Acute Kidney Injury: Advances in Clinical Management

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Nephrology & Urology".

Deadline for manuscript submissions: closed (20 February 2024) | Viewed by 10626

Special Issue Editor


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Guest Editor
Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
Interests: acute kidney injury; sepsis; renal biomarkers; continuos renal replacement therapy; intensive care; clinical nephrology

Special Issue Information

Dear Colleagues,

The incidence of acute kidney injury (AKI) has increased in the last decade. About two-thirds of patients in intensive care units develop AKI, often as part of multiple organ dysfunction syndrome and sepsis, and it is associated with a high mortality rate. These data highlight the importance of precocious diagnosis and appropriate management, based on multidisciplinary collaboration with a pivotal role played by nephrologists.

Two functional biomarkers, serum creatinine (sCr) and urine output, used to define AKI, are limited by delayed changes following kidney injury, with low sensitivity and specificity. Several novel biomarkers have been shown to detect AKI earlier and are more sensitive than sCr. The optimal strategy is combining clinical assessment and validated biomarkers to triage patients and optimize the timing and type of interventions designed to improve processes of care and patient outcomes.

The aim of this Special Issue is to present clinical and experimental scientific reports that improve our understanding of novel biomarkers of early renal damage and their possible utilization in clinical practice. Moreover, evidence on the clinical management of AKI is welcome, as is research analyzing hydroelectrolytic disorders, volemia correction, drug prescription, and the optimal timing of continuous renal replacement therapy.  

Studies reporting on original research (e.g., randomized controlled trials, cohort studies) and literature reviews and meta-analyses within the scope of the Special Issue will be considered.

Dr. Antonio Lacquaniti
Guest Editor

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Keywords

  • acute kidney injury
  • sepsis
  • renal biomarkers
  • continuos renal replacement therapy
  • nephrotoxic drug

Published Papers (8 papers)

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Editorial

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4 pages, 207 KiB  
Editorial
Acute Kidney Injury: Advances in Clinical Management
by Antonio Lacquaniti and Paolo Monardo
J. Clin. Med. 2022, 11(24), 7308; https://doi.org/10.3390/jcm11247308 - 09 Dec 2022
Viewed by 1886
Abstract
Acute kidney injury (AKI), closely related to increased mortality, involved 15–20% of hospitalized patients with higher incidence, with about 50% in the intensive care unit (ICU) [...] Full article
(This article belongs to the Special Issue Acute Kidney Injury: Advances in Clinical Management)

Research

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15 pages, 1611 KiB  
Article
Prognostic Value of the Baseline and Early Changes in Monocyte-to-Lymphocyte Ratio for Short-Term Mortality among Critically Ill Patients with Acute Kidney Injury
by Xinyao Luo, Dingyuan Wan, Ruoxin Xia, Ruoxi Liao and Baihai Su
J. Clin. Med. 2023, 12(23), 7353; https://doi.org/10.3390/jcm12237353 - 28 Nov 2023
Cited by 1 | Viewed by 678
Abstract
(1) Background: Inflammation plays an important role in the onset and progression of acute kidney injury (AKI). Despite this, evidence regarding the prognostic effect of the monocyte-to-lymphocyte ratio (MLR), a novel systemic inflammation marker, among patients with AKI is scarce. This study sets [...] Read more.
(1) Background: Inflammation plays an important role in the onset and progression of acute kidney injury (AKI). Despite this, evidence regarding the prognostic effect of the monocyte-to-lymphocyte ratio (MLR), a novel systemic inflammation marker, among patients with AKI is scarce. This study sets out to investigate the prognostic potential of both baseline and early changes in MLR for short-term mortality among critically ill patients with AKI. (2) Method: Eligible patients with AKI from the Medical Information Mart for Intensive Care IV database were retrospectively analyzed. MLR cutoff values were determined using maximally selected rank statistics and tertiles. The clinical outcomes were 30-day and 90-day mortality in the intensive care unit. A restricted cubic splines model and Cox proportional hazards models were utilized to evaluate the association between the baseline MLR and short-term mortality. Then, the trends in MLR over time were compared between the 30-day survivors and non-survivors using a generalized additive mixed model (GAMM). (3) Result: A total of 15,986 patients were enrolled. Multivariable Cox regression analysis identified baseline MLR ≥ 0.48 as an independent risk factor predicting 30-day mortality (HR 1.33, 95%CI 1.24, 1.45, p < 0.001) and 90-day mortality (HR 1.34, 95%CI 1.23, 1.52, p < 0.001) after adjusting for potential confounders. Similar trends were observed for 30-day and 90-day mortality when tertiles were used to group patients. The restricted cubic splines model revealed a non-linear association between MLR and 30-day and 90-day mortality (both p for non-linear < 0.001, both p for overall < 0.001). The area under the curve of 0.64 for MLR was higher than that of monocytes (0.55) and lymphocytes (0.61). In the subgroup analyses, despite the noted significant interactions, the direction of the observed association between MLR and 30-day mortality was consistent across most prespecified subgroups, except for shock and black ethnicity. The GAMM results highlighted that, as time went on, MLR in the 30-day survival group consistently declined, whereas MLR in the non-survival group rose within 15 days post-ICU admission. The difference between the two groups persisted significantly even after adjusting for confounders (p = 0.006). (4) Conclusion: A higher baseline MLR was identified as an independent risk factor predicting 30-day and 90-day mortality. The early increase in MLR was associated with high 30-day mortality, suggesting that dynamic monitoring of MLR could potentially better predict survival in critically ill patients with AKI. Full article
(This article belongs to the Special Issue Acute Kidney Injury: Advances in Clinical Management)
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9 pages, 1051 KiB  
Article
The Outcome of Childhood Immunoglobulin A Nephropathy with Acute Kidney Injury at the Onset of the Disease—National Study
by M. Mizerska-Wasiak, E. Płatos, J. Małdyk, M. Miklaszewska, D. Drożdż, A. Firszt-Adamczyk, R. Stankiewicz, B. Bieniaś, P. Sikora, A. Rybi-Szumińska, A. Wasilewska, M. Szczepańska, M. Drożynska-Duklas, A. Żurowska, A. Pukajło-Marczyk, D. Zwolińska, M. Tkaczyk and M. Pańczyk-Tomaszewska
J. Clin. Med. 2023, 12(20), 6454; https://doi.org/10.3390/jcm12206454 - 11 Oct 2023
Viewed by 739
Abstract
Introduction: IgA nephropathy (IgAN) is the most common glomerulonephritis worldwide. Decreased glomerular filtration rate is a known risk factor for disease progression. Aim: We aimed to examine factors that may contribute to disease progression in children that present with impaired eGFR at the [...] Read more.
Introduction: IgA nephropathy (IgAN) is the most common glomerulonephritis worldwide. Decreased glomerular filtration rate is a known risk factor for disease progression. Aim: We aimed to examine factors that may contribute to disease progression in children that present with impaired eGFR at the onset of IgAN. Materials and methods: Of the 175 patients with IgAN from the Polish Registry of Children with IgAN and IgAVN, 54 (31%) patients with IgAN who had an onset of renal function impairment (GFR < 90 mL/min) were eligible for the study. All of them were analyzed for initial symptoms (GFR according to Schwartz formula, creatinine, proteinuria, IgA, C3), renal biopsy result with assessment by Oxford classification, treatment used (R—renoprotection, P—prednisone+R, Aza—azathioprine+P+R, Cyc—cyclophosphamide+P+R, CsA—cyclosporine+P+R, MMF—mycophenolate mofetil+P+R), and distant follow-up. Based on the GFR score obtained at the end, patients were divided into two groups: A—GFR > 90 mL/min and B—GFR < 90 mL/min. Results: In the study group, the mean age of onset was 12.87 ± 3.57 years, GFR was 66.1 ± 17.3 mL/min, and proteinuria was 18.1 (0–967) mg/kg/d. Renal biopsy was performed 0.2 (0–7) years after the onset of the disease, and MESTC score averaged 2.57 ± 1.6. Treatment was R only in 39% of children, P+R in 20%, Aza+P+R in 28%, Cyc+P+R in 9%, CsA+P+R in 7%, and MMF+P+R in 3%. The length of the observation period was 2.16 (0.05–11) years. At the follow-up, Group A had 30 patients (56%) and Group B had 24 patients (44%). There were no significant differences in any of the other biochemical parameters (except creatinine) or proteinuria values between the groups and the frequency of the MESTC score ≥ 2 and <2 was not significantly different between Groups A and B. Patients with normal GFR at the follow-up (Group A) were significantly more likely to have received prednisone and/or immunosuppressive treatment than those in Group B (p < 0.05) Conclusions: In a population of Polish children with IgAN and decreased renal function at the onset of the disease, 56% had normal GFR in remote observation. The use of immunosuppressive/corticosteroids treatment in children with IgAN and impaired glomerular filtration rate at the beginning of the disease may contribute to the normalization of GFR in the outcome, although this requires confirmation in a larger group of pediatric patients. Full article
(This article belongs to the Special Issue Acute Kidney Injury: Advances in Clinical Management)
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11 pages, 1407 KiB  
Article
Renal Arteriovenous (AV) Fistula after High-Grade Blunt Renal Trauma Caused by Traffic Accidents
by Susanne Deininger, Peter Törzsök, Lukas Lusuardi, Sebastian Hubertus Markus Deininger, Thomas Freude, Florian Wichlas and Christian Deininger
J. Clin. Med. 2023, 12(19), 6362; https://doi.org/10.3390/jcm12196362 - 04 Oct 2023
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Abstract
Purpose: To report a series of three patients with traumatic renal AV fistulas after blunt renal laceration. Methods: We retrospectively analyzed the renal trauma cases treated in the Department of Urology of Salzburg University Clinic during a time period of 10 years concerning [...] Read more.
Purpose: To report a series of three patients with traumatic renal AV fistulas after blunt renal laceration. Methods: We retrospectively analyzed the renal trauma cases treated in the Department of Urology of Salzburg University Clinic during a time period of 10 years concerning traumatic AV fistula formation and other clinical parameters. Results: In total, 3 cases of traumatic AV fistula formation were identified in 106 blunt renal trauma patients (2.8%), with a mean age of 39 (17–56) years. All renal traumas were classified as American Association for the Surgery of Trauma (AAST) grade IV. Two patients were primarily treated with ureteral stent; one was managed conservatively. All AV fistulas were diagnosed after a mean time of 7 (1–13) days. Two patients were symptomatic with gross hematuria, and the mean time between trauma and onset of symptoms was 11 (9–13) days. All cases were managed via coil embolization after a mean of 10 (8–13) days. Two patients received a second intervention after a mean of 18 (11–25) days. The mean AV fistula size was 18.7 (12–24) mm. Mean hemoglobin loss was 3.6 g/dL. One patient received one erythrocyte concentrate. Discharge was after a mean time of 13.3 (7–12) days, with the mean time of intensive care treatment being 2.3 (1–3) days. Conclusions: Traumatic renal AV fistula is a rare but severe complication associated with higher-grade renal trauma. It can become evident through hematuria or blood loss several days after the initial trauma. The availability of coil embolization in a trauma center can help kidney preservation management. Full article
(This article belongs to the Special Issue Acute Kidney Injury: Advances in Clinical Management)
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11 pages, 1397 KiB  
Article
Acute Kidney Injury and Sepsis after Cardiac Surgery: The Roles of Tissue Inhibitor Metalloproteinase-2, Insulin-like Growth Factor Binding Protein-7, and Mid-Regional Pro-Adrenomedullin
by Antonio Lacquaniti, Fabrizio Ceresa, Susanna Campo, Giovanna Barbera, Daniele Caruso, Elenia Palazzo, Francesco Patanè and Paolo Monardo
J. Clin. Med. 2023, 12(16), 5193; https://doi.org/10.3390/jcm12165193 - 09 Aug 2023
Cited by 9 | Viewed by 883
Abstract
Background: Identifying a panel of markers detecting kidney injury before the glomerular filtration rate reduction is a challenge to improving the diagnosis and management of acute kidney injury (AKI) in septic patients. This study evaluated the roles of tissue inhibitor metal proteinase-2, insulin [...] Read more.
Background: Identifying a panel of markers detecting kidney injury before the glomerular filtration rate reduction is a challenge to improving the diagnosis and management of acute kidney injury (AKI) in septic patients. This study evaluated the roles of tissue inhibitor metal proteinase-2, insulin growth factor binding protein-7 (TIMP2*IGFBP7), and mid-regional pro-adrenomedullin (MR-proADM) in patients with AKI. Patients and Methods: This study was prospectively conducted in an intensive care unit (ICU) enrolling 230 patients who underwent cardiac surgery. Biomarkers were evaluated before and after 4 h of the cardiac surgery. Results: Whereas urine and creatinine alterations appeared at 23.2 (12.7–36.5) hours after cardiac surgery, urinary TIMP2*IGBP7 levels were higher at 4 h in AKI patients (1.1 ± 0.4 mg/L vs. 0.08 ± 0.02 mg/L; p < 0.001). Its concentration > 2 mg/L increases AKI risk within the following 24 h, clearly identifying the population at high risk of renal replacement therapy (RRT). In patients with sepsis, MR-proADM levels were 2.3 nmol/L (0.7–7.8 nmol/L), with the highest values observed in septic shock patients (5.6 nmol/L (3.2–18 nmol/L)) and a better diagnostic profile than procalcitonin and C-reactive protein to identify septic patients. MR-proADM values > 5.1 nmol/L and urine TIMP2*IGBP7 levels > 2 mg/L showed a significantly faster progression to RRT, with a mean follow-up time of 1.1 days. Conclusions: TIMP2*IGBP7 and MR-proADM precociously diagnose AKI in septic patients after cardiac surgery, giving prognostic information for RRT requirement. Full article
(This article belongs to the Special Issue Acute Kidney Injury: Advances in Clinical Management)
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Review

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23 pages, 2365 KiB  
Review
Urgent Implantation of Peritoneal Dialysis Catheter in Chronic Kidney Disease and Acute Kidney Injury—A Review
by Hanna Cholerzyńska, Wiktoria Zasada, Hanna Michalak, Miłosz Miedziaszczyk, Andrzej Oko and Ilona Idasiak-Piechocka
J. Clin. Med. 2023, 12(15), 5079; https://doi.org/10.3390/jcm12155079 - 02 Aug 2023
Viewed by 1444
Abstract
Acute kidney injury (AKI) and sudden exacerbation of chronic kidney disease (CKD) frequently necessitate urgent kidney replacement therapy (UKRT). Peritoneal dialysis (PD) is recognized as a viable modality for managing such patients. Urgent-start peritoneal dialysis (USPD) may be associated with an increased number [...] Read more.
Acute kidney injury (AKI) and sudden exacerbation of chronic kidney disease (CKD) frequently necessitate urgent kidney replacement therapy (UKRT). Peritoneal dialysis (PD) is recognized as a viable modality for managing such patients. Urgent-start peritoneal dialysis (USPD) may be associated with an increased number of complications and is rarely utilized. This review examines recent literature investigating the clinical outcomes of USPD in CKD and AKI. Relevant research was identified through searches of the MEDLINE (PubMed), Scopus, Web of Science, and Google Scholar databases using MeSH terms and relevant keywords. Included studies focused on the emergency use of peritoneal dialysis in CKD or AKI and reported treatment outcomes. While no official recommendations exist for catheter implantation in USPD, the impact of the technique itself on outcomes was found to be less significant compared with the post-implantation factors. USPD represents a safe and effective treatment modality for AKI, although complications such as catheter malfunctions, leakage, and peritonitis were observed. Furthermore, USPD demonstrated efficacy in managing CKD, although it was associated with a higher incidence of complications compared to conventional-start peritoneal dialysis. Despite its cost-effectiveness, PD requires greater technical expertise from medical professionals. Close supervision and pre-planning for catheter insertion are essential for CKD patients. Whenever feasible, an urgent start should be avoided. Nevertheless, in emergency scenarios, USPD does remain a safe and efficient approach. Full article
(This article belongs to the Special Issue Acute Kidney Injury: Advances in Clinical Management)
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Other

13 pages, 16462 KiB  
Case Report
Tenofovir-Induced Fanconi Syndrome Presenting with Life-Threatening Hypokalemia: Review of the Literature and Recommendations for Early Detection
by Efstathia Liatsou, Ioanna Tatouli, Andreas Mpozikas, Maria-Markella Pavlou, Hariklia Gakiopoulou, Ioannis Ntanasis-Stathopoulos, Maria Gavriatopoulou, Sofoklis Kontogiannis and Meletios Athanasios Dimopoulos
J. Clin. Med. 2023, 12(22), 7178; https://doi.org/10.3390/jcm12227178 - 20 Nov 2023
Cited by 1 | Viewed by 1226
Abstract
Tenofovir disoproxil fumarate (TDF) is a nucleotide reverse transcriptase inhibitor that has been widely used for the treatment of patients with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) infections. Despite the excellent safety records of this regimen, a few cases of [...] Read more.
Tenofovir disoproxil fumarate (TDF) is a nucleotide reverse transcriptase inhibitor that has been widely used for the treatment of patients with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) infections. Despite the excellent safety records of this regimen, a few cases of acute renal failure and Fanconi syndrome have been reported among HIV patients exposed to TDF. However, in the HBV monoinfection scenario, only five cases of TDF-associated Fanconi syndrome have been reported thus far, two of them providing a confirmatory kidney biopsy. Here, we describe the case of a 68-year-old woman with chronic hepatitis B (CHB) who developed TDF-induced Fanconi syndrome that reverted after TDF withdrawal from tenofovir alafenamide. Though the overall risk of TDF-associated severe renal toxicity in HBV patients appears to be negligible, both glomerular and tubular functions should be monitored in patients exposed to TDF. Full article
(This article belongs to the Special Issue Acute Kidney Injury: Advances in Clinical Management)
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25 pages, 1628 KiB  
Systematic Review
Renal Manifestations of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome: A Systematic Review of 71 Cases
by Marilia Dagnon da Silva, Sidney Marcel Domingues, Stevan Oluic, Milan Radovanovic, Pratyusha Kodela, Terri Nordin, Margaret R. Paulson, Bojan Joksimović, Omobolanle Adetimehin, Devender Singh, Cristian Madrid, Milena Cardozo, Marko Baralic and Igor Dumic
J. Clin. Med. 2023, 12(14), 4576; https://doi.org/10.3390/jcm12144576 - 10 Jul 2023
Cited by 6 | Viewed by 2238
Abstract
Unlike other adverse drug reactions, visceral organ involvement is a prominent feature of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome and correlates with mortality. The aim of this study was to systematically review cases published in PubMed-indexed, peer-reviewed journals in which [...] Read more.
Unlike other adverse drug reactions, visceral organ involvement is a prominent feature of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome and correlates with mortality. The aim of this study was to systematically review cases published in PubMed-indexed, peer-reviewed journals in which patients had renal injury during the episode of DRESS syndrome (DS). We found 71 cases, of which 67 were adults and 56% were males. Female sex was associated with higher mortality. Chronic kidney disease (CKD) was present in 14% of patients who developed acute kidney injury (AKI) during DS. In 21% of cases, the kidneys were the only visceral organ involved, while 54% of patients had both liver and kidney involvement. Eosinophilia was absent in 24% of patients. The most common classes of medication associated with renal injury in DS were antibiotics in 34%, xanthine oxidase inhibitors in 15%, and anticonvulsants in 11%. Among antibiotics, vancomycin was the most common culprit in 68% of patients. AKI was the most common renal manifestation reported in 96% of cases, while isolated proteinuria or hematuria was present in only 4% of cases. In cases with AKI, 88% had isolated increase in creatinine and decrease in glomerular filtration (GFR), 27% had AKI concomitantly with proteinuria, 18% had oliguria, and 13% had concomitant AKI with hematuria. Anuria was the rarest manifestation, occurring in only 4% of patients with DS. Temporary renal replacement therapy was needed in 30% of cases, and all but one patient fully recovered renal function. Mortality of DS in this cohort was 13%, which is higher than previously reported. Medication class, latency period, or pre-existing CKD were not found to be associated with higher mortality. More research, particularly prospective studies, is needed to better recognize the risks associated with renal injury in patients with DS. The development of disease-specific biomarkers would also be useful so DS with renal involvement can be easier distinguished from other eosinophilic diseases that might affect the kidney. Full article
(This article belongs to the Special Issue Acute Kidney Injury: Advances in Clinical Management)
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