Utilization of small changes in serum creatinine with clinical risk factors to assess the risk of AKI in critically lll adults.

BACKGROUND AND OBJECTIVES: Disease biomarkers require appropriate clinical context to be used effectively. Combining clinical risk factors, in addition to small changes in serum creatinine, has been proposed to improve the assessment of AKI. This notion was developed in order to identify the risk of AKI early in a patient's clinical course. We set out to assess the performance of this combination approach. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A secondary analysis of data from a prospective multicenter intensive care unit cohort study (September 2009 to April 2010) was performed. Patients at high risk using this combination approach were defined as an early increase in serum creatinine of 0.1-0.4 mg/dl, depending on number of clinical factors predisposing to AKI. AKI was defined and staged using the Acute Kidney Injury Network criteria. The primary outcome was evolution to severe AKI (Acute Kidney Injury Network stages 2 and 3) within 7 days in the intensive care unit. RESULTS: Of 506 patients, 214 (42.2%) patients had early creatinine elevation and were deemed at high risk for AKI. This group was more likely to subsequently develop the primary endpoint (16.4% versus 1.0% [not at high risk], P<0.001). The sensitivity of this grouping for severe AKI was 92%, the specificity was 62%, the positive predictive value was 16%, and the negative predictive value was 99%. After adjustment for Sequential Organ Failure Assessment score, serum creatinine, and hazard tier for AKI, early creatinine elevation remained an independent predictor for severe AKI (adjusted relative risk, 12.86; 95% confidence interval, 3.52 to 46.97). Addition of early creatinine elevation to the best clinical model improved prediction of the primary outcome (area under the receiver operating characteristic curve increased from 0.75 to 0.83, P<0.001). CONCLUSION: Critically ill patients at high AKI risk, based on the combination of clinical factors and early creatinine elevation, are significantly more likely to develop severe AKI. As initially hypothesized, the high-risk combination group methodology can be used to identify patients at low risk for severe AKI in whom AKI biomarker testing may be expected to have low yield. The high risk combination group methodology could potentially allow clinicians to optimize biomarker use.

Efecto de la pentoxifilina en la anemia de pacientes en hemodiálisis: estudio retrospectivo observacional de casos y controles / Effect of pentoxifylline on anaemia control in haemodialysis patients: retrospective observational case-control study

INTRODUCCIÓN Y OBJETIVOS: El tratamiento de la anemia en hemodiálisis (HD) con hierro y agentes estimulantes de la eritropoyesis (AEE) no siempre consigue un control adecuado de esta, habiéndose relacionado con la inflamación. El efecto antiinflamatorio de la pentoxifilina (PTX) podría resultar beneficioso en estos casos. El objetivo fue estudiar el posible efecto de la PTX en la anemia de pacientes en hemodiálisis. PACIENTES Y MÉTODOS: Estudio observacional retrospectivo de 18 casos (reciben PTX) y 18 controles (sin PTX, emparejados por edad y sexo) en HD (Clínica Universidad de Navarra). Cuatro pacientes tomaban PTX por vasculopatía y 14 por anemia resistente (definición: hemoglobina [Hb] < 11 g/dl en los últimos 3 meses a pesar de dosis altas de AEE y saturación de transferrina > 20 %). Hb, dosis de MIRCERA(R) y proteína C reactiva fueron recogidas antes del tratamiento con PTX (basal), a los 3 meses y al final del seguimiento. RESULTADOS: En los pacientes con PTX hubo aumento de la Hb (p < 0,001) en 3 meses y descenso de las dosis de AEE al final del estudio (p = 0,002). Las diferencias basales en Hb (menor en casos) (p < 0,001) y en dosis de AEE (mayor en casos) (p = 0,006) entre grupos desaparecieron a los 3 meses. Al final del estudio 11/18 (61,1 %) de los tratados con PTX tenían Hb en rango deseado y recibían dosis de AEE equiparables al control. CONCLUSIONES: PTX en dosis de 800 mg/día mejora significativamente y a corto plazo (3 meses) la Hb de pacientes en HD (respuesta en torno al 61 %) y permite la reducción de dosis de AEE a medio-largo plazo. El efecto se mantiene en el tiempo y el tratamiento es bien tolerado

INTRODUCTION AND OBJECTIVES: Treatment with iron and erythropoiesis-stimulating agent (ESA) does not lead to optimal control of anaemia in some hemodialysis patients, which has been associated with inflammation. Pentoxifylline (PTX) may provide benefits in these cases due to its antiinflammatory properties. We studied the possible effect of PTX on anaemia control in hemodialysis patients. PATIENTS AND METHOD: Retrospective observational case-control study including 18 cases (treated with PTX) and 18 controls (without PTX matched by age and gender) in HD (Clínica Universidad de Navarra). Four patients received PTX due to vasculopathy and 14 patients due to resistent anaemia (which was defined as hemoglobin (Hb) <11g/dL in the last three months despite high doses of ESA and transferrin saturation of >20%). Hb, MIRCERA(R) dose and C-reactive protein were registered at baseline (before starting PTX treatment), after 3 months and at the end of the study. RESULTS: Patients receiving PTX had higher Hb levels (p < 0.001) in the third month and lower ESA requirements at the end of the follow-up (p = 0.002). The baseline differences between groups in terms of Hb levels (lowest of all cases) (p < 0.001) and ESA dosage (highest of all cases) (p = 0.006), disappeared at 3 months. At the end of the study, 11 of 18 (61,1%) treated patients with PTX maintained adequate Hb levels and received doses of ESA comparable with those of controls. CONCLUSIONS: In HD patients, PTX treatment (800mg per day) improves hemoglobin levels (~61% response) in the short-term (3 months) and reduces the required ESA dose in the long term. This effect is sustained over time and does not entail any side effects

Effect of pentoxifylline on anaemia control in haemodialysis patients: retrospective observational case-control study.

INTRODUCTION AND OBJECTIVES: Treatment of anaemia in haemodialysis (HD) with iron and erythropoiesis-stimulating agent (ESA) does not lead to adequate anaemia control and has been associated with inflammation. The anti-inflammatory effect of pentoxifylline (PTX) may be beneficial in these cases. Our aim was to study the potential effect of PTX on anaemia in haemodialysis patients. PATIENTS AND METHOD: Retrospective observational case-control study on 18 patients (treated with PTX) and 18 controls (without PTX matched by age and sex) on HD (Clínica Universidad de Navarra). Four patients received PTX due to vascular disease and 14 due to refractory anaemia (which was defined as haemoglobin [Hb] <11 g/dl in the last three months despite high doses of ESA and transferrin saturation of >20%). Hb, MIRCERA dose and C-reactive protein were recorded before starting PTX treatment (baseline), at 3 months and at the end of the study. RESULTS: In patients who received PTX, there was an increase in Hb (P<.001) over three months and a decrease in the ESA dose at the end of the study (P=.002). The baseline differences in Hb between groups (lowest of all cases) (P<.001) and ESA dose (highest of all cases) (P=.006), disappeared at 3 months. At the end of the study, 11/18 (61.1%) of patients treated with PTX had adequate Hb levels and received doses of ESA comparable with those of the controls. CONCLUSIONS: In HD patients, PTX in doses of 800 mg/day improves Hb significantly and in the short term (3 months) in HD patients (around 61% response) and allows the required ESA dose to be reduced in the medium-long term. This effect is sustained over time and treatment is tolerated well.