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Search Results: 1 - 10 of 206327 matches for " Dinna N Cruz "
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Acute kidney injury in the intensive care unit: current trends in incidence and outcome
Dinna N Cruz, Claudio Ronco
Critical Care , 2007, DOI: 10.1186/cc5965
Abstract: Bagshaw and colleagues [1] report on the epidemiology and outcomes of acute kidney injury (AKI) in Australian intensive care units (ICUs) over a ten year period. It has been said that despite technological advances in nephrology, there has been little improvement in the outcomes of patients with AKI [2]. The literature has been confounded by the use of varying definitions of AKI, reliance on coding for AKI in administrative databases, and lack of adjustment for severity of illness and co-morbidities. Nevertheless, it is undisputed that there has been a notable increase in AKI incidence [3,4], and this has important economic implications.The work by Bagshaw and colleagues [1] confirms the rising AKI incidence, but focuses on the critical care setting. Using a large multicenter ICU adult database, they noted that AKI incidence increased almost 3% annually from 1996 to 2005. Since the ANZICS definition of AKI remained constant, their results are less likely to be affected by changes in coding practices over time. This Australian study now corroborates this 'epidemic' of AKI, at least in the ICU. As it is, this is an alarming trend. Furthermore, as they identified only AKI present within the first 24 hours of ICU admission, this underestimates the magnitude of the problem. Interestingly, the increase in AKI incidence does not appear to be entirely due to the older and sicker patients now in our ICUs, who are more prone to develop AKI. Indeed, the Acute Physiology And Chronic Health Evaluation (APACHE) score and Simplified Acute Physiology score (SAPS) of AKI patients have remained unchanged over the ten-year period. Instead, the trend for increasing AKI incidence is also seen in the less severely ill groups of patients: those with no co-morbid illness and elective ICU admissions. This may be in part related to the fact that the present study refers only to AKI on admission, and is based on blood creatinine levels. This criterion will tend to underdetect AKI in older pat
Heart-Kidney Interaction: Epidemiology of Cardiorenal Syndromes
Dinna N. Cruz,Sean M. Bagshaw
International Journal of Nephrology , 2011, DOI: 10.4061/2011/351291
Abstract: Cardiac and kidney diseases are common, increasingly encountered, and often coexist. Recently, the Acute Dialysis Quality Initiative (ADQI) Working Group convened a consensus conference to develop a classification scheme for the CRS and for five discrete subtypes. These CRS subtypes likely share pathophysiologic mechanisms, however, also have distinguishing clinical features, in terms of precipitating events, risk identification, natural history, and outcomes. Knowledge of the epidemiology of heart-kidney interaction stratified by the proposed CRS subtypes is increasingly important for understanding the overall burden of disease for each CRS subtype, along with associated morbidity, mortality, and health resource utilization. Likewise, an understanding of the epidemiology of CRS is necessary for characterizing whether there exists important knowledge gaps and to aid in the design of clinical studies. This paper will provide a summary of the epidemiology of the cardiorenal syndrome and its subtypes.
Clinical review: RIFLE and AKIN – time for reappraisal
Dinna N Cruz, Zaccaria Ricci, Claudio Ronco
Critical Care , 2009, DOI: 10.1186/cc7759
Abstract: Acute kidney injury (AKI) is an important clinical issue, especially in the critical care setting. AKI has been shown in multiple studies to be a key independent risk factor for mortality, even after adjustment for demographics, severity of illness and other relevant factors [1]. Despite recent evidence suggesting some improvement in outcomes over time [2,3], AKI remains a formidable problem. It is a complex clinical syndrome for which there was no accepted definition for quite some time. Reported incidence and mortality rates vary widely in the literature, with incidence ranging from 1 to 31% and mortality from 28 to 82% [1,4]. This wide variation stems not only from the diverse patient populations in the different studies, but also from the disparate criteria used to define AKI in these studies. Over 30 definitions of acute renal failure/AKI have been used in the literature. These range from looser criteria such as a 25% increase in serum creatinine from baseline to more stringent definitions such as the need for renal replacement therapy (RRT). The more permissive the definition used in a particular study, the higher the incidence of AKI and the lower the associated mortality. The reverse is true with more restrictive AKI criteria [4]. As a result, comparison between different studies has been difficult.A unifying definition was needed to bring order to the AKI literature, in much the same way that consensus definitions for sepsis, acute respiratory distress syndrome and acute lung injury have done. After an initial attempt to stratify AKI for severity [5], a consensus definition was published by the Acute Dialysis Quality Initiative (ADQI) [6]. A modified version was proposed recently by the Acute Kidney Injury Network (AKIN) [7]. Both definitions are briefly described here, and issues relevant to their use and validation in the literature will be reviewed. This is not intended to be a systematic review as one has been recently published [8]. Instead, the presen
A proposed algorithm for initiation of renal replacement therapy in adult critically ill patients
Sean M Bagshaw, Dinna N Cruz, RT Noel Gibney, Claudio Ronco
Critical Care , 2009, DOI: 10.1186/cc8037
Abstract: Acute kidney injury (AKI) is a well-recognized complication of critical illness with an important impact on morbidity, mortality and health resource utilization [1-5]. Renal replacement therapy (RRT) is often required and represents a substantial escalation in the complexity and cost of care for critically ill patients with AKI [4]. Despite its extensive use in clinical practice, there is uncertainty about the optimal time and indications for initiation of RRT in the ICU [6]. Clearly, the process involved in deciding when to initiate RRT in critically ill adult patients is complex and can be influenced by numerous factors, including patient-specific and clinician-specific factors and those related to organizational/logistical issues (Table 1). Indeed, studies have shown marked variation of practice between clinicians, and across institutions and countries [7,8].An evaluation of timing of RRT initiation has been the focus of a number of clinical studies. These have recently been summarized in a systematic review and meta-analysis [6,9-13]. Most of these studies have been small, retrospective or secondary analyses, and have arbitrarily dichotomized the study population into 'early' or 'late' RRT initiation based on biochemical criteria, urine output criteria, or by 'door-to-dialysis' time [14]. The meta-analysis by Seabra and colleagues [12] also included five randomized trials. A pooled analysis from these trials showed a non-statistically significant trend towards reduced mortality with earlier initiation of RRT (relative risk 0.64; 95% confidence interval (CI), 0.40 to 1.05, P = 0.08). However, this pooled analysis only included data from 270 patients, thus limiting its statistical power. Accordingly, this limits the inferences about timing of RRT initiation and prohibits a simple translation of such data easily to the bedside to guide clinical management. While large prospective studies are urgently needed, the currently available data would indicate a potential b
ADPKD: Prototype of Cardiorenal Syndrome Type 4
Grazia Maria Virzì,Valentina Corradi,Anthi Panagiotou,Fiorella Gastaldon,Dinna N. Cruz,Massimo de Cal,Maurizio Clementi,Claudio Ronco
International Journal of Nephrology , 2011, DOI: 10.4061/2011/490795
Abstract: The cardiorenal syndrome type 4 (Chronic Renocardiac Syndrome) is characterized by a condition of primary chronic kidney disease (CKD) that leads to an impairment of the cardiac function, ventricular hypertrophy, diastolic dysfunction, and/or increased risk of adverse cardiovascular events. Clinically, it is very difficult to distinguish between CRS type 2 (Chronic Cardiorenal Syndrome) and CRS type 4 (Chronic Renocardiac Syndrome) because often it is not clear whether the primary cause of the syndrome depends on the heart or the kidney. Autosomal dominant polycystic kidney disease (ADPKD), a genetic disease that causes CKD, could be viewed as an ideal prototype of CRS type 4 because it is certain that the primary cause of cardiorenal syndrome is the kidney disease. In this paper, we will briefly review the epidemiology of ADPKD, conventional and novel biomarkers which may be useful in following the disease process, and prevention and treatment strategies.
Volume Assessment in Mechanically Ventilated Critical Care Patients Using Bioimpedance Vectorial Analysis, Brain Natriuretic Peptide, and Central Venous Pressure
Andrew A. House,Mikko Haapio,Paolo Lentini,Ilona Bobek,Massimo de Cal,Dinna N. Cruz,Grazia M. Virzì,Rizzieri Carraro,Giampiero Gallo,Pasquale Piccinni,Claudio Ronco
International Journal of Nephrology , 2011, DOI: 10.4061/2011/413760
Abstract: Purpose. Strategies for volume assessment of critically ill patients are limited, yet early goal-directed therapy improves outcomes. Central venous pressure (CVP), Bioimpedance Vectorial Analysis (BIVA), and brain natriuretic peptide (BNP) are potentially useful tools. We studied the utility of these measures, alone and in combination, to predict changing oxygenation. Methods. Thirty-four mechanically ventilated patients, 26 of whom had data beyond the first study day, were studied. Relationships were assessed between CVP, BIVA, BNP, and oxygenation index (O2I) in a cross-sectional (baseline) and longitudinal fashion using both univariate and multivariable modeling. Results. At baseline, CVP and O2I were positively correlated (=0.39; =.021), while CVP and BIVA were weakly correlated (=?0.38; =.025). The association between slopes of variables over time was negligible, with the exception of BNP, whose slope was correlated with O2I (=0.40; =.044). Comparing tertiles of CVP, BIVA, and BNP slopes with the slope of O2I revealed only modest agreement between BNP and O2I (kappa=0.25; =.067). In a regression model, only BNP was significantly associated with O2I; however, this was strengthened by including CVP in the model. Conclusions. BNP seems to be a valuable noninvasive measure of volume status in critical care and should be assessed in a prospective manner.
Effectiveness of polymyxin B-immobilized fiber column in sepsis: a systematic review
Dinna N Cruz, Mark A Perazella, Rinaldo Bellomo, Massimo de Cal, Natalia Polanco, Valentina Corradi, Paolo Lentini, Federico Nalesso, Takuya Ueno, V Marco Ranieri, Claudio Ronco
Critical Care , 2007, DOI: 10.1186/cc5780
Abstract: We searched PubMed, the Cochrane Collaboration Database, and bibliographies of retrieved articles and consulted with experts to identify relevant studies. Prospective and retrospective observational studies, pre- and post-intervention design, and randomized controlled trials were included. Three authors reviewed all citations. We identified a total of 28 publications – 9 randomized controlled trials, 7 non-randomized parallel studies, and 12 pre-post design studies – that reported at least one of the specified outcome measures (pooled sample size, 1,425 patients: 978 PMX-F and 447 conventional medical therapy).Overall, mean arterial pressure (MAP) increased by 19 mm Hg (95% confidence interval [CI], 15 to 22 mm Hg; p < 0.001), representing a 26% mean increase in MAP (range, 14% to 42%), whereas dopamine/dobutamine dose decreased by 1.8 μg/kg per minute (95% CI, 0.4 to 3.3 μg/kg per minute; p = 0.01) after PMX-F. There was significant intertrial heterogeneity for these outcomes (p < 0.001), which became non-significant when analysis was stratified for baseline MAP. The mean arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio increased by 32 units (95% CI, 23 to 41 units; p < 0.001). PMX-F therapy was associated with significantly lower mortality risk (risk ratio, 0.53; 95% CI, 0.43 to 0.65). The trials assessed had suboptimal method quality.Based on this critical review of the published literature, direct hemoperfusion with PMX-F appears to have favorable effects on MAP, dopamine use, PaO2/FiO2 ratio, and mortality. However, publication bias and lack of blinding need to be considered. These findings support the need for further rigorous study of this therapy.Severe sepsis and septic shock are common problems encountered in the intensive care unit (ICU), with an estimated incidence in the United States of 750,000 cases per year and a mortality rate of 25% to 80% [1]. Sepsis involves a complex interaction between bacterial toxins and the h
Heart-Kidney Biomarkers in Patients Undergoing Cardiac Stress Testing
Mikko Haapio,Andrew A. House,Massimo de Cal,Dinna N. Cruz,Paolo Lentini,Davide Giavarina,Antonio Fortunato,Luigi Menghetti,Matteo Salgarello,Andrea Lupi,Giuliano Soffiati,Alessandro Fontanelli,Pierluigi Zanco,Claudio Ronco
International Journal of Nephrology , 2011, DOI: 10.4061/2011/425923
Abstract: We examined association of inducible myocardial perfusion defects with cardiorenal biomarkers, and of diminished left ventricular ejection fraction (LVEF) with kidney injury marker plasma neutrophil gelatinase-associated lipocalin (NGAL). Patients undergoing nuclear myocardial perfusion stress imaging were divided into 2 groups. Biomarkers were analyzed pre- and poststress testing. Compared to the patients in the low ischemia group (=16), the patients in the high ischemia group (=18) demonstrated a significantly greater rise in cardiac biomarkers plasma BNP, NT-proBNP and cTnI. Subjects were also categorized based on pre- or poststress test detectable plasma NGAL. With stress, the group with no detectable NGAL had a segmental defect score 4.2 compared to 8.2 (=.06) in the detectable NGAL group, and 0.9 vs. 3.8 (=.03) at rest. BNP rose with stress to a greater degree in patients with detectable NGAL (10.2 vs. 3.5 pg/mL, =.03). LVEF at rest and with stress was significantly lower in the detectable NGAL group; 55.8 versus 65.0 (=.03) and 55.1 vs. 63.8 (=.04), respectively. Myocardial perfusion defects associate with biomarkers of cardiac stress, and detectable plasma NGAL with significantly lower LVEF, suggesting a specific heart-kidney link.
B-Type Natriuretic Peptide in the Critically Ill with Acute Kidney Injury
Massimo de Cal,Mikko Haapio,Dinna N. Cruz,Paolo Lentini,Andrew A. House,Ilona Bobek,Grazia M. Virzì,Valentina Corradi,Flavio Basso,Pasquale Piccinni,Angela D'Angelo,Jamie W. Chang,Mitchell H. Rosner,Claudio Ronco
International Journal of Nephrology , 2011, DOI: 10.4061/2011/951629
Abstract: Introduction. Acute kidney injury (AKI) is common in the intensive care unit (ICU) and associated with poor outcome. Plasma B-type natriuretic peptide (BNP) is a biomarker related to myocardial overload, and is elevated in some ICU patients. There is a high prevalence of both cardiac and renal dysfunction in ICU patients. Aims. To investigate whether plasma BNP levels in the first 48 hours were associated with AKI in ICU patients. Methods. We studied a cohort of 34 consecutive ICU patients. Primary outcome was presence of AKI on presentation, or during ICU stay. Results. For patients with AKI on presentation, BNP was statistically higher at 24 and 48 hours than No-AKI patients (865 versus 148?pg/mL; 1380 versus 131?pg/mL). For patients developing AKI during 48 hours, BNP was statistically higher at 0, 24 and 48 hours than No-AKI patients (510 versus 197?pg/mL; 552 versus 124?pg/mL; 949 versus 104?pg/mL). Conclusion. Critically ill patients with AKI on presentation or during ICU stay have higher levels of the cardiac biomarker BNP relative to No-AKI patients. Elevated levels of plasma BNP may help identify patients with elevated risk of AKI in the ICU setting. The mechanism for this cardiorenal connection requires further investigation. 1. Introduction Acute kidney injury (AKI) is a common clinical problem in intensive care unit (ICU) patients and independently predicts poor outcome [1–4]. In the ICU setting, the overall incidence of AKI is approximately 36% [5, 6], and an increasing trend has been reported [7, 8]. Cardiac dysfunction is also common in patients with AKI in the ICU, and increasing interest exists in how the interaction of these two systems affects clinical outcomes in this group of patients. B-type or brain natriuretic peptide (BNP) is a neurohormone secreted from ventricular myocardium in response to myocardial stretching and volume overload [9]. BNP has diagnostic and prognostic utility in patients with acute decompensated heart failure [10–13], and BNP is an independent predictor for cardiovascular events and overall mortality in various patient groups including those with chronic kidney disease [14–20]. However, it remains unclear whether plasma levels of BNP are useful in predicting AKI in critically ill patients. Therefore, our study aimed to investigate whether BNP levels in the first 48 hours may be useful in diagnosis of established AKI. 2. Methods 2.1. Patients and Study Protocol We studied a cohort of 34 consecutive patients admitted to the ICU of “San Bortolo” Hospital, Vicenza, Italy, between December 2007 and April 2008.
Fluid balance and urine volume are independent predictors of mortality in acute kidney injury
Catarina Teixeira, Francesco Garzotto, Pasquale Piccinni, Nicola Brienza, Michele Iannuzzi, Silvia Gramaticopolo, Francesco Forfori, Paolo Pelaia, Monica Rocco, Claudio Ronco, Clara Anello, Tiziana Bove, Mauro Carlini, Vincenzo Michetti, Dinna N Cruz, for the NEFROlogia e Cura INTensiva (NEFROINT) investigators
Critical Care , 2013, DOI: 10.1186/cc12484
Abstract: We performed a secondary analysis of data from a multicenter, prospective cohort study in 10 Italian ICUs. AKI was defined by renal SOFA score (creatinine>3.5mg/dL or urine output (UO) <500mL/d). Oliguria was defined as a UO <500mL/d. Mean fluid balance (MFB) and mean urine volume (MUV) were calculated as the arithmetic mean of all daily values. Use of diuretics was noted daily. To assess the impact of MFB and MUV on mortality of AKI patients, multivariable analysis was performed by Cox regression.Of the 601 included patients, 132 had AKI during ICU stay and the mortality in this group was 50%. Non-surviving AKI patients presented higher MFB (1.31 +/- 1.24 versus 0.17 +/- 0.72 L/day; P<0.001) and lower MUV (1.28 +/- 0.90 versus 2.35 +/- 0.98 L/day; P<0.001) as compared to survivors. In the multivariate analysis, MFB (adjusted hazard ratio (HR) 1.67 per L/day, 95%CI 1.33-2.09; <0.001) and MUV (adjusted HR 0.47 per L/day, 95%CI 0.33-0.67; <0.001) remained independent risk factors for 28-day mortality after adjustment for age, gender, diabetes, hypertension, diuretic use, non-renal SOFA and sepsis. Diuretic use was associated with better survival in this population (adjusted HR 0.25, 95%CI 0.12-0.52; <0.001).In this multicenter ICU study, a higher fluid balance and a lower urine volume were both important factors associated with 28-day mortality of AKI patients.
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