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Prescribing dialysis to manage acute kidney injury (AKI) is common and recently has become a controversial area for physicians. The concept of dialysis 'dose' initially was developed for end-stage renal disease and has been extended to AKI in the last decade. Urea kinetic modeling has been the mainstay of dose quantification in end-stage renal disease. Extrapolation of these techniques to critically ill patients with AKI is difficult because of a non-steady state leading to a variable increase in urea generation rate, alterations in total-body water and its compartmental distribution, and changing renal excretory capacity. Additional challenges are imposed when dose is considered for different modalities of dialysis that vary in operational characteristics (diffusion, convection, and adsorption), duration (intermittent and continuous), and frequency. The purpose of this article is to review the concept of dialysis dose, perform a critical assessment of the most important clinical trials of dialysis dose in AKI, summarize clinical evidence from these trials, and define key research issues that should be addressed in the future. [ABSTRACT FROM AUTHOR]

Diabetic patients have a 12% to 25% lifetime risk of developing foot complications leading to significant morbidity and mortality. The objective of this study was to assess the effectiveness of group education in improving patient awareness of foot care. The authors evaluated the effect of group size and areas in which knowledge seemed to be most affected. Patients attending a 2-hour teaching session between November 2005 and March 2006 were recruited. Patients filled in an 18-part questionnaire before and after the teaching session to assess knowledge. Fifty-nine patients recently diagnosed with diabetes mellitus or foot complications were recruited for 7 sessions. Analysis of the data showed a statistically significant improvement in foot care knowledge after the teaching session compared with before (69% to 85%,P < .001). Patients in the smaller group (n< 10) had significantly higher scores compared with the bigger groups (n> 10;P < .025). These data show the benefit of group education about foot care for patients with diabetes. Smaller groups benefited more than larger ones did, which could be attributed to the sizes allowing for better interaction between the tutor and patient. As patient knowledge is variable from individual to individual, smaller teaching sessions may allow patients to address specific concerns. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify in a prospective observational study the cardiac structural and functional abnormalities and mortality in patients with end stage renal disease (ESRD) with a raised cardiac troponin T (cTnT) concentration. METHODS: 126 renal transplant candidates were studied over a two year period. Clinical, biochemical, echocardiographic, coronary angiographic, and dobutamine stress echocardiographic (DSE) data were examined in comparison with cTnT concentrations dichotomised at cut off concentrations of < 0.04 microg/l and < 0.10 microg/l. RESULTS: Left ventricular (LV) size and filling pressure were significantly raised and LV systolic and diastolic function parameters significantly impaired in patients with raised cTnT, irrespective of the cut off concentration. The proportions of patients with diabetes and on dialysis were higher in both groups with raised cTnT. With a cut off cTnT concentration of 0.04 microg/l but not 0.10 microg/l, significantly more patients had severe coronary artery disease and a positive DSE result. The total ischaemic burden during DSE was similar in cTnT positive and negative patients, irrespective of the cut off concentration used. LV end systolic diameter index and E:Ea ratio were independent predictors of cTnT rises > or = 0.04 microg/l and > or = 0.10 microg/l, respectively. Diabetes was independently associated with cTnT at both cut off concentrations. Mortality was higher in all patients with raised cTnT. CONCLUSIONS: Patients with ESRD with raised cTnT concentrations have increased mortality. Raised concentrations are strongly associated with diabetes, LV dilatation, and impaired LV systolic and diastolic function, but not with severe coronary artery disease. [ABSTRACT FROM AUTHOR]

AIMS: To determine the prognostic value of the Framingham equation and the United Kingdom Prospective Diabetes Study (UKPDS) risk engine in patients with newly diagnosed Type 2 diabetes. METHODS: A community-based cohort (n=428; aged 30-74 years) free of clinically evident CVD and newly diagnosed with Type 2 diabetes were studied over a median 4.2 (sd+/-0.62) years. Predicted (using baseline variables at diagnosis) and observed proportions of primary CVD and CHD events were compared using the Framingham equations and the UKPDS risk engine (only CHD events). The discrimination (c-statistic) and calibration (HLchi2) of the risk equations were calculated. The sensitivity and specificity of the Framingham equation at a 15%, 10-year CHD risk threshold (NICE guidelines) was compared with that of the ADA lipid threshold (LDLc>or=2.6 mmol/l or triglycerides>or=4.5 mmol/l). RESULTS: The Framingham equations underestimated the overall number of cardiovascular events by 33% and coronary events by 32% and showed modest discrimination and poor calibration for CVD [c=0.673; HLchi2=32.8 (P<0.001)] and CHD risk [c=0.657; HLchi2=19.8 (P=0.011)]. Although the overall underestimate was lower and non-significant with the UKPDS risk engine for CHD (13%), its performance in terms of discrimination and calibration were similar [c=0.670; HLchi2=17.1 (P=0.029)]. The 15%, 10-year CHD risk threshold with both the Framingham and UKPDS risk engines had similar sensitivity for primary CVD as the lipid level threshold [85.7 and 89.8% vs. 93.9% (P=0.21 and 0.34)] and both had greater specificity [33.0 and 30.3% vs. 12.1% (P<0.001 and P<0.001)]. CONCLUSIONS: In people with newly diagnosed Type 2 diabetes, both the Framingham equation and UKPDS risk engine are moderately effective at identifying those at high-risk (discrimination) and are poor at quantifying risk (calibration). Nonetheless, at a population level, a 15% 10-year CHD risk threshold using either risk calculator has similar sensitivity as an approach based on a single lipid risk factor level and may have benefits in terms of cost-effectiveness given the improved specificity. [ABSTRACT FROM AUTHOR]

Purpose: Novel interventions for the prevention or treatment of acute kidney injury (AKI) are currently lacking. To facilitate the evaluation and adoption of new treatments, the use of the most appropriate design and endpoints for clinical trials in AKI is critical and yet there is little consensus regarding these issues. We aimed to develop recommendations on endpoints and trial design for studies of AKI prevention and treatment interventions based on existing data and expert consensus., Methods: At the 31st Acute Disease Quality Initiative (ADQI) meeting, international experts in critical care, nephrology, involving adults and pediatrics, biostatistics and people with lived experience (PWLE) were assembled. We focused on four main areas: (1) patient enrichment strategies, (2) prevention and attenuation studies, (3) treatment studies, and (4) innovative trial designs of studies other than traditional (parallel arm or cluster) randomized controlled trials. Using a modified Delphi process, recommendations and consensus statements were developed based on existing data, with > 90% agreement among panel members required for final adoption., Results: The panel developed 12 consensus statements for clinical trial endpoints, application of enrichment strategies where appropriate, and inclusion of PWLE to inform trial designs. Innovative trial designs were also considered., Conclusion: The current lack of specific therapy for prevention or treatment of AKI demands refinement of future clinical trial design. Here we report the consensus findings of the 31st ADQI group meeting which has attempted to address these issues including the use of predictive and prognostic enrichment strategies to enable appropriate patient selection., (© 2024. The Author(s).)

Patients with cirrhosis are prone to developing acute kidney injury (AKI), a complication associated with a markedly increased in-hospital morbidity and mortality, along with a risk of progression to chronic kidney disease. Whereas patients with cirrhosis are at increased risk of developing any phenotype of AKI, hepatorenal syndrome (HRS), a specific form of AKI (HRS-AKI) in patients with advanced cirrhosis and ascites, carries an especially high mortality risk. Early recognition of HRS-AKI is crucial since administration of splanchnic vasoconstrictors may reverse the AKI and serve as a bridge to liver transplantation, the only curative option. In 2023, a joint meeting of the International Club of Ascites (ICA) and the Acute Disease Quality Initiative (ADQI) was convened to develop new diagnostic criteria for HRS-AKI, to provide graded recommendations for the work-up, management and post-discharge follow-up of patients with cirrhosis and AKI, and to highlight priorities for further research., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Aims: According to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline, the definition of chronic kidney disease (CKD) requires the presence of abnormal kidney structure or function for >3 months with implications for health. CKD in patients with heart failure (HF) has not been defined using this definition, and less is known about the true health implications of CKD in these patients. The objective of the current study was to identify patients with HF who met KDIGO criteria for CKD and examine their outcomes., Methods and Results: Of the 1 419 729 Veterans with HF not receiving kidney replacement therapy, 828 744 had data on ≥2 ambulatory serum creatinine >90 days apart. CKD was defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m 2 (n = 185 821) or urinary albumin-to-creatinine ratio (uACR) >30 mg/g (n = 32 730) present twice >3 months apart. Normal kidney function (NKF) was defined as eGFR ≥60 ml/min/1.73 m 2 , present for >3 months, without any uACR >30 mg/g (n = 365 963). Patients with eGFR <60 ml/min/1.73 m 2 were categorized into four stages: 45-59 (n = 72 606), 30-44 (n = 74 812), 15-29 (n = 32 077), and <15 (n = 6326) ml/min/1.73 m 2 . Five-year all-cause mortality occurred in 40.4%, 57.8%, 65.6%, 73.3%, 69.7%, and 47.5% of patients with NKF, four eGFR stages, and uACR >30mg/g (albuminuria), respectively. Compared with NKF, hazard ratios (HR) (95% confidence intervals [CI]) for all-cause mortality associated with the four eGFR stages and albuminuria were 1.63 (1.62-1.65), 2.00 (1.98-2.02), 2.49 (2.45-2.52), 2.28 (2.21-2.35), and 1.22 (1.20-1.24), respectively. Respective age-adjusted HRs (95% CIs) were 1.13 (1.12-1.14), 1.36 (1.34-1.37), 1.87 (1.84-1.89), 2.24 (2.18-2.31) and 1.19 (1.17-1.21), and multivariable-adjusted HRs (95% CIs) were 1.11 (1.10-1.12), 1.24 (1.22-1.25), 1.46 (1.43-1.48), 1.42 (1.38-1.47), and 1.13 (1.11-1.16). Similar patterns were observed for associations with hospitalizations., Conclusion: Data needed to define CKD using KDIGO criteria were available in six out of ten patients, and CKD could be defined in seven out of ten patients with data. HF patients with KDIGO-defined CKD had higher risks for poor outcomes, most of which was not explained by abnormal kidney structure or function. Future studies need to examine whether CKD defined using a single eGFR is characteristically and prognostically different from CKD defined using KDIGO criteria., (© 2024 European Society of Cardiology This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Background: Acute kidney injury (AKI) is independently associated with increased morbidity and mortality across the life course, yet care for AKI remains mostly supportive. Raising awareness of this life-threatening clinical syndrome through education and advocacy efforts is the key to improving patient outcomes. Here, we describe the unique roles education and advocacy play in the care of children with AKI, discuss the importance of customizing educational outreach efforts to individual groups and contexts, and highlight the opportunities created through innovations and partnerships to optimize lifelong health outcomes., Methods: During the 26th Acute Disease Quality Initiative (ADQI) consensus conference, a multidisciplinary group of experts discussed the evidence and used a modified Delphi process to achieve consensus on recommendations on AKI research, education, practice, and advocacy in children., Results: The consensus statements developed in response to three critical questions about the role of education and advocacy in pediatric AKI care are presented here along with a summary of available evidence and recommendations for both clinical care and research., Conclusions: These consensus statements emphasize that high-quality care for patients with AKI begins in the community with education and awareness campaigns to identify those at risk for AKI. Education is the key across all healthcare and non-healthcare settings to enhance early diagnosis and develop mitigation strategies, thereby improving outcomes for children with AKI. Strong advocacy efforts are essential for implementing these programs and building critical collaborations across all stakeholders and settings., (© 2023. The Author(s).)

Acute kidney injury (AKI) is a common clinical condition with various causes and is associated with increased mortality. Despite advances in supportive care, AKI increases not only the risk of premature death compared with the general population but also the risk of developing chronic kidney disease and progressing towards kidney failure. Currently, no specific therapy exists for preventing or treating AKI other than mitigating further injury and supportive care. To address this unmet need, novel therapeutic interventions targeting the underlying pathophysiology must be developed. New and well-designed clinical trials with appropriate end points must be subsequently designed and implemented to test the efficacy of such new interventions. Herein, we discuss predictive and prognostic enrichment strategies for patient selection, as well as primary and secondary end points that can be used in different clinical trial designs (specifically, prevention and treatment trials) to evaluate novel interventions and improve the outcomes of patients at a high risk of AKI or with established AKI., (© 2023. Springer Nature Limited.)

Acute kidney injury (AKI), which is a common complication of acute illnesses, affects the health of individuals in community, acute care and post-acute care settings. Although the recognition, prevention and management of AKI has advanced over the past decades, its incidence and related morbidity, mortality and health care burden remain overwhelming. The rapid growth of digital technologies has provided a new platform to improve patient care, and reports show demonstrable benefits in care processes and, in some instances, in patient outcomes. However, despite great progress, the potential benefits of using digital technology to manage AKI has not yet been fully explored or implemented in clinical practice. Digital health studies in AKI have shown variable evidence of benefits, and the digital divide means that access to digital technologies is not equitable. Upstream research and development costs, limited stakeholder participation and acceptance, and poor scalability of digital health solutions have hindered their widespread implementation and use. Here, we provide recommendations from the Acute Disease Quality Initiative consensus meeting, which involved experts in adult and paediatric nephrology, critical care, pharmacy and data science, at which the use of digital health for risk prediction, prevention, identification and management of AKI and its consequences was discussed., (© 2023. Springer Nature Limited.)

Drug-induced kidney disease (DIKD) accounts for about one-fourth of all cases of acute kidney injury (AKI) in hospitalized patients, especially in critically ill setting. There is no standard definition or classification system of DIKD. To address this, a phenotype definition of DIKD using expert consensus was introduced in 2015. Recently, a novel framework for DIKD classification was proposed that incorporated functional change and tissue damage biomarkers. Medications were stratified into four categories, including "dysfunction without damage," "damage without dysfunction," "both dysfunction and damage," and "neither dysfunction nor damage" using this novel framework along with predominant mechanism(s) of nephrotoxicity for drugs and drug classes. Here, we briefly describe mechanisms and provide examples of drugs/drug classes related to the categories in the proposed framework. In addition, the possible movement of a patient's kidney disease between certain categories in specific conditions is considered. Finally, opportunities and barriers to adoption of this framework for DIKD classification in real clinical practice are discussed. This new classification system allows congruencies for DIKD with the proposed categorization of AKI, offering clarity as well as consistency for clinicians and researchers., (© 2023. The Author(s).)

Introduction: Retrospective studies report that angiotensin-converting enzyme inhibitors (ACEIs) may reduce the severity of COVID-19, but prospective data on de novo treatment with ACEIs are limited. The RAMIC trial was a randomized, multicenter, placebo-controlled, double-blind, allocation-concealed clinical trial to examine the efficacy of de novo ramipril versus placebo for the treatment of COVID-19., Methods: Eligible participants were aged 18 years and older with a confirmed diagnosis of SARS-CoV-2 infection, recruited from urgent care clinics, emergency departments, and hospital inpatient wards at eight sites in the USA. Participants were randomly assigned to daily ramipril 2.5 mg or placebo orally in a 2:1 ratio, using permuted block randomization. Analyses were conducted on an intention-to-treat basis. The primary outcome was a composite of mortality, intensive care unit (ICU) admission, or invasive mechanical ventilation by day 14., Results: Between 27 May 2020 and 19 April 2021, a total of 114 participants (51% female) were randomized to ramipril (n = 79) or placebo (n = 35). The overall mean (± SD) age and BMI were 45 (± 15) years and 33 (± 8) kg/m 2 . Two participants in the ramipril group required ICU admission and one died, compared with none in the placebo group. There were no significant differences between ramipril and placebo in the primary endpoint (ICU admission, mechanical ventilation, or death) (3% versus 0%, p = 1.00) or adverse events (27% versus 29%, p = 0.82). The study was terminated early because of a low event rate and subsequent Emergency Use Authorization of therapies for COVID-19., Conclusion: De novo ramipril was not different compared with placebo in improving or worsening clinical outcomes from COVID-19 but appeared safe in non-critically ill patients with COVID-19., Trial Registration: Clinicaltrials.gov NCT04366050., (© 2023. The Author(s), under exclusive licence to Springer Healthcare Ltd., part of Springer Nature.)

Sepsis-associated acute kidney injury (SA-AKI) is common in critically ill patients and is strongly associated with adverse outcomes, including an increased risk of chronic kidney disease, cardiovascular events and death. The pathophysiology of SA-AKI remains elusive, although microcirculatory dysfunction, cellular metabolic reprogramming and dysregulated inflammatory responses have been implicated in preclinical studies. SA-AKI is best defined as the occurrence of AKI within 7 days of sepsis onset (diagnosed according to Kidney Disease Improving Global Outcome criteria and Sepsis 3 criteria, respectively). Improving outcomes in SA-AKI is challenging, as patients can present with either clinical or subclinical AKI. Early identification of patients at risk of AKI, or at risk of progressing to severe and/or persistent AKI, is crucial to the timely initiation of adequate supportive measures, including limiting further insults to the kidney. Accordingly, the discovery of biomarkers associated with AKI that can aid in early diagnosis is an area of intensive investigation. Additionally, high-quality evidence on best-practice care of patients with AKI, sepsis and SA-AKI has continued to accrue. Although specific therapeutic options are limited, several clinical trials have evaluated the use of care bundles and extracorporeal techniques as potential therapeutic approaches. Here we provide graded recommendations for managing SA-AKI and highlight priorities for future research., (© 2023. Springer Nature Limited.)

Introduction: Sepsis, the leading cause of acute kidney injury (AKI), is associated with a high morbidity and mortality. Alkaline phosphatase (ALP) is an endogenous detoxifying enzyme. A recombinant human ALP compound, ilofotase alfa, showed no safety or tolerability concerns in a phase 2 trial. Renal function improvement over 28 days was significantly greater in the ilofotase alfa group. Moreover, a significant relative reduction in 28-day all-cause mortality of >40% was observed. A follow-up trial has been designed to confirm these findings., Methods and Analysis: This is a phase 3, global, multi-centre, randomised, double-blind, placebo-controlled, sequential design trial in which patients are randomly assigned to either placebo or 1.6 mg/kg ilofotase alfa. Randomisation is stratified by baseline modified Sequential Organ Failure Assessment (mSOFA) score and trial site. The primary objective is to confirm the survival benefit with ilofotase alfa by demonstrating a reduction in 28-day all-cause mortality in patients with sepsis-associated AKI requiring vasopressors. A maximum of 1400 patients will be enrolled at ∼120 sites in Europe, North America, Japan, Australia and New Zealand. Up to four interim analyses will take place. Based on predefined decision rules, the trial may be stopped early for futility or for effectiveness. In addition, patients with COVID-19 disease and patients with 'moderate to severe' chronic kidney disease are analysed as 2 separate cohorts of 100 patients each. An independent Data Monitoring Committee evaluates safety data at prespecified intervals throughout the trial., Ethics and Dissemination: The trial is approved by relevant institutional review boards/independent ethics committees and is conducted in accordance with the ethical principles of the Declaration of Helsinki, guidelines of Good Clinical Practice, Code of Federal Regulations and all other applicable regulations. Results of this study will determine the potential of ilofotase alfa to reduce mortality in critically ill patients with sepsis-associated AKI and will be published in a peer-reviewed scientific journal., Trial Registration Number: EudraCT CT Number 2019-0046265-24. US IND Number 117 605 Pre-results., Clinicaltrials: gov number: NCT04411472., Competing Interests: Competing interests: PP received advisory board consultancy and travel reimbursements from AM-Pharma. DCA and CJD serve as advisory board consultants for AM-Pharma. JA, EvdB and JB are employees of AM-Pharma. RB, MB, KD, BF, JAK, P-FL, VP and PY received advisory board consultancy reimbursements from AM Pharma. KB worked as an employee of Berry Consultants KB and acted as a consultant to numerous pharmaceutical and device companies. KB is currently an employee of and holds stock in AstraZeneca. JC, ALK and SR are consultants to AM-Pharma. RF received advisory board consultancy reimbursements from AM Pharma and additional consulting reimbursements from BioMerieux, Baxter, Pfizer, MSD, Gilead, Shionogi, Grifols and Beckton Dickinson unrelated to the current study. MJ received advisory board consultancy reimbursements from AM Pharma, additional consulting reimbursement from Baxter and Gilead and grant support from Fresenius and Baxter, unrelated to the current study. KL received advisory board consultancy reimbursements from AM-Pharma, owns stock in Amgen and consultant for Biomerieux, Neumora, Seastar and BOA Medical. RLM received advisory board consultancy reimbursements from AM Pharma and additional consulting reimbursement from BioMerieux, Baxter, Nova Biomed, Abiomed, GE Healthcare, Medtronic, Sanofi and Mallinckrodt, unrelated to the current study. PTM received Trial Steering Committee consultancy payments from AM-Pharma. Other consultancy payments: FAST Biomedical, Novartis, Renibus Therapeutics. MO received speaker honoraria from Fresenius Medical Care, Biomerieux, Baxter and Gilead, and research funding from Fresenius Medical Care, Biomerieux, Baxter and LaJolla Pharma and advisory board consultancy reimbursements from AM-Pharma. AZ received advisory board consultancy reimbursements from AM-Pharma. AZ has received consulting and/or lecture fees from Astute Medical/BioMerieux, Fresenius, Paion, Guard Therapeutics, and Baxter, unrelated to the current study. AZ has received grant support from Astute Medical/BioMerieux, Fresenius and Baxter, unrelated to the current study., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Acute kidney injury (AKI) is a growing epidemic and is independently associated with increased risk of death, chronic kidney disease (CKD) and cardiovascular events. Randomized-controlled trials (RCTs) in this domain are notoriously challenging and many clinical studies in AKI have yielded inconclusive findings. Underlying this conundrum is the inherent heterogeneity of AKI in its etiology, presentation and course. AKI is best understood as a syndrome and identification of AKI subphenotypes is needed to elucidate the disease's myriad etiologies and to tailor effective prevention and treatment strategies. Conventional RCTs are logistically cumbersome and often feature highly selected patient populations that limit external generalizability and thus alternative trial designs should be considered when appropriate. In this narrative review of recent developments in AKI trials based on the Kidney Disease Clinical Trialists (KDCT) 2020 meeting, we discuss barriers to and strategies for improved design and implementation of clinical trials for AKI patients, including predictive and prognostic enrichment techniques, the use of pragmatic trials and adaptive trials., (© The Author(s) 2022. Published by Oxford University Press on behalf of the ERA.)

Introduction: With 65 million cases globally, chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death and imposes a heavy burden on patients' lives and healthcare resources worldwide. Around half of all patients with COPD have frequent (≥2 per year) acute exacerbations of COPD (AECOPD). Rapid readmissions are also common. Exacerbations impact significantly on COPD outcomes, causing significant lung function decline. Prompt exacerbation management optimises recovery and delays the time to the next acute episode., Methods/analysis: The Predict & Prevent AECOPD trial is a phase III, two arm, multi-centre, open label, parallel-group individually randomised clinical trial investigating the use of a personalised early warning decision support system (COPDPredict) to predict and prevent AECOPD. We aim to recruit 384 participants and randomise each individual in a 1:1 ratio to either standard self-management plans with rescue medication (RM) (control arm) or COPDPredict with RM (intervention arm).The trial will inform the future standard of care regarding management of exacerbations in COPD patients. The main outcome measure is to provide further validation, as compared with usual care, for the clinical effectiveness of COPDPredict to help guide and support COPD patients and their respective clinical teams in identifying exacerbations early, with an aim to reduce the total number of AECOPD-induced hospital admissions in the 12 months following each patient's randomisation., Ethics and Dissemination: This study protocol is reported in accordance with the guidance set out in the Standard Protocol Items: Recommendations for Interventional Trials statement. Predict & Prevent AECOPD has obtained ethical approval in England (19/LO/1939). On completion of the trial and publication of results a lay findings summary will be disseminated to trial participants., Trial Registration Number: NCT04136418., Competing Interests: Competing interests: The CI of the trial (AMT) does not have any relevant direct financial disclosures, nor do members of the Trial Management Group (TMG) who are authors of this paper, with the exception of NP who is a founder, director and shareholder of NEPeSMO, who developed the intervention. In addition, MS is CI of the overall NIHR-funded project and is a founder, director and shareholder of NEPeSMO. NEPeSMO is a start-up company from the University Hospitals of North Midlands NHS Trust, owns all intellectual property rights of COPDPredict and is a project collaborator on the grant. AMT has grants from pharmaceutical companies working in the area of COPD (Chiesi, AstraZeneca) and has conducted advisory work for such (Boehringer, CSL Behring) but not in the area of medical devices or admission prevention. Neither has she worked for, or received monies from, any company working on admission prevention in the last 3 years., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Continuous renal replacement therapy (CRRT) is frequently used for fluid management of critically ill patients with acute or chronic kidney failure. There is significant practice variation worldwide in fluid management during CRRT. Multiple clinical studies have suggested that both the magnitude and duration of fluid overload are associated with morbidity and mortality in critically ill patients. Therefore, timely and effective fluid management with CRRT is paramount in managing critically ill patients with fluid overload. While the optimal method of fluid management during CRRT is still unclear and warrants further investigation, observational data have suggested a U-shape relationship between net ultrafiltration rate and mortality. Furthermore, recent clinical data have underpinned a significant gap in prescribed versus achieved fluid balance during CRRT, which is also associated with mortality. This review uses a case-based approach to discuss two fluid management strategies based on net ultrafiltration rate and fluid balance goals during CRRT and harmonizes operational definitions., (© 2023 S. Karger AG, Basel.)

Importance: Increasing evidence indicates that acute kidney injury (AKI) occurs frequently in children and young adults and is associated with poor short-term and long-term outcomes. Guidance is required to focus efforts related to expansion of pediatric AKI knowledge., Objective: To develop expert-driven pediatric specific recommendations on needed AKI research, education, practice, and advocacy., Evidence Review: At the 26th Acute Disease Quality Initiative meeting conducted in November 2021 by 47 multiprofessional international experts in general pediatrics, nephrology, and critical care, the panel focused on 6 areas: (1) epidemiology; (2) diagnostics; (3) fluid overload; (4) kidney support therapies; (5) biology, pharmacology, and nutrition; and (6) education and advocacy. An objective scientific review and distillation of literature through September 2021 was performed of (1) epidemiology, (2) risk assessment and diagnosis, (3) fluid assessment, (4) kidney support and extracorporeal therapies, (5) pathobiology, nutrition, and pharmacology, and (6) education and advocacy. Using an established modified Delphi process based on existing data, workgroups derived consensus statements with recommendations., Findings: The meeting developed 12 consensus statements and 29 research recommendations. Principal suggestions were to address gaps of knowledge by including data from varying socioeconomic groups, broadening definition of AKI phenotypes, adjudicating fluid balance by disease severity, integrating biopathology of child growth and development, and partnering with families and communities in AKI advocacy., Conclusions and Relevance: Existing evidence across observational study supports further efforts to increase knowledge related to AKI in childhood. Significant gaps of knowledge may be addressed by focused efforts.

The use of mobile devices by healthcare providers has transformed many aspects of clinical practice. Mobile devices and medical applications provide many benefits, perhaps most significantly increased access to point-of-care (POC) tools, which has been shown to support better clinical decision making and improved patient outcomes. In LMICs, where computer-based technology is limited, the use of mobile technology has the potential to immensely increase access to point of care tools. In this study, we conducted an interventional, pre-post study to determine whether the use of a medical application could help healthcare providers accurately recognize and diagnose AKI. After preparing 20 clinical vignettes based on AKI cases from our center Global Snapshot study report, we asked 50 last year medical students to identify the presence and stage of AKI first without and then with the use of the IRA SLANH App (IRA SLANH app, Island of the Moon ® V.1, 2014; Cochabamba-Bolivia), which was designed specifically for this study. Before the IRA SLANH app was introduced, the mean number of correctly identified cases of AKI was 14.7 ± 4.7 with a minimum of 3 and a maximum of 20. The stage of AKI was correctly identified in only 6.7 ± 4.4 of the cases. After the app was introduced, the number of correctly identified and staged cases of AKI was 20. Medical applications are useful point-of-care tools in the practice of evidence-based medicine. Their use has the potential to play a very important role in early identification and classification of AKI, particularly in LMICs potentially allowing for earlier intervention with preventive and treatment strategies to reverse kidney injury and improve recovery., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Gaspar, Iturricha-Cáceres, Macedo, Mehta and Claure-Del Granado.)