ETIENNE MARIA VASCONCELLOS DE MACEDO
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- Timing of Dialysis Initiation in Acute Kidney Injury and Acute-On-Chronic Renal Failure(2013) MACEDO, Etienne; MEHTA, Ravindra L.The decision to provide dialytic support and choosing the ideal moment to initiate therapy are common impasses for physicians treating patients with acute kidney injury (AKI). Although renal replacement therapy (RRT) has been extensively used in clinical practice for more than 30years, there is a paucity of evidence to guide clinicians on the optimal utilization of RRT in AKI. In the absence of traditional or urgent indications, there is no consensus on whether dialysis should be offered and when it should be started. The lack of agreed-upon parameters to guide the decision, the fear of the risk of the procedure, and the possible contribution to worse prognosis with RRT have resulted in a considerable variation in practice among physicians and centers. In this review, we summarize the evidence evaluating time of initiation of RRT and discuss possible approaches for future trials in addressing this issue.
- Targeting Recovery from Acute Kidney Injury: Incidence and Prevalence of Recovery(2014) MACEDO, Etienne; MEHTA, Ravindra L.Since the creation of Risk, Injury, Failure, Loss of Kidney Function, and End-Stage Renal Disease (RIFLE) criteria in the last 10 years, the use of a standardized definition of acute kidney injury (AKI) has made it possible for epidemiologic studies to document the increasing incidence of AKI, especially in the critical care setting [1]. In addition, several studies applying the criteria of RIFLE, Acute Kidney Injury Network, and, more recently, the Kidney Disease: Improving Global Outcome, were able to establish the association of severity of AKI with adverse clinical outcomes, including the development of chronic kidney disease (CKD) and end-stage renal disease (ESRD) [2-4]. Although, until recently, it was thought that survivors from an AKI episode frequently recover kidney function, cumulative observational data over the past decade have confirmed the association of AKI with the increased risk for permanent kidney damage, with subsequent development of CKD [5]. The epidemiological studies that we will present and discuss in this review confirm and clarify the association of AKI with the development of CKD and ESRD [6-8]. (C) 2014 S. Karger AG, Basel
- Comprehensive Assessment of Kidney Health in Acute Kidney Injury: Can It Be Achieved?(2019) MACEDO, Etienne; LIMA, CamilaAcute kidney injury (AKI) is a frequent event in hospitalized patients, with an incidence that continues to rise, reaching as high as 70-80% in intensive care settings. The need for dialysis and progression to end-stage kidney disease (ESKD) after an episode of AKI is relatively low, from 5 to 20%. However, it is now recognized that patients with AKI may have very different kidney outcomes, varying from complete recovery, incipient chronic kidney disease (CKD), to progression to ESKD. Recent studies have shown that even mild AKI episodes can be associated with a 90% increased risk of developing CKD during long-term follow-up. There is a significant need to focus our efforts on factors that could mitigate the progression of kidney dysfunction and ultimately improve outcomes from AKI. The first step toward this goal encompasses a better understanding of tubular and glomerular alterations during and following an AKI episode. Our current approach, based solely on glomerular filtration rate (GFR), is flawed, since the loss of kidney function does not correspond to the degree of decline in estimated GFR (eGFR), and eGFR does not reflect tubular function. Changes in tubular concentration, reabsorptive and secretory capacity are recognized in AKI; however, they have not been incorporated in clinical assessments of overall kidney function. Here we review a few candidates to assess glomerular filtration/permeability, tubular dysfunction, and injury and how we expect these markers to alter during the development and recovery phase of AKI.
- Recognition and management of acute kidney injury in the International Society of Nephrology 0by25 Global Snapshot: a multinational cross-sectional study(2016) MEHTA, Ravindra L.; BURDMANN, Emmanuel A.; CERDA, Jorge; FEEHALLY, John; FINKELSTEIN, Fredric; GARCIA-GARCIA, Guillermo; GODIN, Melanie; JHA, Vivekanand; LAMEIRE, Norbert H.; LEVIN, Nathan W.; LEWINGTON, Andrew; LOMBARDI, Raul; MACEDO, Etienne; ROCCO, Michael; ARONOFF-SPENCER, Eliah; TONELLI, Marcello; ZHANG, Jing; REMUZZI, GiuseppeBackground Epidemiological data for acute kidney injury are scarce, especially in low-income countries (LICs) and lower-middle-income countries (LMICs). We aimed to assess regional differences in acute kidney injury recognition, management, and outcomes. Methods In this multinational cross-sectional study, 322 physicians from 289 centres in 72 countries collected prospective data for paediatric and adult patients with confirmed acute kidney injury in hospital and non-hospital settings who met criteria for acute kidney injury. Signs and symptoms at presentation, comorbidities, risk factors for acute kidney injury, and process-of-care data were obtained at the start of acute kidney injury, and need for dialysis, renal recovery, and mortality recorded at 7 days, and at hospital discharge or death, whichever came earlier. We classified countries into high-income countries (HICs), upper-middle-income countries (UMICs), and combined LICs and LMICs (LLMICs) according to their 2014 gross national income per person. Findings Between Sept 29 and Dec 7, 2014, data were collected from 4018 patients. 2337 (58%) patients developed community-acquired acute kidney injury, with 889 (80%) of 1118 patients in LLMICs, 815 (51%) of 1594 in UMICs, and 663 (51%) of 1241 in HICs (for HICs vs UMICs p = 0.33; p < 0.0001 for all other comparisons). Hypotension (1615 [40%] patients) and dehydration (1536 [38%] patients) were the most common causes of acute kidney injury. Dehydration was the most frequent cause of acute kidney injury in LLMICs (526 [46%] of 1153 vs 518 [32%] of 1605 in UMICs vs 492 [39%] of 1260 in HICs) and hypotension in HICs (564 [45%] of 1260 vs 611 [38%%] of 1605 in UMICs vs 440 [38%] of 1153 LLMICs). Mortality at 7 days was 423 (11%) of 3855, and was higher in LLMICs (129 [12%] of 1076) than in HICs (125 [10%] of 1230) and UMICs (169 [11%] of 1549). Interpretation We identified common aetiological factors across all countries, which might be amenable to a standardised approach for early recognition and treatment of acute kidney injury. Study limitations include a small number of patients from outpatient settings and LICs, potentially under-representing the true burden of acute kidney injury in these areas. Additional strategies are needed to raise awareness of acute kidney injury in community healthcare settings, especially in LICs.
- Early detection of acute kidney injury in the perioperative period of liver transplant with neutrophil gelatinase-associated lipocalin(2019) LIMA, Camila; HADDAD, Luciana Bertocco de Paiva; MELO, Patricia Donado Vaz de; MALBOUISSON, Luiz Marcelo; CARMO, Lilian Pires Freitas do; D'ALBUQUERQUE, Luiz Augusto Carneiro; MACEDO, EtienneBackground Acute kidney injury (AKI) is a common complication in patients undergoing liver transplant (LT) and is associated with high morbidity and mortality. We aim to evaluate the pattern of urine and plasma neutrophil gelatinase-associated lipocalin (NGAL) elevation during the perioperative period of LT and to assess it as a prognostic marker for AKI progression, need for dialysis and mortality. Methods We assessed NGAL levels before induction of anesthesia, after portal reperfusion and at 6, 18, 24, and 48 h after surgery. Patients were monitored daily during the first week after LT. Results Of 100 enrolled patients undergoing liver transplant, 59 developed severe AKI based on the KDIGO serum creatinine (sCr) criterion; 34 were dialysed, and 21 died within 60 days after LT. Applying a cut-off value of 136 ng/ml, UNGAL values 6 h after surgery was a good predictor of AKI development within 7 days after surgery, having a positive predictive value (PPV) of 80% with an AUC of 0.76 (95% CI 0.67-0.86). PNGAL at 18 h after LT was also a good predictor of AKI in the first week, having a PPV of 81% and AUC of 0.74 (95% CI 0.60-0.88). Based on PNGAL and UNGAL cut-off criteria levels, time to AKI diagnosis was 28 and 23 h earlier than by sCr, respectively. The best times to assess the need for dialysis were 18 h after LT by PNGAL and 06 h after LT by UNGAL. Conclusion In conclusion, the plasma and urine NGAL elevation pattern in the perioperative period of the liver transplant can predict AKI diagnosis earlier. UNGAL was an early independent predictor of AKI development and need for dialysis. Further studies are needed to assess whether the clinical use of biomarkers can improve patient outcomes.
- Preventing organ dysfunction - is preconditioning still an option?(2016) MACEDO, Etienne; MEHTA, Ravindra L.Over the past decade remote ischaemic preconditioning (RIPC) has evolved as a promising strategy to reduce ischaemia in remote organs. Although previous studies using surrogate outcomes have encouraged further investigation, two recent randomized controlled trials the ERICCA trial and the RIPHeart Study were unable to detect a protective effect of RIPC.
- A clinical score to predict mortality in septic acute kidney injury patients requiring continuous renal replacement therapy: the HELENICC score(2017) PASSOS, Rogerio da Hora; RAMOS, Joao Gabriel Rosa; MENDONCA, Evandro Jose Bulhoes; MIRANDA, Eva Alves; DUTRA, Fabio Ricardo Dantas; COELHO, Maria Fernanda R.; PEDROZA, Andrea C.; CORREIA, Luis Claudio L.; BATISTA, Paulo Benigno Pena; MACEDO, Etienne; DUTRA, Margarida M. D.Background: This study aimed to identify predictors of early (7-day) mortality in patients with septic acute kidney injury (AKI) who required continuous renal replacement therapy (CRRT). Methods: Prospective cohort of 186 septic AKI patients undergoing CRRT at a tertiary hospital, from October 2005 to November 2010. Results: After multivariate adjustment, five variables were associated to early mortality: norepinephrine utilization, liver failure, medical condition, lactate level, and pre-dialysis creatinine level. These variables were combined in a score, which demonstrated good discrimination, with a C-statistic of 0.82 (95% CI = 0.76-0.88), and good calibration (chi(2) = 4.3; p = 0.83). SAPS 3, APACHE II and SOFA scores demonstrated poor performance in this population. Conclusions: The HEpatic failure, LactatE, NorepInephrine, medical Condition, and Creatinine (HELENICC) score outperformed tested generic models. Future studies should further validate this score in different cohorts.
- Blood urea nitrogen beyond estimation of renal function(2011) MACEDO, Etienne
- Clinical Determinants of Renal Recovery(2014) GODIN, Melanie; MACEDO, Etienne; MEHTA, Ravindra L.Acute kidney injury (AKI) is associated with increased mortality, prolonged hospitalization, and renal replacement therapy. Until recently, it was believed that the vast majority of patients recover from AKI without subsequent consequences. It is now recognized that patients with AKI may have very different renal outcomes, including complete recovery, incipient and progressive chronic kidney disease, and end-stage renal disease. Factors that influence these different outcomes have not been thoroughly evaluated and so are not currently understood. The patient's baseline demographic characteristics, subsequent clinical evolution, and factors associated with the treatment of these patients may all influence global and renal outcomes. Recovery from AKI is a potentially modifiable event and should be targeted for therapy. Useful tools are needed to monitor renal recovery and identify the patients at high risk for adverse outcomes. (C) 2014 S. Karger AG, Basel
- Pharmacokinetic and Pharmacodynamic Characteristics of Vancomycin and Meropenem in Critically Ill Patients Receiving Sustained Low-efficiency Dialysis(2020) OLIVEIRA, Maura Salaroli; MACHADO, Anna Silva; MENDES, Elisa Teixeira; CHAVES, Lucas; PERDIGAO NETO, Lauro Vieira; JR, Carlindo Vieira da Silva; SANTOS, Silvia Regina Cavani Jorge; SANCHES, Cristina; MACEDO, Etienne; LEVIN, Anna S.Purpose: Antibiotic dosing is challenge in critically ill patients undergoing renal replacement therapy. Our aim was to evaluate the pharmacokinetic and pharmacodynamic (PK/PD) characteristics of meropenem and vancomycin in patients undergoing SLED. Methods: Consecutive ICU patients undergoing SLED and receiving meropenem and/or vancomycin were prospectively evaluated. Serial blood samples were collected before, during, and at the end of SLED sessions. Antimicrobial concentrations were determined using a validated HPLC method. Noncompartmental PK analysis was performed. AUC was determined for vancomycin. For meropenem, time above MIC was calculated. Findings: A total of 24 patients receiving vancomycin and 21 receiving meropenem were included; 170 plasma samples were obtained. Median serum vancomycin and meropenem concentrations before SLED were 24.5 and 28.0 mu g/mL, respectively; after SLED, 14 and 6 mu g/mL. Mean removal was 42% with vancomycin and 78% with meropenem. With vancomycin, 19 (83%), 16 (70%), and 15 (65%) patients would have achieved the target (AUC(0-24) >400) considering MICs of 1, 2, and 4 mg/L, respectively. With meropenem, 17 (85%), 14 (70%), and 10 (50%) patients would have achieved the target (100% of time above MIC) if infected with isolates with MICs of 1, 4, and 8 mg/L, respectively. (C) 2020 Elsevier Inc.