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Acute kidney injury (AKI) is associated with higher hospital mortality. However, the relationship between geriatric AKI and in-hospital complications is unclear. We prospectively enrolled elderly patients (≥65 years) from general medical wards of National Taiwan University Hospital, part of whom presented AKI at admission. We recorded subsequent in-hospital complications, including catastrophic events, incident gastrointestinal bleeding, hospital-associated infections, and new-onset electrolyte imbalances. Regression analyses were utilized to assess the associations between in-hospital complications and the initial AKI severity. A total of 163 elderly were recruited, with 39% presenting AKI (stage 1: 52%, stage 2: 23%, stage 3: 25%). The incidence of any in-hospital complication was significantly higher in the AKI group than in the non-AKI group (91% vs. 68%, p < 0.01). Multiple regression analyses indicated that elderly patients presenting with AKI had significantly higher risk of developing any complication (Odds ratio [OR] = 3.51, p = 0.01) and new-onset electrolyte imbalance (OR = 7.1, p < 0.01), and a trend toward more hospital-associated infections (OR = 1.99, p = 0.08). The risk of developing complications increased with higher AKI stage. In summary, our results indicate that initial AKI at admission in geriatric patients significantly increased the risk of in-hospital complications.

Polypharmacy is common in the elderly due to multimorbidity and interventions. However, the temporal association between polypharmacy and renal outcomes is rarely addressed and recognized. We investigated the association between cardiovascular (CV) polypharmacy and the risk of acute kidney injury (AKI) in elderly patients.We used the Taiwan National Health Insurance PharmaCloud system to investigate the relationship between cumulative CV medications in the 3 months before admission and risk of AKI in the elderly at their admission to general medical wards in a single center. Community-dwelling elderly patients (>60 years) were prospectively enrolled and classified according to the number of preadmission CV medications. CV polypharmacy was defined as use of 2 or more CV medications.We enrolled 152 patients, 48% with AKI (based upon Kidney Disease Improving Global Outcomes [KDIGO] classification) and 64% with CV polypharmacy. The incidence of AKI was higher in patients taking more CV medications (0 drugs: 33%; 1 drug: 50%; 2 drugs: 57%; 3 or more drugs: 60%; P = 0.05) before admission. Patients with higher KDIGO grades also took more preadmission CV medications (P = 0.04). Multiple regression analysis showed that patients who used 1 or more CV medications before admission had increased risk of AKI at admission (1 drug: odds ratio [OR] = 1.63, P = 0.2; 2 drugs: OR = 4.74, P = 0.03; 3 or more drugs: OR = 5.92, P = 0.02), and that CV polypharmacy is associated with higher risk of AKI (OR 2.58; P = 0.02). Each additional CV medication increased the risk for AKI by 30%.We found that elderly patients taking more CV medications are associated with risk of adverse renal events. Further study to evaluate whether interventions that reduce polypharmacy could reduce the incidence of geriatric AKI is urgently needed.

Medical patients admitted from the ED of a referral centre have a 30-day readmission rate of 16.7%. Post-discharge care should focus on patients with higher Charlson score, longer hospitalisation, anaemia and underlying active malignancy, which are independent predictive factors for 30-day readmission.

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AimsPreoperative proteinuria is associated with post-operative acute kidney injury (AKI), but whether it is also associated with increased long- term mortality and end -stage renal disease (ESRD) is unknown.Methods and ResultsWe studied 925 consecutive patients undergoing CABG. Demographic and clinical data were collected prospectively, and patients were followed for a median of 4.71 years after surgery. Proteinuria, according to dipstick tests, was defined as mild (trace to 1+) or heavy (2+ to 4+) according to the results of the dipstick test. A total of 276 (29.8%) patients had mild proteinuria before surgery and 119 (12.9%) patients had heavy proteinuria. During the follow-up, the Cox proportional hazards model demonstrated that heavy proteinuria (hazard ratio [HR], 27.17) was an independent predictor of long-term ESRD. There was a progressive increased risk for mild proteinuria ([HR], 1.88) and heavy proteinuria ([HR], 2.28) to predict all–cause mortality compared to no proteinuria. Mild ([HR], 2.57) and heavy proteinuria ([HR], 2.70) exhibited a stepwise increased ratio compared to patients without proteinuria for long–term composite catastrophic outcomes (mortality and ESRD), which were independent of the baseline GFR and postoperative acute kidney injury (AKI).ConclusionOur study demonstrated that proteinuria is a powerful independent risk factor of long-term all-cause mortality and ESRD after CABG in addition to preoperative GFR and postoperative AKI. Our study demonstrated that proteinuria should be integrated into clinical risk prediction models for long-term outcomes after CABG. These results provide a high priority for future renal protective strategies and methods for post-operative CABG patients.

BackgroundThe impact of diuretic usage and dosage on the mortality of critically ill patients with acute kidney injury is still unclear.Methods and ResultsIn this prospective, multicenter, observational study, 572 patients with postsurgical acute kidney injury receiving hemodialysis were recruited and followed daily. Thirty-day postdialysis mortality was analyzed using Cox's proportional hazards model with time-dependent covariates. The mean age of the 572 patients was 60.8±16.6 years. Patients with lower serum creatinine (p = 0.031) and blood lactate (p = 0.033) at ICU admission, lower predialysis urine output (p = 0.001) and PaO2/FiO2 (p = 0.039), as well as diabetes (p = 0.037) and heart failure (p = 0.049) were more likely to receive diuretics. A total of 280 (49.0%) patients died within 30 days after acute dialysis initiation. The analysis of 30-day postdialysis mortality by fitting propensity score-adjusted Cox's proportional hazards models with time-dependent covariates showed that higher 3-day accumulated diuretic doses after dialysis initiation (HR = 1.449, p = 0.021) could increase the hazard rate of death. Moreover, higher time-varying 3-day accumulative diuretic doses were associated with hypotension (p<0.001) and less intense hemodialysis (p<0.001) during the acute dialysis period.Background and SignificanceHigher time-varying 3-day accumulative diuretic dose predicts mortality in postsurgical critically ill patients requiring acute dialysis. Higher diuretic doses are associated with hypotension and a lower intensity of dialysis. Caution should be employed before loop diuretics are administered to postsurgical patients during the acute dialysis period.

ABSTRACT. Since outbreaks of highly pathogenic avian influenza (HPAI) in both human and poultry from 2003, it is critical to have effective vaccines. A cDNA fragment coding the entire hemagglutinin (HA) gene derived from an H5N1 strain (A/duck/China/E319-2/03) was cloned and expressed using the baculovirus system. Two weeks after receiving two doses of recombinant HA (rHA) vaccines, chickens develop high antibody response for hemagglutination inhibition (HI) at titer 7.2 log 2 . Challenge studies revealed that vaccinated chickens with HI titers greater than 3 log 2 could have immunoprotection against the same HPAI H5N1 strain virus challenge through intranasal route. Additionally, HI titer of 5 log 2 determined whether the live viruses could not be detected from oropharyngeal, cloacal discharge or in tissues. This result suggests that the rHA expressed from baculovirus system could be a candidate for the development of a safe and efficient subunit vaccine for HPAI (H5N1). KEY WORDS: baculovirus expression system, H5N1, hemagglutination inhibition, highly pathogenic avian influenza (HPAI), subunit vaccine.