Serum Cystatin C for the Diagnosis of Acute Kidney Injury in Patients Admitted in the Emergency Department.

BACKGROUND: Early diagnosis of acute kidney injury (AKI) at emergency department (ED) is a challenging issue. Current diagnostic criteria for AKI poorly recognize early renal dysfunction and may cause delayed diagnosis. We evaluated the use of serum cystatin C (CysC) for the early and accurate diagnosis of AKI in patients hospitalized from the ED. METHODS: In a total of 198 patients (105 males and 93 females), serum CysC, serum creatinine (sCr), and estimated glomerular filtration rate (eGFR) were calculated at 0, 6, 12, 24, 48, and 72 hours after presentation to the ED. We compared two groups according to the presence or absence of AKI. RESULTS: Serial assessment of CysC, sCr, and eGFR was not a strong, reliable tool to distinguish AKI from non-AKI. CysC > 1.44 mg/L at admission, both alone (Odds Ratio = 5.04; 95%CI 2.20-11.52; P < 0.0002) and in combination with sCr and eGFR (Odds Ratio = 5.71; 95%CI 1.86-17.55; P < 0.002), was a strong predictor for the risk of AKI. CONCLUSIONS: Serial assessment of CysC is not superior to sCr and eGFR in distinguishing AKI from non-AKI. Admission CysC, both alone and in combination with sCr and eGFR, could be considered a powerful tool for the prediction of AKI in ED patients.

Diagnostic and prognostic utilities of multimarkers approach using procalcitonin, B-type natriuretic peptide, and neutrophil gelatinase-associated lipocalin in critically ill patients with suspected sepsis.

BACKGROUND: We investigated the diagnostic and prognostic utilities of procalcitonin (PCT), B-type natriuretic peptide (BNP), and neutrophil gelatinase-associated lipocalin (NGAL) in critically ill patients with suspected sepsis, for whom sepsis was diagnosed clinically or based on PCT concentrations. METHODS: PCT, BNP, and NGAL concentrations were measured in 340 patients and were followed up in 109 patients. All studied biomarkers were analyzed according to the diagnosis, severity, and clinical outcomes of sepsis. RESULTS: Clinical sepsis and PCT-based sepsis showed poor agreement (kappa = 0.2475). BNP and NGAL showed significant differences between the two groups of PCT-based sepsis (P = 0.0001 and P < 0.0001), although there was no difference between the two groups of clinical sepsis. BNP and NGAL were significantly different according to the PCT staging and sepsis-related organ failure assessment subscores (P < 0.0001, all). BNP and PCT concentrations were significantly higher in the non-survivors than in the survivors (P = 0.0002) and showed an equal ability to predict in-hospital mortality (P = 0.0001). In the survivors, the follow-up NGAL and PCT concentrations were significantly lower than the initial values (148.7 ng/mL vs. 214.5 ng/mL, P < 0.0001; 0.61 ng/mL vs. 5.56 ng/mL, P = 0.0012). CONCLUSIONS: PCT-based sepsis diagnosis seems to be more reliable and discriminating than clinical sepsis diagnosis. Multimarker approach using PCT, BNP, and NGAL would be useful for the diagnosis, staging, and prognosis prediction in the critically ill patients with suspected sepsis.

Sarcopenia and nutrition.

Preserving or restoring adequate nutritional status is a key factor to delay the onset of chronic diseases and to accelerate recovery from acute illnesses. In particular, consistent and robust data show the loss of muscle mass, that is, sarcopenia, is clinically relevant since it is closely related to increased morbidity and mortality in healthy individuals and patients. Sarcopenia is defined as the age-related loss of muscle mass and function. International study groups have recently proposed separate definitions and diagnostic criteria for sarcopenia. Unfortunately, the rate of agreement in assessing the prevalence of sarcopenia is just fair, which highlights the need for a common effort to harmonize definitions and diagnostic criteria. Sarcopenia should be distinct from myopenia, which is the disease-associated loss of muscle mass, although in clinical practice it may be impossible to separate them (i.e., in old cancer patients). The pathogenesis of sarcopenia is complex and multifactorial. Consequently, its treatment should target the different factors involved, including quantitatively and qualitatively inappropriate food intake and reduced physical activity.

How to manage cardiorenal syndromes in the emergency room.

In the emergency department (ED) a prompt diagnosis and appropriate treatment for all diseases improve a patient's outcome. Acute kidney injury (AKI) is defined as an abrupt deficiency of renal function over a period of hours to days resulting in a failure of the kidney to excrete nitrogenous waste products and to maintain fluid and electrolyte homeostasis. AKI diagnosis could be very challenging for ED physicians because it is often very difficult to obtain some anamnestic data such as daily urine output or a preexisting value of BUN and serum creatinine. The incidence of AKI is progressively increasing in EDs and the mortality rates of these patients range from 50 to 80% in multiorgan failure. For ED physicians it is also crucial to distinguish AKI from prerenal azotemia (volume depletion promptly resolved through administration of fluids) at the time of patient presentation. Moreover, a rapid diagnosis of AKI leads to stop the progressive kidney damage on the basis of an appropriate therapeutic approach. Recent studies have demonstrated that by using a new biomarker, neutrophil gelatinase-associated lipocalin (NGAL), it is possible to obtain an accurate and fast diagnosis of AKI. It is well known that in patients with cardiovascular diseases such as stroke, coronary artery diseases and congestive heart failure, high levels of creatinine are strictly related to a higher mortality. In the ED the occurrence of AKI in patients with acute worsening of cardiac function like acute decompensated heart failure is very common. Moreover, managing acute heart failure strictly depends on renal function. Therefore, a multimarker approach including NGAL+BNP (today easily obtained by a POCT system) could have a tremendous impact on an appropriate diagnosis, treatment and a supposed better patient outcome. Furthermore, an evaluation of total body fluid content is of great utility. We propose a new model of management for ED patients with cardiorenal syndromes using a multimarker approach and non-invasive evaluation of body fluid content by bioelectrical impedance vector analysis.

Fluid assessment and management in the emergency department.

Evaluation of hydration state or water homeostasis is an important component in the assessment and treatment of critically ill patients in the emergency department (ED). The main purpose of ED physicians is to immediately distinguish between normal hydrated, dehydrated and hyperhydrated states. Fluid depletion may result from renal losses and extrarenal losses (from the GI tract, respiratory system, skin, fever, sepsis, third space accumulations). Total body fluid increase can result from heart failure, kidney disease, liver disease, malignant lymphoedema or thyroid disease. In patients with fluid overload due to acute heart failure, diuretics should be given when there is evidence of systemic volume overload, in a dose up-titrated according to renal function, systolic blood pressure, and history of chronic diuretic use. The bioelectrical impedance vector analysis (BIVA) is a noninvasive technique to estimate body mass and water composition by bioelectrical impedance measurements, resistance and reactance. In patients with hyperhydration state due to heart failure, some authors showed that reactance is strongly related to BNP values and the NYHA functional classes. Other authors found a correlation between impedance and central venous pressure in critically ill patients. We have been analyzing the hydration state at admission to the ED, 24, 72 h after admission and at discharge, and found a significant and indirectly proportional correlation between BIVA hydration and the Caval index at the time of presentation to the ED and 24 and 72 h after hospital admission. Moreover, at admission we found an inverse relationship between BIVA hydration and reduced urine output that became directly proportional at 72 h. This confirms the good response to diuretic therapy with the shift of fluids from interstitial spaces.

Assessing early to late stage dementia: the TSI and BANS-S scales in the nursing-home.

BACKGROUND: The traditional assessment tools for dementia, such as the MMSE, have only limited ability to follow subjects with severe dementia because they show a floor effect. Specific observational and performance-based instruments were recently developed. OBJECTIVES: To directly compare an observational scale to a performance-based instrument in moderate to severe dementia. METHODS: We compared a slightly modified version of the performance-based Test for Severe Impairment (mTSI) to the observer-based Bedford Alzheimer Nursing Severity Scale (BANS-S). Both scales were administered, together with the Mini-Mental State Examination (MMSE) and the Clinical Dementia Rating scale (CDR), to a nursing-home sample of 130 women suffering from different types of dementia (CDR range:1-4; MMSE range:0-18), defined according to DSM-IV criteria. Mean age was 86.9 +/- 7.3 years and mean education was 2.7 +/- 1.1 years. RESULTS: The BANS-S could be applied to all patients, the mTSI to 87 subjects (66.9%). Mean mTSI score decreased progressively from CDR stage 2 to CDR stage 4, whereas no difference was detectable between CDR stages 1 and 2. By contrast, the BANS-S was not significantly different for CDR stages 1 to 3, and the mean BANS-S score worsened only in CDR stage 4. Results were similar for AD and non AD dementia. Both scales were independent from age and education and their test-retest and inter-rater reliabilities were satisfactory. CONCLUSION: The mTSI looks promising in the moderate-to-severe range, whereas the BANS-S seems more useful in the very late stage of dementia. However, neither scale was optimal and additional instruments should be tested in future studies.