No abstract

Postoperative acute kidney injury (AKI) increases morbidity and mortality after liver transplantation (LT). Novel methods of assessing AKI including cystatin C (CyC) and neutrophil gelatinase-associated lipocalin (NGAL) have been identified as potential markers of AKI. We compare the ability of standard renal markers (serum creatinine [sCr], estimated glomerular filtration rate [eGFR] and intensive therapy unit organ failure scores with CyC and NGAL to predict AKI within the first 48 hours after LT. 95 patients (median age 50 [interquartile range ¼ 41-59], 60% male) underwent LT (25% with acute liver failure). AKI was defined according to the Acute Kidney Injury Network criteria. Severe AKI was classified as !stage 2. NGAL (urine [u] and plasma [p]) and CyC concentrations taken immediately after transplantation on admission to the Liver Intensive Care Unit were compared with standard markers of renal function. Predictive ability was assessed using the area under the curve generated by receiver operator characteristic analysis (AUROC) and logistic regression. Day 0 sCr, uNGAL, pNGAL, CyC, and eGFR predicted AKI as did SOFA (Sequential Organ Failure Assessment) and APACHE II (Acute Physiology and Chronic Health Evaluation II) scores. APACHE II and pNGAL were the most powerful predictors of severe AKI (APACHE II AUROC ¼ 0.87 [0.77-0.97], P < 0.001; pNGAL AUROC ¼ 0.87 [0.77-0.92], P < 0.001). Using multivariate logistic regression, APACHE II (odds ratio 1.64/point [95% confidence interval ¼ 1.22-2.21, P ¼ 0.001] and pNGAL [odds ratio ¼ 1.01/ng/mL [95% confidence interval ¼ 1.00-1.02], P ¼ 0.002) retained independent significance. A ''renal risk score'' using APACHE II > 13 and pNGAL > 258 ng/mL was calculated with a score of !1 having a 100% sensitivity and 76% specificity for severe AKI. In conclusion, a combination of NGAL and APACHE II predicts AKI with high sensitivity and specificity after LT. Liver Transpl 16:1257-1266, 2010. V C 2010 AASLD.Received March 14, 2010; accepted July 15, 2010.Renal dysfunction is common after liver transplantation (LT). The incidence of acute renal failure complicating the posttransplant period varies between 48% and 94% 1 and affects both short-term and long-term outcome. Mortality in those requiring renal replacement therapy (RRT) may be as high as 40% at 90 days, rising to 54% at 1 year.2 Although many risk factors for developing renal dysfunction posttransplant have been investigated, the greatest impact on outcome is in patients who develop de novo renal impairment, especially in those who require RRT.2 Patients with low glomerular filtration rates (GFR) at 1 month post-LT are also at risk of developing severe renal dysfunction at 5 years post-LT 3 and the need for dialysis in LT recipients has been reported to be as high as 18% at 5 years.

Clinically significant ammonia clearance can be achieved in adult patients with hyperammonaemia utilizing continuous VVHF. Ammonia clearance is closely correlated with ultrafiltration rate. HF was associated with a fall in arterial ammonia concentration.

Author contributions: KH, JMP, LB, CS had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All other authors contributed substantially to the study design, data analysis and interpretation, and the writing of the manuscript.

Objective To identify the key mechanisms that clinicians perceive improve care in the intensive care unit (ICU), as a result of their involvement in post-ICU programs. Methods Qualitative inquiry via focus groups and interviews with members of the Society of Critical Care Medicine’s THRIVE collaborative sites (follow-up clinics and peer support). Framework analysis was used to synthesize and interpret the data. Results Five key mechanisms were identified as drivers of improvement back into the ICU: (1) identifying otherwise unseen targets for ICU quality improvement or education programs—new ideas for quality improvement were generated and greater attention paid to detail in clinical care. (2) Creating a new role for survivors in the ICU—former patients and family members adopted an advocacy or peer volunteer role. (3) Inviting critical care providers to the post-ICU program to educate, sensitize, and motivate them—clinician peers and trainees were invited to attend as a helpful learning strategy to gain insights into post-ICU care requirements. (4) Changing clinician’s own understanding of patient experience—there appeared to be a direct individual benefit from working in post-ICU programs. (5) Improving morale and meaningfulness of ICU work—this was achieved by closing the feedback loop to ICU clinicians regarding patient and family outcomes. Conclusions The follow-up of patients and families in post-ICU care settings is perceived to improve care within the ICU via five key mechanisms. Further research is required in this novel area. Electronic supplementary material The online version of this article (10.1007/s00134-019-05647-5) contains supplementary material, which is available to authorized users.