Kidney international
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Kidney international · Nov 2011
Comparative StudyCombined angiotensin-converting enzyme inhibition and receptor blockade associate with increased risk of cardiovascular death in hemodialysis patients.
To compare the relative effectiveness of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in reducing cardiovascular mortality in chronic hemodialysis patients, we conducted an observational analysis of all patients initiated on ACEI or ARB therapy undergoing chronic hemodialysis at a large dialysis provider. Survival curves with mortality hazard ratios (HRs) were generated using the Kaplan-Meier method and Cox regression. Outcomes were compared using inverse probability of treatment weighting and propensity score matching. ⋯ After adjustment for risk factors, 701 patients initiated on combined ACEI and ARB therapy (HR of 1.45) or 6866 patients on ACEI and non-ARB antihypertensive agent (HR of 1.27) were at increased risk of cardiovascular death compared with 1758 patients initiated on an ARB and non-ACEI antihypertensive therapy. Thus, an ARB, in combination with another antihypertensive medication (but not an ACEI), may have a beneficial effect on cardiovascular mortality. As observational studies may be confounded by indication, even when adjusted, randomized clinical trials are needed to confirm these findings.
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Kidney international · Oct 2011
Multicenter StudyOliguria is an early predictor of higher mortality in critically ill patients.
Oliguria is a valuable marker of kidney function and a criterion for diagnosing and staging acute kidney injury (AKI). However, the utility of urine output as a specific metric for renal dysfunction is somewhat controversial. To study this issue further we tested whether urine output is a sensitive, specific, and early measure for diagnosing and staging AKI in 317 critically ill patients in a prospective observational study. ⋯ The diagnosis of AKI occurred earlier in oliguric than in non-oliguric patients. Oliguria of more than 12 h and oliguria of 3 or more episodes were associated with an increased mortality rate. Thus, urine output is a sensitive and early marker for AKI and is associated with adverse outcomes in intensive care unit patients.
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Kidney international · Oct 2011
Randomized Controlled TrialIschemic preconditioning at a remote site prevents acute kidney injury in patients following cardiac surgery.
Acute kidney injury, a common complication of cardiac surgery with cardiopulmonary bypass, is associated with increased morbidity and mortality. Ischemic preconditioning at a remote site mitigates ischemia-reperfusion injury and may prevent acute kidney injury after cardiac surgery, thus providing clinical benefit. To further study this, we enrolled 120 adult patients undergoing elective cardiac surgery for whom cardiopulmonary bypass was anticipated in a randomized, single-blind, and controlled pilot trial. ⋯ Fifty-nine patients in each group were analyzed on an intention-to-treat basis. Acute kidney injury occurred in 12 remote ischemic preconditioned and 28 control patients, reflecting an absolute risk reduction of 0.27 and a significantly reduced relative risk due to preconditioning of 0.43. Hence, remote ischemic preconditioning prevents acute kidney injury in patients undergoing cardiopulmonary bypass-assisted cardiac surgery.
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Kidney international · Oct 2011
CommentOliguria: an earlier and accurate biomarker of acute kidney injury?
In the context of the critically ill patient, the onset of consistent oliguria is an ominous sign that requires immediate attention. Without intervention, intermittent oliguria may turn into persistent oliguria or evolve to acute kidney injury (AKI), with severe associated morbidity and mortality. Whether the addition of urine output to the serum creatinine criteria permits earlier and more specific detection of AKI is controversial, but current evidence supports its importance in early diagnosis and management.
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Kidney international · Oct 2011
Editorial CommentRenal ischemic preconditioning: finally some good news for prevention of acute kidney injury.
Recent clinical trials of remote ischemic preconditioning offer hope that this well-validated experimental method of protecting tissues against ischemic injury will provide a more robust alternative to pharmaceutical prevention against cardiac and renal ischemic injury.