scholarly journals Achieved blood pressure post-acute kidney injury and risk of adverse outcomes after AKI: A prospective parallel cohort study

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Ian McCoy ◽  
Sandeep Brar ◽  
Kathleen D. Liu ◽  
Alan S. Go ◽  
Raymond K. Hsu ◽  
...  
Keyword(s):  
Heart Failure ◽  
Blood Pressure ◽  
Cohort Study ◽  
Hospital Discharge ◽  
Kidney Function ◽  
Kidney Injury ◽  
Adverse Outcomes ◽  
Post Discharge ◽  
Full Cohort ◽  
Interaction Testing

Abstract Background There has recently been considerable interest in better understanding how blood pressure should be managed after an episode of hospitalized AKI, but there are scant data regarding the associations between blood pressure measured after AKI and subsequent adverse outcomes. We hypothesized that among AKI survivors, higher blood pressure measured three months after hospital discharge would be associated with worse outcomes. We also hypothesized these associations between blood pressure and outcomes would be similar among those who survived non-AKI hospitalizations. Methods We quantified how systolic blood pressure (SBP) observed three months after hospital discharge was associated with risks of subsequent hospitalized AKI, loss of kidney function, mortality, and heart failure events among 769 patients in the prospective ASSESS-AKI cohort study who had hospitalized AKI. We repeated this analysis among the 769 matched non-AKI ASSESS-AKI enrollees. We then formally tested for AKI interaction in the full cohort of 1538 patients to determine if these associations differed among those who did and did not experience AKI during the index hospitalization. Results Among 769 patients with AKI, 42 % had subsequent AKI, 13 % had loss of kidney function, 27 % died, and 18 % had heart failure events. SBP 3 months post-hospitalization did not have a stepwise association with the risk of subsequent AKI, loss of kidney function, mortality, or heart failure events. Among the 769 without AKI, there was also no stepwise association with these risks. In formal interaction testing using the full cohort of 1538 patients, hospitalized AKI did not modify the association between post-discharge SBP and subsequent risks of adverse clinical outcomes. Conclusions Contrary to our first hypothesis, we did not observe that higher stepwise blood pressure measured three months after hospital discharge with AKI was associated with worse outcomes. Our data were consistent with our second hypothesis that the association between blood pressure measured three months after hospital discharge and outcomes among AKI survivors is similar to that observed among those who survived non-AKI hospitalizations.

scholarly journals Guidance for post-discharge care following acute kidney injury: an appropriateness ratings evaluation

BJGP Open ◽  
2020 ◽  
Vol 4 (3) ◽  
pp. bjgpopen20X101054 ◽  
Author(s):  
Jung Yin Tsang ◽  
Jonathan Murray ◽  
Edward Kingdon ◽  
Charlie Tomson ◽  
Kyle Hallas ◽  
...  
Keyword(s):  
Heart Failure ◽  
Acute Kidney Injury ◽  
Kidney Function ◽  
Medication Review ◽  
Kidney Injury ◽  
Transitions Of Care ◽  
Post Discharge ◽  
Discharge Care ◽  
Clinical Scenarios ◽  
Initial Medication

BackgroundAcute kidney injury (AKI) is associated with poor health outcomes, including increased mortality and rehospitalisation. National policy and patient safety drivers have targeted AKI as an example to ensure safer transitions of care.AimTo establish guidance to promote high-quality transitions of care for adults following episodes of illness complicated by AKI.Design & settingAn appropriateness ratings evaluation was undertaken using the RAND/UCLA Appropriateness Method (RAM). The Royal College of General Practitioners (RCGP) AKI working group developed a range of clinical scenarios to help identify the necessary steps to be taken following discharge of a patient from secondary care into primary care in the UK.MethodA 10-person expert panel was convened to rate 819 clinical scenarios, testing the most appropriate time and action following hospital discharge. Specifically, the scenarios focused on determining the appropriateness and urgency for planning: an initial medication review; monitoring of kidney function; and assessment for albuminuria.ResultsTaking no action (that is, no medication review; no kidney monitoring; or no albuminuria testing) was rated inappropriate in all cases. In most scenarios, there was consensus that both the initial medication review and kidney function monitoring should take place within 1–2 weeks or 1 month, depending on clinical context. However, patients with heart failure and poor kidney recovery were rated to require expedited review. There was consensus that assessment for albuminuria should take place at 3 months after discharge following AKI.ConclusionSystems to support tailored and timely post-AKI discharge care are required, especially in high-risk populations, such as people with heart failure.

scholarly journals Are We Barking Up the Wrong Tree? Rise in Serum Creatinine and Heart Failure

2019 ◽  
Vol 48 (3) ◽  
pp. 193-195
Author(s):  
Amir Kazory ◽  
Claudio Ronco
Keyword(s):  
Heart Failure ◽  
Blood Pressure ◽  
Serum Creatinine ◽  
Renal Injury ◽  
Kidney Injury ◽  
Pressure Control ◽  
Adverse Outcomes ◽  
Patients With Heart Failure ◽  
Severe Hyperkalemia ◽  
Intensive Blood Pressure

A significant subset of patients with heart failure (HF) experience small to moderate rise in serum creatinine (RSC) in the setting of otherwise beneficial therapies such as aggressive diuresis or renin-angiotensin-aldosterone system (RAAS) inhibition. Accumulating data suggest that RSC in this setting is dissimilar from conventional causes of renal insult in that it has a negligible impact on the outcomes. There is also emerging evidence on the lack of association between biomarkers of renal injury and RSC in the setting of aggressive diuresis. A similar pattern has been observed in recent hypertension trials where the RSC in patients with intensive blood pressure control has not been associated with biomarker evidence of renal injury or adverse outcomes. Based on these findings, RSC, rather than acute kidney injury, appears to be the preferred terminology in HF (and possibly in hypertension) because of its purely descriptive nature that lacks any potentially inaccurate implication of mechanistic or prognostic reference. From a pragmatic viewpoint, we believe that small to moderate RSC is to be anticipated and tolerated with RAAS inhibition and/or aggressive diuresis in acute or chronic HF and should not prompt discontinuation of the therapy unless complications such as hypotension and severe hyperkalemia develop.

scholarly journals Correction to: Post-discharge prognosis of patients admitted to hospital for heart failure by world region, and national level of income and income disparity (REPORT-HF): a cohort study

2020 ◽  
Vol 8 (8) ◽  
pp. e1001
Author(s):  
Jasper Tromp ◽  
Sahiddah Bamadhaj ◽  
John G F Cleland ◽  
Christiane E Angermann ◽  
Ulf Dahlstrom ◽  
...  
Keyword(s):  
Heart Failure ◽  
Cohort Study ◽  
National Level ◽  
Income Disparity ◽  
Post Discharge ◽  
World Region

scholarly journals Spontaneous one-kidney rats are more susceptible to develop hypertension by DOCA-NaCl and subsequent kidney injury compared with uninephrectomized rats

2016 ◽  
Vol 310 (10) ◽  
pp. F1054-F1064 ◽  
Author(s):  
Xuexiang Wang ◽  
Ashley C. Johnson ◽  
Jennifer M. Sasser ◽  
Jan M. Williams ◽  
Leah C. Solberg Woods ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Kidney Function ◽  
Time Course ◽  
Kidney Injury ◽  
Solitary Kidney ◽  
Course Evaluation ◽  
Significant Rise ◽  
Kidney Weight ◽  
Unilateral Renal Agenesis ◽  
Single Kidney

There is little clinical data of how hypertension may influence individuals with nephron deficiency in the context of being born with a single kidney. We recently developed a new rat model (the heterogeneous stock-derived model of unilateral renal agenesis rat) that is born with a single kidney and exhibits progressive kidney injury and decline in kidney function with age. We hypothesized that DOCA-salt would induce a greater increase in blood pressure and therefore accelerate the progression of kidney injury in rats born with a solitary kidney compared with rats that have undergone unilateral nephrectomy. Time course evaluation of blood pressure, kidney injury, and renal hemodynamics was performed in the following six groups of animals from weeks 13 to 18: 1) DOCA-treated rats with a solitary kidney (DOCA+S group), 2) placebo-treated rats with a solitary kidney, 3) DOCA-treated control rats with two kidneys (DOCA+C group), 4) placebo-treated control rats with two kidneys, 5) DOCA-treated rats with two kidneys that underwent uninephrectomy (DOCA+UNX8 group), and 6) placebo-treated rats with two kidneys that underwent uninephrectomy. DOCA+S rats demonstrated a significant rise ( P < 0.05) in blood pressure (192 ± 4 mmHg), proteinuria (205 ± 31 mg/24 h), and a decline in glomerular filtration rate (600 ± 42 μl·min−1·g kidney weight−1) relative to the DOCA+UNX8 (173 ± 3 mmHg, 76 ± 26 mg/24 h, and 963 ± 36 μl·min−1·g kidney weight−1) and DOCA+C (154 ± 2 mmHg, 7 ± 1 mg/24 h, and 1,484 ± 121 μl·min−1·g kidney weight−1) groups. Placebo-treated groups showed no significant change among the three groups. An assessment of renal injury markers via real-time PCR/Western blot analysis and histological analysis was concordant with the measured physiological parameters. In summary, congenital solitary kidney rats are highly susceptible to the induction of hypertension compared with uninephrectomized rats, suggesting that low nephron endowment is an important driver of elevated blood pressure, hastening nephron injury through the transmission of elevated systemic blood pressure and thereby accelerating decline in kidney function.

scholarly journals Anticholinergic burden in older adult inpatients: patterns from admission to discharge and associations with hospital outcomes

2021 ◽  
Vol 12 ◽  
pp. 204209862110125
Author(s):  
Maria Herrero-Zazo ◽  
Rachel Berry ◽  
Emma Bines ◽  
Debi Bhattacharya ◽  
Phyo K. Myint ◽  
...  
Keyword(s):  
Older Adults ◽  
Hospital Admission ◽  
Hospital Discharge ◽  
Geriatric Medicine ◽  
Prospective Trial ◽  
Adverse Outcomes ◽  
Prescribing Patterns ◽  
Plain Language ◽  
Post Discharge ◽  
Anticholinergic Medications

Background: Anticholinergic medications are associated with adverse outcomes in older adults and should be prescribed cautiously. We describe the Anticholinergic Risk Scale (ARS) scores of older inpatients and associations with outcomes. Methods: We included all emergency, first admissions of adults ⩾65 years old admitted to one hospital over 4 years. Demographics, discharge specialty, dementia/history of cognitive concern, illness acuity and medications were retrieved from electronic records. ARS scores were calculated as the sum of anticholinergic potential for each medication (0 = limited/none; 1 = moderate; 2 = strong and 3 = very strong). We categorised patients based on admission ARS score [ARS = 0 (reference); ARS = 1; ARS = 2; ARS ⩾ 3] and change in ARS score from admission to discharge [admission and discharge ARS = 0 (reference); same; decreased; increased]. We described anticholinergic prescribing patterns by discharge specialty and explored multivariable associations between ARS score categories and mortality using logistic regression [odds ratios (ORs), 95% confidence intervals (CIs)]. Results: From 33,360 patients, 10,183 (31%) were prescribed an anticholinergic medication on admission. Mean admission ARS scores were: Cardiology and Stroke = 0.56; General Medicine = 0.78; Geriatric Medicine = 0.83; Other medicine = 0.81; Trauma and Orthopaedics = 0.66; Other Surgery = 0.65. Mean ARS did not increase from admission to discharge in any specialty but reductions varied significantly, from 4.6% (Other Surgery) to 27.7% (Geriatric Medicine) ( p < 0.001). The odds of both 30-day inpatient and 30-day post-discharge mortality increased with admission ARS = 1 (OR = 1.21, 95% CI 1.01–1.44 and OR = 1.44, 1.18–1.74) but not with ARS = 2 or ARS ⩾ 3. The odds of 30-day post-discharge mortality were higher in all ARS change categories, relative to no anticholinergic exposure (same: OR = 1.45, 1.21–1.74, decreased: OR = 1.27, 1.01–1.57, increased: OR = 2.48, 1.98–3.08). Conclusion: The inconsistent dose–response associations with mortality may be due to confounding and measurement error which may be addressed by a prospective trial. Definitive evidence for this prevalent modifiable risk factor is required to support clinician behaviour-change, thus reducing variation in anticholinergic deprescribing by inpatient speciality. Plain language summary We describe how commonly medicines which block the chemical acetylcholine are prescribed to older adults admitted to hospital as an emergency and explore links between these medicines and death during or soon after hospital admission Backgroud: Medicines which block the chemical acetylcholine are commonly prescribed to treat symptoms such as itch and difficulty sleeping or to treat medical conditions such as depression. However, some studies in older adults have found potential links between these medicines and confusion and falls. Therefore, doctors are recommended to prescribe these drugs cautiously in adults aged 65 years and over. Methods: In our paper we use data collected as part of routine medical care at one university hospital to describe how often these medicines are prescribed in a large sample of older adults admitted to hospital as an emergency. We look at the medicines patients are prescribed on admission to the hospital and also when they are later discharged. Results: We find that these medicines are frequently prescribed. We also find that, in general, patients are prescribed fewer of these potentially harmful medicines on hospital discharge compared with hospital admission. This suggests that clinicians are aware of advice to prescribe acetylcholine blocking medicines cautiously and they are more often stopped in hospital than started. However, we find a lot of variation in practice depending on which hospital specialty was caring for the patient during their inpatient stay. We also find potential links with these medicines and death during the admission or soon after hospital discharge, but these potential links are not always consistent. Conclusion: Further study is needed to fully understand links between medicines that block acetylcholine and late life health. This will be important to reduce variation in prescribing practices.

Abstract 161: Identification of Genetic Variants Associated with Kidney Injury That Leads to Increased Blood Pressure

Hypertension ◽  
2012 ◽  
Vol 60 (suppl_1) ◽  
Author(s):  
Ashlyn C Harmon ◽  
Ashley C Johnson ◽  
Santosh Atanur ◽  
Klio Maratou ◽  
Tim Aitman ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Bone Marrow ◽  
Immune Response ◽  
Renal Function ◽  
Kidney Disease ◽  
Kidney Function ◽  
Genetic Variants ◽  
Kidney Injury ◽  
Chromosome 11 ◽  
Genomic Locus

Hypertension, diabetes and obesity, along with genetic predisposition, contribute to the growing number of chronic kidney disease patients. Our novel congenic model [S.SHR(11)] was developed through genetic modification of the Dahl salt-sensitive (S) rat, a model of hypertension related renal disease. The S.SHR(11) strain exhibits accelerated kidney injury compared to the already highly susceptible S rat. On either a low or high-salt diet, the S.SHR(11) model predominately exhibited more tubulointerstitial fibrosis compared to the S rat (17.1±1.29% vs. 12.9±1.22%). Increased α-SMA and macrophage infiltration was also observed. The S and S.SHR(11) had similar blood pressure (week 12), despite an early reduction in renal function in the S.SHR(11); however at an advanced age the S.SHR(11) demonstrated significantly higher blood pressure than the S (215±6.6 mm Hg vs. 183±5.9, respectively). This suggests that increased kidney injury is driving the development of hypertension later in life. Since these two animal models are identical with exception of chromosome 11, the causative genetic variants contributing to decreased renal function must reside within this region. The Dahl S and SHR genomes have been sequenced; this data provides a catalog of all the genetic variants between the two models. The 95% confidence interval of the genomic locus contains 28 non-synonymous SNP, with 15 of these SNP occurring within only three genes: Retnlg , Trat1 and Myh15. Two of these genes, Retnlg and Trat1, are known to play a role in immune response leading to our hypothesis that genetic variants in these genes alter protein function and lead to an increased immune response. Bone marrow transplant studies have been initiated to test our hypothesis and preliminary data shows that S rats who receive S.SHR(11) bone marrow have kidney function measurements similar to the S.SHR(11). The sequencing information has also lead to the development of nine new, more refined congenic strains. Through functional analysis of these new congenic animals, identification of the causative genetic variations will be expedited. In summary, we are employing a model of accelerated kidney disease to identify genes or genetic variants responsible for reduced kidney function and hypertension.

4877Renal function and intensive blood pressure lowering in high-risk adults without diabetes: insights from the Systolic Blood Pressure Intervention Trial (SPRINT)

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Pareek ◽  
A M D Kristensen ◽  
M Vaduganathan ◽  
T Biering-Sorensen ◽  
C Byrne ◽  
...  
Keyword(s):  
Heart Failure ◽  
Blood Pressure ◽  
Renal Function ◽  
Acute Decompensated Heart Failure ◽  
Kidney Injury ◽  
Decompensated Heart Failure ◽  
Primary Efficacy ◽  
Primary Efficacy Endpoint ◽  
The Relationship ◽  
Intensive Blood Pressure

Abstract Background The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive blood pressure (BP) lowering reduced the rates of cardiovascular events and mortality but increased the risk of certain adverse events, in patients with and without chronic kidney disease at baseline. However, it is unclear whether intensive BP management is well-tolerated and modifies risk uniformly across the entire spectrum of renal function. Purpose To assess the relationship between renal function, treatment response to intensive BP lowering, and cardiovascular (CV) outcomes. Methods SPRINT was a randomized, controlled trial in which 9,361 individuals ≥50 years of age, at high CV risk but without diabetes who had a systolic BP (SBP) 130–180 mmHg, were randomized to intensive (target SBP <120mmHg) or standard antihypertensive treatment (target SBP <140mmHg). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, acute decompensated heart failure, or death from CV causes. The primary safety endpoint was the composite of serious adverse events (SAE). Renal function was assessed using the estimated glomerular filtration rate (GFR), calculated with the Modification of Diet in Renal Disease equation. We first assessed whether a linear association was present between eGFR and clinical endpoints using restricted cubic splines. We then examined the prognostic implications of eGFR, unadjusted and adjusted for demographic, clinical, and laboratory variables. We further explored the effects of intensive BP lowering across the eGFR spectrum. Results Baseline eGFR was available for 9,324 (>99%) individuals. Mean eGFR was similar between the two groups (intensive group 71.8 ml/min/1.73m2 vs. standard group 71.7 ml/min/1.73m2; P=0.92). Median follow-up was 3.3 years (range 0–4.8), with 561 primary efficacy events (6%) and 3,522 SAE (38%) recorded during the study period. Baseline eGFR was non-linearly associated with the risk of the primary efficacy endpoint, death from CV causes, death from any cause, acute decompensated heart failure, SAE, electrolyte abnormality, and acute kidney injury (test for non-linearity, P<0.05; test for overall trend, P<0.001) and remained significantly associated with all tested endpoints upon multivariable adjustment (P<0.05). Baseline eGFR significantly modified the effects of intensive BP lowering on the primary efficacy endpoint (P=0.02), acute decompensated heart failure (P=0.01), SAE (P=0.01), and acute kidney injury (P=0.04). The Figure shows treatment effects (hazard ratios) across the spectrum of eGFR for these four endpoints. P-values are for the interaction between eGFR and treatment effect. Significant interactions were not detected for other endpoints. Figure 1 Conclusions In SPRINT, lower eGFR was associated with a greater risk of both CV events and SAE. Patients with higher eGFR appeared to derive more benefit from intensive BP lowering while the relationship with safety events was complex.

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