Acute kidney injury (AKI) and sepsis are critical clinical conditions associated with high morbidity and mortality. Despite growing research interest, there remains a need for a comprehensive analysis of global research trends in this field. Bibliometric analysis offers a quantitative approach to assessing the evolution of scientific knowledge, collaborative networks, and emerging research areas over time.

This study aims to map the global landscape of research on AKI and sepsis over the last two decades (2004-2024), identify major contributors, collaboration networks, key research trends, and highlight gaps in the literature.

We conducted a bibliometric analysis of research articles from leading databases. The study utilized network visualization techniques to assess co-authorship, citation patterns, and keyword co-occurrence, focusing on the most influential countries, institutions, and research collaborations.

Results reveal China leads in publication volume, yet countries like the United States and Australia show higher international collaboration rates and citation impact. Additionally, thematic analyses highlight critical research areas, including biomarkers, bioenergetics, inflammation, and machine learning, marking significant advancements in the understanding and management of AKI.

This bibliometric analysis offers valuable insights into the evolving landscape of AKI and sepsis research, emphasizing the importance of collaborative efforts to address knowledge gaps and ensure evidence-based care across diverse healthcare settings. Future research should prioritize the development of biomarkers and the integration of AI-driven technologies to enhance early diagnosis and personalize treatment strategies for AKI patients.

Recurrence of IgA nephropathy (IgAN) after kidney transplant (KT) appears associated with worse graft survival; thus, the identification of risk factors is worthwhile to improve pre-transplant evaluation of KT recipients and to identify the optimal treatment strategy. The aim of this study was to determine incidence, risk factors and impact on renal function and graft survival of IgAN recurrence after KT. We performed a retrospective study including 110 patients with biopsy-proven IgAN, who underwent KT at Policlinico di Sant'Orsola Hospital - University of Bologna from 2005 to 2021. IgAN recurred in 14 patients (12.7%) with a median time-to-recurrence of 59 (16-90) months. We found that a faster progression from IgAN diagnosis to end-stage kidney disease (ESKD), a younger age at ESKD, and a younger age at KT were associated with a higher risk of recurrence. During the first 2 years after KT, 24 h proteinuria was higher in patients with IgAN recurrence than in patients without (0.40 (0.11-1.8) vs 0.22 (0.18-0.37) g/day, p = 0.0003). During the follow-up period, a more rapid decline in eGFR was observed in the Recurrence group (p = 0.023). Additionally, graft survival at 10 years post-kidney transplant was significantly lower in this group (log-rank test p = 0.015). In conclusion, we found that patients with a more aggressive form of IgAN, who reached ESKD before 36 years of age, had an higher risk of recurrence in KT. Moreover we confirmed that recurrent IgAN, especially if clinically relevant, is associated with a worse graft outcome.

Background: A newly discovered renal syndrome, shrunken pore syndrome (SPS), has been shown to increase mortality regardless of renal function. SPS is defined as an estimated glomerular filtration rate (eGFR) of cystatin C ≤ 60% than eGFRcreatinine. We set out to study SPS in relation to the survival of heart transplantation patients with a follow-up of up to 12 years. Methods. This was a single-center cohort study including 253 consecutive patients undergoing heart transplantation. The prevalence of SPS at different time points post-transplantation and its effect on survival was evaluated using Kaplan-Meier's analysis and multivariable Cox proportional hazards regression. Results. The prevalence of SPS was 7.5% the day after transplantation (D1), which rose to 71% week 4 after surgery. There was no difference in survival for patients with SPS D1 compared to patients without SPS D1. Patients with SPS 4 weeks compared to patients without SPS 4 weeks after transplantation showed a 5- and 10-year survival of 73% vs. 93% (p = .02) and 63% vs. 90% (p = .005), respectively. SPS developed during the postoperative period was also found to be an independent predictor of mortality (HR 4.65; 95% CI 1.36-15.8). Discussion. SPS that developed in the postoperative course after heart transplantation was found to be an independent predictor of mortality with a severe negative impact on 5- and 10-year survival.

The AKI Department of the Brazilian Society of Nephrology (BSN) has prepared a hospital nephrology assistance guide, which encompasses the aspects involved in the nephrologist's role in caring for patients with kidney diseases within the hospital setting. The guide addresses the following main topics: 1) the role of the nephrologist in hospital care; 2) non-dialysis kidney support therapy; 3) technical standards for hospital dialysis care; and 4) outpatient follow-up of patients with acute kidney injury/disease. It provides a detailed description of the nephrologists' main responsibilities, their role in both non-dialysis and dialysis hospital care, as well as describing all available dialysis methods, the required infrastructure, human resources, and records of these procedures. The guide concludes with recommendations for the outpatient follow-up of nephrological patients after hospital discharge. The primary purpose of this BSN guide is to provide support for a better medical and multidisciplinary assistance for nephrologists and other professionals involved in the hospital patient's nephrology care.

Increased time to surgery is a well-established risk factor for complication and mortality among patients undergoing hip fracture fixation. However, few studies have been completed evaluating the association between time to surgery and complication rates in patients undergoing operative fixation of pelvic ring injuries.

A retrospective cohort study was performed at a Level I trauma center including all patients with operative pelvic ring injuries from 2015 to 2022. Time from hospital admission to surgery, basic demographics, and comorbidities were determined for all patients. Systemic complications including acute respiratory distress syndrome, pneumonia, sepsis, deep venous thrombosis, pulmonary embolus, ileus, acute kidney injury, myocardial infarction, and mortality were recorded. The association between time to surgery and overall complications and each complication individually was estimated using multivariable statistical models.

A total of 1,056 patients were included in the final cohort. Patients who underwent surgery within 48 hours (n = 724) had an overall lower complication rate (17.8%) compared with those patients (n = 332) who underwent surgery greater than 48 hours after admission (34.9%). Each additional hour delay to surgery from admission was associated with a 0.4% increased odds of any complication. With respect to specific complications, each additional hour also increased the odds of sepsis (0.7%), deep venous thrombosis (0.3%), acute kidney injury (0.3%), myocardial infarction (0.5%), and pneumonia (0.4%). The odds of overall complication was 2.10 when patients underwent surgery within 42 hours after admission and increased at every time point afterwards.

Among patients with pelvic ring injuries, increased time to surgery was associated with an increased odds of systemic complication. This underscores the importance of aggressive resuscitation and prompt surgical intervention to reduce morbidity and improve overall patient outcomes.

Prognostic and Epidemiological; Level III.

To evaluate the efficacy and safety of empagliflozin in patients with type 2 diabetes mellitus (T2DM) undergoing elective on-pump coronary artery bypass grafting (CABG).

Investigator-initiated, pragmatic, single-center, randomized, open-label trial with blinded outcome adjudication conducted in Brazil. A total of 145 patients with T2DM scheduled for elective on-pump CABG were randomized to receive empagliflozin 25 mg daily plus standard care (n = 71) for at least 3 months, which was discontinued 72 h before surgery, or to received standard care alone (n = 74). The primary outcome was postoperative acute kidney injury (AKI) within 7 days of surgery, defined by creatinine-based criteria (namely, Acute Kidney Injury Network; Risk, Injury, Failure, Loss of Kidney Function, and End-Stage Kidney Disease; or Kidney Disease: Improving Global Outcomes). Secondary outcomes included 30-day postoperative atrial fibrillation and type 5 myocardial infarction (MI). Safety outcomes were ketoacidosis, urinary tract infection, hospital-acquired pneumonia, and wound infection within 30 days after CABG.

AKI occurred in 22.5% of the empagliflozin group vs. 39.1% in the control group (relative risk [RR] 0.57 [95% CI 0.34-0.96]; P = 0.03). Rates of atrial fibrillation (15.4% vs. 13.5%; RR 1.15 [95% CI 0.52-2.53]; P = 0.73) and type 5 MI (1.4% vs. 4.1%; RR 0.35 [95% CI 0.04-3.26]; P = 0.62) were similar between groups. No statistically significant differences between groups were observed for safety events. Three deaths occurred, all in the control group.

Empagliflozin use before on-pump CABG in patients with T2DM was associated with a reduced incidence of postoperative AKI without an increase in safety events. These findings warrant confirmation in larger clinical trials.

As the last defense against multidrug-resistant gram-negative bacteria, colistin sulfate's clinical use, which is often empirical, risks resistance and adverse reactions. This study aimed to develop a population pharmacokinetic (PPK) model of colistin sulfate for critically ill patients and determine the optimal dosing regimen. This retrospective study included 204 critically ill patients. We used a validated LC-MS/MS method to measure its plasma concentrations and RIFLE criteria for nephrotoxicity evaluation. NONMEM developed PPK models. Monte Carlo simulations set dosing regimens based on the probability of target attainment (PTA). A two-compartment model adequately described the data, creatinine clearance and weight were covariates for elimination rate and central volume, respectively. Only 11.8% had nephrotoxicity. With Monte Carlo simulations, all regimens except the maintenance dose of 0.5 MU administered every 12 h achieved > 90% PTA at the minimum inhibitory concentration (MIC) ≤ 0.5 mg/L. However, at MIC > 0.5 mg/L, the routine regimen resulted in insufficient exposure. Based on our PPK model, the dose of intravenous colistin sulfate should be adjusted according to creatinine clearance (CrCL) and weight. For critically ill patients with infections, under the conventional treatment regimens, when the MIC is ≥ 1 mg/L, it is difficult for patients to achieve the ideal therapeutic effect in terms of exposure dose. When CrCL is below 10 ml/min, the regimen of 1 MU every 8 h used could cause the potential for increasing nephrotoxicity risk, which is significantly concerned.

The condition of sepsis, defined by the misregulation of the body's defensive mechanisms against infection, culminates in the potential for catastrophic organ damage and stands as a primary driver of mortality in Intensive Care Units (ICU) settings. Among patients in a critical condition, sepsis is a predominant factor in the development of acute kidney injury (AKI), and the death rate among those with both sepsis and AKI is considerably higher, underscoring the importance of addressing this health crisis. Sepsis-associated acute kidney injury (S-AKI) is a complex process involving inflammation, microcirculatory issues, and metabolic disorders. Among these, the inflammatory response has become a focal point of interest. Bridging the innate and adaptive immunity, natural killer T (NKT) cells can be rapidly activated in sepsis, contributing to sepsis-associated injury and downstream activation of inflammatory cells through the emission of Th1 or Th2 cytokines. They also contribute to S-AKI through the TNF-α/FasL and perforin pathways. Alpha-Galactosylceramide (α-GalCer), acting as a powerful activator for type I NKT (iNKT) cells, is able to regulate the secretory profile of iNKT cells, responding to the pro-inflammatory response and immunosuppressive profiles of sepsis. This review examines the part played by NKT cells in S-AKI and whether α-Galcer could function as a significant regulator in sepsis, based on studies of regression-related mechanisms.

IntroductionThere is no recommendation regarding the optimal prime solution for the cardiopulmonary bypass circuit in adult cardiac surgery. Despite the lack of scientific evidence, mannitol has frequently been added to the prime solution with intention to prevent acute kidney injury. The aim of this study was to investigate the impact of mannitol in cardiopulmonary bypass circuit prime in patients with preoperative renal dysfunction.MethodsThis prospective, randomized, double-blind study included 70 patients, who underwent coronary artery bypass grafting. One group received 1200 mL of a prime based on Ringer's acetate (n = 35), and the other a prime consisting of 1000 mL Ringer's acetate and 200 mL mannitol (n = 35). Primary endpoint were levels of Cystatin C, a renal function biomarker. Changes in renal-related parameters, electrolytes, osmolality and acid-base status were monitored.ResultsThe median cystatin C on day four in the mannitol group were 1.6 mg/L (IQR 1.4-2.0 mg/L) and 1,8 mg/L (IQR 1.5-2.1 mg/L) in the Ringer's acetate group at the same time. Using mixed model analysis, no differences in cystatin C (p = 0.442), creatinine (p = 0.203), estimated glomerular filtration rate (p = 0.264) and urea (p = 0.141) could be detected between the groups. The mannitol group showed a more pronounced reduction in sodium levels after cardiopulmonary bypass circuit commencement compared to the Ringer's acetate group p < 0.001.ConclusionsIn patients with preoperative renal dysfunction, the addition of mannitol in the prime solution did not show any renoprotective effect measured by cystatin C compared to a cardiopulmonary bypass circuit prime based on Ringer's acetate. This study was reported to ClinicalTrials.org, id: NCT03302286. Effects of Extra Corporeal Circuit Prime on Electrolytes Balance and Clinical Outcome Following Cardiac Surgery https://clinicaltrials.gov/study/NCT03302286?id=NCT03302286&rank=1.

This systematic review and meta-analysis aimed to identify and quantify the risk factors associated with acute kidney injury (AKI) in patients with traumatic brain injury (TBI).

PubMed, Embase, and Web of Science were systematically searched for articles published up to October 2024. Observational studies published in English that reported on risk factors for AKI in TBI patients were included. Data on AKI incidence and risk factors were extracted. A meta-analysis was conducted using a random-effects model when heterogeneity I2 > 50 % and a fixed-effects model when I2 < 50 %. Risk of bias for studies was assessed using the Newcastle-Ottawa Scale (NOS). Certainty of evidence was evaluated using the GRADE approach.

Twenty studies involving 13,115 TBI patients were included in the meta-analysis. The pooled incidence of AKI after TBI was 19 % (95 % CI 16-23). Male gender (odds ratio (OR) 1.43, 95 % CI 1.21-1.70; I2 0 %), diabetes (OR 3.59, 95 % CI 1.74-7.42; I2 0 %), Glasgow Coma Scale (GCS) (mean difference (MD) -0.48, 95 % CI -0.74,-0.23; I2 38 %), GCS ≤ 8 at admission (OR 1.56, 95 % CI 1.28-1.90; I2 0 %), Simplified Acute Physiology Score II (SAPS II) score (MD 4.65, 2.69-6.61; I2 56 %), serum creatinine level at admission (MD 18.17, 95 % CI 1.82-34.51; I2 93 %), hemoglobin (MD -6.82, 95 % CI -12.72, -0.92; I2 79 %), glucose (MD 1.42, 95 % CI 0.64-2.20; I2 0 %), the use of mannitol (OR 2.14, 95 % CI 1.08-4.25; I2 74 %), vancomycin (OR 1.75, 95 % CI 1.35-2.27; I2 0 %) and red blood cell transfusion (OR 3.35, 95 % CI 1.86-6.04; I2 59 %) increased the risk for AKI.

These findings highlighted the critical need for proactive surveillance of these risk factors in clinical practice, enabling the development of prediction models to identify TBI patients at high risk of AKI.

Neutrophil extracellular traps (NETs) are a vital part of the innate immune response, while excessive NET formation can cause tissue damage. H3.1 nucleosomes, a component of NETs, have emerged as a potential biomarker. This study aimed to evaluate H3.1 nucleosomes in critical illness, assessing their relationship with sepsis, organ failure, inflammatory subphenotypes and outcomes.

The MARS cohort was used, comprising of consecutive Intensive Care Unit patients, with plasma samples collected on days 0, 2 and 4. H3.1 nucleosome concentrations were measured using the Nu.Q® NETs Immunoassay. H3.1 nucleosome concentrations were compared across sepsis presence and organ failure, both at baseline and longitudinally. The relationship between H3.1 nucleosome concentrations and clinical outcomes was investigated.

1713 critically ill patients were included, with a total of 3671 plasma samples. Baseline H3.1 nucleosome concentrations differed between sepsis confirmed by clinical adjudication (740 ng/mL), sepsis unconfirmed by clinical adjudication (416 ng/mL) and non-sepsis (463 ng/mL, P < 0.001). H3.1 concentrations were associated with SOFA score (r = 0.40) and were higher in patients with disseminated intravascular coagulation, acute kidney injury and hyperinflammatory sepsis. H3.1 concentration was highly predictive for the need of renal replacement therapy (hazard ratio 2.00 per log10 increase), correcting for mortality.

Sepsis and organ failure were closely associated with plasma H3.1 nucleosome concentrations. While individual diagnostic performance for sepsis and organ failure remained low, H3.1 levels predicted the need for renal replacement therapy and disseminated intravascular coagulation, revealing unique insights into the innate immune response.

ClinicalTrials.gov identifier NCT01905033; IRB number 10-056C, registered June 16, 2010.

Guidelines recommend a target AUC24/MIC of 400-600 for vancomycin dosing in serious MRSA infections. However, various challenges hinder the implementation of AUC-based monitoring. Previously recommended target trough of 15-20 mg/L may be associated with increased nephrotoxicity.

In this single-center, retrospective study, we compared outcomes of targeting troughs of 10-15 mg/L vs 15-20 mg/L for intermittent infusion of vancomycin (IIV) in adult hospitalized patients who received ≥ 48 h of IIV and had ≥ 1 trough measurement within recommended ranges. Local guidelines recommended target troughs of 15-20 mg/L between January 2019 and December 2020 and 10-15 mg/L between January 2022 and October 2023. Treatment failure, acute kidney injury (AKI) and inpatient mortality were compared using a desirability of outcome ranking (DOOR) analysis between the two time periods. The most desirable outcome was treatment success and no AKI, and the least desirable outcome was death.

A total of 173 IIV courses were included. The probability of obtaining a better DOOR was 57.9% (95%CI 50.5-64.9, p = 0.03) when targeting a lower trough. Secondary analyses demonstrated a similar trend. When analyzed separately, the lower target trough group experienced significantly less AKI (OR 0.40, 95%CI 0.16-0.96) with no significant effect on mortality and treatment failure.

Our study showed that targeting a trough of 10-15 mg/L for IIV may be associated with a superior overall outcome compared to targeting 15-20 mg/L. In centers not using AUC-based monitoring for vancomycin dosing, a lower target trough may be preferable.

Background: The eye and kidney share embryological, structural, and pathophysiological similarities, suggesting potential interconnections between retinal and renal microvascular changes. Hypertension, a major risk factor for renal impairment, also affects retinal microvasculature. This study investigates the relationship between retinal vascular density, assessed by Optical Coherence Tomography Angiography (OCT-A), and early renal dysfunction in hypertensive patients. Methods: A total of 142 hypertensive patients (mean age 47 ± 13 years; 74% male) were enrolled from the Nephrology and Hypertension Unit at the University of Palermo. Retinal vascular density was measured using OCT-A, and renal function was assessed using estimated glomerular filtration rate (eGFR). Clinical and hemodynamic parameters, including 24-h aortic blood pressure, were also analyzed. Results: Patients with eGFR < 60 mL/min/1.73 m2 exhibited significantly lower retinal vascular densities, particularly in the parafoveal region. Superficial parafoveal density was inversely associated with aortic pulse pressure (p = 0.012) and directly correlated with eGFR (p = 0.012). Deep parafoveal density was independently associated with eGFR (p = 0.001). Multiple linear regression confirmed that lower retinal vascular density was significantly linked to reduced renal function, independent of age and blood pressure. Conclusions: Retinal vascular density, particularly in the parafoveal region, is associated with renal function decline in hypertensive patients. These findings suggest that retinal microvascular changes could serve as a non-invasive biomarker for kidney dysfunction, with potential applications in early risk stratification and disease monitoring. Further research is needed to establish causality and clinical utility.

Acute kidney injury (AKI) is a critical yet frequently under diagnosed condition in hospitalized patients, impacting morbidity and mortality. Electronic alerts for AKI aimed to assist physicians in early diagnosis and intervention, though evidence for their effectiveness is inconsistent.

A systematic search was conducted in PubMed, the Cochrane Central Register of Controlled Trials, Cochrane Library, and Web of Science from inception to November 2024. Eligible studies included randomized controlled trials (RCTs), before-and-after analyses, and stepped-wedge designs involving hospitalized patients. The primary outcomes were mortality and renal replacement therapy (RRT) rates, Secondary outcomes included hospital length of stay (LoS), AKI progression and recovery. Care-centered outcomes encompassed nephrologist consultation, nephrotoxic medication discontinuation and medication review. Subgroup analysis examined the impact of response intensity, hospital type and geographic region on these outcomes.

Twenty-two studies involving 170,696 participants were included: 8 RCTs (n = 21,710) and 14 non-RCTs or observational studies (n = 148,986). RCTs showed no effect on mortality (RR 1.02; 95% CI 0.97-1.07) or LoS (mean difference 0.04; 95% CI - 0.13 to 0.22) but a significant increase in RRT use (RR 1.13; 95% CI 1.02-1.26) with AKI alert systems. Non-RCTs, however, reported reduced mortality (RR 0.92; 95% CI 0.88-0.96), less AKI progression (RR 0.85; 95% CI 0.77-0.94), enhanced kidney recovery (RR 1.65; 95% CI 1.56-1.75), increased nephrotoxic drug discontinuation (RR 1.20; 95% CI 1.13-1.28), and higher drug review rates (RR 1.19; 95% CI 1.17-1.21), with no impact on RRT use (RR 1.08; 95% CI 0.87-1.36). Subgroup analysis revealed an increased in-hospital mortality in low response intensity (RR 1.15; 95% CI 1.00-1.32), reduced mortality in moderate response intensity (RR 0.93; 95% CI 0.89-0.97), and unclear effects in high response intensity (RR 0.88; 95% CI 0.70-1.09). AKI alert was also favored in teaching hospitals and in several regions (Europe, North America and South America).

The efficacy of AKI alerts remains inconclusive. Current evidence do not support or refute their effectiveness. Variability in response intensity, hospital type and geographic region may help explaining discrepancies, underscoring the need for further research to optimize AKI alert systems with more effective action in clinical practice.

Burn injuries can lead to severe complications across multiple organ systems, with kidney impairment being particularly common and clinically significant. Major adverse kidney events within 30 days post-surgery (MAKE30)-including death, initiation of new renal replacement therapy, or prolonged renal dysfunction-are increasingly used in clinical research to assess mid-term renal outcomes. However, studies on the incidence and risk factors of MAKE30 in burn patients remain limited.

We included burn patients admitted to a single-center burn intensive care unit between 2012 and 2022, excluding those with pre-existing kidney disease. The incidence of MAKE 30 was evaluated, and logistic regression analysis was performed to identify associated risk factors.

Among 848 burn patients who underwent burn surgery during the study period, 286 (33.7 %) developed MAKE30. Postoperative acute kidney injury (AKI), age, diabetes mellitus, inhalation injury, deep burn area, intraoperative vasopressor use, fresh frozen plasma transfusion, and urine output were significantly associated with MAKE30. The incidence of MAKE30 was markedly higher in patients who developed postoperative AKI compared to those who did not (89.6 % vs. 18.3 %, p < 0.001). Additionally, chronic kidney disease (CKD) was significantly more prevalent in patients with MAKE30 than in those without (12.0 % vs. 1.7 %, p < 0.001).

Postoperative AKI is a significant risk factor for MAKE30 following burn surgery, and affected patients exhibit a substantially higher incidence of CKD. This study provides single-center data on incidence and its associated risk factors of MAKE30, underscoring the importance of early kidney function monitoring and intervention in this population.

This study was designed to evaluate the perioperative and long-term outcomes of surgical treatment, including open and hybrid repairs, for patients with penetrating aortic ulcer (PAU) in the aortic arch.

A single-center retrospective analysis from China was conducted on 72 patients with PAU in the aortic arch who underwent surgical treatment including open and hybrid repairs between January 2010 and December 2022. The study included 10 patients in the urgent repair group and 62 patients in the elective repair group. The primary endpoints included major adverse events and long-term survival. Major adverse events included in-hospital mortality, reoperation for bleeding, stroke, paraplegia, and acute renal failure.

The rate of major adverse events was 13.9 ​% (10/72), with an in-hospital mortality rate of 2.8 ​% (2/72). The mean follow-up period was 69 months. The overall survival rates at 1, 5, and 7 years after surgery were 95.8 ​%, 91.8 ​%, and 86.0 ​%, respectively. Subgroup and regression analyses showed that urgent repair was not significantly associated with the occurrence of major adverse events and long-term survival. Age (OR: 1.12, 95 ​% CI: 1.00-1.26; P ​= ​0.042) and diabetes (OR: 5.98, 95 ​% CI: 1.01-35.32; P ​= ​0.048) were found to be independent risk factors for major adverse events as well as NYHA grade ​≥ ​III (HR: 14.68, 95 ​% CI: 2.11-102.10; P ​= ​0.007) and diabetes (HR: 5.39, 95 ​% CI: 1.10-26.37; P ​= ​0.038) proved to be independent risk factors for overall survival. Compared to the elective repair group, patients who underwent urgent repair had larger PAUs (P ​= ​0.052), more frequent localization in Zone 0 or Zone 1 (P ​= ​0.038), and were more likely to undergo open surgery, particularly total arch replacement with frozen elephant trunk (P ​= ​0.001). They also experienced longer cardiopulmonary bypass time (P ​= ​0.004), lower minimum temperature (P ​= ​0.001), and lower total expenditure (P ​< ​0.001).

The surgical management of PAU in the aortic arch using open or hybrid repair techniques appears to be feasible, with favorable perioperative and long-term outcomes. However, heightened vigilance may be required for elderly patients, diabetic patients, and those with cardiac insufficiency.

Determining the optimal antibiotic (ATB) dosage in septic critically ill patients on continuous renal replacement therapy (CRRT) is still challenging. CRRT further disrupts antibiotic PK, already altered by sepsis-induced fluid shifts, volume of distribution (VD) changes and half-life modifications.

Our multi-disciplinary team-comprising an intensivist, nephrologist and clinical pharmacologist-conducted a prospective observational cohort study to evaluate the extent of ATB removal by CRRT and to assess the pharmacokinetic/pharmacodynamic (PK/PD) parameters of the most commonly used antibiotics for treating severe infections.

A total of 135 ATB therapeutic drug monitoring (TDM) assessments were conducted, measuring total drug concentrations (C) in both plasma (P) and ultrafiltrate in 85 septic patients undergoing CRRT. A high sieving coefficient (∼75%) was recorded for all antibiotics, with CRRT-related drug loss described by the following equations: (i) [CUF-ATB](trough level) = 0.77 × [CP-ATB](trough level) + 0.93 ng/mL; (ii) [CUF-ATB](peak) = 0.77 × [CP-ATB](peak) + 3.1 ng/mL. The VD exhibited wide variability, with values exceeding those reported in the literature. Lower ATB molecular weight and steric hindrance were associated with a higher elimination rate constant (Kemin⁻¹). ATB TDM consistently correlated with AUC and AUC/MIC, ensuring effective bactericidal activity.

Despite its limitations, our study suggests to carry out a loading dose for the main antibiotics and consider the daily drug loss, as identified by the linear regression equation, along with daily TDM to guide further dosing adjustments.

Acute Kidney Injury (AKI) is a common complication after cardiac surgery affecting up to 40% leading to increased morbidity and mortality. To date, there is no specific treatment for AKI, thus, clinical research efforts are focused on preventive measures. The only pharmacological preventive intervention that has demonstrated a beneficial effect on AKI in a high-quality, double-blind, randomized controlled trial is a short perioperative infusion of a balanced mixture of amino acid solution. Amino acid infusion reduced the incidence of AKI by recruiting renal functional reserve and, therefore, increasing the glomerular filtration rate. The beneficial effect of amino acids was further confirmed for severe AKI and applied to patients with chronic kidney disease. Among non-pharmacological interventions, international guidelines on AKI suggest the implementation of a bundle of good clinical practice measures to reduce the incidence of perioperative AKI or to improve renal function whenever AKI occurs. The Kidney Disease Improving Global Outcomes (KDIGO) bundle includes the discontinuation of nephrotoxic agents, volume status and perfusion pressure assessment, renal functional hemodynamic monitoring, serum creatine, and urine output monitoring, and the avoidance of hyperglycemia and radiocontrast procedures. However, pooled data from a meta-analysis did not find a significant reduction in AKI. The aim of this review is to delineate the most appropriate evidence-based approach to prevent AKI in cardiac surgery patients.

This review will explore the current knowledge, beginning with the physiologic underpinnings and delve into the evolving scientific literature, encompassing the inextricably intertwined diagnosis and management of sepsis and septic shock in human and small animal patients. Sepsis is a significant cause of morbidity and mortality in patients, mostly for failure to recognize or treat promptly and adequately. Diagnosis is based on the individual patient, clinical context, and clinical acumen. High quality supportive care in the intensive care unit setting is patient-centered with intensive nursing, focused on physiologic systems, goal-oriented, and multi-disciplinary with a team-based approach to patient care.

The ability to predict progression to severe acute kidney injury (AKI) remains an unmet challenge. Contributing to the inability to predict the course of AKI is a void of understanding of the pathophysiological mechanisms of AKI. The identification of novel prognostic biomarkers could both predict patient outcomes and unravel the molecular mechanisms of AKI. We performed a multicenter retrospective observational study from a cohort of patients following cardiac surgery. We identified novel urinary prognostic biomarkers of severe AKI among subjects with early AKI. Of 2,065 proteins identified in the discovery cohort, insulin-like growth factor binding protein 1 (IGFBP-1) was the most promising. We validated IGFBP-1 as a prognostic biomarker of AKI in 213 patients. In addition, we investigated its role in the pathophysiology of AKI using a murine model of cisplatin-induced AKI (CIAKI). Urinary IGFBP-1 concentration in samples collected from patients with stage 1 AKI following cardiothoracic surgery was significantly higher in patients who progressed to severe AKI compared with patients who did not progress beyond stage 1 AKI (40.28 ng/ml vs. 2.8 ng/ml, P < 0.0001) and predicted the progression to the composite outcome (area under the curve: 0.85, P < 0.0001). IGFBP-1 knockout mice showed less renal injury, cell death, and apoptosis following CIAKI, possibly through increased activation of the insulin growth factor receptor 1. IGFBP-1 is a clinical prognostic biomarker of AKI and a direct mediator of the pathophysiology of AKI. Therapies that target the IGFBP-1 pathways may help alleviate the severity of AKI.NEW & NOTEWORTHY The ability to predict progression to severe AKI remains an unmet challenge. Early prognostic biomarkers of AKI hold promise to improve patient outcomes by early implementation of clinical therapy, as well as unravel the pathophysiological mechanisms of AKI. Here, we present a novel urinary biomarker, IGFBP-1, that predicts the progression to severe AKI following cardiac surgery. In addition, we show that IGFBP-1 mice are protected against CIAKI, suggesting a mechanistic role for IGFBP-1 in AKI.

Cardiac surgery-associated acute kidney injury (CSA-AKI) significantly increases postoperative mortality and healthcare costs. Despite the growing volume of CSA-AKI research, the field remains fragmented, with challenges in identifying high-impact studies, collaborative networks, and emerging trends. Bibliometric analysis addresses these gaps by systematically mapping knowledge structures, revealing research priorities, and guiding resource allocation for both researchers and clinicians.

We analyzed 4,474 CSA-AKI-related publications (2014-2023) from the Web of Science Core Collection (WoSCC) using VOSviewer, CiteSpace, the Bibliometrix Package in R, and the bibliometric online analysis platform.

Annual publications increased steadily, with the USA and China leading productivity. The Journal of Cardiothoracic and Vascular Anesthesia serves as the foremost preferred journal within this domain. Critical Care (IF = 15.1) has the highest impact factor. Yunjie Li published the most papers. John A Kellum has the highest H-index. The definition, pathogenesis or etiology, diagnosis, prediction, prevention and treatment, which are the research basis in CSA-AKI. Machine learning (ML) and prediction models emerged as dominant frontiers (2021-2023), reflecting a shift toward personalized risk stratification and real-time perioperative decision-making. These advancements align with clinical demands for early AKI detection and precision prevention.

This study not only maps the evolution of CSA-AKI research but also identifies priority areas for innovation: multicenter validation of predictive models to strengthen generalizability, preventive nephrology frameworks for long-term AKI survivor monitoring, and randomized controlled trials to confirm efficacy of machine learning-based CSA-AKI prediction tools.

Differences exist between Infectious Diseases Society of America guidance and European Society of Clinical Microbiology and Infectious Diseases guidelines on treating pneumonia caused by carbapenem-resistant Acinetobacter baumannii (CRAB). This study compared the outcomes of colistin-based and high-dose ampicillin/sulbactam-based combination therapies in patients with CRAB nosocomial pneumonia. A retrospective cohort study was conducted at a university-affiliated hospital in South Korea. Patients received either a colistin-based regimen with a loading dose followed by a maintenance dose (June 2021-May 2022) or a high-dose ampicillin/sulbactam-based regimen with sulbactam 9 g/day (October 2022-September 2023). The primary outcome was 28-day all-cause mortality; secondary outcomes included 14-day/28-day clinical success rates and 14-day/28-day kidney injury based on the Risk, Injury, Failure, Loss, End-stage renal disease score. Logistic and Poisson regression analyses were used to compare outcomes between groups. Among 179 patients enrolled in the study, 84 received the colistin-based regimen and 95 received the high-dose ampicillin/sulbactam-based regimen. The ampicillin/sulbactam group showed significantly lower 28-day mortality (20% vs. 61%; adjusted relative risk [aRR] = 0.16, 95% CI 0.08-0.32). Clinical success rates were higher in the ampicillin/sulbactam group at both 14 days (39% vs. 23%; aRR = 2.19, 95% CI 1.10-4.37) and 28 days (55% vs. 32%; aRR = 2.71, 95% CI 1.14-5.20). Additionally, 28-day kidney injury was lower in the ampicillin/sulbactam group (0.63 ± 1.16 vs. 1.06 ± 1.35; aRR = 0.56, 95% CI 0.40-0.79). High-dose ampicillin/sulbactam-based combination therapy demonstrates superior outcomes over colistin-based combination therapy for CRAB nosocomial pneumonia, including lower mortality, higher clinical success rates, and reduced kidney injury.

Sepsis associated acute kidney injury (SA-AKI) among hospitalized patients is common with higher morbidity and mortality. There is a need to discover new methods that allow better prediction of its outcomes and prognosis. We aimed to evaluate if combining serial examination of urine sediment to renal cell damage (KIM-1) and arrest (TIMP-2, IGFBP7) biomarkers could improve the prediction of progression and mortality of SA-AKI.

This prospective study enrolled 96 patients with stage 1 or 2 SA-AKI. Measuring of urinary TIMP-2, IGFBP7 and KIM-1 was done at time of AKI diagnosis and examination of urine sediment was performed by calculating Chawla score (CS) and Perazella score (PS) at days 1, 3 and 7. Main study outcomes included AKI progression to stage 3 and mortality.

Ninety-six patients were included in the study. 48% of them progressed to AKI stage 3 and 33.3% died. uTIMP2*IGFBP7 and uKIM-1 showed an area under the curve (AUC) of 0.837 and 0.657 respectively for predicting AKI progression and an AUC of 0.679 and 0.626 respectively for predicting mortality. Combining urine sediment examination at day 3 (P2 and C2) to uTIMP2*IGFBP7, uKIM-1 and both biomarkers significantly improved their prediction ability to an AUC of to 0.977, 0.951 and 0.979 respectively to predict AKI progression, and to an AUC of 0.807, 0.796 and 0.803 respectively to predict mortality.

Combining urine sediment examination with renal cell damage and arrest biomarkers significantly improved their performance of predicting AKI progression and mortality in patients with SA-AKI.

ClinicalTrials.gov Identifier: NCT06064487. First registration date: 21/09/2023.

Acute kidney injury (AKI) is common in the neonatal intensive care unit (NICU) and is associated with increased morbidity and mortality. Mounting evidence suggests infants with AKI in the NICU have higher risks of long-term kidney dysfunction, such as chronic kidney disease. However, guidelines for outpatient kidney-focused follow-up practices are lacking.

As part of the National Institutes of Health-sponsored Consensus Workshop to Address Kidney Health in Neonatal Intensive Care Unit Graduates, a multidisciplinary workgroup within the US performed an in-depth review of the medical literature on term and late preterm (i.e. ≥ 34 weeks gestation) neonates admitted to the NICU with AKI to inform consensus recommendations for outpatient kidney health monitoring for high-risk and at-risk infants.

In this modified Delphi consensus statement, the workgroup developed three consensus recommendations and identified priority research gaps and opportunities for future study. Specific recommendations include completing a NICU discharge kidney health evaluation followed by a comprehensive kidney health assessment six months after discharge for high-risk infants and at two years of age for high-risk and at-risk infants.

Critically ill term and late preterm infants with AKI have an increased risk of long-term kidney dysfunction and merit evaluation at NICU discharge with subsequent comprehensive kidney health assessments based on risk factors. Current research gaps and opportunities for improved care include identifying optimal pre-discharge planning approaches, examining the impacts of different etiologies and severity of AKI on long-term kidney and overall health, exploring modification to current AKI diagnosis standards, and development of high-yield educational tools for families and providers.

Background/Objectives: Acute kidney injury (AKI) is a significant global health issue with a high morbidity and mortality. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines identify various exposures and susceptibilities as risk factors for AKI. However, the predictive significance of these factors in heterogeneous emergency department (ED) populations remains unclear. We hypothesized that assessing KDIGO-listed exposures and susceptibilities for AKI, alone and in combination, would provide an insight into their predictive value for AKI. Furthermore, we investigated whether adding biomarkers, plasma neutrophil gelatinase-associated lipocalin (pNGAL) and C-reactive protein (CRP), could enhance AKI risk prediction. Methods: Data were analyzed from the prospective longitudinal "NGAL study" conducted at North Zealand University Hospital in Denmark. A total of 344 ED patients were included, with AKI diagnosed using KDIGO's creatinine-based criteria. Patient data, including medical history, exposures, and susceptibilities, were extracted and analyzed. Predictive performance was evaluated using a receiver operating characteristic (ROC) analysis on individual and combined risk factors. Additional models incorporated pNGAL and CRP to assess their impact on prediction accuracy. Results: Individual exposures and susceptibilities showed a poor predictive performance, with nephrotoxic drugs and advanced age demonstrating the highest sensitivity but a low positive predictive value (PPV). Combining multiple risk factors improved AKI prediction, with models clustering into those optimizing sensitivity or PPV. The inclusion of pNGAL significantly enhanced predictive performance, achieving the highest combined sensitivity and PPV. Although less than pNGAL, CRP also improved prediction, while requiring fewer variables than pNGAL-inclusive models. Conclusions: No individual KDIGO-listed exposure or susceptibility could reliably predict AKI in the ED setting. Combining multiple exposures and susceptibilities improved the predictive accuracy, but the models excelled either at screening or confirmation, not both. The addition of pNGAL and CRP significantly enhanced AKI prediction, emphasizing the need for biomarker integration in risk stratification models. These findings highlight the limitations of clinical parameters alone and underscore the importance of a multifaceted approach to AKI risk assessment.

In the context of tumor lysis syndrome (TLS), the optimal timing and criteria for initiating kidney replacement therapy (KRT) remain unclear. This study aims to assess the effect of initiating KRT at various phosphatemia thresholds on Major Adverse Kidney Events at day 30 (MAKE30).

We retrospectively emulated a pragmatic clinical trial comparing the effect of KRT initiation at various phosphatemia thresholds versus a conventional approach during TLS on MAKE30. All consecutive patients admitted to the ICU at Saint-Louis University hospital in Paris and Angers University hospital between January 2007 and June 2020, presenting with laboratory TLS were included. The design criteria of a clinical trial were mimicked by using the cloning, censoring and weighting method. The primary outcome was the MAKE30 composite outcome, considering only KRT requirement between day 7 and day 30 for the dialysis criteria. We evaluated multiple phosphatemia thresholds to guide KRT initiation, ranging from 6.20 mg.dL-1 to 9.30 mg.dL-1. Among the initial population of 220 patients, 192 were included in the emulated trial (median age 60 years old, with non-Hodgkin Lymphoma and Acute Leukemia being the most frequent hematological malignancies). TLS-related AKI occurred in 140 patients, and 75 patients met the criteria for MAKE30. Regardless of the phosphate threshold considered, KRT initiation based on phosphate level was not associated with a significant difference in the MAKE30 rate. KRT requirement during the first 7 days (Odd Ratio [OR] 4.01 [1.65-4.86], p = 0.003) and non-renal SOFA (OR 1.39 per 1 point increment [1.25-1.57], p < 0.001) were identified as factors associated with MAKE30 (multivariable analysis).

Our results do not support the strategy of KRT initiation based on a sole critical phosphatemia level in TLS patients.

Acute kidney injury (AKI) is a common and serious complication following cardiac surgery. Dexmedetomidine, a highly selective α2-adrenergic agonist, has shown potential renoprotective effects, but previous studies have yielded conflicting results.

This meta-analysis aimed to evaluate the efficacy and safety of dexmedetomidine in preventing AKI and reducing postoperative serum creatinine levels in adult patients undergoing cardiac surgery.

We comprehensively searched 5 databases for randomized controlled trials comparing dexmedetomidine with control groups in adult cardiac surgery patients. The main outcomes were the incidence of AKI and change in postoperative serum creatinine levels. Meta-analyses were conducted using RevMan 5.4 models, and subgroup analyses were performed based on dexmedetomidine dosing and timing of administration. Continuous outcomes were combined and analyzed using either mean difference (M.D.), while dichotomous outcomes were analyzed using risk ratio (RR) with 95% confidence intervals (CI).

Our study included a total of 14 trials involving 2744 patients. Dexmedetomidine administration significantly reduced the incidence of AKI compared to control groups (RR = 0.54, 95% CI: 0.41-0.70, P < 0.00001). Postoperative serum creatinine levels were also lower with dexmedetomidine (MD = -0.14 mg/dL, 95% CI: -0.28 to -0.001, P =0.04). Subgroup analyses revealed that higher initial doses (>0.5 μg/kg) and administration during intraoperative and postoperative periods were associated with more pronounced renoprotective effects. Dexmedetomidine did not significantly affect mortality but reduced the duration of the length of hospital stay and mechanical ventilation.

This meta-analysis demonstrates that dexmedetomidine administration, particularly at higher doses and during both intraoperative and postoperative periods, reduces the risk of AKI in adults undergoing cardiac surgery. These findings support the use of dexmedetomidine as a preventive strategy to enhance renal outcomes in this population.

Total hip arthroplasty and total knee arthroplasty are among the most successful orthopedic procedures, with increasing numbers performed annually in the United States. However, adverse perioperative complications like acute kidney injury (AKI) can adversely affect patient outcomes and increase health care costs. The incidence of AKI post-total joint arthroplasty varies widely, with large-scale studies reporting less than 2% and smaller studies indicating rates as high as 21.9%. Holding angiotensin converting enzyme inhibitors, aldosterone receptor blockers, NSAIDs, diuretics, and avoiding nephrotoxic antibiotics can help mitigate the risk.

This study aimed to investigate the effects of dietary supplementation with pomegranate peel powder (PP) on the growth performance, serum biochemistry, antioxidant capacity, intestinal microbiota, and duodenal mucosal metabolites of yellow-feathered broilers. A total of 360 yellow-feathered broilers were randomly divided into three groups, with their diets supplemented with different levels of PP (0, 1, and 4 g/kg) for 42 days. Dietary supplementation with PP significantly increased the average body weight and average daily gain of yellow-feathered broilers during the periods of 1-21 and 22-42 days, while reducing the feed conversion ratio (p < 0.05). It also decreased the serum levels of aspartate aminotransferase, alanine aminotransferase, creatinine, and uric acid, increased the activities of glutathione peroxidase and superoxide dismutase, and reduced malondialdehyde content in the serum, liver, and intestinal mucosa (p < 0.05). Furthermore, PP supplementation promoted the mRNA expression of farnesoid X receptor, peroxisome proliferator-activated receptor alpha, fatty acid-binding protein 4, epidermal growth factor/epidermal growth factor receptor, and B-cell lymphoma 2, while decreasing the mRNA expression of caspase-1 and interleukin-1 beta (p < 0.05). Regarding mucosal metabolites, PP supplementation increased the contents of polyunsaturated fatty acids (cis-11-eicosenoic acid, cis-13,16-docosadienoic acid, and cis-11,14-eicosadienoic acid), prostaglandin E2/G2, and secondary bile acids (apocholic, hyodeoxycholic, 7-ketodeoxycholic, and omega-muricholic acids) in the mucosa (p < 0.05). In terms of cecal microbiota, PP supplementation increased the β-diversity index (p < 0.05), elevated the relative abundances of Bacteroidota, Alistipes, Bacilli, and Actinobacteriota, and reduced the relative abundances of Clostridia and Gammaproteobacteria (p < 0.05). In conclusion, dietary supplementation of PP can improve intestinal health and growth performance of yellow-feathered broilers by regulating the composition of the gut microbiota.

Vancomycin (VAN) is empirically used with other broad-spectrum antibiotics, such as piperacillin-tazobactam (PTZ) or carbapenem (CBP). However, conflicting literature on the rates of acute kidney injury (AKI) of VAN with PTZ has been reported.

A multicenter, retrospective cohort study of the risk of AKI was conducted in patients receiving VAN and concomitant PTZ or CBP from January 2019 and June 2023.

In total, 514 eligible patients were included. AKI occurred in a total of 91 patients (17.70%). The prevalence of AKI was significantly higher in the VAN+PTZ group than in the VAN+CBP group (23.37% vs 15.27%, p = 0.028). The survival curves depicting the time to AKI showed the increased incidence and more rapid onset of AKI among patients in the VAN+PTZ group compared to those of the VAN+CBP group (HR 2.186, 95%CI 1.351-3.538, p = 0.0015). VAN+PTZ was associated with a consistently higher AKI rate over VAN+CBP (HR 1.762, 95%CI 1.111-2.795, p = 0.0161) throughout the 14-day combination therapy. VAN with concomitant PTZ, duration of combination therapy ≤ 4 days and VAN trough concentration > 20 mg/L were independent risk factors associated with AKI.

The prevalence of AKI was found to be higher in patients receiving VAN+PTZ therapy compared to those receiving VAN+CBP therapy based on creatinine-defined AKI.

Vancomycin is commonly utilized for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections. Dosing recommendations for vancomycin have shifted in recent years to favor area under the concentration-time curve (AUC) instead of trough-based dosing strategies to decrease vancomycin exposure and rates of acute kidney injury (AKI). However, little data exist on the safety and efficacy of AUC-based dosing in patients with obesity.

This was a single-center retrospective cohort study conducted between 1 January 2014 and 31 December 2022. Adult patients aged ≥18 years were included if they were obese and received vancomycin for treatment of a severe MRSA infection for at least 72 hours. The primary outcome was incidence of AKI based on Kidney Disease: Improving Global Outcomes (KDIGO) criteria.

After initial screening, 398 patients were included, with 230 in the trough group and 168 in the AUC group. Rates of AKI were lower in the AUC group compared to the trough group (11.3% vs 25.2%, P < .001). After adjusting for potential confounders, logistic regression maintained a reduction in AKI with AUC-based dosing for cumulative doses less than the median of 10 250 mg (odds ratio, 0.47 [95% confidence interval, .25-.88]) but not for doses above. Rates of initial target attainment were also higher with AUC-based dosing (50.0% vs 23.9%, P < .001).

Patients with obesity receiving vancomycin for treatment of severe MRSA infections experienced lower rates of AKI when utilizing an AUC- versus trough-based dosing strategy.

Increased monitoring of health-related data for ICU patients holds great potential for the early prediction of medical outcomes. Research on whether the use of clinical notes and concepts from knowledge bases can improve the performance of prediction models is limited. We investigated the effects of combining clinical variables, clinical notes, and clinical concepts. We focus on the early prediction of Acute Kidney Injury (AKI) in the intensive care unit (ICU). AKI is a sudden reduction in kidney function measured by increased serum creatinine (SCr) or decreased urine output. AKI may occur in up to 30% of ICU stays. We developed three models based on convolutional neural networks using data from the Medical Information Mart for Intensive Care (MIMIC) database. The models used clinical variables, free-text notes, and concepts from the Elsevier H-Graph. Our models achieved good predictive performance (AUROC 0.73-0.90). These models were assessed both when using Scr and urine output as predictors and when omitting them. When Scr and urine output were used as predictors, models that included clinical notes and concepts together with clinical variables performed on par with models that only used clinical variables. When excluding SCr and urine output, predictive performance improved by combining multiple modalities. The models that used only clinical variables were externally validated on the eICU dataset and transported fairly to the new population (AUROC 0.68-0.77). Our in-depth comparison of modalities and text representations may further guide researchers and practitioners in applying multimodal models for predicting AKI and inspire them to investigate multimodality and contextualized embeddings for other tasks. Our models can support clinicians to promptly recognize and treat deteriorating AKI patients and may improve patient outcomes in the ICU.

Hypoalbuminemia is a risk factor for mortality in patients with end-stage liver disease (ESLD) and in those undergoing orthotopic liver transplantation (OLT), since it represents a biomarker of post-operative delayed functional recovery of the graft. Despite albumin infusion during and after OLT is frequently adopted in recipients with hypoalbuminemia, it remains unclear whether this procedure could improve post OLT clinical outcomes. Observational studies indicated that treatment with albumin after OLT might be beneficial in reducing ascites and acute kidney injury (AKI) development. However, considering potential complications and the cost of albumin therapy, the decision to use albumin after OLT should be based on careful consideration of patient's individual needs and risks. In addition, the threshold plasma value of albumin below which it could be clinically useful to infuse albumin has not been clearly defined. This systematic review, prepared in accordance with the PRISMA 2020 guidelines, aimed to assess the efficacy of albumin infusion in patients undergoing OLT, in the prevention or treatment of ascites, AKI, and ischemia reperfusion syndrome, as well as its potential impact on patient survival. Furthermore, this review aimed to illustrate the pathophysiological bases justifying the use of albumin infusion in a subset of patients receiving OLT.

Prediction of mortality in intensive care unit (ICU) patients typically relies on black box models (that are unacceptable for use in hospitals) or hand-tuned interpretable models (that might lead to the loss in performance). We aim to bridge the gap between these 2 categories by building on modern interpretable machine learning (ML) techniques to design interpretable mortality risk scores that are as accurate as black boxes.

We developed a new algorithm, GroupFasterRisk, which has several important benefits: it uses both hard and soft direct sparsity regularization, it incorporates group sparsity to allow more cohesive models, it allows for monotonicity constraint to include domain knowledge, and it produces many equally good models, which allows domain experts to choose among them. For evaluation, we leveraged the largest existing public ICU monitoring datasets (MIMIC III and eICU).

Models produced by GroupFasterRisk outperformed OASIS and SAPS II scores and performed similarly to APACHE IV/IVa while using at most a third of the parameters. For patients with sepsis/septicemia, acute myocardial infarction, heart failure, and acute kidney failure, GroupFasterRisk models outperformed OASIS and SOFA. Finally, different mortality prediction ML approaches performed better based on variables selected by GroupFasterRisk as compared to OASIS variables.

GroupFasterRisk's models performed better than risk scores currently used in hospitals, and on par with black box ML models, while being orders of magnitude sparser. Because GroupFasterRisk produces a variety of risk scores, it allows design flexibility-the key enabler of practical model creation.

GroupFasterRisk is a fast, accessible, and flexible procedure that allows learning a diverse set of sparse risk scores for mortality prediction.

Vitamin D receptor activators (VDRAs) are widely used in patients with osteoporosis; however, the frequency of acute kidney injury (AKI) due to VDRAs is unclear. This study aimed to investigate whether the incidence of AKI after VDRA initiation differed among patients with different renal functions.

The medical records of Japanese patients who were newly prescribed with VDRAs for osteoporosis at the Fujita Health University Hospital or Kyoto University Hospital between April 2012 and March 2022 were retrospectively reviewed in this study. The RIFLE (Risk, Injury, Failure, Loss of function, End-stage kidney disease) criteria were used to assess the incidence of AKI within 7 days after initiation of VDRA therapy. Additionally, the AKI algorithm was used to assess the incidence of AKI from 8 to 365 days after initiation of VDRA therapy.

The incidence of AKI, as defined by the RIFLE criteria, was significantly higher in patients with normal renal function or end-stage renal failure than in those with mild renal decline (p < 0.05); the incidence of AKI, defined using the AKI algorithm, showed a similar trend. We found that the lack of serum calcium level monitoring before the initiation of VDRAs might be a risk factor for AKI defined by the RIFLE criteria (odds ratio = 2.004, p = 0.096).

The incidence of AKI after the initiation of VDRA therapy was high, even if renal function was normal. Thus, our results suggest that monitoring serum calcium levels before the initiation of VDRA therapy is necessary, regardless of renal function.

Evidence on the optimal targets of vancomycin for treating other Gram-positive infections apart from methicillin-resistant Staphylococcus aureus (MRSA) is lacking. This review aims to identify the recommended vancomycin therapeutic level for favourable clinical outcomes among patients infected with vancomycin-sensitive enterococcal infections.

Analytical studies describing the vancomycin levels of vancomycin-sensitive enterococcal infections among adult population were searched. The primary outcome was 30-day all-cause mortality, and the secondary outcomes were clinical failure and nephrotoxicity. Study characteristics were extracted and pooled using random-effects meta-analysis. The study quality was assessed using the Joanna Briggs Institute critical appraisal tool.

A total of nine retrospective cohorts studies involving 1013 patients with vancomycin-sensitive enterococci were included. The meta-analysis found that high area under the curve to minimum inhibitory concentration ratio (AUC/MIC) of vancomycin ≥ 389 mg*h/L significantly lowered the 30-day mortality (odds ratio [OR], 0.44, 95% confidence interval [CI], 0.26-0.75). Analysis of the target AUC/MIC showed that high vancomycin AUC/MIC (≥ 389-400 mg*h/L) significantly reduced clinical failure rate (OR 0.59, 95% CI 0.37-0.94). The mortality and treatment failure rates did not differ significantly between those with high or low trough levels. Higher vancomycin AUC/MIC and trough levels were significantly associated with increased nephrotoxicity (OR 3.11, 95% CI 1.65-5.89; OR 2.95, 95% CI 1.60-5.44, respectively).

The use of a higher vancomycin AUC/MIC concentration can be effective to reduce 30-day mortality and clinical failure but this needs to take into consideration the risk of nephrotoxicity. Well-conducted prospective studies are warranted due to the scarcity of evidence.

Acute kidney injury (AKI) develops in 20-50% of patients undergoing cardiac surgery (CS). We aimed to assess the predictive value of urinary biomarkers (UBs) for predicting CS-associated AKI. We also aimed to investigate the accuracy of the combination of UB measurements and their incorporation in predictive models to guide physicians in identifying patients developing CS-associated AKI.

All clinical studies reporting on the diagnostic accuracy of individual or combined UBs were eligible for inclusion. We searched three databases (MEDLINE, EMBASE, and CENTRAL) without any filters or restrictions on the 11th of November, 2022 and reperformed our search on the 3rd of November 2024. Random and mixed effects models were used for meta-analysis. The main effect measure was the area under the Receiver Operating Characteristics curve (AUC). Our primary outcome was the predictive values of each individual UB at different time point measurements to identify patients developing acute kidney injury (KDIGO). As a secondary outcome, we calculated the performance of combinations of UBs and clinical models enhanced by UBs.

We screened 13,908 records and included 95 articles (both randomised and non-randomised studies) in the analysis. The predictive value of UBs measured in the intraoperative and early postoperative period was at maximum acceptable, with the highest AUCs of 0.74 [95% CI 0.68, 0.81], 0.73 [0.65, 0.82] and 0.74 [0.72, 0.77] for predicting severe CS-AKI, respectively. To predict all stages of CS-AKI, UBs measured in the intraoperative and early postoperative period yielded AUCs of 0.75 [0.67, 0.82] and 0.73 [0.54, 0.92]. To identify all and severe cases of acute kidney injury, combinations of UB measurements had AUCs of 0.82 [0.75, 0.88] and 0.85 [0.79, 0.91], respectively.

The combination of urinary biomarkers measurements leads to good accuracy.

Noncardiac arterial procedures (NCAPs) are associated with a high risk of bleeding. Tranexamic acid (TXA) is used among surgical disciplines to reduce blood loss; however, its effectiveness and safety in NCAP remain unclear. This review evaluates the efficacy and safety of TXA during NCAP.

Systematic review and meta-analysis was performed in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Literature searches in PubMed, Embase, and Cochrane databases (October 2023 and October 2024) identified studies investigating TXA in open and endovascular NCAP. Meta-analyses were conducted using Cochrane's Review Manager.

Five studies (n = 4304) were identified. One randomized controlled trial of TXA in noncardiac surgery (n = 9535), including a vascular cohort (14.8%; n = 699 TXA, n = 700 placebo), showed lower composite bleeding outcomes in the overall cohort receiving TXA (9.5% vs 11.7%; P < 0.001), but not in the vascular cohort (hazard ratio 0.85; 95% confidence interval [CI] 0.64-1.13). Another trial found no difference in blood loss or transfusion rates in 100 patients undergoing open abdominal aortic aneurysm surgery. Both trials reported no increased cardiovascular or thromboembolic complications (TECs) or 30-day mortality. A prospective study showed similar thrombosis-related technical failure rates in traumatic vascular injury patients (TXA 6.3% vs 3.8%, P = 0.14) and no significant differences in bleeding or hematoma (TXA 11.4% vs 4.3%, P = 0.13). In 297 carotid endarterectomy (CEA) patients, TXA significantly reduced postoperative hematoma (7.9% vs 1.3%; P = 0.01) without increasing TEC or stroke. TXA during an intraoperative hemostasis protocol during CEA (TXA n = 8) reported similar results. Meta-analysis showed no significant differences in TEC (risk ratio [RR] 1.10; 95% CI 0.71-1.70) or reoperation rates (RR 0.55; 95% CI 0.19-1.63).

TXA does not increase the risk of TEC in NCAP. However, there is currently insufficient evidence that TXA reduces bleeding complications.