Chih-Hsiang Chang

Acute kidney injury classification: comparison of AKIN and RIFLE criteria.

The Acute Kidney Injury Network (AKIN) group has recently proposed modifications to the risk of renal failure, injury to kidney, failure of kidney function, loss of kidney function, and end-stage renal failure (RIFLE) classification system. The few studies that have compared the two classifications have revealed no substantial differences. This study aimed to compare the AKIN and RIFLE classifications for predicting outcome in critically ill patients. This retrospective study investigated the medical records of 291 critically ill patients who were treated in medical intensive care units of a tertiary care hospital between March 2003 and February 2006. This study compared performance of the RIFLE and AKIN criteria for diagnosing and classifying AKI and for predicting hospital mortality. Overall mortality rate was 60.8% (177/291). Increased mortality was progressive and significant (chi-square for trend; P < 0.001) based on the severity of AKIN and RIFLE classification. Hosmer and Lemeshow goodness-of-fit test results demonstrated good fit in both systems. The AKIN and RIFLE scoring systems displayed good areas under the receiver operating characteristic curves (0.720 ± 0.030, P = 0.001; 0.738 ± 0.030, P = 0.001, respectively). Compared with RIFLE criteria, this study indicated that AKIN classification does not improve the sensitivity and ability of outcome prediction in critically ill patients.

Serum interleukin-18 at commencement of renal replacement therapy predicts short-term prognosis in critically ill patients with acute kidney injury.

Background Acute kidney injury (AKI) requiring renal replacement therapy (RRT) in critically ill patients results in a high hospital mortality. Outcome prediction in this selected high-risk collective is challenging due to the lack of appropriate biomarkers. The aim of this study was to identify outcome-specific biomarkers in this patient population. Methodology/Principal Findings Serum samples were collected from 101 critically ill patients with AKI at the initiation of RRT in intensive care units (ICUs) of a tertiary care university hospital between August 2008 and March 2011. Measurements of serum levels of cystatin C (CysC), neutrophil gelatinase-associated lipocalin, and interleukin-18 (IL-18) were performed. The primary outcome measure was hospital mortality. The observed overall mortality rate was 56.4% (57/101). Multiple logistic regression analysis indicated that the serum IL-18 and CysC concentrations and Acute Physiology and Chronic Health Evaluation III (ACPACHE III) scores determined on the first day of RRT were independent predictors of hospital mortality. The APACHE III score had the best discriminatory power (0.872±0.041, p<0.001), whereas serum IL-18 had the best Youden index (0.65) and the highest correctness of prediction (83%). Cumulative survival rates at 6-month follow-up following hospital discharge differed significantly (p<0.001) for serum IL-18 <1786 pg/ml vs. ≥1786 pg/ml in these critically ill patients. Conclusions In this study, we confirmed the grave prognosis for critically ill patients at the commencement of RRT and found a strong correlation between serum IL-18 and the hospital mortality of ICU patients with dialysis-dependent AKI. In addition, we demonstrated that the APACHE III score has the best discriminative power for predicting hospital mortality in these critically ill patients.

Urinary Biomarkers Improve the Diagnosis of Intrinsic Acute Kidney Injury in Coronary Care Units

AbstractAcute kidney injury (AKI) is associated with increased morbidity and mortality and is frequently encountered in coronary care units (CCUs). Its clinical presentation differs considerably from that of prerenal or intrinsic AKI. We used the biomarkers calprotectin and neutrophil gelatinase-associated lipocalin (NGAL) and compared their utility in predicting and differentiating intrinsic AKI.This was a prospective observational study conducted in a CCU of a tertiary care university hospital. Patients who exhibited any comorbidity and a kidney stressor were enrolled. Urinary samples of the enrolled patients collected between September 2012 and August 2013 were tested for calprotectin and NGAL. The definition of AKI was based on Kidney Disease Improving Global Outcomes classification. All prospective demographic, clinical, and laboratory data were evaluated as predictors of AKI.A total of 147 adult patients with a mean age of 67 years were investigated. AKI was diagnosed in 71 (50.3%) patients, whereas intrinsic AKI was diagnosed in 43 (60.5%) of them. Multivariate logistic regression analysis revealed urinary calprotectin and serum albumin as independent risk factors for intrinsic AKI. For predicting intrinsic AKI, both urinary NGAL and calprotectin displayed excellent areas under the receiver operating characteristic curve (AUROC) (0.918 and 0.946, respectively). A combination of these markers revealed an AUROC of 0.946.Our result revealed that calprotectin and NGAL had considerable discriminative powers for predicting intrinsic AKI in CCU patients. Accordingly, careful inspection for medication, choice of therapy, and early intervention in patients exhibiting increased biomarker levels might improve the outcomes of kidney injury.

Acute Kidney Injury Classification for Critically Ill Cirrhotic Patients: A Comparison of the KDIGO, AKIN, and RIFLE Classifications.

Critically ill cirrhotic patients have high mortality rates, particularly when they present with acute kidney injury (AKI) on admission. The Kidney Disease: Improving Global Outcomes (KDIGO) group aimed to standardize the definition of AKI and recently published a new AKI classification. However, the efficacy of the KDIGO classification for predicting outcomes of critically ill cirrhotic patients is unclear. We prospectively enrolled 242 cirrhotic patients from a 10-bed specialized hepatogastroenterology intensive care unit (ICU) in a 2000-bed tertiary-care referral hospital. Demographic parameters and clinical variables on day 1 of admission were prospectively recorded. The overall in-hospital mortality rate was 62.8%. Liver diseases were usually attributed to hepatitis B viral infection (26.9%). The major cause of ICU admission was upper gastrointestinal bleeding (38.0%). Our result showed that the KDIGO classification had better discriminatory power than RIFLE and AKIN criteria in predicting in-hospital mortality. Cumulative survival rates at the 6-month after hospital discharge differed significantly between patients with and without AKI on ICU admission day. In summary, we identified that the outcome prediction performance of KDIGO classification is superior to that of AKIN or RIFLE classification in critically ill cirrhotic patients.

Prognostic factors and complication rates for double-filtration plasmapheresis in patients with Guillain–Barré syndrome

Guillain-Barré syndrome (GBS) is an acute immune-mediated demyelinating polyradiculoneuropathy that could lead to disabilities if not properly treated. There are only limited data on the prognostic factors and complications when using double-filtration plasmapheresis in these patients. We reviewed the medical records of 60 GBS patients who underwent double-filtration plasmapheresis as the first-line therapy at a tertiary care teaching hospital. The severity of disease was evaluated at different time points using disability scores. Functional outcome was defined as good (GBS disability score 0 to 2) or poor (GBS disability score 3 to 6) at 28 days after admission. The cohort included 22 women and 38 men with a mean age of 50u2009±u200918 years. In univariate logistic regression analysis, potential factors associated with poor outcome include an older age (Pu2009=u20090.101), the absence of preceding respiratory tract infection (Pu2009=u20090.043), mechanical ventilation (Pu2009=u20090.016), a lower hematocrit (pu2009=u20090.072), a lower serum sodium level (Pu2009=u20090.153) and a higher disability score on admission (Pu2009<u20090.001). In multivariate analysis, a higher disability score on admission was associated with a poorer outcome (OR, 5.61; 95% CI, 2.34 to 13.43; Pu2009<u20090.001), whereas the presence of prodromal upper respiratory tract infection correlated with a better outcome (OR, 0.13; 95% CI, 0.03-0.59; Pu2009=u20090.009). Among 60 patients, eleven (18.3%) have various complications attributed to plasmapheresis treatment. Six patients (10.0%) developed deep vein thrombosis and two experienced catheter-related infection (3.3%). Hypotension, allergy and hemolysis occurred in one patient each (1.7%). In conclusion, we describe our experiences of using DFPP in the treatment of GBS. The pretreatment severity score was the most significant predictor of treatment outcome, suggesting that early referral and timely treatment are important. Potential complications such as catheter-related infection and deep vein thrombosis should be monitored carefully.

Acute Kidney Injury Enhances Outcome Prediction Ability of Sequential Organ Failure Assessment Score in Critically Ill Patients

Introduction Acute kidney injury (AKI) is a common and serious complication in intensive care unit (ICU) patients and also often part of a multiple organ failure syndrome. The sequential organ failure assessment (SOFA) score is an excellent tool for assessing the extent of organ dysfunction in critically ill patients. This study aimed to evaluate the outcome prediction ability of SOFA and Acute Physiology and Chronic Health Evaluation (APACHE) III score in ICU patients with AKI. Methods A total of 543 critically ill patients were admitted to the medical ICU of a tertiary-care hospital from July 2007 to June 2008. Demographic, clinical and laboratory variables were prospectively recorded for post hoc analysis as predictors of survival on the first day of ICU admission. Results One hundred and eighty-seven (34.4%) patients presented with AKI on the first day of ICU admission based on the risk of renal failure, injury to kidney, failure of kidney function, loss of kidney function, and end-stage renal failure (RIFLE) classification. Major causes of the ICU admissions involved respiratory failure (58%). Overall in-ICU mortality was 37.9% and the hospital mortality was 44.7%. The predictive accuracy for ICU mortality of SOFA (areas under the receiver operating characteristic curves: 0.815±0.032) was as good as APACHE III in the AKI group. However, cumulative survival rates at 6-month follow-up following hospital discharge differed significantly (p<0.001) for SOFA score ≤10 vs. ≥11 in these ICU patients with AKI. Conclusions For patients coexisting with AKI admitted to ICU, this work recommends application of SOFA by physicians to assess ICU mortality because of its practicality and low cost. A SOFA score of ≥ “11” on ICU day 1 should be considered an indicator of negative short-term outcome.

Predicting Acute Kidney Injury Following Mitral Valve Repair

Background: Acute kidney injury (AKI) after cardiac surgery is associated with short-term and long-term adverse outcomes. Novel biomarkers have been identified for the early detection of AKI; however, examining these in every patient who undergoes cardiac surgery is prohibitively expensive. Society of Thoracic Surgeons (STS) and Age, Creatinine, and Ejection Fraction (ACEF) scores have been proven to predict mortality in bypass surgery. The aim of this study was to determine whether these scores can be used to predict AKI after mitral valve repair. Materials and Methods: Between January 2010 and December 2013, 196 patients who underwent mitral valve repair were enrolled. The clinical characteristics, outcomes, and scores of prognostic models were collected. The primary outcome was postoperative AKI, defined using the Kidney Disease Improving Global Outcome 2012 clinical practice guidelines for AKI. Results: A total of 76 patients (38.7%) developed postoperative AKI. The STS renal failure (AUROC: 0.797, P < .001) and ACEF scores (AUROC: 0.758, P < .001) are both satisfactory tools for predicting all AKI. The STS renal failure score exhibited superior accuracy compared with the ACEF score in predicting AKI stage 2 and 3. The overall accuracy of both scores was similar for all AKI and AKI stage 2 and 3 when the cut-off points of the STS renal failure and ACEF scores were 2.2 and 1.1, respectively. Conclusion: In conclusion, the STS renal failure score can be used to accurately predict stage 2 and 3 AKI after mitral valve repair. The ACEF score is a simple tool with satisfactory power in screening patients at risk of all AKI stages. Additional studies can aim to determine the clinical implications of combining preoperative risk stratification and novel biomarkers.

Society of Thoracic Surgeons Score Predicts Kidney Injury in Patients Not Undergoing Bypass Surgery

BACKGROUNDnAcute kidney injury (AKI) is an established indicator of all-cause mortality in a coronary care unit (CCU), and evaluating the risks of renal dysfunction can guide treatment decisions. In this study we used the Society of Thoracic Surgeons (STS) score to predict the incidence of AKI in CCU patients who had not undergone coronary artery bypass surgery (CABG) after a cardiac angiogram.nnnMETHODSnThe study cohort comprised 126 patients diagnosed with 2 or 3 coronary vessels disease who did not receive CABG during their hospital course. This study was performed in the CCU of a tertiary referral university hospital between September 2012 and August 2013. The STS score was evaluated with adjustment in all patients and the outcomes of the risk of mortality, morbidity, or mortality and renal failure were selected for predicting assessment. Furthermore, the performance of the STS scores was compared with that of other scoring systems.nnnRESULTSnA total of 28.5% (36 of 126) of the patients had AKI of varying severity. For predicting AKI, the STS renal failure score was excellent, with areas under the receiver operating characteristic curve of 0.851 ± 0.039, p < 0.001. When compared with other scoring systems, the STS renal failure score demonstrated the highest discriminatory power, the most favorable Youden index, and the highest overall correctness of prediction.nnnCONCLUSIONSnThe STS score is an effective tool for predicting AKI in patients with coronary artery disease who have not undergone CABG. Frequent monitoring of serum creatinine level or early application of AKI biomarkers are warranted for STS renal failure 5.7% or greater.

Application of the Age, Creatinine, and Left Ventricular Ejection Fraction Score for Patients on Extracorporeal Membrane Oxygenation.

Patients on extracorporeal membrane oxygenation (ECMO) usually have high mortality rate and poor outcome. Age, Creatinine, and Left Ventricular Ejection Fraction (ACEF) score is an easy-calculating score and provides good performance on mortality prediction in patients undergoing cardiac operations or percutaneous coronary intervention, but it has not been applied to patients on ECMO before. In this study, we aimed to use ACEF score obtained within 1 week of ECMO support for in-hospital mortality prediction in patients on ECMO due to severe myocardial failure. This study reviewed the medical records of 306 patients on ECMO at a specialized intensive care unit (CVSICU) in a tertiary-care university hospital between March 2002 and December 2011, and 105 patients on veno-arterial ECMO due to severe myocardial failure were enrolled. Demographic, clinical, and laboratory variables were retrospectively collected as survival predictors. The overall mortality rate was 47.6%. The most frequent condition requiring ICU admission was postcardiotomy cardiogenic shock. Multiple logistic regression analysis indicated that post-ECMO ACEF score, Sequential Organ Failure Assessment score, and troponin I on day 1 of ECMO support were independent risk factors for in-hospital mortality. Using the area under the receiver operating characteristic curve (AUROC), the post-ECMO ACEF score indicated a good discriminative power (AUROC 0.801u2009±u20090.042). Finally, cumulative survival rates at 6-month follow-up differed significantly (Pu2009<u20090.001) for an ACEF scoreu2009≤u20092.22 versus those with an ACEF scoreu2009>u20092.22. After ECMO treatment due to severe myocardial failure, post-ECMO ACEF score provides an easy-calculating method with a reproducible evaluation tool with excellent prognostic abilities in these patients.

Using acute kidney injury severity and scoring systems to predict outcome in patients with burn injury

BACKGROUND/PURPOSEnAcute kidney injury (AKI) is a frequent complication of severe burn injury and is associated with mortality. The definition of AKI was modified by the Kidney Disease Improving Global Outcomes Group in 2012. So far, no study has compared the outcome accuracy of the new AKI staging guidelines with that of the complex score system. Hence, we compared the accuracy of these approaches in predicting mortality.nnnMETHODSnThis was a post hoc analysis of prospectively collected data from an intensive care burn unit in a tertiary care university hospital. Patients admitted to this unit from July 2004 to December 2006 were enrolled. Demographic, clinical, and laboratory data and prognostic risk scores were used as predictors of mortality.nnnRESULTSnA total of 145 adult patients with a mean age of 41.9 years were studied. Thirty-five patients (24.1%) died during the hospital course. Among the prognostic risk models, the Acute Physiology and Chronic Health Evaluation III system exhibited the strongest discriminative power and the AKI staging system also predicted mortality well (areas under the receiver operating characteristic curve: 0.889 vs. 0.835). Multivariate logistic regression analysis identified total burn surface area, ventilator use, AKI, and toxic epidermal necrolysis as independent risk factors for mortality.nnnCONCLUSIONnOur results revealed that AKI stage has considerable discriminative power for predicting mortality. Compared with other prognostic models, AKI stage is easier to use to assess outcome in patients with severe burn injury.