Acute kidney injury in acute respiratory distress syndrome: why ventilator settings matter

Vashisht, Rishik; Duggal, Abhijit

doi:10.21037/atm-20-2163

Cited by 4 publications

(5 citation statements)

References 19 publications

(16 reference statements)

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“…Additionally, PH patients may be more vulnerable to ventilator-induced kidney injury (VIKI). Although it is difficult to characterize the role of ventilatory settings in the pathogenesis of VIKI, 38,39 we observed increased AKI in PH patients despite similar PEEP settings between our PH and control cohorts. It is well known that AKI is independently associated with increased mortality and would compound upon the mortality contributed by ETI and PH.…”

Section: Discussionmentioning

confidence: 57%

Outcomes and Prognostic Factors of Pulmonary Hypertension Patients Undergoing Emergent Endotracheal Intubation

Hong

Toppen

Lee

et al. 2022

J Intensive Care Med

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Background: Emergent endotracheal intubations (ETI) in pulmonary hypertension (PH) patients are associated with increased mortality. Post-intubation interventions that could increase survivability in this population have not been explored. We evaluate early clinical characteristics and complications following emergent endotracheal intubation and seek predictors of adverse outcomes during this post-intubation period. Methods: Retrospective cohort analysis of adult patients with groups 1 and 3 PH who underwent emergent intubation between 2005-2021 in medical and liver transplant ICUs at a tertiary medical center. PH patients were compared to non-PH patients, matched by Charlson Comorbidity Index. Primary outcomes were 24-h post-intubation and inpatient mortalities. Various 24-h post-intubation secondary outcomes were compared between PH and control cohorts. Results: We identified 48 PH and 110 non-PH patients. Pulmonary hypertension was not associated with increased 24-h mortality (OR 1.32, 95%CI 0.35-4.94, P = .18), but was associated with inpatient mortality (OR 4.03, 95%CI 1.29-12.5, P = .016) after intubation. Within 24 h post-intubation, PH patients experienced more frequent acute kidney injury (43.5% vs. 19.8%, P = .006) and required higher norepinephrine dosing equivalents (6.90 [0.13-10.6] mcg/kg/min, vs. 0.20 [0.10-2.03] mcg/kg/min, P = .037). Additionally, the median P/F ratio (PaO2/FiO2) was lower in PH patients (96.3 [58.9-201] vs. 233 [146-346] in non-PH, P = .001). Finally, a post-intubation increase in PaCO2 was associated with mortality in the PH cohort (post-intubation change in PaCO2 +5.14 ± 16.1 in non-survivors vs. −18.7 ± 28.0 in survivors, P = .007). Conclusions: Pulmonary hypertension was associated with worse outcomes after emergent endotracheal intubation than similar patients without PH. More importantly, our data suggest that the first 24 hours following intubation in the PH group represent a particularly vulnerable period that may determine long-term outcomes. Early post-intubation interventions may be key to improving survival in this population.

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Section: Discussionmentioning

confidence: 57%

Outcomes and Prognostic Factors of Pulmonary Hypertension Patients Undergoing Emergent Endotracheal Intubation

Hong

Toppen

Lee

et al. 2022

J Intensive Care Med

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“… 2 , 16 Respiratory compliance, PEEP, and driving pressure are all factors associated with severe AKI. 17 , 18 However, AKI may also be due to factors such as hypotension, hypovolemia, persistent shock, and hospital-acquired causes. 5 …”

Section: Discussionmentioning

confidence: 99%

Incidence, Outcomes, and Predictors of Subphenotypes of Acute Kidney Injury among Acute Respiratory Distress Syndrome Patients: A Prospective Observational Study

Todur,

Nileshwar,

Chaudhuri

et al. 2023

Indian Journal of Critical Care Medicine

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A bstract Background Acute kidney injury (AKI) is a heterogeneous syndrome with subphenotypes. Acute kidney injury is one of the most common complications in acute respiratory distress syndrome (ARDS) patients, which influences mortality. Material and methods It was a single-center observational study on 266 ARDS patients on invasive mechanical ventilation (IMV) to determine the subphenotypes of AKI associated with ARDS. Subphenotyping was done based on the serum creatinine (SCr) trajectories from day 1 to day 5 of IMV into resolving (subphenotype 1) or non-resolving (subphenotype 2) AKI. Results Out of 266 ARDS patients, 222 patients were included for data analysis. 141 patients (63.51%) had AKI. The incidence of subphenotype 2 AKI among the ARDS cohort was 78/222 (35.13%). Subphenotype 2 AKI was significantly more among the non-survivors (87.7% vs 36.2 %, p < 0.001). Subphenotype 2 AKI was an independent predictor of mortality among ARDS patients ( p < 0.001, adjusted odds ratio 8.978, 95% CI [2.790–28.89]. AKI subphenotype 1 had higher median day 1 SCr than subphenotype 2 but lower levels by day 3 and day 5 of IMV. The median time of survival was 8 days in AKI subphenotype 2 vs 45 days in AKI with subphenotype 1 [Log-Rank (Mantel-Cox) p < 0.001]. The novel DRONE score (Driving pressure, Oxygenation, and Nutritional Evaluation) ≥ 4 predicted subphenotype 2 AKI. Conclusion The incidence of subphenotype 2 (non-resolving) AKI among ARDS patients on IMV was about 35% (vs 20% subphenotype 1 AKI), and it was an independent predictor of mortality. The DRONE score ≥4 can predict the AKI subphenotype 2. Highlights The serum creatinine trajectory-based subphenotype of AKI (resolving vs non-resolving) determines survival in ARDS patients. Non-resolving AKI subphenotype 2 is an independent predictor of mortality in ARDS. The novel DRONE score (driving pressure, oxygenation, and nutritional evaluation) ≥ 4 within 48 hours of IMV predicted the AKI subphenotype 2 among ventilated ARDS patients. How to cite this article Todur P, Nileshwar A, Chaudhuri S, Srinivas T. Incidence, Outcomes, and Predictors of Subphenotypes of Acute Kidney Injury among Acute Respiratory Distress Syndrome Patients: A Prospective Observational Study. Indian J Crit Care Med 2023;27(10):724–731.

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“…The pathophysiologic link between ARDS and AKI has been investigated, inflammatory cytokine storm, oxidative stress and dysregulation of ion/water transport channels play a crucial role in the development of ARDS complicating AKI [ 24 ]. Alternatively, with its attendant hypoxemia and mechanical ventilation-associated high PEEP, ARDS could increase renal vascular resistance, redistribute renal blood flow and activate neurohormonal pathways, leading to deteriorative renal hemodynamics [ 25 ]. Kidney-lung interactions contribute to an inflammatory loop that aggravates kidney injury and pulmonary vascular permeability [ 26–28 ].…”

Section: Discussionmentioning

confidence: 99%

Development of a predictive nomogram for acute respiratory distress syndrome in patients with acute pancreatitis complicated with acute kidney injury

Yang,

Kang,

et al. 2023

Renal Failure

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Background Acute respiratory distress syndrome (ARDS) is a common complication in patients with acute pancreatitis (AP), especially when patients complicated with acute kidney injury (AKI), resulting in increased duration of hospitalization and mortality. It is of potential clinical significance to develop a predictive model to identify the the high-risk patients. Method AP patients complicated with AKI from January 2019 to March 2022 were enrolled in this study and randomly divided into training cohort and validation cohort at a ratio of 2:1. The Least absolute shrinkage and selection operator(LASSO) regression and machine learning algorithms were applied to select features. A nomogram was developed based on the multivariate logistic regression. The performance of the nomogram was evaluated by AUC, calibration curves, and decision curve analysis. Results A total of 292 patients were enrolled in the study, with 206 in the training cohort and 86 in the validation cohort. Multivariate logistic analysis showed that IAP (Odds Ratio (OR)=4.60, 95%CI:1.23-18.24, p = 0.02), shock (OR = 12.99, 95%CI:3.47-64.04, p < 0.001), CRP(OR= 26.19, 95%CI:9.37-85.57, p < 0.001), LDH (OR = 13.13, 95%CI:4.76-40.42, p < 0.001) were independent predictors of ARDS. The nomogram was developed based on IAP, shock, CRP and LDH. The nomogram showed good discriminative ability with an AUC value of 0.954 and 0.995 in the training and validation cohort, respectively. The calibration curve indicating good concordance between the predicted and observed values. The DCA showed favorable net clinical benefit. Conclusion This study developed a simple model for predicting ARDS in AP patients complicated with AKI. The nomogram can help clinicians identify high-risk patients and optimize therapeutic strategies.

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Acute kidney injury in acute respiratory distress syndrome: why ventilator settings matter

Cited by 4 publications

References 19 publications

Outcomes and Prognostic Factors of Pulmonary Hypertension Patients Undergoing Emergent Endotracheal Intubation

Outcomes and Prognostic Factors of Pulmonary Hypertension Patients Undergoing Emergent Endotracheal Intubation

Incidence, Outcomes, and Predictors of Subphenotypes of Acute Kidney Injury among Acute Respiratory Distress Syndrome Patients: A Prospective Observational Study

Development of a predictive nomogram for acute respiratory distress syndrome in patients with acute pancreatitis complicated with acute kidney injury

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