Hemodynamic Study Of Acute Kidney Injury Associated With Critical Illness

Part One The systemic and renal perfusion assessment during fluid resuscitation in sepsisObjective:The purpose of this study was to explore the significance of renal doppler ultrasound in estimating systemic and renal perfusion changes in patients with sepsis during fluid resuscitation.Methods:40 patients who were diagnosed sepsis in ICU of the Fourth Hospital of Hebei Medical University were selected and 35 patients out of them were enrolled in the study.According to the result of volume responsiveness,the patients were divided into volume responsiveness(+)group,volume responsiveness(-)group.According to the creatinine and urine output changes,the patients were divided into AKI(+)group and AKI(-)group.At last,we compared the characteristics of hemodynamic changes of all patients in different subgroups and analyzed the relationship between hemodynamic changes and the change of RRI and RBF classification.Results:During the fluid resuscitation,HR and Cre and Lac decreased while SV and CVP increased in all patients and volume responsiveness(+)group.HR decreased in volume responsiveness(-)group,HR and Cre and Lac decreased in AKI(+)group,HR decreased while CVP and SV increased in AKI(-)group.There were statistical differences between the volume responsiveness(+)group and(-)group in HR,Lac and Lac%after fluid resuscitation.In all groups,there were no statistical differences in RRI during the fluid resuscitation.During the fluid resuscitation,RRI in AKI(+)group were significantly higher than RRI in AKI(-)group,and AKI(+)group had a lower RBF classification than AKI(-)group.In addition,AKI(+)group had a higher RRI%than the AKI(-)group.There was a significant rise in the RBF classification during fluid resuscitation except volume responsiveness(-)group.In all patients and volume responsiveness(+)group and volume responsiveness(-)group and AKI(-)group,there were no relationship between RRI%and SV%,RRI%and Lac%.Summary:1.Fluid resuscitation leads to significant optimization of systemic hemodynamics and improvement of tissue perfusion.2.Renal blood flow(RBF)grading can be used to evaluate systemic and renal perfusion before and after fluid resuscitation in patients with sepsis.3.Higher CVP after fluid resuscitation improves patient hemodynamics may mean a worse prognosis.Part Two Impact of central venous pressure on the mortality of patients with sepsis-related acute kidney injury:a propensity score-matched analysis based on the MIMIC Ⅳ databaseObjective:Sepsis has long been an life-threatening organ dysfunction.Sepsis associated acute kidney injury(SA-AKI)is an important complication of sepsis,as an important hemodynamic index,the impact of central venous pressure on sepsis patients needs to be explored.Thus this study aimed to investigate the relationship between central venous pressure(CVP)and the mortality of SA-AKI.Methods:Clinical data of adult patients with sepsis-related acute kidney injury,defined as met both the Sepsis 3.0 criteria and the Kidney Disease Improving Global Outcomes Clinical Practice Guideline(KDIGO)criteria,were obtained from the Medical Information Mart for Intensive Care-Ⅳ(MIMIC-Ⅳ)database.The included cohort was divided into CVP≥13mmHg and CVP<13mmHg group were determined based on the cuf-off value from receiver operating characteristic curve,with propensity score-matched analysis of the 28-day mortality for both groups and sensitivity analysis using inverse the probability-weighting model,multifactorial regression,and doubly robust estimation,patients acquired chronic coronary syndrome(CCS)and diabetes were also taken into consideration.Results:Of 1,377 patients with sepsis-related acute kidney injury,CVP>13mmHg group was 32.6%(n=449)and CVP<13mmHg group was 67.4%(n=928).The two groups were matched 1:1 by propensity score to obtain a matched cohort(n=288).The mortality rates in the high versus low CVP group(34.7%vs.19.4%)were statistically difference(OR:2.204,95%CI:1.297,3.804,p<0.05).Moreover,the bistable analysis of logistic regression of the matched cohort(OR:2.306,95%CI:1.321,4.401,p<0.05),propensity score inverse probability weighting(OR:1.828,95%CI:1.519,2.201,p<0.05),and multifactorial logistic regression(OR:2.845;95%CI:1.073,7.882,p<0.05)all yielded the same results.Summary:A study based on the MIMIC IV database showed that CVP≥13 mmHg was an independent risk factor for patient prognosis in patients with sepsis-related acute kidney injury.Part Three Prognostic impact of transthoracic ultrasound use in patients with sepsis-related acute kidney injury-a propensity scorematched analysis based on the MIMIC IV database.Objective:Hemodynamic monitoring is very important for patients with sepsis.Existing invasive monitoring methods are associated with higher risks,while transthoracic echocardiography,with its unique non-invasive and intuitive features,can be used in the blood of patients with sepsis.Fluid dynamics monitoring occupies a very important position.The purpose of this study was to investigate the effect of transthoracic echocardiography on the prognosis of patients with sepsis-related acute kidney injury.Methods:This study is based on the MIMIC-IV database.Patients were included in the database in accordance with Sepsis 3.0 diagnosis of sepsis and were divided into transthoracic echocardiography TTE group and non-TTE group according to whether transthoracic echocardiography assessment was performed within 24 hours after the diagnosis of sepsis.Two groups were randomized using propensity score matching.Subsequent subgroup analysis was used to determine whether there were differences in the effect of TTE on patients with different renal injury grades.Results:A total of 6123 patients were enrolled in the study,and after propensity score matching,121 patients were finally enrolled in each of the two groups,the TTE and non-TTE groups.The results showed a lower 28-day mortality rate in the TTE group compared with the non-TTE group(13.2%vs.26.4%,p<0.05),and transthoracic ultrasound evaluation was a protective factor for prognosis in patients with sepsis-related acute kidney injury(OR 0.42,95%CI 0.21-0.81,p<0.05).The study also performed a subgroup analysis for different acute kidney injury grades and showed no clear correlation between transthoracic ultrasound assessment and mortality for patients with KIDGO grades 1 and 2,but for patients with KDIGDO grade 3,patients who underwent transthoracic ultrasound assessment had a lower 28-day mortality rate(OR 0.81,95%CI 0.68-0.96,p<0.05).Summary:A study based on the MIMIC IV database showed that patients with sepsis-related acute kidney injury who underwent transthoracic ultrasound had a lower 28-day mortality rate,which was more pronounced in patients with KIDGO stage 3.Conclusions:1.Single-center clinical studies have shown that fluid resuscitation leads to optimized systemic hemodynamics and improved tissue perfusion,and that higher CVP may mean a worse prognosis after fluid resuscitation improves patient hemodynamics.2.A study based on the MIMIC IV database showed that CVP ≥ 13 mmHg was an independent risk factor for patient prognosis in patients with sepsis-related acute kidney injury.3.A study based on the MIMIC IV database showed that patients with sepsis-related acute kidney injury who underwent transthoracic ultrasound had a lower 28-day mortality rate,which was more pronounced in patients with KIDGO stage 3.