Objective To evaluate the value of Kidney Disease:Improving Global Outcomes (KDIGO) criteria in investigating clinical feature and prognosis of acute kidney injury (AKI) patients with sepsis in ICU.Methods Clinical data of patients with AKI defined by KDIGO criteria in ICU of Wuxi People's Hospital from June 2007 to June 2012 were collected.Clinical characteristics,prognosis and major risk factors of death of septic AKI patients were retrospectively analyzed.Results Of the enrolled 703 AKI patients,395 (56.2％) were caused by sepsis (septic AKI),which indicated that sepsis mainly contributed to the causes of AKI.For septic AKI stratified by KDIGO classification,146(37.0％) patients belonged to AKI Ⅰ,154(39.0％) to AKI Ⅱ,and 95 (24.1％) to AKI Ⅲ.Compared with the patients with non-septic AKI,septic AKI patients had greater APACHE Ⅱ and SOFA score (25.1 ±4.9 vs 20.5 ±6.4,12.9 ±2.6vs 10.4 ± 4.5 ; all P values ＜ 0.05).Although there was no significant difference in baseline serum creatinine [(82.9 ± 22.2) μmol/L vs (83.1 ± 30.O) μmol/L,P ＞ 0.05] between the two groups,patients with sepsis had higher serum creatinine [(143.5 ± 21.6) μmol/L vs (96.2 ± 15.5) μmol/L; P ＜ 0.05],a higher proportion fulfilled KDIGO categories for both AKI Ⅱ and Ⅲ (63.0％ vs 33.1％ ; P ＜ 0.05),a higher renal replacement therapy (RRT) rate (22.3％ vs 6.2％ ; P ＜ 0.05) and a lower proportion of complete renal recovery(74.4％ vs 82.8％) (all P values ＜ 0.05).The 90-day mortality of septic AKI patients was higher than that of non-septic AKI patients (52.2％ vs 34.1％ ; P ＜ 0.05).Septic AKI,graded by KDIGO,was associated with an increased mortality.Logistic regression analysis showed that APACHE Ⅱ score (OR =5.451,95％ CI:3.095-9.416),SOFA score (OR =2.166,95％ CI:1.964-4.515) and RRT (OR =4.021,95％ CI:2.975-6.324) were independent risk factors for mortality of septic AKI patients.Conclusion Septic AKI patients have a higher burden of illness,worse renal function and higher mortality.APACHE Ⅱ score,SOFA score and RRT are independent risk factors to septic AKI mortality.

Objective To determine whether triggering receptor expressed on myeloid cells-1 (sTREM-1) and urinary neutrophil gelatinase-associated lipocalin (NGAL) were early biomarkers of acute kidney injury (AKI) secondary to sepsis.Methods A total of 141 eligible patients were enrolled in this prospective study.Blood and urine samples were collected at different time points as soon as sepsis was diagnosed.The concentrations of serum creatinine (Scr),urine sTREM-1 and NGAL were measured.According to AKI criteria,patients were divided into the AKI group and non-AKI group.Dynamic changes of levels of Scr,urine sTREM-1 and NGAL were observed in two groups.The receiver operating characteristic curves were used to evaluate the early diagnostic value of urine sTREM-1 and NGAL.Results Among 141 septic patients,44 (31.2％) cases had concomitant AKI.Twenty four hours after sepsis diagnosed,the level of Scr rose to 1.91 times of the baseline [(140.5±13.6) vs (82.6± 15.3) μmol/L,P ＜ 0.05],which met the diagnostic criteria of AKI.In the AKI group,urinary concentrations of sTREM-1 and NGAL at 8 h after the diagnosis of sepsis began to rise significantly from baseline [(100.5±17.4) vs (38.9± 14.7) ng/L; (144.6±51.9) vs (56.2±43.8) μg/L,both P ＜ 0.05].And at the following time points,urinary concentrations of sTREM-1 and NGAL were significantly higher than the baseline levels and that of the non-AKI group (all P ＜ 0.05).At 8 h time point,thearea under the curve of urine sTREM-1 was 0.877 (95％CI 0.756-0.914),the sensitivity was 89.1％ and specificity was 82.0％ with a cutoff value of 70 ng/L.At 8 h time point,the area under the curve of urine NGAL was 0.862 (95％ CI 0.703-0.958),the sensitivity was 87.4％ and specificity was 85.5％ with a cutoff value of 90 μg/L.Conclusions Urinary concentrations of sTREM-1 and NGAL at 8 h time point after the diagnosis of sepsis have predictive value for AKI and their diagnostic time is much earlier than that of Scr.Therefore,urinary sTREM-1 and NGAL can be used as early biomarkers of septic AKI.

Objective To determine whether urinary neutrophil gelatinase-associated lipecalin (uNGAL) and urinary intedeukin-18 (uIL-18) are early markers of acute kidney injury (AKI) in critically ill patients. Methods Ninety-two critically ill patients were studied for one week after their enrollment into our hospital. During the study, 46 patients who met the RIFLE criteria were selected as AKI group and the remaining 46 patients without AKI taken as a control group. The two groups were matched for age, gender and illness severity. Urine samples were collected daily for one week. The receiver operating characteristic curve was used to evaluate the early diagnostic value of uNGAL, uIL-18 and serum creatininc (SCr). Results As compared with the levels obtained 3 days before the diagnosis of AKI, the uNGAL levels in the AKI group increased significantly (P <0. 05), while uIL-18 and SCr levels did not change 2 days prior to the diagnosis of A KI (all P > 0. 05). uNGAL and uIL-18 levels increased significantly (all P < 0. 05), while SCr levels did not change 1 day prior to the diagnosis of AKI in the AKI group (P > 0. 05). The levels of uNGAL, uIL-18 and SCr did not change significantly in the control group during the study period (all P > 0. 05). Three days before the diagnosis of AKI, concentrations of uNGAL, uIL-18 and SCr were not the predictive of AKI. Two days before the diagnosis of AKI, the area under the curve (AUC) of uNGAL was 0. 840 (95% CI 0. 672-1. 009, P < 0. 05), which indicated that uNGAL was the predictive of AKI while uIL-18 and SCr were not. One day before the diagnosis of AKI, the AUC of uNGAL and ulL-18 were 0. 830 (95 % CI 0. 711-0. 950, P < 0. 05) and 0. 818 (95 % CI 0. 697-0. 938, P < 0. 05), indicating that uNGAL and uIL-18 were the predictive of AKI while SCr was not. Conclusion uNGAL and uIL-18 may be the early predictive markers of AKI in critically ill patients.

Objective To evaluate prognostic significance of early lactate clearance rate for cardiogenic shock patients on extracorporeal membrane oxygenation(ECMO).Methods Forty-seven patients with cardiogenic shock supported by venoarterial ECMO were prospectively enrolled from May 2010 to May 2013.Arterial blood lactate at pre-ECMO support(0 h),at post-ECMO 6 hours(6 h) were measured and then 6 h lactate clearance rate was calculated.90 days after admission was the endpoint of research.Patients were divided into the survival group(n =25) and the death group(n =22).6 h lactate clearance rate was compared between groups.The 6 h lactate clearance rate for predicting death was evaluated by receiver operating characteristic(ROC) curves.The surviving curve was drawn using the Kaplan-Meier method,and the survival of the patients was analyzed by the Log-rank test.Factors influencing the prognosis were analyzed by applying the multiplelogistic regression analysis.Results The 6 h lactate clearance rate was higher in survivors than in nonsurvivors [(38.6 ± 15.1) ％ vs.(14.4 ± 13.8) ％,P ＜ 0.05].The area under the ROC curve of 6 h lactate clearance rate for predicting death was 0.869 ± 0.075 (95％ CI:0.753-0.991).The best cutoff point was 20.0％ with a sensitivity of 92.0％ and specificity of 85.0％.KaplanMeier survival analysis showed that 90 days survival rate of high lactate clearance rate group and low lactate clearance rate group were 66.7％ and 35.0％,with significant difference between the two groups(Log-rank test,P ＜ 0.05).Multivariate logistic regression analysis showed that 6 h lactate clearance rate (OR =3.156,95 ％ CI:2.326-7.253,P ＜ 0.05) was one of the independent risk factors associated with mortality of patients on ECMO.Conclusion Early lactate clearance rate could be used as an important maker for evaluating the prognosis of cardiogenic shock patients on ECMO.

Objective To test whether the changes of partial end-tidal carbon dioxide pressure (PETCO2) during passive leg raising (PLR) predict fluid responsiveness in mechanically ventilated patients with septic shock.Methods Forty-two mechanically ventilated patients with septic shock admitted from January 2012 to November 2012 were prospectively recruited.Hemodynamic parameters monitored by a pulse indicator continuous cardiac output(PiCCO) device and PETCO2 monitored by an expiratory-CO2 device were studied at baseline,after PLR,and after volume expansion.Fluid responsiveness was defined as an increase in cardiac index (CI) of 15％ or greater after volume expansion.The correlation between PLR-induced CI change (△CIPLR) and PETCO2 (△PETCO2-PLR) was analyzed.The value of △PETCO2-PLR to predict fluid responsiveness was evaluated by receiver operating characteristic (ROC) curves.Results A total of 42 patients were enrolled in this study,of whom,24 had a CI increase of ≥ 15％ after volume expansion (responders).After PLR,CI and PETCO2 were both significantly increased in the response group compared with baseline [(21.4 ± 12.9) ％ of CI and (9.6 ± 4.7) ％ of PETCO2,P ＜ 0.05],while no significant changes were observed (P ＞ 0.05) in the non-response group.Both △CIPLR and △PETCO2-PLR were significantly higher in responder group than in the non-responder group (both P ＜ 0.05).△CI and △PETCO2 after PLR were strongly correlated (r =0.64,P ＜ 0.05).In responders after PLR,the area under ROC curve of △PETCO2-PLR was 0.900 ± 0.056 (95％ CI 0.775-1.000,P ＜ 0.05).An increase of ≥ 5％ in △PETCO2-PLR predicted fluid responsiveness with a sensitivity of 88.0％ and specificity of 88.2％.Conclusions The change of PETCO2 induced by passive leg raising is a non-invasive and easy way to predict fluid responsiveness in mechanically ventilated patients with septic shock.

Objective To analyze the value of the potential risk factors on predicting primary graft dysfunction (PGD) after bilateral lung transplantation for the patients with idiopathic pulmonary fibrosis (IPF).Methods A retrospective study was conducted. Fifty-eight patients with IPF who underwent the bilateral lung transplantation admitted to Wuxi People's Hospital Affiliated to Nanjing Medical University from June 2014 to March 2017 were enrolled. The grade 3 PGD happened within 72 hours after transplantation was taken as the outcome event, and these patients were divided into PGD and non-PGD groups. The age, gender, body mass index (BMI), underlying disease, and N-terminal-probrain natriuretic peptide (NT-proBNP) before operation, pulmonary artery systolic pressure (PASP), pulmonary artery diastolic pressure (PADP), and mean pulmonary artery pressure (mPAP) before and after operation, duration of operation, the volume of blood transfusion during operation and postoperation, the use of extracorporeal membrane oxygenation (ECMO) during the operation, blood purification treatment after operation, and shock within 3 days after operation were recorded. The differences of parameters mentioned above between the two groups were compared. The predictive factors of PGD were searched by binary logistic regression analysis, and the receiver operating characteristic curve (ROC) was plotted to analyze the predictive value of preoperative PADP for grade 3 PGD after transplantation.Results Among 58 patients who underwent the bilateral lung transplantation, 52 patients were enrolled. The rest patients were excluded because of incomplete clinical data. There were 17 patients in the PGDgroup, with a mortality rate of 47.06%. The non-PGD group included 35 patients with a mortality rate of 8.57%. PADP and mPAP ahead of operation, the dosage of red cells suspension after the operation, and the total amount of blood transfusion during and after the operation in PGD group were significantly higher than those in non-PGD group [PADP ahead of operation (mmHg, 1 mmHg = 0.133 kPa): 33.7±10.5 vs. 25.3±10.1, mPAP ahead of operation (mmHg): 40.4±14.1 vs. 32.8±11.1, the dosage of red cells suspension after the operation (mL): 700 (300, 1500) vs. 300 (300, 500), the total amount of blood transfusion during and after the operation (mL): 2250 (1850, 4275) vs. 1800 (1550, 2800)], with statistically significant differences (all P < 0.05). There were no significant differences in age, gender, BMI, underlying disease, NT-proBNP before operation, PASP before and after operation, PADP and mPAP after operation, duration of operation, amount of plasma and red cells suspension as well as total amount of blood transfusion during operation, plasma amount and total amount of blood transfusion after operation, amount of plasma and red cells suspension during and after operation, use of ECMO during operation, blood purification treatment after operation, and shock after operation between the two groups (all P > 0.05). It was shown by binary logistic regression analysis that the preoperative PADP was the independent risk factor of grade 3 PGD after lung transplantation [odds ratio (OR) = 1.084, 95% confidence interval (95%CI) = 1.016-1.156,P = 0.015]. It was shown by ROC curve that the area under the ROC curve (AUC) of the PADP before operation for predicting the grade 3 PGD after lung transplantation was 0.728. When the cut-off value was 36 mmHg, the sensitivity was 47.1%, and the specificity was 91.4%.Conclusions Compared with the non-PGD group, the patients with higher preoperative PADP were more common in the PGD group, and the patients in the PGD group were more likely to be characterized by grade 3 PGD after lung transplantation. The preoperative PADP was an effective predictor of grade 3 PGD after lung transplantation.

Objective To determine the association between plasma concentrations of brain derived neurotrophic factor (BDNF), neuron-specific enolase (NSE), and S100β, and the occurrence of delirium in critically ill patients. Methods Totally 65 patients in Intensive Care Unit (ICU) of Wuxi People's Hospital of Nanjing Medical University between June 2015 and February 2016 were included in the present study. Delirium diagnosis was used by confusion assessment method for the ICU (CAM-ICU). Plasma BDNF, NSE, and S100β concentrations were determined on day 1(T1), 3(T3), and 10(T10) after ICU admission. The day of ICU admission was defined as T0. Results Compared with the plasma BDNF level on T1 (0.23±0.22) μg/L, the plasma BDNF level on T3 (0.59±0.34) μg/L and T10 (0.24±0.21) μg/L were higher, especially for that on T3 with a significant difference (F=21.58, P=0.018). Plasma NSE level on T3 (1.68±0.25) μg/L was significantly higher than that on T1 (1.22±0.32) μg/L (F=10.24, P=0.042). Compared with those without delirium, the delirious patients had lower BDNF, higher NSE and S100β on T1, T3 and T10, of which the difference of BDNF [T1: (0.23±0.22) μg/L vs. (1.02±0.24) μg/L, F=116.25,P<0.01; T3: (0.59±0.34) μg/L vs. (1.55±0.36) μg/L, F=82.39, P<0.01; T10: (0.24±0.21) μg/L vs. (1.09±0.55)μg/L, F=50.93, P=0.003, and NSE (T1: (1.22±0.32) μg/L vs. (0.47±0.23) μg/L, F=94.30, P<0.01;T3:(1.68±0.25) μg/L vs. (0.79±0.28) μg/L, F=78.63, P=0.017; T10: (0.98±0.37) μg/L vs. (0.51±0.22) μg/L, F=70.95, P=0.026) reached significant differences. Conclusions Plasma BDNF and NSE are closely related to the occurrence of delirium in critically ill patients, especially for BDNF. Clinical monitoring of plasma levels of BDNF can help to predict the outcome of brain function in critically ill patients.

Objective To investigate the pathogen distribution and drug resistance condition in patients after lung transplantation so as to guide the reasonable use of antibiotics.Methods The clinical specimens from 242 lung transplantation patients in Wuxi People's Hospital between Jan.2010 to Dec.2016 were retrospectively analyzed.Among the 242 patients,182 were males and 60 were females with the average age of (52 ± 15) years old.Automatic analysis instrument VITEK-2 was applied for pathogen detection and K-B method was used to test drug resistance.Results From 2373specimens,1005 strains of pathogens were isolated and the detection rate was 42.35％ (1005/2373),in which gram-negative bacteria accounted for 81.79％ (822/1005).The specimens mainly resulted from sputum (76.19 ％) and bronchoalveolar lavage (19.76 ％).Among those strains,acinetobacter baumannii (28.76％),pseudomonas aeruginosa (16.62％),klebsiella pneumonia (14.33％),escherichia coli (5.57％) and Stenotrophomonas maltophilia (4.88％) ranked the top five species.Acinetobacter baumannii strains were highly resistant to most of antibiotic agents,with the drug resistant rate from 59.52％ to 100％,except cefperazone-sulbactam (＜ 50％).Pseudomonas aeruginosa strains were highly resistant to cefazolin,ceftriaxone,cefotetan,ampicillin,ampicillinsulbactam with the resistance rate of 80.24％-98.80％,while compared to other anibiotics with the resistance rate less than 50％.Stenotrophomonas maltophilia strains with intrinsic drug resistance to imipenem were sensitive to trimethoprim-sulfamethoxazole,cefperazone-sulbactam,piperacillintazobactam,levofloxacin,ciprofloxacin with the drug resistance rate of 12.24％,14.29％,32.65％,16.33％ and 18.37％ respectively.Klebsiella Klebsiella pneumoniae and escherichia coli,whose resistant rate to ceftazidime,cefperazone-sulbactam,piperacillin-tazobactam,aztreonam,amikacin and tobramycin was all less than 50％,were highly sensitive to imipenem,with the resistance rate of 24.31％ and 7.14％ respectively.Gram-positive bacteria were accounted for 9.35％,mainly Staphylococcus aureus,Staphylococcus haemolyticus and Staphylococcus epidemics,and drug resistant rate of them to vancomycin was all less than 20.00％.Fungi were accounted for 8.86％,mainly Candida albicans and Filamentous fungi,whose drug resistance rate to 5 antifungal drugs was less than 20.00％.The drug resistance rate of C.glabrata strains and C.krusei strains to fluconazole was 80.00％ and 100.00％,respectively.Conclusion The incidence of gram-negative bacteria infection and multiple bacterial strain infection in patients after lung transplantation is very high and the nonfermentation bacteria are highly resistant to multiple antibiotics.So,the rational antibiotics' use inclinical practice should be based on drug sensitivity results in order to improve the lung transplant recipients' survival rate.