short-term operative risks for patients undergoing cardiovascular surgery.

Comparison of acute kidney injury in patients prescribed vancomycin in combination with piperacillin–tazobactam or cefepime for diabetic foot infections

Concomitant therapy with vancomycin (VAN) and piperacillin–tazobactam (PTZ) has been associated with acute kidney injury (AKI). Diabetic patients may be more susceptible to AKI due to various factors. In an observational, retrospective, cohort study of adults treated for diabetic foot infections (DFIs), rates of AKI were compared between groups receiving VAN+PTZ versus VAN+cefepime (CFP). Among 356 patients screened for inclusion, 210 were analyzed. Forty-nine of 140 patients (35%) in the VAN+PTZ group and 5 of 70 patients (7%) in the VAN+CFP group developed AKI according to the Acute Kidney Injury Network criteria (OR 7.00 (95% CI 2.64 to 18.53), p<0.001). After adjusting for baseline differences, VAN+PTZ was an independent predictor of AKI (OR 6.21 (95% CI 2.30 to 16.72), p<0.001). Time to AKI was 102.1 hours (IQR 47–152.7) in the VAN+PTZ group versus 78.3 hours (IQR 39.8–100.6) in the VAN+CFP group (p>0.999). Median length of stay was significantly higher in the VAN+PTZ group at 11.9 days (IQR 7.9–17.8) versus 7.8 days (IQR 4.9–12.1) in the VAN+CFP group (p<0.001). VAN+PTZ was also associated with higher total hospital charges at US$99,742.83 (IQR US$69,342.50–US$165,549.59) compared with US$74,260.25 (IQR US$48,446.88–US$107,396.99) in the VAN+CFP arm (p<0.001). In conclusion, VAN+CFP should be the preferred empiric regimen in patients with severe DFI.

Post operative acute kidney injury in abdominal Surgeries – A retrospective analysis of single center in western India

ABSTRACTAIMThe aim of our study was to evaluate the incidence and causative factors for acute kidney injury in abdominal surgeries.Material and MethodsAll the abdominal surgeries performed between April 2018 to December 2020, in our institution have been analyzed for acute kidney injury. Acute kidney injury defined according to acute kidney injury network classification. Categorical variables were evaluated by chi-square t-test or fisher’s t-test wherever appropriate and continuous variables by Mann Whitney U test for nonparametric data and student t-test for parametric test after skewness and kurtosis analysis. Statistical analysis was done using SPSS version 23. P< 0.05 was considered statistically significant.ResultsWe performed 402 gastrointestinal and hepatobiliary surgery from April 2018 to December 2020. After exclusion 372 patients were included in the study population. 20 patients (5.37%) were defined as having acute kidney injury according to acute kidney injury network classifications. On univariate analysis acute kidney injury was associated with open surgery (p= 0.003), Intraoperative hypotension (p<0.001), Colorectal surgeries (p<0.0001), Emergency surgery (p=0.028), CDC grade of surgery (p<0.001), increased used to blood products (p=0.001), higher ASA grade (p<0.0001), increased operative time(p<0.0001). On multivariate logistic regression analysis higher ASA grade (p<0.0001) and increased operative time (0.049) independently predicted acute kidney injury. Acute kidney injury was also significantly associated with 90 days mortality. (p= <0.0001).ConclusionPost-operative acute kidney injury was associated with significant mortality in abdominal surgery. Higher ASA grades and increased operative time predicted acute kidney injury.

INCIDENCE AND DIFFERENT RISK FACTORS OF CARDIAC SURGERY ASSOCIATED ACUTE KIDNEY INJURY

Objective: To identify the incidence of cardiac surgery associated acute kidney injury and its association with different risk factors. Study Design: Descriptive cross sectional study. Place and Duration of Study: Adult cardiac surgery department, AFIC/NIHD, from Jan to Jun 2019. Methodology: Three hundred forty patients undergoing cardiac surgery were evaluated for Cardiac Surgery associated acute kidney injury according to acute kidney injury network criteria over a period of 6 months. The chi-square test was used find the relationship of different factor for cardiac surgery associated acute kidney injury. Results: Total of 430 patients were included. 345 (80.2%) were male and mean age of 55 ± 11.6 years and mean pre operative creatinine clearance was 80.7 ml/hr. Coronary artery bypass grafting was the most common procedure performed. Intra aortic balloon pump, Cardio-pulmonary bypass time, AXc time, ionotropes, transfusion of RCC and FFPs were found to be highly significant risk factors of acute kidney injury. Conclusion: Cardiac surgery associated acute kidney injury is very common complication; some of the modifiablefactors should be identified and controlled to reduce acute kidney injury.

Etiology of acute kidney injury in intensive care unit settings

Introduction: Acute kidney injury (AKI) is defined as a rapid loss of kidney function occurring over few hours or days. In intensive care unit settings, acute kidney injury (AKI) is a very prevalent condition as most of the patients who are admitted in intensive care units are critically ill. The incidence of acute kidney injury is increasing throughout the world mainly because of aging population and comorbidities which are associated with aging. In intensive care unit settings, the incidence of AKI may reach up to 67%. Though AKI effects depend on clinical situation yet associated with high morbidity and mortality. Objective: To determine the frequency of etiology of acute kidney injury in medical intensive care unit of KRL Hospital. Setting: Medical ICU, KRL Hospital, Islamabad. Duration: six months from 17th May 2017 to 17th November 2017. Study design: Descriptive case series. Material and method: In this study 118 patients were observed. After screening and application of exclusion criteria, a total of 118 patients who were fulfilling the inclusion criteria were selected as the study sample and were included in the final analysis regarding prevalence of risk factors associated with AKI. AKI was further classified using acute kidney injury network (AKIN) classification system. Patient age, gender, serum creatinine, etiology and outcome in form of recovery or mortality was recorded on specific proforma. Results: Overall incidence of AKI in ICU settings in this study was 37.8%(n=118) .Out of 118 patients who had AKI, 59.3%(n=70) were male , whereas 40.7% (n=48) were females. Most common risk factor associated with development of AKI was sepsis secondary to infectious illnesses and 39% (n=46) of the patients who developed AKI were suffering from infectious illnesses. Gastrointestinal, drugs and cardiac causes constitutes the 32.2% (n=38), 18.6% (n=22) and 10.2% (n=12) respectively of the AKI in ICU settings. Conclusion: Our study concludes that the frequency of etiology including infectious causes was 39%, cardiac pathology 10%, GI causes 32%, drugs was 19%.

Dickkopf-3 in the prediction of contrast media induced acute kidney injury

Background Dickkopf-3 (DKK3) has recently been discovered as a urinary biomarker for the prediction of acute kidney injury (AKI) after cardiac surgery. This finding needs to be confirmed for AKI in other clinical settings. The present study investigates whether DKK3 can predict contrast-induced AKI (CI-AKI). Methods We performed a prospective study in 490 patients undergoing coronary angiography. Primary endpoint was an increase in serum creatinine concentration ≥ 0.3 mg/dl within 72 h after the procedure. DKK3 was assessed < 24 h before coronary angiography. Predictive accuracy was assessed by receiver operating characteristic (ROC) curves. Results CI-AKI was observed in 30 (6.1%) patients, of whom 27 corresponded to stage I and 3 to stage II according to the Acute Kidney Injury Network (AKIN) criteria. Subjects who developed CI-AKI had a 3.8-fold higher urinary DKK3/creatinine ratio than those without CI-AKI (7.5 pg/mg [interquartile range [IQR] 1.2–1392.0] vs. 2.0 pg/mg [IQR 0.9–174.0]; p = 0.047). ROC analysis revealed an area under the curve (AUC) of 0.61. Among subjects without clinically overt chronic kidney disease (estimated glomerular filtration rate [eGFR] > 60 ml/min, urinary albumin creatinine ratio < 30 mg/g), the DKK3/creatinine ratio was 5.4-fold higher in those with subsequent CI-AKI (7.5 pg/mg [IQR 0.9–590.1] vs. 1.38 pg/mg [IQR 0.8–51.0]; p = 0.007; AUC 0.62). Coronary angiography was associated with a 43 times increase in the urinary DKK3/creatinine ratio. Conclusions Urinary DKK3 is an independent predictor of CI-AKI even in the absence of overt chronic kidney disease (CKD). The study thereby expands the findings on DKK3 in the prediction of postoperative loss of kidney function to other entities of AKI. Graphic abstract