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      Usefulness of Urine Output Criteria for Early Detection of Acute Kidney Injury after Transcatheter Aortic Valve Implantation

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          Abstract

          Background: Previous studies demonstrated that acute kidney injury (AKI) following transcatheter aortic valve implantation (TAVI) is frequent and associated with adverse outcomes. However, these studies only applied the serum creatinine (sCr) criteria while ignoring the urine output criteria. We hypothesized that adding the urine output criteria might contribute to an earlier diagnosis of AKI. Methods: We included 143 patients with severe aortic stenosis who underwent transfemoral TAVI between December 2012 and April 2014. Urine output was assessed hourly for at least 24 h following TAVI, and sCr was assessed at least daily until discharge. Based on the Valve Academic Research Consortium-2 (VARC-2), AKI was determined using both sCr and urine output criteria. We compared the incidence of AKI and time to AKI diagnosis based on these two methods. Results: The mean age was 81 w 6 years (range 61-94) and 56% were male. AKI occurred in 27 (19%) patients, 13 (9%) of whom had AKI defined by sCr criteria. Twenty (14%) patients had AKI defined by urine output criteria, only 6 of whom had AKI also defined by sCr criteria. The use of urine output criteria resulted in earlier identification of AKI (18 w 4 vs. 64 w 57 h, p = 0.02) and was associated with lower sCr elevation in patients having AKI defined by only urine output criteria (0.03 w 0.12 vs. 0.37 w 0.06 mg/dl, p < 0.001). Conclusion: The use of the VARC-2 urine output criteria significantly increased the incidence of AKI and shortened the time to AKI diagnosis. i 2014 S. Karger AG, Basel

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          Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document.

          The aim of the current Valve Academic Research Consortium (VARC)-2 initiative was to revisit the selection and definitions of transcatheter aortic valve implantation (TAVI) clinical endpoints to make them more suitable to the present and future needs of clinical trials. In addition, this document is intended to expand the understanding of patient risk stratification and case selection. A recent study confirmed that VARC definitions have already been incorporated into clinical and research practice and represent a new standard for consistency in reporting clinical outcomes of patients with symptomatic severe aortic stenosis (AS) undergoing TAVI. However, as the clinical experience with this technology has matured and expanded, certain definitions have become unsuitable or ambiguous. Two in-person meetings (held in September 2011 in Washington, DC, USA, and in February 2012 in Rotterdam, the Netherlands) involving VARC study group members, independent experts (including surgeons, interventional and non-interventional cardiologists, imaging specialists, neurologists, geriatric specialists, and clinical trialists), the US Food and Drug Administration (FDA), and industry representatives, provided much of the substantive discussion from which this VARC-2 consensus manuscript was derived. This document provides an overview of risk assessment and patient stratification that need to be considered for accurate patient inclusion in studies. Working groups were assigned to define the following clinical endpoints: mortality, stroke, myocardial infarction, bleeding complications, acute kidney injury, vascular complications, conduction disturbances and arrhythmias, and a miscellaneous category including relevant complications not previously categorized. Furthermore, comprehensive echocardiography recommendations are provided for the evaluation of prosthetic valve (dys)function. Definitions for the quality of life assessments are also reported. These endpoints formed the basis for several recommended composite endpoints. This VARC-2 document has provided further standardization of endpoint definitions for studies evaluating the use of TAVI, which will lead to improved comparability and interpretability of the study results, supplying an increasingly growing body of evidence with respect to TAVI and/or surgical aortic valve replacement. This initiative and document can furthermore be used as a model during current endeavors of applying definitions to other transcatheter valve therapies (for example, mitral valve repair). Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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            The RIFLE criteria and mortality in acute kidney injury: A systematic review.

            In 2004, the Acute Dialysis Quality Initiative workgroup proposed a multilevel classification system for acute kidney injury (AKI) identified by the acronym RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease). Several studies have been published aiming to validate and apply it in clinical practice, verifying whether outcome progressively worsened with the severity of AKI. A literature search from August 2004 to June 2007 was conducted: 24 studies in which the RIFLE classification was used to define AKI were identified. In 13 studies, patient-level data on mortality were available for Risk, Injury, and Failure patients, as well as those without AKI (non-AKI). Death was reported at ICU discharge, hospital discharge, 28, 30, 60, and 90 days. The pooled estimate of relative risk (RR) for mortality for patients with R, I, or F levels compared with non-AKI patients were analyzed. Over 71 000 patients were included in the analysis of published reports. With respect to non-AKI, there appeared to be a stepwise increase in RR for death going from Risk (RR=2.40) to Injury (RR=4.15) to Failure (6.37, P<0.0001 for all). There was significant intertrial heterogeneity as expected with the varying patient populations studied. The RIFLE classification is a simple, readily available clinical tool to classify AKI in different populations. It seems to be a good outcome predictor, with a progressive increase in mortality with worsening RIFLE class. It also suggests that even mild degrees of kidney dysfunction may have a negative impact on outcome. Further refinement of RIFLE nomenclature and classification is ongoing.
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              Contrast-induced kidney injury: mechanisms, risk factors, and prevention.

              In general, iodinated contrast media (CM) are tolerated well, and CM use is steadily increasing. Acute kidney injury is the leading life-threatening side effect of CM. Here, we highlight endpoints used to assess CM-induced acute kidney injury (CIAKI), CM types, risk factors, and CIAKI prevention. Moreover, we put forward a unifying theory as to how CIAKI comes about; the kidney medulla's unique hyperosmolar environment concentrates CM in the tubules and vasculature. Highly concentrated CM in the tubules and vessels increases fluid viscosity. Thus, flow through medullary tubules and vessels decreases. Reducing the flow rate will increase the contact time of cytotoxic CM with the tubular epithelial cells and vascular endothelium, and thereby damage cells and generate oxygen radicals. As a result, medullary vasoconstriction takes place, causing hypoxia. Moreover, the glomerular filtration rate declines due to congestion of highly viscous tubular fluid. Effective prevention aims at reducing the medullary concentration of CM, thereby diminishing fluid viscosity. This is achieved by generous hydration using isotonic electrolyte solutions. Even forced diuresis may prove efficient if accompanied by adequate volume supplementation. Limiting the CM dose is the most effective measure to diminish fluid viscosity and to reduce cytotoxic effects.
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                Author and article information

                Journal
                CRM
                Cardiorenal Med
                10.1159/issn.1664-5502
                Cardiorenal Medicine
                S. Karger AG
                1664-3828
                1664-5502
                2014
                December 2014
                14 August 2014
                : 4
                : 3-4
                : 155-160
                Affiliations
                Departments of aCardiology and bNephrology, Tel-Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
                Author notes
                *Dr. Yacov Shacham, Department of Cardiology, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel-Aviv 64239 (Israel), E-Mail kobyshacham@gmail.com
                Author information
                https://orcid.org/0000-0003-4258-6313
                Article
                365936 PMC4299170 Cardiorenal Med 2014;4:155-160
                10.1159/000365936
                PMC4299170
                25737679
                4d508aee-61ca-4c5a-9667-65067e82d46b
                © 2014 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                : 15 May 2014
                : 07 July 2014
                Page count
                Tables: 3, Pages: 6
                Categories
                Original Paper

                Cardiovascular Medicine,Nephrology
                Contrast media,Transcatheter aortic valve implantation,Acute kidney injury

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