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To systematically review AKI outcome prediction models and their external validation studies, to describe the discrepancy of reported accuracy between the results of internal and external validations, and to identify variables frequently included in the prediction models. We searched the MEDLINE and Web of Science electronic databases (until January 2016). Studies were eligible if they derived a model to predict mortality of AKI patients or externally validated at least one of the prediction models, and presented area under the receiver-operator characteristic curves (AUROC) to assess model discrimination. Studies were excluded if they described only results of logistic regression without reporting a scoring system, or if a prediction model was generated from a specific cohort. A total of 2204 potentially relevant articles were found and screened, of which 12 articles reporting original prediction models for hospital mortality in AKI patients and nine articles assessing external validation were selected. Among the 21 studies for AKI prediction models and their external validation, 12 were single-center (57%), and only three included more than 1,000 patients (14%). The definition of AKI was not uniform and none used recently published consensus criteria for AKI. Although good performance was reported in their internal validation, most of the prediction models had poor discrimination with an AUROC below 0.7 in the external validation studies. There were 10 common non-renal variables that were reported in more than three prediction models: mechanical ventilation, age, gender, hypotension, liver failure, oliguria, sepsis/septic shock, low albumin, consciousness and low platelet count. Information in this systematic review should be useful for future prediction model derivation by providing potential candidate predictors, and for future external validation by listing up the published prediction models.

The role of arterial blood gas (ABG) testing in the intensive care unit (ICU) remains debated within the \"less is more\" paradigm. While unnecessary testing may pose risks without benefit, timely ABGs provide critical information in unstable patients. Institutional variation in early ABG utilization and its association with outcomes remains unclear. We conducted a multicenter retrospective cohort study using the Japanese Intensive Care PAtient Database (JIPAD) between April 2015 and March 2023. Adult ICU patients with a stay ≥24 h and arterial line placement were included. The standardized number of ABGs (SNABGs) within the first 24 h was calculated as the ratio of observed to expected values, where expectations were derived from a multivariable model adjusting for patient covariates. ICUs were categorized into tertiles according to SNABG utilization. The primary outcome was in-hospital mortality, analyzed using multilevel logistic regression with ICU-level random intercepts. Restricted cubic splines were used to explore non-linear associations. Among 117,546 patients from 87 ICUs, the mean number of ABGs varied widely. After standardization, SNABGs ranged from 0.73-0.90 in the low tertile to 1.09-1.15 in the high tertile. In the multilevel model, SNABG was not significantly associated with in-hospital mortality (adjusted OR 0.942 [95% CI 0.807-1.100] for tertile 2; 0.874 [95% CI 0.751-1.017] for tertile 3). Flexible modeling suggested a non-linear trend toward better outcomes with higher utilization, but confidence intervals included unity. Early ABG utilization varied across ICUs, yet was not significantly associated with mortality. Sensitivity analysis suggested a non-linear relationship, with a tendency toward better outcomes at higher utilization. These findings warrant further investigation to clarify the role of early ABG utilization in critical care.

Purpose Current reports on acute kidney injury (AKI) in the intensive care unit (ICU) show wide variation in occurrence rate and are limited by study biases such as use of incomplete AKI definition, selected cohorts, or retrospective design. Our aim was to prospectively investigate the occurrence and outcomes of AKI in ICU patients. Methods The Acute Kidney Injury–Epidemiologic Prospective Investigation (AKI-EPI) study was an international cross-sectional study performed in 97 centers on patients during the first week of ICU admission. We measured AKI by Kidney Disease: Improving Global Outcomes (KDIGO) criteria, and outcomes at hospital discharge. Results A total of 1032 ICU patients out of 1802 [57.3 %; 95 % confidence interval (CI) 55.0–59.6] had AKI. Increasing AKI severity was associated with hospital mortality when adjusted for other variables; odds ratio of stage 1 = 1.679 (95 % CI 0.890–3.169; p  = 0.109), stage 2 = 2.945 (95 % CI 1.382–6.276; p  = 0.005), and stage 3 = 6.884 (95 % CI 3.876–12.228; p  < 0.001). Risk-adjusted rates of AKI and mortality were similar across the world. Patients developing AKI had worse kidney function at hospital discharge with estimated glomerular filtration rate less than 60 mL/min/1.73 m 2 in 47.7 % (95 % CI 43.6–51.7) versus 14.8 % (95 % CI 11.9–18.2) in those without AKI, p  < 0.001. Conclusions This is the first multinational cross-sectional study on the epidemiology of AKI in ICU patients using the complete KDIGO criteria. We found that AKI occurred in more than half of ICU patients. Increasing AKI severity was associated with increased mortality, and AKI patients had worse renal function at the time of hospital discharge. Adjusted risks for AKI and mortality were similar across different continents and regions.

PurposeThere are several causes for delayed constipation in critically ill patients. Constipation in critically ill patients is reportedly associated with poor outcomes. However, a consistent definition for constipation and reports on the prognosis of critically ill patients with constipation are lacking. Therefore, we aimed to determine the epidemiology of constipation during critical illness, and assess the association between constipation and in-hospital mortality based on the two definitions of constipation used in previous studies.MethodsThis retrospective cohort study comprised adult patients in a general intensive care unit (ICU) during 2011–2018. We retrieved the information regarding their bowel movements and assessed the impact of constipation on the in-hospital mortality based on the previous definitions (absence of defecation for 72 and 144 h).ResultsAmong the 1933 adult ICU patients included, the proportion of patients with constipation decreased with a longer duration of constipation (72 h: 67%, 144 h: 36%). In-hospital mortality in the constipation group was much lower than that in the non-constipation group in the univariable analysis (72 h, 27% vs. 13%; 144 h, 31% vs. 21%). However, constipation was not associated with in-hospital mortality in the multivariable analysis (adjusted odds ratio: 0.91, 95% confidence interval: 0.64–1.30 and adjusted odds ratio: 1.14, 95% confidence interval: 0.70–1.85 at 72 and 144 h, respectively).ConclusionsConstipation in critically ill patients was not associated with in-hospital mortality based on any definition of constipation used in previous studies. Further prospective studies are necessary to validate our findings.

This study assessed model performance of the Acute Physiology and Chronic Health Evaluation (APACHE) III and Japan Risk of Death (JROD) when degraded by the number and category of missing variables. We also examined the impact of missing data on predicted mortality for facilities with missing physiological variables. We obtained data from the Japanese Intensive care PAtient Database (JIPAD). We calculated observed and predicted mortality rates using the APACHE III and JROD and the standardized mortality ratio (SMR) by the number and category of missing variables. Smoothed spline curves were calculated for the SMR to the missing proportion of the facility. A total of 61,357 patients from 57 ICUs were included between April 2015 and March 2019. The APACHE III and JROD SMRs increased as the number of missing values increased. The SMR in the APACHE III model was elevated in facilities with a larger proportion of missing in each of the APS categories, arterial blood gas, albumin, glucose, and bilirubin. Facilities with a high proportion of missing albumin data preserved their SMRs in only the JROD model. An increased number of missing physiological variables resulted in falsely low predicted mortality rates and high SMRs. •General severity scoring systems are widely used in the ICU to predict patient outcomes.•An increased number of missing physiological variables resulted in falsely low predicted mortality rates.•Arterial blood gas and albumin should be available for accurate assessment of ICU performance.

To evaluate the predictive ability of a mortality prediction model in subgroups of intensive care unit (ICU) patients and test the validity for monitoring the outcome. A Japanese ICU database was used for the analyses. Adults admitted to an ICU between April 1, 2019, and March 31, 2020, were included. Nine clinically relevant subgroups were selected, and we evaluated the discrimination and calibration of the Japan Risk of Death model, a recalibrated Acute Physiology and Chronic Health Evaluation III-j model. Funnel plots and exponentially weighted moving average (EWMA) charts were used to check its validity for monitoring in-hospital mortality. If the predictive performance was poor, the model was recalibrated and model performance was reassessed. The study population comprised 14,513 patients across nine subgroups. The in-hospital mortality rate ranged from 11.3% to 30.9%. The calibration was poor in most subgroups, and the funnel plots and EWMA charts frequently revealed “out-of-control” signals crossing the control limit of three standard deviations (SDs). The calibration improved after recalibration, and the number of “out-of-control” signals decreased. When monitoring the quality of care among subgroups of patients, testing the predictive ability and recalibration of the risk model are needed.

Background In vasopressor-dependent patients who had undergone cardiovascular surgery, we examined whether those with progression of acute kidney injury (AKI) had a greater difference (deficit) between premorbid and within-ICU hemodynamic pressure-related parameters compared to those without AKI progression. Methods We assessed consecutive adults who underwent cardiovascular surgery and who stayed in our ICU for at least 48 hours and received vasopressor support for more than 4 hours. We obtained premorbid and vasopressor-associated, time-weighted average values for hemodynamic pressure-related parameters (systolic [SAP], diastolic [DAP], and mean arterial pressure [MAP]; central venous pressure [CVP], mean perfusion pressure [MPP], and diastolic perfusion pressure [DPP]) and calculated deficits in those values. We defined AKI progression as an increase of at least one Kidney Disease: Improving Global Outcomes stage. Results We screened 159 patients who satisfied the inclusion criteria and identified 76 eligible patients. Thirty-six patients (47 %) had AKI progression. All achieved pressure-related values were similar between patients with or without AKI progression. However, deficits in DAP ( P  = 0.027), MPP ( P  = 0.023), and DPP ( P  = 0.002) were significantly greater in patients with AKI progression. Conclusions Patients with AKI progression had greater DAP, MPP, and DPP deficits compared to patients without AKI progression. Such deficits might be modifiable risk factors for the prevention of AKI progression.

The Japanese Intensive care PAtient Database (JIPAD) was established to construct a high-quality Japanese intensive care unit (ICU) database. A data collection structure for consecutive ICU admissions in adults (≥16 years) and children (≤15 years) has been established in Japan since 2014. We herein report a current summary of the data in JIPAD for admissions between April 2015 and March 2017. There were 21,617 ICU admissions from 21 ICUs (217 beds) including 8416 (38.9%) for postoperative or procedural monitoring, defined as adult admissions following elective surgery or for procedures and discharged alive within 24 h, 11,755 (54.4%) critically ill adults other than monitoring, and 1446 (6.7%) children. The standardized mortality ratios (SMRs) based on the Acute Physiology and Chronic Health Evaluation (APACHE) III-j, APACHE II, and Simplified Acute Physiology Score II scores in adults ranged from 0.387 to 0.534, whereas the SMR based on the Paediatric Index of Mortality 2 in children was 0.867. The data revealed that the SMRs based on general severity scores in adults were low because of high proportions of elective and monitoring admission. The development of a new mortality prediction model for Japanese ICU patients is needed. •The Japanese Intensive care PAtient Database (JIPAD) project started in 2014.•The primary aim of JIPAD is to improve the quality of intensive care in Japan.•A total of 21 ICUs (217 beds) contributed to this report examined in the two years.•In Japanese ICUs, the proportion of elective and monitoring admissions was high.•The standardized mortality ratios based on severity scores in adults were low.

Epidemiological information is lacking after identification of new-onset atrial fibrillation (AF) in critically ill patients. This study aimed to describe the clinical course after the identification of new-onset AF. This prospective cohort study enrolled adult patients with new-onset AF in 32 Japanese ICUs during 2017–2018. We collected data on patient comorbidities, physiological information before and at the AF onset, interventions for AF, cardiac rhythm transition, adverse events and in-hospital death and stroke. We included 423 new-onset AF patients. At the AF onset, mean arterial pressure decreased and the heart rate increased. Eighty-four patients (20%) spontaneously restored sinus rhythm and 328 patients (78%) received various pharmacological interventions (rate-control drugs, 67%; rhythm-control drugs, 34%). Anticoagulants were administered in 173 patients (40%) and 13 patients (3%) experienced bleeding complications. Twenty-four patients (6%) were still in AF at 168 h after the onset (sustained AF 4%; recurrent AF 2%). The overall hospital mortality was 26% and the incidence of in-hospital stroke was 4.5%. Although the proportion of patients with AF continued to decrease with various treatments, these patients had high risk of death. Further research to assess the management of new-onset AF in critically ill patients is warranted. •This study included 423 new-onset AF patients.•Eighty-four patients (20%) spontaneously restored sinus rhythm.•Anticoagulants were administered in 173 patients (40%).•Among patient in ICU at 168 h, twenty-four patients (14%) were still in AF.•Hospital mortality was 26% and the incidence of in-hospital stroke was 4.5%.

There are few reports describing the association of naldemedine with defecation in critically ill patients with opioid-induced constipation. The purpose of this study was to determine whether naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation. In this retrospective cohort study, patients admitted to the Intensive Care Unit (ICU) without defecation for 48 hours while receiving opioids were eligible for enrollment. The primary endpoint was the time of the first defecation within 96 hours after inclusion. Secondary endpoints included presence of diarrhea, duration of mechanical ventilation, ICU length of stay, ICU mortality, and in-hospital mortality. The Cox proportional hazard regression analysis with time-dependent covariates was used to evaluate the association naldemedine with earlier defecation. A total of 875 patients were enrolled and were divided into 63 patients treated with naldemedine and 812 patients not treated. Defecation was observed in 58.7% of the naldemedine group and 48.8% of the no-naldemedine group during the study (p = 0.150). The naldemedine group had statistically significantly prolonged duration of mechanical ventilation (8.7 days vs 5.5 days, p < 0.001) and ICU length of stay (11.8 days vs 9.2 days, p = 0.001) compared to the no-naldemedine group. However, the administration of naldemedine was significantly associated with earlier defecation [hazard ratio:2.53; 95% confidence interval: 1.71-3.75, p < 0.001]. The present study shows that naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation.