Statins Reduce Mortality Risk in Dialysis-Requiring AKI
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Hajeong Lee Corresponding Author E-mail address: mdhjlee gmail. Eunjeong Kang and Minsu Park are contributed equally to this work. Hyung Jin Yoon and Hajeong Lee are contributed equally to this research.
Reducing Mortality in Acute Kidney Injury
Tools Request permission Export citation Add to favorites Track citation. Share Give access Share full text access. Share full text access. Please review our Terms and Conditions of Use and check box below to share full-text version of article. Abstract Background Acute kidney injury AKI is a critical issue in cancer patients because it is not only a morbid complication but also able to interrupt timely diagnostic evaluation or planned optimal treatment. Results During 3. Figure 1 Open in figure viewer PowerPoint.
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Flow diagram of the study populations. Figure 2 Open in figure viewer PowerPoint. Description of AKI stage according to cancer type. Univariate analysis Model 1 a a AKI stage adjusted for age, age, cancer type. Figure 3 Open in figure viewer PowerPoint. Forest plot of multivariable COX analysis according to cancer type. Figure 4 Open in figure viewer PowerPoint.
Acute kidney injury predicts all‐cause mortality in patients with cancer
Figure 5 Open in figure viewer PowerPoint. Forest plot of multivariable COX analysis according to cancer treatment. Supporting Information Filename Description camsupSupplementary. Acute renal failure in cancer patients. Ann Med.
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Crossref PubMed Google Scholar. PubMed Google Scholar. Volume 8 , Issue 6 June Pages Figures References Related Information. High-chloride fluids may be associated with increased risk of AKI and mortality in patients with sepsis [ 77 ]. Early goal-directed therapy with close monitoring of central venous pressure, mean arterial pressure, and oxygen saturation has been shown to be protective against AKI in patients admitted to the intensive care unit with sepsis [ 78 , 79 ].
Atrial natriuretic peptide ANP is produced by cardiac atrial myocytes in response to atrial distension or increased atrial pressure. It induces afferent dilatation and efferent vasoconstriction, thereby increasing glomerular filtration and urinary sodium excretion [ 80 ].
B-type brain natriuretic peptide BNP is primarily produced in the cardiac ventricles and has similar effects [ 81 , 82 ]. Low doses of recombinant human ANP-enhanced renal excretory function, decreased the probability of dialysis, and improved dialysis-free survival in early, ischemic acute renal dysfunction after complicated cardiac surgery [ 83 ].
Similar effects were observed in patients undergoing liver transplantation [ 84 , 85 ]. However, larger doses of ANP were not effective in improving dialysis-free survival or reduction in dialysis in large randomized clinical trials [ 86 , 87 ]. Theophylline, an adenosine antagonist has been shown in several preliminary reports to be beneficial in the prevention of contrast nephropathy and cisplatin nephrotoxicity [ 88 , 89 , 90 ]. A few adjunctive agents such as flavonoids silymarin and carotenoids lycopene , have been tried in pilot studies in cancer patients receiving cisplatin with limited success in some but not all studies [ 91 , 92 , 93 ].
Adequately powered, controlled studies to support the efficacy of these agents are lacking.
Levosimendan, a calcium sensitizer, has inodilator, cardioprotective, and anti-inflammatory effects [ 94 ]. Two meta-analyses suggested that the use of levosimendan was associated with a reduction of renal replacement therapy in critically ill patients and patients undergoing cardiac surgery [ 95 , 96 ]. The studies in both meta-analyses were small, heterogeneous, and AKI was not always a predefined endpoint.
The role of loop diuretics and osmotic agents in the prevention and treatment of AKI in humans has been disappointing despite their ability to decrease the tubular oxygen consumption and relieve intratubular obstruction in animal models [ 97 , 98 , 99 ]. A metanalysis has shown that frusemide was not associated with any significant clinical benefits in the prevention and treatment of AKI in adults, in addition to the concern of increased risk of ototoxicity associated with high doses [ ]. N-acetyl-cysteine, a thiol-containing antioxidant has been investigated in several trials, mainly in the prevention of contrast-induced nephropathy.
Despite some positive reports [ , ], the protective effect of N-acetyl-cysteine is still controversial [ , , , ]. Similarly, N-acetyl-cysteine was not found to be protective against other causes of AKI particularly in hypotensive patients in the ICU or patients undergoing cardiac surgery [ , ]. Hydration with sodium bicarbonate, as compared to normal saline, has been shown in some studies to be superior to normal saline in the prevention of contrast-induced nephropathy [ , , ].
Other studies have shown no superiority of sodium bicarbonate over saline in the prevention of contrast nephropathy [ , ]. Hydration with isotonic solutions either normal saline or sodium bicarbonate in addition to the use of low osmolar contrast agents is the most effective strategy to prevent contrast-induced nephropathy. Statins may have a beneficial effect in high-risk patients exposed to contrast administration for angiography. The day rate of adverse cardiovascular and renal events was also reduced in the rosuvastatin group 3. In a subgroup analysis of this study, rosuvastatin had a protective effect among female diabetic patients with CKD [ ].
The protective effect of statins has been confirmed in multiple meta-analyses [ , , ]. However, the beneficial effect of statins in patients undergoing coronary interventions was not observed in patients undergoing cardiac surgery. In this group of patients, the use of statin either showed no benefit or was detrimental [ , , ].
There is a wide variation in clinical practice relating to the indication for and timing of RRT for patients with AKI. There is also no agreement on the selection of the specific modality of RRT and prescription of intensity of therapy. Among the several modalities of RRT, continuous renal replacement therapy has become very popular, especially in the ICU setting where patients may be hemodynamically unstable to tolerate intermittent hemodialysis. There does not appear to be a significant difference in either mortality or recovery of renal function associated with the various modalities of RRT.
Reducing Mortality in Acute Kidney Injury | Giovanni Landoni | Springer
This is discussed in details in other sections of the book designated for RRT. The recommendations are summarized as follows: timely resuscitation with fluids, vasopressors, and inotropic agents remains the cornerstone in the prevention of AKI. Volume expansion with isotonic crystalloids is reserved for true and suspected hypovolemia.
The use of starches and dextrans should be avoided. In hypotensive patients, vasoconstrictors, preferably norepinephrine, should be administered with or following volume expansion. Review of all medications and cessation of nephrotoxic agents is mandatory.
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Diuretics should not be used for prevention of AKI but may benefit in cases of volume overload and congestion. Hyperglycemia should be avoided. The effect of statins appears to depend on the setting, with promising results in contrast administration but no effect or even harm in cardiac surgery patients [ ].
With the advent of agreed definition and classification of AKI based on changes in serum creatinine and urine output, there is now increasing awareness of the poor prognosis following AKI. Multiple studies have shown that patients with AKI are at high risk for progression to advanced stage CKD and death following hospital discharge. In another meta-analysis of 48 studies containing 47, patients between and the incidence rate of mortality was 8.
This indicates that baseline renal function is an important determinant factor for outcome following an episode of AKI. A retrospective cohort study showed that patients who developed AKI during a hospitalization were at substantial risk for the development of CKD in the following year, and the timing of recovery was a strong predictor, even for the mildest forms of AKI [ ]. The incidence will likely continue to rise with the aging population and increase in comorbidities in patients admitted to the ICU.
Risk factors associated with progressing to CKD among AKI survivors have been identified and include advanced age, diabetes mellitus, decreased baseline glomerular filtration rate, severity of AKI, and a low concentration of serum albumin [ 6 , ]. Acute kidney injury, previously named acute renal failure, is characterized by abrupt deterioration in renal function.
The incidence of AKI has lately increased, both in the hospital and community setting. Management of AKI involves fluid resuscitation, avoidance of nephrotoxic agents, adjustment of medications, and correction of fluid, acid-base and electrolyte imbalance. Depending on the severity of renal insult, AKI may require renal replacement therapy in the form of dialysis or continuous renal replacement. Despite all the advances in the field, AKI still carries a high mortality and long term consequences. Licensee IntechOpen.