Six-month survival and quality of life of intensive care patients with acute kidney injury

Introduction

Acute kidney injury (AKI) has high incidence among the critically ill and associates with dismal outcome. Not only the long-term survival, but also the quality of life (QOL) of patients with AKI is relevant due to substantial burden of care regarding these patients. We aimed to study the long-term outcome and QOL of patients with AKI treated in intensive care units.

Methods

We conducted a predefined six-month follow-up of adult intensive care unit (ICU) patients from the prospective, observational, multi-centre FINNAKI study. We evaluated the QOL of survivors with the EuroQol (EQ-5D) questionnaire. We included all participating sites with at least 70% rate of QOL measurements in the analysis.

Results

Of the 1,568 study patients, 635 (40.5%, 95% confidence interval (CI) 38.0-43.0%) had AKI according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Of the 635 AKI patients, 224 (35.3%), as compared to 154/933 (16.5%) patients without AKI, died within six months. Of the 1,190 survivors, 959 (80.6%) answered the EQ-5D questionnaire at six months. The QOL (median with Interquartile range, IQR) measured with the EQ-5D index and compared to age- and sex-matched general population was: 0.676 (0.520-1.00) versus 0.826 (0.812-0.859) for AKI patients, and 0.690 (0.533-1.00) versus 0.845 (0.812-0.882) for patients without AKI (P <0.001 in both). The EQ-5D at the time of ICU admission was available for 774 (80.7%) of the six-month respondents. We detected a mean increase of 0.017 for non-AKI and of 0.024 for AKI patients in the EQ-5D index (P = 0.728). The EQ-5D visual analogue scores (median with IQR) of patients with AKI (70 (50–83)) and patients without AKI (75 (60–87)) were not different from the age- and sex-matched general population (69 (68–73) and 70 (68–77)).

Conclusions

The health-related quality of life of patients with and without AKI was already lower on ICU admission than that of the age- and sex-matched general population, and did not change significantly during critical illness. Patients with and without AKI rate their subjective health to be as good as age and sex-matched general population despite statistically significantly lower QOL indexes measured by EQ-5D.     

Hemodynamic variables and progression of acute kidney injury in critically ill patients with severe sepsis: data from the prospective observational FINNAKI study

Introduction

Knowledge of the association of hemodynamics with progression of septic acute kidney injury (AKI) is limited. However, some recent data suggest that mean arterial pressure (MAP) exceeding current guidelines (60–65 mmHg) may be needed to prevent AKI. We hypothesized that higher MAP during the first 24 hours in the intensive care unit (ICU), would be associated with a lower risk of progression of AKI in patients with severe sepsis.

Methods

We identified 423 patients with severe sepsis and electronically recorded continuous hemodynamic data in the prospective observational FINNAKI study. The primary endpoint was progression of AKI within the first 5 days of ICU admission defined as new onset or worsening of AKI by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. We evaluated the association of hemodynamic variables with this endpoint. We included 53724 10-minute medians of MAP in the analysis. We analysed the ability of time-adjusted MAP to predict progression of AKI by receiver operating characteristic (ROC) analysis.

Results

Of 423 patients, 153 (36.2%) had progression of AKI. Patients with progression of AKI had significantly lower time-adjusted MAP, 74.4 mmHg [68.3-80.8], than those without progression, 78.6 mmHg [72.9-85.4], P < 0.001. A cut-off value of 73 mmHg for time-adjusted MAP best predicted the progression of AKI. Chronic kidney disease, higher lactate, higher dose of furosemide, use of dobutamine and time-adjusted MAP below 73 mmHg were independent predictors of progression of AKI.

Conclusions

The findings of this large prospective multicenter observational study suggest that hypotensive episodes (MAP under 73 mmHg) are associated with progression of AKI in critically ill patients with severe sepsis.     

Strength and mobility of the neck-shoulder region in adolescent headache

The significance of the musculoskeletal function of the neck-shoulder region in different headache types in children and adolescents is not clear. The purpose of this study was to investigate the association between different types of headache and the strength and mobility of the neck-shoulder region in 13-year-old schoolchildren. A structured questionnaire on headache was sent to all 1,409 children in the sixth grade in the city of Turku. Of the 1,135 (81%) children who completed the questionnaire, a sample from different headache groups was randomly selected for clinical examination. The study consisted of 59 children with migraine, 65 with episodic tension-type headache (TTHA), and 59 headache-free controls. Dynamic muscle strength of the upper extremities (UE endurance), mobility of both shoulders (UE mobility), and the cervical range of motion (CROM) were measured. Girls with episodic TTHA had lower UE endurance of both dominant and nondominant sides than girls in the other study groups. Girls with migraine had lower UE endurance of nondominant side than girls in the control group. In boys, no significant differences were observed. An interesting association between the function of the neck-shoulder region and headache complaints in adolescents was ascertained.     

Human Biological Monitoring of Occupational Genotoxic Exposures

Human biological monitoring is a valuable tool for exposure assessment in groups of persons occupationally exposed to genotoxic agents. If the monitoring activity covers genetic material the term genetic monitoring is used. The methods used for genetic monitoring are either substance specific, e.g. the quantitation of identified DNA-adducts or substance unspecific as is the measurement of DNA-repair. The sample material used for analysis must be well characterized and subject to uniform processing for comparison of the results. Confounding factors of smoking, age and sex must be well controlled for and the biomonitoring results should preferentially be linked with accurate ambient air monitoring. In persons occupationally exposed to styrene the endpoints of DNA-damage and DNA-repair in genetic monitoring are methods of choice in exposure situations above the current Danish (25 ppm) or Finnish (20 ppm) occupational exposure limit value of styrene in ambient air. The consideration of ethical issues in human genetic monitoring is an important but often overlooked aspect. This includes the scientific and preventional relevance of performing a test on individuals, pre- and post study information of donors and confidentiality as well as ownership of the results.     

Distribution of adhesion receptors in recurrent oral ulcers

When activated under physiologic or pathologic conditions leukocytes adhere to one another or to other cell types. Adhesion receptors mediate these interactions. In the study reported here, the distribution of the adhesion receptors LFA-1 (CD11a/CD18), ICAM-1 (CD54), CD2 and LFA-3 (CD58) in recurrent oral ulcers (ROU) were studied. Nine tissue specimens from five female patients (mean age 33 yr, age range 21-40 yr) with ROU were studied using the avidin-biotin-peroxidase complex (ABC) method. The main mononuclear cell infiltrations were in lamina propria (LP) and the epithelium next to the basement membrane (BM), laterally to the ulcers. In this area, ICAM-1 was strongly expressed in capillaries and in postcapillary venules. LFA-1, LFA-3 and CD2 were expressed in 65 +/- 1.1%, 70 +/- 16% and 80 +/- 1%, respectively, of all mononuclear cells. The findings indicate that LFA-1/ICAM-1 and CD2/LFA-3 interactions may play roles in cell to cell adhesion events in ROU.     

Determination of 6-thioguanine resistant lymphocytes in human blood by immunohistochemical antibromodeoxyuridine staining

An immunohistochemical method for the determination of 6-thioguanine resistant (TGr) lymphocytes in human blood samples has been developed. The new technique is a modification of the autoradiographic assay and uses labelling of DNA synthesizing cells by bromodeoxyuridine (BrdU) instead of tritiated thymidine. The label is detected immunohistochemically by using a monoclonal antibody against BrdU in single-stranded DNA. Thawed cryopreserved isolated mononuclear cells are cultured with (TG cultures) and without (control cultures) TG for 40 h, the last 16 h with BrdU. The cells are harvested, fixed and put on microscopic slides; for the TG cultures, all material is used, while slides from the control culture are prepared at a dilution of 1:300. The immunohistochemical staining of the slides involves denaturation of DNA in formamide, incubation with anti-BrdU-DNA antibody, followed by a secondary antibody conjugated with peroxidase and staining with diaminobenzidine. Nuclei that have incorporated BrdU appear brown while all other material remains unstained. The number of all labelled nuclei is scored similarly in control and TG slides and the frequency of TGr lymphocytes is obtained by dividing the number of labelled nuclei in TG slides with that (multiplied by the dilution factor) in control slides. The anti-BrdU method will much simplify and speed up the microscopical evaluation of the TG variants and is very suitable for automation.     

Assessment of passive and transplacental exposure to tobacco smoke

Although tobacco smoke has been shown to be highly genotoxic in various experimental systems, most nonmolecular methods designed to assess exposure to mutagens are too insensitive to detect passive exposure to tobacco smoke. Biochemical markers of intake--cotinine and thiocyanates in body fluids--were shown to be elevated after occupational, passive or transplacental exposure to tobacco smoke, while no response was seen in the frequency of sister chromatid exchanges (SCE) in cultured blood lymphocytes. After occupational exposure to environmental tobacco smoke, the intake marker levels are generally less than 5% of the levels found in active smokers, while cord blood levels (representing fetal exposure) are at about the same level as in the mothers at the time of delivery.     

Subjective disease experience in Sj?gren's syndrome. A computerized discrimination analysis

A study was made of the ability of a computerized discrimination analysis to distinguish between primary or secondary Sj?gren's syndrome on the one hand and, on the other, various rheumatic diseases which may be, but in this study were not, complicated by Sj?gren's syndrome. The analysis was based on a questionnaire including 76 two- or three-scale items. Among these 76 questions, five with a maximum potential for distinguishing between various subgroups were selected and obviously represent the questions for the physician to ask when taking the patient's history. As shown by classification matrix tables, computerized analysis of questionnaires might represent a useful way to assess the prevalence of clinical cases of Sj?gren's syndrome and to aid health care administrators in assessing the extent of the Sj?gren's syndrome problem. In contrast, manual analysis of patients' graded answers did not provide any simple or practicable method for the diagnostic work-up of cases. Therefore it seems that subjective symptoms should not be included in the diagnostic criteria for Sj?gren's syndrome, which in clinical work should be based on objective evidence alone.