Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Dear Editor,
Acute kidney injury (AKI) remains a common and significant complication in critically ill patients. As no curative treatment exists, prevention of AKI is paramount, especially in high-risk patients. Several randomized controlled trials suggest that a biomarker-guided implementation of the Kidney Disease Improving Global Outcomes (KDIGO) care bundle reduces the incidence of AKI postoperatively [1‐3]. Implementation of this care bundle is recommended in high-risk patients after cardiac surgery [4]. This comprises regular monitoring of kidney function, hemodynamic optimization, and consideration of advanced hemodynamic monitoring, as well as avoidance of hyperglycemia, nephrotoxic drugs, and radiocontrast agents, if possible.
Anzeige
So far, the impact of each individual component of the bundle is unclear. Better understanding would enable prioritization, resource-allocation and clinical management of those at high risk of AKI. To investigate the treatment effects of individual bundle components, we combined data of the two PrevAKI-trials including 554 cardiac surgery patients at high risk for AKI, as defined by elevated urinary biomarkers TIMP2*IGFBP7 [1, 2]. Patients were randomized to standard care versus implementation of the care bundle (Supplementary S1).
Univariate logistic regression of the bundle’s components was performed as a risk factor analysis of the whole cohort. Following this, individual treatment effects were analyzed, using the same method for the intervention group only (Fig. 1a). Hypotension, low cardiac index (CI), and use of radiocontrast agents significantly increased the risk for AKI. Optimizing the hemodynamic situation (avoiding hypotension and a low cardiac output state) and avoidance of nephrotoxic drugs were the most important measures to prevent AKI (Fig. 1a). Based on these results, we investigated the role of hemodynamic optimization. AKI occurred significantly less frequently, when hypotension and low CI were prevented (Fig. 1b), particularly for severe stages of AKI.
Fig. 1
a Univariate, binary logistic regression analysis for development of any AKI. ACEi angiotensin-converting enzyme inhibitors, ARBs angiotensin receptor blockers, OR odds ratio, MAP median arterial pressure, CI cardiac index. Hypotension: MAP < 60 mmHg on one reading or MAP < 65 mmHg on two readings during the intervention period. Hyperglycemia defined as: blood glucose levels ≥ 150 mg/dl longer than three hours during intervention period. b Hemodynamic status and AKI incidence. (gray = high MAP and/or CI; red = low MAP and/or CI). c Treatment effects of hemodynamic optimization for AKI prevention
×
Testing the effect of hemodynamic optimization, further analyses demonstrated the effect of hemodynamic optimization between the first and the consecutive hemodynamic measurement (Fig. 1c). Patients with hypotension at presentation had statistically lower rates of AKI when successfully optimized until the next measurement, compared to patients in which median arterial pressure optimization could not be achieved. AKI rates were lowest in patients in which hypotension was avoided entirely. Differences of AKI rates in patients with successful optimization of cardiac index were not statistically significant.
In conclusion, our findings demonstrate the importance of maintaining adequate systemic blood pressure and cardiac output. If hypotension or low cardiac output occurs, timely hemodynamic optimization should be performed to prevent AKI. Whilst our analyses suggested a possible role for radiocontrast agents and nephrotoxic drugs, these factors had wide confidence intervals, indicating low certainty of these findings. Besides hemodynamic optimization, other bundle components had little or no impact on the bundle’s overall effectiveness.
Anzeige
For patients at risk for AKI, we recommend avoiding even short periods of hypotension [5]. Finally, we suggest that improvement of cardiac index using inotropes, may be a key, yet all too often ignored, aspect of AKI prevention.
Acknowledgements
We would like to thank Mr Jannik Feld, MSc, Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany and Dr. rer. nat. Joachim Gerß, Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany, for their statistical advice. Furthermore, we thank all PrevAKI-investigators for their contribution, namely Christoph Schmidt, Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany. Andreas Hoffmeier, Department of Cardiac Surgery, University of Münster, Münster, Germany. Hugo van Aken, Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany. Carola Wempe, Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany. Mira Küllmar, Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany. Gianluca Lucchese, Department of Critical Care & Nephrology, King’s College London, Guy’s & St Thomas' Hospital, London, SE1 7EH, UK. Kamran Baig, Department of Critical Care & Nephrology, King's College London, Guy's & St Thomas' Hospital, London, SE1 7EH, UK. Armando Cennamo, Department of Critical Care & Nephrology, King’s College London, Guy’s & St Thomas’ Hospital, London, SE1 7EH, UK. Ronak Rajani, Department of Critical Care & Nephrology, King's College London, Guy's & St Thomas' Hospital, London, SE1 7EH, UK. Stuart McCorkell, Department of Critical Care & Nephrology, King's College London, Guy's & St Thomas' Hospital, London, SE1 7EH, UK. Christian Arndt, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany. Hinnerk Wulf, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany. Marc Irqsusi, Department of Cardiovascular Surgery, Philipps University of Marburg, Marburg, Germany. Fabrizio Monaco, Department of Anesthesia and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy. Ambra Licia Di Prima, Department of Anesthesia and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy. Mercedes García Alvarez, Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain. Stefano Italiano, Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain. Jordi Miralles Bagan, Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain. Gudrun Kunst, Department of Anesthetics, King's College Hospital, Denmark Hill, London, United Kingdom. Shrijit Nair, Department of Anesthetics, King's College Hospital, Denmark Hill, London, United Kingdom. Camilla L’Acqua, Department of Anesthesia and Critical Care, Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy. Eric Hoste, Department of Intensive Care Medicine, University Hospital Gent, Gent, Belgium. Wim Vandenberghe, Department of Intensive Care Medicine, University Hospital Gent, Gent, Belgium. Patrick M. Honore, Department of Intensive Care, CHU Brugmann University Hospital, Brussels, Belgium. John A. Kellum, Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Philippe Grieshaber, Department of Cardiac Surgery, University Hospital Giessen, Giessen, Germany. Christina Massoth, Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany. Raphael Weiss, Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany.
Declarations
Conflict of interest
TCVG and MO declared no conflict of interest. AZ reported receiving research grants from Baxter, Fresenius, Astute Medical, and Astellas and receiving personal fees from Fresenius, AM Pharma and Biomerieux. MM reported receiving personal fees from Astute Medical, FMC, and Baxter. LGF declared research support and personal fees from Astute Medical, La Jolla Pharmaceuticals, Medibeacon, Baxter, and Fresenius.
Ethical approval
Not required.
Open AccessThis article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Mit e.Med Innere Medizin erhalten Sie Zugang zu CME-Fortbildungen des Fachgebietes Innere Medizin, den Premium-Inhalten der internistischen Fachzeitschriften, inklusive einer gedruckten internistischen Zeitschrift Ihrer Wahl.
Mit e.Med Anästhesiologie erhalten Sie Zugang zu CME-Fortbildungen des Fachgebietes AINS, den Premium-Inhalten der AINS-Fachzeitschriften, inklusive einer gedruckten AINS-Zeitschrift Ihrer Wahl.
Der optimale Ansatz für die Blutdruckkontrolle bei Patientinnen und Patienten mit akutem Schlaganfall ist noch nicht gefunden. Ob sich eine frühzeitige Therapie der Hypertonie noch während des Transports in die Klinik lohnt, hat jetzt eine Studie aus China untersucht.
Laut einer Studie aus den USA und Kanada scheint es bei der Reanimation von Kindern außerhalb einer Klinik keinen Unterschied für das Überleben zu machen, ob die Wiederbelebungsmaßnahmen während des Transports in die Klinik stattfinden oder vor Ort ausgeführt werden. Jedoch gibt es dabei einige Einschränkungen und eine wichtige Ausnahme.
Eine ältere Frau trinkt regelmäßig Sennesblättertee gegen ihre Verstopfung. Der scheint plötzlich gut zu wirken. Auf Durchfall und Erbrechen folgt allerdings eine Hyponatriämie. Nach deren Korrektur kommt es plötzlich zu progredienten Kognitions- und Verhaltensstörungen.
In der Notaufnahme wird die Chance, Opfer von häuslicher Gewalt zu identifizieren, von Orthopäden und Orthopädinnen offenbar zu wenig genutzt. Darauf deuten die Ergebnisse einer Fragebogenstudie an der Sahlgrenska-Universität in Schweden hin.
Update AINS
Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.
