Electronic alert outpatient protocol improves the quality of care for the risk of postcontrast acute kidney injury following computed tomography

Prevention and diagnosis of postcontrast acute kidney injury (AKI) after contrast-enhanced computed tomography is burdensome in outpatient department. We investigated whether an electronic alert system could improve prevention and diagnosis of postcontrast AKI. Methods: In March 2018, we launched an electronic alert system that automatically identifies patients with a baseline estimated glomerular filtration rate of <45 mL/min/1.73 m2, provides a prescription of fluid regimen, and recommends a follow-up for serum creatinine measurement. Participants prescribed contrast-enhanced computed tomography at outpatient department before and after the launch of the system were categorized as historical and alert group, respectively. Propensity for the surveillance of postcontrast AKI was compared using logistic regression. Risks of AKI, admission, mortality, and renal replacement therapy were analyzed. Results: The historical and alert groups included 289 and 309 participants, respectively. The alert group was more likely to be men and take diuretics. The most frequent volume of prophylactic fluid in historical and alert group was 1,000 and 750 mL, respectively. Follow-up for AKI was more common in the alert group (adjusted odds ratio, 6.00; p < 0.001). Among them, incidence of postcontrast AKI was not statistically different. The two groups did not differ in risks of admission, mortality, or renal replacement therapy. Conclusion: The electronic alert system could assist in the detection of high-risk patients, prevention with reduced fluid volume, and proper diagnosis of postcontrast AKI, while limiting the prescribing clinicians’ burden. Whether the system can improve long-term outcomes remains unclear.

Comparison of dominant and nondominant C3 deposition in primary glomerulonephritis

Alternative complement pathway dysregulation plays a key role in glomerulonephritis (GN) and is associated with C3 deposition. Herein, we examined pathological and clinical differences between cases of primary GN with C3-dominant (C3D-GN) and nondominant (C3ND-GN) deposition. Methods: We extracted primary GN data from the Korean GlomeruloNEphritis sTudy (KoGNET). C3D-GN was defined as C3 staining two grades greater than C1q, C4, and immunoglobulin via immunofluorescence analysis. To overcome a large difference in the number of patients between the C3D-GN and C3ND-GN groups (31 vs. 9,689), permutation testing was used for analysis. Results: The C3D-GN group exhibited higher serum creatinine (p ≤ 0.001), a greater prevalence of estimated glomerular filtration rate of <60 mL/min/1.72 m2 (p ≤ 0.001), higher (but not significantly so) C-reactive protein level, and lower serum C3 level (p ≤ 0.001). Serum albumin, urine protein/creatinine ratio, number of patients who progressed to end-stage renal disease, and all-cause mortality were comparable between groups. Interstitial fibrosis and mesangial cellularity were greater in the C3D-GN group (p = 0.04 and p = 0.01, respectively) than in the C3ND-GN group. C3 deposition was dominant in the former group (p < 0.001), in parallel with increased subendothelial deposition (p ≤ 0.001). Conclusion: Greater progression of renal injury and higher mortality occurred in patients with C3D-GN than with C3ND-GN, along with pathologic differences in interstitial and mesangial changes.

Additive harmful effects of acute kidney injury and acute heart failure on mortality in hospitalized patients

Organ crosstalk between the kidney and the heart has been suggested. Acute kidney injury (AKI) and acute heart failure (AHF) are well-known independent risk factors for mortality in hospitalized patients. This study aimed to investigate if these conditions have an additive effect on mortality in hospitalized patients, as this has not been explored in previous studies. Methods: We retrospectively reviewed the records of 101,804 hospitalized patients who visited two tertiary hospitals in the Republic of Korea over a period of 5 years. AKI was diagnosed using serum creatinine-based criteria, and AHF was classified using International Classification of Diseases codes within 2 weeks after admission. Patients were divided into four groups according to the two conditions. The primary outcome was all-cause mortality. Results: AKI occurred in 6.8% of all patients (n = 6,920) and AHF in 1.2% (n = 1,244). Three hundred thirty-one patients (0.3%) developed both conditions while AKI alone was present in 6,589 patients (6.5%) and AHF alone in 913 patients (0.9%). Among the 5,181 patients (5.1%) who died, 20.8% died within 1 month. The hazard ratio for 1-month mortality was 29.23 in patients with both conditions, 15.00 for AKI only, and 3.39 for AHF only. The relative excess risk of interaction was 11.85 (95% confidence interval, 2.43–21.27), and was more prominent in patients aged <75 years and those without chronic heart failure. Conclusion: AKI and AHF have a detrimental additive effect on short-term mortality in hospitalized patients.

Long-term risk of all-cause mortality in live kidney donors: a matched cohort study

Long-term outcomes of live kidney donors remain controversial, although this information is crucial for selecting potential donors. Thus, this study compared the long-term risk of all-cause mortality between live kidney donors and healthy control. Methods: We performed a retrospective cohort study including donors from seven tertiary hospitals in South Korea. Persons who underwent voluntary health screening were included as controls. We created a matched control group considering age, sex, era, body mass index, baseline hypertension, diabetes, estimated glomerular filtration rate, and dipstick albuminuria. The study outcome was progression to end-stage kidney disease (ESKD), and all-cause mortality as identified in the linked claims database. Results: We screened 1,878 kidney donors and 78,115 health screening examinees from 2003 to 2016. After matching, 1,701 persons remained in each group. The median age of the matched study subjects was 44 years, and 46.6% were male. Among the study subjects, 2.7% and 16.6% had underlying diabetes and hypertension, respectively. There were no ESKD events in the matched donor and control groups. There were 24 (1.4%) and 12 mortality cases (0.7%) in the matched donor and control groups, respectively. In the age-sex adjusted model, the risk for all-cause mortality was significantly higher in the donor group than in the control group. However, the significance was not retained after socioeconomic status was included as a covariate (adjusted hazard ratio, 1.82; 95% confidence interval, 0.87–3.80). Conclusion: All-cause mortality was similar in live kidney donors and matched non-donor healthy controls with similar health status and socioeconomic status in the Korean population.

Renal outcomes of laparoscopic versus open surgery in patients with rectal cancer: a propensity score analysis

Background@#A laparoscopic approach is widely used in abdominal surgery. Although several studies have compared surgical and oncological outcomes between laparoscopic surgery (LS) and open surgery (OS) in rectal cancer patients, there have been few studies on postoperative renal outcomes. @*Methods@#We conducted a retrospective cohort study involving 1,633 patients who underwent rectal cancer surgery between 2003 and 2017. Postoperative acute kidney injury (AKI) was diagnosed according to the serum creatinine criteria of the Kidney Disease: Improving Global Outcomes classification. @*Results@#Among the 1,633 patients, 1,072 (65.6%) underwent LS. After matching propensity scores, 395 patients were included in each group. The incidence of postoperative AKI in the LS group was significantly lower than in the OS group (9.9% vs. 15.9%; p = 0.01). Operation time, estimated blood loss, and incidence of transfusion in the LS group were significantly lower than those in the OS group. Cox proportional hazard models revealed that LS was associated with decreased risk of postoperative AKI (hazard ratio [HR], 0.599; 95% confidence interval [CI], 0.402–0.893; p = 0.01) and postoperative transfusion was associated with increased risk of AKI (HR, 2.495; 95% CI, 1.529–4.072; p < 0.001). In the subgroup analysis, the incidence of postoperative AKI in patients with middle or high rectal cancer who underwent LS was much lower than in those who underwent OS (HR, 0.373; 95% CI, 0.197–0.705; p = 0.002). @*Conclusion@#This study showed that LS may have a favorable effect on the development of postoperative AKI in patients with rectal cancer.

Metabolic risks in living kidney donors in South Korea

Background@#Considering the growing prevalence of Western lifestyles and related chronic diseases occurring in South Korea, this study aimed to explore the progression of metabolic risk factors in living kidney donors compared to a control group. @*Methods@#This study enrolled living kidney donors from seven hospitals from 1982 to 2016. The controls were individuals that voluntarily received health check-ups from 1995 to 2016 that were matched with donors according to age, sex, diabetes status, baseline estimated glomerular filtration rate, and date of the medical record. Data on hyperuricemia, hypertension, hypercholesterolemia, and overweight/obesity were collected to determine metabolic risks. The proportion of individuals with three or more metabolic risk factors was evaluated. Logistic regressions with interaction terms between the medical record date and donor status were used to compare the trends in metabolic risks over time in the two groups. @*Results@#A total of 2,018 living kidney donors and matched non-donors were included. The median age was 44.0 years (interquartile range, 34.0–51.0 years) and 54% were women. The living kidney donors showed a lower absolute prevalence for all metabolic risk factors, except for those that were overweight/obese, than the non-donors. The proportion of subjects that were overweight/obese was consistently higher over time in the donor group. The changes over time in the prevalence of each metabolic risk were not significantly different between groups, except for a lower prevalence of metabolic risk factors ≥ 3 in donors. @*Conclusion@#Over time, metabolic risks in living kidney donors are generally the same as in non-donors, except for a lower prevalence of metabolic risk factors ≥ 3 in donors.

Effect of estimating equations for glomerular filtration rate on novel surrogate markers for renal outcome

Background@#s: Recently, alternative surrogate endpoints such as a 30% or 40% decline in estimated glomerular filtration rate (eGFR) or eGFR slope over 2 to 3 years have been proposed for predicting renal outcomes. However, the impact of GFR estimation methods on the accuracy and effectiveness of surrogate markers is unknown. @*Methods@#We retrospectively enrolled participants in health screening programs at three hospitals from 1995 to 2009. We defined two different participant groups as YR1 and YR3, which had available 1-year or 3-year eGFR values along with their baseline eGFR levels. We compared the effectiveness of eGFR percentage change or slope to estimate end-stage renal disease (ESRD) risk according to two estimating equations (modified Modification of Diet in Renal Disease equation [eGFRm] and Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation [eGFRc]) for GFR. @*Results@#In the YR1 and YR3 groups, 9,971 and 10,171 candidates were enrolled and ESRD incidence during follow-up was 0.26% and 0.19%, respectively. The eGFR percentage change was more effective than eGFR slope in estimating ESRD risk, regardless of the method of estimation. A 40% of decline in eGFR was better than 30%, and a 3-year baseline period was better than a 1-year period for prediction accuracy. Although some diagnostic indices from the CKD-EPI equation were better, we found no significant differences in the discriminative ability and hazard ratios for incident ESRD between eGFRc and eGFRm in either eGFR percentage change or eGFR slope. @*Conclusion@#There were no significant differences in the prediction accuracy of GFR percentage change or eGFR slope between eGFRc and eGFRm in the general population.

Effect of estimating equations for glomerular filtration rate on novel surrogate markers for renal outcome

Background@#s: Recently, alternative surrogate endpoints such as a 30% or 40% decline in estimated glomerular filtration rate (eGFR) or eGFR slope over 2 to 3 years have been proposed for predicting renal outcomes. However, the impact of GFR estimation methods on the accuracy and effectiveness of surrogate markers is unknown. @*Methods@#We retrospectively enrolled participants in health screening programs at three hospitals from 1995 to 2009. We defined two different participant groups as YR1 and YR3, which had available 1-year or 3-year eGFR values along with their baseline eGFR levels. We compared the effectiveness of eGFR percentage change or slope to estimate end-stage renal disease (ESRD) risk according to two estimating equations (modified Modification of Diet in Renal Disease equation [eGFRm] and Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation [eGFRc]) for GFR. @*Results@#In the YR1 and YR3 groups, 9,971 and 10,171 candidates were enrolled and ESRD incidence during follow-up was 0.26% and 0.19%, respectively. The eGFR percentage change was more effective than eGFR slope in estimating ESRD risk, regardless of the method of estimation. A 40% of decline in eGFR was better than 30%, and a 3-year baseline period was better than a 1-year period for prediction accuracy. Although some diagnostic indices from the CKD-EPI equation were better, we found no significant differences in the discriminative ability and hazard ratios for incident ESRD between eGFRc and eGFRm in either eGFR percentage change or eGFR slope. @*Conclusion@#There were no significant differences in the prediction accuracy of GFR percentage change or eGFR slope between eGFRc and eGFRm in the general population.

Association of ambulatory blood pressure monitoring with renal outcome in patients with chronic kidney disease

Background@#The significance of ambulatory blood pressure (ABP) in Korean patients with chronic kidney disease (CKD) in relation to renal outcome or death remains unclear. We investigated the role of ABP in predicting end-stage renal disease or death in patients with CKD. @*Methods@#We enrolled 387 patients with hypertension and CKD who underwent ABP monitoring and were followed for 1 year. Data on clinical parameters and outcomes from August 2014 to May 2018 were retrospectively collected. The composite endpoint was end-stage renal disease or death. Patients were grouped according to the mean ABP. @*Results@#There were 66 endpoint events, 52 end-stage renal disease cases, and 15 mortalities. Among all patients, one developed end-stage renal disease and died. Mean ABP in the systolic and diastolic phases were risk factors for the development of composite outcome with hazard ratios of 1.03 (95% confidence interval [CI], 1.01-1.04; P < 0.001) and 1.04 (95% CI, 1.02-1.07; P = 0.001) for every 1 mmHg increase in BP, respectively. Patients with mean ABP between 125/75 and 130/80 mmHg had a 2.56-fold higher risk for the development of composite outcome (95% CI, 0.72-9.12; P = 0.147) as compared to those with mean ABP ≤ 125/75 mmHg. Patients with mean ABP ≥ 130/80 mmHg had a 4.79-fold higher risk (95% CI, 1.68-13.70; P = 0.003) compared to those with mean ABP ≤ 125/75 mmHg. Office blood pressure (OBP) was not a risk factor for the composite outcome when adjusted for covariates. @*Conclusion@#In contrast to OBP, ABP was a significant risk factor for end-stage renal disease or death in CKD patients.

Glycemic Efficacy and Metabolic Consequences of an Empagliflozin Add-on versus Conventional Dose-Increasing Strategy in Patients with Type 2 Diabetes Inadequately Controlled by Metformin and Sulfonylurea

Background@#We assessed the glucose-lowering efficacy of adding empagliflozin versus dose escalating existing medications in patients with uncontrolled type 2 diabetes (T2D). @*Methods@#This was a 6-month retrospective case-control study in subjects with uncontrolled T2D (glycated hemoglobin [HbA1c] >7%) on conventional treatment. The study group started add-on therapy with empagliflozin (10 mg once a day) while the control group was up-titrated with existing medication, using either monotherapy or a combination of metformin, sulfonylurea, and a dipeptidyl peptidase-4 inhibitor. The primary endpoints included changes in HbA1c, fasting plasma glucose (FPG), and 2-hour postprandial glucose (PP2) levels. Secondary outcomes included changes in body composition, body mass index (BMI), and serum ketone bodies, and urinary excretion of sodium, potassium, chlorine, calcium, phosphorus, and glucose. @*Results@#After treatment, the reduction in HbA1c was significantly greater in the empagliflozin group than in controls (from 8.6%±1.6% to 7.6%±1.5% vs. 8.5%±1.1% to 8.1%±1.1%; P<0.01). Similar patterns were found in FPG and PP2 levels. Empagliflozin decreased systolic and diastolic blood pressure, triglycerides, and alanine and aspartate aminotransferase levels. Body weight, BMI, waist circumference, fat mass, and abdominal visceral fat area decreased significantly while lean body mass was maintained. Total ketones, β-hydroxybutyrate, and acetoacetate levels increased significantly after empagliflozin. @*Conclusion@#In addition to glucose lowering, an empagliflozin add-on regimen decreased blood pressure and body fat, and improved metabolic profiles significantly. Empagliflozin add-on is superior to dose escalation in patients with T2D who have inadequate glycemic control on standard medications.

Current findings of kidney biopsy including nephropathy associated with hypertension anddiabetes mellitus in Korea

Background/Aims@#This study aimed to investigate long-term temporal trends and outcomes of biopsy-proven kidney diseases in a multicenter kidney biopsy cohort, focusing on hypertension and diabetes, the leading causes of end-stage kidney disease (ESKD). @*Methods@#The study included a total of 21,426 patients who underwent kidney biopsy from 1979 to 2018 in 18 hospitals in Korea. We selected subgroups of adults with diabetes (n = 2,813) or clinically presumed hypertensive nephrosclerosis (HTN, n = 2,917). Clinical, demographic, and laboratory data were collected in conjunction with pathologic findings. The prevalence of pathologically confirmed kidney diseases over time and their associations with clinical outcomes were evaluated. @*Results@#The prevalence of biopsy-proven diabetic nephropathy (DN) has increased significantly from 2.5% to 6.0% in the total cohort in the recent 30 yearswith an increase in the prevalence of diabetes. Approximately 68% of total diabeticpatients had non-diabetic renal disease (NDRD); the proportion was retained since 2000s. DN showed a significantly higher risk of ESKD than NDRD (hazard ratio [HR], 1.59; 95% confidence interval [CI], 1.35 to 1.88). The prevalence of biopsy- proven HT-N remained < 2% in the total cohort for several decades. There was no difference in risks of ESKD between patients with or without biopsy-proven HT-N (HR, 0.93; 95% CI, 0.54 to 1.59). @*Conclusions@#In recent decades, the prevalence of diabetes and DN has significantlyincreased in the kidney biopsy cohort, showing an increased risk of ESKD. Despite the large numbers of patients meeting the clinical criteria of HT-N, most of those were diagnosed with pathologic diagnoses other than HT-N.

Association between Serum Uric Acid Level and ESRD or Death in a Korean Population

Background@#Serum uric acid (SUA) is recognized as a risk factor for chronic kidney disease (CKD) and mortality. However, there is controversy as to whether a high or low level of SUA is related to the risk of CKD progression or death, and whether it differs between males and females. @*Methods@#We included 143,762 adults who underwent voluntary health screening between 1995 and 2009 in Korea. For each sex, we divided participants into sex-specific quintiles according to SUA levels and compared end-stage renal disease (ESRD) incidence and mortality between the groups with low and high SUA levels and those with middle SUA levels. Sex-specific Cox proportional hazard analyses were performed for ESRD and all-cause mortality. @*Results@#Among the 143,762 participants, 0.2% (n = 272) developed ESRD. The hazard ratio (HR) of ESRD was higher in the highest (adjusted HR, 2.13; 95% confidence interval [CI], 1.18–3.84) and lowest (adjusted HR, 1.90; 95% CI, 1.02–3.51) SUA quintiles than in the middle SUA quintile in males and the highest SUA quintile in females (adjusted HR, 2.31; 95% CI, 1.10–4.84). Four-point three percent (n = 6,215) of participants died during a mean follow-up period of 157 months. The hazard ratio (HR) of all-cause mortality was higher in the highest SUA quintile than in the middle SUA quintile in males (adjusted HR, 1.15; 95% CI, 1.03–1.28) and females (adjusted HR, 1.17; 95% CI, 1.01–1.35). @*Conclusion@#Elevated levels of SUA are associated with increased risk for ESRD and all-cause mortality in both sexes. Low levels of SUA might be related to ESRD and death only in males, showing U-shaped associations. Our findings suggest sex-specific associations between SUA levels and ESRD development and mortality.

Long-term Renal Outcome of Biopsy-proven Acute Tubular Necrosis and Acute Interstitial Nephritis

Background@#Although emerging evidence suggest acute kidney injury (AKI) progress to chronic kidney disease (CKD), long-term renal outcome of AKI still remains unclear. Acute tubular necrosis (ATN) is the most common cause of AKI due to ischemia, toxin or sepsis. Acute interstitial nephritis (AIN), caused by drugs or autoimmune diseases is also increasingly recognized as an important cause of AKI. Unlike glomerular diseases, AKI is usually diagnosed in the clinical context without kidney biopsies, and lack of histology might contribute to this uncertainty. @*Methods@#Among 8,769 biopsy series, 253 adults who were histologically diagnosed with ATN and AIN from 1982 to 2018 at five university hospitals were included. Demographic and pathological features that are associated with the development of end stage renal disease (ESRD) were also examined. @*Results@#Rate of non-recovery of renal function at 6 month was significantly higher in the AIN (ATN vs AIN 49.3 vs 69.4%, P = 0.007) with a 2.71-fold higher risk of non- recovery compared to ATN (95% confidence interval [CI], 1.20–6.47). During the mean follow up of 76.5 ± 91.9 months, ESRD developed in 39.4% of patients with AIN, and 21.5% patients of ATN. The risk of ESRD was significantly higher in AIN (23.05; 95% CI, 2.42–219.53) and also in ATN (12.14; 95% CI, 1.19–24.24) compared to control with non-specific pathology. Older age, female gender, renal function at the time of biopsy and at 6 months, proteinuria and pathological features including interstitial inflammation and fibrosis, tubulitis, vascular lesion were significantly associated with progression to ESRD. @*Conclusion@#Our study demonstrated that patients with biopsy proven ATN and AIN are at high risk of developing ESRD. AIN showed higher rate of non-renal recovery at 6 month than ATN.

Severe Hypocalcemia in a Patient with Tuberous Sclerosis Complex

Tuberous sclerosis complex (TSC) is an autosomal dominant genetic disorder affecting multiple organs, including the brain, skin, lung, and kidney. Among the multiple comorbidities in TSC, bone mineral disturbances remain relatively unrecognized, and only a few studies have reported alteration in calcium homeostasis. Hypocalcemia is a serious medical condition in patients with TSC who are at high risk for seizures. Therefore, hypocalcemia should be thoroughly evaluated by obtaining a history of associated medication use and measuring vitamin D levels. Here, we report the case of a patient with TSC who presented with severe hypocalcemia which may have been related to a history of anticonvulsant use and a recent decline in kidney function, and was successfully treated with calcium and vitamin D replacement.

Patient Participation in Patient Safety and Its Relationships with Nurses' Patient-Centered Care Competency, Teamwork, and Safety Climate

PURPOSE: This study's aim was to examine degrees of patient participation in patient safety activities in hospitals and to investigate their relationships with nurses' patient-centered care competency (PCC), teamwork, and safety climate. METHODS: A cross-sectional study designwas used. Data were collected with 479 nurses from two general hospitals in Seoul, Korea, using a questionnaire designed to collect data on patient participation in patient safety activities, PCC, teamwork perceptions, and safety climate. The response rate was 74.1% (N = 355). Data were analyzed using descriptive statistics and multiple logistic regression analysis. RESULTS: The mean score for patient participation was 2.76 ± 0.46 of 4.0. The mean scores for PCC, teamwork, and safety climate were 3.61 ± 0.46, 3.64 ± 0.41, and 3.35 ± 0.57 of 5.0, respectively. Nurses who experienced high patient participation in patient safety activities (≥ 3.0) had higher scores for PCC, teamwork, and safety climate. Multiple logistic regression analysis revealed that PCC (OR = 2.31, 95% CI = 1.14–4.70) and safety climate (OR = 2.51, 95% CI = 1.09–5.78) scores were the significant factors associated with patient participation. CONCLUSION: The degree of patient participation in patient safety activities was not high. Nurses' PCC, teamwork, and safety climate were positively related with patient participation. In particular, the findings indicate that enhancing nurses' competency for patient-centered care and creating a strong safety climate are important to promote patient participation for safer health care.

Optimal systolic blood pressure in noncritically ill patients with acute kidney injury: A retrospective cohort study

BACKGROUND: Few data showed the optimal blood pressure (BP) in noncritically ill patients with acute kidney injury (AKI) relative to mortality or severe AKI. We therefore sought to analyze the data that exist for the ideal target range for BP in noncritically ill patients with AKI. METHODS: We performed a retrospective cohort study involving 1,612 hospitalized patients who were diagnosed with AKI using the Kidney Disease: Improving Global Outcomes definition based on serum creatinine measurements for a period of 1 year. The average systolic BP (SBP) was categorized into 10-mmHg increments (within 48 hours after the development of AKI). The primary outcome was a composite of severe AKI or 90-day mortality. RESULTS: The composite outcome rate in patients was 18.7% (302/1,612). The relationship between BP and the composite outcome followed a U-shaped curve, with an increased event rate observed at both low and high BP values. The average SBP after AKI predicted the composite outcome after adjusting for baseline variables (reference SBP: 120–129 mmHg; < 100 mmHg: hazard ratio [HR] 1.84, P = 0.015; 100–109 mmHg: HR 1.56, P = 0.038; 110–119 mmHg: HR 1.15, P = 0.483; 130–139 mmHg: HR 1.51, P = 0.045; ≥ 140 mmHg: HR 1.73, P = 0.005). CONCLUSION: Among noncritically ill patients with AKI, a U-shaped curve association was observed between the average SBP within 48 hours after AKI and the composite primary outcome of this study, with the lowest event rate for SBP ranging from approximately 110 to 129 mmHg.

Differential Signature of Obesity in the Relationship with Acute Kidney Injury and Mortality after Coronary Artery Bypass Grafting

BACKGROUND: Obesity is related to several comorbidities and mortality, but its relationship with acute kidney injury (AKI) and long-term mortality remain undetermined in patients undergoing coronary artery bypass grafting. METHODS: Data from 3,018 patients (age ≥ 18 years) who underwent coronary artery bypass graft surgery from two tertiary referral centers were retrospectively reviewed between 2004 and 2015. Obesity was defined using the body mass index, according to the World Health Organization's recommendation. The odds and hazard ratios in post-surgical, AKI, and all-cause mortality were calculated after adjustment for multiple covariates. Patients were followed for 90 ± 40.9 months (maximum: 13 years). RESULTS: Among the cohort, 37.4%, 2.4%, 21.1%, 35.1%, and 4.0% of patients were classified as normal weight, underweight, overweight-at-risk, obese I, and obese II, respectively. Post-surgical AKI developed in 799 patients (26.5%). Patients in the obese groups (overweight-at-risk to obese II) had a higher risk of AKI than did those in the normal-weight group. During the follow-up period, 787 patients (26.1%) died. Underweight patients had a higher risk of mortality than did normal-weight patients, whereas overweight-at-risk, obese I, and obese II patients showed better survival rates. CONCLUSION: After coronary artery bypass graft surgery, obese patients encountered a high risk of AKI, and underweight patients exhibited a low chance of survival. Awareness of both obese and underweight statuses should be raised in these patients.

Chronic Kidney Disease and Hepatitis B Virus Surface Antigenemia

No abstract available.

Timing for initiation of sequential continuous renal replacement therapy in patients on extracorporeal membrane oxygenation

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a lifesaving therapy used in critically ill patients with severe cardiopulmonary dysfunction. Continuous renal replacement therapy (CRRT) is supplemented to treat fluid overload, acute kidney injury, and electrolyte disturbances during ECMO. However, the best time to initiate CRRT is not well-defined. We performed this study to identify the optimal timing of CRRT for ECMO. METHODS: We conducted a multicenter retrospective cohort study of 296 patients over 12 years. Patients received CRRT during ECMO at Seoul National University Hospital, Seoul National University Bundang Hospital, or Yonsei University Hospital. We assigned patients to an early or late CRRT group depending on the CRRT initiation time. We considered early CRRT to be CRRT instituted within 72 hours of ECMO initiation. RESULTS: Among 296 patients, 212 patients (71.6%) received early CRRT. After using a propensity score matching method, 47 patients were included in each group. The time from ECMO initiation to CRRT initiation was 1.1 ± 0.9 days in the early CRRT group and 14.6 ± 18.6 days in the late CRRT group. No difference in patients’ mortality (P = 0.834) or hospital stay (P = 0.627) between the early and late CRRT groups was found. After adjusting all covariables, there was no significant difference in mortality between the early and late CRRT groups (hazard ratio, 0.697; 95% confidence interval, 0.410–1.184; P = 0.182). CONCLUSION: This study showed that early CRRT may not be superior to late CRRT in ECMO patients. Further clinical trials are warranted.

Clinical Usefulness of Unenhanced Computed Tomography in Patients with Acute Pyelonephritis

BACKGROUND: Unenhanced computed tomography (UCT) may be useful for evaluating acute pyelonephritis; however, no study has compared UCT with enhanced computed tomography (ECT) as a diagnostic tool. We evaluated a clinical usefulness of UCT versus ECT in acute pyelonephritis (APN). METHODS: We reviewed the clinical and radiological data from 183 APN-suspected patients who underwent UCT and ECT simultaneously at emergency room (ER) over a two-year period. Demographic, clinical parameters and computed tomography (CT) parameters of 149 patients were compared. RESULTS: The average patient age was 61.2 (± 10) years: 31 patients were men. Ninety-nine (66.4%) patients showed stones (18.7%), perinephric infiltration (56%), swelling (21%), and hydronephrosis (6.7%) on UCT. Seventeen patients (11.4%) had an atypical clinical course, requiring additional tests for accurate diagnosis. In 7 patients UCT and ECT results did not differ; in 10 patients, the diagnosis changed on ECT. On ECT, 112/149 (75.2%) patients had stones (16.7%), perinephric infiltrations (57%), swelling (21%), and hydronephrosis (6.7%); 62.5% showed parenchymal involvement: 34 (22.8%) patients had no abnormal ECT findings. APN CT findings are similar on stone, perinephric infiltration, swelling and hydronephrosis on both CTs. Twelve patients (8.0%) had an abnormal ECT finding, i.e., low-grade (1 and 2) parenchymal involvement. Six (4%) patients developed contrast-induced acute kidney injury within 2 days after ECT. CONCLUSION: We demonstrate that UCT is not inferior to ECT as an initial tool for evaluating APN for screening nephrolithiasis and hydronephrosis without the risk of contrast-induced acute kidney injury (CIAKI). However, patients with an atypical clinical course may still need ECT.