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Koyner JL, Mackey RH, Echeverri J, Rosenthal NA, Carabuena LA, Bronson-Lowe D, Harenski K, Neyra JA. Initial renal replacement therapy (RRT) modality associates with 90-day postdischarge RRT dependence in critically ill AKI survivors. J Crit Care 2024; 82:154764. [PMID: 38460295 DOI: 10.1016/j.jcrc.2024.154764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/02/2024] [Accepted: 02/26/2024] [Indexed: 03/11/2024]
Abstract
PURPOSE Real-world comparison of RRT modality on RRT dependence at 90 days postdischarge among ICU patients discharged alive after RRT for acute kidney injury (AKI). METHODS Using claims-linked to US hospital discharge data (Premier PINC AI Healthcare Database [PHD]), we compared continuous renal replacement therapy (CRRT) vs. intermittent hemodialysis (IHD) for AKI in adult ICU patients discharged alive from January 1, 2018 to June 30, 2021. RRT dependence at 90 days postdischarge was defined as ≥2 RRT treatments in the last 8 days. Between-group differences were balanced using inverse probability treatment weighting (IPTW). RESULTS Of 34,804 patients, 3804 patients (from 382 hospitals) had claims coverage for days 83-90 postdischarge. Compared to IHD-treated patients (n = 2740), CRRT-treated patients (n = 1064) were younger; had more admission to large teaching hospitals, surgery, sepsis, shock, mechanical ventilation, but lower prevalence of comorbidities (p < 0.05 for all). Compared to IHD-treated patients, CRRT-treated patients had lower RRT dependence at hospital discharge (26.5% vs. 29.8%, p = 0.04) and lower RRT dependence at 90 days postdischarge (4.9% vs. 7.4% p = 0.006) with weighted adjusted OR (95% CI): 0.68 (0.47-0.97), p = 0.03. Results persisted in sensitivity analyses including patients who died during days 1-90 postdischarge (n = 112) or excluding patients from hospitals with IHD patients only (n = 335), or when excluding patients who switched RRT modalities (n = 451). CONCLUSIONS Adjusted for potential confounders, the odds of RRT dependence at 90 days postdischarge among survivors of RRT for AKI was 30% lower for those treated first with CRRT vs. IHD, overall and in several sensitivity analyses. SUMMARY Critically ill patients in intensive care units (ICU) may develop acute kidney injury (AKI) that requires renal replacement therapy (RRT) to temporarily replace the injured kidney function of cleaning the blood. Two main types of RRT in the ICU are called continuous renal replacement therapy (CRRT), which is performed almost continuously, i.e., for >18 h per day, and intermittent hemodialysis (IHD), which is a more rapid RRT that is usually completed in a little bit over 6 h, several times per week. The slower CRRT may be gentler on the kidneys and is more likely to be used in the sickest patients, who may not be able to tolerate IHD. We conducted a data-analysis study to evaluate whether long-term effects on kidney function (assessed by ongoing need for RRT, i.e., RRT dependence) differ depending on use of CRRT vs. IHD. In a very large US linked hospital-discharge/claims database we found that among ICU patients discharge alive after RRT for AKI, fewer CRRT-treated patients had RRT dependence at hospital discharge (26.5% vs. 29.8%, p = 0.04) and at 90 days after discharge (4.9% vs. 7.4% p = 0.006). In adjusted models, RRT dependence at 90 days postdischarge was >30% lower for CRRT than IHD-treated patients. These results from a non-randomized study suggest that among survivors of RRT for AKI, CRRT may result in less RRT dependence 90 days after hospital discharge.
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Affiliation(s)
- Jay L Koyner
- Section of Nephrology, University of Chicago, Chicago, IL, USA
| | - Rachel H Mackey
- Premier, Inc., PINC AI Applied Sciences, Charlotte, NC, USA; Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA.
| | - Jorge Echeverri
- Baxter Healthcare, Global Medical Affairs, Deerfield, IL, USA
| | | | | | | | - Kai Harenski
- Baxter Deutschland GmbH, Unterschleissheim, Germany
| | - Javier A Neyra
- University of Alabama at Birmingham, Birmingham, AL, USA
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Aggarwal HK, Jain D, Agarwal A, Dahiya S, Misra P, Saha A. Comparison of outcomes of different modalities of renal replacement therapy in patients of acute kidney injury: a single centre prospective observational study. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2024; 62:138-149. [PMID: 38153884 DOI: 10.2478/rjim-2023-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Acute Kidney Injury (AKI) is one of the most important causes of in-hospital mortality. The global burden of AKI continues to rise without a marked reduction in mortality. As such, the use of renal replacement therapy (RRT) forms an integral part of AKI management, especially in critically ill patients. There has been much debate over the preferred modality of RRT between continuous, intermittent and intermediate modes. While there is abundant data from Europe and North America, data from tropical countries especially the Indian subcontinent is sparse. Our study aims to provide an Indian perspective on the dialytic management of tropical AKI in a tertiary care hospital setup. METHODS 90 patients of AKI, 30 each undergoing Continuous Renal Replacement Therapy (CRRT), Intermittent Hemodialysis (IHD) and SLED (Sustained Low-Efficiency Dialysis) were included in this prospective cohort study. At the end of 28 days of hospital stay, discharge or death, outcome measures were ascertained which included mortality, duration of hospital stay, recovery of renal function and requirement of RRT after discharge. In addition median of the net change of renal parameters was also computed across the three groups. Lastly, Kaplan Meier analysis was performed to assess the probability of survival with the use of each modality of RRT. RESULTS There was no significant difference in the primary outcome of mortality between the three cohorts (p=0.27). However, CRRT was associated with greater renal recovery (p= 0.015) than IHD or SLED. On the other hand, SLED and IHD were associated with a greater net reduction in blood urea (p=0.004) and serum creatinine (p=0.053). CONCLUSION CRRT, IHD and SLED are all complementary to each other and are viable options in the treatment of AKI patients.
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Affiliation(s)
- H K Aggarwal
- 1Sr. Professor & Head, Department of Medicine, PGIMS, Rohtak, India
| | - Deepak Jain
- 2Sr. Professor, Department of Medicine, PGIMS, Rohtak, India
| | - Arpit Agarwal
- 3Resident, Department of Medicine, Department of Medicine, PGIMS, Rohtak, India
| | - Shaveta Dahiya
- 4Assistant professor, Department of Medicine, PGIMS, Rohtak, India
| | - Prabhakar Misra
- 5Additional Professor, Dept. of Biostatistics, SGPGIMS Lucknow
| | - Arup Saha
- 6Senior Resident, Department of Community Medicine, Andaman & Nicobar Islands Institute of Medical Sciences, A & N Island
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Chander S, Luhana S, Sadarat F, Parkash O, Rahaman Z, Wang HY, Kiran F, Lohana AC, Sapna F, Kumari R. Mortality and mode of dialysis: meta-analysis and systematic review. BMC Nephrol 2024; 25:1. [PMID: 38172835 PMCID: PMC10763097 DOI: 10.1186/s12882-023-03435-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The global use of kidney replacement therapy (KRT) has increased, mirroring the incidence of acute kidney injury and chronic kidney disease. Despite its growing clinical usage, patient outcomes with KRT modalities remain controversial. In this meta-analysis, we sought to compare the mortality outcomes of patients with any kidney disease requiring peritoneal dialysis (PD), hemodialysis (HD), or continuous renal replacement therapy (CRRT). METHODS The investigation was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed (MEDLINE), Cochrane Library, and Embase databases were screened for randomized trials and observational studies comparing mortality rates with different KRT modalities in patients with acute or chronic kidney failure. A random-effects model was applied to compute the risk ratio (RR) and 95% confidence intervals (95%CI) with CRRT vs. HD, CRRT vs. PD, and HD vs. PD. Heterogeneity was assessed using I2 statistics, and sensitivity using leave-one-out analysis. RESULTS Fifteen eligible studies were identified, allowing comparisons of mortality risk with different dialytic modalities. The relative risk was non-significant in CRRT vs. PD [RR = 0.95, (95%CI 0.53, 1.73), p = 0.92 from 4 studies] and HD vs. CRRT [RR = 1.10, (95%CI 0.95, 1.27), p = 0.21 from five studies] comparisons. The findings remained unchanged in the leave-one-out sensitivity analysis. Although PD was associated with lower mortality risk than HD [RR = 0.78, (95%CI 0.62, 0.97), p = 0.03], the significance was lost with the exclusion of 4 out of 5 included studies. CONCLUSION The current evidence indicates that while patients receiving CRRT may have similar mortality risks compared to those receiving HD or PD, PD may be associated with lower mortality risk compared to HD. However, high heterogeneity among the included studies limits the generalizability of our findings. High-quality studies comparing mortality outcomes with different dialytic modalities in CKD are necessary for a more robust safety and efficacy evaluation.
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Affiliation(s)
- Subhash Chander
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Sindhu Luhana
- Department of Medicine, AGA khan University Hospital, Karachi, Pakistan
| | - Fnu Sadarat
- Department of Medicine, University at Buffalo, New York, USA
| | - Om Parkash
- Department of Medicine, Montefiore Medical Centre, Wakefield, New York, USA
| | - Zubair Rahaman
- Department of Medicine, University at Buffalo, New York, USA
| | - Hong Yu Wang
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Fnu Kiran
- Department of Pathology, Northwell Health Staten Island University Hospital, New York, USA
| | - Abhi Chand Lohana
- Department of Medicine, WVU, Camden Clark Medical Centre, Parkersburg, WV, USA
| | - Fnu Sapna
- Department of Pathology, Albert Einstein School of Medicine, Montefiore Medical Centre, New York, USA
| | - Roopa Kumari
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, USA
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Smit JM, Krijthe JH, Kant WMR, Labrecque JA, Komorowski M, Gommers DAMPJ, van Bommel J, Reinders MJT, van Genderen ME. Causal inference using observational intensive care unit data: a scoping review and recommendations for future practice. NPJ Digit Med 2023; 6:221. [PMID: 38012221 PMCID: PMC10682453 DOI: 10.1038/s41746-023-00961-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/05/2023] [Indexed: 11/29/2023] Open
Abstract
This scoping review focuses on the essential role of models for causal inference in shaping actionable artificial intelligence (AI) designed to aid clinicians in decision-making. The objective was to identify and evaluate the reporting quality of studies introducing models for causal inference in intensive care units (ICUs), and to provide recommendations to improve the future landscape of research practices in this domain. To achieve this, we searched various databases including Embase, MEDLINE ALL, Web of Science Core Collection, Google Scholar, medRxiv, bioRxiv, arXiv, and the ACM Digital Library. Studies involving models for causal inference addressing time-varying treatments in the adult ICU were reviewed. Data extraction encompassed the study settings and methodologies applied. Furthermore, we assessed reporting quality of target trial components (i.e., eligibility criteria, treatment strategies, follow-up period, outcome, and analysis plan) and main causal assumptions (i.e., conditional exchangeability, positivity, and consistency). Among the 2184 titles screened, 79 studies met the inclusion criteria. The methodologies used were G methods (61%) and reinforcement learning methods (39%). Studies considered both static (51%) and dynamic treatment regimes (49%). Only 30 (38%) of the studies reported all five target trial components, and only seven (9%) studies mentioned all three causal assumptions. To achieve actionable AI in the ICU, we advocate careful consideration of the causal question of interest, describing this research question as a target trial emulation, usage of appropriate causal inference methods, and acknowledgement (and examination of potential violations of) the causal assumptions.
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Affiliation(s)
- J M Smit
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands.
- Pattern Recognition & Bioinformatics group, EEMCS, Delft University of Technology, Delft, The Netherlands.
| | - J H Krijthe
- Pattern Recognition & Bioinformatics group, EEMCS, Delft University of Technology, Delft, The Netherlands
| | - W M R Kant
- Data Science group, Institute for Computing and Information Sciences, Radboud University, Nijmegen, The Netherlands
| | - J A Labrecque
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - M Komorowski
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Intensive Care Unit, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - D A M P J Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J van Bommel
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M J T Reinders
- Pattern Recognition & Bioinformatics group, EEMCS, Delft University of Technology, Delft, The Netherlands
| | - M E van Genderen
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
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Bagshaw SM, Neyra JA, Tolwani AJ, Wald R. Debate: Intermittent Hemodialysis versus Continuous Kidney Replacement Therapy in the Critically Ill Patient: The Argument for CKRT. Clin J Am Soc Nephrol 2023; 18:647-660. [PMID: 39074305 DOI: 10.2215/cjn.0000000000000056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
Continuous kidney replacement therapy (CKRT) is well entrenched as one of the dominant KRT modalities in modern critical care practice. Since its introduction four decades ago, there have been considerable innovations in CKRT machines that have improved precision, safety, and simplicity. CKRT is the preferred KRT modality for critically ill patients with hemodynamic instability. Early physical therapy and rehabilitation can be feasibly and safely provided to patients connected to CKRT, thus obviating concerns about immobility. Although randomized clinical trials have not shown a mortality difference when comparing CKRT and intermittent hemodialysis, CKRT allows precision delivery of solute and fluid removal that can be readily adjusted in the face of dynamic circumstances. Accumulated evidence from observational studies, although susceptible to bias, has shown that CKRT, when compared with intermittent hemodialysis, is associated with better short- and long-term kidney recovery and KRT independence. Critical care medicine encompasses a wide range of sick patients, and no single KRT modality is likely to ideally suit every patient in every context and for every condition. The provision of KRT represents a spectrum of modalities to which patients can flexibly transition in response to their evolving condition. As a vital tool for organ support in the intensive care unit, CKRT enables the personalization of KRT to meet the clinical demands of patients during the most severe phases of their illness.
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Affiliation(s)
- Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, Alberta, Canada
| | - Javier A Neyra
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashita J Tolwani
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital and the University of Toronto and the Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
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Chaïbi K, Dreyfuss D, Gaudry S. Debate: Intermittent Hemodialysis versus Continuous Kidney Replacement Therapy in the Critically Ill Patient: The Choice Should Be Evidence Based. Clin J Am Soc Nephrol 2023; 18:661-667. [PMID: 36723298 PMCID: PMC10278838 DOI: 10.2215/cjn.0000000000000104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 02/02/2023]
Abstract
Kidney replacement therapy (KRT) plays a major role in the treatment of severe AKI. Intermittent hemodialysis (HD) and continuous KRT (CKRT) are the main modalities in critically ill patients with AKI. CKRT is the preferred modality in many countries because of its alleged superiority on both hemodynamic tolerance and on kidney function recovery. In fact, randomized controlled trials (RCTs) comparing the two modalities have not shown any actual benefit of one technique over the other on mortality, hemodynamics, or kidney function recovery. Those RCTs were conducted more than 15 years ago. Major progress was eventually made leading to much lower mortality rates in recent studies than in previous studies. In addition, those RCTs included a noticeable proportion of patients who could have recovered without ever receiving KRT, as demonstrated by several recent studies. In the absence of evidence of clinical superiority of one KRT modality, the choice must be addressed not only regarding clinical outcome but also resources and logistics. Conclusions of health technology assessments and study reports were heterogeneous and conflicting concerning cost-effectiveness of intermittent HD versus CKRT. All these considerations justify a reevaluation of the issue in new RCTs that take into account recent knowledge on KRT initiation and management. Pending results of such study, the choice should be guided mainly by organizational considerations in each unit and without condemning any modality in the absence of proof.
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Affiliation(s)
- Khalil Chaïbi
- AP-HP, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, Bobigny, France
- French National Institute of Health and Medical Research (INSERM), UMR_S1155, CORAKID, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Didier Dreyfuss
- French National Institute of Health and Medical Research (INSERM), UMR_S1155, CORAKID, Hôpital Tenon, Sorbonne Université, Paris, France
- Service de Médecine Intensive Réanimation, Hôpital Louis Mourier, Assistance Publique, Colombes, France
- Université de Paris-Cité, Paris, France
| | - Stéphane Gaudry
- AP-HP, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, Bobigny, France
- French National Institute of Health and Medical Research (INSERM), UMR_S1155, CORAKID, Hôpital Tenon, Sorbonne Université, Paris, France
- Health Care Simulation Center, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France
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7
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Kim SG, Lee J, Yun D, Kang MW, Kim YC, Kim DK, Oh KH, Joo KW, Kim YS, Han SS. Hyperlactatemia is a predictor of mortality in patients undergoing continuous renal replacement therapy for acute kidney injury. BMC Nephrol 2023; 24:11. [PMID: 36641421 PMCID: PMC9840420 DOI: 10.1186/s12882-023-03063-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Hyperlactatemia occurs frequently in critically ill patients, and this pathologic condition leads to worse outcomes in several disease subsets. Herein, we addressed whether hyperlactatemia is associated with the risk of mortality in patients undergoing continuous renal replacement therapy (CRRT) due to acute kidney injury. METHODS A total of 1,661 patients who underwent CRRT for severe acute kidney injury were retrospectively reviewed between 2010 and 2020. The patients were categorized according to their serum lactate levels, such as high (≥ 7.6 mmol/l), moderate (2.1-7.5 mmol/l) and low (≤ 2 mmol/l), at the time of CRRT initiation. The hazard ratios (HRs) for the risk of in-hospital mortality were calculated with adjustment of multiple variables. The increase in the area under the receiver operating characteristic curve (AUROC) for the mortality risk was evaluated after adding serum lactate levels to the Sequential Organ Failure Assessment (SOFA) and the Acute Physiology and Chronic Health Evaluation (APACHE) II score-based models. RESULTS A total of 802 (48.3%) and 542 (32.6%) patients had moderate and high lactate levels, respectively. The moderate and high lactate groups had a higher risk of mortality than the low lactate group, with HRs of 1.64 (1.22-2.20) and 4.18 (2.99-5.85), respectively. The lactate-enhanced models had higher AUROCs than the models without lactates (0.764 vs. 0.702 for SOFA score; 0.737 vs. 0.678 for APACHE II score). CONCLUSIONS Hyperlactatemia is associated with mortality outcomes in patients undergoing CRRT for acute kidney injury. Serum lactate levels may need to be monitored in this patient subset.
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Affiliation(s)
- Seong Geun Kim
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Jinwoo Lee
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Donghwan Yun
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Min Woo Kang
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Yong Chul Kim
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Dong Ki Kim
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Kook-Hwan Oh
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Kwon Wook Joo
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Yon Su Kim
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Seung Seok Han
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
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8
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Hellman T, Uusalo P, Järvisalo MJ. Pre-emptive vs. classic criteria for initiation of dialysis in critically ill patients with acute kidney injury (AKI) - A retrospective real-world study. Hemodial Int 2023; 27:28-37. [PMID: 36351743 DOI: 10.1111/hdi.13052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/05/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Guidelines recommend starting renal replacement therapy (RRT) in critically ill acute kidney injury (AKI) patients according to classic criteria for the initiation of dialysis (CCID). However, comparative data on the presence or absence of CCID in patients receiving continuous veno-venous hemodialysis (CVVHD) or intermittent hemodialysis (IHD) as the initial modality are scarce. METHODS Altogether 733 critically ill AKI patients receiving CVVHD or IHD at the research hospital between 2010 and 2019 were screened for this real-world study. All patients on maintenance dialysis were excluded. Patient survival was studied in 662 patients and adverse renal outcomes in 375 surviving patients at 90 days follow-up. The adverse renal outcome was defined as RRT requirement and the secondary outcome was estimated glomerular filtration rate (eGFR) at 90 days follow-up. FINDINGS Altogether 472 (71.3%) patients received CVVHD and 190 (28.7%) IHD, and CCID was present at the time of RRT initiation in 250 (37.8%). The CCID was independently associated with mortality in a multivariable logistic regression analysis (odds ratio [OR] 2.226, 95% confidence interval [CI] 1.455-3.407, p < 0.001) adjusted for age, sex, baseline eGFR, disease severity, RRT modality, hypertension, and diabetes. The presence of CCID at the start of RRT was not associated with adverse renal outcome (OR 0.548, 95% CI 0.230-1.305, p = 1.74) nor eGFR (β = 0.155, p = 0.066) at 90 days follow-up. However, starting RRT in the presence of CCID was independently associated with eGFR at 90 days follow-up in a multivariable ordinal regression analysis (β = 0.930, p = 0.018) after adjusting for age, sex, baseline eGFR, disease severity markers, hypertension, and diabetes in patients receiving CVVHD but not IHD as the initial modality. DISCUSSION The presence of CCID at the initiation of RRT was associated with mortality but not adverse renal outcomes in this large real-world study on critically ill AKI patients requiring RRT. Initiating RRT in the presence of CCID was associated with improved eGFR at 90 days follow-up in patients receiving CVVHD as the initial modality.
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Affiliation(s)
- Tapio Hellman
- Kidney Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Panu Uusalo
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Mikko J Järvisalo
- Kidney Center, Turku University Hospital and University of Turku, Turku, Finland.,Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Turku, Finland
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9
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Soum E, Timsit JF, Ruckly S, Gruson D, Canet E, Klouche K, Argaud L, Garrouste-Orgeas M, Mariat C, Vincent F, Cayot S, Darmon M, Bohé J, Schwebel C, Bouadma L, Dupuis C, Souweine B, Lautrette A. Predictive factors for severe long-term chronic kidney disease after acute kidney injury requiring renal replacement therapy in critically ill patients: an ancillary study of the ELVIS randomized controlled trial. Crit Care 2022; 26:367. [PMID: 36447221 PMCID: PMC9706988 DOI: 10.1186/s13054-022-04233-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/10/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) requiring renal replacement therapy (RRT) is a serious complication in the ICU that results in increased mortality and risk of chronic kidney disease (CKD). Some studies suggest RRT modality may have an impact on long-term renal recovery after AKI. However, other predictive factors of severe long-term CKD in ICU patients with AKI requiring RRT are unknown. METHODS We performed an ancillary study of the multicenter ELVIS trial in the population with AKI requiring RRT. Patients alive 3 months after RRT initiation were eligible. Serum creatinine levels available at 3, 6 and 12 months and 3 and 5 years were recorded. CKD stage was determined according to the glomerular filtration rate as estimated by the CKD-EPI formula. At each timepoint, two groups of patients were compared, a no/mild CKD group with normal or mildly to moderately decreased renal function (stages 1, 2 and 3 of the international classification) and a severe CKD group (stages 4 and 5). Our objective was to identify predictive factors of severe long-term CKD. RESULTS Of the 287 eligible patients, 183 had follow-up at 3 months, 136 (74.3%) from the no/mild CKD group and 47 (25.7%) from the severe CKD group, and 122 patients at 5 years comprising 96 (78.7%) from the no/mild CKD group and 26 (21.3%) from the severe CKD group. Multivariate analysis showed that a long RRT period was associated with severe CKD up to 12 months (ORM12 = 1.03 95% CI [1.02-1.05] per day) and that a high SOFA score at the initiation of RRT was not associated with severe CKD up to 5 years (ORM60 = 0.85 95% CI [0.77-0.93] per point). CONCLUSION Severe long-term CKD was found in 21% of ICU survivors who underwent RRT for AKI. The duration of the RRT in AKI patients was identified as a new predictive factor for severe long-term CKD. This finding should be taken into consideration in future studies on the prognosis of ICU patients with AKI requiring RRT. Trial registration ELVIS trial was registered with ClinicalTrials.gov, number: NCT00875069 (June 16, 2014), and this ancillary study was registered with ClinicalTrials.gov, number: NCT03302624 (October 6, 2017).
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Affiliation(s)
- Edouard Soum
- Medical Intensive Care Unit, Intensive Care Medicine, Montpied Teaching Hospital, 54 Rue Montalembert, BP69, 63003 Clermont-Ferrand, Cedex 1, France
| | - Jean-François Timsit
- Medical Intensive Care Unit, Albert Michallon Teaching Hospital, Grenoble, France ,Medical Intensive Care Unit, Bichat-Claude Bernard Teaching Hospital, Paris, France
| | | | - Didier Gruson
- Medical Intensive Care Unit, Pellegrin Teaching Hospital, Bordeaux, France
| | - Emmanuel Canet
- Medical Intensive Care Unit, Saint Louis Teaching Hospital, Paris, France
| | - Kada Klouche
- Medical Intensive Care Unit, Lapeyronie Teaching Hospital, Montpellier, France
| | - Laurent Argaud
- Medical Intensive Care Unit, Edouard Herriot Teaching Hospital, Lyon, France
| | | | - Christophe Mariat
- Nephrology and Critical Care Unit, Nord Teaching Hospital, Saint Etienne, France
| | - François Vincent
- Medical Intensive Care Unit, Avicenne Teaching Hospital, Paris, France
| | - Sophie Cayot
- Department of Anaesthesiology and Critical Care Medicine, Estaing Teaching Hospital, Clermont-Ferrand, France
| | - Michael Darmon
- grid.411147.60000 0004 0472 0283Medical Intensive Care Unit, Nord Teaching Hospital, Saint Etienne, France
| | - Julien Bohé
- grid.413852.90000 0001 2163 3825Medical Intensive Care Unit, Groupement Hospitalier Sud, Hospices Civils de Lyon, Pierre Bénite, Lyon, France
| | - Carole Schwebel
- Medical Intensive Care Unit, Albert Michallon Teaching Hospital, Grenoble, France
| | - Lila Bouadma
- Medical Intensive Care Unit, Bichat-Claude Bernard Teaching Hospital, Paris, France
| | - Claire Dupuis
- Medical Intensive Care Unit, Intensive Care Medicine, Montpied Teaching Hospital, 54 Rue Montalembert, BP69, 63003 Clermont-Ferrand, Cedex 1, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, Intensive Care Medicine, Montpied Teaching Hospital, 54 Rue Montalembert, BP69, 63003 Clermont-Ferrand, Cedex 1, France ,grid.494717.80000000115480420LMGE (Laboratoire Micro-Organismes: Génome et Environnement), UMR CNRS 6023, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Alexandre Lautrette
- Medical Intensive Care Unit, Intensive Care Medicine, Montpied Teaching Hospital, 54 Rue Montalembert, BP69, 63003 Clermont-Ferrand, Cedex 1, France ,grid.494717.80000000115480420LMGE (Laboratoire Micro-Organismes: Génome et Environnement), UMR CNRS 6023, Université Clermont Auvergne, Clermont-Ferrand, France
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10
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Rutherford E, Leach JF, Bennett EJA, Rutherford JS, Urquhart L, Watt E, Allen RM, Wrathall DW, Williams D, Muniraju TM. Acute intermittent renal replacement therapy in a rural Scottish intensive care unit - a review of patient and renal outcomes. J Intensive Care Soc 2022; 23:503-505. [PMID: 36751344 PMCID: PMC9679914 DOI: 10.1177/17511437211018616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In this study we report 5-year outcomes for patients who received intermittent haemodiafiltration for Acute Kidney Injury (AKI) between 2010 and 2014 in a small Scottish Intensive Care Unit (ICU). Dialysis independence and mortality at ICU discharge, 30 and 90 days, one and five years were determined. There were 1496 admissions to ICU during the study period. 12% of patient admissions required Renal Replacement Therapy (RRT). 56.3% of patients survived to ICU discharge and all were RRT independent at ICU discharge. 30 day, 90 day, 1 year and 5 year survival was 52.3%, 50.6%, 46.6% and 30.7% respectively. By 5 years, 2 patients had developed end stage kidney disease.
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Affiliation(s)
- Elaine Rutherford
- Department of Nephrology, Mountainhall Treatment Centre and
Dumfries and Galloway Royal Infirmary, Dumfries, UK,Institute of Cardiovascular and Medical Sciences, BHF Clinical
Research Centre, University of Glasgow, Glasgow, UK
| | - James F Leach
- Department of Nephrology, Mountainhall Treatment Centre and
Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - Ella JA Bennett
- Department of Nephrology, Mountainhall Treatment Centre and
Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - John S Rutherford
- Department of Anaesthetics and Critical Care, Dumfries and
Galloway Royal Infirmary, Dumfries, UK
| | - Leo Urquhart
- Department of Anaesthetics and Critical Care, Dumfries and
Galloway Royal Infirmary, Dumfries, UK
| | - Euan Watt
- Department of Nephrology, Mountainhall Treatment Centre and
Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - Ruridh M Allen
- Department of Nephrology, Mountainhall Treatment Centre and
Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - D Wayne Wrathall
- Department of Anaesthetics and Critical Care, Dumfries and
Galloway Royal Infirmary, Dumfries, UK
| | - Dewi Williams
- Department of Anaesthetics and Critical Care, Dumfries and
Galloway Royal Infirmary, Dumfries, UK
| | - Thalakunte M Muniraju
- Department of Nephrology, Mountainhall Treatment Centre and
Dumfries and Galloway Royal Infirmary, Dumfries, UK,Thalakunte Muniraju, NHS Dumfries &
Galloway Health Board, Renal Unit, Mountainhall Treatment Centre, Bankend Road,
Dumfries DG1 4AP, UK.
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11
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Lee CC, Kuo G, Chan MJ, Fan PC, Chen JJ, Yen CL, Tsai TY, Chen YC, Tian YC, Chang CH. Characteristics of and Outcomes After Dialysis-Treated Acute Kidney Injury, 2009-2018: A Taiwanese Multicenter Study. Am J Kidney Dis 2022; 81:665-674.e1. [PMID: 36252882 DOI: 10.1053/j.ajkd.2022.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022]
Abstract
RATIONALE & OBJECTIVE Dialysis-treated acute kidney injury (AKI) is increasingly common in intensive care units (ICUs) and is associated with poor outcomes. Few studies have explored the temporal trends in severity of acute illness at dialysis initiation, indications for dialysis, and their association with patient outcomes. STUDY DESIGN Multicenter retrospective cohort study. SETTING & PARTICIPANTS 9,535 adult patients admitted to the ICU who received their first dialysis treatment from Chang Gung Memorial Hospital system in Taiwan from 2009 through 2018. EXPOSURE Calendar year. OUTCOMES ICU mortality and dialysis treatment at discharge among hospital survivors. ANALYTICAL APPROACH The temporal trends during the study period were investigated using test statistics suited for continuous or categorical data. The association between the study year and the risk of mortality was analyzed using multivariable Cox regression with adjustment for relevant clinical variables, including the severity of acute illness, defined by Sequential Organ Failure Assessment (SOFA) score. RESULTS The mean SOFA score at dialysis initiation decreased slightly from 14.0 in 2009 to 13.6 in 2018. There was no significant trend in the number of indications for dialysis initiation that were fulfilled over time. Observed ICU mortality decreased over time, and the curve appeared to be reverse J-shaped, with a substantial decrease from 56.1% in 2009 to 46.3% in 2015 and a slight increase afterward. The risk of mortality was significantly reduced from 2013 to 2018 compared with 2009 in adjusted models. The decreasing trend in ICU mortality over time remained significant. There was an increase in dialysis treatment at discharge among survivors, mainly in patients with estimated glomerular filtration rate<60mL/min/1.73m2, from 36.8% in 2009 to 43.9% in 2018. LIMITATIONS Residual confounding from unmeasured factors over time such as severity of comorbidities, detailed medication interventions, and delivered dialysis dose. CONCLUSIONS We observed reductions in mortality among ICU patients with dialysis-treated acute kidney injury between 2009 and 2018, even after adjusting for dialysis indication and severity of illness at dialysis initiation. However, dialysis treatment at discharge among survivors has increased over time, mainly in patients with preexisting kidney disease.
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Affiliation(s)
- Cheng-Chia Lee
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - George Kuo
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Jen Chan
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pei-Chun Fan
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jia-Jin Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chieh-Li Yen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tsung-Yu Tsai
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Chang Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ya-Chung Tian
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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12
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Wald R, Beaubien-Souligny W, Chanchlani R, Clark EG, Neyra JA, Ostermann M, Silver SA, Vaara S, Zarbock A, Bagshaw SM. Delivering optimal renal replacement therapy to critically ill patients with acute kidney injury. Intensive Care Med 2022; 48:1368-1381. [PMID: 36066597 DOI: 10.1007/s00134-022-06851-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
Critical illness is often complicated by acute kidney injury (AKI). In patients with severe AKI, renal replacement therapy (RRT) is deployed to address metabolic dysfunction and volume excess until kidney function recovers. This review is intended to provide a comprehensive update on key aspects of RRT prescription and delivery to critically ill patients. Recently completed trials have enhanced the evidence base regarding several RRT practices, most notably the timing of RRT initiation and anticoagulation for continuous therapies. Better evidence is still needed to clarify several aspects of care including optimal targets for ultrafiltration and effective strategies for RRT weaning and discontinuation.
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Affiliation(s)
- Ron Wald
- Division of Nephrology, St. Michael's Hospital and the University of Toronto, 61 Queen Street East, 9-140, Toronto, ON, M5C 2T2, Canada. .,Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
| | | | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Javier A Neyra
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marlies Ostermann
- Department of Critical Care Medicine, Guys and St. Thomas Hospital, London, UK
| | - Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada
| | - Suvi Vaara
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, Muenster, Germany
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
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13
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Verma S, Graham MM, Lecamwasam A, Romanovsky A, Duggan S, Bagshaw S, Senaratne JM. Cardiorenal Interactions: A Review. CJC Open 2022; 4:873-885. [PMID: 36254331 PMCID: PMC9568715 DOI: 10.1016/j.cjco.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 06/24/2022] [Indexed: 10/29/2022] Open
Abstract
A complex interaction occurs between cardiac and renal function. They are intricately tied together, and a range of disorders in both the heart and kidneys can alter the function of the other. The pathophysiology is complex, and these conditions are termed cardiorenal syndromes. They can be acute and/or chronic in nature, they result in and from hemodynamic consequences, systemic congestion, and metabolic abnormalities, and they lead to dysfunction of both the heart and kidneys. The aim of this article is to provide a review for cardiologists and intensivists who are treating patients for whom cardiac and renal interactions may complicate their picture. We review acute kidney injuries, management of the complications of renal dysfunction, renal replacement therapy, and cardiorenal syndromes.
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Affiliation(s)
- Sanam Verma
- Division of Cardiology, Department of Medicine, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle M. Graham
- Division of Cardiology, Department of Medicine, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Ashani Lecamwasam
- School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia
- Department of Nephrology, Northern Health, Epping, Victoria, Australia
- Epworth UroRenal and Vascular Clinical Institute, Internal Medicine Clinical Institute, Victoria, Australia
| | - Adam Romanovsky
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Shelley Duggan
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sean Bagshaw
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Janek Manoj Senaratne
- Division of Cardiology, Department of Medicine, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
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14
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Gaudry S, Grolleau F, Barbar S, Martin-Lefevre L, Pons B, Boulet É, Boyer A, Chevrel G, Montini F, Bohe J, Badie J, Rigaud JP, Vinsonneau C, Porcher R, Quenot JP, Dreyfuss D. Continuous renal replacement therapy versus intermittent hemodialysis as first modality for renal replacement therapy in severe acute kidney injury: a secondary analysis of AKIKI and IDEAL-ICU studies. Crit Care 2022; 26:93. [PMID: 35379300 PMCID: PMC8981658 DOI: 10.1186/s13054-022-03955-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/03/2022] [Indexed: 01/05/2023] Open
Abstract
Background Intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) are the two main RRT modalities in patients with severe acute kidney injury (AKI). Meta-analyses conducted more than 10 years ago did not show survival difference between these two modalities. As the quality of RRT delivery has improved since then, we aimed to reassess whether the choice of IHD or CRRT as first modality affects survival of patients with severe AKI. Methods This is a secondary analysis of two multicenter randomized controlled trials (AKIKI and IDEAL-ICU) that compared an early RRT initiation strategy with a delayed one. We included patients allocated to the early strategy in order to emulate a trial where patients would have been randomized to receive either IHD or CRRT within twelve hours after the documentation of severe AKI. We determined each patient’s modality group as the first RRT modality they received. The primary outcome was 60-day overall survival. We used two propensity score methods to balance the differences in baseline characteristics between groups and the primary analysis relied on inverse probability of treatment weighting. Results A total of 543 patients were included. Continuous RRT was the first modality in 269 patients and IHD in 274. Patients receiving CRRT had higher cardiovascular and total-SOFA scores. Inverse probability weighting allowed to adequately balance groups on all predefined confounders. The weighted Kaplan–Meier death rate at day 60 was 54·4% in the CRRT group and 46·5% in the IHD group (weighted HR 1·26, 95% CI 1·01–1·60). In a complementary analysis of less severely ill patients (SOFA score: 3–10), receiving IHD was associated with better day 60 survival compared to CRRT (weighted HR 1.82, 95% CI 1·01–3·28; p < 0.01). We found no evidence of a survival difference between the two RRT modalities in more severe patients. Conclusion Compared to IHD, CRRT as first modality seemed to convey no benefit in terms of survival or of kidney recovery and might even have been associated with less favorable outcome in patients with lesser severity of disease. A prospective randomized non-inferiority trial should be implemented to solve the persistent conundrum of the optimal RRT technique. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03955-9.
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Affiliation(s)
- Stéphane Gaudry
- Département de Réanimation Médico-Chirurgicale, APHP Hôpital Avicenne, Bobigny, France. .,Health Care Simulation Center, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France. .,Common and Rare Kidney Diseases, INSERM, UMR-S 1155, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France. .,Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Bobigny, France.
| | - François Grolleau
- Centre of Research in Epidemiology and Statistics (CRESS), Université de Paris, French Institute of Health and Medical Research (INSERM), National Institute of Agricultural Research (INRA), Paris, France
| | | | | | | | - Éric Boulet
- Réanimation Et USC, GH Carnelle Portes de L'Oise, 95260, Beaumont sur Oise, France
| | - Alexandre Boyer
- CHU de Bordeaux, Service de Réanimation Médicale, 33000, Bordeaux, France
| | | | - Florent Montini
- Réanimation Polyvalente, Centre Hospitalier d'Avignon, Avignon, France
| | - Julien Bohe
- Anesthésie Réanimation Médicale et Chirurgicale, CH Lyon Sud, Pierre Benite, France
| | - Julio Badie
- Réanimation Polyvalente, Hôpital Nord Franche-Comte CH Belfort, Belfort, France
| | | | - Christophe Vinsonneau
- Médecine Intensive Réanimation, CH Bethune Beuvry - Germont et Gauthier, Bethune, France
| | - Raphaël Porcher
- Centre of Research in Epidemiology and Statistics (CRESS), Université de Paris, French Institute of Health and Medical Research (INSERM), National Institute of Agricultural Research (INRA), Paris, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France.,INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Didier Dreyfuss
- Common and Rare Kidney Diseases, INSERM, UMR-S 1155, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France.,Médecine Intensive-Réanimation, APHP, Hôpital Louis Mourier, Université de Paris, Colombes, France
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15
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Yılmaz Aydın F, Aydın E, Kadiroglu AK. Comparison of the Treatment Efficacy of Continuous Renal Replacement Therapy and Intermittent Hemodialysis in Patients With Acute Kidney İnjury Admitted to the Intensive Care Unit. Cureus 2022; 14:e21707. [PMID: 35242474 PMCID: PMC8884082 DOI: 10.7759/cureus.21707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction and aim Acute kidney injury (AKI) is part of the multiple organ dysfunction syndrome in critically ill patients and is a common condition in intensive care units (ICUs). Renal replacement therapy (RRT) is the cornerstone of treatment for AKI in critically ill patients. This patient population has a high mortality rate despite RRT. There are two methods of RRT for patients in ICUs: intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT). Both CRRT and IHD similarly provide adequate metabolic control. We aimed to compare these two RRT modalities in terms of ICU stay, mortality, and laboratory recovery in these patients with high mortality. Materials and methods A total of 120 patients with AKI who needed RRT in the ICU were included in the study (CRRT, n:40; IHD, n:80). Acute Physiology and Chronic Health Evaluation (APACHE) II, Sepsis-related Organ Failure Assessment (SOFA), and Simplified Acute Physiology Score (SAPS)-II scores at the time of admission to the ICU were calculated. Mean arterial pressure, urea, creatinine, sodium, potassium, calcium, pH, lactate, and bicarbonate levels were measured before and after dialysis. Patients were classified as living and deceased. Factors affecting the length of stay in the intensive care unit and 30-day mortality were evaluated. The variability in laboratory parameters between groups before and after dialysis was examined. The groups were compared with these parameters. Results Sixty-one point seven percent (61.7%, n:74) of the patients were female. The mean age was 62.90±13.64 years. At the time of admission to the ICU, the patients' SAPS II score was 45.05±12.76, APACHE II score was 22.05±6.32, and SOFA score was 8.26±2.48. 66.7% (n:80) of the patients included in the study died, and the length of stay of these patients in the ICU was 12.85±10.23 days. When the groups were compared, SAPS II, APACHE II scores, and SOFA scores were significantly higher in the CRRT group than in the IHD group (p:0.038, p:0.015, p:0.027, respectively). Although the length of stay in the ICU was shorter in the CRRT group, it was not statistically significant (p:0.075). There was no statistically significant difference between the groups in terms of mortality (p: 0.891). SAPS-II, APACHE II, and SOFA score affected 30-day mortality while age, gender, and RRT modalities were not associated with mortality. The improvement in laboratory parameters between the pre and post-RRT groups was statistically more significant in the IHD group (p<0.001). It was determined that there was a statistically greater decrease in mean arterial pressure in the IHD group (p<0.001). Conclusions It was determined that there was no difference between the CRRT and IHD modalities applied in patients with AKI admitted to the ICU in terms of mortality and length of stay in the ICU. It was observed that both modalities improved on laboratory parameters, but the improvement was greater in the IHD group. However, it was determined that there was a statistically greater decrease in mean arterial pressure in the IHD group.
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16
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Thongprayoon C, Cheungpasitporn W, Radhakrishnan Y, Zabala Genovez JL, Petnak T, Shawwa K, Qureshi F, Mao MA, Kashani KB. Association of Serum Potassium Derangements with Mortality among Patients Requiring Continuous Renal Replacement Therapy. Ther Apher Dial 2022; 26:1098-1105. [PMID: 35067000 DOI: 10.1111/1744-9987.13804] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/05/2022] [Accepted: 01/19/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND We aimed to assess the association between serum potassium and mortality in patients receiving continuous renal replacement therapy (CRRT). METHODS We studied 1,279 acute kidney injury patients receiving CRRT in a tertiary referral hospital in the United States. We used logistic regression to assess the association of serum potassium before CRRT and mean serum potassium during CRRT with 90-day mortality after CRRT initiation, using serum potassium 4.0-4.4 mmol/L as reference group. RESULTS Before CRRT, there was a U-shaped association between serum potassium and 90-day mortality. There was a significant increase in mortality when serum potassium before CRRT was ≤3.4 and ≥4.5 mmol/L. During CRRT, progressively increased mortality was noted when mean serum potassium was ≥4.5 mmol/L. The odds ratio of 90-day mortality was significantly higher when mean serum potassium was ≥4.5 mmol/L. CONCLUSION Hypokalemia and hyperkalemia before CRRT and hyperkalemia during CRRT predicts 90-day mortality. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Jose L Zabala Genovez
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Tananchai Petnak
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.,Division of Pulmonary and Pulmonary Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Khaled Shawwa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Fawad Qureshi
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
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17
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Griffin BR, Eyck PT, Faubel S, Jalal D, Gallagher M, Bellomo R. Platelet Decreases following Continuous Renal Replacement Therapy Initiation as a Novel Risk Factor for Renal Nonrecovery. Blood Purif 2022; 51:559-566. [PMID: 34521084 PMCID: PMC8918433 DOI: 10.1159/000517232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/12/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) is a form of dialysis used in critically ill patients, and has recently been associated with renal nonrecovery. Decreases in platelets following CRRT initiation are common and are associated with mortality, but associations with renal recovery are unclear. Our objective was to determine if platelet nadir or the degree of platelet decrease following CRRT initiation was associated with renal nonrecovery. METHODS This is a secondary analysis of the Randomized Evaluation of Normal versus Augmented Level (RENAL) trial. Primary predictors were platelet nadir discretized by median value and percent platelet decrease following CRRT initiation, with cut points evaluated by decile from 30 to 60%. The 2 primary outcomes were time to RRT-independence and RRT-free days. Secondary outcomes were 28-day mortality, 90-day mortality, intensive care unit (ICU)-free, and hospital-free days. RESULTS Time to RRT independence censored for death was achieved less frequently in patients with low platelet nadir (hazard ratio [HR] 0.77, confidence interval [CI] 0.66-0.91) and in those with >50% platelet decrease (HR 0.84, CI 0.72-0.97). RRT-free days were lower in both low platelet nadir (odds ratio [OR] 0.94, CI 0.90-0.97) and >50% platelet decrease (OR 0.91, CI 0.88-0.95). These groups also had higher rates of 28- and 90-day mortality and fewer ICU-free and hospital-free days. Thrombocytopenia at CRRT initiation was also associated with renal nonrecovery, although the clinical effect was small. CONCLUSIONS Platelet nadir <100 × 103/µL and platelet decrease by >50% following CRRT initiation were both associated with lower rates of renal recovery. Further research is needed to evaluate mechanisms-linking platelet changes and renal nonrecovery in CRRT.
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Affiliation(s)
- Benjamin R Griffin
- Division of Nephrology, University of Iowa Carver College of Medicine, Iowa City, IA, USA, Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Patrick Ten Eyck
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Sarah Faubel
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Diana Jalal
- Division of Nephrology, University of Iowa Carver College of Medicine, Iowa City, IA, USA, Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Martin Gallagher
- The Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Rinaldo Bellomo
- The Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
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Chen X, Zhou J, Fang M, Yang J, Wang X, Wang S, Li L, Zhu T, Ji L, Yang L. Incidence- and In-hospital Mortality-Related Risk Factors of Acute Kidney Injury Requiring Continuous Renal Replacement Therapy in Patients Undergoing Surgery for Acute Type a Aortic Dissection. Front Cardiovasc Med 2021; 8:749592. [PMID: 34888362 PMCID: PMC8650701 DOI: 10.3389/fcvm.2021.749592] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/27/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Few studies on the risk factors for postoperative continuous renal replacement therapy (CRRT) in a homogeneous population of patients with acute type A aortic dissection (AAAD). This retrospective analysis aimed to investigate the risk factors for CRRT and in-hospital mortality in the patients undergoing AAAD surgery and to discuss the perioperative comorbidities and short-term outcomes. Methods: The study collected electronic medical records and laboratory data from 432 patients undergoing surgery for AAAD between March 2009 and June 2021. All the patients were divided into CRRT and non-CRRT groups; those in the CRRT group were divided into the survivor and non-survivor groups. The univariable and multivariable analyses were used to identify the independent risk factors for CRRT and in-hospital mortality. Results: The proportion of requiring CRRT and in-hospital mortality in the patients with CRRT was 14.6 and 46.0%, respectively. Baseline serum creatinine (SCr) [odds ratio (OR), 1.006], cystatin C (OR, 1.438), lung infection (OR, 2.292), second thoracotomy (OR, 5.185), diabetes mellitus (OR, 6.868), AKI stage 2-3 (OR, 22.901) were the independent risk factors for receiving CRRT. In-hospital mortality in the CRRT group (46%) was 4.6 times higher than in the non-CRRT group (10%). In the non-survivor (n = 29) and survivor (n = 34) groups, New York Heart Association (NYHA) class III-IV (OR, 10.272, P = 0.019), lactic acidosis (OR, 10.224, P = 0.019) were the independent risk factors for in-hospital mortality in patients receiving CRRT. Conclusion: There was a high rate of CRRT requirement and high in-hospital mortality after AAAD surgery. The risk factors for CRRT and in-hospital mortality in the patients undergoing AAAD surgery were determined to help identify the high-risk patients and make appropriate clinical decisions. Further randomized controlled studies are urgently needed to establish the risk factors for CRRT and in-hospital mortality.
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Affiliation(s)
- Xuelian Chen
- Division of Nephrology, Department of Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Jiaojiao Zhou
- Division of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Miao Fang
- Department of Orthopedics, Second People's Hospital of Chengdu, Chengdu, China
| | - Jia Yang
- Division of Nephrology, Department of Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Xin Wang
- Department of Pediatric Nephrology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Siwen Wang
- Division of Nephrology, Department of Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Linji Li
- Department of Anesthesiology, West China Hospital, Sichuan University, The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
| | - Ling Ji
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Lichuan Yang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
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Lin J, Zhuang HZ, Zhi DY, Qi Z, Bai J, Dong L, Liu S, Duan M. Impact of Cumulative Fluid Balance During Continuous Renal Replacement Therapy on Mortality in Patients With Septic Acute Kidney Injury: A Retrospective Cohort Study. Front Med (Lausanne) 2021; 8:762112. [PMID: 34869467 PMCID: PMC8636134 DOI: 10.3389/fmed.2021.762112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 10/01/2021] [Indexed: 11/25/2022] Open
Abstract
Background: The clinicians often use continuous renal replacement therapy (CRRT) for the fluid management of patients with septic acute kidney injury (AKI). However, there is limited knowledge of the effects of changes in fluid balance (FB) on CRRT and its association with outcomes in patients with septic AKI. Objective: This study aimed to determine the association of cumulative FB (CFB) during treatment with 28-day all-cause mortality in the patients with septic AKI who require CRRT. Methods: This retrospective observational study examined patients who received CRRT due to septic AKI in a mixed intensive care unit (ICU) of a tertiary teaching hospital between January 2015 and December 2018. The patients were divided into three groups—negative FB, even FB, and positive FB—based on the CFB during CRRT. The primary outcome was 28-day all-cause mortality. Results: We examined 227 eligible patients and the mean age was 62.4 ± 18.3 years. The even FB group had a significantly lower 28-day mortality (43.0%, p = 0.007) than the positive FB group (72.7%) and the negative FB group (54.8%). The unadjusted and adjusted Cox regression models indicated that the positive FB group had an increased risk for 28-day all-cause mortality relative to the even FB group. A restricted cubic splines model indicated a J-shaped association between the CFB and 28-day all-cause mortality in the unadjusted model. Conclusion: Among the critically ill patients with septic AKI who require CRRT, those with positive FB had a higher mortality rate than those with even FB.
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Affiliation(s)
- Jin Lin
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hai Zhou Zhuang
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - De Yuan Zhi
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhili Qi
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jing Bai
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lei Dong
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shuai Liu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Meili Duan
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Yen CL, Fan PC, Kuo G, Lee CC, Chen JJ, Lee TH, Tu YR, Hsu HH, Tian YC, Chang CH. Prognostic Performance of Existing Scoring Systems among Critically Ill Patients Requiring Continuous Renal Replacement Therapy: An Observational Study. J Clin Med 2021; 10:4592. [PMID: 34640610 PMCID: PMC8509572 DOI: 10.3390/jcm10194592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 09/30/2021] [Accepted: 10/01/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Among critical patients, few studies have evaluated the discrimination of current illness scoring systems in predicting outcomes after continuous renal replacement therapy (CRRT) initiation. METHODS Patients receiving CRRT in the ICU between 2005 and 2018 from the Chang Gung Research Database were extracted. All the components of the Acute Physiology Assessment and Chronic Health Evaluation (APACHE) III, Sequential Organ Failure Assessment (SOFA), qSOFA, and MOSAIC scoring systems on days 1, 3, and 7 of CRRT were recorded. Patients older than 80 years were identified and analyzed separately. RESULTS We identified 3370 adult patients for analysis. The discrimination ability of the scoring systems was acceptable at day 7 after CRRT initiation, including SOFA (area under the receiver operating characteristic curve, 74.1% (95% confidence interval, 71.7-76.5%)), APACHEIII (74.7% (72.3-77.1%)), and MOSAIC (71.3% (68.8%-73.9%)). These systems were not ideal on days 1 and 3, and that of qSOFA was poor at any time point. The discrimination performance was slightly better among patients ≥80 years. CONCLUSIONS APACHE III, MOSAIC, and SOFA can be intensivists and families' reference to make their decision of withdrawing or withholding CRRT after a short period of treatment, especially in adults ≥80 years old.
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Affiliation(s)
- Chieh-Li Yen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Pei-Chun Fan
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - George Kuo
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Cheng-Chia Lee
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Jia-Jin Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Tao-Han Lee
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Yi-Ran Tu
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Hsiang-Hao Hsu
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Ya-Chung Tian
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Chih-Hsiang Chang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
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Zhang K, Shang J, Chen Y, Huo Y, Li B, Hu Z. The prognosis and risk factors for acute kidney injury in high-risk patients after surgery for type A aortic dissection in the ICU. J Thorac Dis 2021; 13:4427-4437. [PMID: 34422369 PMCID: PMC8339792 DOI: 10.21037/jtd-21-823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 07/13/2021] [Indexed: 12/29/2022]
Abstract
Background Acute kidney injury (AKI) is a major complication of cardiac surgery, with high rates of morbidity and mortality. The aim of this study was to identify risk factors for the incidence and prognosis of AKI in high-risk patients before and after surgery for acute type A aortic dissection (TAAD) in the intensive care unit (ICU). Methods We performed a retrospective cohort study from April 2018 to April 2019. The primary end points of this study were morbidity due to AKI and risk factors for incidence, and the secondary end points were mortality at 28 days and risk factors for death. Results We enrolled 60 patients, 52 (86.67%) patients developed postoperative AKI, 28 (53.84%) patients died. Preoperative lactic acid level (P=0.022) and cardiopulmonary bypass (CPB) duration (P=0.009) were identified as independent risk factors for postoperative AKI. The 28-day mortality for postoperative patients with TAAD was 46.67%, 53.84% for those with TAAD and AKI, 67.5% for those who required continue renal replacement therapy (CRRT). The risk factors for 28-day mortality due to postoperative AKI for patients requiring CRRT were CPB duration (P=0.019) and norepinephrine dose upon diagnosis of AKI (P=0.037). Conclusions Morbidity due to AKI in postoperative patients with TAAD was 86.67%, and preoperative lactic acid level and CPB duration were independent risk factors. The 28-day mortality of postoperative patients with TAAD was 46.67%, 53.84% for those with TAAD and AKI, and 67.5% for those requiring CRRT. CPB duration and norepinephrine dose upon diagnosis of AKI may influence patients’ short-term prognosis.
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Affiliation(s)
- Kun Zhang
- Intensive Care Unit, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Shijiazhuang, China
| | - Jiuyan Shang
- Department of Pathology, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Shijiazhuang, China
| | - Yuhong Chen
- Intensive Care Unit, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Shijiazhuang, China
| | - Yan Huo
- Intensive Care Unit, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Shijiazhuang, China
| | - Bin Li
- Intensive Care Unit, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Shijiazhuang, China
| | - Zhenjie Hu
- Intensive Care Unit, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Shijiazhuang, China
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Zhou X, Dong P, Pan J, Wang H, Xu Z, Chen B. Renal replacement therapy modality in critically ill patients with acute kidney injury - A network meta-analysis of randomized controlled trials. J Crit Care 2021; 64:82-90. [PMID: 33836397 DOI: 10.1016/j.jcrc.2021.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 02/04/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE This network meta-analysis aims to compare the efficacy and safety of various renal replacement therapy (RRT) modalities in critically ill patients with acute kidney injury (AKI). MATERIALS AND METHODS We searched the electronic databases for randomized controlled trials (RCTs) comparing different RRT modalities, including continuous RRT, intermittent RRT, hybrid RRT, and peritoneal dialysis (PD), in critically ill patients with AKI through July 26, 2020. The primary outcomes were renal recovery and short-term mortality. The study protocol was registered with PROSPERO (CRD42020188115). RESULTS Twenty-three studies were included. No difference in the renal recovery or short-term mortality was observed among the four RRT modalities (low certainty). The four RRT modalities had similar effects on the incidence of infectious complications (low certainty). PD was associated with less fluid removal volume and lower incidence of hypotension compared with the extracorporeal modalities, yet no difference in the two outcomes was identified among the extracorporeal modalities (very low to moderate certainty). CONCLUSIONS No superiority of one particular RRT modality over another in terms of renal recovery and short-term mortality in critically ill patients with AKI. PD exhibited worse fluid removal and better safety in the prevention of hypotension than the extracorporeal modalities.
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Affiliation(s)
- Xiaoyang Zhou
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China; Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China
| | - Pingping Dong
- Baihe Street Community Health Service Center, Ningbo, Zhejiang 315000, China
| | - Jianneng Pan
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China; Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China
| | - Hua Wang
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China; Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China
| | - Zhaojun Xu
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China; Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China
| | - Bixin Chen
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China; Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China.
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Abdel-Rahman EM, Turgut F, Gautam JK, Gautam SC. Determinants of Outcomes of Acute Kidney Injury: Clinical Predictors and Beyond. J Clin Med 2021; 10:jcm10061175. [PMID: 33799741 PMCID: PMC7999959 DOI: 10.3390/jcm10061175] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/05/2021] [Accepted: 03/10/2021] [Indexed: 12/24/2022] Open
Abstract
Acute kidney injury (AKI) is a common clinical syndrome characterized by rapid impairment of kidney function. The incidence of AKI and its severe form AKI requiring dialysis (AKI-D) has been increasing over the years. AKI etiology may be multifactorial and is substantially associated with increased morbidity and mortality. The outcome of AKI-D can vary from partial or complete recovery to transitioning to chronic kidney disease, end stage kidney disease, or even death. Predicting outcomes of patients with AKI is crucial as it may allow clinicians to guide policy regarding adequate management of this problem and offer the best long-term options to their patients in advance. In this manuscript, we will review the current evidence regarding the determinants of AKI outcomes, focusing on AKI-D.
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Affiliation(s)
- Emaad M. Abdel-Rahman
- Division of Nephrology, University of Virginia, Charlottesville, VA 22908, USA;
- Correspondence: ; Tel.: +1-(434)-243-2671
| | - Faruk Turgut
- Internal Medicine/Nephrology, Faculty of Medicine, Mustafa Kemal University, Antakya/Hatay 31100, Turkey;
| | - Jitendra K. Gautam
- Division of Nephrology, University of Virginia, Charlottesville, VA 22908, USA;
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Abstract
Supplemental Digital Content is available in the text. Objectives: The determinants of decisions to limit life support (withholding or withdrawal) in ventilated stroke patients have been evaluated mainly for patients with intracranial hemorrhages. We aimed to evaluate the frequency of life support limitations in ventilated ischemic and hemorrhagic stroke patients compared with a nonbrain-injured population and to determine factors associated with such decisions. Design: Multicenter prospective French observational study. Setting: Fourteen ICUs of the French OutcomeRea network. PATIENTS: From 2005 to 2016, we included stroke patients and nonbrain-injured patients requiring invasive ventilation within 24 hours of ICU admission. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We identified 373 stroke patients (ischemic, n = 167 [45%]; hemorrhagic, n = 206 [55%]) and 5,683 nonbrain-injured patients. Decisions to limit life support were taken in 41% of ischemic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.59 [95% CI, 2.78–4.65]) and in 33% of hemorrhagic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.9 [95% CI, 2.97–5.11]). Time from ICU admission to the first limitation was longer in ischemic than in hemorrhagic stroke (5 [3–9] vs 2 d [1–6] d; p < 0.01). Limitation of life support preceded ICU death in 70% of ischemic strokes and 45% of hemorrhagic strokes (p < 0.01). Life support limitations in ischemic stroke were increased by a vertebrobasilar location (vs anterior circulation, subdistribution hazard ratio, 1.61 [95% CI, 1.01–2.59]) and a prestroke modified Rankin score greater than 2 (2.38 [1.27–4.55]). In hemorrhagic stroke, an age greater than 70 years (2.29 [1.43–3.69]) and a Glasgow Coma Scale score less than 8 (2.15 [1.08–4.3]) were associated with an increased risk of limitation, whereas a higher nonneurologic admission Sequential Organ Failure Assessment score was associated with a reduced risk (per point, 0.89 [0.82–0.97]). Conclusions: In ventilated stroke patients, decisions to limit life support are more than three times more frequent than in nonbrain-injured patients, with different timing and associated risk factors between ischemic and hemorrhagic strokes.
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Weidhase L, de Fallois J, Haußig E, Kaiser T, Mende M, Petros S. Myoglobin clearance with continuous veno-venous hemodialysis using high cutoff dialyzer versus continuous veno-venous hemodiafiltration using high-flux dialyzer: a prospective randomized controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:644. [PMID: 33176824 PMCID: PMC7659077 DOI: 10.1186/s13054-020-03366-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023]
Abstract
Background Myoglobin clearance in acute kidney injury requiring renal replacement therapy is important because myoglobin has direct renal toxic effects. Clinical data comparing different modalities of renal replacement therapy addressing myoglobin clearance are limited. This study aimed to compare two renal replacement modalities regarding myoglobin clearance. Methods In this prospective, randomized, single-blinded, single-center trial, 70 critically ill patients requiring renal replacement therapy were randomized 1:1 into an intervention arm using continuous veno-venous hemodialysis with high cutoff dialyzer and a control arm using continuous veno-venous hemodiafiltration postdilution with high-flux dialyzer. Regional citrate anticoagulation was used in both groups to maintain the extracorporeal circuit. The concentrations of myoglobin, urea, creatinine, β2-microglobulin, interleukin-6 and albumin were measured before and after the dialyzer at 1 h, 6 h, 12 h, 24 h and 48 h after initiating continuous renal replacement therapy. Results Thirty-three patients were allocated to the control arm (CVVHDF with high-flux dialyzer) and 35 patients to the intervention arm (CVVHD with high cutoff dialyzer). Myoglobin clearance, as a primary endpoint, was significantly better in the intervention arm than in the control arm throughout the whole study period. The clearance values for urea and creatinine were higher in the control arm. There was no measurable albumin clearance in both arms. The clearance data for β2-microglobulin and interleukin-6 were non-inferior in the intervention arm compared to those for the control arm. Dialyzer lifespan was 57.0 [38.0, 72.0] hours in the control arm and 70.0 [56.75, 72.0] hours in the intervention arm (p = 0.029). Conclusions Myoglobin clearance using continuous veno-venous hemodialysis with high cutoff dialyzer and regional citrate anticoagulation is better than that with continuous veno-venous hemodiafiltration with regional citrate anticoagulation. Trial registration German Clinical Trials Registry (DRKS00012407); date of registration 23/05/2017. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00012407.
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Affiliation(s)
- Lorenz Weidhase
- Medical Intensive Care Unit, University Hospital Leipzig, Leipzig, Saxony, Germany.
| | - Jonathan de Fallois
- Division of Nephrology, Medical Department III, University Hospital Leipzig, Leipzig, Saxony, Germany
| | - Elena Haußig
- Medical Intensive Care Unit, University Hospital Leipzig, Leipzig, Saxony, Germany
| | - Thorsten Kaiser
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Hospital Leipzig, Leipzig, Saxony, Germany
| | - Meinhard Mende
- Institute for Medical Informatics, Statistics and Epidemiology, University Leipzig, Leipzig, Saxony, Germany
| | - Sirak Petros
- Medical Intensive Care Unit, University Hospital Leipzig, Leipzig, Saxony, Germany
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Abstract
Acute kidney injury (AKI) is a critical burden on intensive care units in Asia. Renal replacement therapy (RRT) acts as strong supportive care for severe AKI. However, various RRT modalities are used in Asia because of the diversity in ethics, climate, geographic features, and socioeconomic status. Extracorporeal blood purification is used commonly in Asian intensive care units; however, intermittent RRT is preferred in developing countries because of cost and infrastructure issues. Conversely, continuous RRT is preferred in developed countries, indicating the predominance of hospital-acquired AKI patients with complications of hemodynamic instability. Peritoneal dialysis is delivered less frequently, although several studies have suggested promising results for peritoneal dialysis in AKI treatment. Of note, not all RRT modalities are available as a standard procedure in some Asian regions, and it is absolutely necessary to develop a sustainable infrastructure that can deliver optimal care for all AKI patients.
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Affiliation(s)
- Ryo Matsuura
- Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kent Doi
- Department of Emergency and Critical Care and Medicine, The University of Tokyo Hospital, Tokyo, Japan.
| | - Yoshifumi Hamasaki
- Department of Hemodialysis and Apheresis, The University of Tokyo, Tokyo, Japan
| | - Masaomi Nangaku
- Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
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Ostermann M, Bellomo R, Burdmann EA, Doi K, Endre ZH, Goldstein SL, Kane-Gill SL, Liu KD, Prowle JR, Shaw AD, Srisawat N, Cheung M, Jadoul M, Winkelmayer WC, Kellum JA. Controversies in acute kidney injury: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference. Kidney Int 2020; 98:294-309. [PMID: 32709292 PMCID: PMC8481001 DOI: 10.1016/j.kint.2020.04.020] [Citation(s) in RCA: 239] [Impact Index Per Article: 59.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/31/2020] [Accepted: 04/09/2020] [Indexed: 12/19/2022]
Abstract
In 2012, Kidney Disease: Improving Global Outcomes (KDIGO) published a guideline on the classification and management of acute kidney injury (AKI). The guideline was derived from evidence available through February 2011. Since then, new evidence has emerged that has important implications for clinical practice in diagnosing and managing AKI. In April of 2019, KDIGO held a controversies conference entitled Acute Kidney Injury with the following goals: determine best practices and areas of uncertainty in treating AKI; review key relevant literature published since the 2012 KDIGO AKI guideline; address ongoing controversial issues; identify new topics or issues to be revisited for the next iteration of the KDIGO AKI guideline; and outline research needed to improve AKI management. Here, we present the findings of this conference and describe key areas that future guidelines may address.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St. Thomas' Hospital, King's College London, London, UK.
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Emmanuel A Burdmann
- Laboratório de Investigação Médica 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan
| | - Zoltan H Endre
- Prince of Wales Hospital and Clinical School, University of New South Wales, Randwick, NSW, Australia
| | - Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Kathleen D Liu
- Department of Medicine, Division of Nephrology, University of California, San Francisco, San Francisco, California, USA; Department of Anesthesia, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California, USA
| | - John R Prowle
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand; Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Academy of Science, Royal Society of Thailand, Bangkok, Thailand
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Schaubroeck HA, Gevaert S, Bagshaw SM, Kellum JA, Hoste EA. Acute cardiorenal syndrome in acute heart failure: focus on renal replacement therapy. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:802-811. [PMID: 32597679 DOI: 10.1177/2048872620936371] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Almost half of hospitalised patients with acute heart failure develop acute cardiorenal syndrome. Treatment consists of optimisation of fluid status and haemodynamics, targeted therapy for the underlying cardiac disease, optimisation of heart failure treatment and preventive measures such as avoidance of nephrotoxic agents. Renal replacement therapy may be temporarily needed to support kidney function, mostly in case of diuretic resistant fluid overload or severe metabolic derangement. The best timing to initiate renal replacement therapy and the best modality in acute heart failure are still under debate. Several modalities are available such as intermittent and continuous renal replacement therapy as well as hybrid techniques, based on two main principles: haemofiltration and haemodialysis. Although continuous techniques have been associated with less haemodynamic instability and a greater chance of renal recovery, cohort data are conflicting and randomised controlled trials have not shown a difference in recovery or mortality. In the presence of diuretic resistance, isolated ultrafiltration with individualisation of ultrafiltration rates is a valid option for decongestion in acute heart failure patients. Practical tools to optimise the use of renal replacement therapy in acute heart failure-related acute cardiorenal syndrome were discussed.
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Affiliation(s)
| | - Sofie Gevaert
- Department of Cardiology, Ghent University Hospital, Belgium
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta, Canada
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, USA
| | - Eric Aj Hoste
- Intensive Care Unit, Ghent University Hospital, Belgium.,Research Foundation-Flanders (FWO), Brussels, Belgium
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de Montmollin E, Terzi N, Dupuis C, Garrouste-Orgeas M, da Silva D, Darmon M, Laurent V, Thiéry G, Oziel J, Marcotte G, Gainnier M, Siami S, Sztrymf B, Adrie C, Reignier J, Ruckly S, Sonneville R, Timsit JF. One-year survival in acute stroke patients requiring mechanical ventilation: a multicenter cohort study. Ann Intensive Care 2020; 10:53. [PMID: 32383104 PMCID: PMC7205929 DOI: 10.1186/s13613-020-00669-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/26/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Most prognostic studies in acute stroke patients requiring invasive mechanical ventilation are outdated and have limitations such as single-center retrospective designs. We aimed to study the association of ICU admission factors, including the reason for intubation, with 1-year survival of acute stroke patients requiring mechanical ventilation. METHODS We conducted a secondary data use analysis of a prospective multicenter database (14 ICUs) between 1997 and 2016 on consecutive ICU stroke patients requiring mechanical ventilation at admission. We excluded patients with stroke of traumatic origin, subdural hematoma or cerebral venous thrombosis. The primary outcome was survival 1 year after ICU admission. Factors associated with the primary outcome were identified using a multivariable Cox model stratified on inclusion center. RESULTS We identified 419 patients (age 68 [58-76] years, males 60%) with a Glasgow coma score (GCS) of 4 [3-8] at admission. Stroke subtypes were acute ischemic stroke (AIS, 46%), intracranial hemorrhage (ICH, 42%) and subarachnoid hemorrhage (SAH, 12%). At 1 year, 96 (23%) patients were alive. Factors independently associated with decreased 1-year survival were ICH and SAH stroke subtypes, a lower GCS score at admission, a higher non-neurological SOFA score. Conversely, patients receiving acute-phase therapy had improved 1-year survival. Intubation for acute respiratory failure or coma was associated with comparable survival hazard ratios, whereas intubation for seizure was not associated with a worse prognosis than for elective procedure. Survival did not improve over the study period, but patients included in the most recent period had more comorbidities and presented higher severity scores at admission. CONCLUSIONS In acute stroke patients requiring mechanical ventilation, the reason for intubation and the opportunity to receive acute-phase stroke therapy were independently associated with 1-year survival. These variables could assist in the decision process regarding the initiation of mechanical ventilation in acute stroke patients.
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Affiliation(s)
- Etienne de Montmollin
- Université de Paris, UMR 1137, IAME, Paris, France.
- APHP, Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris, France.
| | - Nicolas Terzi
- Medical Intensive Care Unit, Grenoble University Hospital, La Tronche, France
| | - Claire Dupuis
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | | | - Daniel da Silva
- Intensive Care Unit, Delafontaine Hospital, Saint-Denis, France
| | - Michaël Darmon
- Medical Intensive Care Unit, Saint-Louis Hospital, Paris, France
| | | | | | - Johana Oziel
- APHP, Intensive Care Unit, Avicenne Hospital, Bobigny, France
| | | | - Marc Gainnier
- Intensive Care Unit, La Timone Hospital, Marseille, France
| | - Shidasp Siami
- Intensive Care Unit, Sud-Essonne Hospital, Etampes, France
| | - Benjamin Sztrymf
- APHP, Intensive Care Unit, Antoine Béclère Hospital, Clamart, France
| | | | - Jean Reignier
- Medical Intensive Care Unit, Nantes University Hospital, Nantes, France
| | | | - Romain Sonneville
- APHP, Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris, France
- Université de Paris, UMR 1148, LVTS, Paris, France
| | - Jean-François Timsit
- Université de Paris, UMR 1137, IAME, Paris, France
- APHP, Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris, France
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30
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Heyard R, Timsit J, Held L. Validation of discrete time-to-event prediction models in the presence of competing risks. Biom J 2020; 62:643-657. [PMID: 31368172 PMCID: PMC7217187 DOI: 10.1002/bimj.201800293] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 06/21/2019] [Accepted: 06/28/2019] [Indexed: 11/06/2022]
Abstract
Clinical prediction models play a key role in risk stratification, therapy assignment and many other fields of medical decision making. Before they can enter clinical practice, their usefulness has to be demonstrated using systematic validation. Methods to assess their predictive performance have been proposed for continuous, binary, and time-to-event outcomes, but the literature on validation methods for discrete time-to-event models with competing risks is sparse. The present paper tries to fill this gap and proposes new methodology to quantify discrimination, calibration, and prediction error (PE) for discrete time-to-event outcomes in the presence of competing risks. In our case study, the goal was to predict the risk of ventilator-associated pneumonia (VAP) attributed to Pseudomonas aeruginosa in intensive care units (ICUs). Competing events are extubation, death, and VAP due to other bacteria. The aim of this application is to validate complex prediction models developed in previous work on more recently available validation data.
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Affiliation(s)
- Rachel Heyard
- Department of Biostatistics at the EpidemiologyBiostatistics and Prevention InstituteUniversity of ZurichHirschengrabenSwitzerland
| | | | - Leonhard Held
- Department of Biostatistics at the EpidemiologyBiostatistics and Prevention InstituteUniversity of ZurichHirschengrabenSwitzerland
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31
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Vinclair C, De Montmollin E, Sonneville R, Reuter J, Lebut J, Cally R, Mourvillier B, Neuville M, Ruckly S, Timsit JF, Bouadma L. Factors associated with major adverse kidney events in patients who underwent veno-arterial extracorporeal membrane oxygenation. Ann Intensive Care 2020; 10:44. [PMID: 32307616 PMCID: PMC7167383 DOI: 10.1186/s13613-020-00656-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/31/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To describe acute kidney injury (AKI) natural history and to identify predictors of major adverse kidney events (MAKE) within 1 year in patients supported by veno-arterial extracorporeal membrane oxygenation (VA-ECMO). DESIGN Retrospective observational study. SETTING Medical French intensive care unit between January 2014 and December 2016. PATIENTS Consecutive patients implanted with VA-ECMO ≥ 16 years, VA-ECMO for at least ≥ 48 h, and without end-stage chronic kidney disease (CKD). INTERVENTION None. MEASUREMENTS Multivariate logistic regression of factors associated with MAKE at 1 year defined as one of the following criteria within day 360: death and receipt of renal replacement therapy (RRT) or persistent renal dysfunction, i.e., CKD ≥ stage 3 corresponding to an estimated glomerular filtration rate (eGFR) ≤ 60 ml/min/1.73 m2 and MAKE at day 30 and day 90 defined as one of the following criteria within day 30 or day 90: death, receipt of renal replacement therapy and serum creatinine ≥ threefold increase. MAIN RESULTS 158 consecutive patients were included (male sex: 75.9%; median and interquartile range: age: 59 [47-66], Simplified Acute Physiology Score II: 55 [39-66], Sepsis-related Organ Failure Assessment Score: 9 [7-12], time on VA-ECMO: 7.5 [4-12] days). Among them 145 (91.8%) developed an AKI during the intensive care unit (ICU) stay and 85 (53.8%) needed renal replacement therapy (RRT). 59.9% (91/152), 60.5% (89/147) and 85.1% (120/141) evaluable patients had a MAKE-30, MAKE-90 and MAKE-360, respectively. Factors significantly associated with MAKE-360 were eGFR at baseline (odds ratio (OR) 0.98, confidence interval 95% (CI) [0.97;1.00], p 0.02), Kidney Disease Improving Global Outcome (KDIGO) stage at cannulation (p = 0.03), e.g., stage 3 vs. reference stage 0 OR 10.20 [1.77-58.87], and number of red blood cell (RBC) packs received while under ECMO (OR 1.14, CI 95% [1.01;1.28], p = 0.03). At 1 year among the 51 survivors, almost half of the alive patients (n = 20/51) had a decline of estimated glomerular filtration (eGFR) > 30% mL/min/1.73 m2. Their median eGFR decline was - 26.3% [- 46.6;- 10.7]. CONCLUSION Patients undergoing VA-ECMO had a high risk of AKI during the ICU stay. Factors associated with MAKE 360 were mainly eGFR at baseline, KDIGO stage at cannulation and, number of RBC packs received while under ECMO. Among survivors at 1 year, almost half of the alive patients (n = 20/51) had a decline eGFR > 30%.
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Affiliation(s)
- Camille Vinclair
- Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, 46 rue Henri Huchard, 75018, Paris, France
| | - Etienne De Montmollin
- Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, 46 rue Henri Huchard, 75018, Paris, France
- UMR 1137-IAME Team 5-DeSCID: Decision SCiences in Infectious Diseases control and care INSERM/Univ Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France
| | - Romain Sonneville
- Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, 46 rue Henri Huchard, 75018, Paris, France
| | - Jean Reuter
- Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, 46 rue Henri Huchard, 75018, Paris, France
| | - Jordane Lebut
- Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, 46 rue Henri Huchard, 75018, Paris, France
| | - Radj Cally
- Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, 46 rue Henri Huchard, 75018, Paris, France
| | - Bruno Mourvillier
- Medical Intensive Care Unit, Robert Debré University Hospital, rue du Géneral Koening, 51000, Reims, France
| | - Mathilde Neuville
- Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, 46 rue Henri Huchard, 75018, Paris, France
| | - Stéphane Ruckly
- UMR 1137-IAME Team 5-DeSCID: Decision SCiences in Infectious Diseases control and care INSERM/Univ Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France
| | - Jean-François Timsit
- Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, 46 rue Henri Huchard, 75018, Paris, France
- UMR 1137-IAME Team 5-DeSCID: Decision SCiences in Infectious Diseases control and care INSERM/Univ Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France
| | - Lila Bouadma
- Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, 46 rue Henri Huchard, 75018, Paris, France.
- UMR 1137-IAME Team 5-DeSCID: Decision SCiences in Infectious Diseases control and care INSERM/Univ Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France.
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Dou L, Meng D, Dong Y, Chen L, Han X, Fan D, Dong H. Dosage regimen and toxicity risk assessment of linezolid in sepsis patients. Int J Infect Dis 2020; 96:105-111. [PMID: 32251797 DOI: 10.1016/j.ijid.2020.03.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 02/19/2020] [Accepted: 03/23/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Significant alterations in the pharmacokinetic characteristics of linezolid are often seen in sepsis patients. The study aimed to identify a target pharmacokinetics/pharmacodynamics (PK/PD) index of the efficacy of linezolid treatment, and to estimate the optimum dosage regimen of linezolid in sepsis patients. METHODS The PK data were modeled using the one-compartment model, which determined the target PK/PD index for successful treatment by logistic regression. The probability of thrombocytopenia was identified by establishing a logistic model. Different dosing regimens were evaluated using Monte Carlo simulation. RESULTS Reaching 80% bacterial eradication required an AUC24/MIC of 100, which defined the therapeutic target. The proposed regimen to attain a cumulative fraction of response ≥80% was 800 mg/12 h (safety probability 66.8%) for sepsis patients with normal renal function or mild kidney damage. By contrast, the target cumulative fraction of response was attained with a standard dosing regimen in sepsis patients on continuous renal replacement therapy [600 mg/12 h (safety probability 49.7%)]. CONCLUSIONS This study identified different dosing strategies to achieve target linezolid PK/PD values according to whether sepsis patients were treated with continuous renal replacement therapy. Due to the high incidence of thrombocytopenia in sepsis patients on continuous renal replacement therapy, therapeutic drug monitoring should be encouraged for optimizing linezolid exposure in sepsis patients.
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Affiliation(s)
- Linjie Dou
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Dandan Meng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Lihong Chen
- Department of International Medical Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Xinyan Han
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Di Fan
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Haiyan Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China.
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Zhao Y, Chen Y. Effect of renal replacement therapy modalities on renal recovery and mortality for acute kidney injury: A PRISMA-compliant systematic review and meta-analysis. Semin Dial 2020; 33:127-132. [PMID: 32149415 DOI: 10.1111/sdi.12861] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Previous investigations showed inconsistent results for comparison in renal recovery, in-hospital, and in-intensive care unit (ICU) mortalities between acute kidney injury (AKI) patients treated with continuous renal replacement therapy (CRRT) and some kinds of intermittent renal replacement therapies (IRRTs). We systematically searched for articles published in the databases (PubMed, Web of Science, EMBASE, Medline, and Google Scholar) until June 2019. We made all statistical analysis using STATA 12.0 software. In the present meta-analysis, relative risks with 95% confidence intervals were calculated for binary outcomes (renal recovery status or mortality). The present study indicated no significant differences in renal recovery, in-hospital mortality, and in-ICU mortality between AKI patients given CRRT and those given sustained low-efficiency dialysis (SLED). Additionally, the study showed no significant difference in in-hospital mortality between AKI patients given CRRT and those given intermittent hemodialysis (IHD), whereas elevated in-ICU mortality was detected in AKI patients given CRRT, compared to those given IHD. The three modalities (CRRT, IHD, and SLED) have their own advantages and disadvantages. More rigorous trials design with large cohort should be made to explore the differences in renal recovery, in-hospital, and in-ICU mortalities between different kinds of RRTs.
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Affiliation(s)
- Yuanyuan Zhao
- Department of Nephrology, Nanjing Lishui People's Hospital, Nanjing, Jiangsu, China.,Department of Nephrology, Zhongda Hospital Lishui Branch, Southeast University, Nanjing, Jiangsu, China
| | - Yifei Chen
- Department of Emergency, The Affiliated Hospital of Yangzhou University, Yangzhou, Jiangsu, China
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34
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Wong JJM, Liu S, Dang H, Anantasit N, Phan PH, Phumeetham S, Qian S, Ong JSM, Gan CS, Chor YK, Samransamruajkit R, Loh TF, Feng M, Lee JH. The impact of high frequency oscillatory ventilation on mortality in paediatric acute respiratory distress syndrome. Crit Care 2020; 24:31. [PMID: 32005285 PMCID: PMC6995130 DOI: 10.1186/s13054-020-2741-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/14/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND High-frequency oscillatory ventilation (HFOV) use was associated with greater mortality in adult acute respiratory distress syndrome (ARDS). Nevertheless, HFOV is still frequently used as rescue therapy in paediatric acute respiratory distress syndrome (PARDS). In view of the limited evidence for HFOV in PARDS and evidence demonstrating harm in adult patients with ARDS, we hypothesized that HFOV use compared to other modes of mechanical ventilation is associated with increased mortality in PARDS. METHODS Patients with PARDS from 10 paediatric intensive care units across Asia from 2009 to 2015 were identified. Data on epidemiology and clinical outcomes were collected. Patients on HFOV were compared to patients on other modes of ventilation. The primary outcome was 28-day mortality and secondary outcomes were 28-day ventilator- (VFD) and intensive care unit- (IFD) free days. Genetic matching (GM) method was used to analyse the association between HFOV treatment with the primary outcome. Additionally, we performed a sensitivity analysis, including propensity score (PS) matching, inverse probability of treatment weighting (IPTW) and marginal structural modelling (MSM) to estimate the treatment effect. RESULTS A total of 328 patients were included. In the first 7 days of PARDS, 122/328 (37.2%) patients were supported with HFOV. There were significant differences in baseline oxygenation index (OI) between the HFOV and non-HFOV groups (18.8 [12.0, 30.2] vs. 7.7 [5.1, 13.1] respectively; p < 0.001). A total of 118 pairs were matched in the GM method which found a significant association between HFOV with 28-day mortality in PARDS [odds ratio 2.3, 95% confidence interval (CI) 1.3, 4.4, p value 0.01]. VFD was indifferent between the HFOV and non-HFOV group [mean difference - 1.3 (95%CI - 3.4, 0.9); p = 0.29] but IFD was significantly lower in the HFOV group [- 2.5 (95%CI - 4.9, - 0.5); p = 0.03]. From the sensitivity analysis, PS matching, IPTW and MSM all showed consistent direction of HFOV treatment effect in PARDS. CONCLUSION The use of HFOV was associated with increased 28-day mortality in PARDS. This study suggests caution but does not eliminate equivocality and a randomized controlled trial is justified to examine the true association.
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Affiliation(s)
- Judith Ju-Ming Wong
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
| | - Siqi Liu
- Saw Swee Hock School of Public Health, National University Health System, NUS Graduate School for Integrative Science and Engineering, National University of Singapore, 12 Science Drive 2, Singapore, 117549, Singapore
| | - Hongxing Dang
- Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Rd, Yuzhong district, Chongqing, 400041, China
| | - Nattachai Anantasit
- Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Phuc Huu Phan
- National Children's Hospital, 18/879 La Thành, Láng Thượng, Đống Đa, Hanoi, Vietnam
| | - Suwannee Phumeetham
- Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road Bangkoknoi, Bangkok, 10700, Thailand
| | - Suyun Qian
- Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Rd, Xicheng District, Beijing, 100045, China
| | - Jacqueline Soo May Ong
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Chin Seng Gan
- Department of Pediatrics, University of Malaya. Jalan Universiti, 50603, Wilayah Persekutuan, Kuala Lumpur, Malaysia
| | - Yek Kee Chor
- Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia
| | - Rujipat Samransamruajkit
- Critical Care Excellence Center, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University Bangkok, Bangkok, 10330, Thailand
| | - Tsee Foong Loh
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Mengling Feng
- Saw Swee Hock School of Public Health, National University Health System, NUS Graduate School for Integrative Science and Engineering, National University of Singapore, 12 Science Drive 2, Singapore, 117549, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
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35
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Bailly S, Galerneau LM, Ruckly S, Seiller A, Terzi N, Schwebel C, Dupuis C, Tamisier R, Mourvillier B, Pepin JL, Timsit JF. Impact of obstructive sleep apnea on the obesity paradox in critically ill patients. J Crit Care 2019; 56:120-124. [PMID: 31896445 DOI: 10.1016/j.jcrc.2019.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 12/12/2019] [Accepted: 12/19/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Patients admitted to an intensive care unit (ICU) frequently suffer from multiple chronic diseases, including obstructive sleep apnea (OSA). Until recently OSA was not considered as a key determinant in an ICU patient's prognosis. The objective of this study was to document the impact of OSA on the prognosis of ICU patients. METHODS Data were retrospectively collected concerning adult patients admitted to ICU at two university hospitals. In a nested study OSA status was checked using the hospital electronic medical records to identify exposed and unexposed cases. The following outcomes were considered: length of stay in the ICU, ICU mortality, in-hospital mortality, ventilator-associated pneumonia (VAP). RESULTS Out of 5146 patients included in the study, 289 had OSA at ICU admission (5.6%). After matching, the overall impact of OSA on length of ICU stay was not significant (p = .24). In a predefined subgroup analysis, there was a significant impact of OSA on the length of ICU stay for patients with BMI over 40 kg/m2 (IRR: 1.56 [1.05; 2.32], p = .03). OSA status had no impact on ICU or hospital mortality and VAP. CONCLUSION In general, known OSA did not increase the ICU stay except for patients with both OSA and morbid obesity.
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Affiliation(s)
- Sébastien Bailly
- Univ. Grenoble Alpes, INSERM U1042, HP2, 38000 Grenoble, France; EFCR laboratory, Grenoble Alpes University Hospital, Grenoble, France.
| | - Louis-Marie Galerneau
- Univ. Grenoble Alpes, INSERM U1042, HP2, 38000 Grenoble, France; Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Stéphane Ruckly
- INSERM U1137, Université Paris Diderot, Sorbonne Paris Cite, Paris, France
| | - Alexandre Seiller
- INSERM U1137, Université Paris Diderot, Sorbonne Paris Cite, Paris, France
| | - Nicolas Terzi
- Univ. Grenoble Alpes, INSERM U1042, HP2, 38000 Grenoble, France; Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Carole Schwebel
- Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France; INSERM U1039 Radiopharmaceutiques Biocliniques, Grenoble, France
| | - Claire Dupuis
- INSERM U1137, Université Paris Diderot, Sorbonne Paris Cite, Paris, France; Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, Paris, France
| | - Renaud Tamisier
- Univ. Grenoble Alpes, INSERM U1042, HP2, 38000 Grenoble, France; EFCR laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Bernard Mourvillier
- INSERM U1137, Université Paris Diderot, Sorbonne Paris Cite, Paris, France; Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, Paris, France
| | - Jean-Louis Pepin
- Univ. Grenoble Alpes, INSERM U1042, HP2, 38000 Grenoble, France; EFCR laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean-François Timsit
- INSERM U1137, Université Paris Diderot, Sorbonne Paris Cite, Paris, France; Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, Paris, France
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Jiang L, Zhu Y, Luo X, Wen Y, Du B, Wang M, Zhao Z, Yin Y, Zhu B, Xi X. Epidemiology of acute kidney injury in intensive care units in Beijing: the multi-center BAKIT study. BMC Nephrol 2019; 20:468. [PMID: 31842787 PMCID: PMC6915890 DOI: 10.1186/s12882-019-1660-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 12/05/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) commonly occurs in intensive care units (ICUs), leading to adverse clinical outcomes and increasing costs. However, there are limited epidemiological data of AKI in the critically ill in Beijing, China. METHODS In this prospective cohort study in 30 ICUs, we screened the patients up to 10 days after ICU admission. Characteristics and outcomes were compared between AKI and non-AKI, renal replacement therapy (RRT) and non-RRT patients. Nomograms of logistic regression and Cox regression were performed to examine potential risk factors for AKI and mortality. RESULTS A total of 3107 patients were included in the final analysis. The incidence of AKI was 51.0%; stages 1 to 3 accounted for 23.1, 11.8, and 15.7%, respectively. The majority (87.6%) of patients with AKI developed AKI on the first 4 days after admission to the ICU. A total of 281 patients were treated with RRT. Continuous RRT with predilution, citrate for anticoagulation and femoral vein for vascular access was the most common RRT pattern (29.9%, 84 of 281). Patients with AKI were associated with longer ICU-LOS and higher mortality and costs (P<0.001). In patients treated with RRT, 78.6 and 28.5% of RRTs were dependent on the 7th and 28th days, respectively. The 28 day mortalities of non-AKI, AKI stages 1-3, and septic shock patients were 6.83, 15.04, 27.99, 45.18 and 36.5%, respectively. CONCLUSIONS Approximately half of our ICU patients experienced AKI. The majority of patients with AKI developed AKI during the first 4 days after admission to the ICU. Continuous RRT with predilution, citrate for anticoagulation and femoral vein for vascular access was the most common RRT pattern in our ICUs. AKI was associated with a higher mortality and costs, incomplete kidney recovery and s series of adverse outcomes.
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Affiliation(s)
- Li Jiang
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, 20A Fuxingmenwai Street, Xicheng District, Beijing, 100038, China
| | - Yibing Zhu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, 20A Fuxingmenwai Street, Xicheng District, Beijing, 100038, China. .,Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Room 101-106, Block A, Shilong West Road, Mentougou District, Beijing, 102300, China.
| | - Xuying Luo
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, 20A Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.,Department of Critical Care Medicine, Tiantan Hospital, Capital Medical University, 119 Nansihuanxi Road, Fengtai District, Beijing, 100070, China
| | - Ying Wen
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, 20A Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.,Departmrnt of General Practice, Beitaipingzhuang Community Health Service Center, Building 6, Wenhuiyuan, Wenhuiyuan South Road, Haidian District, Beijing, 100082, China
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, China
| | - Meiping Wang
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, 20A Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.,Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, 10 Xitoutiao, Youanmenwai, Fengtai District, Beijing, 100069, China
| | - Zhen Zhao
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, 20A Fuxingmenwai Street, Xicheng District, Beijing, 100038, China
| | - Yanyan Yin
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, 20A Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.,Center of urology and metabolism, Beijing Rehabilitation Hospital, Capital Medical University, Xixiazhuang, Badachu Road, Shijingshan District, Beijing, 100114, China
| | - Bo Zhu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, 20A Fuxingmenwai Street, Xicheng District, Beijing, 100038, China
| | - Xiuming Xi
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, 20A Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.
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Intermittent Hemodialysis for Managing Metabolic Acidosis During Resuscitation of Septic Shock: A Descriptive Study. Crit Care Explor 2019; 1:e0065. [PMID: 32166246 PMCID: PMC7063923 DOI: 10.1097/cce.0000000000000065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Septic shock is often complicated by severe metabolic acidosis, for which renal replacement therapy may be considered. However, little is known about the use of intermittent hemodialysis to manage this condition. The aim of this study was to compare physiologic and biochemical variables and vasopressor requirements before and after intermittent hemodialysis among patients who received intermittent hemodialysis to manage metabolic acidosis during resuscitation of septic shock.
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Postdischarge Major Adverse Cardiovascular Events of ICU Survivors Who Received Acute Renal Replacement Therapy. Crit Care Med 2019; 46:e1047-e1054. [PMID: 30095497 DOI: 10.1097/ccm.0000000000003357] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Long-term risk of a major adverse cardiovascular events in ICU survivors who underwent acute renal replacement therapy requires further investigation. DESIGN Nationwide population-based study using the claims database of Korea. SETTING Index admission cases of ICU survivors in government-designated tertiary hospitals PATIENTS:: The study group consisted of ICU survivors who underwent acute renal replacement therapy, and the control group consisted of those without acute renal replacement therapy. Patients were excluded if they 1) were under age 20, 2) expired within 30 days after discharge, 3) received ICU care for less than 24 hours, 4) had a previous ICU admission, 5) had a history of major adverse cardiovascular event, or 6) had a major adverse cardiovascular event-related cardio/cerebrovascular diseases. The outcomes of the patients who received continuous renal replacement therapy were compared with those of patients who received only intermittent renal replacement therapy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Information regarding patient characteristics and treatment modalities was collected and adjusted. The main outcome was major adverse cardiovascular event, including acute myocardial infarction, revascularization, and acute ischemic stroke. Patient mortality and progression to end-stage renal disease were also evaluated. We included 12,380 acute renal replacement therapy patients and 382,018 patients in the control group. Among the study group, 6,891 patients were included in the continuous renal replacement therapy group, and 5,034 in the intermittent renal replacement therapy group. The risks of major adverse cardiovascular event (adjusted hazard ratio, 1.463 [1.323-1.619]; p < 0.001), all-cause mortality (adjusted hazard ratio, 1.323 [1.256-1.393]; p < 0.001), and end-stage renal disease (adjusted hazard ratio, 18.110 [15.779-20.786]; p < 0.001) were higher in the acute renal replacement therapy patients than the control group. When we compared the continuous renal replacement therapy patients with the intermittent renal replacement therapy patients, the risk of major adverse cardiovascular event was comparable (adjusted hazard ratio, 1.049 [0.888-1.239]; p = 0.575). CONCLUSIONS Clinicians should note the increased risk of a long-term major adverse cardiovascular event in acute renal replacement therapy patients and consider appropriate risk factor management. Significant difference in the risk of postdischarge major adverse cardiovascular event was not identified between continuous renal replacement therapy and intermittent renal replacement therapy.
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Renal replacement therapy in the ICU: intermittent hemodialysis, sustained low-efficiency dialysis or continuous renal replacement therapy? Curr Opin Crit Care 2019; 24:437-442. [PMID: 30247213 DOI: 10.1097/mcc.0000000000000541] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Severe acute kidney injury in the ICU setting often requires renal replacement therapy (RRT). Intermittent hemodialysis (IHD), hybrid forms of RRT such as sustained low-efficiency dialysis (SLED), as well as continuous renal replacement therapy (CRRT) are the three common modalities of extracorporeal RRT used in the adult ICU setting in developed countries. This review summarizes recently published data regarding comparisons of these three RRT modalities on clinical outcomes (e.g., mortality and recovery of renal function) in severe acute kidney injury (AKI) patients. RECENT FINDINGS There is still controversy on the superiority of one RRT modality over another in terms of clinical outcomes in patients with AKI in ICU. Although there is increasing acceptance that CRRT should be used in hemodynamic unstable patients, its survival advantages over IHD remains unproven because of inadequate evidence from suitably powered randomized controlled trials (RCTs). Moreover, CRRT does not show superiority to intermittent renal replacement therapy (IRRT) in hemodynamic stable patients. Although patients receiving sustained low-efficiency dialysis appear to have lower mortality than CRRT, its survival benefit is largely derived from observational studies and is confounded by selection bias. Current literature supports no differences in mortality among the three RRT modalities. However, the effect of choice of RRT modality on short-term and long-term renal outcomes need further studies, especially larger RCTs and longer duration of follow-up. SUMMARY There is lack of solid evidence showing superiority of any mode of RRT in patients with severe AKI in terms of patient survival. However, based on observational data, IHD treatment of AKI may delay renal recovery. Patients' hemodynamic status, coexisting medical conditions, local expertise, and availability of staff and resources as well as potential effect on long-term renal outcomes should be taken into consideration when selecting modalities of RRT for adult ICU patients.
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Renal Replacement Therapy Modality in the ICU and Renal Recovery at Hospital Discharge. Crit Care Med 2019; 46:e102-e110. [PMID: 29088005 DOI: 10.1097/ccm.0000000000002796] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Acute kidney injury requiring renal replacement therapy is a major concern in ICUs. Initial renal replacement therapy modality, continuous renal replacement therapy or intermittent hemodialysis, may impact renal recovery. The aim of this study was to assess the influence of initial renal replacement therapy modality on renal recovery at hospital discharge. DESIGN Retrospective cohort study of all ICU stays from January 1, 2010, to December 31, 2013, with a "renal replacement therapy for acute kidney injury" code using the French hospital discharge database. SETTING Two hundred ninety-one ICUs in France. PATIENTS A total of 1,031,120 stays: 58,635 with renal replacement therapy for acute kidney injury and 25,750 included in the main analysis. INTERVENTIONS None. MEASUREMENTS MAIN RESULTS PPatients alive at hospital discharge were grouped according to initial modality (continuous renal replacement therapy or intermittent hemodialysis) and included in the main analysis to identify predictors of renal recovery. Renal recovery was defined as greater than 3 days without renal replacement therapy before hospital discharge. The main analysis was a hierarchical logistic regression analysis including patient demographics, comorbidities, and severity variables, as well as center characteristics. Three sensitivity analyses were performed. Overall mortality was 56.1%, and overall renal recovery was 86.2%. Intermittent hemodialysis was associated with a lower likelihood of recovery at hospital discharge; odds ratio, 0.910 (95% CI, 0.834-0.992) p value equals to 0.0327. Results were consistent across all sensitivity analyses with odds/hazards ratios ranging from 0.883 to 0.958. CONCLUSIONS In this large retrospective study, intermittent hemodialysis as an initial modality was associated with lower renal recovery at hospital discharge among patients with acute kidney injury, although the difference seems somewhat clinically limited.
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Panitchote A, Mehkri O, Hastings A, Hanane T, Demirjian S, Torbic H, Mireles-Cabodevila E, Krishnan S, Duggal A. Clinical predictors of renal non-recovery in acute respiratory distress syndrome. BMC Nephrol 2019; 20:255. [PMID: 31291909 PMCID: PMC6617675 DOI: 10.1186/s12882-019-1439-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 06/24/2019] [Indexed: 12/26/2022] Open
Abstract
Background Acute kidney injury (AKI) is the most common extra-pulmonary organ failure in acute respiratory distress syndrome (ARDS). Renal recovery after AKI is determined by several factors. The objective of this study was to determine the predictors of renal non-recovery in ARDS patients. Methods A single center retrospective cohort study of patients with AKI after onset of ARDS. Patients with preexisting chronic kidney disease or intensive care unit stay < 24 h were excluded. AKI staging was defined according to the Kidney Disease Improving Global Outcomes (KDIGO) 2012 guidelines. Renal non-recovery was defined as death, dialysis dependence, serum creatinine ≥1.5 times the baseline, or urine output < 0.5 mL/kg/h more than 6 h. Results Of the 244 patients that met study criteria, 60 (24.6%) had stage I AKI, 66 (27%) had stage II AKI, and 118 (48.4%) had stage III AKI. Of those, 148 (60.7%) patients had renal non-recovery. On multivariable analysis, factors associated with renal non-recovery were a higher stage of AKI (odds ratio [OR] stage II 5.71, 95% confidence interval [CI] 2.17–14.98; OR stage III 45.85, 95% CI 16.27–129.2), delay in the onset of AKI (OR 1.12, 95% CI 1.03–1.21), history of malignancy (OR 4.02, 95% CI 1.59–10.15), septic shock (OR 3.2, 95% CI 1.52–6.76), and a higher tidal volume on day 1–3 of ARDS (OR 1.41, 95% CI 1.05–1.90). Subgroup analysis of survival at day 28 of ARDS also found that higher severity of AKI (OR stage II 8.17, 95% CI 0.84–79.91; OR stage III 111.67, 95% CI 12.69–982.91), delayed onset of AKI (OR 1.12, 95% CI 1.02–1.23), and active malignancy (OR 6.55, 95% CI 1.34–32.04) were significant predictors of renal non-recovery. Conclusions A higher stage of AKI, delayed onset of AKI, a history of malignancy, septic shock, and a higher tidal volume on day 1–3 of ARDS predicted renal non-recovery in ARDS patients. Among survivors, a higher stage of AKI, delayed onset of AKI, and a history of malignancy were associated with renal non-recovery. Electronic supplementary material The online version of this article (10.1186/s12882-019-1439-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anupol Panitchote
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Omar Mehkri
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andrei Hastings
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tarik Hanane
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sevag Demirjian
- Department of Nephrology, Cleveland Clinic, Cleveland, OH, USA
| | - Heather Torbic
- Department of Pharmacology, Cleveland Clinic, Cleveland, OH, USA
| | | | - Sudhir Krishnan
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
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Pneumonia in acute ischemic stroke patients requiring invasive ventilation: Impact on short and long-term outcomes. J Infect 2019; 79:220-227. [PMID: 31238051 DOI: 10.1016/j.jinf.2019.06.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/06/2019] [Accepted: 06/20/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To describe the epidemiology and prognostic impact of pneumonia in acute ischemic stroke patients requiring invasive mechanical ventilation. METHODS Retrospective analysis from a prospective multicenter cohort study of critically ill patients with acute ischemic stroke requiring invasive mechanical ventilation at admission. Impact of pneumonia was investigated using Cox regression for 1-year mortality, and competing risk survival models for ICU mortality censored at 30-days. RESULTS We included 195 patients. Stroke was supratentorial in 62% and 64% of patients had a Glasgow coma scale score <8 on admission. Mortality at day-30 and 1 year were 56%, and 70%, respectively. Post-stroke pneumonia was identified in 78 (40%) patients, of which 46/78 (59%) episodes were present at ICU admission. Post-stroke pneumonia was associated with an increase in 1-year mortality (adjusted HR 1.49, 95%CI [1.01-2.20]). Post-stroke pneumonia was not associated with ICU mortality but was associated with a 1.6-fold increase in ICU length of stay (CSHR 0.62 [0.39-0.99], p = 0.06). CONCLUSIONS In ischemic stroke patients requiring invasive ventilation, pneumonia occurred in 40% of cases and was associated with a 49% increase in 1-year mortality. Post-stroke pneumonia did not impact day-30 mortality but increased ICU length of stay.
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Middle molecule clearance with high cut-off dialyzer versus high-flux dialyzer using continuous veno-venous hemodialysis with regional citrate anticoagulation: A prospective randomized controlled trial. PLoS One 2019; 14:e0215823. [PMID: 31026303 PMCID: PMC6485708 DOI: 10.1371/journal.pone.0215823] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 04/09/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Regional anticoagulation with citrate during renal replacement therapy (RRT) reduces the risk of bleeding, extends dialyzer lifespan and is cost-effective. Therefore, current guidelines recommend its use if patients are not anticoagulated for another reason and if there are no contraindications against citrate. RRT with regional citrate anticoagulation has been established in critically ill patients as continuous veno-venous hemodialysis (CVVHD) to reduce citrate load. However, CVVHD is inferior regarding middle molecule clearance compared to continuous veno-venous hemofiltration (CVVH). The use of a high cut-off dialyzer in CVVHD may thus present an option for middle molecule clearance similar to CVVH. This may allow combining the advantages of both techniques. METHODS In this prospective, randomized, single-blinded single-center-trial, sixty patients with acute renal failure and established indication for renal replacement therapy were randomized 1:1 into two groups. The control group was put on CVVHD using regional citrate anticoagulation and a high-flux dialyzer, while the intervention group was on CVVHD using regional citrate anticoagulation and a high-cut-off dialyzer. The concentrations of urea, creatinine, β2-microglobulin, myoglobin, interleukin 6 and albumin were measured pre- and post-dialyzer 1, 6, 12, 24 and 48 hours after initiating CVVHD. RESULTS Mean plasma clearance for β2-microglobulin was 19.6±5.8 ml/min in the intervention group vs. 12.2±3.6 ml/min in the control group (p<0.001). For myoglobin (8.0±4.5 ml/min vs. 0.2±3.6 ml/min, p<0.001) and IL-6 (1.5±4.3 vs. -2.5±3.5 ml/min, p = 0.002) a higher mean plasma clearance using high-cut-off dialyzer could be detected too, but no difference for urea, creatinine and albumin could be observed concerning this parameter between the two groups. CONCLUSION CVVHD using a high cut-off dialyzer results in more effective middle molecule clearance than that with high-flux dialyzer. TRIAL REGISTRATION German Clinical Trials Register (DRKS00005254, registered 26th November 2013).
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Lee S, Park S, Kang MW, Yoo HW, Han K, Kim Y, Lee JP, Joo KW, Lim CS, Kim YS, Kim H, Kim DK. Postdischarge long-term cardiovascular outcomes of intensive care unit survivors who developed dialysis-requiring acute kidney injury after cardiac surgery. J Crit Care 2019; 50:92-98. [DOI: 10.1016/j.jcrc.2018.11.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/22/2018] [Accepted: 11/23/2018] [Indexed: 11/29/2022]
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45
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Chaïbi K, Barbar S, Quenot JP, Dreyfuss D, Gaudry S. Retarder une épuration extrarénale dans l’insuffisance rénale aiguë : la nuit nous appartient. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2018-0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Les indications de l’épuration extrarénale (EER) dans le contexte d’insuffisance rénale aiguë en réanimation sont débattues avec une certaine passion. Il est évident que les situations qui peuvent menacer immédiatement le pronostic vital (hyperkaliémie ou acidose métabolique réfractaire et sévère ou oedème pulmonaire de surcharge chez le patient anurique) nécessitent un recours urgent à l’EER. Hormis ces situations extrêmes, des études de haut niveau de preuve ont récemment montré que retarder l’indication de l’EER n’affecte pas la survie des patients et pourrait même favoriser la récupération de la fonction rénale par comparaison à une EER trop précoce. Cette mise au point se propose de discuter les risques théoriques liés au fait de différer l’EER et s’attache à montrer qu’ils constituent plus des craintes que des réalités.
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Eskola M, Vaara ST, Korhonen A, Sauranen J, Koivuviita N, Honkanen E, Pettilä V, Haapio M, Laru‐Sompa R, Pulkkinen A, Saarelainen M, Reilama M, Rantalainen U, Vääräniemi K, Taskinen M, Boman H, Pirttinen N, Sanisalo T, Kahrapää P, Lohi H, Lantto M, Anderson S, Jääskeläinen K, Tamminen M, Vainiotalo M, Sinkko J, Metso M, Tertti R, Salmela A. One- and three-year outcomes in patients treated with intermittent hemodialysis for acute kidney injury: prospective observational multicenter post-hoc FINNAKI study. Acta Anaesthesiol Scand 2018; 62:1452-1459. [PMID: 29978569 DOI: 10.1111/aas.13203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 05/09/2018] [Accepted: 06/06/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Studies reporting renal and overall survival after acute kidney injury (AKI) treated exclusively with intermittent modalities of renal replacement therapy (IRRT) are rare. This study focused on outcomes of AKI patients treated with IRRT both in intensive care units (ICUs) and non-ICU dialysis units. METHODS This prospective observational study was carried on during a 5-month period in 17 ICUs and 17 non-ICUs. ICU and non-ICU patients (total n = 138; 65 ICU, 73 non-ICU) requiring RRT for AKI and chosen to receive IRRT were included. Patient and RRT characteristics as well as outcomes at 90 days, 1 year, and 3 years were registered. RESULTS Characteristics of ICU and non-ICU patients differed markedly. Pre-existing chronic kidney disease (CKD) and chronic heart failure were significantly more common among non-ICU patients. At 1 year, RRT dependence was significantly more common in the non-ICU group. At 3 years, there was no significant difference between the groups either in RRT dependence or mortality. CONCLUSION Outcome of AKI patients treated with IRRT is dismal with regard to 3-year kidney function and mortality. Although pre-existing CKD emerged as a major risk factor for end-stage renal disease after AKI, the poor kidney survival was also seen in patients without prior CKD.
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Affiliation(s)
- Maija Eskola
- Nephrology Helsinki University Hospital University of Helsinki Helsinki Finland
| | - Suvi T. Vaara
- Division of Intensive Care Medicine Department of Anesthesiology, Intensive Care and Pain Medicine Helsinki University Hospital University of Helsinki Helsinki Finland
| | - Anna‐Maija Korhonen
- Division of Intensive Care Medicine Department of Anesthesiology, Intensive Care and Pain Medicine Helsinki University Hospital University of Helsinki Helsinki Finland
| | - Jukka Sauranen
- Department of Medicine Tampere University Hospital Tampere Finland
| | - Niina Koivuviita
- Division of Medicine Department of Nephrology Turku University Hospital Turku Finland
| | - Eero Honkanen
- Nephrology Helsinki University Hospital University of Helsinki Helsinki Finland
| | - Ville Pettilä
- Division of Intensive Care Medicine Department of Anesthesiology, Intensive Care and Pain Medicine Helsinki University Hospital University of Helsinki Helsinki Finland
| | - Mikko Haapio
- Nephrology Helsinki University Hospital University of Helsinki Helsinki Finland
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Factors Associated with Early Mortality in Critically Ill Patients Following the Initiation of Continuous Renal Replacement Therapy. J Clin Med 2018; 7:jcm7100334. [PMID: 30297660 PMCID: PMC6210947 DOI: 10.3390/jcm7100334] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 09/30/2018] [Accepted: 10/05/2018] [Indexed: 01/11/2023] Open
Abstract
Continuous renal replacement therapy (CRRT) is an important modality to support critically ill patients, and the need for CRRT treatment has been increasing. However, CRRT management is costly, and the associated resources are limited. Thus, it remains challenging to identify patients that are likely to have a poor outcome, despite active treatment with CRRT. We sought to elucidate the factors associated with early mortality after CRRT initiation. We analyzed 240 patients who initiated CRRT at an academic medical center between September 2016 and January 2018. We compared baseline characteristics between patients who died within seven days of initiating CRRT (early mortality), and those that survived more than seven days beyond the initiation of CRRT. Of the patients assessed, 130 (54.2%) died within seven days of CRRT initiation. Multivariate logistic regression models revealed that low mean arterial pressure, low arterial pH, and high Sequential Organ Failure Assessment score before CRRT initiation were significantly associated with increased early mortality in patients requiring CRRT. In conclusion, the mortality within seven days following CRRT initiation was very high in this study. We identified several factors that are associated with early mortality in patients undergoing CRRT, which may be useful in predicting early outcomes, despite active treatment with CRRT.
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Heyard R, Timsit J, Essaied WI, Held L. Dynamic clinical prediction models for discrete time‐to‐event data with competing risks—A case study on the OUTCOMEREA database. Biom J 2018; 61:514-534. [DOI: 10.1002/bimj.201700259] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 08/10/2018] [Accepted: 08/14/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Rachel Heyard
- Department of Biostatistics at the Epidemiology, Biostatistics and Prevention InstituteUniversity of ZurichHirschengraben 84 Zurich Switzerland
| | | | | | - Leonhard Held
- Department of Biostatistics at the Epidemiology, Biostatistics and Prevention InstituteUniversity of ZurichHirschengraben 84 Zurich Switzerland
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Abstract
PURPOSE OF REVIEW The increasing incidence of acute kidney injury has the immediate effect of a growing need for renal replacement therapy (RRT). Shedding light on the questions of who, when, why, and how RRT should be performed is difficult to accomplish because of ambiguous study results, poor quality evidence, and low standardization. RECENT FINDINGS Critically ill patients are exposed to multiple factors known to deteriorate kidney function. Especially severe fluid overload is strongly associated with worse outcome and may be considered as a trigger for initiating RRT. In the absence of life-threatening complications, a strategy of early initiation of RRT might be most advantageous keeping in mind the potential adverse effects of RRT. By providing better hemodynamic stability and superior control of fluid balance continuous RRT is the first choice therapeutic tool as compared with intermittent techniques. The femoral and jugular veins are the preferred insertion sites for temporary catheters. Although data are still weak, there is some preliminary evidence that regional citrate anticoagulation is superior to systemic heparinization. SUMMARY The best management of RRT is still a subject of controversy. Continuous RRT with regional citrate anticoagulation via a temporary catheter in a jugular vein is the recommended first choice treatment option in critically ill patients with acute kidney injury.
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Azoulay E, Lemiale V, Mourvillier B, Garrouste-Orgeas M, Schwebel C, Ruckly S, Argaud L, Cohen Y, Souweine B, Papazian L, Reignier J, Marcotte G, Siami S, Kallel H, Darmon M, Timsit JF. Management and outcomes of acute respiratory distress syndrome patients with and without comorbid conditions. Intensive Care Med 2018; 44:1050-1060. [PMID: 29881987 PMCID: PMC7095161 DOI: 10.1007/s00134-018-5209-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/05/2018] [Indexed: 12/14/2022]
Abstract
Rationale The standard of care for patients with acute respiratory distress syndrome (ARDS) has been developed based on studies that usually excluded patients with major comorbidities. Objectives To describe treatments and outcomes according to comorbidities in patients with ARDS admitted to 19 ICUs (1997–2014). Methods Patients were grouped based on comorbidities. Determinants of day-28 mortality were identified by multivariable Cox analysis stratified on center. Measurements and main results Among 4953 ARDS patients, 2545 (51.4%) had major comorbidities; the proportion with major comorbidities increased after 2008. Hematological malignancy was associated with severe ARDS and rescue therapies for refractory hypoxemia. COPD, HIV infection, and hematological malignancy were associated with a lower likelihood of invasive mechanical ventilation on the admission day. Admission-day SOFA score was higher in patients with major comorbidities, who more often received vasopressors, dialysis, or treatment-limitation decisions. Day-28 mortality was 33.7% overall, 27.2% in patients without major comorbidities, and 31.1% (COPD) to 56% (hematological malignancy) in patients with major comorbidities. By multivariable analysis, mortality was lower in patients with COPD and higher in those with chronic heart failure, solid tumors, or hematological malignancies. Mortality was independently associated with PaO2/FiO2 and PaCO2 on day 1, ARDS of pulmonary origin, worse SOFA score, and ICU-acquired events. Conclusions Half the patients with ARDS had major comorbidities, which were associated with severe ARDS, multiple organ dysfunction, and day-28 mortality. These findings do not support the exclusion of ARDS patients with severe comorbidities from randomized clinical trials. Trials in ARDS patients with whatever comorbidities are warranted. Electronic supplementary material The online version of this article (10.1007/s00134-018-5209-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elie Azoulay
- Medical Intensive Care Unit, AP-HP, Saint-Louis hospital, ECSTRA Team, Biostatistics and CLINICAL EPIDEMIOLOGY, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France.
| | - Virginie Lemiale
- Medical Intensive Care Unit, AP-HP, Saint-Louis hospital, ECSTRA Team, Biostatistics and CLINICAL EPIDEMIOLOGY, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France
| | - Bruno Mourvillier
- Réanimation Médicale et Infectieuse, Hôpital Bichat Claude Bernard, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Carole Schwebel
- Service de Réanimation Médicale, Centre Hospitalier Universitaire Grenoble-Alpes, CS10217, Grenoble Cedex 09, France
| | | | - Laurent Argaud
- Medical ICU, Edouard Hériot University Hospital, Lyon, France
| | - Yves Cohen
- Medical-Surgical ICU, Bobigny University hospital, Paris, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Laurent Papazian
- Réanimation des Détresses Respiratoires et Infections Sévères, Hôpital Nord, Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille, Unité de Recherche sur les Maladies Infectieuses et Tropicales Émergentes (URMITE), UMR CNRS 7278, Marseille, France
| | - Jean Reignier
- Medical Intensive Care Unit, Nantes University Hospital Center, Nantes, France
| | | | - Shidasp Siami
- Réanimation polyvalente-Surveillance Continue-Site d'Etampes, Centre hospitalier Sud Essonne (Etampes), Paris, France
| | - Hatem Kallel
- Medical Surgical ICU, Centre hospitalier de Cayenne, Guyane, France
| | - Michael Darmon
- Medical Intensive Care Unit, AP-HP, Saint-Louis hospital, ECSTRA Team, Biostatistics and CLINICAL EPIDEMIOLOGY, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France
| | - Jean-François Timsit
- UMR 1137, Infection Antimicrobials Modelling Evolution (IAME) Team 5, Decision Sciences in Infectious Diseases (DeSCID), Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, Paris, France
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