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Background: Oliguria is a sign of impaired kidney function and has been shown to be an early predictor of adverse prognoses in patients with acute kidney injury. The relationship between urine output (UOP) and early lactate levels in neonates with perinatal asphyxia (PA) has not been extensively explored. This study aimed to investigate the link between oliguria during the first 24 h of life and early lactate levels in neonates with PA., Methods: The medical records of 293 term neonates with asphyxia from 9216 hospitalized newborns were retrospectively analyzed, including 127 cases designated as the oliguria group and 166 cases as controls. Peripheral arterial blood gas after PA and UOP within 24 h after birth were analyzed. Logistic regression analyses and receiver operating characteristic curve analysis were conducted., Results: Oliguria occurred in 43.34% of neonates with PA. The median UOP of the oliguria and control groups were 0.65 and 1.46 mL/kg/h, respectively. Elevated lactate levels after PA are an independent risk factor for oliguria in the following 24 h (p = 0.01; OR: 1.19; 95%CI: 1.04-1.35) and show a moderate discriminatory power for oliguria (AUC = 0.62). Using a cut off value of 8.15 mmol/L, the positive and negative predictive values and the specificity were 59.34%, 63.86%, and 78.30%, respectively., Conclusion: Neonates with elevated lactate levels after PA face a risk of oliguria in the following 24 h. Based on early elevated lactate levels after resuscitation, especially ≥ 8.15 mmol/L, meticulously monitoring UOP will allow this vulnerable population to receive early, tailored fluid management and medical intervention., (© 2024. The Author(s).)

Purpose: Acute kidney injury (AKI) is a common organ dysfunction in ICU and up to now there is no good way to predict the AKI progression and patient prognosis. Blood electrolyte tests are common in ICU, but there are few studies on early blood electrolytes and the AKI progression and patient prognosis. Therefore, we concentrated on the serum sodium and potassium levels before AKI diagnosis and evaluated the relationship between serum sodium and potassium levels and the severity and prognosis of AKI., Methods: This study included data of all patients from the MIMIC-III. We used the urine output criteria in the KDIGO as diagnostic criteria for oliguric AKI. Patients admitted to the ICU several times only included their initial ICU admission results. Patients younger than 18 years old, diagnosed with AKI stage 3, ICU stays less than 24 h or without corresponding laboratory results or data were excluded. The included patients were divided into four groups based on the interquartile range of serum sodium and potassium. We evaluated the serum sodium and potassium levels before AKI diagnosis and AKI severity and prognosis through retrospective analysis., Results: Patients with serum potassium > 4.6 mmol/L were more likely to progress to AKI stage 3 or death than patients with serum potassium ≤ 4.6 mmol/L (overall p < 0.0001). Patients with sodium < 137 mmol/L or > 141 mmol/L had a higher risk of progressing to AKI stage 3 (overall p = 0.00023) and risk of death (overall p < 0.0001) than other patients. In the Cox regression model, after adjusting for age, sex, and BMI, serum sodium or potassium were associated with AKI progression and prognosis (p < 0.01). After continuing to adjust for comorbidities, serum potassium was still associated with AKI progression and prognosis (p < 0.01), but serum sodium was only associated with prognosis (p = 0.027). After adjusting for other indicators, there was no statistically significant correlation between serum sodium or potassium and AKI progression and prognosis. After adjusting for serum sodium or potassium, the corresponding results were not significantly different from those before adjustment., Conclusion: This study found that abnormal serum sodium or potassium levels before AKI diagnosis were more likely to lead to AKI progression and poor prognosis, of which lower serum sodium and higher serum potassium were more likely to progress to AKI stage 3 or death.

Background: Acute kidney injury (AKI) after hepatectomy occurs in around 10% of cases. AKI is often defined based only on postoperative serum creatinine increase. This study aimed to assess if postoperative urine output (UO) correlated with serum creatinine after hepatectomy., Methods: All consecutive hepatectomy patients (2010-2016) were assessed. AKI was defined according to KDIGO criteria: serum creatinine increase ≥26.5 μmol/l, creatinine increase ≥1.5x baseline creatinine, or postoperative oliguria. Oliguria was defined as daily mean UO <0.5 mL/kg/h. AKI was subdivided into creatinine-based or oliguria-based AKI according to the defining criterion., Results: Out of 285 patients, AKI was observed in 79 cases (28%). Creatinine-based AKI occurred in 25 patients (9%) and oliguria-based only AKI in 54 patients (19%). Ten patients fulfilled both criteria (4%). Postoperative UO correlated poorly with postoperative serum creatinine level in both whole cohort (rho = -0.34, p <0.001) and AKI subgroup (rho = -0.189, p = 0.124). No association was found between postoperative oliguria and postoperative serum creatinine increase (HR = 0.5, 95%CI: 0.2-1.9, p = 0.341). On multivariable analysis, operation duration >360 minutes was the only predictor of creatinine increase (HR = 3.6, 95%CI: 1.1-11.4, p = 0.032)., Conclusion: Postoperative UO showed poor correlation with postoperative serum creatinine both in all patients and AKI patients. Surgery duration >360 minutes appeared as the only independent predictor of postoperative serum creatinine increase., (Copyright © 2019 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Acute kidney injury (AKI) occurs in 6.1%-22.4% of patients undergoing major noncardiac surgery. Previous studies have shown no association between intraoperative urine output and postoperative acute renal failure. However, these studies used various definitions of acute renal failure. We therefore investigated the association between intraoperative oliguria and postoperative AKI defined by the serum creatinine criteria of the Risk, Injury, Failure, Loss, and End-stage kidney disease (RIFLE) classification., Methods: In this single-center, retrospective, observational study, we screened 26,984 patients undergoing elective or emergency surgery during the period September 1, 2008 to October 31, 2011 at a university hospital. Exclusion criteria were age <18 years; duration of anesthesia <120 minutes; hospital stay <2 nights; local anesthesia only; urologic or cardiac surgery; coexisting end-stage kidney disease; and absence of serum creatinine measurement, intraoperative urine output data, or information regarding intraoperative drug use. Multivariable logistic regression analysis was used as the primary analytic method., Results: A total of 5894 patients were analyzed. The incidence of postoperative AKI was 7.3%. By multivariable analysis, ≥120 minutes of oliguria (odds ratio = 2.104, 95% CI, 1.593-2.778; P < .001) was independently associated with the development of postoperative AKI. After propensity-score matching of patients with ≥120 and <120 minutes of oliguria on baseline characteristics, the incidence of AKI in patients with ≥120 minutes of oliguria (n = 827; 10%) was significantly greater than that in those with <120 minutes of oliguria (n = 827; 4.8%; odds ratio = 2.195, 95% CI, 1.806-2.668; P < .001)., Conclusions: Contrary to previous studies, we found that intraoperative oliguria is associated with the incidence of AKI after major noncardiac surgery.

Vancomycin is known to be unintentionally eliminated by continuous renal replacement therapy, and the protein bound fraction of vancomycin is also known to be different in adults and children. However, there are only a few studies investigating the relationship between the dose of continuous venovenous hemodiafiltration (CVVHDF) parameters and serum concentration of vancomycin in pediatric patients. The aim of this study was to determine clinical and demographic parameters that significantly affect serum vancomycin concentrations. This retrospective cohort study was conducted at a pediatric intensive care unit in a tertiary university children's hospital. Data from oliguric patients who underwent CVVHDF and vancomycin therapeutic drug monitoring were collected. The correlation between factors affecting serum concentration of vancomycin was analyzed using mixed effect model. A total of 177 serum samples undergoing vancomycin therapeutic drug monitoring were analyzed. The median age of study participants was 2.23 (interquartile range, 0.3-11.84) years, and 126 (71.19%) were male patients. Serum concentration of vancomycin decreased significantly as the effluent flow rate (EFR; P < 0.001), dialysate flow rate (DFR; P = 0.009), replacement fluid flow rate (RFFR; P = 0.008), the proportion of RFFR in the sum of DFR and RFFR (P = 0.025), and residual urine output increased. The adjusted R2 of the multivariate regression model was 0.874 (P < 0.001) and the equation was as follows: Vancomycin trough level (mg/L) = (0.283 × daily dose of vancomycin [mg/kg/d]) + (365.139 / EFR [mL/h/kg])-(15.842 × residual urine output [mL/h/kg]). This study demonstrated that the serum concentration of vancomycin was associated with EFR, DFR, RFFR, the proportion of RFFR, and residual urine output in oliguric pediatric patients receiving CVVHDF., Competing Interests: The authors have declared that no competing interests exist.

EDL peptide produced a nephroprotective effect on experimental models gentamycin-induced nephropathy and ischemia/reperfusion kidney injury in rats. The nephroprotective effect of EDL peptide manifested in prevention of oliguria and retention azotemia, a decrease in proteinuria and sodium excretion, prevention of critical decrease in activities of antioxidant enzymes, suppression of LPO, and normalization of energy supply to kidneys cells. Our findings confirm the prospects of further studies of the nephroprotective properties of peptide EDL in various pathologies of the kidneys.

Background: In infants, oliguria is defined as a urine output of <1.5 mL/kg/h. The aim of our study was to assess the impact of oliguria on urinary neutrophil gelatinase-associated lipocalin (NGAL) and serum cystatin C (CysC) levels in very-low-birth-weight infants (VLBWIs) with a normal serum creatinine (Cr) level., Methods: Fifty-seven VLBWIs were enrolled in the study. Urinary NGAL, serum CysC and Cr levels and urinary NGAL/Cr ratios were measured. Infants with Apgar scores of >5 at 5 min and/or a serum Cr level of >1.5 mg/dL or those treated for patent ductus arteriosus were excluded. In case of antibiotic treatment, blood and urine samples were collected at ≥48 h after discontinuation of antibiotic treatment., Results: There was a significant difference in gestational age between infants with oliguric episodes during hospitalization and those without, but not in birth weight, perinatal or postnatal factors. Gestational age was negatively correlated with urinary NGAL and serum CysC levels and urinary NGAL/Cr ratio (p < 0.05), whereas postnatal age was negatively correlated with serum Cr level and urinary NGAL/Cr ratio (p < 0.05). Of the 117 urine and blood samples collected, 25 (21.4%) were obtained from neonates with oliguric episodes. After adjusting for gestational age and postnatal age, comparison of samples collected in infants with and without oliguric episodes revealed significant differences in the mean level of urinary NGAL and in the urinary NGAL/Cr ratio, but not in mean serum CysC or serum Cr levels. The urinary NGAL level [area under the curve (AUC) 0.886, 95% confidence interval (CI) 0.814-0.937] and urinary NGAL/Cr ratio (AUC 0.853, 95% CI 0.775-0.911) showed significantly greater discrimination for oliguria than serum CysC (AUC 0.610, 95% CI: 0.515-0.699) or serum Cr (AUC 0.747, 95%CI 0.659-0.823) levels., Conclusions: Urinary NGAL level and urinary NGAL/Cr ratio were more sensitive markers for the presence of oliguria in VLBWIs with normal serum Cr levels than serum CysC level.

Background: Urine volume is an important clinical finding particularly during the early neonatal period. Oliguria is not a sign of impaired renal function but also a predictive factor for various complications and prognoses. It has been postulated that serum cystatin C (S-CysC) is a more sensitive biomarker for renal function than serum creatinine (S-Cr) in both adults and children. The objective of the current study was to investigate whether urine volume during 24 h after birth can be predicted using S-CysC., Methods: The subjects were 87 infants. The average gestational age was 34.7 ± 2.9 weeks and the average birth weight was 2135 ± 614 g. Blood samples were obtained from either the umbilical cord or the peripheral veins or artery of the newborn at birth. Data regarding the amount of urine volume and fluid intake during the first 24 h of life, maternal S-Cr and S-CysC levels within 48 h before delivery, and neonatal S-Cr and S-CysC levels at birth were collected from the medical records., Results: A significantly positive correlation was observed between maternal and neonatal S-Cr levels (r = 0.84, p < 0.0001) but not between maternal S-Cr levels and neonatal S-CysC levels (r = -0.069, p = 0.52). A significant negative correlation was seen between neonatal S-CysC levels and urine volume (r = -0.47, p < 0.0001)., Conclusion: The present study findings indicate that it may be possible to use S-CysC levels at birth to predict urine volume during the first 24 h of life.

Background: Acute kidney injury (AKI) is a common complication after liver transplantation and is associated with significant morbidity and mortality. Although clinical guidelines recommend defining AKI based on serum creatinine increase and oliguria, the validity and utility of the oliguric component of AKI definition remains largely unexplored. This study examined the incidence and the impact on clinical outcomes of oliguria meeting the urine output criterion of AKI in patients undergoing liver transplantation. The authors hypothesised that oliguria was an independent risk factor for adverse post-operative outcomes., Methods: This study retrospectively examined 320 patients who underwent living donor liver transplantation at our centre. AKI stages were allocated according to recent guidelines based on serum creatinine or urine output within 7 days of surgery., Results: The incidence of oliguria meeting the urine output criterion of AKI was 50.3%. Compared with creatinine criterion alone, incorporating oliguria into the diagnostic criteria dramatically increased the measured incidence of AKI from 39.7% to 62.2%. Compared with patients diagnosed without AKI using either criterion, oliguric patients without serum creatinine increase had significantly longer intensive care unit stays (median: 5 vs. 4 days, P = 0.016), longer hospital stays (median: 60 vs. 49 days, P = 0.014) and lower chronic kidney disease-free survival rate on post-operative day 90 (54.2% vs. 73.3%, P = 0.008)., Conclusion: Oliguria is common after liver transplantation, and incorporating oliguria into the diagnostic criteria dramatically increases the measured incidence of AKI. Oliguria without serum creatinine increase was significantly associated with adverse post-operative outcomes., (© 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: Oliguria is a common symptom in critically ill patients and puts patients in a high risk category for further worsening renal function (WRF). We performed this study to explore the predictive value of biomarkers to predict WRF in oliguric intensive care unit (ICU) patients., Patients and Methods: Single-center prospective observational study. ICU patients were included when they presented a first episode of oliguria. Plasma and urine biomarkers were measured: plasma and urine neutrophil gelatinase-associated lipocalin (pNGAL and uNGAL), urine α1-microglobulin, urine γ-glutamyl transferase, urine indices of tubular function, cystatin C, C terminal fragment of pro-arginine vasopressin (CT-ProAVP), and proadrenomedullin (MR-ProADM)., Results: One hundred eleven patients formed the cohort, of whom 41 [corrected] had worsening renal function. Simplified Acute Physiology Score (SAPS) II was 41 (31-51). WRF was associated with increased mortality (hazard ratio 8.65 [95 % confidence interval (CI) 3.0-24.9], p = 0.0002). pNGAL, MR-ProADM, and cystatin C had the best odds ratio and area under the receiver-operating characteristic curve (AUC-ROC: 0.83 [0.75-0.9], 0.82 [0.71-0.91], and 0.83 [0.74-0.90]), but not different from serum creatinine (Screat, 0.80 [0.70-0.88]). A clinical model that included age, sepsis, SAPS II, and Screat had AUC-ROC of 0.79 [0.69-0.87]; inclusion of pNGAL increased the AUC-ROC to 0.86 (p = 0.03). The category-free net reclassification index improved with pNGAL (total net reclassification index for events to higher risk 61 % and nonevents to lower 82 %)., Conclusions: All episodes of oliguria do not carry the same risk. No biomarker further improved prediction of WRF compared with Screat in this selected cohort of patients at increased risk defined by oliguria.

Background and Objectives: To promote early detection of AKI, recently proposed pretest probability models combine sub-Kidney Disease Improving Global Outcomes (KDIGO) AKI criteria with baseline AKI risk. The primary objective of this study was to determine sub-KDIGO thresholds that identify patients with septic shock at highest risk for AKI., Design, Setting, Participants, & Measurements: This was a retrospective analysis of 390 adult patients admitted to the medical intensive care unit (ICU) of a tertiary, academic medical center with septic shock between January 2008 and December 2010. Hourly urine output was collected from the time of septic shock recognition (hour 0) to hour 96, urine catheter removal, or ICU discharge (whichever occurred first). All available serum creatinine (SCr) measurements were collected until hour 96. The AKI pretest probability model was assessed during the first 12 hours of resuscitation and included the initial episode of oliguria, increase from baseline to peak SCr level, and Acute Physiology and Chronic Health Evaluation (APACHE) III score in a multivariable receiver-operator characteristic (ROC) analysis. The primary outcome was the incidence of stage II or III (stage II+) AKI defined by KDIGO criteria. Secondary outcomes included the need for RRT and 28-day mortality., Results: Ninety-eight (25%) patients developed stage II+ AKI after septic shock recognition. APACHE III score and increase in SCr level in the first 12 hours were not statistically associated with stage II+ AKI in multivariable ROC analysis. Consecutive oliguria for 3 hours had fair predictive ability for achieving stage II+ AKI criteria (area under ROC curve, 0.73; 95% confidence interval [95% CI], 0.68 to 0.78), and oliguria for 5 hours demonstrated optimal accuracy (82%; 95% CI, 79% to 86%)., Conclusions: Three to 5 hours of consecutive oliguria in patients with septic shock may provide a valuable measure of AKI risk. Further validation to support this finding is needed., (Copyright © 2014 by the American Society of Nephrology.)

Background: This study was designed to determine whether a decrease in renal oxygenation occurs during CO2 pneumoperitoneum in children with normal renal function undergoing laparoscopy., Methods: Near infrared spectroscopy (NIRS) probes were applied to both the lateral flank (T10-L2) and lateral cerebral area of all patients with normal renal function undergoing a laparoscopic procedure. Information was recorded in 5-s intervals for 15-min before, during, and for 15-min after pneumoperitoneum insufflation and desufflation. Simultaneously, additional hemodynamic parameters (arterial saturation, mean arterial pressure, end tidal CO2, and urine output) were recorded every 5-min. Pneumoperitoneum pressures used were: 0-1 month old, <6 mmHg; 2-12 months old, <8 mmHg; 1-2 years old, <10 mmHg, and 2-8 years old, <12 mmHg. The lowest possible pressure was used to obtain adequate vision., Results: Twenty-nine patients were enrolled in the study. Renal regional oxygen saturation (rSO2) did not decrease significantly between baseline (preinsufflation), insufflation, and desufflation of the pneumoperitoneum (p = 0.343). Meta-analysis of this data demonstrated a pooled weighted difference of -1.4 (-3.5 to 0.54), confirming no significant change. A significant increase in cerebral rSO2 occurred during the insufflation period of the CO2 pneumoperitoneum (p = 0.001). Heart rate (F = 11.05; p < 0.001) and mean arterial pressure (MAP) (F = 19.2; p < 0.001) also increased significantly during the laparoscopy. No significant correlation was identified between fluid input and urine output during the laparoscopy (r = 0.012; p = 0.953)., Conclusions: Renal hypoxia does not occur during laparoscopic surgery in children if the minimum age-appropriate intra-abdominal pressures are used. Alternative causes must account for the oliguria and anuria demonstrated in children undergoing laparoscopy.

Objective: To study the effects on the renal system in a porcine model of intraabdominal hypertension, and to determine the indirect technique of choice for determination of the intraabdominal pressure., Material and Methods: 30 pigs were used divided in two groups according with increased intraabdominal pressure values (20 mmHg and 30 mmHg). In both groups pressures were registered 8 times, summing up to 3 hours, with a CO₂ insufflator. Three different measures of the intraabdominal pressure were taken: a direct transperitoneal measure, using a catheter of Jackson-Pratt connected to a pressure transducer, and two indirect measures, a transvesical by means of a Foley to manometer system, and a transgastric by introducing in the stomach a catheter connected to a pressure monitor with electronic hardware. Mean arterial pressure was calculated, along with the cardiac index, production of urine and serum creatinine., Results: There was a greater correlation between the transvesical and the transperitoneal intraabdominal pressures (R(2)=0,95). Average transgastric intraabdominal pressure was inferior to the transperitoneal indicator in all taken measurements. The average arterial pressure descended in both groups, with earlier significant differences observed at 30 mmHg (p<0,020). Urine production was lower at 30 mmHg compared with the 20 mmHg group (9,63 ± 1,57 versus 3.26 ml ± 1,73). Serum creatinine increased in both groups being pathological at 30 mmHg after 1h 20 min, with existing differences between early pressures (p<0,027)., Conclusions: This study revealed marked renal affectation with higher severity at 30 mmHg pressures. The transvesical technique showed a greater correlation with the direct measurement technique used, defining this as the method of choice for determination of intraabdominal pressure., (Copyright © 2012 AEU. Published by Elsevier Espana. All rights reserved.)

Purpose: The observation periods and thresholds of serum creatinine and urine output defined in the Acute Kidney Injury Network (AKIN) criteria were not empirically derived. By continuously varying creatinine/urine output thresholds as well as the observation period, we sought to investigate the empirical relationships among creatinine, oliguria, in-hospital mortality, and receipt of renal replacement therapy (RRT)., Methods: Using a high-resolution database (Multiparameter Intelligent Monitoring in Intensive Care II), we extracted data from 17,227 critically ill patients with an in-hospital mortality rate of 10.9 %. The 14,526 patients had urine output measurements. Various combinations of creatinine/urine output thresholds and observation periods were investigated by building multivariate logistic regression models for in-hospital mortality and RRT predictions. For creatinine, both absolute and percentage increases were analyzed. To visualize the dependence of adjusted mortality and RRT rate on creatinine, the urine output, and the observation period, we generated contour plots., Results: Mortality risk was high when absolute creatinine increase was high regardless of the observation period, when percentage creatinine increase was high and the observation period was long, and when oliguria was sustained for a long period of time. Similar contour patterns emerged for RRT. The variability in predictive accuracy was small across different combinations of thresholds and observation periods., Conclusions: The contour plots presented in this article complement the AKIN definition. A multi-center study should confirm the universal validity of the results presented in this article.

The aim of the study was to find out if there is an optimal mean arterial blood pressure (MABP) during cardiopulmonary bypass (CPB) for renal function in elderly patients during the early postoperative period. We analysed the data of 122 patients >70 years of age with normal preoperative renal function who had been subjected to coronary artery bypass grafting (CABG) procedures on CPB. Patients were divided into 3 groups, according to MABP during CPB: group MP (n=50) included patients whose MABP was maintained between 60-70 mmHg; group LP (n=36), the MABP was <60 mmHg; and group HP (n=36) where the MABP was >70 mmHg. The patients' clinical data were evaluated during the first three postoperative days. The rate of renal impairment (urine output <50ml/h) in the early postoperative period after cardiac surgery did not differ among the groups. Oliguria developed in 3 patients (6%) of the MP group, in 2 patients (5.6%) in the LP group and in 6 patients (16.7%) in the HP group (χ(2)=3.6, df=2, p=0.161). Evaluation of MABP on renal excretion showed that there was no difference in urine output among the groups. Serum creatinine levels at the end of the first postoperative day in groups MP, LP and HP were 102.7±20.1, 116.4±58.6 and 113.2±39.8 µmol/L, respectively (F=0.5, df=2, p=0.640). There were no significant differences among the groups at the end of the second and the third day either. Volume balance at the end of surgery and during the early postoperative period was similar in all groups. The need for diuretics did not differ among the groups. The length of postoperative hospital stay was not significantly different among the groups. Our study did not reveal any relationship between a MABP of 48-80 and postoperative renal dysfunction in elderly patients after CABG surgery.

Although leptospirosis may be fatal in childhood, the experience of many clinicians working in disease-endemic areas is that classic Weil's disease and death are less common among pediatric patients. The aim of the study was to ascertain disease spectrum and outcome differences in severe pediatric and adult leptospirosis in a large at-risk population. Epidemiologic, clinical, and laboratory data were obtained on hospitalized cases from São Paulo during 2004-2006. A total of 42 case-patients < 18 years of age and 328 case-patients ≥ 18 years of age were tested during the study. Compared with children, adults had higher rates of jaundice (P = 0.01), elevated serum bilirubin levels (P < 0.01), oliguria (P = 0.02), and elevated creatinine levels (P = 0.01) but not for thrombocytopenia or pulmonary involvement. The overall case-fatality rate was 27% (adult) versus 5% (pediatric) (P < 0.01). Severe pediatric leptospirosis may be less likely to show all classic features of Weil's disease and may be less fatal than in adults.

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. Urine output was assessed every hour and serum creatinine every 12 to 24  h. The sensitivity and specificity of different definitions of oliguria for the diagnosis of AKI were compared with the Acute Kidney Injury Network serum creatinine criterion. The incidence of AKI increased from 24%, based solely on serum creatinine, to 52% by adding the urine output as a diagnostic criterion. Oliguric patients without a change in serum creatinine had an intensive care unit mortality rate (8.8%) significantly higher than patients without AKI (1.3%), and similar to oliguric patients with an increase in serum creatinine (10.4%). 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.

Background: Since kidneys from deceased donors with oliguria have not been widely used, compared their outcomes with those in recipients of kidneys without oliguria at the time of organ procurement., Methods: We reviewed the deceased donors and kidney recipients between January 1999 and December 2009, all of whom were defined as standard criteria donors (SCD)., Results: The group included 26 recipients whose terminal serum creatinine level (P < .001), estimated glomerular filtration rates (P < .001), and deceased donor scores (P < .001) were higher than those of the control group. Delayed graft function (P = .044) occurred more often among recipients with donor kidneys with oliguria than those without oliguria, and their hospitalization period was longer (P = .012). The serum creatinine levels in both groups were comparable posttransplantation; there was no significant difference in graft survivals., Conclusion: Deceased donors with oliguria at organ procurement appeared to be poor predictors of outcomes in the early posttransplantation period. Kidneys from deceased donors with oliguria should not be discarded for transplantation. The present study suggested that it is acceptable to use kidneys from selected deceased donors with oliguria., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: In a third of patients presenting with rhabdomyolysis-induced acute renal failure (ARF), a biphasic plasma calcium profile may occur., Methods: We report a case of rhabdomyolysis-induced ARF presenting hypocalcemia during oliguria, followed by a severe hypercalcemia in the polyuric phase. A hypocalcemia-induced acute increase of plasma parathyroid hormone in the early stage of ARF was followed by a down-regulation of parathyroid hormone, 1,25(OH)2 vitamin D and 25(OH) vitamin D during the renal function recovery, associated with an acute hypercalcemia. The plasma calcium increase induced in our patient severe neurological disturbances, life-threatening short QT interval and Brugada-like syndrome at risk of malignant arrhythmias. This complication was treated by hemodialysis and pamidronic acid infusion., Results: This case confirms that the pathogenesis of the biphasic calcium profile may be related to the massive calcium uptake in the ischemic muscle cells during oliguria, followed by a muscle calcium release later in the polyuric stage of ARF. Therefore, the behavior of calciotropic hormones may be the consequence rather than the cause of plasma calcium changes., Conclusions: We would like to emphasize the danger of sudden death that may occur in the recovery phase of rhabdomyolysis-induced ARF when the physician might be wrongly convinced that the major risks have disappeared.

Background: In view of the role of fibronectin in adhesion, signal transduction pathways and the infectious disease process, changes in serum fibronectin levels may influence disease evolution and severity in patients with hemorrhagic fever with renal syndrome (HFRS)., Methods: The levels of fibronectin were measured in serum samples from 112 patients with HFRS at various phases, and 30 healthy individuals were monitored as controls., Results: The serum levels of fibronectin in patients with HFRS at all clinical phases were higher than those in the controls, with the levels of patients at the fever, oliguric and polyuric phases of disease significantly different from controls (P < 0.01). The serum fibronectin concentration in the patients with more severe clinical disease types was higher than that in those with milder types. The serum fibronectin level in the more severe patient group was significantly higher than that in milder patient group at the oliguric phase (P < 0.05)., Conclusions: Serum fibronectin concentration in patients with HFRS was increased and associated with disease phases and severity, suggesting the value of detection of fibronectin levels for evaluating HFRS disease progression and severity.

The objective of this study was to determine the incidence, risk factors, and morbidities associated with nonoliguric hyperkalemia (NOHK) in neonates. Infants were eligible for the study if they were born at Al Qassimi Hospital and fulfilled the diagnostic criteria of NOHK (serum potassium [SK] > or = 7 mmol/L during the first 72 hours of life with urinary output > or = 1 mL/kg/h). The next admitted infant with gestational age +/- 1 week and normal SK acted as control. Exclusion criteria were severe congenital malformation, renal failure, failure of adequate urinary collection, and early blood transfusion within the first 72 hours of life. Fluid intake and urinary output were monitored. Infants who developed hyperkalemia (SK > or = 6.5 mmol/L in two nonhemolysed venous or arterial blood samples) had serum potassium measured every 4 hours until it reached below 6 mmol/L. Hyperkalemia was identified between 6 and 36 hours of age in 45 infants (peak SK 7 to 9.3 mmol/L). During the time of the study, the prevalence of NOHK was 24% among extremely-low-birth-weight infants (with birth weight < 1000 g) who comprised 83% of those identified. Of infants with NOHK, 13% developed tachycardiac arrhythmia and 17% died. NOHK was significantly associated with fetal distress, early metabolic acidosis, early hyperglycemia, and absence of antenatal steroid administration. Hyperkalemic infants had significantly lower serum calcium and higher serum phosphorous, urea, and creatinine. Early polyuric episodes and high urinary output were also more common in hyperkalemic infants. NOHK affects mainly preterm infants. Electrolyte disturbance and increased serum urea and creatinine were associated with hyperkalemia. Infants with NOHK also had high incidence of cardiac arrhythmias and mortality.

Background: Acute kidney injury (AKI) occurs in 10 to 60% of patients with leptospirosis. The aim of this study is to investigate markers for oliguric AKI in leptospirosis., Methods: A retrospective study was performed with 196 consecutive patients with leptospirosis-associated AKI. These patients were categorized into either oliguric or non-oliguric according to their urine output. Clinical and laboratory characteristics were compared between the two groups., Results: Among these patients, 64 (32.6%) were oliguric and 132 (67.4%) nonoliguric. Markers for oliguria were age higher than 40 years (OR = 1.02, p = 0.04), hyponatremia (OR = 0.94, p = 0.03), elevated serum creatinine (OR = 1.11, p = 0.04), low arterial pH (OR = 1.0002, p = 0.01), high levels of AST (OR = 1.005, p = 0.01), crackles (OR = 3.83, p < 0.001) and direct bilirubin (OR = 1.03, p = 0.03). Elevated activated prothrombin time (OR = 0.97, p = 0.03) was a factor associated with nonoliguric AKI. Independent markers for oliguria were crackles (OR = 5.17, p = 0.0016) and direct bilirubin levels (OR = 1.051, p = 0.04). Mortality was significantly higher in oliguric than nonoliguric (27 vs. 8%, p < 0.001). Renal function at discharge was similar in oliguric and nonoliguric patients., Conclusion: Age higher than 40 years, hyponatremia, elevated serum creatinine, low arterial pH, high levels of AST, crackles and direct bilirubin levels would be useful to early identify patients with oliguric AKI in leptospirosis., (Copyright 2009 S. Karger AG, Basel.)

Background: Patients suffering from hemorrhagic fever with renal syndrome (HFRS) often showed strikingly reduced high-density lipoprotein (HDL)-cholesterol levels during the oliguric phase, indicating severe alterations in lipoprotein metabolism., Objective: To compare changes in the functions and composition of HDL, lipoprotein metabolism parameters were analyzed in the sera of HFRS patients in the oliguric phase and after recovery., Methods: The serum cholesterol, triglyceride (TG), and lipoprotein/apolipoprotein profiles of HFRS patients in the oliguric and recovery phases were compared with those of normal reference sera. The activities of HDL-associated enzymes, lecithin:cholesterol acyltransferase (LCAT), and paraoxonase (PON) were also assessed., Results: In the oliguric phase, serum cholesterol was substantially decreased and serum TG was increased. As observed by electron microscopy, the sizes of the HDL particles from the HFRS patients were smaller than those seen in the reference sera, with more heterogeneous distribution. Serum amyloid A (SAA) and apolipoprotein (apo) C-III were overexpressed in the oliguric phase, particularly in the HDL fraction. However, in immunodetection, the levels of apoA-I in the HDL(2) and HDL(3) of the HFRS patients were lower than those of the reference HDL. Serum LCAT and PON activities were reduced significantly in the oliguric phase, which is associated with a reduction in HDL-cholesterol levels and HDL particle size., Conclusion: Overexpression of both apoC-III and apoSAA in HDL and attenuated serum LCAT and PON activity were observed during the oliguric phase in HFRS patients. These results demonstrate that structural, functional, and compositional changes of HDL occurred to a substantial degree in the oliguric phase.

Background: Tertiary hyperparathyroidism typically occurs in patients who have recovered from renal failure after renal transplantation. This report describes a syndrome of tertiary hyperparathyroidism after recovery from multiple organ failure (MOF) with acute oliguric renal failure (AORF)., Methods: Six patients with MOF including AORF are presented. Increased parathyroid hormone (PTH) levels were documented as early as 3 weeks after injury or septic insult and remained increased in some patients for several weeks., Results: The resultant increase in calcium levels led to recurrent bouts of bradycardia, often leading to asystole requiring cardiopulmonary resuscitation. Hypercalcemic-induced bradycardia was refractory to hydration, loop diuresis, atropine, and external pacing. Definitive treatment requires bisphosphonate therapy, which must be repeated until organ function has returned to normal., Conclusions: A new syndrome of life-threatening tertiary hyperparathyroidism is described in patients with critical illness. This syndrome probably is being overlooked frequently in critical care units. Early diagnosis and prophylactic treatment with bisphosphonate may preclude the life-threatening cardiac arrhythmias.

Background: Acute renal failure (ARF) is a common complication after liver transplantation (LTx). Identification of risk factors may prevent the development and attenuate the impact of ARF on patients outcome after LTX., Methods: Retrospective analysis of variables in the pre, intra, and postoperative periods of 92 patients submitted to LTx was performed in order to identify risk factors for development of ARF after LTx. ARF was defined as serum creatinine > or = 2.0 mg/dL in the first 30 days after LTx. Univariate and multivariate analysis by logistic regression were performed., Results: ARF group comprised 56 patients (61%). Preoperative serum creatinine was higher in ARF group. During the intraoperative period, ARF group required more blood transfusions, developed more episodes of hypotension and presented longer anesthesia time. In the postoperative period, ARF group presented higher serum bilirubin and more episodes of hypotension. Dialysis was required in 10 patients (11%). The identifled risk factors for development of ARF were: preoperative serum creatinine > 1.0 mg/dL. more than five blood transfusions in the intraoperative period, hypotension during intra and postoperative periods. The identified mortality risk factors were hypotension in the postoperative period and no recovery of renal function after 30 days., Conclusions: Several factors are involved in the pathogenesis of ARF after LTx and may influence patients outcome and mortality. Pretransplant renal function and hemodynamic conditions in the operative and postoperative periods were identified as risk factors for development of ARF after LTx. Nonrenal function recovery and postoperative hypotension were identified as mortality risk factors after LTx.

Patients undergoing surgery for idiopathic scoliosis were studied to determine the incidence and aetiology of oliguria during the perioperative period and to evaluate the efficacy of low dose dopamine in preventing its occurrence. Thirty patients, aged 6-18 years undergoing elective surgery were studied. Anaesthesia was standardized. Patients were randomized to receive either dopamine infusion (3 micrograms.kg-1.min-1) (Group A) (n = 15) or dextrose infusion (control) (Group B) (n = 15). Serum and urinary electrolytes and osmolalities and serum antidiuretic hormone (ADH) concentrations were measured. Urine output and haemodynamic parameters were recorded. Intraoperative oliguria occurred in 7% of patients in Group A and 47% in Group B (P < 0.05). Postoperative oliguria occurred in 20% of patients in Group A and 47% in Group B (P > 0.05). Urine and serum biochemical analysis revealed a statistically significant decrease in serum sodium and osmolality (P < 0.005) and an increase in urinary sodium and osmolality in both groups. Serum ADH concentrations were increased in both groups (P < 0.05), returning to baseline 18 h postoperatively. We conclude that oliguria during corrective spinal surgery occurs in association with excess ADH secretion as opposed to perioperative hypovolaemia. Dopamine increases urine output in the perioperative period but does not prevent the release of ADH and its subsequent biochemical effects.

The impact of continuous hemofiltration (CHF) using a polyacrylonitrile membrane on the kinetics of tumor necrosis factor alpha (TNF alpha), interleukin-1 beta (IL-1 beta), and their inhibitors (soluble TNF receptors [sTNFrI, sTNFrII], interleukin-1 receptor antagonist [IL-1Ra]) was assessed in nine oliguric patients suffering from systemic inflammatory response syndrome. Blood and plasma flow (Qb, Qp), sieving coefficient (SC), plasma and ultrafiltrate clearances (Kp, Kuf), and plasma extraction rates (ERp) were calculated at different time points using standard formulas. No significant improvement of hemodynamics or gas exchange was noted following HF but a significant increase in serum bicarbonate occurred after 24 h (P < 0.05). TNF alpha was detected in plasma from all patients (153 +/- 2.3 pg/mL [mean +/- SEM]). None of the patients had detectable IL-1 beta levels. High levels of the TNF receptors (sTNFrI 20.338 +/- 2.431 pg/mL; sTNFrII 17.839 +/- 2.630 pg/mL) and IL-1Ra (19.775 +/- 3.943 pg/mL) were found in all patients. Upon initiation of hemofiltration (HF), the mean individual sTNFrI/TNF alpha ratio amounted to 269 +/- 84.6 and the sTNFrII/TNF alpha ratio to 249 +/- 91.8. Mean ultrafiltrate volume (Vuf) was 11.8 +/- 0.4 L/day. Appreciable sieving of IL-1Ra (SC 0.45 +/- 0.10), but not of the other cytokines, was noted (SC TNF alpha, sTNFrI, sTNFrII < 0.09). Despite minimal Kuf of TNF alpha, sTNFrI, and STNFrII (Kuf < 0.8 mL/min), appreciable Kp was noted, suggesting that membrane adsorption occurs (Kp approximately 8 mL/min). There was a nonsignificant increase of the ratios between both TNF receptors and TNF alpha across the filter (sTNFrI/TNF alpha ratio [pre] 231 +/- 37.9 versus [post] 312 +/- 75.3); sTNFrII/TNF alpha ratio [pre] 211 +/- 42.1 versus [post] 291 +/- 79.3). Appreciable Kp of IL-1Ra was noted (Kp 17.3 +/- 1.61 mL/min), which was only in part due to Kuf (4.0 +/- 0.86 mL/min). There was a significant decrease of IL-1Ra levels across the membrane, both overall ([pre] 20.223 +/- 2.282 versus [post] 16.637 +/- 2.039 pg/mL; P < 0.01) and at different time points (P < 0.01). Only for IL-1Ra was significant extraction from plasma noted (ERp 26 +/- 6.0%). Plasma levels of TNF alpha, sTNFrI, sTNFrII, and IL-1Ra were not altered by 24 h of CHF. In conclusion, both cytokines and cytokine inhibitors can be removed from the circulation, either by convective transport or by membrane adsorption. Using low-volume HF (Vuf approximately 12 L/day), no impact on cytokine plasma levels nor the patients hemodynamics or gas exchange was noted. The appreciable SC of IL-1Ra (0.45), however, suggests that HF with high(er) UF volumes (> 50 L/day) may be able to achieve reductions in plasma levels of some peptide (anti)mediators. However, whether this aspecific elimination of both mediators and antimediators may alter the clinical course in critically ill patients remains to be investigated.

Hypophyseo-adrenal and hypophyseo-thyroid systems were studied in 102 patients aged 16-55 (88 males and 14 females) who suffered from hemorrhagic fever with renal syndrome. Measurements of serum levels of ACTH, hydrocortisone, TTH, T3 and T4 recorded supernormal concentrations of ACTH, hydrocortisone and TTH against subnormal concentrations of T3 and T4 in oliguric and polyuric periods of the disease. In convalescence TTH, T3 and T4 returned to normal levels, while ACTH and hydrocortisone were lower than in controls. It is inferred that in hemorrhagic fever with renal syndrome the activity of the system hypophysis-adrenals in convalescence is declined, whereas hypophysis-thyroid interaction is disturbed at the height of the disease.

The effect of intravenous (i.v.) essential amino acids (EAA) in the treatment of acute renal failure was evaluated in 50 patients. Thirty patients (Group A) received daily 13.4 g of i.v. EAA solution [Nephramine (Don Baxter, McGraw) 250 ml/d]+dopamine i.v. 2 micrograms/kg/min + 20% hypertonic glucose solution 500 ml/d as compared with twenty patients (Group B) who received dopamine i.v. 2 micrograms/kg/min + 20% hypertonic glucose solution 500 ml/d. In Group A patients showed lower daily increase in blood urea nitrogen (BUN) (p < 0.05), higher serum total protein and albumin levels on the 15th day of the posttherapy period (p < 0.001), lower complication rate (p < 0.005), lower mortality rate (p < 0.005) and a reverse relation between serum total protein concentration, duration of oliguria and age (p < 0.01, r2 = 0.26; p < 0.001, r2 = 0.32). These data suggest that treatment of such patients with i.v. EAA solutions significantly improves survival.

Objective: To determine whether the diuretic and natriuretic effects of low-dose dopamine (2.5 micrograms/kg/min) are associated with changes in serum aldosterone concentration., Design: Prospective clinical study., Setting: Surgical intensive care unit (SICU) of a university hospital., Participants: Oliguric (urine output < 0.5 mL/kg/h) SICU patients. All patients were resuscitated to pulmonary artery occlusion pressure > 10 mm Hg, mean arterial pressure > 65 mm Hg, and cardiac index > 2.5 L/min/m2. Patients with a serum creatinine concentration > 176.8 mumol/L (2.0 mg/dL), those who received diuretics within 12 hours prior to entry into the study, and renal transplant recipients were excluded., Main Outcome Measures: Hourly urine output (mean +/- SD) was recorded 2 hours before and for 6 hours after the initiation of low-dose dopamine. Urine sodium and serum aldosterone concentrations were obtained prior to and 6 hours after the start of low-dose dopamine., Results: Fifteen patients were enrolled in the study. Urine output (mean +/- SD) increased from 0.31 +/- 0.11 mL/kg/h before to 0.80 +/- 0.34 mL/kg/h following low-dose dopamine (p < 0.01). Urine sodium concentrations increased from 46 +/- 32 mmol/L baseline to 72 +/- 53 mmol/L following low-dose dopamine (p < 0.05), and serum aldosterone concentrations decreased from 415.82 +/- 341.48 pmol/L prior to low-dose dopamine infusion to 256.04 +/- 204.17 pmol/L (p < 0.05). Cardiac output, pulmonary artery occlusion pressure, mean arterial pressure, and heart rate did not change., Conclusions: Low-dose dopamine significantly increases urine output and urine sodium excretion in oliguric, critically ill, surgical patients, and is associated with a decrease in serum aldosterone concentration. The diuretic and natriuretic effects of low-dose dopamine may be, in part, related to a dopamine-mediated inhibition of aldosterone secretion.

Objective: To determine the mechanism by which oliguria develops during raised intra-abdominal pressure secondary to CO2 insufflation, we created a rat pneumoperitoneum model., Methods: Male Sprague-Dawley rats (n = 67) were organized into three groups. Each group was subjected to abdominal pressures of 0 (control), 5, or 10 mm Hg, over one, two, and four hours. Fourteen additional rats underwent a two-hour period of 10 mm Hg insufflation pressure followed by desufflation to 0 mm Hg. Urine output (UO) and serum creatinine levels were measured both during insufflation at one, two, and four hours, and two, four, ten, and twenty-two hours following its release. These measurements were compared to control values at each time point. Ultrasonic flow probes placed around both the inferior vena cava (IVC) and abdominal aorta during insufflation characterized the effects of increased abdominal pressure on blood flow. The flow rate was determined at insufflation pressures of 0 (control, 100% flow) to 25 mm Hg., Results: Rats subjected to 10 mm Hg pressure had significant decreases in UO (oliguria) compared to controls for up to four hours (P < 0.01). There were no significant differences in UO in the control or 5 mm Hg groups over each time interval. While a reduction in UO was observed at two, four, and ten hours postrelease, significance was achieved only at ten hours (P < 0.006). By twenty-two hours postrelease, no differences in UO were observed. Serum creatinine elevations declined two hours postdesufflation. IVC flow was reduced by 92.9 percent at 10 mm Hg, while arterial flow decreased by 46.4 percent. Flow was restored to preinsufflation levels after release of pneumoperitoneum., Conclusions: Oliguria can be produced in rats undergoing pneumoperitoneum. The renal effects of pneumoperitoneum are most likely related to renal vascular insufficiency from central venous compression.

In patients with haemorrhagic fever with renal syndrome (HFRS) and in those who had HFRS in the past ionized calcium (Ca2+) and parathyroid hormone (PTH) levels were measured in the blood. High levels of PTH in normal or low those of Ca2+ were typical for HFRS oliguria. Hyperparathyroidism observed was assessed as an adaptation reaction preventing oliguria-related Ca2+ fall. In cured patients neither Ca2+ nor PTH deviation were reported.

Altogether 38 patients (33 men and 5 women) suffering from grave and moderate hemorrhagic fever with nephrotic syndrome (HFNS) were examined. The hemolysate aggregation test and ADP were employed to explore the aggregation ability of platelets in those patients. Besides, measurements were made of the activity of the 3rd platelet factor in the plasma and serotonin content in each platelet. A considerable rise of the aggregation activity of platelets was established to take place in the oligoanuric and polyuric periods of HFNS. At the same time the increase in the blood of the 3rd platelet factor and lowering of serotonin in each platelet were noted. The role of platelet hyperaggregation in the pathogenesis of HFNS is discussed. The conclusion is made that such patients were in a prethrombotic state in the oligoanuric and to a lesser degree in the polyuric periods.

A total of 29 patients with severe hemorrhagic fever associated with the renal syndrome were studied for impact of extracorporeal hemodialysis on the activity of the renin-aldosterone system (RAS), plasma vasopressin and osmolality and the levels of the major osmotically active agents, as well as the circadian urine output and blood pressures. In patients with oliguria there was a significant activation of RAS, an increase in plasma vasopressin ad osmolality due to the increment of the urea in presence of hyponatremia. Hemodialysis led to a temporary normalization of plasma aldosterone and vasopressin levels and a decrease in blood pressure. No significant changes were documented in the activity of the plasma renin and circadian urinary output. A direct correlation was established between the plasma osmolality and the levels of vasopressin. In patients with polyuria developed in presence of hypernatremic hyperosmia plasma vasopressin elevated and aldosterone dropped.

As many as 56 patients with associated hemorrhagic fever and the renal syndrome were examined for vascular permeability, microcirculation and blood plasma histamine, serotonin, kallikrein and prekallikrein. In all the disease periods, the majority of the patients (n-52) demonstrated a rise of vascular permeability for protein and liquid part of the plasma, with this being marked in particular in the oligoanuric period. Besides, significant perivascular and intravascular changes in microcirculation were noted in the oligoanuric and polyuric disease periods. It was established during examination of biologically active substances that the greatest shifts were experienced by the kinin system. Sometimes the content of kallikrein surpassed the control values more than 7-fold. Less pronounced changes were seen in blood plasma serotonin and histamine. A direct correlation was established between vascular permeability, microcirculation and the content of all biologically active substances explored by the authors. The strongest correlation was found to exist between the above parameters and the kinin system of blood plasma.

A basal value of antidiuretic activity (ADA) of the plasma was determined in 79 HFRS patients and stimulated activity using the insulin tolerance test in 24 persons. A decrease in the plasma ADA was observed in the acute period of disease. The insulin tolerance test did not cause a statistically significant increment of the plasma ADA in the HFRS patients.

We cared for four neonates with transient hyperammonemia of the newborn (THAN), all of whom exhibited sclerema during their course. Sclerema is a hardening of the subcutaneous tissues, which gives the tissue a firm, rubber-like quality. This association has not been previously reported, and it may provide a clue to early diagnosis and intervention in THAN.

Rational intraoperative fluid therapy is based on an understanding of the pathophysiology of severe trauma and surgery. Fluids of suitable compositions are administered in sufficient quantities to form part of the daily maintenance requirement and also to replace blood and ECF lost during surgery.

Resistant oliguria with increasing serum creatine phosphokinase (CPK) level are the most important early signs of the development of acute renal failure in leptospirosis. This symptomocomplex must be considered as indication for urgent hemosorption. Diuresis and normalisation of creatine phosphokinase level are the criteria for accessing the efficiency of hemosorptions.