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Background and purpose Treatment of elevated intracranial pressure (ICP) is central to neurocritical care, but not all patients are eligible for invasive ICP-monitoring. A promising noninvasive option is ultrasound measurement of the optic nerve sheath diameter (ONSD). However, meta-analyses of ONSD for elevated ICP show wide confidence intervals. This might be due to baseline variations, inter-rater variability, and varying measurement methods. No standardized protocol has been validated. Corrections for eyeball diameter (ED) and optic nerve diameter (OND) may compensate for baseline variations. We evaluated a protocol and compared two different measurement methods for ONSD ultrasound. Methods Two operators, blinded to each other's measurements, measured ONSD, ED, and OND twice in 20 patients. ONSD was measured with two different methods in use: internal (ONSDint) or external (ONSDext) of the dura mater. Intra-class correlation (ICC) was calculated for inter-rater and intra-rater reliability. Results ICCs for inter-rater reliability of ONSDext and ONSDint (95% confidence interval) were 0.96 (0.93, 0.98) and 0.88 (0.79, 0.94), respectively. ICCs for intra-rater reliability of ONSDext and ONSDint were 0.97 (0.94, 0.99) and 0.93 (0.87, 0.96), respectively. There was no significant bias or difference in intra-rater reliability between operators. Conclusions ONSD can be measured with an excellent inter- and intra-rater reliability and low risk of inter-rater bias, when using this protocol. ONSDext yields a higher inter- and intra-rater reliability than ONSDint. Corrections for ED and OND can be performed reliably.

Background Renal resistive index (RRI) is a promising tool for the assessment of acute kidney injury (AKI) in critically ill patients in general, but its role and association to AKI among patients with Coronavirus disease 2019 (COVID-19) is not known. Objective The aim of this study was to describe the pattern of RRI in relation to AKI in patients with COVID-19 treated in the intensive care unit. Methods In this observational cohort study, RRI was measured in COVID-19 patients in six intensive care units at two sites of a Swedish University Hospital. AKI was defined by the creatinine criteria in the Kidney Disease Improving Global Outcomes classification. We investigated the association between RRI and AKI diagnosis, different AKI stages and urine output. Results RRI was measured in 51 patients, of which 23 patients (45%) had AKI at the time of measurement. Median RRI in patients with AKI was 0.80 (IQR 0.71–0.85) compared to 0.72 (IQR 0.67–0.78) in patients without AKI (p = 0.004). Compared to patients without AKI, RRI was higher in patients with AKI stage 3 (median 0.83, IQR 0.71–0.85, p = 0.006) but not in patients with AKI stage 1 (median 0.76, IQR 0.71–0.83, p = 0.347) or AKI stage 2 (median 0.79, min/max 0.79/0.80, n = 2, p = 0.134). RRI was higher in patients with an ongoing AKI episode compared to patients who never developed AKI (median 0.72, IQR 0.69–0.78, p = 0.015) or patients who developed AKI but had recovered at the time of measurement (median 0.68, IQR 0.67–0.81, p = 0.021). Oliguric patients had higher RRI (median 0.84, IQR 0.83–0.85) compared to non-oliguric patients (median 0.74, IQR 0.69–0.81) (p = 0.009). After multivariable adjustment, RRI was independently associated with AKI (OR for 0.01 increments of RRI 1.22, 95% CI 1.07–1.41). Conclusions Critically ill COVID-19 patients with AKI have higher RRI compared to those without AKI, and elevated RRI may have a role in identifying severe and oliguric AKI at the bedside in these patients.

Background Questions remain about long-term outcome for COVID-19 patients in general, and differences between men and women in particular given the fact that men seem to suffer a more dramatic course of the disease. We therefore analysed outcome beyond 90 days in ICU patients with COVID-19, with special focus on differences between men and women. Methods We identified all patient ≥ 18 years with COVID-19 admitted between March 6 and June 30, 2020, in the Swedish Intensive Care Registry. Patients were followed until death or study end-point October 22, 2020. Association with patient sex and mortality, in addition to clinical variables, was estimated using Cox regression. We also performed a logistic regression model estimating factors associated with 90-day mortality. Results In total, 2354 patients with COVID-19 were included. Four patients were still in the ICU at study end-point. Median follow-up time was 183 days. Mortality at 90-days was 26.9%, 23.4% in women and 28.2% in men. After 90 days until end of follow-up, only 11 deaths occurred. On multivariable Cox regression analysis, male sex (HR 1.28, 95% CI 1.06–1.54) remained significantly associated with mortality even after adjustments. Additionally, age, COPD/asthma, immune deficiency, malignancy, SAPS3 and admission month were associated with mortality. The logistic regression model of 90-day mortality showed almost identical results. Conclusions In this nationwide study of ICU patients with COVID-19, men were at higher risk of poor long-term outcome compared to their female counterparts. The underlying mechanisms for these differences are not fully understood and warrant further studies.

Background Noncardiac surgery is increasingly offered to an older, more comorbid population. The aim was to characterize patients with the diagnosis of heart failure (HF) undergoing elective and emergency noncardiac surgery in a broad, contemporary Swedish cohort, and to assess the short- and long-term mortality in patients with HF as compared with patients without HF. Methods and Results Data from 200,638 and 97,129 patients undergoing elective and emergency surgical procedures at 23 Swedish university, county, and district hospitals during 2007 to 2013 were analyzed through linkage of the surgical Orbit Database to the National Patient and the Cause of Death registries. In total 7212 patients (3.6%) with a diagnosis of HF before surgery underwent elective and 6455 patients (6.6%) underwent emergency surgery. Patients with HF were older had more comorbidities, and higher mortality than patients without HF. Crude and adjusted risk ratios for 30-day mortality after elective surgery were 5.36 (95% confidence interval [CI] 4.67-6.16) and 1.79 (95% CI 1.50–2.14) (adjusted for comorbidities, surgical risk level, age, and sex). Corresponding data for emergency surgery was 3.84 (95% CI 3.58–4.12) and 1.48 (95% CI 1.31–1.62). Mortality in patients with HF after elective surgery at 30 days, 90 days, and 1 year was 3.2%, 6.5%, and 16.2% and after emergency surgery it was 13.7%, 22.4%, and 39.3%. Conclusions Patients with HF undergoing elective or emergency noncardiac surgery in a modern surgical setting have a substantial mortality risk and HF is both a risk factor and a strong marker for increasd risk. The reasons for the high mortality are not well-understood and warrant further attention.

Background: One of the most common adverse events during continuous renal replacement therapy (CRRT) is hypothermia, reported to occur in over 4/10 cases. In turn, hypothermia is known to be associated with higher mortality rates among patients treated in intensive care units (ICU). The present study examined if a novel warming device in the current generation of CRRT systems could lower incidence of hypothermia compared to previous generation technology. Methods: We included ICU patients >18 years, at Skane University Hospital, Lund from November 2006 to August 2019 and treated with CRRT. Temperature measurements were recorded from the CRRT systems and from the patients hourly. Results: In total, 310 patients treated with the older system vs 32 patients treated using the newer CRRT system were included. We found that historic Prismaflex patients spent 11.43% of their time in hypothermia, as compared to the novel Prismax CRRT system, where 10.06% of patient hours were below 36.0°C (Chi-Square P =.0063). The novel blood warmer is associated with less heat loss compared to the older warmer: mean patient temperature was 37°C vs 36.5°C for these two groups and mean set return temperature was 37.9°C vs 40.9°C (both P

Background The Doppler-derived renal resistive index (RRI) is emerging as a promising bedside tool for assessing renal perfusion and risk of developing acute kidney injury in critically ill patients. It is not known what level of ultrasonography competence is needed to obtain reliable RRI values. Objective The aim of this study was to evaluate the feasibility of RRI measurements by an intermediate and novice sonographer in a volunteer population. Methods After a focused teaching session, an intermediate (resident), novice (medical student) and expert sonographer performed RRI measurements in 23 volunteers consecutively and blinded to the results of one another. Intraclass correlation coefficients and Bland–Altman plots were used to evaluate interobserver reliability, bias and precision. Results Both non-experts were able to obtain RRI values in all volunteers. Median RRI in the population measured by the expert was 0.58 (interquartile range 0.52–0.62). The intraclass correlation coefficient was 0.96 (95% confidence interval 0.90–0.98) for the intermediate and expert, and 0.85 (95% confidence interval 0.69–0.94) for the novice and expert. In relation to the measurements of the expert, both non-experts showed negligible bias (mean difference 0.002 [95% confidence interval − 0.005 to 0.009, p = 0.597] between intermediate and expert, mean difference 0.002 [95% confidence interval − 0.011 to 0.015, p = 0.752] between novice and expert) and clinically acceptable precision (95% limits of agreement − 0.031 to 0.035 for the intermediate, 95% limits of agreement − 0.056 to 0.060 for the novice). Conclusions RRI measurements by both an intermediate and novice sonographer in a volunteer population were reliable, accurate and precise after a brief course. RRI is easy to learn and feasible within the scope of point-of-care ultrasound.

It has been reported that there are differences in the care given within the intensive care unit (ICU) between men and women. The aim of this study is to investigate if any differences still exist between men and women regarding the level of intensive care provided, using prespecified intensive care items. This is a retrospective cohort study of 9017 ICU patients admitted to a university hospital between 2006 and 2016. Differences in use of mechanical ventilation, invasive monitoring, vasoactive treatment, inotropic treatment, echocardiography, renal replacement therapy and central venous catheters based on the sex of the patient were analysed using univariate and multivariable logistic regressions. Subgroup analyses were performed on patients diagnosed with sepsis, cardiac arrest and respiratory disease. Approximately one third of the patients were women. Overall, men received more mechanical ventilation, more dialysis and more vasoactive treatment. Among patients admitted with a respiratory disease, men were more likely to receive mechanical ventilation. Furthermore, men were more likely to receive levosimendan if admitted with cardiac arrest. We conclude that differences in the level of intensive care provided to men and women still exist.

BackgroundAn understanding of differences in clinical phenotypes and outcomes COVID-19 compared with other respiratory viral infections is important to optimise the management of patients and plan healthcare. Herein we sought to investigate such differences in patients positive for SARS-CoV-2 compared with influenza, respiratory syncytial virus (RSV) and other respiratory viruses.MethodsWe performed a retrospective cohort study of hospitalised adults and children (≤15 years) who tested positive for SARS-CoV-2, influenza virus A/B, RSV, rhinovirus, enterovirus, parainfluenza viruses, metapneumovirus, seasonal coronaviruses, adenovirus or bocavirus in a respiratory sample at admission between 2011 and 2020.ResultsA total of 6321 adult (1721 SARS-CoV-2) and 6379 paediatric (101 SARS-CoV-2) healthcare episodes were included in the study. In adults, SARS-CoV-2 positivity was independently associated with younger age, male sex, overweight/obesity, diabetes and hypertension, tachypnoea as well as better haemodynamic measurements, white cell count, platelet count and creatinine values. Furthermore, SARS-CoV-2 was associated with higher 30-day mortality as compared with influenza (adjusted HR (aHR) 4.43, 95% CI 3.51 to 5.59), RSV (aHR 3.81, 95% CI 2.72 to 5.34) and other respiratory viruses (aHR 3.46, 95% CI 2.61 to 4.60), as well as higher 90-day mortality, ICU admission, ICU mortality and pulmonary embolism in adults. In children, patients with SARS-CoV-2 were older and had lower prevalence of chronic cardiac and respiratory diseases compared with other viruses.ConclusionsSARS-CoV-2 is associated with more severe outcomes compared with other respiratory viruses, and although associated with specific patient and clinical characteristics at admission, a substantial overlap precludes discrimination based on these characteristics.

Purpose: Severe COVID-19 is associated with inflammation, thromboembolic disease, and high mortality. We studied factors associated with fatal outcomes in consecutive COVID-19 patients examined by computed tomography pulmonary angiogram (CTPA).Methods: This retrospective, single-center cohort analysis included 130 PCR-positive patients hospitalized for COVID-19 [35 women and 95 men, median age 57 years (interquartile range 51–64)] with suspected pulmonary embolism based on clinical suspicion. The presence and extent of embolism and parenchymal abnormalities on CTPA were recorded. The severity of pulmonary parenchymal involvement was stratified by two experienced radiologists into two groups: lesions affecting ≤50% or >50% of the parenchyma. Patient characteristics, radiological aspects, laboratory parameters, and 60-day mortality data were collected.Results: Pulmonary embolism was present in 26% of the patients. Most emboli were small and peripheral. Patients with widespread parenchymal abnormalities, with or without pulmonary embolism, had increased main pulmonary artery diameter (p < 0.05) and higher C-reactive protein (p < 0.01), D-dimer (p < 0.01), and troponin T (p < 0.001) and lower hemoglobin (p < 0.001). A wider main pulmonary artery diameter correlated positively with C-reactive protein (r = 0.28, p = 0.001, and n = 130) and procalcitonin. In a multivariant analysis, D-dimer >7.2 mg/L [odds ratio (±95% confidence interval) 4.1 (1.4–12.0)] and ICU stay were significantly associated with embolism (p < 0.001). The highest 60-day mortality was found in patients with widespread parenchymal abnormalities combined with pulmonary embolism (36%), followed by patients with widespread parenchymal abnormalities without pulmonary embolism (26%). In multivariate analysis, high troponin T, D-dimer, and plasma creatinine and widespread parenchymal abnormalities on CT were associated with 60-day mortality.Conclusions: Pulmonary embolism combined with widespread parenchymal abnormalities contributed to mortality risk in COVID-19. Elevated C-reactive protein, D-dimer, troponin-T, P-creatinine, and enlarged pulmonary artery were associated with a worse outcome and may mirror a more severe systemic disease. A liberal approach to radiological investigation should be recommended at clinical deterioration, when the situation allows it. Computed tomography imaging, even without intravenous contrast to assess the severity of pulmonary infiltrates, are of value to predict outcome in COVID-19. Better radiological techniques with higher resolution could potentially improve the detection of microthromboses. This could influence anticoagulant treatment strategies, preventing clinical detoriation.

Since the beginning of the Covid-19 pandemic, the scientific community has explored determinants of Covid 19 disease severity. However, the majority of studies are based on in-hospital patients with high risk of collider- or selection bias. The present investigation details risk factors associated with overall mortality, hospitalization and intensive care unit (ICU) admission in Covid-19 infections, with complete population coverage and high-resolution data on patient characteristics and comorbid conditions. Methods: This population-based observational study comprises all residents 18 years and older in Stockholm Region – 1.8 million inhabitants - using the real-time Covid-19 monitoring framework. The observation period lasted between March 1 to December 31, 2020. Hazard ratios (HR) for risk factors of Covid-19 disease severity were assessed using Cox proportional hazard models. Results: In total, 3,322 deaths, 11,508 hospitalizations and 1,423 ICU-admissions related to Covid-19 occurred during the study period. Kidney failure, diabetes and obesity increased risk of mortality and so did heart failure and ischemic heart disease. However, atrial fibrillation and hypertension did not. Risk of hospitalization follow a similar pattern, whereas admission to intensive care differs; triage processes where clearly present as certain co-morbid conditions were associated with lower ICU-admission. Conclusions: Observed differences in risk of mortality and hospitalization among patients with Covid 19 raise important questions about potentially protective co-medication which will be further addressed using the real-time Covid-19 monitoring framework.

Background Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global pandemic. The understanding of the transmission and the duration of viral shedding in SARS-CoV-2 infection is still limited. Objectives To assess the timeframe and potential risk of SARS-CoV-2 transmission from hospitalized COVID-19 patients in relation to antibody response. Method We performed a cross-sectional study of 36 COVID-19 patients hospitalized at Karolinska University Hospital. Patients with more than 8 days of symptom duration were sampled from airways, for PCR analysis of SARS-CoV-2 RNA and in vitro culture of replicating virus. Serum SARS-CoV-2-specific immunoglobulin G (IgG) and neutralizing antibodies titers were assessed by immunofluorescence assay (IFA) and microneutralization assay. Results SARS-CoV-2 RNA was detected in airway samples in 23 patients (symptom duration median 15 days, range 9–53 days), whereas 13 patients were SARS-CoV-2 RNA negative (symptom duration median 21 days, range 10–37 days). Replicating virus was detected in samples from 4 patients at 9–16 days. All but two patients had detectable levels of SARS-CoV-2-specific IgG in serum, and SARS-CoV-2 neutralizing antibodies were detected in 33 out of 36 patients. Total SARS-CoV-2-specific IgG titers and neutralizing antibody titers were positively correlated. High levels of both total IgG and neutralizing antibody titers were observed in patients sampled later after symptom onset and in patients where replicating virus could not be detected. Conclusions Our data suggest that the presence of SARS-Cov-2 specific antibodies in serum may indicate a lower risk of shedding infectious SARS-CoV-2 by hospitalized COVID-19 patients.

Peri-operative mortality remains a global problem and an improved pre-operative risk assessment identifying those at highest risk for peri-operative myocardial injury might improve postsurgical outcomes.To determine whether pre-operative measures of advanced electrocardiography (A-ECG) could predict elevated serum troponin T (TnT) in patients undergoing elective, major non-cardiac surgery.This observational cohort study included 257 surgical patients who underwent elective major non-cardiac surgery between the years 2012-2013 and 2015-2016 at Karolinska University Hospital. All selected patients were ≥ 18 years of age [median age 70 (63-75) years], had a pre-operative digital 12‑lead ECG6 months prior to the procedure and a postoperative high-sensitivity cardiac TnT (hs-cTnT) sample. A-ECG confounders including atrial fibrillation or flutter, abundant premature atrial or ventricular contractions, bundle branch blocks, QRS duration110 ms, heart rate100 beats/min and paced rhythms were excluded. Previously validated A-ECG diagnostic scores that detect cardiovascular pathologies were calculated and compared in patients with and without peri-operative myocardial injury, defined as hs-cTnT14 ng lPre-operative left ventricular systolic dysfunction by A-ECG was more probable in patients with than without peri-operative myocardial injury (p = 0.03).While a pre-operative A-ECG score for LVSD was able to differentiate between patients with versus without elevated peri-operative TnT levels, it did not add any further utility to standard clinical parameters for predicting troponin-related events in the studied population.

Background: The COVID-19 pandemic led to a rapidly increased demand for intensive care unit (ICU) and renal replacement therapy (RRT) worldwide. RRT delivery was threatened by a lack of specially trained staff and equipment. We investigated how the first wave of COVID-19 affected RRT delivery in Swedish ICUs. Methods: An Internet-based questionnaire was sent to ICU lead physicians which included quantitative and qualitative questions regarding RRT demand, equipment availability, and use of continuous renal replacement therapy (CRRT), intermittent haemodialysis (IHD), and peritoneal dialysis (PD) during spring 2020. Results: Twenty-five ICUs responded and these treated 64% of COVID-19 ICU patients in Sweden. ICU capacity increased by 292% (IQR 171–347%). Median peak capacity was reached during the 18th week of the year. RRT use increased overall by 133% and in Stockholm by 188%. 36% of units sequestered CRRT machines. IHD was used in 68% and PD in 12% of ICUs. RRT fluid and filter shortages were experienced by 45% and 33% of wards, respectively; consequently, prescription alterations were made by 24% of ICUs. Calcium solution shortages were reported in 12% of units that led to citrate protocol changes. Staffing shortages resulted in RRT sometimes being delivered by non-RRT-trained staff, safety incidents relating to this occurred, although no patient harm was reported. Conclusion: During the first wave of the COVID-19 pandemic, RRT demand increased extensively causing staff and equipment shortages, altered CRRT protocols, and increased use of IHD and PD. The impact on patient outcomes should be assessed to effectively plan for further surge capacity RRT demand.

Background Electroconvulsive therapy (ECT) is a safe and effective treatment for major depressive disorder (MDD). ECT treatment effect relies on induced generalised seizures. Most anaesthetics raise the seizure threshold and shorten seizure duration. There are no conclusive studies on the effect of anaesthetic dose on response and remission rates with ECT for MDD. Aims We aimed to examine the effect of different dose intervals of anaesthetics on response and remission after ECT for MDD. Method We conducted a nationwide cohort study, using data from Swedish registers. Low-, medium- and high-dose intervals, adjusted for age and gender, were constructed for each anaesthetic drug. Response and remission were measured with the Clinical Global Impression – Severity and Improvement scales (CGI-I and CGI-S), and a self-rated version of the Montgomery–Åsberg Depression Rating Scale (MADRS-S). Logistic regression models were used to calculate adjusted odds ratios for response and remission rates. Results The study included 7917 patients who received ECT for MDD during 2012–2018. Patients were given either thiopental (64.1%) or propofol (35.9%). Low-dose intervals of anaesthetics were associated with increased rates of response (CGI-I: odds ratio 1.22, 95% CI 1.07–1.40, P = 0.004; MADRS-S: odds ratio 1.31, 95% CI 1.09–1.56, P = 0.004) and remission (CGI-S: odds ratio 1.37, 95% CI 1.17–1.60, P ≤ 0.001; MADRS-S: odds ratio 1.31, 95% CI 1.10–1.54, P = 0.002). Conclusions We found improved treatment outcomes with low- compared with high-dose anaesthetic during ECT for MDD. To enhance treatment effect, deep anaesthesia during ECT for MDD should be avoided.

Postoperative acute kidney injury (PO-AKI) is a common complication of major surgery that is strongly associated with short-term surgical complications and long-term adverse outcomes, including increased risk of chronic kidney disease, cardiovascular events and death. Risk factors for PO-AKI include older age and comorbid diseases such as chronic kidney disease and diabetes mellitus. PO-AKI is best defined as AKI occurring within 7 days of an operative intervention using the Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI; however, additional prognostic information may be gained from detailed clinical assessment and other diagnostic investigations in the form of a focused kidney health assessment (KHA). Prevention of PO-AKI is largely based on identification of high baseline risk, monitoring and reduction of nephrotoxic insults, whereas treatment involves the application of a bundle of interventions to avoid secondary kidney injury and mitigate the severity of AKI. As PO-AKI is strongly associated with long-term adverse outcomes, some form of follow-up KHA is essential; however, the form and location of this will be dictated by the nature and severity of the AKI. In this Consensus Statement, we provide graded recommendations for AKI after non-cardiac surgery and highlight priorities for future research., The development of acute kidney injury (AKI) after major non-cardiac surgery is associated with substantial long-term morbidity and mortality. This joint Consensus Statement from the Acute Disease Quality Initiative and the PeriOperative Quality Initiative provides recommendations for the definition, prevention and management of postoperative AKI.

OBJECTIVE The presence of tachycardia in critically ill patients is frequently used as an indication of severity of illness and to guide treatment decisions but can be influenced by body temperature, thus confounding its interpretation. There are few data available on the relationship between body temperature and heart rate in critically ill patients. DESIGN Retrospective analysis of prospectively collected data. SETTING Mixed medical-surgical university hospital ICU. PATIENTS All patients admitted to the ICU between November 2006 and August 2019. MEASUREMENTS AND MAIN RESULTS Body temperature was recorded in the electronic medical records at least hourly, from invasive measurements (esophageal probe, indwelling urinary catheter, pulse contour cardiac output monitoring system, or pulmonary artery catheter) or manual tympanic recordings. Heart rate was monitored continuously and hourly values were recorded in the electronic medical record. Change in heart rate with change in body temperature was assessed by extracting pairs of simultaneous body temperature and corresponding heart rate measurements from the electronic medical record: 472,941 simultaneous pairs were obtained from the 9,046 patients admitted during the study period. Each 1°C increase in body temperature between 32.0°C and 42.0°C was associated with an 8.35 beats/min increase in heart rate. Crude linear regression showed an r2 of 0.855 between body temperature and heart rate. Heart rate increased more in females than in males (9.46 vs 7.24 beats/min for each 1°C, p < 0.0001); this relationship was not affected by age or adrenergic drugs. The increase in heart rate was related to the severity of organ dysfunction. CONCLUSIONS Increase in body temperature is associated with a linear increase in heart rate of 9.46 beats/min/°C in female and 7.24 beats/min/°C in male patients. These observations will help to correctly interpret heart rate values at different body temperatures and enable more accurate evaluation of other factors associated with tachycardia.

Hemodynamic instability during anesthesia and surgery is common and associated with cardiac morbidity and mortality. Information is needed regarding optimal blood pressure (BP) threshold in the perioperative period. Therefore, the effect of intraoperative hypotension (IOH) on risk of perioperative myocardial infarction (MI) was explored.A nested case-control study with patients developing MI30 days postsurgery matched with non-MI patients, sampled from a large surgery cohort. Study participants were adults undergoing noncardiac surgery at 3 university hospitals in Sweden, 2007-2014. Matching criteria were age, sex, American Society of Anesthesiologists (ASA) physical status, cardiovascular disease, hospital, year-, type-, and extent of surgery. Medical records were reviewed to validate MI diagnoses and retrieve information on comorbid history, baseline BP, laboratory and intraoperative data. Main exposure was IOH, defined as a decrease in systolic blood pressure (SBP), in mm Hg, from preoperative individual resting baseline lasting at least 5 minutes. Outcomes were acute MI, fulfilling the universal criteria, subclassified as type 1 and 2, occurring within 30 days and mortality beyond 30 days among case and control patients. Conditional logistic regression assessed the association between IOH, decrease in SBP from individual baseline, and perioperative MI. Mortality rates were estimated using Cox proportional hazards. Relative risk estimates are reported as are the corresponding absolute risks derived from the well-characterized source population.A total of 326 cases met the inclusion criteria and were successfully matched with 326 controls. The distribution of MI type was 59 (18%) type 1 and 267 (82%) type 2. Median time to MI diagnosis was 2 days; 75% were detected within a week of surgery. Multivariable analysis acknowledged IOH as an independent risk factor of perioperative MI. IOH, with reduction of 41-50 mm Hg, from individual baseline SBP, was associated with a more than tripled increased odds, odds ratio (OR) = 3.42 (95% confidence interval [CI], 1.13-10.3), and a hypotensive event50 mm Hg with considerably increased odds in respect to MI risk, OR = 22.6, (95% CI, 7.69-66.2). In patients with a very high-risk burden, the absolute risk of an MI diagnosis increased from 3.6 to 68 per 1000 surgeries.In patients undergoing noncardiac surgery, IOH is a possible contributor to clinically significant perioperative MI. The high absolute MI risk associated with IOH, among a growing population of patients with a high-risk burden, suggests that increased vigilance of BP control in these patients may be beneficial.

The first dialysis treatment in Sweden of a patient with acute kidney failure was performed already in 1946 by the pioneer Nils Alwall in Lund. Since then, there has been a tremendous development in the practice of nephrology in Sweden. The first kidney transplant was performed in 1964, and during the following decades, dialysis and nephrology departments emerged in all regions of the country. Today, Sweden has 10 million inhabitants and about 10,000 patients on renal replacement therapy, corresponding to a prevalence of 1000 pmp, out of which about 60% have a functioning transplant. A vast majority is treated in public hospitals. Sweden has about 300 nephrologists, making up less than 1% of the physicians in the country. About 1100 patients start renal replacement therapy yearly corresponding to an incidence rate of 120 pmp, diabetes being the most common primary cause of uremia, although end-stage renal disease caused by type 1 diabetes is decreasing. The yearly incident rate has levelled off and now seems to decrease which may be attributed to an improved care of patients with chronic kidney disease.

ObjectiveDecreased kidney function increases cardiovascular risk and predicts poor survival. Estimated glomerular filtration rate (eGFR) by creatinine may theoretically be less accurate in the critically ill. This observational study compares long-term cardiovascular mortality risk by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation; Caucasian, Asian, paediatric and adult cohort (CAPA) cystatin C equation and the CKD-EPI combined creatinine/cystatin C equation.MethodsThe nationwide study includes 22 488 intensive care patients in Uppsala, Karolinska and Lund University Hospitals, Sweden, between 2004 and 2015. Creatinine and cystatin C were analysed with accredited methods at admission. Reclassification and model discrimination with C-statistics was used to compare creatinine and cystatin C for cardiovascular mortality prediction.ResultsDuring 5 years of follow-up, 2960 (13 %) of the patients died of cardiovascular causes. Reduced eGFR was significantly associated with cardiovascular death by all eGFR equations in Cox regression models. In each creatinine-based GFR category, 17%, 19% and 31% reclassified to a lower GFR category by cystatin C. These patients had significantly higher cardiovascular mortality risk, adjusted HR (95% CI), 1.55 (1.38 to 1.74), 1.76 (1.53 to 2.03) and 1.44 (1.11 to 1.86), respectively, compared with patients not reclassified. Harrell’s C-statistic for cardiovascular death for cystatin C, alone or combined with creatinine, was 0.73, significantly higher than for creatinine (0.71), pConclusionsA single cystatin C at admission to the intensive care unit added significant predictive value to creatinine for long-term cardiovascular death risk assessment. Cystatin C, alone or in combination with creatinine, should be used for estimating GFR for long-term risk prediction in critically ill.

Understanding the presence and durability of antibodies against SARS-CoV-2 in the airways is required to provide insights on the ability of individuals to neutralize the virus locally and prevent viral spread. Here, we longitudinally assessed both systemic and airway immune responses upon SARS-CoV-2 infection in a clinically well-characterized cohort of 147 infected individuals representing the full spectrum of COVID-19 severity; from asymptomatic infection to fatal disease. In addition, we evaluated how SARS-CoV-2 vaccination influenced the antibody responses in a subset of these individuals during convalescence as compared to naïve individuals. Not only systemic but also airway antibody responses correlated with the degree of COVID-19 disease severity. However, while systemic IgG levels were durable for up to 8 months, airway IgG and IgA had declined significantly within 3 months. After vaccination, there was an increase in both systemic and airway antibodies, in particular IgG, often exceeding the levels found during acute disease. In contrast, naïve individuals showed low airway antibodies after vaccination. In the former COVID-19 patients, airway antibody levels were significantly elevated after the boost vaccination, highlighting the importance of prime and boost vaccination also for previously infected individuals to obtain optimal mucosal protection.

PURPOSE OF REVIEW The current narrative review discusses practical applications of stress and damage biomarkers for the management of acute kidney injury (AKI) based on clinical trials and real-world evaluations. RECENT FINDINGS In 2013 with the discovery and validation study of biomarkers for AKI (Sapphire) advancement in care was provided allowing for the early identification of patients at high risk for developing AKI. It was the combination of new biomarkers and the Kidney Disease Improving Global Outcomes (KDIGO) guidelines for managing patients with AKI that provided an opportunity to improve patient care. In 2017, the PrevAKI study implemented KDIGO guideline management in high-risk patients identified by biomarkers followed in 2018 with the BigPAK study that used a similar approach, both of which demonstrated positive outcomes in patient care. Next, real-world evaluations followed supporting biomarker guided management of AKI in clinical practice. Also, proposals for better nephrotoxin management, a major modifiable exposure to prevent AKI, were provided with the foresight in identifying high-risk patients. SUMMARY Stress and damage biomarker-based approaches to patient care seem to be promising for identifying patients at high risk for developing AKI and thus offers an opportunity for early management to prevent and ameliorate AKI and drug-associated AKI.

To understand the risk of transmission of SARS-CoV-2 in hospitalized COVID-19 patients we simultaneously assessed the presence of SARS-CoV-2 RNA, live infectious virus in the airways, and virus-specific IgG and neutralizing antibodies in sera in 36 hospitalized COVID-19 patients. SARS-CoV-2 could be cultured from four patients, all with low or undetectable antibody response. Our data suggests that the level of SARS-CoV-2 antibodies may correlate to risk for shedding live SARS-CoV-2 virus in hospitalized COVID-19 patients.

The immunopathology of COVID-19 remains enigmatic, exhibiting immunodysregulation and T cell lymphopenia. Monocytic myeloid-derived suppressor cells (M-MDSC) are T cell suppressors that expand in inflammatory conditions, but their role in acute respiratory infections remains unclear. We studied blood and airways of COVID-19 patients across disease severity at multiple timepoints. M-MDSC frequencies were elevated in blood but not in nasopharyngeal or endotracheal aspirates of COVID-19 patients compared to controls. M-MDSCs isolated from COVID-19 patients suppressed T cell proliferation and IFNγ production partly via an arginase-1 (Arg-1) dependent mechanism. Furthermore, patients showed increased Arg-1 and IL-6 plasma levels. COVID-19 patients had fewer T cells, and displayed downregulated expression of the CD3ζ chain. Ordinal regression showed that early M-MDSC frequency predicted subsequent disease severity. In conclusion, M-MDSCs expand in blood of COVID-19 patients, suppress T cells and strongly associate with disease severity, suggesting a role for M-MDSCs in the dysregulated COVID-19 immune response.

Objective: Neutrophil gelatinase-associated lipocalin (NGAL) is secreted by injured kidney cells as well as by activated neutrophils in response to bacterial infections. We assessed the influence of acute renal dysfunction on the association between plasma NGAL and sepsis. Methods: NGAL was measured daily in 138 critically ill patients. Simultaneous recordings of sepsis status and fluctuations in renal function were made. Results: Elevated NGAL was associated with sepsis independent of level of acute renal dysfunction. A cut-off value of 98 ng/mL distinguished sepsis from systemic inflammation with high sensitivity (0.77) and specificity (0.79). Conclusions: Plasma NGAL can help clinicians to identify bacterial infections in critically ill patients.

Background The precise incidence of perioperative myocardial infarction (MI) after noncardiac surgery remains unclear. We determined the incidence and risk factors for perioperative MI after noncardiac surgery and the risk of MI and mortality compared with matched non-surgical patients. Methods Patients >18 yr undergoing noncardiac surgery in 23 Swedish hospitals from 2007 to 2014 were included in this national observational retrospective cohort study. We combined national surgical and outcome databases with Swedeheart, a national quality registry capturing data from patients with acute MI. The primary outcome was incidence of MI within 30 days of surgery. Multivariable logistic regression identified preoperative risk factors associated with MI, including ASA grade, diabetes mellitus, and cardiovascular pathology including previous MI. Standardised incidence rate ratios were calculated. Mortality rates were estimated using Cox proportional hazards. Results A total of 1605/400 742 (0.41%) patients (median age: 64 [49–75] yr) had an MI after surgery, which was independently associated with increasing age, comorbidities and higher risk (vascular, thoracic), emergency surgery, or all. The incidence of perioperative MI (per 1000 surgeries) varied from 0.064 (95% confidence interval [CI], 0.02–012) in low-risk patients (ASA physical status 1) to 15.8 (95% CI, 14.9–16.8) among higher risk patients (ASA physical status ≥3, age ≥80 yr, high-risk surgery). Perioperative MI was associated with higher 30-day mortality (adjusted odds ratio: 5.49 [95% 4.76–6.32]). Compared with the non-surgical Swedish population, the perioperative standardised incidence rate ratio was five-fold higher (odds ratio: 5.35 [95% CI: 5.09–5.61]). Conclusions In a large Swedish surgical cohort, the incidence of MI within 30 days of noncardiac surgery was 0.41%, chiefly occurring in a small subset of higher risk patients.

Background/Aims: We assessed how the novel PrisMax continuous renal replacement therapy (CRRT) system performed in a prospective international multicentre setting. We compared this device to its predecessor, the Prismaflex, with regards to multiple treatment parameters. Additionally, we performed a survey, aiming to measure user satisfaction. Methods: Data was prospectively collected from 7 intensive care units (ICU) in 6 countries. The PrisMax device data logs constituted the raw material. Clinical parameters like treatment time, filter life span, downtime, delivered dose and number and type of alarms were recorded. A user questionnaire was sent out to 3 of the participating ICUs. Results: Filter life, downtime, blood pump stops, bag changing time and number of malfunction alarms showed significantly improved values compared to the historic Prismaflex data. The survey showed high scores with regards to user friendliness. Conclusion: The PrisMax CRRT device is safe and outperformed its’ previous generation counterpart in virtually all aspects. Video Journal Club “Cappuccino with Claudio Ronco” at http://www.karger.com/?doi=489213.

Background: In elderly reclassification of ASA3 class by functional dependency improved prediction of postoperative mortality. We hypothesized that such a reclassification could improve the risk pred ...

The gender distribution in intensive care units is consistently found to be around 60% men and 40% women. This might be medically sound. Our main purpose with this study was to investigate if physicians admit men and women to the intensive care unit equally. We sought to answer this question using a blinded randomized survey study. We used an online survey tool, with a hyperlink on European society of intensive care medicine webpage. Responders were randomized to either a critical care case Jane or a critical care case John, otherwise identical. The responders were asked if they would admit Jane/John to an intensive care unit, yes or no. Possible differences in admittance rate on the basis of the gender of the patient were analysed. In addition, we analysed if the gender of the responder affected admittance rate, regardless of the gender of the patient. 70.1% of the responders randomized to the John case opted to admit, vs. 68.3% of the responders randomized to the Jane case, p = 0.341. Regardless the gender of the patient, 70.1% of male responders opted to admit the patient, vs. 69.7% of female responders, p = 0.886. In this blinded randomized multicentre survey study, we could not demonstrate any difference in willingness to admit a patient to ICU, solely based on the gender of the patient. Patient gender as a factor for ICU admittance. A blinded randomized survey.

Purpose To investigate if patient sex affects intensive care unit (ICU) admission and discharge patterns. Specifically, we investigate if the patients sex affects length of stay (LOS) and probability of ICU discharge and 30- and 90-day mortality. Methods In a retrospective cohort study with 8598 adult patients admitted between 2006 and 2016 to a university hospital ICU in Stockholm, Sweden, we analysed ICU-LOS using univariate and multivariable quantile regression, and performed a competing risk regression model to assess the association between probability of discharge and sex. Mortality was analysed using logistic regression. Results Of 8598 included patients, 37% were women. No differences in age or median severity illness scores were found. After excluding trauma patients men were older, had a higher Charlson Co-morbidity Index, higher median SAPS 3 and higher probability of mortality than women. Women had a higher probability of being discharged from the ICU. There were no differences in 30- or 90-day mortality. Conclusion In this large cohort study of critically ill patients we have shown that women and men had an equal length of stay, but women had a significantly higher probability of being discharged. There was no difference in mortality between women and men.

Background: Surgical audit, sometimes including public reporting, is an important foundation of high quality health care. We aimed to assess the validity of a novel outcome metric, days at home up to 30 days after surgery, as a surgical outcome measure in clinical trials and quality assurance. Methods: This was a multicentre, registry-based cohort study. We used prospectively collected hospital and national healthcare registry data obtained from patients aged 18 years or older undergoing a broad range of surgeries in Sweden over a 10-year period. The association between days at home up to 30 days after surgery and patient (older age, poorer physical status, comorbidity) and surgical (elective or non-elective, complexity, duration) risk factors, process of care outcomes (re-admissions, discharge destination), clinical outcomes (major complications, 30-day mortality) and death up to 1 year after surgery were measured. Findings: From January, 2005, to December, 2014, we obtained demographic and perioperative data on 636,885 patients from 21 Swedish hospitals. Mortality at 30 days and one year was 1.8% and 7.3%, respectively. The median (IQR) days at home up to 30 days after surgery was 27 (23–29), being significantly lower among high-risk patients, those recovering from more complex surgical procedures, and suffering serious postoperative complications (all p

Markers of renal function are widely used in intensive care and sudden changes are important indicators of acute kidney injury. The problem is to distinguish between disease progression/improvement from the natural variation in the patient. The aim of the present study was thus to study the normal intraday variation in ICU patients.We studied the intra-day variation of creatinine, cystatin C and estimated GFR based on these two markers in 28 clinically stable ICU patients.The median diurnal coefficient of variation sCV) for creatinine was 3.70% (1.92-9.25%) while the median CV for cystatin C was 3.66% (1.36-8.11%). The corresponding CVs for the estimated GFRs were 2.00% (0.89-9.82%) for eGFRcreatinine and 4.60% (1.65-10.24%) for eGFRcystc.The eGFRcreatinine values in individual patients were clearly higher than the eGFRcystc values. The median CV for creatinine, cystatin C and the eGFR measurements were below 5% which means that 95% of the test results will vary by10% between sampling times in stable ICU patients. Differences10% between sampling times are thus likely to be an indication of changes in biomarker levels due to the disease/treatment.

Perioperative myocardial damage and infarction (MI) is associated with increased mortality and other postoperative complications.To assess the incidence of perioperative myocardial damage in patients undergoing major elective noncardiac surgery, to elucidate any association with postoperative MI and mortality and to estimate the impact of preoperative risk factors and intraoperative hypotension.Observational cohort study.Karolinska University Hospital, Stockholm, Sweden, from October 2012 to May 2013.In this single-centre study, all adult patients undergoing major elective noncardiac surgery who were scheduled for an overnight admission to the postoperative unit were included. Patients undergoing phaeochromocytoma surgery were excluded. Preoperative risk factors (co-morbidities), intraoperative events (hypotension defined as a 50% decrease in SBP relative to each patient's baseline and lasting5 min) and postoperative data were collected from medical records. Levels of high-sensitivity cardiac troponin T (hs-cTnT) were measured on postoperative day 1. Myocardial damage was defined as an increase in the hs-cTnT value above 14 ng l. A cardiologist reviewed all cases of MI occurring within 30 days after surgery.Myocardial damage, MI and mortality within 30 days after surgery.Of the final cohort of 300 patients, 90 (30%) had myocardial damage on postoperative day 1 and 15 (5%) developed postoperative MI within 30 days. Multivariate logistic regression analysis demonstrated that an intraoperative reduction in SBP more than 50% from baseline lasting more than 5 min was an independent predictor of postoperative hs-cTnT elevation (odds ratio, 4.4; 95% confidence interval, 1.8 to 11.1).In a cohort of 300 patients undergoing major elective noncardiac surgery, there was a high incidence of myocardial damage and an association between an intraoperative reduction in SBP more than 50% from baseline lasting more than 5 min and myocardial damage.

To develop a liver function-related risk prediction tool to identify acute-on-chronic liver failure patients at greatest risk of in-hospital mortality. The LiFe (liver, injury, failure, evaluation) score, was constructed based on the opinions of 157 intensivists within the European Society for Intensive Care Medicine. Experts were surveyed and instructed to weigh the diagnostic importance of each feature of a proposed prediction model. We performed a retrospective cohort study of 1916 patients with chronic liver disease admitted to a medical or surgical ICU between 1997, and 2011 in three large hospitals in Boston, USA, and London, UK, with arterial lactate, total bilirubin and INR drawn at ICU admission. The derivation cohort consisted of ICU patients from Brigham and Women’s Hospital and Massachusetts General Hospital in Boston (n = 945), and the validation cohort comprised patients from Kings College Hospital, London, admitted to the Liver Intensive Therapy Unit (n = 971). A clinical prediction model was derived and validated based on a logistic regression model describing the risk of in-hospital mortality as a function of the predictors (arterial lactate 0–1.9, ≥2.0–3.9, ≥4.0–5.9, ≥6.0 mg/dL; total bilirubin 0–1.9, ≥2.0–3.9, ≥4.0–5.9, ≥6.0 mg/dL; INR 0–1.9, ≥2.0–3.9, ≥4.0–5.9, ≥6.0) at ICU admission. Performance analysis of the LiFe score against SOFA, CLIF-SOFA, APACHE II and SAPS II was completed in the validation cohort of critically ill cirrhotic patients. The derivation cohort (n = 941) was 53 % male with a mean age of 65 years and an in-hospital mortality rate of 30 %. The validation cohort (n = 971) was 63 % male with mean age of 51 years and an in-hospital mortality rate of 52 %. The C statistic for the prediction model was 0.74 (95 % CI 0.70–0.77) in the derivation cohort and 0.77 (95 % CI 0.74–0.80) in the validation cohort. In the validation cohort, in-hospital mortality was 17 % in the low-risk group (0 risk score points), 28 % in the intermediate-risk group (1–3 points), 47 % in the high-risk group (4–8 points), and 77 % in the very high-risk group (>8 points). In the validation cohort, the C statistics for SOFA, CLIF-SOFA, APACHE II, and SAPS II were 0.80, 0.81, 0.77, and 0.78, respectively. Further, a significant positive correlation exists between LiFe score and acute-on-chronic liver failure grade, (r = 0.478, P

Background: Sepsis is a challenge to healthcare systems, and morbidity and mortality remain high. In the worldwide Surviving Sepsis Campaign, there has been a focus on the timing of antibiotic administration to septic patients. The objective of this study was to describe current practice regarding the timing of antibiotic administration in septic patients admitted to intensive care units (ICUs) in Sweden.Methods: This was an observational cohort study of septic patients in four ICUs in the Stockholm area during 2005-2010. Inclusion criteria were age > 18 years, sepsis upon hospital admission, and a registered time point for the first dose of antibiotic administration. Information on time of arrival at the hospital, physiological parameters within the first hour of arrival, time of administration of antibiotics, results of blood culture, other laboratory results, diagnosis, and medical procedures were retrieved from the medical charts. Patients requiring surgery for source control were labelled as having surgical sepsis.Results: Overall, 64 of 210 septic patients (30%) received antibiotics within one hour of hospital admission. Initiation of antimicrobial therapy was delayed in female patients. Surgical patients received antibiotics later but still had a lower mortality than non-surgical patients.Conclusions: The reason for the delay of antibiotics to female patients and the impact on clinical outcomes of such a gender difference in the treatment of sepsis needs to be further investigated. Citation: Maria Cronhjort, Susanne Rysz, Mattias Sandstrom, Christer Svensen, Johan Martensson, Max Bell, et al. Timing of antibiotic treatment in a Swedish cohort of septic intensive care patients. J Anesth Perioper Med 2015; 2: 287-94. doi: 10.24015/JAPM.2015.0039This is an open-access article, published by Evidence Based Communications (EBC). This work is licensed under the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium or format for any lawful purpose. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

Background/Aims: We assessed how the novel PrisMax continuous renal replacement therapy (CRRT) system performed in an international multicentre setting. The system has multiple novel tools aiming to increase accuracy and dose delivery. Methods: Data was prospectively collected from 7 intensive care units in 6 countries. The PrisMax device data logs constituted the raw material and last generation Prismaflex data was used as comparison. Clinical parameters like treatment time, filter life span, downtime as well as prescribed and delivered dose were recorded. Results: PrisMax delivered/prescribed effluent ratios (mean ± SD) 0.92 ± 0.15 vs. Prismaflex ratios 0.85 ± 0.21, p < 0.001; delivered effluent dose (mL/kg/h) was 18.16 ± 12.93 vs. 10.95 ± 10.96, p < 0.0001; and (Kt/V) 0.76 ± 0.52 vs. 0.44 ± 0.44, p < 0.0001. Moreover, downtime was 27 minutes less for the newer device. Conclusion: The PrisMax CRRT device outperforms its predecessor with regard to dose delivery and accuracy.

Perioperative acute kidney injury (AKI) is common and increases the risk of morbidity and mortality.To determine the association between intraoperative hypotension, defined as an individual decrease from baseline and the risk of perioperative AKI.Observational cohort study.Karolinska University Hospital, Stockholm, Sweden, from October 2012 to May 2013 and October 2015 and April 2016.All adult patients undergoing major elective noncardiac surgery who were scheduled for an overnight admission in the postoperative unit were included. Patients undergoing phaeochromocytoma surgery were excluded.Preoperative risk factors (comorbidities), intraoperative events (hypotension defined as a more than 40 or 50% decrease in SBP relative to each patient's baseline and lasting more than 5 min) and postoperative data were collected from medical records.AKI within the first two postoperative days.Of the final cohort of 470 patients, 127 (27%) developed AKI in the perioperative period. AKI was associated with male sex [(66 vs. 48%) P 0.001], a higher preoperative creatinine (81 vs. 73 μmol l, P = 0.003), American Society of Anaesthesiologists class more than two (54 vs. 42%, P = 0.014) and preoperative hypertension (54 vs. 40%, P = 0.005). During surgery, the AKI subgroup had more hypotensive events (40%, 70 vs. 57%, P = 0.013;50%, 20 vs. 12%, P = 0.024) and greater blood loss (800 vs. 400 ml, P 0.001). Postoperatively, in AKI patients a positive fluid balance was more common (3123 vs. 2700 ml, P 0.001), as was 30-day mortality (4 vs. 1%, P 0.005). Multivariate analyses demonstrated that an intraoperative reduction of SBP more than 50% was associated with a more than doubled risk of AKI, adjusted odds ratio 2.27; 95% CI, 1.20 to 4.30, P = 0.013.In patients undergoing noncardiac surgery, there was a high incidence of perioperative AKI. Intraoperative avoidance of hypotension may decrease the risk of AKI.

Renal outcomes after critical illness are seldom assessed despite strong correlation between chronic kidney disease and survival. Outside hospital, renal dysfunction is more strongly associated with mortality when assessed by serum cystatin C than by creatinine. The relationship between creatinine and longer term mortality might be particularly weak in survivors of critical illness.Retrospective observational cohort study.In 3,077 adult ICU survivors, we compared ICU discharge cystatin C and creatinine and their association with 1-year mortality. Exclusions were death within 72 hours of ICU discharge, ICU stay less than 24 hours, and end-stage renal disease.None.During ICU admission, serum cystatin C and creatinine diverged, so that by ICU discharge, almost twice as many patients had glomerular filtration rate less than 60 mL/min/1.73 m when estimated from cystatin C compared with glomerular filtration rate estimated from creatinine, 44% versus 26%. In 743 patients without acute kidney injury, where ICU discharge renal function should reflect ongoing baseline, discharge glomerular filtration rate estimated from creatinine consistently overestimated follow-up glomerular filtration rate estimated from creatinine, whereas ICU discharge glomerular filtration rate estimated from cystatin C well matched follow-up chronic kidney disease status. By 1 year, 535 (17.4%) had died. In survival analysis adjusted for age, sex, and comorbidity, cystatin C was near-linearly associated with increased mortality, hazard ratio equals to 1.78 (95% CI, 1.46-2.18), 75th versus 25th centile. Conversely, creatinine demonstrated a J-shaped relationship with mortality, so that in the majority of patients, there was no significant association with survival, hazard ratio equals to 1.03 (0.87-1.2), 75th versus 25th centile. After adjustment for both creatinine and cystatin C levels, higher discharge creatinine was then associated with lower long-term mortality.In contrast to creatinine, cystatin C consistently associated with long-term mortality, identifying patients at both high and low risk, and better correlated with follow-up renal function. Conversely, lower creatinine relative to cystatin C appeared to confer adverse prognosis, confounding creatinine interpretation in isolation. Cystatin C warrants further investigation as a more meaningful measure of renal function after critical illness.