Kidney transplantation from donors with rhabdomyolysis and acute renal failure

Rhabdomyolysis in deceased donors usually causes acute renal failure (ARF), which may be considered a contraindication for kidney transplantation. From January 2012 to December 2016, 30 kidneys from 15 deceased donors with severe rhabdomyolysis and ARF were accepted for transplantation at our center. The peak serum creatinine (SCr) kinase, myoglobin, and SCr of the these donors were 15 569±8597 U/L, 37 092±42 100 μg/L, and 422±167 μmol/L, respectively. Two donors received continuous renal replacement therapy due to anuria. Six kidneys exhibited a discolored appearance (from brown to glossy black) due to myoglobin casts. The kidney transplant results from the donors with rhabdomyolysis donors were compared with those of 90 renal grafts from standard criteria donors (SCD). The estimated glomerular filtration rate at 2 years was similar between kidney transplants from donors with rhabdomyolysis and SCD (70.3±14.6 mL/min/1.73 m² vs 72.3±15.1 mL/min/1.73 m²). We conclude that excellent graft function can be achieved from kidneys donors with ARF caused by rhabdomyolysis.     

Clinical practice guideline on prevention of rhabdomyolysis induced acute kidney injury: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

The Scandinavian Society of Anaesthesiology and Intensive Care Medicine Clinical Practice Committee endorses the recent DASAIM/DSIT guideline for prevention of rhabdomyolysis-induced acute kidney injury. However, we emphasize the low quality of evidence with only weak recommendations for all interventions, highlighting that further research is very likely to have an important impact on the confidence in the estimate of effect and is likely to change the estimates.     

The incidence of acute kidney injury in patients with traumatic brain injury

There is limited information on the incidence of acute kidney injury (AKI) in patients with traumatic brain injury (TBI) although AKI may contribute to morbidity and mortality. We investigated the incidence of AKI in patients with moderate and severe TBI and the association of AKI with risk factors and outcomes in these patients.

We studied all TBI patients over 16 years of age admitted to the two designated trauma hospitals in the state of Victoria, Australia from 1 January to 31 December 2008. Patients were included if they had head trauma and presented with a Glasgow coma scale (GCS) <13. Prospectively collected data from the hospital trauma registries, ICUs, and pathology databases were analyzed retrospectively. Risk injury failure loss end (RIFLE) criteria were used to categorize renal function.

The incidence of AKI was 9.2% (19/207). Patients who developed AKI were older, had higher severity of illness scores, and a lower GCS. Overall 42.1% of these patients died in hospital compared with 18.1% in patients without AKI. In univariable linear regression analysis, age, severity of illness, and admitting hospital were associated with AKI. After multivariable logistic regression, the occurrence of AKI was associated with age (p < 0.001) and higher APACHE III scores (p = 0.016).

AKI is relatively common even in patients with TBI. Its association with age and APACHE III scores helps identify patients at higher risk of AKI.     

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ICU中急性肾损伤(AKI)病人营养支持的主要目的在于确保适当的热量,预防组织蛋白和瘦肉组织不必要的浪费,改善组织修复,支持免疫系统,降低病死率。应首选肠内途径,但即便如此,仍然经常需要辅以肠外营养,以满足目标营养的需求。需要特别关注肾脏替代治疗(RRT)对三大营养素和微量营养素的影响以及可能导致并发症的防范。事实上,由于肾脏体液平衡功能的急性丢失,常需要RRT治疗,AKI病人尤其易出现血糖异常、高甘油三酯血症以及体液、酸碱、电解质的失衡。     

Deceased-donor acute kidney injury is not associated with kidney allograft failure

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Prognosis for children with acute kidney injury in the intensive care unit

To define factors of prognostic importance for critically ill infants and children with acute kidney injury (AKI), we have studied 110 children, ages from 1 month to 180 months, admitted between March 1, 2002 and September 30, 2004 to the intensive care unit of Joana de Gusmão Children’s Hospital. These patients represent 8% of all intensive care unit admissions during the entire study period. The diagnosis at admission was primary renal parenchyma disease (eight patients, 7.2%) and secondary renal disease (102 patients, 92.8%). Thirty-seven patients (33.6%) died, all of whom had secondary renal insufficiency; six patients (5.4%) died as a result of septic shock, and 31 (28.2%) patients died from multiple organ failure (MOF). The variables were analyzed using Fisher’s exact test for qualitative variables and Student’s t-test for quantitative variables. Stratified analysis was performed to assess the relative importance of variables using the Mantel–Haenszel technique. Among the variables analyzed, the following were found to be significantly related to mortality: anuria, oliguria, arterial hypotension, need for pressor drugs, need for mechanical ventilation, need for dialysis, the association with MOF, and high values of lactic acid.     

Monocyte-to-lymphocyte ratio: a potential novel predictor for acute kidney injury in the intensive care unit

Monocyte-to-lymphocyte ratio (MLR) and neutrophil-to-lymphocyte ratio (NLR) are considered as surrogate inflammatory indexes. Previous studies indicated that NLR was associated with the development of septic acute kidney injury (AKI). The objective of the present study was to explore the value of MLR and NLR in the occurrence of AKI in intensive care unit (ICU) patients. The clinical details of adult patients (n = 1500) who were admitted to the ICU from January 2016 to December 2019 were retrospectively examined. AKI was diagnosed according to the Kidney Disease: Improving Global Outcomes criteria. The development of AKI was the main outcome, and the secondary outcome was in-hospital mortality. Overall, 615 (41%) patients were diagnosed with AKI. Both MLR and NLR were positively correlated with AKI incidence (p < 0.001). Multivariate logistic regression analysis suggested that the risk value of MLR for the occurrence of AKI was nearly three-fold higher than NLR (OR = 3.904, 95% CI: 1.623‒9.391 vs. OR = 1.161, 95% CI: 1.135‒1.187, p < 0.001). The areas under the receiver operating characteristic curve (AUC) for MLR and NLR in the prediction of AKI incidence were 0.899 (95% CI: 0.881‒0.917) and 0.780 (95% CI: 0.755‒0.804) (all p < 0.001), with cutoff values of 0.693 and 12.4. However, the AUC of MLR and NLR in the prediction of in-hospital mortality was 0.583 (95% CI: 0.546‒0.620, p < 0.001) and 0.564 (95% CI: 0.528‒0.601, p = 0.001). MLR, an inexpensive and widely available parameter, is a reliable biomarker in predicting the occurrence of AKI in ICU patients.     

Complement activation is a crucial driver of acute kidney injury in rhabdomyolysis

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Machine learning for the prediction of acute kidney injury in critical care patients with acute cerebrovascular disease

PurposeAcute kidney injury (AKI) is a common complication and associated with a poor clinical outcome. In this study, we developed and validated a model for predicting the risk of AKI through machine learning methods in critical care patients with acute cerebrovascular disease.MethodsThis study was a retrospective study based on two different cohorts. Five machine learning methods were used to develop AKI risk prediction models. We used six popular metrics (AUROC, F2-Score, accuracy, sensitivity, specificity and precision) to evaluate the performance of these models.ResultsWe identified 2935 patients in the MIMIC-III database and 499 patients in our local database to develop and validate the AKI risk prediction model. The incidence of AKI in these two different cohorts was 18.3% and 61.7%, respectively. Analysis showed that several laboratory parameters (serum creatinine, hemoglobin, white blood cell count, bicarbonate, blood urea nitrogen, sodium, albumin, and platelet count), age, and length of hospital stay, were the top ten important factors associated with AKI. The analysis demonstrated that the XGBoost had higher AUROC (0.880, 95%CI: 0.831–0.929), indicating that the XGBoost model was better at predicting AKI risk in patients with acute cerebrovascular disease than other models.ConclusionsThis study developed machine learning methods to identify critically ill patients with acute cerebrovascular disease who are at a high risk of developing AKI. This result suggested that machine learning techniques had the potential to improve the prediction of AKI risk models in critical care.     

Serum creatine kinase levels are not associated with an increased need for continuous renal replacement therapy in patients with acute kidney injury following rhabdomyolysis

Severe rhabdomyolysis can lead to acute kidney injury (AKI). Previous studies have reported a benefit from continuous renal replacement therapy (CRRT) for rhabdomyolysis-associated AKI. Here, we investigated the potential for serum creatine kinase (CK) levels to be used as a marker for CRRT termination in patients with AKI following rhabdomyolysis. We compared different CK levels in patients after CRRT termination and observed their clinical outcomes. We retrospectively collected 86 cases with confirmed rhabdomyolysis-associated AKI, who were receiving CRRT in Tongji Hospital. Patients’ renal functions were assessed within 24 h of intermission, patients with urine output ≥ 1,000 mL and serum creatinine ≤ 265 umol/L were considered for CRRT termination. After termination, 33 patients with a CK > 5,000 U/L were included in an experimental group, and 53 patients with a CK < 5,000 U/L were included in a control group. Clinical outcomes were compared between the two groups. Higher CK levels, as well as worse renal functions, predicted the necessity of CRRT. After CRRT termination, the in-hospital mortality (p = 0.389) and Multiple Organ Dysfunction Syndrome (MODS) incidence (p = 0.064) were similar between the two groups, while the experimental group showed a significantly shorter in-hospital length of stay (p = 0.026) and Intensive Care Unit (ICU) length of stay (p = 0.038). CRRT termination may be independent of CK levels for patients with rhabdomyolysis-associated AKI, and this is contingent on their renal functions having recovered to an appropriate level.     

Kidney outcomes and prognostic factors of myeloma associated acute kidney injury in the contemporary era

Myeloma cast nephropathy (MCN) has historically been associated with poor kidney outcomes. We aimed to evaluate the kidney outcomes and identify prognostic factors of myeloma-associated acute kidney injury (M-AKI) in the contemporary era of anti-plasma cell therapy. Patients who received anti-myeloma therapy with M-AKI (January 2012 to June 2020) from a single centre were identified from electronic medical records. Diagnosis of MCN was either biopsy confirmed (BC) or clinically suspected (CS), the latter defined as acute kidney injury with reduced estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m² and involved serum free light chains (iSFLC) >500 mg/L at diagnosis. Twenty-six patients with M-AKI were identified (BC: n = 13, CS: n = 13). Median eGFR at diagnosis was 12 (interquartile range 6–20) mL/min/1.73 m². All six dialysis-requiring patients achieved dialysis independence after 71 (43–208) days. The best-achieved eGFR was 47 (32–67) mL/min/1.73 m² after 120 (63–167) days post-treatment, which was maintained at 47 (33–66) mL/min/1.73 m² 12 months post-treatment. Patients with best-achieved eGFR above the median were more likely to have achieved an iSFLC of <20 mg/L (above median group 62% versus below median group 0%; p < .001) and lower best post-treatment iSFLC (20 (12–90) versus 67 (29–146) mg/L; p < .05). Best-achieved iSFLC was a prognostic factor for superior eGFR following treatment for M-AKI. Despite low eGFR at diagnosis, contemporary anti-myeloma therapy can achieve significant recovery of kidney function.