Special Issue "Diagnostics, Risk Factors, Treatment and Outcomes of Acute Kidney Injury in a New Paradigm"

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Nephrology & Urology".

Deadline for manuscript submissions: 31 December 2019.

Special Issue Editors

Dr. Wisit Cheungpasitporn
E-Mail Website
Guest Editor
Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Mississippi, USA
Interests: meta-analysis; systematic review; acute kidney injury; clinical nephrology; nephrology; kidney transplantation
Special Issues and Collections in MDPI journals
Dr. Charat Thongprayoon
E-Mail Website
Guest Editor
Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
Tel. 507-266-1044
Interests: nephrology; kidney stone; acute kidney injury; renal replacement therapy; epidemiology; outcome study
Special Issues and Collections in MDPI journals
Dr. Wisit Kaewput
E-Mail Website
Guest Editor
Department of Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand
Tel. +6623547733
Interests: acute kidney injury; observational studies; statistical analysis; epidemiology

Special Issue Information

Dear Colleagues,

Acute kidney injury (AKI) is a frequent clinical syndrome among hospitalized patients, independently associated with both short- and long-term mortality. Previous investigations have attempted to identify effective interventions to prevent AKI or promote kidney function recovery in patients with AKI. Nevertheless, most were unsuccessful. Hence, additional studies are required in the field of AKI research.

In this Special Issue, we are making a call to action to stimulate researchers and clinicians to submit their invaluable studies on AKI, as has been done in nephrology, internal medicine, critical care, and other disciplines that will provide additional knowledge and skills in the field of AKI research, ultimately to improve patient outcomes. Original investigations, review articles, and short communications are especially welcome.

Potential topics include, but are not limited to, the following:

AKI definition and diagnosis
AKI prevention
AKI in cardiac surgery
AKI after bone marrow or solid organ transplantation
Biomarkers of AKI
Cardiorenal Syndrome
Contrast-induced AKI
Critical care nephrology
Drug-induced AKI
Electronic AKI Alerts
Hepatorenal Syndrome
Ischemic reperfusion injury
Outcomes and complications associated with AKI
Pathogenesis of AKI
Postoperative AKI
Quality improvement projects in AKI care
Renal replacement therapy in ICU
Rhabdomyolysis-associated AKI
Risk factors/predictors for AKI
Remote ischemic preconditioning and renoprotection
Sepsis and AKI

Dr. Wisit Cheungpasitporn
Dr. Charat Thongprayoon
Dr. Wisit Kaewput
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All papers will be peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 1800 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • acute kidney injury
  • acute renal failure
  • biomarkers
  • critical care
  • renal replacement therapy
  • risk factors
  • outcomes
  • predictors

Published Papers (34 papers)

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Open AccessArticle
Secretory Leukocyte Protease Inhibitor (SLPI)—A Novel Predictive Biomarker of Acute Kidney Injury after Cardiac Surgery: A Prospective Observational Study
J. Clin. Med. 2019, 8(11), 1931; https://doi.org/10.3390/jcm8111931 - 09 Nov 2019
Abstract
Acute kidney injury (AKI) is one of the most frequent complications after cardiac surgery and is associated with poor outcomes. Biomarkers of AKI are crucial for the early diagnosis of this condition. Secretory leukocyte protease inhibitor (SLPI) is an alarm anti-protease that has [...] Read more.
Acute kidney injury (AKI) is one of the most frequent complications after cardiac surgery and is associated with poor outcomes. Biomarkers of AKI are crucial for the early diagnosis of this condition. Secretory leukocyte protease inhibitor (SLPI) is an alarm anti-protease that has been implicated in the pathogenesis of AKI but has not yet been studied as a diagnostic biomarker of AKI. Using two independent cohorts (development cohort (DC), n = 60; validation cohort (VC), n = 148), we investigated the performance of SLPI as a diagnostic marker of AKI after cardiac surgery. Serum and urinary levels of SLPI were quantified by ELISA. SLPI was significantly elevated in AKI patients compared with non-AKI patients (6 h, DC: 102.1 vs. 64.9 ng/mL, p < 0.001). The area under the receiver operating characteristic curve of serum SLPI 6 h after surgery was 0.87 ((0.76–0.97); DC). The addition of SLPI to standard clinical predictors significantly improved the predictive accuracy of AKI (24 h, VC: odds ratio (OR) = 3.91 (1.44–12.13)). In a subgroup, the increase in serum SLPI was evident before AKI was diagnosed on the basis of serum creatinine or urine output (24 h, VC: OR = 4.89 (1.54–19.92)). In this study, SLPI was identified as a novel candidate biomarker for the early diagnosis of AKI after cardiac surgery. Full article
Open AccessArticle
Acute Kidney Injury and Septic Shock—Defined by Updated Sepsis-3 Criteria in Critically Ill Patients
J. Clin. Med. 2019, 8(10), 1731; https://doi.org/10.3390/jcm8101731 - 18 Oct 2019
Abstract
Sepsis is commonly associated with acute kidney injury (AKI), particularly in those requiring dialysis (AKI-D). To date, Sepsis-3 criteria have not been applied to AKI-D patients. We investigated sepsis prevalence defined by Sepsis-3 criteria and evaluated the outcomes of septic-associated AKI-D among critically [...] Read more.
Sepsis is commonly associated with acute kidney injury (AKI), particularly in those requiring dialysis (AKI-D). To date, Sepsis-3 criteria have not been applied to AKI-D patients. We investigated sepsis prevalence defined by Sepsis-3 criteria and evaluated the outcomes of septic-associated AKI-D among critically ill patients. Using the data collected from a prospective multi-center observational study, we applied the Sepsis-3 criteria to critically ill AKI-D patients treated in intensive care units (ICUs) in 30 hospitals between September 2014 and December 2015. We described the prevalence, outcomes, and characteristics of sepsis as defined by the screening Sepsis-3 criteria among AKI-D patients, and compared the outcomes of AKI-D patients with or without sepsis using the Sepsis-3 criteria. A total of 1078 patients (median 70 years; 673 (62.4%) men) with AKI-D were analyzed. The main etiology of AKI was sepsis (71.43%) and the most frequent indication for acute dialysis was oliguria (64.4%). A total of 577 (53.3% of 1078 patients) met the Sepsis-3 criteria, and 206 among the 577 patients (19.1%) had septic shock. Having sepsis and septic shock were independently associated with 90-day mortality among these ICU AKI-D patients (hazard ratio (HR) 1.23 (p = 0.027) and 1.39 (p = 0.004), respectively). Taking mortality as a competing risk factor, AKI-D patients with septic shock had a significantly reduced chance of weaning from dialysis at 90 days than those without sepsis (HR 0.65, p = 0.026). The combination of the Sepsis-3 criteria with the AKI risk score led to better performance in forecasting 90-day mortality. Sepsis affects more than 50% of ICU AKI patients requiring dialysis, and one-fifth of these patients had septic shock. In AKI-D patients, coexistent with or induced by sepsis (as screened by the Sepsis-3 criteria), there is a significantly higher mortality and reduced chance of recovering sufficient renal function, when compared to those without sepsis. Full article
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Open AccessArticle
Acute Kidney Injury after Lung Transplantation: A Systematic Review and Meta-Analysis
J. Clin. Med. 2019, 8(10), 1713; https://doi.org/10.3390/jcm8101713 - 17 Oct 2019
Abstract
Background: Lung transplantation has been increasingly performed worldwide and is considered an effective therapy for patients with various causes of end-stage lung diseases. We performed a systematic review to assess the incidence and impact of acute kidney injury (AKI) and severe AKI requiring [...] Read more.
Background: Lung transplantation has been increasingly performed worldwide and is considered an effective therapy for patients with various causes of end-stage lung diseases. We performed a systematic review to assess the incidence and impact of acute kidney injury (AKI) and severe AKI requiring renal replacement therapy (RRT) in patients after lung transplantation. Methods: A literature search was conducted utilizing Ovid MEDLINE, EMBASE, and Cochrane Database from inception through June 2019. We included studies that evaluated the incidence of AKI, severe AKI requiring RRT, and mortality risk of AKI among patients after lung transplantation. Pooled incidence and odds ratios (ORs) with 95% confidence interval (CI) were obtained using random-effects meta-analysis. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42019134095). Results: A total of 26 cohort studies with a total of 40,592 patients after lung transplantation were enrolled. Overall, the pooled estimated incidence rates of AKI (by standard AKI definitions) and severe AKI requiring RRT following lung transplantation were 52.5% (95% CI: 45.8–59.1%) and 9.3% (95% CI: 7.6–11.4%). Meta-regression analysis demonstrated that the year of study did not significantly affect the incidence of AKI (p = 0.22) and severe AKI requiring RRT (p = 0.68). The pooled ORs of in-hospital mortality in patients after lung transplantation with AKI and severe AKI requiring RRT were 2.75 (95% CI, 1.18–6.41) and 10.89 (95% CI, 5.03–23.58). At five years, the pooled ORs of mortality among patients after lung transplantation with AKI and severe AKI requiring RRT were 1.47 (95% CI, 1.11–1.94) and 4.79 (95% CI, 3.58–6.40), respectively. Conclusion: The overall estimated incidence rates of AKI and severe AKI requiring RRT in patients after lung transplantation are 52.5% and 9.3%, respectively. Despite advances in therapy, the incidence of AKI in patients after lung transplantation does not seem to have decreased. In addition, AKI after lung transplantation is significantly associated with reduced short-term and long-term survival. Full article
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Open AccessArticle
General Anesthetic Agents and Renal Function after Nephrectomy
J. Clin. Med. 2019, 8(10), 1530; https://doi.org/10.3390/jcm8101530 - 24 Sep 2019
Abstract
The association between the choice of general anesthetic agents and the risk of acute kidney injury (AKI) and long-term renal dysfunction after nephrectomy has not yet been evaluated. We reviewed 1087 cases of partial or radical nephrectomy. The incidence of postoperative AKI, new-onset [...] Read more.
The association between the choice of general anesthetic agents and the risk of acute kidney injury (AKI) and long-term renal dysfunction after nephrectomy has not yet been evaluated. We reviewed 1087 cases of partial or radical nephrectomy. The incidence of postoperative AKI, new-onset chronic kidney disease (CKD) and CKD upstaging were compared between general anesthetic agent groups (propofol, sevoflurane, and desflurane). Four different propensity score analyses were performed to minimize confounding for each pair of comparison (propofol vs. sevoflurane; propofol vs. desflurane; sevoflurane vs. desflurane; propofol vs. volatile agents). Study outcomes were compared before and after matching. Kaplan-Meier survival curve analysis was performed to compare renal survival determined by the development of new-onset CKD between groups up to 36 months after nephrectomy. Propofol was associated with a lower incidence of AKI (propofol 23.2% vs. sevoflurane 39.5%, p = 0.004; vs. propofol 21.0% vs. desflurane 34.3%, p = 0.031), a lower incidence of CKD upstaging (propofol 27.2% vs. sevoflurane 58.4%, p < 0.001; propofol 32.4% vs. desflurane 48.6%, p = 0.017) and better three-year renal survival after nephrectomy compared to sevoflurane or desflurane group (Log-rank test propofol vs. sevoflurane p < 0.001; vs. desflurane p = 0.015) after matching. Propofol was also associated with a lower incidence of new-onset CKD after nephrectomy compared to sevoflurane after matching (p < 0.001). There were no significant differences between sevoflurane and desflurane. However, subgroup analysis of partial nephrectomy showed a significant difference only in CKD upstaging. In conclusion, propofol, compared to volatile agents, could be a better general anesthetic agent for nephrectomy to attenuate postoperative renal dysfunction. However, limitations of the retrospective study design and inconsistent results of the subgroup analysis preclude firm conclusions. Full article
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Open AccessArticle
Acute Kidney Injury Adjusted for Parenchymal Mass Reduction and Long-Term Renal Function after Partial Nephrectomy
J. Clin. Med. 2019, 8(9), 1482; https://doi.org/10.3390/jcm8091482 - 18 Sep 2019
Abstract
We sought to evaluate the association of postoperative acute kidney injury (AKI) adjusted for parenchymal mass reduction with long-term renal function in patients undergoing partial nephrectomy. A total of 629 patients undergoing partial nephrectomy were reviewed. Postoperative AKI was defined by the Kidney [...] Read more.
We sought to evaluate the association of postoperative acute kidney injury (AKI) adjusted for parenchymal mass reduction with long-term renal function in patients undergoing partial nephrectomy. A total of 629 patients undergoing partial nephrectomy were reviewed. Postoperative AKI was defined by the Kidney Disease: Improving Global Outcomes (KDIGO) serum creatinine criteria, by using either the unadjusted or adjusted baseline serum creatinine level, accounting for renal parenchymal mass reduction. Estimated glomerular filtration rates (eGFRs) were followed up to 61 months (median 28 months) after surgery. The primary outcome was the functional change ratio (FCR) of eGFR calculated by the ratio of the most recent follow-up value, at least 24 months after surgery, to eGFR at 3–12 months after surgery. Multivariable linear regression analysis was performed to evaluate whether unadjusted or adjusted AKI was an independent predictor of FCR. As a sensitivity analysis, functional recovery at 3–12 months after surgery compared to the preoperative baseline was analyzed. Median parenchymal mass reduction was 11%. Unadjusted AKI occurred in 16.5% (104/625) and adjusted AKI occurred in 8.6% (54/629). AKI using adjusted baseline creatinine was significantly associated with a long-term FCR (β = −0.129 ± 0.026, p < 0.001), while unadjusted AKI was not. Adjusted AKI was also a significant predictor of functional recovery (β = −0.243 ± 0.106, p = 0.023), while unadjusted AKI was not. AKI adjusted for the parenchymal mass reduction was significantly associated with a long-term functional decline after partial nephrectomy. A creatinine increase due to remaining parenchymal ischemic injury may be important in order to predict long-term renal functional outcomes after partial nephrectomy. Full article
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Open AccessArticle
Acute Kidney Injury and In-Hospital Mortality: A Retrospective Analysis of a Nationwide Administrative Database of Elderly Subjects in Italy
J. Clin. Med. 2019, 8(9), 1371; https://doi.org/10.3390/jcm8091371 - 02 Sep 2019
Abstract
Background: The aim of this study was to investigate the association between acute kidney injury (AKI) and in-hospital mortality (IHM) in a large nationwide cohort of elderly subjects in Italy. Methods: We analyzed the hospitalization data of all patients aged ≥65 years, who [...] Read more.
Background: The aim of this study was to investigate the association between acute kidney injury (AKI) and in-hospital mortality (IHM) in a large nationwide cohort of elderly subjects in Italy. Methods: We analyzed the hospitalization data of all patients aged ≥65 years, who were discharged with a diagnosis of AKI, which was identified by the presence of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), and extracted from the Italian Health Ministry database (January 2000 to December 2015). Data regarding age, gender, dialysis treatment, and comorbidity, including the development of sepsis, were also collected. Results: We evaluated 760,664 hospitalizations, the mean age was 80.5 ± 7.8 years, males represented 52.2% of the population, and 9% underwent dialysis treatment. IHM was 27.7% (210,661 admissions): Deceased patients were more likely to be older, undergoing dialysis treatment, and to be sicker than the survivors. The population was classified on the basis of tertiles of comorbidity score (the first group 7.48 ± 1.99, the second 13.67 ± 2,04, and third 22.12 ± 4.13). IHM was higher in the third tertile, whilst dialysis-dependent AKI was highest in the first. Dialysis-dependent AKI was associated with an odds ratios (OR) of 2.721; 95% confidence interval (CI) 2.676–2.766; p < 0.001, development of sepsis was associated with an OR of 1.990; 95% CI 1.948–2.033; p < 0.001, the second tertile of comorbidity was associated with an OR of 1.750; 95% CI 1.726–1.774; p < 0.001, and the third tertile of comorbidity was associated with an OR of 2.522; 95% CI 2.486–2.559; p < 0.001. Conclusions: In elderly subjects with AKI discharge codes, IHM is a frequent complication affecting more than a quarter of the investigated population. The increasing burden of comorbidity, dialysis-dependent AKI, and sepsis are the major risk factors. Full article
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Open AccessArticle
Impact on Outcomes across KDIGO-2012 AKI Criteria According to Baseline Renal Function
J. Clin. Med. 2019, 8(9), 1323; https://doi.org/10.3390/jcm8091323 - 28 Aug 2019
Abstract
Acute kidney injury (AKI) and Chronic Kidney Disease (CKD) are global health problems. The pathophysiology of acute-on-chronic kidney disease (AoCKD) is not well understood. We aimed to study clinical outcomes in patients with previous normal (pure acute kidney injury; P-AKI) or impaired kidney [...] Read more.
Acute kidney injury (AKI) and Chronic Kidney Disease (CKD) are global health problems. The pathophysiology of acute-on-chronic kidney disease (AoCKD) is not well understood. We aimed to study clinical outcomes in patients with previous normal (pure acute kidney injury; P-AKI) or impaired kidney function (AoCKD) across the 2012 Kidney Disease Improving Global Outcomes (KDIGO) AKI classification. We performed a retrospective study of patients with AKI, divided into P-AKI and AoCKD groups, evaluating clinical and epidemiological features, distribution across KDIGO-2012 criteria, in-hospital mortality and need for dialysis. One thousand, two hundred and sixty-nine subjects were included. AoCKD individuals were older and had higher comorbidity. P-AKI individuals fulfilled more often the serum creatinine (SCr) ≥ 3.0× criterion in AKI-Stage3, AoCKD subjects reached SCr ≥ 4.0 mg/dL criterion more frequently. AKI severity was associated with in-hospital mortality independently of baseline renal function. AoCKD subjects presented higher mortality when fulfilling AKI-Stage1 criteria or SCr ≥ 3.0× criterion within AKI-Stage3. The relationship between mortality and associated risk factors, such as the net increase of SCr or AoCKD status, fluctuated depending on AKI stage and stage criteria sub-strata. AoCKD patients that fulfil SCr increment rate criteria may be exposed to more severe insults, possibly explaining the higher mortality. AoCKD may constitute a unique clinical syndrome. Adequate staging criteria may help prompt diagnosis and administration of appropriate therapy. Full article
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Open AccessArticle
Does the Implementation of a Quality Improvement Care Bundle Reduce the Incidence of Acute Kidney Injury in Patients Undergoing Emergency Laparotomy?
J. Clin. Med. 2019, 8(8), 1265; https://doi.org/10.3390/jcm8081265 - 20 Aug 2019
Abstract
Purpose: Previous work has demonstrated a survival improvement following the introduction of an enhanced recovery protocol in patients undergoing emergency laparotomy (the emergency laparotomy pathway quality improvement care (ELPQuiC) bundle). Implementation of this bundle increased the use of intra-operative goal directed fluid therapy [...] Read more.
Purpose: Previous work has demonstrated a survival improvement following the introduction of an enhanced recovery protocol in patients undergoing emergency laparotomy (the emergency laparotomy pathway quality improvement care (ELPQuiC) bundle). Implementation of this bundle increased the use of intra-operative goal directed fluid therapy and ICU admission, both evidence-based strategies recommended to improve kidney outcomes. The aim of this study was to determine if the observed mortality benefit could be explained by a difference in the incidence of AKI pre- and post-implementation of the protocol. Method: The primary outcome was the incidence of AKI in the pre- and post-ELPQuiC bundle patient population in four acute trusts in the United Kingdom. Secondary outcomes included the KDIGO stage specific incidence of AKI. Serum creatinine values were obtained retrospectively at baseline, in the post-operative period and the maximum recorded creatinine between day 1 and day 30 were obtained. Results: A total of 303 patients pre-ELPQuiC bundle and 426 patients post-ELPQuiC bundle implementation were identified across the four centres. The overall AKI incidence was 18.4% in the pre-bundle group versus 19.8% in the post bundle group p = 0.653. No significant differences were observed between the groups. Conclusions: Despite this multi-centre cohort study demonstrating an overall survival benefit, implementation of the quality improvement care bundle did not affect the incidence of AKI. Full article
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Open AccessArticle
The Predictive Value of Hyperuricemia on Renal Outcome after Contrast-Enhanced Computerized Tomography
J. Clin. Med. 2019, 8(7), 1003; https://doi.org/10.3390/jcm8071003 - 10 Jul 2019
Abstract
The aim of this study was to determine whether elevated serum level of uric acid (sUA) could predict renal outcome after contrast-enhanced computerized tomography (CCT). We used a historical cohort of 58,106 non-dialysis adult patients who received non-ionic iso-osmolar CCT from 1 June [...] Read more.
The aim of this study was to determine whether elevated serum level of uric acid (sUA) could predict renal outcome after contrast-enhanced computerized tomography (CCT). We used a historical cohort of 58,106 non-dialysis adult patients who received non-ionic iso-osmolar CCT from 1 June 2008 to 31 March 2015 to evaluate the association of sUA and renal outcome. The exclusion criteria were patients with pre-existing acute kidney injury (AKI), multiple exposure, non-standard volume of contrast, and missing data for analysis. A total of 1440 patients were enrolled. Post-contrast-AKI (PC-AKI), defined by the increase in serum creatinine ≥ 0.3 mg/dL within 48 h or ≥50% within seven days after CCT, occurred in 180 (12.5%) patients and the need of hemodialysis within 30 days developed in 90 (6.3%) patients, both incidences were increased in patients with higher sUA. sUA ≥ 8.0 mg/dL was associated with an increased risk of PC-AKI (odds ratio (OR) of 2.62; 95% confidence interval (CI), 1.27~5.38, p = 0.009) and the need of hemodialysis (OR, 5.40; 95% CI, 1.39~21.04, p = 0.015). Comparing with sUA < 8.0 mg/dL, patients with sUA ≥ 8.0 mg/dL had higher incidence of PC-AKI (16.7% vs. 11.1%, p = 0.012) and higher incidence of hemodialysis (12.1% vs. 4.3%, p < 0.001). We concluded that sUA ≥ 8.0 mg/dL is associated with worse renal outcome after CCT. We suggest that hyperuricemia may have potential as an independent risk factor for PC-AKI in patients receiving contrast-enhanced image study. Full article
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Open AccessArticle
Incidence and Impact of Acute Kidney Injury in Patients Receiving Extracorporeal Membrane Oxygenation: A Meta-Analysis
J. Clin. Med. 2019, 8(7), 981; https://doi.org/10.3390/jcm8070981 - 05 Jul 2019
Cited by 2
Abstract
Background: Although acute kidney injury (AKI) is a frequent complication in patients receiving extracorporeal membrane oxygenation (ECMO), the incidence and impact of AKI on mortality among patients on ECMO remain unclear. We conducted this systematic review to summarize the incidence and impact of [...] Read more.
Background: Although acute kidney injury (AKI) is a frequent complication in patients receiving extracorporeal membrane oxygenation (ECMO), the incidence and impact of AKI on mortality among patients on ECMO remain unclear. We conducted this systematic review to summarize the incidence and impact of AKI on mortality risk among adult patients on ECMO. Methods: A literature search was performed using EMBASE, Ovid MEDLINE, and Cochrane Databases from inception until March 2019 to identify studies assessing the incidence of AKI (using a standard AKI definition), severe AKI requiring renal replacement therapy (RRT), and the impact of AKI among adult patients on ECMO. Effect estimates from the individual studies were obtained and combined utilizing random-effects, generic inverse variance method of DerSimonian-Laird. The protocol for this systematic review is registered with PROSPERO (no. CRD42018103527). Results: 41 cohort studies with a total of 10,282 adult patients receiving ECMO were enrolled. Overall, the pooled estimated incidence of AKI and severe AKI requiring RRT were 62.8% (95%CI: 52.1%–72.4%) and 44.9% (95%CI: 40.8%–49.0%), respectively. Meta-regression showed that the year of study did not significantly affect the incidence of AKI (p = 0.67) or AKI requiring RRT (p = 0.83). The pooled odds ratio (OR) of hospital mortality among patients receiving ECMO with AKI on RRT was 3.73 (95% CI, 2.87–4.85). When the analysis was limited to studies with confounder-adjusted analysis, increased hospital mortality remained significant among patients receiving ECMO with AKI requiring RRT with pooled OR of 3.32 (95% CI, 2.21–4.99). There was no publication bias as evaluated by the funnel plot and Egger’s regression asymmetry test with p = 0.62 and p = 0.17 for the incidence of AKI and severe AKI requiring RRT, respectively. Conclusion: Among patients receiving ECMO, the incidence rates of AKI and severe AKI requiring RRT are high, which has not changed over time. Patients who develop AKI requiring RRT while on ECMO carry 3.7-fold higher hospital mortality. Full article
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Open AccessArticle
Incidence and Cost of Acute Kidney Injury in Hospitalized Patients with Infective Endocarditis
J. Clin. Med. 2019, 8(7), 927; https://doi.org/10.3390/jcm8070927 - 27 Jun 2019
Abstract
Acute kidney injury (AKI) is a frequent complication of hospitalized patients with infective endocarditis (IE). Further, AKI in the setting of IE is associated with high morbidity and mortality. We aimed to examine the incidence, clinical parameters, and hospital costs associated with AKI [...] Read more.
Acute kidney injury (AKI) is a frequent complication of hospitalized patients with infective endocarditis (IE). Further, AKI in the setting of IE is associated with high morbidity and mortality. We aimed to examine the incidence, clinical parameters, and hospital costs associated with AKI in hospitalized patients with IE in an endemic area with an increasing prevalence of opioid use. This retrospective cohort study included 269 patients admitted to a major referral center in Kentucky with a primary diagnosis of IE from January 2013 to December 2015. Of these, 178 (66.2%) patients had AKI by Kidney Disease Improving Global Outcomes (KDIGO) serum creatinine criteria: 74 (41.6%) had AKI stage 1 and 104 (58.4%) had AKI stage ≥2. In multivariable analysis, higher comorbidity scores and the need for diuretics were independently associated with AKI, while the involvement of the tricuspid valve and the need for vasopressor/inotrope support were independently associated with severe AKI (stage ≥2). The median total direct cost of hospitalization was progressively higher according to each stage of AKI ($17,069 for no AKI; $37,111 for AKI stage 1; and $61,357 for AKI stage ≥2; p < 0.001). In conclusion, two-thirds of patients admitted to the hospital due to IE had incident AKI. The occurrence of AKI significantly increased healthcare costs. The higher level of comorbidity, the affection of the tricuspid valve, and the need for diuretics and/or vasoactive drugs were associated with severe AKI in this susceptible population. Full article
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Open AccessArticle
Effect of Anesthetic Technique on the Occurrence of Acute Kidney Injury after Total Knee Arthroplasty
J. Clin. Med. 2019, 8(6), 778; https://doi.org/10.3390/jcm8060778 - 31 May 2019
Abstract
Recent studies have reported the advantages of spinal anesthesia over general anesthesia in orthopedic patients. However, little is known about the relationship between acute kidney injury (AKI) after total knee arthroplasty (TKA) and anesthetic technique. This study aimed to identify the influence of [...] Read more.
Recent studies have reported the advantages of spinal anesthesia over general anesthesia in orthopedic patients. However, little is known about the relationship between acute kidney injury (AKI) after total knee arthroplasty (TKA) and anesthetic technique. This study aimed to identify the influence of anesthetic technique on AKI in TKA patients. We also evaluated whether the choice of anesthetic technique affected other clinical outcomes. We retrospectively reviewed medical records of patients who underwent TKA between January 2008 and August 2016. Perioperative data were obtained and analyzed. To reduce the influence of potential confounding factors, propensity score (PS) analysis was performed. A total of 2809 patients and 2987 cases of TKA were included in this study. A crude analysis of the total set demonstrated a significantly lower risk of AKI in the spinal anesthesia group. After PS matching, the spinal anesthesia group showed a tendency for reduced AKI, without statistical significance. Furthermore, the spinal anesthesia group showed a lower risk of pulmonary and vascular complications, and shortened hospital stay after PS matching. In TKA patients, spinal anesthesia had a tendency to reduce AKI. Moreover, spinal anesthesia not only reduced vascular and pulmonary complications, but also shortened hospital stay. Full article
Open AccessArticle
Effect of Diabetes Mellitus on Acute Kidney Injury after Minimally Invasive Partial Nephrectomy: A Case-Matched Retrospective Analysis
J. Clin. Med. 2019, 8(4), 468; https://doi.org/10.3390/jcm8040468 - 05 Apr 2019
Cited by 2
Abstract
Postoperative acute kidney injury (AKI) is still a concern in partial nephrectomy (PN), even with the development of minimally invasive technique. We aimed to compare AKI incidence between patients with and without diabetes mellitus (DM) and to determine the predictive factors for postoperative [...] Read more.
Postoperative acute kidney injury (AKI) is still a concern in partial nephrectomy (PN), even with the development of minimally invasive technique. We aimed to compare AKI incidence between patients with and without diabetes mellitus (DM) and to determine the predictive factors for postoperative AKI. This case-matched retrospective study included 884 patients with preoperative creatinine levels ≤1.4 mg/dL who underwent laparoscopic or robot-assisted laparoscopic PN between December 2005 and May 2018. Propensity score matching was employed to match patients with and without DM in a 1:3 ratio (101 and 303 patients, respectively). Of 884 patients, 20.4% had postoperative AKI. After propensity score matching, the incidence of postoperative AKI in DM and non-DM patients was 30.7% and 14.9%, respectively (P < 0.001). In multivariate analysis, male sex and warm ischemia time (WIT) >25 min were significantly associated with postoperative AKI in patients with and without DM. In patients with DM, hemoglobin A1c (HbA1c) >7% was a predictive factor for AKI, odds ratio (OR) = 4.59 (95% CI, 1.47–14.36). In conclusion, DM increased the risk of AKI after minimally invasive PN; male sex, longer WIT, and elevated HbA1c were independent risk factors for AKI in patients with DM. Full article
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Open AccessArticle
Fluctuations in Serum Chloride and Acute Kidney Injury among Critically Ill Patients: A Retrospective Association Study
J. Clin. Med. 2019, 8(4), 447; https://doi.org/10.3390/jcm8040447 - 02 Apr 2019
Cited by 1
Abstract
Exposure to dyschloremia among critically ill patients is associated with an increased risk of acute kidney injury (AKI). We aimed to investigate how fluctuations in serum chloride (Cl) are associated with the development of AKI in critically ill patients. We retrospectively [...] Read more.
Exposure to dyschloremia among critically ill patients is associated with an increased risk of acute kidney injury (AKI). We aimed to investigate how fluctuations in serum chloride (Cl) are associated with the development of AKI in critically ill patients. We retrospectively analyzed medical records of adult patients admitted to the intensive care unit (ICU) between January 2012 and December 2017. Positive and negative fluctuations in Cl were defined as the difference between the baseline Cl- and maximum Cl- levels and the difference between the baseline Cl and minimum Cl levels measured within 72 h after ICU admission, respectively. In total, 19,707 patients were included. The odds of developing AKI increased 1.06-fold for every 1 mmol L−1 increase in the positive fluctuations in Cl (odds ratio: 1.06; 95% confidence interval: 1.04 to 1.08; p < 0.001) and 1.04-fold for every 1 mmol L−1 increase in the negative fluctuations in Cl (odds ratio: 1.04; 95% confidence interval: 1.02 to 1.06; p < 0.001). Increases in both the positive and negative fluctuations in Cl- after ICU admission were associated with an increased risk of AKI. Furthermore, these associations differed based on the functional status of the kidneys at ICU admission or postoperative ICU admission. Full article
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Open AccessArticle
Incidence and Impact of Acute Kidney Injury after Liver Transplantation: A Meta-Analysis
J. Clin. Med. 2019, 8(3), 372; https://doi.org/10.3390/jcm8030372 - 17 Mar 2019
Cited by 4
Abstract
Background: The study’s aim was to summarize the incidence and impacts of post-liver transplant (LTx) acute kidney injury (AKI) on outcomes after LTx. Methods: A literature search was performed using the MEDLINE, EMBASE and Cochrane Databases from inception until December 2018 to identify [...] Read more.
Background: The study’s aim was to summarize the incidence and impacts of post-liver transplant (LTx) acute kidney injury (AKI) on outcomes after LTx. Methods: A literature search was performed using the MEDLINE, EMBASE and Cochrane Databases from inception until December 2018 to identify studies assessing the incidence of AKI (using a standard AKI definition) in adult patients undergoing LTx. Effect estimates from the individual studies were derived and consolidated utilizing random-effect, the generic inverse variance approach of DerSimonian and Laird. The protocol for this systematic review is registered with PROSPERO (no. CRD42018100664). Results: Thirty-eight cohort studies, with a total of 13,422 LTx patients, were enrolled. Overall, the pooled estimated incidence rates of post-LTx AKI and severe AKI requiring renal replacement therapy (RRT) were 40.7% (95% CI: 35.4%–46.2%) and 7.7% (95% CI: 5.1%–11.4%), respectively. Meta-regression showed that the year of study did not significantly affect the incidence of post-LTx AKI (p = 0.81). The pooled estimated in-hospital or 30-day mortality, and 1-year mortality rates of patients with post-LTx AKI were 16.5% (95% CI: 10.8%–24.3%) and 31.1% (95% CI: 22.4%–41.5%), respectively. Post-LTx AKI and severe AKI requiring RRT were associated with significantly higher mortality with pooled ORs of 2.96 (95% CI: 2.32–3.77) and 8.15 (95%CI: 4.52–14.69), respectively. Compared to those without post-LTx AKI, recipients with post-LTx AKI had significantly increased risk of liver graft failure and chronic kidney disease with pooled ORs of 3.76 (95% CI: 1.56–9.03) and 2.35 (95% CI: 1.53–3.61), respectively. Conclusion: The overall estimated incidence rates of post-LTx AKI and severe AKI requiring RRT are 40.8% and 7.0%, respectively. There are significant associations of post-LTx AKI with increased mortality and graft failure after transplantation. Furthermore, the incidence of post-LTx AKI has remained stable over the ten years of the study. Full article
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Open AccessArticle
Common Inflammation-Related Candidate Gene Variants and Acute Kidney Injury in 2647 Critically Ill Finnish Patients
J. Clin. Med. 2019, 8(3), 342; https://doi.org/10.3390/jcm8030342 - 11 Mar 2019
Abstract
Acute kidney injury (AKI) is a syndrome with high incidence among the critically ill. Because the clinical variables and currently used biomarkers have failed to predict the individual susceptibility to AKI, candidate gene variants for the trait have been studied. Studies about genetic [...] Read more.
Acute kidney injury (AKI) is a syndrome with high incidence among the critically ill. Because the clinical variables and currently used biomarkers have failed to predict the individual susceptibility to AKI, candidate gene variants for the trait have been studied. Studies about genetic predisposition to AKI have been mainly underpowered and of moderate quality. We report the association study of 27 genetic variants in a cohort of Finnish critically ill patients, focusing on the replication of associations detected with variants in genes related to inflammation, cell survival, or circulation. In this prospective, observational Finnish Acute Kidney Injury (FINNAKI) study, 2647 patients without chronic kidney disease were genotyped. We defined AKI according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria. We compared severe AKI (Stages 2 and 3, n = 625) to controls (Stage 0, n = 1582). For genotyping we used iPLEXTM Assay (Agena Bioscience). We performed the association analyses with PLINK software, using an additive genetic model in logistic regression. Despite the numerous, although contradictory, studies about association between polymorphisms rs1800629 in TNFA and rs1800896 in IL10 and AKI, we found no association (odds ratios 1.06 (95% CI 0.89–1.28, p = 0.51) and 0.92 (95% CI 0.80–1.05, p = 0.20), respectively). Adjusting for confounders did not change the results. To conclude, we could not confirm the associations reported in previous studies in a cohort of critically ill patients. Full article
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Open AccessArticle
Acute Kidney Injury in Patients Undergoing Total Hip Arthroplasty: A Systematic Review and Meta-Analysis
J. Clin. Med. 2019, 8(1), 66; https://doi.org/10.3390/jcm8010066 - 09 Jan 2019
Cited by 1
Abstract
Background: The number of total hip arthroplasties (THA) performed across the world is growing rapidly. We performed this meta-analysis to evaluate the incidence of acute kidney injury (AKI) in patients undergoing THA. Methods: A literature search was performed using MEDLINE, EMBASE and Cochrane [...] Read more.
Background: The number of total hip arthroplasties (THA) performed across the world is growing rapidly. We performed this meta-analysis to evaluate the incidence of acute kidney injury (AKI) in patients undergoing THA. Methods: A literature search was performed using MEDLINE, EMBASE and Cochrane Database from inception until July 2018 to identify studies assessing the incidence of AKI (using standard AKI definitions of RIFLE, AKIN, and KDIGO classifications) in patients undergoing THA. We applied a random-effects model to estimate the incidence of AKI. The protocol for this meta-analysis is registered with PROSPERO (no. CRD42018101928). Results: Seventeen cohort studies with a total of 24,158 patients undergoing THA were enrolled. Overall, the pooled estimated incidence rates of AKI and severe AKI requiring dialysis following THA were 6.3% (95% CI: 3.8%–10.2%) and 0.5% (95% CI: 0.1%–2.3%). Subgroup analysis based on the countries by continent was performed and demonstrated the pooled estimated incidence of AKI following THA of 9.2% (95% CI: 5.6%–14.8%) in Asia, 8.1% (95% CI: 4.9%–13.2%) in Australia, 7.4% (95% CI: 3.2%–16.3%) in Europe, and 2.8% (95% CI: 1.2%–17.0%) in North America. Meta-regression of all included studies showed significant negative correlation between incidence of AKI following THA and study year (slope = −0.37, p <0.001). There was no publication bias as assessed by the funnel plot and Egger’s regression asymmetry test with p = 0.13 for the incidence of AKI in patients undergoing THA. Conclusion: The overall estimated incidence rates of AKI and severe AKI requiring dialysis in patients undergoing THA are 6.3% and 0.5%, respectively. There has been potential improvement in AKI incidence for patients undergoing THA over time. Full article
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Open AccessArticle
Intraoperative Oliguria with Decreased SvO2 Predicts Acute Kidney Injury after Living Donor Liver Transplantation
J. Clin. Med. 2019, 8(1), 29; https://doi.org/10.3390/jcm8010029 - 28 Dec 2018
Cited by 3
Abstract
Acute kidney injury (AKI) is a frequent complication after living donor liver transplantation (LDLT), and is associated with increased mortality. However, the association between intraoperative oliguria and the risk of AKI remains uncertain for LDLT. We sought to determine the association between intraoperative [...] Read more.
Acute kidney injury (AKI) is a frequent complication after living donor liver transplantation (LDLT), and is associated with increased mortality. However, the association between intraoperative oliguria and the risk of AKI remains uncertain for LDLT. We sought to determine the association between intraoperative oliguria alone and oliguria coupled with hemodynamic derangement and the risk of AKI after LDLT. We evaluated the hemodynamic variables, including mean arterial pressure, cardiac index, and mixed venous oxygen saturation (SvO2). We reviewed 583 adult patients without baseline renal dysfunction and who did not receive hydroxyethyl starch during surgery. AKI was defined using the Kidney Disease Improving Global Outcomes criteria according to the serum creatinine criteria. Multivariable logistic regression analysis was performed with and without oliguria and oliguria coupled with a decrease in SvO2. The performance was compared with respect to the area under the receiver operating characteristic curve (AUC). Intraoperative oliguria <0.5 and <0.3 mL/kg/h were significantly associated with the risk of AKI; however, their performance in predicting AKI was poor. The AUC of single predictors increased significantly when oliguria was combined with decreased SvO2 (AUC 0.72; 95% confidence interval (CI) 0.68–0.75 vs. AUC of oliguria alone 0.61; 95% CI 0.56–0.61; p < 0.0001; vs. AUC of SvO2 alone 0.66; 95% CI 0.61–0.70; p < 0.0001). Addition of oliguria coupled with SvO2 reduction also increased the AUC of multivariable prediction (AUC 0.87; 95% CI 0.84–0.90 vs. AUC with oliguria 0.73; 95% CI 0.69–0.77; p < 0.0001; vs. AUC with neither oliguria nor SvO2 reduction 0.68; 95% CI 0.64–0.72; p < 0.0001). Intraoperative oliguria coupled with a decrease in SvO2 may suggest the risk of AKI after LDLT more reliably than oliguria alone or decrease in SvO2 alone. Intraoperative oliguria should be interpreted in conjunction with SvO2 to predict AKI in patients with normal preoperative renal function and who did not receive hydroxyethyl starch during surgery. Full article
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Open AccessArticle
Preadmission Statin Therapy Is Associated with a Lower Incidence of Acute Kidney Injury in Critically Ill Patients: A Retrospective Observational Study
J. Clin. Med. 2019, 8(1), 25; https://doi.org/10.3390/jcm8010025 - 25 Dec 2018
Abstract
This study aimed to investigate the association between preadmission statin use and acute kidney injury (AKI) incidence among critically ill patients who needed admission to the intensive care unit (ICU) for medical care. Medical records of patients admitted to the ICU were reviewed. [...] Read more.
This study aimed to investigate the association between preadmission statin use and acute kidney injury (AKI) incidence among critically ill patients who needed admission to the intensive care unit (ICU) for medical care. Medical records of patients admitted to the ICU were reviewed. Patients who continuously took statin for >1 month prior to ICU admission were defined as statin users. We investigated whether preadmission statin use was associated with AKI incidence within 72 h after ICU admission and whether the association differs according to preadmission estimated glomerular filtration rate (eGFR; in mL min−1 1.73 m−2). Among 21,236 patients examined, 5756 (27.1%) were preadmission statin users and 15,480 (72.9%) were non-statin users. Total AKI incidence within 72 h after ICU admission was 31% lower in preadmission statin users than in non-statin users [odds ratio (OR), 0.69; 95% confidence interval (CI), 0.61–0.79; p < 0.001]. This association was insignificant among individuals with eGFR <30 mL min−1 1.73 m−2 (p > 0.05). Our results suggested that preadmission statin therapy is associated with a lower incidence of AKI among critically ill patients; however, this effect might not be applicable for patients with eGFR <30 mL min−1 1.73 m−2. Full article
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Open AccessArticle
One-Year Progression and Risk Factors for the Development of Chronic Kidney Disease in Septic Shock Patients with Acute Kidney Injury: A Single-Centre Retrospective Cohort Study
J. Clin. Med. 2018, 7(12), 554; https://doi.org/10.3390/jcm7120554 - 15 Dec 2018
Cited by 3
Abstract
(1) Background: Sepsis-associated acute kidney injury (AKI) can lead to permanent kidney damage, although the long-term prognosis in patients with septic shock remains unclear. This study aimed to identify risk factors for the development of chronic kidney disease (CKD) in septic shock patients [...] Read more.
(1) Background: Sepsis-associated acute kidney injury (AKI) can lead to permanent kidney damage, although the long-term prognosis in patients with septic shock remains unclear. This study aimed to identify risk factors for the development of chronic kidney disease (CKD) in septic shock patients with AKI. (2) Methods: A single-site, retrospective cohort study was conducted using a registry of adult septic shock patients. Data from patients who had developed AKI between January 2011 and April 2017 were extracted, and 1-year follow-up data were analysed to identify patients who developed CKD. (3) Results: Among 2208 patients with septic shock, 839 (38%) had AKI on admission (stage 1: 163 (19%), stage 2: 339 (40%), stage 3: 337 (40%)). After one year, kidney function had recovered in 27% of patients, and 6% had progressed to CKD. In patients with stage 1 AKI, 10% developed CKD, and mortality was 13% at one year; in patients with stage 2 and 3 AKI, the CKD rate was 6%, and the mortality rate was 42% and 47%, respectively. Old age, female, diabetes, low haemoglobin levels and a high creatinine level at discharge were seen to be risk factors for the development of CKD. (4) Conclusions: AKI severity correlated with mortality, but it did not correlate with the development of CKD, and patients progressed to CKD, even when initial AKI stage was not severe. Physicians should focus on the recovery of renal function, and ensure the careful follow-up of patients with risk factors for the development of CKD. Full article
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Open AccessArticle
Utility of Novel Cardiorenal Biomarkers in the Prediction and Early Detection of Congestive Kidney Injury Following Cardiac Surgery
J. Clin. Med. 2018, 7(12), 540; https://doi.org/10.3390/jcm7120540 - 12 Dec 2018
Cited by 2
Abstract
Acute Kidney Injury (AKI) in the context of right ventricular failure (RVF) is thought to be largely congestive in nature. This study assessed the utility of biomarkers high sensitivity cardiac troponin T (hs-cTnT), N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP), and neutrophil gelatinase-associated lipocalin (NGAL) [...] Read more.
Acute Kidney Injury (AKI) in the context of right ventricular failure (RVF) is thought to be largely congestive in nature. This study assessed the utility of biomarkers high sensitivity cardiac troponin T (hs-cTnT), N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP), and neutrophil gelatinase-associated lipocalin (NGAL) for prediction and early detection of congestive AKI (c-AKI) following cardiac surgery. This prospective nested case-control study recruited 350 consecutive patients undergoing elective cardiac surgery requiring cardiopulmonary bypass. Cases were patients who developed (1) AKI (2) new or worsening RVF, or (3) c-AKI. Controls were patients free of these complications. Biomarker levels were measured at baseline after anesthesia induction and immediately postoperatively. Patients with c-AKI had increased mean duration of mechanical ventilation and length of stay in hospital and in the intensive care unit (p < 0.01). For prediction of c-AKI, baseline NT-proBNP yielded an area under the curve (AUC) of 0.74 (95% CI, 0.60–0.89). For early detection of c-AKI, postoperative NT-proBNP yielded an AUC of 0.78 (0.66–0.91), postoperative hs-cTnT yielded an AUC of 0.75 (0.58–0.92), and ∆hs-cTnT yielded an AUC of 0.80 (0.64–0.96). The addition of baseline creatinine to ∆hs-cTnT improved the AUC to 0.87 (0.76–0.99), and addition of diabetes improved the AUC to 0.93 (0.88–0.99). Δhs-cTnT alone, or in combination with baseline creatinine or diabetes, detects c-AKI with high accuracy following cardiac surgery. Full article
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Open AccessArticle
Preoperative Albuminuria and Intraoperative Chloride Load: Predictors of Acute Kidney Injury Following Major Abdominal Surgery
J. Clin. Med. 2018, 7(11), 431; https://doi.org/10.3390/jcm7110431 - 09 Nov 2018
Cited by 1
Abstract
Background: Postoperative Acute Kidney Injury (AKI) is a common and serious complication associated with significant morbidity and mortality. While several pre- and intra-operative risk factors for AKI have been recognized in cardiac surgery patients, relatively few data are available regarding the incidence and [...] Read more.
Background: Postoperative Acute Kidney Injury (AKI) is a common and serious complication associated with significant morbidity and mortality. While several pre- and intra-operative risk factors for AKI have been recognized in cardiac surgery patients, relatively few data are available regarding the incidence and risk factors for perioperative AKI in other surgical operations. The aim of the present study was to determine the risk factors for perioperative AKI in patients undergoing major abdominal surgery. Methods: This was a prospective, observational study of patients undergoing major abdominal surgery in a tertiary care center. Postoperative AKI was diagnosed according to the Acute Kidney Injury Network criteria within 48 h after surgery. Patients with chronic kidney disease stage IV or V were excluded. Logistic regression analysis was used to evaluate the association between perioperative factors and the risk of developing postoperative AKI. Results: Eleven out of 61 patients developed postoperative AKI. Four intra-operative variables were identified as predictors of AKI: intra-operative blood loss (p = 0.002), transfusion of fresh frozen plasma (p = 0.004) and red blood cells (p = 0.038), as well as high chloride load (p = 0.033, cut-off value > 500 mEq). Multivariate analysis demonstrated an independent association between AKI development and preoperative albuminuria, defined as a urinary Albumin to Creatinine ratio ≥ 30 mg·g−1 (OR = 6.88, 95% CI: 1.43–33.04, p = 0.016) as well as perioperative chloride load > 500 mEq (OR = 6.87, 95% CI: 1.46–32.4, p = 0.015). Conclusion: Preoperative albuminuria, as well as a high intraoperative chloride load, were identified as predictors of postoperative AKI in patients undergoing major abdominal surgery. Full article
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Open AccessArticle
Factors Associated with Early Mortality in Critically Ill Patients Following the Initiation of Continuous Renal Replacement Therapy
J. Clin. Med. 2018, 7(10), 334; https://doi.org/10.3390/jcm7100334 - 08 Oct 2018
Cited by 2
Abstract
Continuous renal replacement therapy (CRRT) is an important modality to support critically ill patients, and the need for CRRT treatment has been increasing. However, CRRT management is costly, and the associated resources are limited. Thus, it remains challenging to identify patients that are [...] Read more.
Continuous renal replacement therapy (CRRT) is an important modality to support critically ill patients, and the need for CRRT treatment has been increasing. However, CRRT management is costly, and the associated resources are limited. Thus, it remains challenging to identify patients that are likely to have a poor outcome, despite active treatment with CRRT. We sought to elucidate the factors associated with early mortality after CRRT initiation. We analyzed 240 patients who initiated CRRT at an academic medical center between September 2016 and January 2018. We compared baseline characteristics between patients who died within seven days of initiating CRRT (early mortality), and those that survived more than seven days beyond the initiation of CRRT. Of the patients assessed, 130 (54.2%) died within seven days of CRRT initiation. Multivariate logistic regression models revealed that low mean arterial pressure, low arterial pH, and high Sequential Organ Failure Assessment score before CRRT initiation were significantly associated with increased early mortality in patients requiring CRRT. In conclusion, the mortality within seven days following CRRT initiation was very high in this study. We identified several factors that are associated with early mortality in patients undergoing CRRT, which may be useful in predicting early outcomes, despite active treatment with CRRT. Full article
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Open AccessArticle
Derivation and Validation of Machine Learning Approaches to Predict Acute Kidney Injury after Cardiac Surgery
J. Clin. Med. 2018, 7(10), 322; https://doi.org/10.3390/jcm7100322 - 03 Oct 2018
Cited by 5
Abstract
Machine learning approaches were introduced for better or comparable predictive ability than statistical analysis to predict postoperative outcomes. We sought to compare the performance of machine learning approaches with that of logistic regression analysis to predict acute kidney injury after cardiac surgery. We [...] Read more.
Machine learning approaches were introduced for better or comparable predictive ability than statistical analysis to predict postoperative outcomes. We sought to compare the performance of machine learning approaches with that of logistic regression analysis to predict acute kidney injury after cardiac surgery. We retrospectively reviewed 2010 patients who underwent open heart surgery and thoracic aortic surgery. Baseline medical condition, intraoperative anesthesia, and surgery-related data were obtained. The primary outcome was postoperative acute kidney injury (AKI) defined according to the Kidney Disease Improving Global Outcomes criteria. The following machine learning techniques were used: decision tree, random forest, extreme gradient boosting, support vector machine, neural network classifier, and deep learning. The performance of these techniques was compared with that of logistic regression analysis regarding the area under the receiver-operating characteristic curve (AUC). During the first postoperative week, AKI occurred in 770 patients (38.3%). The best performance regarding AUC was achieved by the gradient boosting machine to predict the AKI of all stages (0.78, 95% confidence interval (CI) 0.75–0.80) or stage 2 or 3 AKI. The AUC of logistic regression analysis was 0.69 (95% CI 0.66–0.72). Decision tree, random forest, and support vector machine showed similar performance to logistic regression. In our comprehensive comparison of machine learning approaches with logistic regression analysis, gradient boosting technique showed the best performance with the highest AUC and lower error rate. We developed an Internet–based risk estimator which could be used for real-time processing of patient data to estimate the risk of AKI at the end of surgery. Full article
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Open AccessArticle
Safety Lapses Prior to Initiation of Hemodialysis for Acute Kidney Injury in Hospitalized Patients: A Patient Safety Initiative
J. Clin. Med. 2018, 7(10), 317; https://doi.org/10.3390/jcm7100317 - 01 Oct 2018
Cited by 1
Abstract
Background: Safety lapses in hospitalized patients with acute kidney injury (AKI) may lead to hemodialysis (HD) being required before renal recovery might have otherwise occurred. We sought to identify safety lapses that, if prevented, could reduce the need for unnecessary HD after AKI; [...] Read more.
Background: Safety lapses in hospitalized patients with acute kidney injury (AKI) may lead to hemodialysis (HD) being required before renal recovery might have otherwise occurred. We sought to identify safety lapses that, if prevented, could reduce the need for unnecessary HD after AKI; Methods: We conducted a retrospective observational study that included consecutive patients treated with HD for AKI at a large, tertiary academic center between 1 September 2015 and 31 August 2016. Exposures of interest were pre-specified iatrogenic processes that could contribute to the need for HD after AKI, such as nephrotoxic medication or potassium supplement administration. Other outcomes included time from AKI diagnosis to initial management steps, including Nephrology referral; Results: After screening 344 charts, 80 patients were included for full chart review, and 264 were excluded because they required HD within 72 h of admission, were deemed to have progression to end-stage kidney disease (ESKD), or required other renal replacement therapy (RRT) modalities in critical care settings such as continuous renal replacement therapy (CRRT) or sustained low efficiency dialysis (SLED). Multiple safety lapses were identified. Sixteen patients (20%) received an angiotensin converting enzyme inhibitor or angiotensin receptor blocker after AKI onset. Of 35 patients with an eventual diagnosis of pre-renal AKI due to hypovolemia, only 29 (83%) received a fluid bolus within 24 h. For 28 patients with hyperkalemia as an indication for starting HD, six (21%) had received a medication associated with hyperkalemia and 13 (46%) did not have a low potassium diet ordered. Nephrology consultation occurred after a median (IQR) time after AKI onset of 3.0 (1.0–5.7) days; Conclusions: Although the majority of patients had multiple indications for the initiation of HD for AKI, we identified many safety lapses related to the diagnosis and management of patients with AKI. We cannot conclude that HD initiation was avoidable, but, improving safety lapses may delay the need for HD initiation, thereby allowing more time for renal recovery. Thus, development of automated processes not only to identify AKI at an early stage but also to guide appropriate AKI management may improve renal recovery rates. Full article
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Open AccessArticle
Norepinephrine Administration Is Associated with Higher Mortality in Dialysis Requiring Acute Kidney Injury Patients with Septic Shock
J. Clin. Med. 2018, 7(9), 274; https://doi.org/10.3390/jcm7090274 - 12 Sep 2018
Cited by 2
Abstract
(1) Background: Norepinephrine (NE) is the first-line vasoactive agent used in septic shock patients; however, the effect of norepinephrine on dialysis-required septic acute kidney injury (AKI-D) patients is uncertain. (2) Methods: To evaluate the impact of NE on 90-day mortality and renal recovery [...] Read more.
(1) Background: Norepinephrine (NE) is the first-line vasoactive agent used in septic shock patients; however, the effect of norepinephrine on dialysis-required septic acute kidney injury (AKI-D) patients is uncertain. (2) Methods: To evaluate the impact of NE on 90-day mortality and renal recovery in septic AKI-D patients, we enrolled patients in intensive care units from 30 hospitals in Taiwan. (3) Results: 372 patients were enrolled and were divided into norepinephrine users and non-users. After adjustment by Inverse probability of treatment weighted (IPTW), there was no significant difference of baseline comorbidities between the two groups. NE users had significantly higher 90-day mortality rate and using NE is a strong predictor of 90-day mortality in the multivariate Cox regression (HR = 1.497, p = 0.027) after adjustment. The generalized additive model disclosed norepinephrine alone exerted a dose–dependent effect on 90-day mortality, while other vasoactive agents were not. (4) Conclusion: Using norepinephrine in septic AKI-D patients is associated with higher 90-day mortality and the effect is dose-dependent. Further study to explore the potential mechanism is needed. Full article
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Open AccessArticle
Risk of Incident Non-Valvular Atrial Fibrillation after Dialysis-Requiring Acute Kidney Injury
J. Clin. Med. 2018, 7(9), 248; https://doi.org/10.3390/jcm7090248 - 29 Aug 2018
Abstract
The influence of acute kidney injury (AKI) on subsequent incident atrial fibrillation (AF) has not yet been fully addressed. This retrospective nationwide cohort study was conducted using Taiwan’s National Health Insurance Research Database from 1 January 2000 to 31 December 2010. A total [...] Read more.
The influence of acute kidney injury (AKI) on subsequent incident atrial fibrillation (AF) has not yet been fully addressed. This retrospective nationwide cohort study was conducted using Taiwan’s National Health Insurance Research Database from 1 January 2000 to 31 December 2010. A total of 41,463 patients without a previous AF, mitral valve disease, and hyperthyroidism who developed de novo dialysis-requiring AKI (AKI-D) during their index hospitalization were enrolled. After propensity score matching, “non-recovery group” (n = 2895), “AKI-recovery group” (n = 2895) and “non-AKI group” (control group, n = 5790) were categorized. Within a follow-up period of 6.52 ± 3.88 years (median, 6.87 years), we found that the adjusted risks for subsequent incident AF were increased in both AKI-recovery group (adjusted hazard ratio (aHR) = 1.30; 95% confidence intervals (CI), 1.07–1.58; p ≤ 0.01) and non-recovery group (aHR = 1.62; 95% CI, 1.36–1.94) compared to the non-AKI group. Furthermore, the development of AF carried elevated risks for major adverse cardiac events (aHR = 2.11; 95% CI, 1.83–2.43), ischemic stroke (aHR = 1.33; 95% CI, 1.19–1.49), and all stroke (aHR = 1.28; 95% CI, 1.15–1.43). (all p ≤ 0.001, except otherwise expressed) The authors concluded that AKI-D, even in those who withdrew from temporary dialysis, independently increases the subsequent risk of de novo AF. Full article
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Open AccessArticle
Long-Term Outcomes in Patients with Incident Chronic Obstructive Pulmonary Disease after Acute Kidney Injury: A Competing-Risk Analysis of a Nationwide Cohort
J. Clin. Med. 2018, 7(9), 237; https://doi.org/10.3390/jcm7090237 - 24 Aug 2018
Abstract
Both acute kidney injury (AKI) and chronic obstructive pulmonary disease (COPD) are associated with increased morbidity and mortality. However, the incidence of de novo COPD in patients with AKI, and the impact of concurrent COPD on the outcome during post-AKI care is unclear. [...] Read more.
Both acute kidney injury (AKI) and chronic obstructive pulmonary disease (COPD) are associated with increased morbidity and mortality. However, the incidence of de novo COPD in patients with AKI, and the impact of concurrent COPD on the outcome during post-AKI care is unclear. Patients who recovered from dialysis-requiring AKI (AKI-D) during index hospitalizations between 1998 and 2010 were identified from nationwide administrative registries. A competing risk analysis was conducted to predict the incidence of adverse cardiovascular events and mortality. Among the 14,871 patients who recovered from temporary dialysis, 1535 (10.7%) were identified as having COPD (COPD group) one year after index discharge and matched with 1473 patients without COPD (non-COPD group) using propensity scores. Patients with acute kidney disease superimposed withs COPD were associated with a higher risk of incident ischemic stroke (subdistribution hazard ratio (sHR), 1.52; 95% confidence interval (95% CI), 1.17 to 1.97; p = 0.002) and congestive heart failure (CHF; sHR, 1.61; (95% CI), 1.39 to 1.86; p < 0.001). The risks of incident hemorrhagic stroke, myocardial infarction, end-stage renal disease, and mortality were not statistically different between the COPD and non-COPD groups. This observation adds another dimension to accumulating evidence regarding pulmo-renal consequences after AKI. Full article
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Open AccessArticle
Use of Estimating Equations for Dosing Antimicrobials in Patients with Acute Kidney Injury Not Receiving Renal Replacement Therapy
J. Clin. Med. 2018, 7(8), 211; https://doi.org/10.3390/jcm7080211 - 11 Aug 2018
Abstract
Acute kidney injury (AKI) can potentially lead to the accumulation of antimicrobial drugs with significant renal clearance. Drug dosing adjustments are commonly made using the Cockcroft-Gault estimate of creatinine clearance (CLcr). The Modified Jelliffe equation is significantly better at estimating kidney function than [...] Read more.
Acute kidney injury (AKI) can potentially lead to the accumulation of antimicrobial drugs with significant renal clearance. Drug dosing adjustments are commonly made using the Cockcroft-Gault estimate of creatinine clearance (CLcr). The Modified Jelliffe equation is significantly better at estimating kidney function than the Cockcroft-Gault equation in the setting of AKI. The objective of this study is to assess the degree of antimicrobial dosing discordance using different glomerular filtration rate (GFR) estimating equations. This is a retrospective evaluation of antimicrobial dosing using different estimating equations for kidney function in AKI and comparison to Cockcroft-Gault estimation as a reference. Considering the Cockcroft-Gault estimate as the criterion standard, antimicrobials were appropriately adjusted at most 80.7% of the time. On average, kidney function changed by 30 mL/min over the course of an AKI episode. The median clearance at the peak serum creatinine was 27.4 (9.3–66.3) mL/min for Cockcroft Gault, 19.8 (9.8–47.0) mL/min/1.73 m2 for MDRD and 20.5 (4.9–49.6) mL/min for the Modified Jelliffe equations. The discordance rate for antimicrobial dosing ranged from a minimum of 8.6% to a maximum of 16.4%. In the event of discordance, the dose administered was supra-therapeutic 100% of the time using the Modified Jelliffe equation. Use of estimating equations other than the Cockcroft Gault equation may significantly alter dosing of antimicrobials in AKI. Full article
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Open AccessArticle
Outcome Prediction of Acute Kidney Injury Biomarkers at Initiation of Dialysis in Critical Units
J. Clin. Med. 2018, 7(8), 202; https://doi.org/10.3390/jcm7080202 - 06 Aug 2018
Cited by 3
Abstract
The ideal circumstances for whether and when to start RRT remain unclear. The outcome predictive ability of acute kidney injury (AKI) biomarkers measuring at dialysis initializing need more validation. This prospective, multi-center observational cohort study enrolled 257 patients with AKI undergoing renal replacement [...] Read more.
The ideal circumstances for whether and when to start RRT remain unclear. The outcome predictive ability of acute kidney injury (AKI) biomarkers measuring at dialysis initializing need more validation. This prospective, multi-center observational cohort study enrolled 257 patients with AKI undergoing renal replacement therapy (RRT) shortly after admission. At the start of RRT, blood and urine samples were collected for relevant biomarker measurement. RRT dependence and all-cause mortality were recorded up to 90 days after discharge. Areas under the receiver operator characteristic (AUROC) curves and a multivariate generalized additive model were applied to predict outcomes. One hundred and thirty-five (52.5%) patients died within 90 days of hospital discharge. Plasma c-terminal FGF-23 (cFGF-23) had the best discriminative ability (AUROC, 0.687) as compared with intact FGF-23 (iFGF-23) (AUROC, 0.504), creatinine-adjusted urine neutrophil gelatinase-associated lipocalin (AUROC, 0.599), and adjusted urine cFGF-23 (AUROC, 0.653) regardless whether patients were alive or not on day 90. Plasma cFGF-23 levels above 2050 RU/mL were independently associated with higher 90-day mortality (HR 1.76, p = 0.020). Higher cFGF-23 levels predicted less weaning from dialysis in survivors (HR, 0.62, p = 0.032), taking mortality as a competing risk. Adding cFGF-23 measurement to the AKI risk predicting score significantly improved risk stratification and 90-day mortality prediction (total net reclassification improvement = 0.148; p = 0.002). In patients with AKI who required RRT, increased plasma cFGF-23 levels correlated with higher 90-day overall mortality after discharge and predicted worse kidney recovery in survivors. When coupled to the AKI risk predicting score, cFGF-23 significantly improved mortality risk prediction. This observation adds evidence that cFGF-23 could be used as an optimal timing biomarker to initiate RRT. Full article
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Review

Jump to: Research, Other

Open AccessReview
Utilizing the Patient Care Process to Minimize the Risk of Vancomycin-Associated Nephrotoxicity
J. Clin. Med. 2019, 8(6), 781; https://doi.org/10.3390/jcm8060781 - 01 Jun 2019
Abstract
Vancomycin-associated acute kidney injury (AKI) is a popular topic in the medical literature with few clear answers. While many studies evaluate the risk of AKI associated with vancomycin, few data are high quality and/or long in duration of follow-up. This review takes the [...] Read more.
Vancomycin-associated acute kidney injury (AKI) is a popular topic in the medical literature with few clear answers. While many studies evaluate the risk of AKI associated with vancomycin, few data are high quality and/or long in duration of follow-up. This review takes the clinician through an approach to evaluate a patient for risk of AKI. This evaluation should include patient assessment, antibiotic prescription, duration, and monitoring. Patient assessment involves evaluating severity of illness, baseline renal function, hypotension/vasopressor use, and concomitant nephrotoxins. Evaluation of antibiotic prescription includes evaluating the need for methicillin-resistant Staphylococcus aureus (MRSA) coverage and/or vancomycin use. Duration of therapy has been shown to increase the risk of AKI. Efforts to de-escalate vancomycin from the antimicrobial regimen, including MRSA nasal swabs and rapid diagnostics, should be used to lessen the likelihood of AKI. Adequate monitoring includes therapeutic drug monitoring, ongoing fluid status evaluations, and a continual reassessment of AKI risk. The issues with serum creatinine make the timely evaluation of renal function and diagnosis of the cause of AKI problematic. Most notably, concomitant piperacillin-tazobactam can increase serum creatinine via tubular secretion, resulting in higher rates of AKI being reported. The few studies evaluating the long-term prognosis of AKI in patients receiving vancomycin have found that few patients require renal replacement therapy and that the long-term risk of death is unaffected for patients surviving after the initial 28-day period. Full article
Open AccessReview
Meta-Analysis: Urinary Calprotectin for Discrimination of Intrinsic and Prerenal Acute Kidney Injury
J. Clin. Med. 2019, 8(1), 74; https://doi.org/10.3390/jcm8010074 - 10 Jan 2019
Abstract
Background: Urinary calprotectin is a novel biomarker that distinguishes between intrinsic or prerenal acute kidney injury (AKI) in different studies. However, these studies were based on different populations and different AKI criteria. We evaluated the diagnostic accuracy of urinary calprotectin and compared its [...] Read more.
Background: Urinary calprotectin is a novel biomarker that distinguishes between intrinsic or prerenal acute kidney injury (AKI) in different studies. However, these studies were based on different populations and different AKI criteria. We evaluated the diagnostic accuracy of urinary calprotectin and compared its diagnostic performance in different AKI criteria and study populations. Method: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched PubMed, Embase, and the Cochrane database up to September 2018. The diagnostic performance of urinary calprotectin (sensitivity, specificity, predictive ratio, and cutoff point) was extracted and evaluated. Result: This study included six studies with a total of 502 patients. The pooled sensitivity and specificity were 0.90 and 0.93, respectively. The pooled positive likelihood ratio (LR) was 15.15, and the negative LR was 0.11. The symmetric summary receiver operating characteristic (symmetric SROC) with pooled diagnostic accuracy was 0.9667. The relative diagnostic odds ratio (RDOC) of the adult to pediatric population and RDOCs of different acute kidney injury criteria showed no significant difference in their diagnostic accuracy. Conclusion: Urinary calprotectin is a good diagnostic tool for the discrimination of intrinsic and prerenal AKI under careful inspection after exclusion of urinary tract infection and urogenital malignancies. Its performance is not affected by different AKI criteria and adult or pediatric populations. Full article
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Open AccessReview
Acute Kidney Injury Definition and Diagnosis: A Narrative Review
J. Clin. Med. 2018, 7(10), 307; https://doi.org/10.3390/jcm7100307 - 28 Sep 2018
Cited by 8
Abstract
Acute kidney injury (AKI) is a complex syndrome characterized by a decrease in renal function and associated with numerous etiologies and pathophysiological mechanisms. It is a common diagnosis in hospitalized patients, with increasing incidence in recent decades, and associated with poorer short- and [...] Read more.
Acute kidney injury (AKI) is a complex syndrome characterized by a decrease in renal function and associated with numerous etiologies and pathophysiological mechanisms. It is a common diagnosis in hospitalized patients, with increasing incidence in recent decades, and associated with poorer short- and long-term outcomes and increased health care costs. Considering its impact on patient prognosis, research has focused on methods to assess patients at risk of developing AKI and diagnose subclinical AKI, as well as prevention and treatment strategies, for which an understanding of the epidemiology of AKI is crucial. In this review, we discuss the evolving definition and classification of AKI, and novel diagnostic methods. Full article

Other

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Open AccessPerspective
Why Have Detection, Understanding and Management of Kidney Hypoxic Injury Lagged behind Those for the Heart?
J. Clin. Med. 2019, 8(2), 267; https://doi.org/10.3390/jcm8020267 - 21 Feb 2019
Abstract
The outcome of patients with acute myocardial infarction (AMI) has dramatically improved over recent decades, thanks to early detection and prompt interventions to restore coronary blood flow. In contrast, the prognosis of patients with hypoxic acute kidney injury (AKI) remained unchanged over the [...] Read more.
The outcome of patients with acute myocardial infarction (AMI) has dramatically improved over recent decades, thanks to early detection and prompt interventions to restore coronary blood flow. In contrast, the prognosis of patients with hypoxic acute kidney injury (AKI) remained unchanged over the years. Delayed diagnosis of AKI is a major reason for this discrepancy, reflecting the lack of symptoms and diagnostic tools indicating at real time altered renal microcirculation, oxygenation, functional derangement and tissue injury. New tools addressing these deficiencies, such as biomarkers of tissue damage are yet far less distinctive than myocardial biomarkers and advanced functional renal imaging technologies are non-available in the clinical practice. Moreover, our understanding of pathogenic mechanisms likely suffers from conceptual errors, generated by the extensive use of the wrong animal model, namely warm ischemia and reperfusion. This model parallels mechanistically type I AMI, which properly represents the rare conditions leading to renal infarcts, whereas common scenarios leading to hypoxic AKI parallel physiologically type II AMI, with tissue hypoxic damage generated by altered oxygen supply/demand equilibrium. Better understanding the pathogenesis of hypoxic AKI and its management requires a more extensive use of models of type II-rather than type I hypoxic AKI. Full article
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Planned Papers

The below list represents only planned manuscripts. Some of these manuscripts have not been received by the Editorial Office yet. Papers submitted to MDPI journals are subject to peer-review.

Title 1: Novel Therapy and Future Implications in Management of Sepsis-associated Acute Kidney Injury 
Author Names: Wisit Kaewput , MD, Charat Thongprayoon, MD, Aldo Torres-Ortiz , MD, Michael A Mao, MD, Wisit Cheungpasitporn, MD

Title 2: Acute kidney injury in Patients Undergoing Total Hip Arthroplasty: A Systematic Review and Meta-analysis
Author Names: Charat Thongprayoon, MD, Patompong Ungprasert, MD, Tarun Bathini, MD, Wonngarm Kittanamongkolchai, MD, Wisit Cheungpasitporn, MD

Title 3: Incidence and Impact of Acute Kidney Injury after Liver Transplantation: A Meta-analysis
Author Names: Wisit Cheungpasitporn, MD, Charat Thongprayoon, MD, Michael A Mao, MD, Nadine Khoury, MD, Napat Leeaphorn, MD, Karn Wijarnpreecha, MD, Tarun Bathini, MD, Wisit Kaewput, MD

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