Spectrum of renal failure in elderly patients

Acute Kidney Injury Outcomes of Elderly and Nonelderly Patients in the Medical Intensive Care Unit of a University Hospital in a Developing Country

Background

Aging is associated with a high risk of acute kidney injury (AKI), and the elderly with AKI show a higher mortality rate than those without AKI. In this study, we compared AKI outcomes between elderly and nonelderly patients in a university hospital in a developing country.

Materials and Methods

This retrospective cohort study included patients with AKI who were admitted to the medical intensive care unit (ICU) between January 1, 2012, and December 31, 2017. The patients were divided into the elderly (eAKI; age ≥65 years; n = 158) and nonelderly (nAKI; n = 142) groups. Baseline characteristics, comorbidities, principle diagnosis, renal replacement therapy (RRT) requirement, hospital course, and in-hospital mortality were recorded. The primary outcome was in-hospital mortality.

Results

The eAKI group included more females, patients with higher Acute Physiology and Chronic Health Evaluation II scores, and patients with more comorbidities than the nAKI group. The etiology and staging of AKI were similar between the two groups. There were no significant differences in in-hospital mortality (p=0.338) and RRT requirement (p=0.802) between the two groups. After adjusting for covariates, the 28-day mortality rate was similar between the two groups (p=0.654), but the 28-day RRT requirement was higher in the eAKI group than in the nAKI group (p=0.042).

Conclusion

Elderly and nonelderly ICU patients showed similar survival outcomes of AKI, although the elderly were at a higher risk of requiring RRT.

[Kidney disease care for the elderly]

In our aging population, kidney disease management needs to take into account the frailty of the elderly. Standardized geriatric assessments can be proposed to help clinicians apprehend this dimension in their daily practice. These tools allow to better identify frail patients and offer them more personalized and harmless treatments. This article aims to focus on the kidney diseases commonly observed in elderly patients and analyze their specific nephrogeriatric care modalities. It should be noticed that all known kidney diseases can be also observed in the elderly, most often with a quite similar clinical presentation. This review is thus focused on the diseases most frequently and most specifically observed in elderly patients (except for monoclonal gammopathy associated nephropathies, out of the scope of this work), as well as the peculiarities of old age nephrological care.

Urinary Neutrophil Gelatinase-Associated Lipocalin Is Excellent Predictor of Acute Kidney Injury in Septic Elderly Patients

Elderly is the main age group affected by acute kidney injury (AKI). There are no studies that investigated the predictive properties of urinary (u) NGAL as an AKI marker in septic elderly population. This study aimed to evaluate the efficacy of uNGAL as predictor of AKI diagnosis and prognosis in elderly septic patients admitted to ICUs. We prospectively studied elderly patients with sepsis admitted to ICUs from October 2014 to November 2015. Assessment of renal function was performed daily by serum creatinine and urine output. The level of uNGAL was performed within the first 48 hours of the diagnosis of sepsis (NGAL1) and between 48 and 96 hours (NGAL2). The results were presented using descriptive statistics and area under the receiver operating characteristic curve (AUC-ROC) and p value was 5%. Seventy-five patients were included, 47 (62.7%) developed AKI. At logistic regression, chronic kidney disease and low mean blood pressure at admission were identified as factors associated with AKI (OR=0.05, CI=0.01-0.60, p=0.045 and OR=0.81, CI=0,13-0.47; p=0.047). The uNGAL was excellent predictor of AKI diagnosis (AUC-ROC >0.95, and sensitivity and specificity>0.89), anticipating the AKI diagnosis in 2.1±0.3 days. Factors associated with mortality in the logistic regression were presence of AKI (OR=2.14, CI=1.42-3.98, p=0.04), chronic obstructive pulmonary disease (OR = 9.37, CI =1.79-49.1, p=0.008) and vasoactive drugs (OR=2.06, CI=0.98-1.02, p=0.04). The accuracy of NGALu 1 and 2 as predictors of death was intermediate, with AUC-ROC of 0.61 and 0.62; sensitivity between 0.65 and 0.77 and specificity lower than 0.6. The uNGAL was excellent predictor of AKI in septic elderly patients in ICUs and can anticipate the diagnosis of AKI in 2.1 days.

Acute kidney injury in elderly intensive care patients from a developing country: clinical features and outcome

AIM

The elderly are at high risk of acute kidney injury (AKI) because of structural and functional degeneration over time and with the aging of the population, the demand for intensive care unit (ICU) admission for older patients has risen recently. However, data from developing countries are scarce. This study aimed to describe the incidence of AKI in elderly patients admitted to ICU from a developing country, to determine the most frequent etiologies for renal impairment and identify its risk factors and outcome.

METHODS

All patients admitted to the ICU at a Brazilian teaching hospital for 12 consecutive months were followed prospectively from the time of admission until ICU discharge. Elderly was defined as aged >60 years and AKI was defined according to the Kidney Disease Improving Global Outcomes 2012 criteria. Multivariable logistic regression was used to adjust confounding and selection bias.

RESULTS

Two hundred elderly patients were included in the study. AKI incidence was 27% and the main etiology was sepsis (48.1%). At logistic regression, baseline creatinine (odds ratio [OR]=5.17, p<0.0001), Acute Physiology and Chronic Health Evaluation (APACHE) II (OR=1.20, p<0.0001), sepsis (OR=2.96, p<0.0001), and longer ICU stay (OR=1.68, p<0.0001) were associated with AKI in elderly patients. Baseline creatinine (OR=1.97, p=0.018), APACHE II (OR=1.29, p<0.0001), sepsis (OR=1.87, p<0.0001), and AKI severity (OR=2.57, p=0.027) were identified as predictors of death.

CONCLUSION

AKI was frequent in elderly patients admitted to ICU from a developing country, and it was identified as a risk factor for death. Sepsis was an important risk factor for both AKI and mortality, similar to developed countries and in younger populations.

Acute kidney injury in the elderly population

The elderly population is more prone to acute kidney injury (AKI) than younger populations. Older patients have less renal reserve because of reduced glomerular filtration rates due to anatomic/functional changes, and concomitant diseases such as hypertension, diabetes, atherosclerosis, heart failure, ischemic renal disease, and obstructive uropathy. The risk of AKI may also increase as a result of aggressive diagnostic and therapeutic procedures, which include medical agents, radiology, and surgical intervention. AKI in the elderly has a multifactorial physiopathology due to different etiologies. Studies that have specifically compared prognosis of AKI in elderly versus young over the recent years suggest that age is a predictor of long-term outcome. In most cases, the treatment of AKI is similar for all age groups. The majority of critically ill patients with AKI will eventually need renal replacement therapy (RRT). The influence of RRT on renal outcome remains a subject of intense investigation and debate. Avoiding situations that could damage the kidney is an important strategy to prevent AKI development in the elderly, besides medical and interventional therapeutics.

Challenges in pediatric peritoneal dialysis in Turkey

Chronic peritoneal dialysis (CPD) is the modality of choice for children with end-stage renal disease in Turkey. CPD was first instituted in 1989 in Turkish pediatric patients by using imported basic equipment and solutions since then the number of patients on CPD increased gradually. Parallel to the developments in the PD industry, in 2002, the Turkish Pediatric Nephrology Association established the Turkish Pediatric Peritoneal Dialysis (TUPEPD) Study Group to study peritoneal dialysis in children and adolescents. Today in Turkey, almost all of the PD equipment and PD solutions are available. Turkish pediatric nephrologists now have a significant experience with PD. Physicians, parents, and the children prefer to start with CPD because of its advantages, such as a more liberal social life and better school attendance.

Comparison between early and delayed acute kidney injury secondary to infectious disease in the intensive care unit

BACKGROUND

Results from a number of studies suggest that the delayed manifestation of acute kidney injury (AKI) is associated with higher in-hospital mortality, while other studies were unable to demonstrate any difference among early and delayed AKI in terms of in-hospital mortality.

OBJECTIVE

The aim of this study was to investigate differences in outcome among patients with AKI upon admission to an intensive care unit (ICU) and those who develop AKI post-admission.

METHODS

We studied patients with AKI secondary to infectious diseases admitted to the ICU. We retrospectively compared data on patients admitted with AKI (early AKI) with data on those who developed AKI 24 h after admission (delayed AKI).

RESULTS

Acute kidney injury occurred in 147 of 829 (17.7%) patients admitted to the ICU. Of these, 96 (65%) had early AKI and 51 (35%) had delayed AKI. Renal failure was classified according to RIFLE criteria-an AKI-specific severity score that is used to place patients into one of five categories: risk, injury, failure, loss or end-stage renal disease. Based on these criteria, 6% of the early AKI and 4% of the delayed AKI patients were in risk category, 18% of the early AKI and 27% of the delayed AKI patients were in the injury category and 76% of the early AKI and 69% of the delayed AKI patients were in the failure category. We found no significant association between RIFLE and death. On admission, patients with early AKI had statistically significantly higher serum urea and creatinine levels than delayed AKI patients (P<0.0001). Arterial bicarbonate was lower in early AKI (P=0.02). Sepsis, hypotension and use of mechanical ventilation were more frequent in delayed AKI (P<0.05). The APACHE II score was higher in early AKI (P=0.05) patients. In total, 98 (66.7%) patients died, with a tendency towards higher mortality in patients with delayed AKI (61.5 vs. 76.5%, P=0.07).

CONCLUSION

Mortality among patients with infectious diseases-associated AKI admitted to the ICU is high, with a trend to be higher in those who developed delayed AKI.