Cell-cycle arrest biomarkers in urine to predict acute kidney injury in septic and non-septic critically ill patients

Purpose: To analyse the usefulness of the composite index of the tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) as urinary biomarkers for the early prediction of AKI in septic and non-septic patients. Methods: This is a prospective, observational study including patients admitted to ICU from acute care departments and hospital length of stay 0.8 predicted a rate of AKI of 71% and AKIN >= 2 of 62.9%. Conclusions: In our study, urinary [TIMP-2].[IGFBP7] was an early predictor of AKI in ICU patients regardless of sepsis. Besides, index values < 0.8(ng/mL)(2)/1000 ruled out the need for renal replacement

Does whole-blood neutrophil gelatinase-associated lipocalin stratify acute kidney injury in critically ill patients?

Purpose. To analyse the capacity of whole-blood NGAL (wbNGAL) to stratify AKI in critically ill patients with and without sepsis. Methods. Whole-blood NGAL was measured with a point-of-care device at admission and 48 hours later in patients admitted to a general ICU. Patients were classified by the AKIN and KDIGO classifications at admission and 24 and 48 hours. We performed an ROC curve analysis. wbNGAL values at admission were compared in patients with sepsis and septic shock. Results. The study included 100 consecutively admitted patients (40 female) with mean age 59 1 ± 17 8 years. Thirty-three patients presented AKI at admission, and 10 more developed it in the next 48 h. Eighteen patients had AKI stage 3, 14 of them at admission. Nine patients required renal replacement therapy. According to KDIGO at admission, wbNGAL values were 78 μg/L (60-187) in stage 0 (n = 67), 263 μg/L (89-314) in stage 1 (n = 8), 484 μg/L (333-708) in stage 2 (n = 11), and 623 μg/L (231-911) in stage 3 (n = 14), p = 0 0001 for trend. Ten patients did not complete 48 hours of study: 6 of 10 were discharged (initial wbNGAL 130 μg/L (60- 514)) and 4 died (773 μg/L (311-1010)). The AUROC curve of wbNGAL to predict AKI was 0.838 (95% confidence interval 0.76-0.92, p = 0 0001), with optimal cut-off value of 178 μg/L (sensitivity 76.7%, specificity 78.9%, p < 0 0001). At admission, twenty-nine patients had sepsis, of whom 20 were in septic shock. wbNGAL concentrations were 81 μg/L (60-187) in patients without sepsis, 481 (247-687) in those with sepsis, and 623.5 μg/L (361-798) in the subgroup of septic shock (p < 0 0001). Conclusions. Whole-blood NGAL concentration at ICU admission was a good stratifier of AKI in critically ill patients. However, wbNGAL concentrations were higher in septic patients irrespective of AKI occurrence

Surgical site infection in critically ill patients with secondary and tertiary peritonitis: epidemiology, microbiology and influence in outcomes

Background: Surgical site infection (SSI) remains a significant problem in the postoperative period that can negatively affect clinical outcomes. Microbiology findings are typically similar to other nosocomial infections, with differences dependent on microbiology selection due to antibiotic pressure or the resident flora. However, this is poorly understood in the critical care setting. We therefore aimed to assess the incidence, epidemiology and microbiology of SSI and its association with outcomes in patients with severe peritonitis in the intensive care unit (ICU). Methods: We prospectively studied 305 consecutive patients admitted to our surgical ICU from 2010 to 2014 with a diagnosis of secondary or tertiary peritonitis. We collected the following data: SSI diagnosis, demographics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II score, type of surgery, microbiology, antibiotic treatment and outcomes. Microbiological sampling was done by means of swabs. Results: We identified 269 episodes of SSI in 162 patients (53.1 %) aged 64.4 +/- 14.3 years, of which 200 episodes occurred in men (64.6 %). The mean APACHE II and SAPS II scores were 19.7 +/- 7.8 and 36.5 +/- 16.1 respectively. The mean ICU and hospital stays were 19.8 +/- 24.8 and 21.7 +/- 30 days respectively. Pseudomonas spp. (n = 52, 19.3 %), Escherichia coli (n = 55, 20.4 %) and Candida spp. (n = 46, 17.1 %) were the most frequently isolated microorganisms, but gram-positive cocci (n = 80, 29.7 %) were also frequent. Microorganisms isolated from SSIs were associated with a higher incidence of antibiotic resistance (64.9 %) in ICU patients, but not with higher in-hospital mortality. However, patients who suffered from SSI had longer ICU admissions (odds ratio = 1.024, 95 % confidence interval 1.010-1.039, P = 0.001). Conclusions: The incidence of SSI in secondary or tertiary peritonitis requiring ICU admission is very high. Physicians may consider antibiotic-resistant pathogens, gram-positive cocci and fungi when choosing empiric antibiotic treatment for SSI, although more studies are needed to confirm our results due to the inherent limitations of the microbiological sampling with swabs performed in our research. The presence of SSI may be associated with prolonged ICU stays, but without any influence on overall mortality

Efecto del cambio de posición de decúbito supino a decúbito prono en la presión intraabdominal y su relación con la función renal

Es tracta d'un estudi observacional prospectiu en 18 pacients afectats de la síndrome de destret respiratori agut que van requerir un canvi de posició de decúbit supí a decúbit pron per tal de millorar l'oxigenació. La hipòtesi de treball era que aquest canvi de posició podia augmentar la pressió intraabdominal i, en conseqüència, alterar la funció renal per causa prerrenal. Foren registrades variables hemodinàmiques, respiratòries i pressions intrabdominals, i valorada la funció renal. La posició en decúbit pron va produir un augment significatiu de la pressió intraabdominal, però no varem objectivar un descens del filtrat glomerular ni un empitjorament de l'aclariment de creatininaEl presente es un estudio observacional prospectivo realizado en 18 pacientes afectados de síndrome de distrés respiratorio agudo que requirieron un cambio de posición de decúbito supino a decúbito prono con el objetivo de mejorar la oxigenación. La hipótesis de trabajo era que la maniobra de pronación podía aumentar la presión intrabdominal y con ello alterar la función renal de forma prerenal. Se registraron variables hemodinámicas, respiratorias, presión intrabdominal y función renal. La posición en decúbito prono produjo un aumento significativo de la presión intraabdominal, pero no objetivamos un descenso del filtrado glomerular ni un empeoramiento del aclaramiento de creatinina

Efectos gasométricos de la inhalación de óxido nítrico en pacientes con insuficiencia respiratoria aguda

Descripció del recurs: 1 octubre 201

Neutrophil gelatinase-associated lipocalin (NGAL) como biomarcador de disfunción renal aguda en pacientes postoperados de cirugía cardiaca

La disfunción renal aguda (DRA) es una complicación frecuente en el postoperatorio inmediato de cirugía cardiaca; la probabilidad de desarrollarla puede llegar a ser de un 40%. La disfunción renal aguda con necesidad de diálisis (DRA-D), la forma más grave de DRA, tiene una incidencia que alcanza un 5%. El desarrollo de DRA asociada a la cirugía cardiaca (DRA-ACC) tiene un impacto directo en el pronóstico de estos pacientes aumentando la morbi-mortalidad a corto y largo plazo; además se asocia con un tiempo de estancia hospitalaria más prolongado y un incremento del gasto sanitario. La identificación de pacientes en riesgo de desarrollar DRA-ACC o su diagnóstico precoz, permitiría intentar evitar su aparición y/o su progresión a formas más graves, mejorando significativamente el pronóstico de este grupo de pacientes. Actualmente, la creatinina es el único biomarcador disponible y validado para el diagnóstico de DRA. No obstante, la creatinina es un biomarcador diagnóstico tardío (su concentración en plasma se eleva 24 - 48 h tras el daño renal) y, al ser un biomarcador de función glomerular, proporciona información sobre la misma, pero no sobre la existencia de daño celular renal. La proteína Neutrophil Gelatinase-Associated Lipocalin (NGAL), biomarcador estructural de daño celular renal, se ha propuesto como uno de los biomarcadores más prometedores para el diagnóstico temprano de DRA, así como para la predicción de complicaciones asociada a la misma, como mortalidad y/o necesidad de diálisis. Se desarrolló un estudio observacional prospectivo para investigar comportamiento de la proteína NGAL en orina (uNGAL) como biomarcador de DRA-ACC. Entre marzo y noviembre de 2011, todos los pacientes intervenidos de cirugía cardiaca bajo circulación extracorpórea (CEC), mini-circulación extracorpórea (mini-CEC) o sin CEC que cumplían los criterios de inclusión y no presentaban ninguno de los criterios de exclusión fueron considerados como candidatos a participar en el estudio. El objetivo principal del estudio fue determinar la capacidad del biomarcador uNGAL medido seriadamente en orina y del porcentaje de cambio del mismo (ΔuNGAL) para identificar de manera precoz el desarrollo de DRA-ACC y predecir complicaciones importantes, a corto y largo plazo, asociadas como: la necesidad de diálisis, la mortalidad en la Unidad de Cuidados Intensivos (UCI) y a los 12 meses y la presencia de un evento compuesto, evaluado al año de la cirugía, y denominado MAKE365 (Major Adverse Kidney Events) que engloba muerte, necesidad de diálisis o persistencia de disfunción renal. Otro objetivo del estudio fue analizar el comportamiento de la proteína NGAL en base al uso o no de CEC, y al tipo de circuito utilizado (convencional vs. mini-CEC). Se reclutaron consecutivamente 317 pacientes candidatos a ser incluidos en el estudio, según los criterios de inclusión definidos. De los mismos, un total de 288 fueron los que finalmente constituyeron el grupo de estudio. En base a los resultados obtenidos, se puede concluir que: (1) la capacidad de la proteína uNGAL para predecir el desarrollo de DRA-ACC así como la necesidad de diálisis, mortalidad y el desarrollo del evento compuesto MAKE365 es limitada; (2) la evaluación del cambio en las concentraciones de uNGAL en relación al tiempo transcurrido entre dos determinaciones seriadas (ΔuNGAL) no mejora la capacidad para predecir DRA-ACC y las complicaciones asociadas, respecto a los valores absolutos de uNGAL; (3) los pacientes con tiempos de CEC más largos y aquellos intervenidos bajo CEC en comparación con pacientes intervenidos con mini-CEC o sin CEC) tuvieron concentraciones más altas de uNGAL inmediatamente tras la cirugía. En base a nuestros resultados no se puede recomendar en el momento actual, la medida de uNGAL para diagnosticar de manera precoz DRA-ACC, así como las complicaciones más importantes asociadas.Acute kidney injury (AKI) is a frequent and serious complication after cardiac surgery; the incidence of AKI can reach 40%. Acute kidney injury requiring dialysis (AKI-D), the most severe form of AKI, may occur in 5% of patients following cardiac surgery. The development of AKI after cardiac surgery (CSA-AKI) has a direct impact on the prognosis of these patients and remains a cause of major short- and long-term morbidity and mortality; it is also associated with longer hospital stay and increased health care costs. Identifying patients at risk of developing CSA-AKI or early diagnosis, would allow us to prevent the onset and/or progression to more serious forms, improving significantly the prognosis of these patients. Currently, creatinine is the only available and validated biomarker for diagnosing CSA-AKI. However, creatinine is a late diagnostic biomarker (its plasma concentration increases 24 - 48 h after kidney injury) and, as a biomarker of glomerular function, it only provides information about it, but not about the existence of kidney cell injury. The protein Neutrophil Gelatinase-Associated Lipocalin (NGAL), a kidney cell injury biomarker, has been proposed as one of the most promising biomarker for early diagnosis of CSA-AKI and to predict major renal outcomes as mortality and need for dialysis. Accordingly, we conducted a prospective observational study to investigate the behaviour of NGAL as a biomarker of CSA-AKI in cardiac surgical patients. During the period between March and November 2011, all patients undergoing cardiac surgery under cardiopulmonary bypass (CPB), mini-extracorporeal circulation (mini-CPB) or without CPB (off-pump) that met the inclusion criteria and did not present any of the criteria exclusion were considered as candidates to participate in the study. The main objective of the study was to determine the ability of uNGAL and the rate of change of uNGAL concentration over time (ΔuNGAL) to accurately predict CSA-AKI and other short- and long-term outcomes as need for continuous renal replacement therapy, mortality in the Intensive Care Unit (ICU) and 12 months and the presence of a composite outcome of Major Adverse Events Kidney at 365 days (MAKE365) which includes death, persistent need for dialysis or renal dysfunction. We also investigated the influence of the use of CPB and the type of circuit (conventional vs. mini-CPB) on NGAL release. We recruited 317 consecutive patients candidates who met the inclusion criteria and gave written informed consent. We obtained full data and biomarker measurements from 288 for statistical analyses. In this study we found, first, that uNGAL was only a fair biomarker for the prediction of CSA-AKI and other relevant renal outcomes as need for dialysis, mortality and the development of the composite outcome MAKE365. Second, we found that ΔuNGAL over time was not better than absolute values of uNGAL at predicting CSA-AKI and the related complications. Third, patients with longer duration of CPB and those receiving standard CPB compared to mini-CPB or off-pump surgery had significantly higher concentrations of uNGAL immediately after surgery. Therefore, our findings do not support a continued role for uNGAL measurements for the prediction of CSA-AKI or other major renal clinical outcomes

Efecto del cambio de posición de decúbito supino a decúbito prono en la presión intraabdominal y su relación con la función renal

Es tracta d'un estudi observacional prospectiu en 18 pacients afectats de la síndrome de destret respiratori agut que van requerir un canvi de posició de decúbit supí a decúbit pron per tal de millorar l'oxigenació. La hipòtesi de treball era que aquest canvi de posició podia augmentar la pressió intraabdominal i, en conseqüència, alterar la funció renal per causa prerrenal. Foren registrades variables hemodinàmiques, respiratòries i pressions intrabdominals, i valorada la funció renal. La posició en decúbit pron va produir un augment significatiu de la pressió intraabdominal, però no varem objectivar un descens del filtrat glomerular ni un empitjorament de l'aclariment de creatininaEl presente es un estudio observacional prospectivo realizado en 18 pacientes afectados de síndrome de distrés respiratorio agudo que requirieron un cambio de posición de decúbito supino a decúbito prono con el objetivo de mejorar la oxigenación. La hipótesis de trabajo era que la maniobra de pronación podía aumentar la presión intrabdominal y con ello alterar la función renal de forma prerenal. Se registraron variables hemodinámicas, respiratorias, presión intrabdominal y función renal. La posición en decúbito prono produjo un aumento significativo de la presión intraabdominal, pero no objetivamos un descenso del filtrado glomerular ni un empeoramiento del aclaramiento de creatinina

Cell-cycle arrest biomarkers in urine to predict acute kidney injury in septic and non-septic critically ill patients

To analyse the usefulness of the composite index of the tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) as urinary biomarkers for the early prediction of AKI in septic and non-septic patients. This is a prospective, observational study including patients admitted to ICU from acute care departments and hospital length of stay 0.8 predicted a rate of AKI of 71% and AKIN ≥ 2 of 62.9%. In our study, urinary [TIMP-2]·[IGFBP7] was an early predictor of AKI in ICU patients regardless of sepsis. Besides, index values <0.8(ng/mL) 2 /1000 ruled out the need for renal replacement. The online version of this article (doi:10.1186/s13613-017-0317-y) contains supplementary material, which is available to authorized users

Surgical site infection in critically ill patients with secondary and tertiary peritonitis : epidemiology, microbiology and influence in outcomes

Surgical site infection (SSI) remains a significant problem in the postoperative period that can negatively affect clinical outcomes. Microbiology findings are typically similar to other nosocomial infections, with differences dependent on microbiology selection due to antibiotic pressure or the resident flora. However, this is poorly understood in the critical care setting. We therefore aimed to assess the incidence, epidemiology and microbiology of SSI and its association with outcomes in patients with severe peritonitis in the intensive care unit (ICU). We prospectively studied 305 consecutive patients admitted to our surgical ICU from 2010 to 2014 with a diagnosis of secondary or tertiary peritonitis. We collected the following data: SSI diagnosis, demographics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II score, type of surgery, microbiology, antibiotic treatment and outcomes. Microbiological sampling was done by means of swabs. We identified 269 episodes of SSI in 162 patients (53.1 %) aged 64.4 ± 14.3 years, of which 200 episodes occurred in men (64.6 %). The mean APACHE II and SAPS II scores were 19.7 ± 7.8 and 36.5 ± 16.1 respectively. The mean ICU and hospital stays were 19.8 ± 24.8 and 21.7 ± 30 days respectively. Pseudomonas spp. (n = 52, 19.3 %), Escherichia coli (n = 55, 20.4 %) and Candida spp. (n = 46, 17.1 %) were the most frequently isolated microorganisms, but gram-positive cocci (n = 80, 29.7 %) were also frequent. Microorganisms isolated from SSIs were associated with a higher incidence of antibiotic resistance (64.9 %) in ICU patients, but not with higher in-hospital mortality. However, patients who suffered from SSI had longer ICU admissions (odds ratio = 1.024, 95 % confidence interval 1.010-1.039, P = 0.001). The incidence of SSI in secondary or tertiary peritonitis requiring ICU admission is very high. Physicians may consider antibiotic-resistant pathogens, gram-positive cocci and fungi when choosing empiric antibiotic treatment for SSI, although more studies are needed to confirm our results due to the inherent limitations of the microbiological sampling with swabs performed in our research. The presence of SSI may be associated with prolonged ICU stays, but without any influence on overall mortality