Estimates of glomerular filtration rate in critically ill patients with sepsis: comparisons of different equations

INTRODUCTION: Accurate assessment of glomerular filtration rate (GFR) is important in the critically ill. Kinetic estimate of GFR (keGFR) considers the changes of creatinine, creatinine production rate, and volume of distribution hence postulated to be a more accurate estimate of GFR, where there are rapidly changing kidney functions. We evaluated the association of the estimated GFR by established equations and keGFR with creatinine clearance (CrCl) measurement. MATERIALS AND METHODS: This is a prospective observational study of critically ill patients. Inclusion criteria were patients older than 18 years old with sepsis (clinical infection and increase in SOFA score>2), and plasma procalcitonin>0.5ng/ml. Plasma creatinine and Cystatin C (CysC) were measured on admission and 4 hours later, and the eGFR was calculated by the Cockcroft Gault (CG), MDRD, CKD-EPI, and keGFR equations, and compared to the CrCl measurement. RESULTS: A total of 70 patients were recruited. eGFR by all 4 equations strongly correlates with CrCl. keGFR had the least bias depicted by the mean differences nearest to zero (-18ml/min). Similarly, keGFRCysC had less bias than eGFRCysC, with a mean difference of -21ml/min. eGFRCG had the greatest precision depicted by the narrower SD lines, however, the precision of both keGFR were not much different compared to those of eGFRCG. CONCLUSIONS: In critically ill patients with sepsis, keGFRCr and keGFRCysC had the least bias and fair precision when compared to creatinine clearance measurement. In the absence of creatinine clearance measurement, keGFR calculations are useful as a surrogate for kidney function

Development and validation of estimates of Glomerular Filtration Rate (GFR) equations in the Malaysian setting

Introduction: Accurate assessment of glomerular filtration rate (GFR) in perioperative and intensive care patients is very important for diagnostic and therapeutic intervention. Clinically, GFR is estimated from plasma creatinine using equations such as Cockcroft-Gault, Modification of Diet in Renal Disease, and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. However, these were developed in the Western population. There was no equation that has been developed specifically in our population. Objectives: We developed a new equation based on the gold standard of 99mTc-DTPA imaging measured GFR. We then performed an internal validation by comparing the bias, precision and accuracy of the new equation, and the other equations with the gold standard of 99mTc-DTPA imaging measured GFR. Methods: This was a cross sectional study using the existing record of patients that was referred for 99mTc-DTPA imaging at the Nuclear Medicine Centre, International Islamic University Malaysia. As this is a retrospective study utilizing routinely collected data from the existing pool of data ethical committee has waived the need for informed consent. Results: Data of 187 patients was analysed from January 2016 to March 2021. Of these, 94 were randomized to the development cohort, and 93 to the validation cohort. A new equation of eGFR was determined as 16.637 * 0.9935Age * (SCr/23.473)-0.45159. In the validation cohort, both CKD-EPI and the new equation had the highest correlation to 99mTc-DTPA with correlation coefficient of 0.81 (p<0.0001). However, the new equation had the least bias and was the most precise (mean bias of -3.58 ± 12.01) and accurate (P30 of 64.5% and P50 of 84.9%) compared to the other equations. Conclusion: The new equation which was developed specifically using our local data population was the most accurate and precise, with less bias compared to the other equations. Further study validating this equation in the perioperative and intensive care patients is needed

Human factors in provision of safe anaesthesia: A continuous effort

Pursuing safe anaesthesia is a never-ending journey. Enormous progression had been made previously and this is still an ongoing process. The bulk of anaesthesia that used to be only performed in operating theatres have moved further beyond. Failure to provide a safe anaesthesia is catastrophic. Human factors played an important role, and this article will touch upon communication, teamwork, situational awareness, human error and the usage of checklists. During our current situation of COVID-19 pandemic, providing safe anaesthesia is not solely limited to patients but now it also involves the healthcare providers. Guidelines pertaining to COVID-19 management had been published for healthcare providers to follow. Ultimately, more studies and guidelines are required in our own setting in providing a safe anaesthesi

Estimates of Glomerular Filtration Rate: comparison of different creatinine based equations

Objective: Kidney disease is a worldwide health concern with an increasing number of patients and increasing mortality in the past 10 years. The Kidney Disease Improving Global Outcomes (KDIGO) guideline advocates the use of estimated glomerular filtration rate equation (eGFR) to estimate renal function. We evaluated the performance of Cockroft Gault (CG), Modified Diet of Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations to measured GFR 99mTc-DTPA considering BMI and age group. Methods: This is a cross sectional study using the existing record of patients that as referred for 99mTc-DTPA scan at the Breast Centre of International Islamic University Malaysia. The record was taken from patients visiting the center from January 2016 to December 2019. The inclusion criteria include age more than 18 years old and not pregnant. Results: A total of 126 patients’ data was collected. All estimated GFR were analyzed in relation to measured GFR by 99m Tc-DTPA scan. The mean measured GFR by 99mTc-DTPA scan was 42.2 + 20.38 ml/min, these was lower than that estimated by CG, MDRD and CKD-EPI equations (53.81 + 36.11, 53.65 + 34.24 and 53.28 + 32.9 ml/min, respectively). CKD-EPI had the highest correlation of 0.72, least bias (mean bias of 11.08 + 23.08) and was more precise (r2 of 0.4) as compared to MDRD and CG. In patients younger than 65 years old, CKD-EPI had the highest correlation however MDRD had the least bias and highest accuracy. In terms of BMI, CKD-EPI had the least bias and highest accuracy for BMI more than 30 and with highest correlation for all classes of BMI. Conclusion: By comparing estimated GFR to measured GFR, CKD-EPI has the best estimation of GFR considering the effect of BMI, age and different stages of chronic kidney diseas

Comparison of various creatinine-based estimates of glomerular filtration rate equations in the Malaysian setting

Introduction: Kidney disease is a worldwide health concern with an increasing mortality in the past 10 years. The Kidney Disease Improving Global Outcomes (KDIGO) guideline advocates the use of estimated glomerular filtration rate equation (eGFR) to estimate renal function. Objectives: We evaluated the performance of Cockroft Gault (CG), Modified Diet of Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations to measured GFR 99mTc-DTPA taking into account of body mass index (BMI) and age group. Methods: This is a cross sectional study of patients referred for 99mTc-DTPA scan at the Nuclear Medicine Centre of International Islamic University Malaysia. The record was taken from patients visiting the centre from January 2016 to December 2019. Results: The mean measured GFR by 99mTc-DTPA scan was 42.2 ± 20.38 ml/min, these was lower than that estimated by CG, MDRD and CKD-EPI equations. CKD-EPI had the highest correlation of 0.72, least bias (mean bias of 11.08 ± 23.08) and was more precise (r2 of 0.4) as compared to MDRD and CG. In patients 30 and with highest correlation for all classes of BMI. Conclusion: CKD-EPI has the best estimation of GFR taking into account the effect of BMI and age. A further study can be done to determine the correlation of estimated GFR equations with different ethnicity in Malaysia

Estimates of glomerular filtration rate based on creatinine and cystatin c equations in critically ill patients

Introduction and Aim: Accurate assessment of renal function in the critically ill is a complex task. Estimated glomerular filtration rate (eGFR) is the best indicator to help physicians estimate kidney function and determine different stages of kidney disease. eGFR can be calculated using serum Creatinine (SCr), or serum Cystatin C (SCysC), age, body size, race and gender using different equations. We evaluated eGFR based on SCr and SCysC equations in critically ill patients to find an accurate, precise, and less biased equation for GFR estimation. Methods: This is a single cantered, cross-sectional observational study in critically ill patients older than 18 years staying for over 24-hours in intensive care units. Urinary Creatinine, SCr, and SCysC were measured at 8, 24, and 72-hour intervals. Acute kidney injury (AKI) was defined at admission using the Creatinine definition of the Kidney Disease Improving Global Outcome (KDIGO) guideline. After estimating GFR from Creatinine (eGFRCr), Cystatin C (eGFRCysC), and combining Creatinine and Cystatin C (eGFRCr-CysC), results were compared with measured Creatinine clearance (CrCL). CrCL was defined based on urinary Creatinine, SCr, and urinary volume in a 24-hour period. Results: Forty-three patients were recruited, of which 6 died and 37 alive. eGFRCr-24hrs had the highest correlation to measured CrCL-24hrs, with correlation coefficient of 0.81 (p0.05 for in- hospital-mortality prediction, addressing none of the equations led to death prediction. Conclusions: eGFRCr-24hrs had the highest correlation to measured CrCL-24hrs, with correlation coefficient of 0.81 (p<0.001). The most accurate equation was eGFRCr-72hrs However, eGFRCysC-24hrs equation had the lowest bias and was relatively more precise (60.0?ml/min). Using logistic regression, most of the equations contributed to diagnosing AKI. However, none of the equation predicted in-hospital-mortality

Estimates of glomerular filtration rate by the chronic kidney disease epidemiology collaboration equations best correlates with kinetic estimates of glomerular filtration rates in the critically ill

Introduction: Kinetic estimate of GFR (keGFR) is a more accurate estimate of GFR in the acute settings with rapidly changing kidney functions. It takes into account the changes of creatinine over time, creatinine production rate, and the volume of distribution, however needs serial measurement of creatinine. We evaluated which methods of the conventional eGFR measurement best correlates with keGFR. This could assist clinicians in using a simpler method of calculation and is useful in the absence of serial plasma creatinine. Methods: This is a secondary analysis of prospective observational study. Inclusion criteria includes age more than 18 years old, and exclusion criteria includes ICU admission of less than 48 hours, post elective surgery, and ICU readmission. Plasma creatinine were measured daily for five days, and eGFR were calculated using the Cockcroft-Gault, MDRD, CKD-EPI and keGFR equations. Results: One hundred and forty three patients were analysed, of which 78(54.5%) had AKI. keGFR strongly correlated with eGFRCKD-EPI at all time points (all r≥0.90, p<0.0001). The correlation persisted in both AKI and No AKI patients. keGFR only correlated well with eGFRMDRD and eGFRCG in AKI patients but less in patients without AKI. Bland Altman analysis showed that eGFRMDRD had the least bias, but eGFRCKD-EPI had the greatest precision. Conclusions: The new equation, keGFR strongly correlated with the eGFR by the CKD-EPI equation regardless of the time points and AKI status, and had the greatest precision. In the absence of serial plasma creatinine measurement, eGFR can accurately be estimated by the CKD-EPI equation compared to others

Development and Validation of Creatinine-Based Estimates of the Glomerular Filtration Rate Equation from 99mTc-DTPA Imaging in the Malaysian Setting

Introduction. Accurate assessment of glomerular filtration rate (GFR) is very important for diagnostic and therapeutic intervention. Clinically, GFR is estimated from plasma creatinine using equations such as Cockcroft–Gault, Modification of Diet in Renal Disease, and Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equations. However, these were developed in the Western population. To the best of our knowledge, there was no equation that has been developed specifically in our population. Objectives. We developed a new equation based on the gold standard of 99mTc-DTPA imaging measured GFR. We then performed an internal validation by comparing the bias, precision, and accuracy of the new equation and the other equations with the gold standard of 99mTc-DTPA imaging measured GFR. Methods. This was a cross-sectional study using the existing record of patients who were referred for 99mTc-DTPA imaging at the Nuclear Medicine Centre, International Islamic University Malaysia. As this is a retrospective study utilising routinely collected data from the existing pool of data, the ethical committee has waived the need for informed consent. Results. Data of 187 patients were analysed from January 2016 to March 2021. Of these, 94 were randomised to the development cohort and 93 to the validation cohort. A new equation of eGFR was determined as 16.637 ∗ 0.9935Age ∗ (SCr/23.473)−0.45159. In the validation cohort, both CKD-EPI and the new equation had the highest correlation to 99mTc-DTPA with a correlation coefficient of 0.81 (). However, the new equation had the least bias and was the most precise (mean bias of −3.58 ± 12.01) and accurate (P30 of 64.5% and P50 of 84.9%) compared to the other equations. Conclusion. The new equation which was developed specifically using our local data population was the most accurate and precise, with less bias compared to the other equations. Further study validating this equation in the perioperative and intensive care patients is needed

Obstacles of continuous peripheral nerve block in physiotherapy

Introduction: Perineural local anesthetic infusion also known as continuous peripheral nerve blocks (PNB), is a technique of providing analgesia for multiples days or even weeks by administrating local anesthesia via catheter following insertion of a catheter to peripheral nerve. The technique has been applied to different body regions for a wide range of operations for both hospitalized and ambulatory patients. It is commonly used in providing analgesia post-operation or assisting patient in physiotherapy. Despite of numerous benefits of continuous PNB, various complications have been reported relating to either, needle or catheter insertion or local anaesthetic administered. We hereby report obstacles on a patient with continuous PNB. Case description: A 22-year-old gentleman complicated with right elbow stiffness after underwent two operations for right olecranon process fracture, planned for aggressive physiotherapy. He was subsequently received continuous PNB via supraclavicular approach with continuous infusion. During 17 days of physiotherapy course, the catheter been changed multiple times due to dislodgement despite using topical skin adhesive glue, suture technique, single or double tunneling method, and require alternating insertion via supra-clavicular and costoclavicular approach. Patient also developed Horner’s syndrome invariably despite titrating down infusion rate, limiting boluses volume, minimal local anesthetic concentration, and adjust to multiple staged small boluses. Later, patient complicated with catheter related infection over insertion site with minimal pus formation. Catheter was removed following infection and patient recovered well with a course of oral antibiotic. Conclusion: Despite of peripheral nerve block catheter inserted using aseptic technique under ultrasound guided together with nerve stimulator, dislodgement, Horner Syndrome and infection complications still can happen. Various challenges associated with PNB especially with long course catheter insertion, to have optimal analgesia for physiotherapy with minimal complications. The team and with patient’s co-operation did the best that can be done to help the patient

Characteristics and outcomes of an international cohort of 600 000 hospitalized patients with COVID-19

Background: We describe demographic features, treatments and clinical outcomes in the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) COVID-19 cohort, one of the world's largest international, standardized data sets concerning hospitalized patients. Methods: The data set analysed includes COVID-19 patients hospitalized between January 2020 and January 2022 in 52 countries. We investigated how symptoms on admission, co-morbidities, risk factors and treatments varied by age, sex and other characteristics. We used Cox regression models to investigate associations between demographics, symptoms, co-morbidities and other factors with risk of death, admission to an intensive care unit (ICU) and invasive mechanical ventilation (IMV). Results: Data were available for 689 572 patients with laboratory-confirmed (91.1%) or clinically diagnosed (8.9%) SARS-CoV-2 infection from 52 countries. Age [adjusted hazard ratio per 10 years 1.49 (95% CI 1.48, 1.49)] and male sex [1.23 (1.21, 1.24)] were associated with a higher risk of death. Rates of admission to an ICU and use of IMV increased with age up to age 60&nbsp;years then dropped. Symptoms, co-morbidities and treatments varied by age and had varied associations with clinical outcomes. The case-fatality ratio varied by country partly due to differences in the clinical characteristics of recruited patients and was on average 21.5%. Conclusions: Age was the strongest determinant of risk of death, with a ∼30-fold difference between the oldest and youngest groups; each of the co-morbidities included was associated with up to an almost 2-fold increase in risk. Smoking and obesity were also associated with a higher risk of death.&nbsp;The size of our international database and the standardized data collection method make this study a comprehensive international description of COVID-19 clinical features. Our findings may inform strategies that involve prioritization of patients hospitalized with COVID-19 who have a higher risk of death