Intraoperative oliguria does not predict postoperative acute kidney injury in major abdominal surgery: a cohort analysis / A oligúria intraoperatória não prediz lesão renal aguda pós-operatória em grandes cirurgias abdominais: Análise de uma coorte

Abstract Background: Acute kidney injury (AKI) is a common complication in patients undergoing major abdominal surgery and is associated with considerable morbidity and mortality. Several studies investigating the association between intraoperative urine output and postoperative AKI have shown conflicting results. Here, we investigated the association of intraoperative oliguria with postoperative AKI in a cohort of patients submitted to elective major abdominal surgery. Methods: This was a single-center retrospective analysis of adult patients who underwent elective major abdominal surgery from January 2016 to December 2018. AKI was defined according to the serum creatinine criteria of the KDIGO classification. Intraoperative oliguria was defined as urine output of less than 0.5 mL/kg/h. Risk factors were evaluated using multivariate logistic regression analysis. Results: A total of 165 patients were analyzed. In the first 48 h after surgery the incidence of AKI was 19.4%. Postoperative AKI was associated with hospital mortality (p=0.011). Twenty percent of patients developed intraoperative oliguria. There was no association between preexisting comorbidities and development of intraoperative oliguria. There was no correlation between the type of anesthesia used and occurrence of intraoperative oliguria, but longer anesthesia time was associated with intraoperative oliguria (p=0.007). Higher baseline SCr (p=0.001), need of vasoactive drugs (p=0.007), and NSAIDs use (p=0.022) were associated with development of intraoperative oliguria. Intraoperative oliguria was not associated with development of postoperative AKI (p=0.772), prolonged hospital stays (p=0.176) or in-hospital mortality (p=0.820). Conclusion: In this cohort of patients we demonstrated that intraoperative oliguria does not predict postoperative AKI in major abdominal surgery.

Resumo Introdução: Lesão renal aguda (LRA) é uma complicação comum em pacientes submetidos a grandes cirurgias abdominais, e está associada a considerável morbimortalidade. Vários estudos investigando a associação entre débito urinário intraoperatório e LRA pós-operatória mostraram resultados conflitantes. Neste trabalho investigamos a associação de oligúria intraoperatória com LRA pós-operatória em uma coorte de pacientes submetidos à grandes cirurgias abdominais. Métodos: Análise retrospectiva de centro único envolvendo pacientes adultos submetidos à grandes cirurgias abdominais, de janeiro de 2016 a dezembro de 2018. A LRA foi definida segundo critérios de creatinina da KDIGO. Definimos oligúria intraoperatória como débito urinário inferior a 0,5 mL/kg/h. Fatores de risco foram avaliados por análise de regressão logística multivariada. Resultados: Analisamos 165 pacientes. Nas primeiras 48 horas após a cirurgia, a incidência de LRA foi de 19,4%. LRA pós-operatória foi associada à mortalidade hospitalar (p = 0,011). 20% dos pacientes desenvolveram oligúria intraoperatória, sem associação com comorbidades preexistentes. Não houve correlação entre o tipo de anestesia e oligúria intraoperatória; entretanto, maior tempo de anestesia esteve associado à oligúria intraoperatória (p = 0,007). Maior creatinina sérica (Cr) inicial (p = 0,001), necessidade de drogas vasoativas (p = 0,007) e uso de AINEs (p = 0,022) foram associados à oligúria intraoperatória. Oligúria intraoperatória não foi associada ao desenvolvimento de LRA no pós-operatório (p = 0,772), à permanência hospitalar prolongada (p = 0,176) ou à mortalidade intra-hospitalar (p = 0,820). Conclusão: Demonstramos que a oligúria intraoperatória não prediz LRA pós-operatória em cirurgias abdominais de grande porte.

Pacientes oligúricos hemodinamicamente estáveis geralmente não respondem ao desafio hídrico / Hemodynamically stable oliguric patients usually do not respond to fluid challenge

RESUMO Objetivo: Avaliar a responsividade renal após desafio hídrico em pacientes oligúricos na unidade de terapia intensiva. Método: Conduzimos um estudo observacional prospectivo em uma unidade de terapia intensiva universitária. Pacientes com débito urinário inferior a 0,5mL/kg/hora por 3 horas, com pressão arterial média acima de 60mmHg receberam um desafio hídrico. Examinamos a responsividade renal aos fluidos (definida como débito urinário acima de 0,5mL/kg/hora por 3 horas) após o desafio hídrico. Resultados: Avaliaram-se 42 pacientes (idade 67 ± 13 anos; APACHE II 16 ± 6). As características dos pacientes foram similares entre os respondedores e os não respondedores renais. Treze pacientes (31%) foram respondedores renais. Antes do desafio hídrico, os parâmetros hemodinâmicos e de perfusão não foram diferentes entre os pacientes que apresentaram aumento do débito urinário e os que não apresentaram. Calcularam-se as áreas sob a curva receiver operating characteristic para os níveis pré-desafio hídrico de pressão arterial média, frequência cardíaca, creatinina, ureia, depuração de creatinina, proporção ureia/creatinina e lactato. Nenhum desses parâmetros foi sensível ou suficientemente específico para predizer a reversão da oligúria. Conclusão: Após obtenção de estabilidade hemodinâmica, os pacientes oligúricos não alcançaram aumento do débito urinário em resposta ao desafio hídrico. Os parâmetros de hemodinâmica sistêmica, perfusão ou renais foram preditores fracos de responsividade urinária. Nossos resultados sugerem que a reposição de volume com objetivo de corrigir oligúria em pacientes sem hipovolemia óbvia deve ser realizada com cautela.

ABSTRACT Objective: To evaluate renal responsiveness in oliguric critically ill patients after a fluid challenge. Methods: We conducted a prospective observational study in one university intensive care unit. Patients with urine output < 0.5mL/kg/h for 3 hours with a mean arterial pressure > 60mmHg received a fluid challenge. We examined renal fluid responsiveness (defined as urine output > 0.5mL/kg/h for 3 hours) after fluid challenge. Results: Forty-two patients (age 67 ± 13 years; APACHE II score 16 ± 6) were evaluated. Patient characteristics were similar between renal responders and renal nonresponders. Thirteen patients (31%) were renal responders. Hemodynamic or perfusion parameters were not different between those who did and those who did not increase urine output before the fluid challenge. The areas under the receiver operating characteristic curves were calculated for mean arterial pressure, heart rate, creatinine, urea, creatinine clearance, urea/creatinine ratio and lactate before the fluid challenge. None of these parameters were sensitive or specific enough to predict reversal of oliguria. Conclusion: After achieving hemodynamic stability, oliguric patients did not increase urine output after a fluid challenge. Systemic hemodynamic, perfusion or renal parameters were weak predictors of urine responsiveness. Our results suggest that volume replacement to correct oliguria in patients without obvious hypovolemia should be done with caution.

Impact of oliguria during lung surgery on postoperative acute kidney injury / 北京大学学报(医学版)

OBJECTIVE@#To explore the influence of intraoperative urine volume on postoperative acute kidney injury (AKI) and the independent risk factors of AKI.@*METHODS@#This was a retrospective cohort study recruiting patients who received selective pulmonary resection under general anesthesia in Peking University First Hospital from July, 2017 to June, 2019. The patients were divided into the AKI group and the control group according to whether they developed postoperative AKI or not. Firstly, univariate analysis was used to analyze the relationship between perioperative variables and postoperative AKI. Secondly, receiver operating characteristic (ROC) curve was used to explore the predictive value of intraoperative urine output for postoperative AKI. The nearest four cutoff values [with the interval of 0.1 mL/(kg·h)] at maximum Youden index were used as cutoff values of oliguria. Then univariate analysis was used to explore the relationship between oliguria defined by these four cutoff values and the risk of AKI. And the cutoff value with maximum OR was chosen as the threshold of oliguria in this study. Lastly, the variables with P < 0.10 in the univariate analysis were selected for inclusion in a multivariate Logistic model to analyze the independent predictors of postoperative AKI.@*RESULTS@#A total of 1 393 patients were enrolled in the study. The incidence of postoperative AKI was 2.2%. ROC curve analysis showed that the area under curve (AUC) of intraoperative urine volume used for predicting postoperative AKI was 0.636 (P=0.009), and the cutoff value of oliguria was 0.785 mL/(kg·h) when Youden index was maximum (Youden index =0.234, sensitivity =48.4%, specificity =75.0%). Furthermore, 0.7, 0.8, 0.9, 1.0 mL/(kg·h) and the traditional cutoff value of 0.5 mL/(kg·h) were used to analyze the influence of oliguria on postoperative AKI. Univariate analysis showed that, when 0.8 mL/(kg·h) was selected as the threshold of oliguria, the patients with oliguria had the most significantly increased risk of AKI (AKI group 48.4% vs. control group 25.3%, OR=2.774, 95%CI 1.357－5.671, P=0.004). Multivariate regression analysis showed that intraoperative urine output < 0.8 mL/(kg·h) was one of the independent risk factors of postoperative AKI (OR=2.698, 95%CI 1.260－5.778, P=0.011). The other two were preoperative hemoglobin ≤120.0 g/L (OR=3.605, 95%CI 1.545－8.412, P=0.003) and preoperative estimated glomerular filtration rate < 30 mL/(min·1.73 m2) (OR=11.009, 95%CI 1.813－66.843, P=0.009).@*CONCLUSION@#Oliguria is an independent risk fact or of postoperative AKI after pulmonary resection, and urine volume < 0.8 mL/(kg·h) is a possible screening criterium.

Severity and Outcomes in Association with Known Exposures and Susceptibilities among Afro-Caribbean Patients with Hospital-acquired Acute Kidney Injury / Severidad y resultados clínicos asociados con exposiciones y susceptibilidades conocidas entre pacientes afrocaribeños con lesión renal aguda adquirida en el hospital

ABSTRACT Objective: To investigate the severity and outcomes associated with known exposures and susceptibilities in Afro-Caribbean patients with hospital-acquired acute kidney injury (HA-AKI). Methods: This was a single centre hospital-based cohort study. Acute kidney injury was diagnosed and staged by the criteria of Kidney Disease: Improving Global Outcomes. Results: Among 107 Afro-Caribbean patients who were newly diagnosed with HA-AKI within a one-year period, hypertension (51.4%) and diabetes mellitus (34.6%) were the most common co-existing susceptibilities. None of the selected susceptibilities led to a higher demand for renal replacement therapy (RRT) or a higher risk of 90-day mortality, except in a small subgroup with underlying malignancy in which 12 out of 28 (42.9%) demised at ≤ 90 days after AKI (odds ratio (OR): 2.36; 95% confidence interval (CI): 1.05, 5.87; p = 0.05). The risk for the requirement for dialysis was nine-fold higher if the patient had oliguria/anuria (OR: 9.06; 95% CI: 3.06, 29.04; p ≤ 0.001). Oliguria/anuria was also found to be a major risk factor for 90-day mortality (OR: 4.46; 95% CI: 1.83, 10.84; p < 0.001). Sepsis was the most frequent exposure (66%) with a high chronic kidney disease conversion rate of 25.7% (OR: 1.296; 95% CI: 0.70, 2.38). Patients with HA-AKI and sepsis had a three-fold higher mortality among hospitalized patients with AKI (OR: 2.87; 95% CI: 1.05, 7.87; p = 0.03). Both complicated non-cardiac major surgeries and cardiac surgeries were significantly associated with requirement for RRT (57.1% versus 56.3% and OR: 5.01; 95% CI: 1.04, 24.1; p = 0.02 versus OR: 6.02; 95% CI: 1.95, 18.57; p ≤ 0.001, respectively). The requirement for RRT in patients with HA-AKI was also significantly associated with admission to the intensive care unit (ICU) (42.1%; OR: 4.6; 95% CI: 1.54, 13.77; p = 0.004), systemic hypotension (OR: 5.86; 95% CI: 2.07, 16.62; p = 0.001) and haemorrhagic shock (OR: 5.78; 95% CI: 1.63, 20.51; p = 0.003). The former two groups carried a significantly higher 90-day mortality rate (OR: 6.22; 95% CI: 2.15, 17.99; p ≤ 0.001 versus OR: 5.54; 95% CI: 2.14, 14.33; p ≤ 0.001, respectively). Conclusion: We observed that certain exposures (such as sepsis, oliguria, systemic hypotension, haemorrhagic shock, ICU admission and complicated major surgeries) had a significant influence on severity and adverse renal outcomes and this was independent of susceptibilities.

RESUMEN Objetivo: Investigar la severidad y los resultados clínicos asociados con exposiciones y susceptibilidades conocidas en pacientes afrocaribeños con lesión renal aguda adquirida en el hospital (LRA-AH). Métodos: Se trató de un estudio de cohorte basado en un solo centro hospitalario. La lesión renal aguda fue diagnosticada y estadificada según los criterios de la enfermedad renal: mejorar los resultados globales. Resultados: Entre los 107 pacientes afrocaribeños que fueron diagnosticados recientemente con LRA-AH en el período de un año, la hipertensión (51.4%) y la diabetes mellitus (34.6%) fueron las susceptibilidades coexistentes más comunes. Ninguna de las susceptibilidades seleccionadas condujo a una mayor demanda de terapia de reemplazo renal (TRR) o a un mayor riesgo de mortalidad de 90 días, excepto en un pequeño subgrupo con malignidad subyacente en el que 12 de 28 (42.9%) fallecen a ≤ 90 días después de LRA (odds ratio (OR): 2.36; 95% intervalo de confianza (CI): 1.05, 5.87; p = 0.05). El riesgo de la necesidad de diálisis fue nueve veces mayor si el paciente tenía oliguria/anuria (OR: 9.06; 95% IC: 3.06, 29.04; p ≤ 0.001). También se descubrió que la oliguria/anuria era un factor de riesgo importante para la mortalidad en 90 días (OR: 4.46; 95% IC: 1.83, 10.84; p < 0.001). Sepsis fue la exposición más frecuente (66%) con una tasa de conversión de la enfermedad renal crónica alta de 25.7% (OR: 1.296; 95% IC: 0.70, 2.38). Los pacientes con LRA-AH y sepsis tuvieron una mortalidad tres veces mayor entre los pacientes hospitalizados con LRA (OR: 2.87; 95% IC: 1.05, 7.87; p = 0.03). Tanto las cirugías principales no cardíacas complicadas como las cirugías cardíacas se asociaron significativamente con la necesidad de TRR (57.1% versus 56.3% y OR: 5.01; 95% IC: 1.04, 24.1; p = 0.02 versus OR: 6.02; 95% IC: 1.95, 18.57; p ≤ 0.001, respectivamente). La necesidad de TRR en pacientes con LRA-AH también se asoció significativamente con la admisión a la unidad de cuidados intensivos (UCI) (42.1%; OR: 4.6; 95% IC: 1.54, 13.77; p = 0.004), hipotensión sistémica (OR: 5.86; 95% IC: 2.07, 16.62; p = 0.001) y choque hemorrágico (OR: 5.78; 95% IC: 1.63, 20.51; p = 0.003). Los dos grupos anteriores tuvieron una tasa de mortalidad de 90 días significativamente mayor (OR: 6.22; 95% IC: 2.15, 17.99; p ≤ 0.001 versus OR: 5.54; 95% IC: 2.14, 14.33; p ≤ 0.001, respectivamente). Conclusión: Observamos que ciertas exposiciones (tales como sepsis, oliguria, hipotensión sistémica, shock hemorrágico, admisión en la UCI, y cirugías principales complicadas) tuvieron una influencia significativa en la severidad y los resultados clínicos renales adversos, con independencia de las susceptibilidades.

A study of clinical profile of patients with malaria in tertiary care hospital

Background: Malaria a tropical disease has a wide clinical spectrum ranging from uncomplicated disease to a fatal one. The objectives were to study clinical profile of Malaria with special reference to its complications and outcome. Materials and methods: A study was carried out in a tertiary care hospital including total of 50 patients diagnosed with P. Vivax or P. Falciparum Malaria. Data on patients’ clinical details with investigations, complications, and outcome was studied. Results: Out of 50 patients (37 male and 13 female), 41 had P. Vivax and 9 had P. Falciparum Malaria. Total 3 patients were complicated; two had cerebral malaria due to P.falciparum and one had multi organ failure due to P. vivax which eventually succumbed. Conclusions: Clinical profile of Malaria was studied which suggest, P.falciparum malaria was more complicated; which comprises cerebral complications, renal complication, hepato-biliary and respiratory complications leading to increased morbidity and mortality. It was observed that P. vivax had better outcome but it can also present with serious and life-threatening complication.

Preliminary study of the arm equilibrium pressure to predict the effect of fluid challenge on urine output in oliguric intensive care unit patients / 中华内科杂志

Objective To evaluate whether arm equilibrium pressure (Parm) is helpful to predict the effect of fluid load in improving oliguria in intensive care unit(ICU) patients.Methods Hemodynamically stable patients [mean artery pressure (MAP)＞65 mmHg (1 mmHg=0.133 kPa),heart rate (HR)＜120 beats/min,lactic acid＜2 mmol/L] with urine output (UO)＜0.5 ml· kg-1· h-1 for 3 consecutive hours were enrolled.The fluid loading was performed by infusion of ringer's lactate 500 ml within 30 minute after baseline hemodynamic data were recorded.The positive renal response was defined as UO increased more than 0.5 ml· kg-1 · h-1 1 hour after fluid challenge,otherwise was negative.Results A total of 30 oliguric ICU patients were enrolled including 17 males and 13 females with median age (54.2±16.3) years.After fluid load,patients' HR decreased[(84± 13)beat/min vs.(80± 10) beat/min,P＜0.01],central venous pressure (CVP) increased[(7.0±2.4)mmHg vs.(8.8±2.6) mmHg,P＜0.01],30s Parm [(33.4±5.3) mmHg vs.(35.4±5.8) mmHg,P＜0.01] and 60s Parm [(26.9±4.5) mmHg vs.(28.7±5.0) mmHg,P＜0.01] increased,and UO [(18.5±8.8)ml/h vs.(64.1±38.3)ml/h,P＜0.01] increased significantly,while MAP and lactic acid did not change (P＞0.05).There were eighteen renal responders and 12 patients did not response.In responding group,MAP[(78.1 ±10.7) mmHg vs.(91.2±11.7) mmHg,P＜0.01],30s Parm[(30.4±3.8) mmHg vs.(38.0±3.7) mmHg,P＜0.01]and 60s Parm [(24.3±2.5) mmHg vs.(30.8±4.0) mmHg,P＜0.01] before fluid load were lower than those in negative group.HR,CVP,lactic acid,age and body weight were comparable between two groups (P＞0.05).After volume loading,MAP,30s and 60s Parrn in positive group were still lower than those in negative group (P＜0.05),while HR,CVP and lactic acid were similar (P＞0.05).Correlation analysis showed that baseline 30s Parm (r=-0.75,P＜0.01),60s Parm (r=-0.69,P＜0.01),and MAP (r=-0.46,P＜0.05) were negatively correlated with 1 h UO after fluid load,but HR and CVP were not (P＞0.05).The receiver operating curve (ROC) showed that 30s Parm had the largest area under curve (AUC) of 0.94 (95％ CI 0.84-1.05,P＜0.01),which 35.5 mmHg was the best threshold with sensitivity 94.4％ and specificity 91.7％(likelihood ratio 11.37).Conclusion In hemodynamically stable oliguric ICU patients,if Parm is lower than normal reference value,volume expansion is more likely to increase UO.Thus Parm can be used to predict the effect of fluid loadon UO.

The Role of Oliguria and the Absence of Fluid Administration and Balance Information in Illness Severity Scores / 대한구급학회지

Urinary examination has formed part of patient assessment since the earliest days of medicine. Current definitions of oliguria are essentially arbitrary, but duration and intensity of oliguria have been associated with an increased risk of mortality, and this risk is not completely attributable to the development of concomitant acute kidney injury (AKI) as defined by changes in serum creatinine concentration. The increased risk of death associated with the development of AKI itself may be modified by directly or indirectly by progressive fluid accumulation, due to reduced elimination and increased fluid administration. None of the currently extant major illness severity scoring systems or outcome prediction models use modern definitions of AKI or oliguria, or any values representative of fluid volumes variables. Even if a direct relationship with mortality is not observed, then it is possible that fluid balance or fluid volume variables mediate the relationship between illness severity and mortality in the renal and respiratory physiological domains. Fluid administration and fluid balance may then be an important, easily modifiable therapeutic target for future investigation. These relationships require exploration in large datasets before being prospectively validated in groups of critically ill patients from differing jurisdictions to improve prognostication and mortality prediction.

The Role of Oliguria and the Absence of Fluid Administration and Balance Information in Illness Severity Scores / 대한중환자의학회지

Urinary examination has formed part of patient assessment since the earliest days of medicine. Current definitions of oliguria are essentially arbitrary, but duration and intensity of oliguria have been associated with an increased risk of mortality, and this risk is not completely attributable to the development of concomitant acute kidney injury (AKI) as defined by changes in serum creatinine concentration. The increased risk of death associated with the development of AKI itself may be modified by directly or indirectly by progressive fluid accumulation, due to reduced elimination and increased fluid administration. None of the currently extant major illness severity scoring systems or outcome prediction models use modern definitions of AKI or oliguria, or any values representative of fluid volumes variables. Even if a direct relationship with mortality is not observed, then it is possible that fluid balance or fluid volume variables mediate the relationship between illness severity and mortality in the renal and respiratory physiological domains. Fluid administration and fluid balance may then be an important, easily modifiable therapeutic target for future investigation. These relationships require exploration in large datasets before being prospectively validated in groups of critically ill patients from differing jurisdictions to improve prognostication and mortality prediction.

Clinical profile of pregnancy related acute renal failure: An experience at a tertiary level hospital in Mumbai

Background: Pregnancy-related acute renal failure (ARF) can be caused by any of the disorders leading to ARF in the general population. We aimed to study the clinical profile of pregnancy related acute renal failure, management and clinical outcomes. Materials and methods: After obtaining ethical committee’s approval, a prospective observational study was carried out on hospitalized patients in our hospital from 1st August 2007 till 30th September 2008, where all pregnant females referred to nephrology unit were enrolled. Results: A total of 41 patients were included in the study in which oliguria was the commonest symptom (58.53%). Fluid overload was the most common complication encountered (33.33%). Respiratory system involvement was associated with increased mortality. No correlation between serum creatinine level and mortality was observed. Neonatal deaths were seen in 2.43% of patients while IUFD was seen in 19.51% of patients. Conclusions: Incidence of PR-ARF is still high in our country as compared to western countries. Multigravidas were more commonly affected than primigravidas. More than two organ involvement was associated with higher mortality and majority of the patients were treated conservatively. Maternal and fetal mortality were high, 17.07% and 2.43% respectively.

Malarial Acute Kidney Injury: 25 Years Experience from a Center in an Endemic Region.

Background: While malaria rarely occurs in many parts of the world, it still causes serious complications like acute kidney injury (AKI) in endemic areas and needs to be reported. Methods: This study was carried out at Sindh Institute of Urology and Transplantation, Karachi, Pakistan. From January 1990 – December 2014, 5623 patients with acute kidney injury (AKI) were registered at this institution. AKI was defined as sudden rise in creatinine or decline in urine output or both. All patients had normal sized non obstructed kidneys on ultrasonography, with no previous co morbidity. Malaria parasite was seen on blood peripheral film in all patients. Results: Among total patients with AKI, 671 (11.93%) developed AKI in association with malarial infection. Average age of patients was 33.70±16.426 (range 4-98 years) with M: F ratio of 3:1. The causes were plasmodium falciparum in 59%, vivax in 15.2%, dual infection in 3.57% and undefined species in the rest. Oligo-anuria and vomiting were the most common associated symptoms along with fever. Renal replacement therapy was required in 76.6% of patients. Complete recovery was seen in 64.82%, while 21.2% died during the acute phase of illness. Jaundice, old age, altered level of consciousness, raised total leukocyte count, oliguria, hyperkalemia and falciparum malaria were the independent risk factors associated with high mortality. Conclusion: Malaria still causes significant morbidity and mortality in our part of the world. Vivax malaria which was thought to be ‘benign’ can present with hemolysis, thrombocytopenia and kidney failure, though risk of death is 2.36 fold higher with falciparum malaria.

Oliguria as an early indicator of mortality risk in patients with multiple myeloma and renal impairment

BACKGROUND: A change in urine output has been recently recognized as a valuable biomarker of acute kidney injury that is associated with mortality in critically ill patients. We investigated the prognostic impact of oliguria for survival outcomes in multiple myeloma (MM) patients presenting with renal impairment (RI). METHODS: Retrospective data on 98 patients with MM and RI, who received initial treatment with novel therapies, were analyzed. Oliguria was defined as a urine output of <0.5 mL/kg/h. RESULTS: The baseline median eGFR was 39.7 mL/min (range, 5.1-59.8). Achievement of renal complete response (CR) was observed in 39.8% of patients. Nine patients (9.2%) presented with oliguria at initial diagnosis, and 4 initially required dialysis. Over a median follow-up period of 17.1 months (range, 1.7-100.0), the median overall survival (OS) was 38.7 months (95% CI 25.0-52.5). Multivariate analyses indicated that oliguria at diagnosis [hazard ratio (HR) 3.628, 95% CI 1.366-9.849, P=0.011], and thrombocytopenia <100x10(9)/L at diagnosis (HR 2.534, 95% CI 1.068-6.015, P=0.035), were significantly associated with overall survival. CONCLUSION: Oliguria was significantly associated with higher mortality in MM patients with RI. Therefore, close monitoring of urine output could be important for these patients.

Etiology and outcomes of anuria in acute kidney injury: a single center study

BACKGROUND: It was previously known that anuric acute kidney injury (AKI) is uncommon and its occurrence suggests complete ureteral obstruction, shock, or a major vascular event. As the epidemiology of AKI has significantly changed over the past decade, it is possible that the incidence, etiology, or clinical characteristics of anuric AKI have also changed. METHODS: A prospective cohort study was conducted that included all patients undergoing renal replacement therapy (RRT) for AKI during a 2-year period in a tertiary hospital. Patients were classified as having anuric, oliguric, or nonoliguric AKI based on their volume of urine when RRT started using the modified Acute Kidney Injury Network criteria. RESULTS: Of the 203 patients included in the study, 21.2% met the criteria for anuric AKI. Septic and postoperative AKI were the main causes of anuric AKI, with 60.5% of incidences occurring in hospital. Anuric AKI was associated with a younger age, a lower prevalence of pre-morbid chronic kidney disease and diabetes, more frequent continuous RRT requirement, and multi-organ dysfunction. In addition, patients with anuric AKI had a higher rate of in-hospital mortality and long-term dependence on RRT than patients with nonanuric AKI. CONCLUSION: Anuric AKI is common, with sepsis as the main etiological insult, and is associated with adverse outcomes among patients with AKI who require RRT.

Acute Kidney Injury (AKI) in perinatal asphyxia.

Background: Acute kidney injury (AKI) is a common consequence of perinatal asphyxia, occurring in upto 56% of these neonates. It is important to recognize AKI in asphyxiated neonates to facilitate administration of appropriate fluids and electrolytes in order to improve their outcome. Objectives: To determine the incidence of AKI in asphyxiated neonates and to correlate the severity and type of AKI with Apgar score and severity of hypoxic ischemic encephalopathy (HIE). Methods: 75 neonates were enrolled – 50 asphyxiated and 25 healthy neonates. Renal functions were assessed using urine output, urine microscopy, biochemical parameters and sonography. The values obtained were correlated with the severity of HIE. Neonates with AKI were managed as per unit protocol. Results: Of the 50 asphyxiated neonates, 32 (64%) had AKI: 25 (78.12 %) neonates with pre-renal AKI and the remaining 7 (21.88 %) with intrinsic AKI. Out of the 32 asphyxiated neonates with AKI, 12 (37.5%) had oliguric AKI, while the remaining 20 (62.5%) had non-oliguric AKI. Levels of blood urea and serum creatinine were significantly higher in asphyxiated neonates as compared to healthy controls (p<0.001). Biochemical derangements correlated well with the severity of HIE and Apgar scores. Serum sodium and creatinine clearance showed significantly different values in asphyxiated babies compared to controls. There was no significant difference in the urine ouput in the control and study group. Sonographic abnormalities were seen most often in oliguric babies, and indicated bad prognosis. Mortality was higher in babies with oliguric AKI. Conclusions: Perinatal asphyxia is an important cause of neonatal AKI. Majority of the babies had non-oliguric AKI and responded well to fluid challenge. Abnormalities in the renal function correlates well with the severity of HIE. Intrinsic AKI, oliguria, hyponatremia, reduced creatinine clearance and abnormal sonographic scan suggest bad prognosis in neonatal AKI secondary to perinatal asphyxia.

Predictive factors for renal failure and a control and treatment algorithm / Fatores preditivos da insuficiência renal e algoritmo de controle e tratamento / Factores de predicción de la insuficiencia renal y el algoritmo de control y tratamiento

OBJECTIVES: to evaluate the renal function of patients in an intensive care unit, to identify the predisposing factors for the development of renal failure, and to develop an algorithm to help in the control of the disease. METHOD: exploratory, descriptive, prospective study with a quantitative approach. RESULTS: a total of 30 patients (75.0%) were diagnosed with kidney failure and the main factors associated with this disease were: advanced age, systemic arterial hypertension, diabetes mellitus, lung diseases, and antibiotic use. Of these, 23 patients (76.6%) showed a reduction in creatinine clearance in the first 24 hours of hospitalization. CONCLUSION: a decline in renal function was observed in a significant number of subjects, therefore, an algorithm was developed with the aim of helping in the control of renal failure in a practical and functional way. .

OBJETIVOS: avaliar a função renal de pacientes em uma unidade de terapia intensiva, identificar os fatores predisponentes ao desenvolvimento da insuficiência renal e desenvolver um algoritmo para auxiliar no controle da doença. MÉTODO: estudo exploratório, descritivo, prospectivo, com abordagem quantitativa. RESULTADOS: trinta pacientes (75,0%) tiveram diagnóstico de insuficiência renal e os principais fatores associados a essa doença foram: a idade avançada, a hipertensão arterial sistêmica, o diabetes mellitus, as doenças pulmonares e o uso de antibióticos. Dos pacientes, 23 (76,6%) apresentaram redução do clearance de creatinina nas primeiras 24 horas de internação. CONCLUSÃO: houve redução da função renal de um expressivo número de sujeitos, portanto, foi desenvolvido um algoritmo com a finalidade de auxiliar o controle da insuficiencia renal de forma prática e funcional. .

OBJETIVOS: evaluar la función renal de pacientes en una unidad de terapia intensiva, identificar los factores predisponentes al desarrollo de la insuficiencia renal y desarrollar un algoritmo para auxiliar en el control de la enfermedad. MÉTODO: estudio exploratorio, descriptivo y prospectivo, con abordaje cuantitativo. RESULTADOS: 30 pacientes (75,0%) tuvieron diagnóstico de insuficiencia renal y los principales factores asociados a esa enfermedad fueron la edad avanzada, la hipertensión arterial sistémica, la diabetes mellitus, las enfermedades pulmonares y el uso de antibióticos. 23 pacientes (76,6%) presentaron reducción del clearance de creatinina en las primeras 24 horas de internación. CONCLUSIÓN: hubo reducción de la función renal de un expresivo número de sujetos, por tanto, fue elaborado un algoritmo con la finalidad de auxiliar en el control de la insuficiencia renal de forma práctica y funcional. .

A Case of Oliguric Mannitol Induced Acute Kidney Injury Early Treated by Continuous Renal Replacement Therapy / 고신대학교의과대학학술지

We report oliguric mannitol-induced acute kidney injury (AKI) early treated by continuous renal replacement therapy. A 70-year-old woman was admitted to the Department of Neurology with diagnosis of acute intracranial hemorrhage. Mannitol was infused for intracranial pressure control. At admission third day, urine output was abruptly decreased to 57 ml during first 6 hours and blood urea nitrogen (BUN) and serum creatinine was increased to 54.2 mg/dL and 5.3 mg/dL respectively. Plasma osmolality was 340 mOsm/kg and osmolar gap was 70. Mannitol was immediately withdrawn and continuous renal replacement therapy (CRRT) was performed to remove mannitol rapidly. Urine output was increased 6 hours later after continuous veno-veno hemodiafiltration (CVVHDF) start. BUN and creatinine was decreased to 21.4 and 1.2 mg/dL at admission ninth day. Mannitol can develop oliguric AKI and CRRT may be of more benefit than conventional hemodialysis in the case of increased intracranial pressure.

Pseudomyxoma Peritonei: A Rare Cause of Oliguric Acute Kidney Injury / 전남의대학술지

Pseudomyxoma peritonei is a rare clinical condition that causes the accumulation of mucinous ascites, which gradually results in the compression of intra-abdominal organs. Most published reports of pseudomyxoma peritonei concern the mass effect of the resulting ascites, which presents as abdominal pain or intestinal ileus in severe cases. However, few reports of renal complications of the disease have been published. Here, we present a case of oliguric acute kidney injury caused by external compression by pseudomyxoma peritonei. After decompression with external drainage, the patient's renal function rapidly improved.

Pseudomyxoma Peritonei: A Rare Cause of Oliguric Acute Kidney Injury / 전남의대학술지

Pseudomyxoma peritonei is a rare clinical condition that causes the accumulation of mucinous ascites, which gradually results in the compression of intra-abdominal organs. Most published reports of pseudomyxoma peritonei concern the mass effect of the resulting ascites, which presents as abdominal pain or intestinal ileus in severe cases. However, few reports of renal complications of the disease have been published. Here, we present a case of oliguric acute kidney injury caused by external compression by pseudomyxoma peritonei. After decompression with external drainage, the patient's renal function rapidly improved.

Pressão intra-abdominal em cães / Intra-abdominal pressure in dogs

Sob consenso recente em pacientes humanos, os valores basais da pressão intra-abdominal (PIA) e seus prováveis limiares em casos mórbidos, foram estipulados com intuito de favorecer a homogeneidade de estudos científicos, além de fornecer diretrizes para conduta diagnóstica e terapêutica destes pacientes. Valores basais e alterações na pressão intra-abdominal em animais não são ainda suficientemente conhecidos e cientificamente determinados. Médicos veterinários necessitam conhecer melhor os estados mórbidos que cursam com Hipertensão Intra-Abdominal (HIA) ou Síndrome de Compartimento Abdominal (SCA). O presente estudo objetivou testar em cães a técnica já descrita sob consenso na medicina como modelo de mensuração da pressão intra-abdominal, assim como determinar os valores normais para a espécie. Foram utilizados 15 cães hígidos, machos e fêmeas, homogêneos e todos sem raça definida. A mensuração da pressão intra-abdominal foi realizada por meio da técnica indireta de sondagem vesical e utilização de coluna de água com régua graduada em cm de H2O, sendo seu valor final convertido para a unidade de mm de Hg. Foi observado valor mínimo subatmosférico (abaixo de zero mm de Hg) até o valor máximo de 3,75 mmHg. Houve importante variação entre os valores encontrados individualmente em determinados cães, colocando sob discussão questões como massa corporal, freqüência/volume total de solução fisiológica a ser infundida e agitação destes pacientes no momento do exame. Os valores limítrofes encontrados são considerados fisiológicos, indicando confiabilidade da técnica e possibilidade do seu emprego clínico. A ausência de sedação e utilização de sonda uretral não inviabilizou a realização da mensuração, porém podendo culminar numa sub ou superestimativa dos valores encontrados.

In order to favor the homogeneity of scientific studies and to provide guidelines on the diagnosis and therapy, human basal values of the intra-abdominal pressure (IAP) and their probable thresholds in morbid cases were recently established. However, basal values and changes in the intra-abdominal pressure in animals are still partly unknown and not scientifically confirmed. Veterinarians have the need to expand their knowledge on morbid conditions that develop with Intra-Abdominal Hypertension (IAH) or Abdominal Compartment Syndrome (ACS). The present study aims to test in dogs the technique adopted in human medicine as a model for measurement of intra-abdominal pressure (1) and determine normal values for the species (2). Fifteen known mongrel healthy dogs, males and females and homogenous were tested. The measurement of IAP was done through an indirect technique which involves catheterizing the bladder and using a water column with a graduate ruler in cm of H(2)0 - its final value converted to mm of Hg. The values observed ranged from a minimum sub atmospheric value (below of zero mm of Hg) to 3,75 mmHg. There was a considerable variation within the individual values observed in some animals, bringing up considerations related to body mass, frequency/total volume of the physiologic solution to be administered and inquietude of these dogs during the treatment. The thresholds values found are considered physiologic, indicating reliability of the technique and possibility of its clinical use. The absence of sedation and the use of urethral catheter did not compromised the measurement, however could have resulted in under- or overestimation of the values found.

Prognostic indicators of patients with acute kidney injury in intensive care unit / 世界急诊医学杂志（英文）

BACKGROUND: Acute kidney injury (AKI) is associated with a high mortality. This study was undertaken to detect the factors associated with the prognosis of AKI. METHODS: We retrospectively reviewed 98 patients with AKI treated from March 2008 to August 2009 at this hospital. In these patients, 60 were male and 38 female. Their age ranged from 19 to 89 years (mean 52.4±16.1 years). The excluded patients were those who died within 24 hours after admission to ICU or those who had a history of chronic kidney disease or incomplete data. After 60 days of treatment, the patients were divided into a survival group and a death group. Clinical data including gender, age, history of chronic diseases, the worst laboratory values within 24 hours after diagnosis (values of routine blood tests, blood gas analysis, liver and renal function, levels of serum cystatin C, and blood electrolytes) were analyzed. Acute physiology, chronic health evaluation (APACHE) II scores and 60-day mortality were calculated. Univariate analysis was performed to find variables relevant to prognosis, odds ratio (OR) and 95％ confidence interval (CI). Multiple-factor analysis with logistic regression analysis was made to analyze the correlation between risk factors and mortality. RESULTS: The 60-day mortality was 34.7％ (34/98). The APACHE II score of the death group was higher than that of the survival group (17.4±4.3 vs. 14.2±4.8, P<0.05). The mortality of the patients with a high level of cystatin C>1.3 mg/L was higher than that of the patients with a low level of cystatin C (<1.3 mg/L) (50％ vs. 20％, P<0.05). The univariate analysis indicated that organ failures≥2, oliguria, APACHE II>15 scores, cystatin C>1.3 mg/L, cystatin C>1.3 mg/L+APACHE II>15 scores were the risk factors of AKI. Logistic regression analysis, however, showed that organ failures≥2, oliguria, cystatin C>1.3 mg/L +APACHE II>15 scores were the independent risk factors of AKI. CONCLUSION: Cystatin C>1.3 mg/L+APACHE II>15 scores is useful in predicting adverse clinical outcomes in patients with AKI.

Clinical characteristics and predictors of acute oliguric renal failure in hemorrhagic fever with renal syndrome / 대한내과학회지

BACKGROUND: Hemorrhagic fever with renal syndrom (HFRS), caused by hantaviruses infection, develops acute renal failure (ARF) of variable severity. Because oliguric ARF is severe form, associated with more complications and hemodialysis requirement, we investigated the characteristics and predictors of oliguric ARF in HFRS patients. METHODS: From Oct. 2000 to Dec. 2004, Sixty one patients, admitted at Armed Forces Capital Hospital, with typical clinical feature of HFRS and serologically confirmed hantaan virus infection were studied. The medical records were reviewed retrospectively and patients were categorized into oliguric and nonoliguric ARF group according to urine output (or=15x10(9)/L (RR 2.36 [95% CI 1.19-4.67]), platelet countor=110IU/L (RR 3.10 [95% CI 1.43-6.73]) and microscopic hematuria>or=5/HPF (RR 3.68 [95% CI 1.24-10.91]). CONCLUSIONS: HFRS patients with oliguric ARF showed more elevation of serum creatinine and more requirement of hemodialysis than HFRS patients with non-oliguric ARF and leukocyte count, platelet count, AST and microscopic hematuria on admission were helpful to predict the development of oliguric ARF in HFRS patients.