RESUMO
OBJECT: This study aimed to analyse the risk factors and prognosis of sepsis complicated with acute kidney injury (AKI). METHODS: The clinical data of 324 patients with sepsis in the nephrology department of our hospital from January 2022 to January 2023 were collected. A total of 188 patients with AKI were the occurrence group, and 136 patients without AKI were the non-occurrence group. The influencing factors and prognosis of sepsis complicated with AKI were analysed. RESULTS: We observed significant differences in Acute Physiology and Chronic Health Evaluation II (APACHE II), total length of hospital stay, Intensive Care Unit (ICU) stay, mechanical ventilation support, diabetes mellitus and urine volume >1500 mL between the two groups (p < 0.05). After a follow-up period of 1 month, 125 (66.49%) of 188 patients with sepsis complicated with AKI died, and 63 (33.51%) survived. The results of logistic regression analysis showed that Sequential Organ Failure Assessment (SOFA), APACHE II, mechanical ventilation support, diabetes, urine volume >1500 mL and serum creatinine were independent risk factors of sepsis complicated with AKI (p < 0.05). Moreover, SOFA, APACHE II, ICU admission days, mechanical ventilation support, serum creatinine and non-continuous renal replacement therapy were independent risk factors of death in patients with sepsis complicated with AKI (p < 0.05). CONCLUSIONS: SOFA, APACHE II, ICU admission days, mechanical ventilation support, serum creatinine and non-continuous renal replacement therapy may be the influencing factors leading to death in patients with sepsis complicated with AKI. Early clinical intervention should be performed.
Assuntos
Injúria Renal Aguda, Sepse, Humanos, Injúria Renal Aguda/etiologia, Injúria Renal Aguda/terapia, Injúria Renal Aguda/complicações, Sepse/complicações, Masculino, Feminino, Fatores de Risco, Prognóstico, Pessoa de Meia-Idade, Idoso, Hospitalização, Estudos RetrospectivosRESUMO
To investigate the clinical features and death risk factors of pneumocystis jirovecii pneumonia (PJP) in kidney disease patients with immunosuppressive patients. A Retrospective case series study was performed in 52 PJP patients with kidney disease who received immunosuppressive therapy in Nephrology or Respiratory department of Peking University First Hospital from January 1, 2006 to August 31, 2021. Patients were divided into survival group (36 cases) and death group (16 cases) according to their clinical outcomes. Univariate analysis was performed to compare the differences of clinical features between the two groups. Multivariate logistic regression model was used to analyze the death risk factors. The results showed that the median serum creatinine was 192.5 (109.8, 293.7) µmol/L, and the incidence of acute kidney injury was 63.5% (33/52). Univariate analysis showed that age (t=1.197,P=0.030), C-reactive protein level (t=2.378,P=0.022), time from onset to diagnosis (χ2=6.62,P=0.010), PJP severity (χ2=5.482,P=0.019), complicated with septic shock (χ2=3.997,P=0.046), mechanical ventilation (χ2=11.755,P=0.001), and blood purification therapy (χ2=4.748,P=0.029) were statistically significant. There were no statistically significant differences between the two groups in gender, duration and dosage of hormone therapy before PJP onset, intravenous methylprednisolone pulse therapy, immunosuppressant use, and serum creatinine level before and after hospitalization for anti-PJP treatment (all P>0.05). Multivariate analysis showed that the time from onset to diagnosis of PJP was >10 days (OR=40.945, 95%CI: 1.738-451.214; P=0.021) and severe PJP (OR=25.502, 95%CI: 1.426-74.806; P=0.028) was an independent death risk factor for kidney disease complicated with PJP of immunosuppressive therapy. In conclusion, the time from onset to diagnosis of PJP and PJP severity are independent death risk factors in patients with kidney disease complicated with PJP of immunosuppressive therapy. Close attention should be paid to oxygenation condition and early diagnosis can prevent the aggravation of PJP and improve the prognosis.
Assuntos
Pneumocystis carinii, Pneumonia por Pneumocystis, Humanos, Estudos Retrospectivos, Fatores de Risco, Imunossupressores/uso terapêutico, Nefropatias, Masculino, Injúria Renal Aguda/etiologia, Feminino, Proteína C-Reativa/análise, Terapia de Imunossupressão, Pessoa de Meia-IdadeRESUMO
PURPOSE: To evaluate the impact of severe acute kidney injury (AKI) on short-term mortality in patients with urosepsis. METHODS: This prospective cohort study evaluated 207 patients with urosepsis. AKI was diagnosed in accordance with the Kidney Disease Improving Global Outcomes criteria, and severe AKI was defined as stage 2 or 3 AKI. Patients were divided into two groups: patients who developed severe AKI (severe AKI group) and patients who did not (control group). The primary endpoint was all-cause mortality within 30 days. The secondary endpoints were 90-day mortality and in-hospital mortality. The exploratory outcomes were the risk factors for severe AKI development. RESULTS: The median patient age was 79 years. Of the 207 patients, 56 (27%) developed severe AKI. The 30-day mortality rate in the severe AKI group was significantly higher than that in the control group (20% vs. 2.0%, respectively; P < 0.001). In the multivariable analysis, performance status and severe AKI were significantly associated with 30-day mortality. The in-hospital mortality and 90-day mortality rates in the severe AKI group were significantly higher than those in the control group (P < 0.001 and P < 0.001, respectively). In the multivariable analysis, age, urolithiasis-related sepsis, lactate values, and disseminated intravascular coagulation were significantly associated with severe AKI development. CONCLUSIONS: Severe AKI was a common complication in patients with urosepsis and contributed to high short-term mortality rates.
Assuntos
Injúria Renal Aguda, Mortalidade Hospitalar, Sepse, Índice de Gravidade de Doença, Infecções Urinárias, Humanos, Injúria Renal Aguda/mortalidade, Injúria Renal Aguda/etiologia, Feminino, Masculino, Sepse/complicações, Sepse/mortalidade, Idoso, Estudos Prospectivos, Infecções Urinárias/complicações, Infecções Urinárias/epidemiologia, Infecções Urinárias/mortalidade, Idoso de 80 Anos ou mais, Fatores de Tempo, Estudos de Coortes, Pessoa de Meia-Idade, Causas de MorteRESUMO
Incidence of acute kidney injury (AKI) remained relatively stable over the last decade and the adjusted risks for it and mortality are similar across different continents and regions. Also, the mortality of septic-AKI can reach 70% in critically-ill patients. These sole facts can give rise to a question: is there something we do not understand yet? Currently, there are no specific therapies for septic AKI and the treatment aims only to maintain the mean arterial pressure over 65mmHg by ensuring a good fluid resuscitation and by using vasopressors, along with antibiotics. On the other hand, there is an increased concern about the different hemodynamic changes in septic AKI versus other forms and the link between the gut microbiome and the severity of septic AKI. Fortunately, progress has been made in the form of administration of pre- and probiotics, short chain fatty acids (SCFA), especially acetate, and also broad-spectrum antibiotics or selective decontaminants of the digestive tract in a successful attempt to modulate the microbial flora and to decrease both the severity of AKI and mortality. In conclusion, septic-AKI is a severe form of kidney injury, with particular hemodynamic changes and with a strong link between the kidney and the gut microbiome. By modulating the immune response we could not only treat but also prevent severe forms. The most difficult part is to categorize patients and to better understand the key mechanisms of inflammation and cellular adaptation to the injury, as these mechanisms can serve in the future as target therapies.
Assuntos
Injúria Renal Aguda, Microbioma Gastrointestinal, Sepse, Humanos, Injúria Renal Aguda/terapia, Injúria Renal Aguda/etiologia, Microbioma Gastrointestinal/fisiologia, Sepse/complicações, Antibacterianos/uso terapêutico, Probióticos/uso terapêutico, Hidratação/métodosRESUMO
This study aimed to investigate the association between acute kidney injury (AKI) recovery subtypes and days alive out of hospital within the first 3 months (DAOH-90) in patients undergoing lung transplantation. Patients who underwent lung transplantation from January 2012 to December 2021 were retrospectively analyzed and stratified into three groups: no-AKI, early recovery AKI (within 7 days), and non-early recovery AKI group. AKI occurred in 86 (35%) of patients, of which 40 (16%) achieved early recovery, and the remaining 46 (19%) did not. The median DAOH-90 was 21 days shorter in the AKI than in the no-AKI (P = 0.002), and 29 days shorter in the non-early recovery AKI group than in the no-AKI group (P < 0.001). Non-early recovery AKI and preoperative tracheostomy status were independently associated with shorter DAOH-90. The prevalence of CKD (76%), and 1-year mortality (48%) were highest in the non-early recovery AKI group. Postoperative AKI was associated with an adverse patient-centered quality measure for perioperative care, and shorter DAOH-90. The non-early recovery AKI group exhibited the worst prognosis in terms of DAOH-90, CKD progression, and 1-year mortality, highlighting the important role of AKI and early-recovery AKI on both the quality of life and clinical outcomes after lung transplantation.
Assuntos
Injúria Renal Aguda, Transplante de Pulmão, Humanos, Injúria Renal Aguda/etiologia, Injúria Renal Aguda/epidemiologia, Transplante de Pulmão/efeitos adversos, Masculino, Feminino, Pessoa de Meia-Idade, Estudos Retrospectivos, Adulto, Complicações Pós-Operatórias/epidemiologia, Complicações Pós-Operatórias/etiologia, PrognósticoRESUMO
BACKGROUND: Type 3 cardiorenal syndrome (CRS type 3) triggers acute cardiac injury from acute kidney injury (AKI), raising mortality in AKI patients. We aimed to identify risk factors for CRS type 3 and develop a predictive nomogram. METHODS: In this retrospective study, 805 AKI patients admitted at the Department of Nephrology, Second Hospital of Shanxi Medical University from 1 January 2017, to 31 December 2021, were categorized into a study cohort (406 patients from 2017.1.1-2021.6.30, with 63 CRS type 3 cases) and a validation cohort (126 patients from 1 July 2021 to 31 Dec 2021, with 22 CRS type 3 cases). Risk factors for CRS type 3, identified by logistic regression, informed the construction of a predictive nomogram. Its performance and accuracy were evaluated by the area under the curve (AUC), calibration curve and decision curve analysis, with further validation through a validation cohort. RESULTS: The nomogram included 6 risk factors: age (OR = 1.03; 95%CI = 1.009-1.052; p = 0.006), cardiovascular disease (CVD) history (OR = 2.802; 95%CI = 1.193-6.582; p = 0.018), mean artery pressure (MAP) (OR = 1.033; 95%CI = 1.012-1.054; p = 0.002), hemoglobin (OR = 0.973; 95%CI = 0.96--0.987; p < 0.001), homocysteine (OR = 1.05; 95%CI = 1.03-1.069; p < 0.001), AKI stage [(stage 1: reference), (stage 2: OR = 5.427; 95%CI = 1.781-16.534; p = 0.003), (stage 3: OR = 5.554; 95%CI = 2.234-13.805; p < 0.001)]. The nomogram exhibited excellent predictive performance with an AUC of 0.907 in the study cohort and 0.892 in the validation cohort. Calibration and decision curve analyses upheld its accuracy and clinical utility. CONCLUSIONS: We developed a nomogram predicting CRS type 3 in AKI patients, incorporating 6 risk factors: age, CVD history, MAP, hemoglobin, homocysteine, and AKI stage, enhancing early risk identification and patient management.
Assuntos
Injúria Renal Aguda, Síndrome Cardiorrenal, Nomogramas, Humanos, Feminino, Masculino, Injúria Renal Aguda/diagnóstico, Injúria Renal Aguda/etiologia, Injúria Renal Aguda/sangue, Estudos Retrospectivos, Pessoa de Meia-Idade, Fatores de Risco, Síndrome Cardiorrenal/diagnóstico, Síndrome Cardiorrenal/complicações, Síndrome Cardiorrenal/etiologia, Idoso, Medição de Risco/métodos, China/epidemiologia, Modelos Logísticos, AdultoRESUMO
Background: During the acute heart failure (AHF), acute kidney injury (AKI) is highly prevalent in critically ill patients. The occurrence of the latter condition increases the risk of mortality in patients with acute heart failure. The current research on the relationship between nutritional risk and the occurrence of acute kidney injury in patients with acute heart failure is very limited. Methods: This retrospective cohort study utilized data from the Medical Information Mart for Intensive Care IV (MIMIC-IV, version 2.1) database. We included adult patients with AHF who were admitted to the intensive care unit in the study. Results: A total of 1310 critically ill patients with acute heart failure were included. The AUC of geriatric nutritional risk index (GNRI) (0.694) is slightly superior to that of controlling nutritional status (CONUT) (0.656) and prognostic nutritional index (PNI) (0.669). The Log-rank test revealed a higher risk of acute kidney injury in patients with high nutritional risk (p < 0.001). Multivariate COX regression analysis indicated that a high GNRI (adjusted HR 0.62, p < 0.001) was associated with a reduced risk of AKI during hospitalization in AHF patients. The final subgroup analysis demonstrated no significant interaction of GNRI in all subgroups except for diabetes subgroup and ventilation subgroup (P for interaction: 0.057-0.785). Conclusion: Our study findings suggest a correlation between GNRI and the occurrence of acute kidney injury in patients hospitalized with acute heart failure.
Assuntos
Injúria Renal Aguda, Estado Terminal, Insuficiência Cardíaca, Unidades de Terapia Intensiva, Avaliação Nutricional, Estado Nutricional, Humanos, Insuficiência Cardíaca/epidemiologia, Insuficiência Cardíaca/complicações, Feminino, Masculino, Injúria Renal Aguda/epidemiologia, Injúria Renal Aguda/etiologia, Estudos Retrospectivos, Idoso, Unidades de Terapia Intensiva/estatística & dados numéricos, Pessoa de Meia-Idade, Idoso de 80 Anos ou mais, Fatores de Risco, Medição de Risco, Avaliação Geriátrica, Prognóstico, Modelos de Riscos ProporcionaisRESUMO
OBJECTIVE: To explore the relationship between lactate-to-albumin ratio (LAR) at ICU admission and prognosis in critically ill patients with acute kidney injury (AKI). METHODS: A retrospective analysis was conducted. Patients were divided into low (<0.659) LAR and high LAR (≥0.659) groups. Least absolute shrinkage and selection operator regression analysis was conducted to select variables associated with the 30-day prognosis. Cox regression analyses were performed to assess the association between LAR and mortality. Kaplan-Meier curves were plotted to compare cumulative survival rates between high and low LAR groups. Subgroup analysis was employed to assess the stability of the results. ROC curve was used to determine the diagnostic efficacy of LAR on prognosis. RESULTS: A nonlinear relationship was observed between LAR and the risk of 30-day and 360-day all-cause mortality in AKI patients (p < 0.001). Cox regulation showed that high LAR (≥ 0.659) was an independent risk factor for 30-day and 360-day all-cause mortality in patients with AKI (p < 0.001). The Kaplan-Meier survival curves demonstrated a noteworthy decrease in cumulative survival rates at both 30 and 360 days for the high LAR group in comparison to the low LAR group (p < 0.001). Subgroup analyses demonstrated the stability of the results. ROC curves showed that LAR had a diagnostic advantage when compared with lactate or albumin alone (p < 0.001). CONCLUSION: High LAR (≥0.659) at ICU admission was an independent risk factor for both short-term (30-day) and long-term (360-day) all-cause mortality in patients with AKI.
Assuntos
Injúria Renal Aguda, Estado Terminal, Unidades de Terapia Intensiva, Ácido Láctico, Curva ROC, Humanos, Injúria Renal Aguda/sangue, Injúria Renal Aguda/diagnóstico, Injúria Renal Aguda/mortalidade, Injúria Renal Aguda/etiologia, Masculino, Feminino, Estudos Retrospectivos, Pessoa de Meia-Idade, Prognóstico, Idoso, Ácido Láctico/sangue, Unidades de Terapia Intensiva/estatística & dados numéricos, Albumina Sérica/análise, Estimativa de Kaplan-Meier, Fatores de Risco, Biomarcadores/sangue, Modelos de Riscos Proporcionais, Taxa de Sobrevida, Adulto, Relevância ClínicaRESUMO
Kidney ischemia and reperfusion injury (IRI) is a significant contributor to acute kidney injury (AKI), characterized by tubular injury and kidney dysfunction. Salvador family WW domain containing protein 1 (SAV1) is a key component of the Hippo pathway and plays a crucial role in the regulation of organ size and tissue regeneration. However, whether SAV1 plays a role in kidney IRI is not investigated. In this study, we investigated the role of SAV1 in kidney injury and regeneration following IRI. A proximal tubule-specific knockout of SAV1 in kidneys (SAV1ptKO) was generated, and wild-type and SAV1ptKO mice underwent kidney IRI or sham operation. Plasma creatinine and blood urea nitrogen were measured to assess kidney function. Histological studies, including periodic acid-Schiff staining and immunohistochemistry, were conducted to assess tubular injury, SAV1 expression, and cell proliferation. Western blot analysis was employed to assess the Hippo pathway-related and proliferation-related proteins. SAV1 exhibited faint expression in the proximal tubules and was predominantly expressed in the connecting tubule to the collecting duct. At 48 h after IRI, SAV1ptKO mice continued to exhibit severe kidney dysfunction, compared to attenuated kidney dysfunction in wild-type mice. Consistent with the functional data, severe tubular damage induced by kidney IRI in the cortex was significantly decreased in wild-type mice at 48 h after IRI but not in SAV1ptKO mice. Furthermore, 48 h after IRI, the number of Ki67-positive cells in the cortex was significantly higher in wild-type mice than SAV1ptKO mice. After IRI, activation and expression of Hippo pathway-related proteins were enhanced, with no significant differences observed between wild-type and SAV1ptKO mice. Notably, at 48 h after IRI, protein kinase B activation (AKT) was significantly enhanced in SAV1ptKO mice compared to wild-type mice. This study demonstrates that SAV1 deficiency in the kidney proximal tubule worsens the injury and delays kidney regeneration after IRI, potentially through the overactivation of AKT.
Assuntos
Injúria Renal Aguda, Proteínas de Ciclo Celular, Túbulos Renais Proximais, Camundongos Knockout, Traumatismo por Reperfusão, Animais, Traumatismo por Reperfusão/metabolismo, Traumatismo por Reperfusão/patologia, Traumatismo por Reperfusão/genética, Túbulos Renais Proximais/metabolismo, Túbulos Renais Proximais/patologia, Camundongos, Injúria Renal Aguda/metabolismo, Injúria Renal Aguda/patologia, Injúria Renal Aguda/etiologia, Injúria Renal Aguda/genética, Proteínas de Ciclo Celular/metabolismo, Proteínas de Ciclo Celular/genética, Masculino, Proliferação de Células, Transdução de Sinais, Via de Sinalização Hippo, Camundongos Endogâmicos C57BL, Modelos Animais de DoençasRESUMO
Acute kidney injury (AKI) following surgery with cardiopulmonary bypass (CPB-AKI) is common in pediatrics. Urinary liver-type fatty acid binding protein (uL-FABP) increases in some kidney diseases and may indicate CPB-AKI earlier than current methods. The aim of this systematic review with meta-analysis was to evaluate the potential role of uL-FABP in the early diagnosis and prediction of CPB-AKI. Databases Pubmed/MEDLINE, Scopus, and Web of Science were searched on 12 November 2023, using the MeSH terms "Children", "CPB", "L-FABP", and "Acute Kidney Injury". Included papers were revised. AUC values from similar studies were pooled by meta-analysis, performed using random- and fixed-effect models, with p < 0.05. Of 508 studies assessed, nine were included, comprising 1658 children, of whom 561 (33.8%) developed CPB-AKI. Significantly higher uL-FABP levels in AKI versus non-AKI patients first manifested at baseline to 6 h post-CPB. At 6 h, uL-FABP correlated with CPB duration (r = 0.498, p = 0.036), postoperative serum creatinine (r = 0.567, p < 0.010), and length of hospital stay (r = 0.722, p < 0.0001). Importantly, uL-FABP at baseline (AUC = 0.77, 95% CI: 0.64-0.89, n = 365), 2 h (AUC = 0.71, 95% CI: 0.52-0.90, n = 509), and 6 h (AUC = 0.76, 95% CI: 0.72-0.80, n = 509) diagnosed CPB-AKI earlier. Hence, higher uL-FABP levels associate with worse clinical parameters and may diagnose and predict CPB-AKI earlier.
Assuntos
Injúria Renal Aguda, Biomarcadores, Ponte Cardiopulmonar, Proteínas de Ligação a Ácido Graxo, Humanos, Injúria Renal Aguda/etiologia, Injúria Renal Aguda/urina, Injúria Renal Aguda/diagnóstico, Injúria Renal Aguda/sangue, Ponte Cardiopulmonar/efeitos adversos, Proteínas de Ligação a Ácido Graxo/urina, Proteínas de Ligação a Ácido Graxo/sangue, Biomarcadores/urina, Criança, Procedimentos Cirúrgicos Cardíacos/efeitos adversos, Complicações Pós-Operatórias/urina, Complicações Pós-Operatórias/etiologia, Complicações Pós-Operatórias/diagnóstico, Pré-EscolarRESUMO
BACKGROUND AND OBJECTIVES: Acute kidney injury (AKI) is one of the most common and severe clinical syndromes of diffuse proliferative lupus nephritis (DPLN), of which poor prognosis is indicated by aggravated renal function deterioration. However, the specific therapy and mechanisms of AKI in DPLN remain to be explored. METHODS: The correlation between AKI and clinical pathological changes in DPLN patients was analyzed. Expression of STAT3 signaling was detected in MRL/lpr mice with DPLN using immunohistochemical staining and immunoblotting. Inhibition of STAT3 activation by combination therapy was assessed in MRL/lpr mice. RESULTS: Correlation analysis revealed only the interstitial leukocytes were significantly related to AKI in endocapillary DPLN patients. MRL/lpr mice treated with vehicle, which can recapitulate renal damages of DPLN patients, showed upregulation of STAT3, pSTAT3 and caspase-1 in renal cortex. FLLL32 combined with methylprednisolone therapy significantly inhibited the STAT3 activation, improved acute kidney damage, reduced the interstitial infiltration of inflammatory cells and decreased the AKI incidence in MRL/lpr mice. CONCLUSION: STAT3 activation may play an important role in the pathogenesis of DPLN and the development of AKI. Hence, STAT3 inhibition based on the combination of FLLL32 with methylprednisolone may represent a new strategy for treatment of DPLN with AKI.
Assuntos
Injúria Renal Aguda, Modelos Animais de Doenças, Nefrite Lúpica, Camundongos Endogâmicos MRL lpr, Fator de Transcrição STAT3, Animais, Nefrite Lúpica/tratamento farmacológico, Nefrite Lúpica/patologia, Nefrite Lúpica/metabolismo, Fator de Transcrição STAT3/metabolismo, Fator de Transcrição STAT3/antagonistas & inibidores, Camundongos, Feminino, Injúria Renal Aguda/tratamento farmacológico, Injúria Renal Aguda/metabolismo, Injúria Renal Aguda/etiologia, Humanos, Metilprednisolona/uso terapêutico, Rim/patologia, Rim/efeitos dos fármacos, Transdução de Sinais/efeitos dos fármacos, Adulto, MasculinoRESUMO
As no unified treatment protocol or evidence yet exists for plasmapheresis without plasma, this study explored the outcomes of using 4% human albumin (ALB) solution as a replacement solution in patients undergoing plasma exchange for multiple myeloma (MM) patients with acute kidney injury (AKI). This study was prospectively registered (ChiCTR2000030640 and NCT05251896). Bortezomib-based chemotherapy plus therapeutic plasmapheresis (TPP) with 4% human ALB solution was assessed for three years in patients with MM aged >18 years, with AKI according to the Kidney Disease Improving Global Outcomes criteria, and without previous renal impairment from other causes. The primary endpoints were changes in renal function over 18 weeks and survival outcomes at 36 months. The secondary endpoints were the incidence of adverse reactions and symptom improvement. Among the 119 patients included in the analysis, 108 experienced renal reactions. The M protein (absolute changes: median -12.12%, interquartile ranges (IQRs) -18.62 to -5.626) and creatine (median -46.91 µmol/L, IQR -64.70 to -29.12) levels decreased, whereas the estimated glomerular filtration rate (eGFR) increased (median 20.66 mL/(min·1.73 m2), IQR 16.03-25.29). Regarding patient survival, 68.1% and 35.3% of patients survived for >12 and >36 months, respectively. The three symptoms with the greatest relief were urine foam, poor appetite, and blurred vision. All 11 patients (7.6%) who experienced mild adverse reactions achieved remission. In conclusion, in MM patients with AKI, plasma-free plasmapheresis with 4% human ALB solution and bortezomib-based chemotherapy effectively alleviated light chain damage to kidney function while improving patient quality of life.
Assuntos
Injúria Renal Aguda, Bortezomib, Taxa de Filtração Glomerular, Mieloma Múltiplo, Plasmaferese, Humanos, Mieloma Múltiplo/complicações, Mieloma Múltiplo/terapia, Injúria Renal Aguda/terapia, Injúria Renal Aguda/etiologia, Plasmaferese/métodos, Masculino, Feminino, Pessoa de Meia-Idade, Estudos Prospectivos, Idoso, Bortezomib/administração & dosagem, Bortezomib/uso terapêutico, Estudo de Prova de Conceito, Albumina Sérica Humana/análise, Albumina Sérica Humana/administração & dosagem, Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico, Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos, Resultado do Tratamento, Adulto, Terapia Combinada, Proteínas do MielomaRESUMO
BACKGROUND: Multiple myeloma (MM) is a malignant disorder characterized by monoclonal differentiated plasma cells. While it is more commonly diagnosed in elderly individuals, it can also affect younger populations, though with a lower incidence. CASE PRESENTATION: Here, we present the case of a 32-year-old woman diagnosed with IgA lambda MM. She presented with fatigue, nausea, acute kidney injury (AKI) with a rapid increase in creatinine, and anemia. A kidney biopsy was done to rule out a rapidly progressive glomerular disease and a diagnosis was thus reached. A genetic workup revealed t(14;16) translocation and an extra copy of TP53. The patient received aggressive intravenous steroids and intravenous fluid resuscitation, resulting in an improvement in renal function. Treatment with daratumumab in combination with bortezomib, thalidomide, and dexamethasone was initiated and well tolerated. Despite the generally poor prognosis of IgA MM, our case emphasizes the importance of considering MM in young patients with unexplained kidney injury. CONCLUSION: Early recognition and prompt intervention are essential in managing MM patients, especially in those with high-risk cytogenetic abnormalities. This case serves as a reminder for clinicians to maintain a high index of suspicion for MM, even in younger populations, when presented with unexplained kidney injury.
Assuntos
Injúria Renal Aguda, Mieloma Múltiplo, Proteinúria, Translocação Genética, Humanos, Feminino, Adulto, Mieloma Múltiplo/complicações, Mieloma Múltiplo/genética, Mieloma Múltiplo/diagnóstico, Mieloma Múltiplo/tratamento farmacológico, Proteinúria/etiologia, Injúria Renal Aguda/etiologia, Injúria Renal Aguda/genética, Imunoglobulina A, Cadeias lambda de Imunoglobulina/genética, Cromossomos Humanos Par 14/genéticaRESUMO
Background: Recent studies have demonstrated a strong association between acute kidney injury (AKI) and chronic kidney disease (CKD), while the unresolved inflammation is believed to be a driving force for this chronic transition process. As a transmembrane pattern recognition receptor, Mincle (macrophage-inducible C-type lectin, Clec4e) was identified to participate in the early immune response after AKI. However, the impact of Mincle on the chronic transition of AKI remains largely unclear. Methods: We performed single-cell RNA sequencing (scRNA-seq) with the unilateral ischemia-reperfusion (UIR) murine model of AKI at days 1, 3, 14 and 28 after injury. Potential effects and mechanism of Mincle on renal inflammation and fibrosis were further validated in vivo utilizing Mincle knockout mice. Results: The dynamic expression of Mincle in macrophages and neutrophils throughout the transition from AKI to CKD was observed. For both cell types, Mincle expression was significantly up-regulated on day 1 following AKI, with a second rise observed on day 14. Notably, we identified distinct subclusters of Minclehigh neutrophils and Minclehigh macrophages that exhibited time-dependent influx with dual peaks characterized with remarkable pro-inflammatory and pro-fibrotic functions. Moreover, we identified that Minclehigh neutrophils represented an "aged" mature neutrophil subset derived from the "fresh" mature neutrophil cluster in kidney. Additionally, we observed a synergistic mechanism whereby Mincle-expressing macrophages and neutrophils sustained renal inflammation by tumor necrosis factor (TNF) production. Mincle-deficient mice exhibited reduced renal injury and fibrosis following AKI. Conclusion: The present findings have unveiled combined persistence of Minclehigh neutrophils and macrophages during AKI-to-CKD transition, contributing to unresolved inflammation followed by fibrosis via TNF-α as a central pro-inflammatory cytokine. Targeting Mincle may offer a novel therapeutic strategy for preventing the transition from AKI to CKD.
Assuntos
Injúria Renal Aguda, Modelos Animais de Doenças, Lectinas Tipo C, Macrófagos, Proteínas de Membrana, Camundongos Knockout, Neutrófilos, Insuficiência Renal Crônica, Animais, Lectinas Tipo C/metabolismo, Lectinas Tipo C/genética, Injúria Renal Aguda/etiologia, Injúria Renal Aguda/imunologia, Injúria Renal Aguda/metabolismo, Macrófagos/imunologia, Macrófagos/metabolismo, Neutrófilos/imunologia, Neutrófilos/metabolismo, Camundongos, Insuficiência Renal Crônica/imunologia, Insuficiência Renal Crônica/etiologia, Insuficiência Renal Crônica/metabolismo, Insuficiência Renal Crônica/patologia, Proteínas de Membrana/genética, Proteínas de Membrana/metabolismo, Masculino, Inflamação/imunologia, Camundongos Endogâmicos C57BL, Traumatismo por Reperfusão/imunologia, Traumatismo por Reperfusão/metabolismo, Fibrose, Progressão da DoençaRESUMO
OBJECTIVES: To evaluate the clinical and laboratory features, complications, and outcomes of patients with rhabdomyolysis in the Saudi population. METHODS: Retrospectives descriptive study of adult patients who presented to King Abdulaziz Medical City (KAMC) withrhabdomyolysis between January 2016 and December 2022. RESULTS: Most of the participants (84.5%) were male, with a median age of 41 years and a body mass index of 26.5 kg/m2. Medications, mainly statins (22.4%) and illicit drugs (15.5%), constituted the root causes of rhabdomyolysis in the cohort (44.8%). The most common presenting complaints were myalgia (63.8%) and fatigue (37.9%). More than one-third of the participants (32.8%) developed AKI, with 3 patients requiring temporary hemodialysis, and only 8.6% developed acute liver failure (ALF). Intensive care unit (ICU) admission was required for 10 patients (17.2%), and the overall mortality rate was 8.6%. Patients who developed complications (composite outcomes of AKI, ALF, multiorgan failure, or death) had significantly reduced kidney function and higher levels of blood urea nitrogen, anion gap, and uric acid upon admission than those who did not. CONCLUSION: This study offers a thorough understanding of clinical and laboratory features, causes, complications, and outcomes of rhabdomyolysis among Saudi patients. The insights gained enhance our understanding of rhabdomyolysis within this population, providing a foundation for future research and improvements in clinical management.
Assuntos
Injúria Renal Aguda, Rabdomiólise, Centros de Atenção Terciária, Humanos, Rabdomiólise/epidemiologia, Rabdomiólise/etiologia, Rabdomiólise/complicações, Rabdomiólise/terapia, Masculino, Feminino, Adulto, Pessoa de Meia-Idade, Arábia Saudita/epidemiologia, Injúria Renal Aguda/epidemiologia, Injúria Renal Aguda/etiologia, Injúria Renal Aguda/terapia, Injúria Renal Aguda/mortalidade, Estudos Retrospectivos, Falência Hepática Aguda/mortalidade, Falência Hepática Aguda/epidemiologia, Falência Hepática Aguda/terapia, Falência Hepática Aguda/etiologia, Falência Hepática Aguda/complicações, Unidades de Terapia Intensiva, Diálise Renal, Insuficiência de Múltiplos Órgãos/etiologia, Insuficiência de Múltiplos Órgãos/epidemiologia, Insuficiência de Múltiplos Órgãos/mortalidade, Fadiga/etiologia, Adulto JovemRESUMO
INTRODUCTION: Acute kidney injury (AKI) is an abrupt deterioration of kidney function. The incidence of pediatric AKI is increasing worldwide, both in critically and non-critically ill settings. We aimed to characterize the presentation, etiology, evolution, and outcome of AKI in pediatric patients admitted to a tertiary care center. METHODS: We performed a retrospective observational single-center study of patients aged 29 days to 17 years and 365 days admitted to our Pediatric Nephrology Unit from January 2012 to December 2021, with the diagnosis of AKI. AKI severity was categorized according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. The outcomes considered were death or sequelae (proteinuria, hypertension, or changes in renal function at 3 to 6 months follow-up assessments). RESULTS: Forty-six patients with a median age of 13.0 (3.5-15.5) years were included. About half of the patients (n = 24, 52.2%) had an identifiable risk factor for the development of AKI. Thirteen patients (28.3%) were anuric, and all of those were categorized as AKI KDIGO stage 3 (p < 0.001). Almost one quarter (n = 10, 21.7%) of patients required renal replacement therapy. Approximately 60% of patients (n = 26) had at least one sequelae, with proteinuria being the most common (n = 15, 38.5%; median (P25-75) urinary protein-to-creatinine ratio 0.30 (0.27-0.44) mg/mg), followed by reduced glomerular filtration rate (GFR) (n = 11, 27.5%; median (P25-75) GFR 75 (62-83) mL/min/1.73 m2). CONCLUSIONS: Pediatric AKI is associated with substantial morbidity, with potential for proteinuria development and renal function impairment and a relevant impact on long-term prognosis.
Assuntos
Injúria Renal Aguda, Centros de Atenção Terciária, Humanos, Injúria Renal Aguda/etiologia, Injúria Renal Aguda/diagnóstico, Injúria Renal Aguda/epidemiologia, Estudos Retrospectivos, Criança, Centros de Atenção Terciária/estatística & dados numéricos, Adolescente, Feminino, Masculino, Pré-Escolar, Nefrologia, Fatores de Risco, Lactente, Índice de Gravidade de Doença, Terapia de Substituição Renal, ProteinúriaRESUMO
AIM: To evaluate a potential role of different patterns of intrarenal blood flow using Doppler ultrasound as a part of determining the severity of venous congestion, predicting impairment of renal function and an unfavorable prognosis in patients with acute decompensated chronic heart failure (ADCHF). MATERIAL AND METHODS: This prospective observational single-site study included 75 patients admitted in the intensive care unit for ADCHF. Upon admission all patients underwent bedside renal venous Doppler ultrasound to determine the blood flow pattern (continuous, biphasic, monophasic). In one hour after the initiation of intravenous diuretic therapy, sodium concentration was measured in a urine sample. The primary endpoint was the development of acute kidney injury (AKI). The secondary endpoints were the development of diuretic resistance (a need to increase the furosemide daily dose by more than 2 times compared with the baseline), decreased natriuretic response (defined as urine sodium concentration less than 50-70 mmol/l), and in-hospital death. RESULTS: According to the data of Doppler ultrasound, normal renal blood flow was observed in 40 (53%) patients, biphasic in 21 (28%) patients, and monophasic in 14 (19%) patients. The monophasic pattern of intrarenal blood flow was associated with the highest incidence of AKI: among 14 patients in this group, AKI developed in 100% of cases (OR 3.8, 95% CI: 2.5-5.8, p<0.01), while among patients with normal and moderate impairment of renal blood flow, there was no significant increase in the risk of developing AKI. The odds of in-hospital death were increased 25.77 times in patients with monophasic renal blood flow (95% CI: 5.35-123.99, p<0.001). Patients with a monophasic intrarenal blood flow pattern were also more likely to develop diuretic resistance compared to patients with other blood flow patterns (p<0.001) and had a decreased sodium concentration to less than 50 mmol/l (p<0.001) in a spot urine test obtained one hour after the initiation of furosemide administration. CONCLUSION: Patients with monophasic intrarenal blood flow are at a higher risk of developing AKI, diuretic resistance with decreased natriuretic response, and in-hospital death.
Assuntos
Injúria Renal Aguda, Insuficiência Cardíaca, Hemodinâmica, Humanos, Feminino, Masculino, Insuficiência Cardíaca/fisiopatologia, Idoso, Prognóstico, Estudos Prospectivos, Injúria Renal Aguda/fisiopatologia, Injúria Renal Aguda/etiologia, Pessoa de Meia-Idade, Circulação Renal/fisiologia, Ultrassonografia Doppler/métodos, Diuréticos/administração & dosagem, Rim/fisiopatologiaRESUMO
INTRODUCTION: Acute kidney injury (AKI) is associated with increased risk of heart failure (HF). Determining the type of HF experienced by AKI survivors (heart failure with preserved or reduced ejection fraction, HFpEF or HFrEF) could suggest potential mechanisms underlying the association and opportunities for improving post-AKI care. METHODS: In this retrospective study of adults within the Vanderbilt University health system with a diagnosis of HF, we tested whether AKI events in the two years preceding incident HF associated more with HFpEF or HFrEF while controlling for known predictors. HF outcomes were defined by administrative codes and classified as HFpEF or HFrEF by echocardiogram data. We used multivariable logistic regression models to estimate the effects of AKI on the odds of incident HFpEF versus HFrEF. RESULTS: AKI (all stages) trended towards a preferential association with HFpEF in adjusted analyses (adjusted OR 0.80, 95% CI 0.63 - 1.01). Stage 1 AKI was associated with higher odds of HFpEF that was statistically significant (adjusted OR 0.62, 95% CI 0.43 - 0.88), whereas stages 2-3 AKI showed a trend toward HFrEF that did not reach statistical significance (adjusted OR 1.11, 95% CI 0.76 - 1.63). CONCLUSIONS: AKI as a binary outcome trended towards a preferential association with HFpEF. Stage 1 AKI was associated with higher odds of HFpEF, whereas stage 2-3 trended towards an association with HFrEF that did not meet statistical significance. Different mechanisms may predominate in incident HF following mild versus more severe AKI. Close follow-up with particular attention to volume status and cardiac function after discharge is warranted after even mild AKI.
