Fabian Gleibs

Established and emerging kidney biomarkers reflect filtration, tubular injury, inflammation, or cellular stress, but their relationships with estimated glomerular filtration rate (eGFR) are incompletely characterized. TRUE-GFR was a prospective cross-sectional study of 200 adults undergoing elective renal scintigraphy. Twelve serum or urinary biomarkers were measured, and eGFR was calculated using Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine, cystatin C, and combined creatinine–cystatin C equations. Among biomarkers not incorporated into the equations, urea showed the strongest and most consistent correlations across all three eGFR definitions (r = −0.733 to −0.795). Kidney injury molecule-1 (KIM-1), proenkephalin A 119–159 (penKid), and soluble urokinase-type plasminogen activator receptor (suPAR) showed moderate associations, strongest for cystatin C-based and combined eGFR. Neutrophil gelatinase-associated lipocalin (NGAL) correlated moderately with cystatin C-based eGFR (r = −0.505) but weakly with creatinine-based eGFR (r = −0.241). Cysteine-rich protein 1 (CRIP1) correlations were weak, and urinary NephroCheck was unrelated to eGFR. These findings characterize concordance with estimated GFR and should not be interpreted as comparative diagnostic accuracy for true glomerular filtration.

Background: Prone positioning improves survival in patients with moderate to severe acute respiratory distress syndrome (ARDS), yet its implementation in routine clinical practice remains poorly characterized. We conducted a survey to assess contemporary prone positioning practices and their heterogeneity in the management of ARDS across European intensive care units (ICUs). Methods: A cross-sectional, questionnaire-based survey was conducted among clinicians involved in ARDS management between March and August 2025. The survey was developed by a panel of experts in intensive care medicine and underwent testing for face and content validity prior to dissemination. The questionnaire was distributed through European networks, including the European Society of Intensive Care Medicine (ESICM), the PROtective VEntilation Network (PROVE Network), the European Society of Anaesthesiology and Intensive Care (ESAIC), and national societies. Results: Out of 592 eligible responses, 451 responses were complete and from European clinicians (66.1% male), with the largest contributions being from Italy (28.6%), Germany (18.4%) and Austria (11.5%). Of these, 446 respondents (98.9%) reported performing prone positioning. Initiation thresholds for prone positioning varied, most commonly a ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO₂/FiO₂) ≤ 150 mmHg (55.4%), followed by ≤100 mmHg (26.9%), ≤200 mmHg (11.4%), and ≤300 mmHg (1.8%). Full prone positioning was reported as always or often used by 38.6% and 37.7% of participants, whereas semi-prone positioning (7.0% and 21.1%) or lateral positioning (2.5% and 14.8%) was used less often. The duration of prone positioning varied: 47.8% reported 16 h, 17.0% 12 h and 7.8% 8 h per session. Conclusions: Among self-selected clinicians working in European ICUs, prone positioning was commonly reported, though reported practice varied with respect to initiation thresholds, prone positioning strategy and duration. These findings identify specific areas where practice diverges and where current guidance and evidence remain incomplete.

Background: ICU admissions among very old patients are increasing. Invasive ventilation (IV) is common, but its benefit in patients aged ≥ 90 years is uncertain given high mortality and ethical concerns. Methods: This retrospective cohort study analysed all consecutive ICU patients aged ≥ 90 years admitted between 2008 and 2023 at a tertiary care centre in Germany. Demographic, clinical, and outcome data were extracted from electronic health records. Multivariable logistic regression was used to identify predictors of hospital mortality, while Kaplan–Meier survival analysis and Cox proportional hazards regression were used to assess predictors of 1-year mortality. Results: Of 113,950 patients, 1422 (1.25%) aged ≥ 90 years were identified (median 92 years, IQR 91–94; 66% female). IV was administered to 434 patients (31%), while 988 (69%) were not invasively ventilated. Median ICU length of stay was 1.7 days (IQR 1–4) overall. Among ventilated patients, the median duration of IV was 13 h (IQR 4–44), and 66% received IV for less than 24 h. IV was associated with higher illness severity at admission (SOFA score 9 [IQR 7–11] vs. 2 [IQR 1–4], p < 0.001), longer ICU stays (2.9 days [IQR 1.1–7.4] vs. 1.5 days [IQR 0.9–3.1], p < 0.001), as well as higher requirement of vasopressors at admission (0.112 µg/kg/min [IQR 0.056–0.278] vs. 0.072 µg/kg/min [IQR 0.038–0.133], p < 0.001) and renal replacement therapy (3.5% [n = 15] vs. 1.7% [n = 17], p = 0.042). In patients requiring IV, ICU and hospital mortality were 35.7% (n = 155) and 49.3% (n = 214) vs. 11.5% (n = 114) and 21.5% (n = 212) in non-IV patients, respectively (both p < 0.001). Independent and significant predictors of hospital mortality included prolonged IV duration (> 72 h: OR 4.01), peak lactate ≥ 4 mmol/l within 72 h (OR 6.67), as well as elevated SOFA scores (4–7: OR 1.96, ≥ 8: OR 3.46), and CCI ≥ 3 (OR 1.74) at admission. One-year mortality risks were 73.2% (95% CI 68.5–77.3%) and 53.4% (95% CI 50.0–56.6%) for IV and no-IV patients (p < 0.001), respectively. Conclusions: In this selected cohort of ICU patients aged ≥ 90 years, invasive ventilation–particularly beyond 72 h–identified a subgroup with very high ICU and hospital mortality and greater illness severity. These observational data support using invasive ventilation in nonagenarians as a trigger for early, patient-centred goals-of-care discussions, rather than as evidence that ventilation itself causes excess mortality.

Background: Haemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome characterised by uncontrolled immune activation and multi-organ dysfunction. Whilst initially described in paediatric populations, HLH is increasingly recognised in critically ill adults, often triggered by malignancies, infections, or autoimmune diseases. Methods: This single-centre retrospective study analysed 43 adult patients with HLH admitted to the ICU between 2008 and 2024. Clinical characteristics, laboratory parameters, organ support requirements, and outcomes were assessed. Temporal trends in routine parameters surrounding HLH diagnosis were also evaluated. Results: The median age was 45 years (IQR: 33–60), and 65% were male. Respiratory failure (62.8%) and sepsis (41.9%) were the leading causes of ICU admission. Disease severity was high, with a median SOFA score of 14 (IQR: 11–17), and ICU mortality reached 65.1%. Invasive mechanical ventilation was required in 83.7% of patients, and continuous renal replacement therapy in 72.1%. Ferritin levels were markedly elevated, with a median peak of 25,045 μg/l (IQR: 12,771–94,586), with 93% of patients exceeding 6,000 μg/l. The median HScore was 245 (IQR: 210–273) and did not differ significantly between survivors and non-survivors ( p = 0.64). Conclusion: HLH in adult ICUs carries high mortality and demands extensive organ support. Existing diagnostic scores provide limited bedside guidance, highlighting the need for ICU-specific validation and improved prognostic markers.

A 24-year-old male patient, without further symptoms or comorbidities presented to the emergency room with acute dyspnea after heavy lifting two days before. On auscultation an attenuated vesicular breath was noticed on the right lung. In the initial chest radiograph a right-sided primary spontaneous pneumothorax with minor mediastinal shift was diagnosed. After insertion of a 12-French chest tube the patient’s clinical condition deteriorated. The following chest radiograph and computed tomography of the thorax showed a reexpansion pulmonary edema in the right lung. The patient was admitted to the ICU and supportive treatment was initiated. Pulmonary reexpansion edema after drainage of a pneumothorax is a very rare complication with mortality rates reaching up to 20%. The exact pathophysiology remains unknown. Typical Symptoms include dyspnea, hypotension, and tachycardia. To minimize the risk of a pulmonary reexpansion edema, not more than 1200–1800 ml of air should be drained at once and the drainage should be stopped when the patient starts coughing.

Pulse pressure variation (PPV) and cardiac output (CO) can guide perioperative fluid management. Capstesia (Galenic App, Vitoria-Gasteiz, Spain) is a mobile application for snapshot pulse wave analysis (PWAsnap) and estimates PPV and CO using pulse wave analysis of a snapshot of the arterial blood pressure waveform displayed on any patient monitor. We evaluated the PPV and CO measurement performance of PWAsnap in adults having major abdominal surgery. In a prospective study, we simultaneously measured PPV and CO using PWAsnap installed on a tablet computer (PPVPWAsnap, COPWAsnap) and using invasive internally calibrated pulse wave analysis (ProAQT; Pulsion Medical Systems, Feldkirchen, Germany; PPVProAQT, COProAQT). We determined the diagnostic accuracy of PPV(PWAsnap)in comparison to PPV(ProAQT)according to three predefined PPV categories and by computing Cohen's kappa coefficient. We compared CO(ProAQT)and CO(PWAsnap)using Bland-Altman analysis, the percentage error, and four quadrant plot/concordance rate analysis to determine trending ability. We analyzed 190 paired PPV and CO measurements from 38 patients. The overall diagnostic agreement between PPV(PWAsnap)and PPV(ProAQT)across the three predefined PPV categories was 64.7% with a Cohen's kappa coefficient of 0.45. The mean (+/- standard deviation) of the differences between CO(PWAsnap)and CO(ProAQT)was 0.6 +/- 1.3 L min(- 1)(95% limits of agreement 3.1 to - 1.9 L min(- 1)) with a percentage error of 48.7% and a concordance rate of 45.1%. In adults having major abdominal surgery, PPV(PWAsnap)moderately agrees with PPVProAQT. The absolute and trending agreement between CO(PWAsnap)with CO(ProAQT)is poor. Technical improvements are needed before PWAsnap can be recommended for hemodynamic monitoring.