Thongprayoon, Charat

Ventilator-associated events (VAEs) are associated with increased risk of poor outcomes, including death. Bundle practices including thromboembolism prophylaxis, stress ulcer prophylaxis, oral care, and daily sedation breaks and spontaneous breathing trials aim to reduce rates of VAEs and are endorsed as quality metrics in the intensive care units. We sought to create electronic search algorithms (digital signatures) to evaluate compliance with ventilator bundle components as the first step in a larger project evaluating the ventilator bundle effect on VAE. We developed digital signatures of bundle compliance using a retrospective cohort of 542 ICU patients from 2010 for derivation and validation and testing of signature accuracy from a cohort of random 100 patients from 2012. Accuracy was evaluated against manual chart review. Overall, digital signatures performed well, with median sensitivity of 100% (range, 94.4%–100%) and median specificity of 100% (range, 100%–99.8%). Automated ascertainment from electronic medical records accurately assesses ventilator bundle compliance and can be used for quality reporting and research in VAE.

AbstractAimThis study aimed to investigate how varied methods of determining baseline serum creatinine (SCr) would affect acute kidney injury (AKI) diagnosis and prediction of 60 day mortality in critically ill patients following an episode of AKI.MethodsThis is a single‐centre retrospective study conducted at a tertiary referral hospital. All adult intensive care unit (ICU) patients between January and December 2011, who had at least one SCr values measured between 7 days and 180 days before hospital admission and during ICU stay, were analyzed. The baseline SCr was calculated using either the most recent (SCrmost recent) or the minimum (SCrmin) value of SCr measurement over the specified assessment period before hospital admission. AKI was defined based on KDIGO SCr definition. The primary outcome was 60 day mortality after ICU admission.ResultsA total of 4020 patients were included in the analysis. AKI was detected in 1204 (30.0%) using the SCrmin and 945 (23.5%) using the SCrmost recent (P < 0.001). Compared with patients without AKI regardless of baseline SCr methodology, the 60 day mortality risk of patients who developed AKI using the SCrmin and SCrmost recent was significantly increased (odds ratio (OR) = 3.74; 95% confidence interval (CI) 2.98–4.70). Similarly, the risk of 60 day mortality in patients who met AKI criteria using the SCrmin but not the SCrmost recent was significant higher than in patients without AKI (OR = 2.04; 95% CI 1.36–3.00).ConclusionUsing the minimum value of preadmission SCr as a baseline kidney function not only can detect more AKI cases, but also provides the better predictive ability for 60 day mortality.

Background. The study investigates the occurrence, severity, and outcomes of acute kidney injury (AKI) in octogenarians following heart valve surgery.Methods. All patients, age>80 years, not on dialysis and without kidney transplant, undergoing heart valve replacement at Mayo Clinic, Rochester, in the years 2002-2003 were enrolled. AKI was diagnosed based on AKIN criteria.Results. 209 octogenarians (88.0% aortic valve, 6.2% mitral valve, 1.0% tricuspid valve, and 4.8% multivalve) with (58.4%) and without CABG were studied. 34 (16.3%) had preexisting CKD. After surgery, 98 (46.8%) developed AKI. 76.5% of the AKI were in Stage 1, 9.2% in Stage 2, and 14.3% in Stage 3. 76.5% CKD patients developed AKI. Length of hospital stay was longer for AKI patients. More AKI patients were discharged to care facilities. Patient survival at 30 days and 1 year for AKI versus non-AKI was 88.8 versus 98.7%,p=0.003, and 76.5 versus 88.3%,p=0.025, respectively. With follow-up of3.94±0.28years, Kaplan-Meier analysis showed a reduced survival for AKI octogenarians. Preexisting CKD and large volume intraoperative fluid administration were independent AKI predictors.Conclusions. Nearly half of the octogenarians developed AKI after valve replacement surgery. AKI was associated with significant functional impairment and reduced survival.

Abstract Aim The objective of this meta‐analysis was to compare the effects of off‐pump and on‐pump coronary artery bypass grafting ( CABG ) on acute kidney injury ( AKI ) and the need of dialysis after surgery. Methods Comprehensive literature searches for randomized controlled trials ( RCTs ) of CABG with on‐pump and off‐pump was performed using MEDLINE , EMBASE , C ochrane D atabase of S ystematic R eviews, C ochrane C entral R egister of C ontrolled T rials S ystematic R eviews and clinicaltrials.gov from inception through S eptember 2014. Primary outcomes were the incidence of AKI and the need of dialysis. Mortality was assessed among the studies that reported renal outcomes. Pooled risk ratios ( RR s) and 95% confidence interval ( CI ) were calculated using a random‐effect, generic inverse variance method. Results Thirty‐three RCTs with 17 322 patients were enrolled in our study. Patients in the off‐pump CABG group had overall lower incidence of AKI (19.1%) compared with the on‐pump CABG group (22.2%). There was a protective effect of off‐pump CABG on the incidence of AKI compared with the on‐pump CABG group ( RR : 0.87; 95% CI : 0.77–0.98). However, there was no significant difference in the need for dialysis in the off‐pump group compared with the on‐pump group ( RR : 0.84; 95% CI 0.63–1.13). Within the selected trials, post hoc analysis assessing the mortality outcome demonstrated a pooled RR of 0.97 (95% CI , 0.77–1.23) in off‐pump versus on‐pump CABGs . Conclusions Our study demonstrates a beneficial effect of off‐pump CABG on the incidence of AKI . However, our meta‐analysis does not show benefits of the need of dialysis or survival among patients undergoing off‐pump CABG .

AbstractBackgroundThe reported risk of depression in patients with hypomagnesaemia is controversial.AimThe objective of this meta‐analysis was to assess the association between depression and hypomagnesaemia.MethodsA literature search was performed using MEDLINE, EMBASE, Cochrane Database and clinicaltrials.gov from inception through October 2014. Studies that reported odds ratios, relative risks or hazard ratios comparing the risk of depression in patients with hypomagnesaemia were included. Pooled risk ratios (RR) and 95% confidence interval (CI) were calculated using a random‐effect, generic inverse variance method.ResultsSix observational studies (three cohort studies, two cross‐sectional studies and a case–control study) with a total of 19 137 patients were identified and included in the data analysis. The pooled RR of depression in patients with hypomagnesaemia was 1.34 (95% CI, 1.01–1.79, I2 = 33%). The association between depression and hypomagnesaemia was marginally insignificant after the sensitivity analysis including only cohort and case–control studies, with a pooled RR of 1.38 (95% CI, 0.92–2.07, I2 = 24%).ConclusionOur study demonstrates a potential association between hypomagnesaemia and depression. Further studies assessing the benefits of treatment of hypomagnesaemia in patients with depression are needed.

AbstractAimData on clinicopathological features, treatment and outcomes of IgA nephropathy (IgAN) in elderly patients are limited.MethodsNative kidney biopsies with a pathological diagnosis of IgAN (n = 1084) from Mayo Clinic Rochester in the years 1994–2013 were examined. After exclusion of the secondary IgAN, 45 elderly IgAN patients (age ≥65 years) were identified. One hundred sixty‐two younger adults (age 18–64 years) with IgAN were randomly selected for comparison.ResultsCompared with younger adults, elderly patients showed a higher rate of chronic hypertension (62.2 vs 27.2%), higher pulse pressures (65 ± 17 vs 51 ± 15 mmHg), requiring greater number of antihypertensive medications (2.5 ± 1.2 vs 1.7 ± 0.7) and lower blood haemoglobin (11.1 ± 2.3 vs 12.7 ± 2.1 g/dL) at time of kidney biopsy, all P < 0.001. Pathologically, elderly kidneys showed a higher degree of tubulointerstitial fibrosis (P = 0.04) and vascular sclerosis (P < 0.001). Treatments (including the use of angiotensin‐converting enzyme inhibitor (ACEI) inhibitor, angiotensin II receptor blocker (ARB) and immunosuppressants) were similar in the two cohorts. Elderly patients had more end‐stage renal disease at 6 months (HR 5.51; 95% CI 1.46–22.3, P = 0.01) and higher 6‐month and 5‐year mortality (HR 2.31; 95% CI 1.04–5.17, P = 0.04) after adjusting the age and comorbidities.ConclusionIgAN diagnosed at age >65 years tends to have a faster renal disease progression and higher patient mortality.