1
|
Zhang Q, Wang X, Chao Y, Liu L. Focus on oliguria during renal replacement therapy. J Anesth 2024; 38:681-691. [PMID: 38777933 DOI: 10.1007/s00540-024-03342-4] [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: 06/08/2023] [Accepted: 04/29/2024] [Indexed: 05/25/2024]
Abstract
Oliguria is a clinical symptom characterized by decreased urine output, which can occur at any stage of acute kidney injury and also during renal replacement therapy. In some cases, oliguria may resolve with adjustment of blood purification dose or fluid management, while in others, it may suggest a need for further evaluation and intervention. It is important to determine the underlying cause of oliguria during renal replacement therapy and to develop an appropriate treatment plan. This review looks into the mechanisms of urine production to investigate the mechanism of oliguria during renal replacement therapy from two aspects: diminished glomerular filtration rate and tubular abnormalities. The above conditions all implying a renal oxygen supply-demand imbalance, which is the signal of worsening kidney injury. It also proposes a viable clinical pathway for the treatment and management of patients with acute kidney injury receiving renal replacement therapy.
Collapse
Affiliation(s)
- Qian Zhang
- Department of Intensive Care Unit (ICU), The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, 550004, People's Republic of China
| | - Xiaoting Wang
- Department of Intensive Care Unit (ICU), Peking Union Medical College Hospital, Beijing, 100005, People's Republic of China
| | - Yangong Chao
- Department of Intensive Care Unit (ICU), The First Affiliated Hospital of Tsinghua University, Beijing, 100016, People's Republic of China
| | - Lixia Liu
- Department of Intensive Care Unit (ICU), The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, People's Republic of China.
| |
Collapse
|
2
|
da Hora Passos R, Coelho FO, Caldas JR, Dosde Santos GalvãoMelo EB, de Carvalho Farias AM, Messeder OHC, Macedo E. Predicting intradialytic hypotension in critically ill patients undergoing intermittent hemodialysis: a prospective observational study. Intensive Care Med Exp 2024; 12:82. [PMID: 39331284 PMCID: PMC11436581 DOI: 10.1186/s40635-024-00676-x] [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: 07/21/2024] [Accepted: 09/11/2024] [Indexed: 09/28/2024] Open
Abstract
BACKGROUND Hypotension during dialysis arises from vasomotor tone alterations and hypovolemia, with disrupted counterregulatory mechanisms in acute kidney injury (AKI) patients. This study investigated the predictive value of preload dependency, assessed by the passive leg raising (PLR) test, and arterial tone, measured by dynamic elastance (Eadyn), for intradialytic hypotension (IDH). METHODS In this prospective observational study conducted in a tertiary hospital ICU, hemodynamic parameters were collected from critically ill AKI patients undergoing intermittent hemodialysis using the FloTrac/Vigileo system. Baseline measurements were recorded before KRT initiation, including the PLR test and Eadyn calculation. IDH was defined as mean arterial pressure (MAP) < 65 mmHg during dialysis. Logistic regression was used to identify predictors of IDH, and Kaplan-Meier analysis assessed 90-day survival. RESULTS Of 187 patients, 27.3% experienced IDH. Preload dependency, identified by positive PLR test, was significantly associated with IDH (OR 8.54, 95% CI 5.25-27.74), while baseline Eadyn was not predictive of IDH in this cohort. Other significant predictors of IDH included norepinephrine use (OR 16.35, 95% CI 3.87-68.98) and lower baseline MAP (OR 0.96, 95% CI 0.94-1.00). IDH and a positive PLR test were associated with lower 90-day survival (p < 0.001). CONCLUSIONS The PLR test is a valuable tool for predicting IDH in critically ill AKI patients undergoing KRT, while baseline Eadyn did not demonstrate predictive value in this setting. Continuous hemodynamic monitoring, including assessment of preload dependency, may optimize patient management and potentially improve outcomes. Further research is warranted to validate these findings and develop targeted interventions to prevent IDH.
Collapse
Affiliation(s)
- Rogério da Hora Passos
- Departamento de Pacientes Graves, Hospital Israelita Albert Einstein, Av Albert Einstein, 627/701, Morumbi, São Paulo, SP, Brazil.
- Davita Tratamento Renal, Rio de Janeiro, Brazil.
| | | | | | | | | | | | - Etienne Macedo
- Nephrology Division, University of California, San Diego, USA
| |
Collapse
|
3
|
Nie A, Zhang S, Cai M, Yu L, Li J, Su X. Incidence and associated factors for hypotension during continuous renal replacement therapy in critically ill patients. Int J Nurs Pract 2024:e13296. [PMID: 39075855 DOI: 10.1111/ijn.13296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/01/2024] [Accepted: 07/17/2024] [Indexed: 07/31/2024]
Abstract
AIMS This work aimed to analyse retrospective data on hypotension incidence and associated factors among patients requiring continuous renal replacement therapy. BACKGROUND The incidence and risk factors of continuous renal replacement therapy-related hypotension have not been adequately explored. DESIGN The study was designed as a retrospective analysis. METHODS Patients who required continuous renal replacement therapy in the ICU between January 2017 and June 2021 were reviewed. The multivariate logistic regression model was used to determine the associated factors of hypotension. RESULTS Hypotension occurred in 242 out of 885 circuits (27.3%) among 140 patients. The logistic regression analysis identified seven factors associated with the occurrence of hypotension during CRRT: serum albumin (OR = 0.969, 95%CI: 0.934-0.999), serum calcium (OR = 0.514, 95%CI: 0.345-0.905), CO2CP (OR = 0.933, 95%CI: 0.897-0.971), use of vasopressors (OR = 5.731, 95%CI: 4.023-8.165), hypotension before CRRT initiation (OR = 2.779, 95%CI:1.238-6.242), age (OR = 1.016, 95%CI: 1.005-1.027), and fluid removal rate (OR = 1.002, 95%CI: 1.001-1.003). CONCLUSIONS Hypotension frequently occurs in patients receiving continuous renal replacement therapy, especially in the early stages. Multiple factors can be associated with cardiac output or peripheral resistance changes, including excessive ultrafiltration, vasopressors, serum albumin and serum calcium levels, and carbon dioxide combining power.
Collapse
Affiliation(s)
- Anliu Nie
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shuzeng Zhang
- School of Nursing, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Mingju Cai
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Limei Yu
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jianfeng Li
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiangfen Su
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| |
Collapse
|
4
|
Maeda A, Inokuchi R, Bellomo R, Doi K. Heterogeneity in the definition of major adverse kidney events: a scoping review. Intensive Care Med 2024; 50:1049-1063. [PMID: 38801518 PMCID: PMC11245451 DOI: 10.1007/s00134-024-07480-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/03/2024] [Indexed: 05/29/2024]
Abstract
Acute kidney injury (AKI) is associated with persistent renal dysfunction, the receipt of dialysis, dialysis dependence, and mortality. Accordingly, the concept of major adverse kidney events (MAKE) has been adopted as an endpoint for assessing the impact of AKI. However, applied criteria or observation periods for operationalizing MAKE appear to vary across studies. To evaluate this heterogeneity for MAKE evaluation, we performed a systematic scoping review of studies that employed MAKE as an AKI endpoint. Four major academic databases were searched, and we identified 122 studies with increasing numbers over time. We found marked heterogeneity in applied criteria and observation periods for MAKE across these studies, with some even lacking a description of criteria. Moreover, 13 different observation periods were employed, with 30 days and 90 days as the most common. Persistent renal dysfunction was evaluated by estimated glomerular filtration rate (34%) or serum creatinine concentration (48%); however, 37 different definitions for this component were employed in terms of parameters, cut-off criteria, and assessment periods. The definition for the dialysis component also showed significant heterogeneity regarding assessment periods and duration of dialysis requirement (chronic vs temporary). Finally, MAKE rates could vary by 7% [interquartile range: 1.7-16.7%] with different observation periods or by 36.4% with different dialysis component definitions. Our findings revealed marked heterogeneity in MAKE definitions, particularly regarding component assessment and observation periods. Dedicated discussion is needed to establish uniform and acceptable standards to operationalize MAKE in terms of selection and applied criteria of components, observation period, and reporting criteria for future trials on AKI and related conditions.
Collapse
Affiliation(s)
- Akinori Maeda
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Emergency and Critical Care Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Ryota Inokuchi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
- Department of Clinical Engineering, The University of Tokyo Hospital, Tokyo, Japan
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| |
Collapse
|
5
|
Doddi A, Abbasi A, Ramesh A, Moursy S, Sakhuja A, Shawwa K. Impact of Using Blood Warmer During Continuous Kidney Replacement Therapy in Patients With Acute Kidney Injury. J Intensive Care Med 2024; 39:387-394. [PMID: 37885206 PMCID: PMC11150979 DOI: 10.1177/08850666231210225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
PURPOSE We investigated the impact of blood warmer use on hypotensive episodes in patients with acute kidney injury (AKI) receiving continuous kidney replacement therapy (CKRT). MATERIALS AND METHODS We included patients with AKI undergoing CKRT between January 1, 2012, and January 1, 2021, at a tertiary academic hospital. Hypotensive episodes were defined as mean arterial pressure (MAP) <60 mm Hg or a decrease in MAP by ≥10 mm Hg, systolic blood pressure (SBP) < 90 mm Hg or a decrease in SBP by ≥20 mm Hg, or increased vasopressor requirement. These were analyzed by Poisson regression with repeated-measures analysis of variance using generalized estimation equation. RESULTS There were 669 patients with AKI that required CKRT. Use of blood warmer on first day of CKRT was in 324 (48%) patients. Incidence rate ratio of hypotensive episodes during the first 24-h of CKRT in patients where a blood warmer was used was 1.06 (95% confidence interval [CI]: 0.98-1.13) compared to those where blood warmer was not used. This did not change in adjusted model. Overall, the within-subject effect of temperature on hypotensive episodes showed that higher temperature was associated with fewer episodes (0.94, 95% CI: 0.9-0.99 per 10 degrees increase, P = .007). CONCLUSION Blood rewarming was not associated with hypotensive episodes during CKRT.
Collapse
Affiliation(s)
- Akshith Doddi
- Department of Medicine, West Virginia University, Morgantown, USA
| | - Aisha Abbasi
- Department of Medicine, West Virginia University, Morgantown, USA
| | - Ambika Ramesh
- Department of Medicine, West Virginia University, Morgantown, USA
| | - Safa Moursy
- Division of Nephrology, Department of Medicine, West Virginia University, Morgantown, USA
| | - Ankit Sakhuja
- Division of Cardiovascular Critical Care. Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV
| | - Khaled Shawwa
- Division of Nephrology, Department of Medicine, West Virginia University, Morgantown, USA
| |
Collapse
|
6
|
Imberti S, Comoretto R, Ceschia G, Longo G, Benetti E, Amigoni A, Daverio M. Impact of the first 24 h of continuous kidney replacement therapy on hemodynamics, ventilation, and analgo-sedation in critically ill children. Pediatr Nephrol 2024; 39:879-887. [PMID: 37723304 DOI: 10.1007/s00467-023-06155-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/25/2023] [Accepted: 08/17/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND In a group of children admitted to the paediatric intensive care unit (PICU) receiving continuous kidney replacement therapy (CKRT), we aim to evaluate the data about their hemodynamic, ventilation and analgo-sedation profile in the first 24 h of treatment and possible associations with mortality. METHODS Retrospective cohort study of children admitted to the PICU of the University Hospital of Padova undergoing CKRT between January 2011 and March 2021. Data was collected at baseline (T0), after 1 h (T1) and 24 h (T24) of CKRT treatment. The differences in outcome measures were compared between these time points, and between survivors and non-survivors. RESULTS Sixty-nine patients received CKRT, of whom 38 (55%) died during the PICU stay. Overall, the vasoactive inotropic score and the adrenaline dose increased at T1 compared to T0 (p = 0.012 and p = 0.022, respectively). Compared to T0, at T24 patients showed an improvement in the following ventilatory parameters: Oxygenation Index (p = 0.005), Oxygenation Saturation Index (p = 0.013) PaO2/FiO2 ratio (p = 0.005), SpO2/FiO2 ratio (p = 0.002) and Mean Airway Pressure (p = 0.016). These improvements remained significant in survivors (p = 0.01, p = 0.027, p = 0.01 and p = 0.015, respectively) but not in non-survivors. No changes in analgo-sedative drugs have been described. CONCLUSIONS CKRT showed a significant impact on hemodynamics and ventilation in the first 24 h of treatment. We observed a significant rise in the inotropic/vasoactive support required after 1 h of treatment in the overall population, and an improvement in the ventilation parameters at 24 h only in survivors.
Collapse
Affiliation(s)
- Simona Imberti
- Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Rosanna Comoretto
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Giovanni Ceschia
- Department of Women's and Children's Health, University of Padua, Padua, Italy
- Pediatric Nephrology, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Germana Longo
- Pediatric Nephrology, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Elisa Benetti
- Pediatric Nephrology, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy.
| |
Collapse
|
7
|
Liu L, Liu D, Hu Z, Wang X, Chao Y, Wu J, Yin W, Zhang H, Zhang L, He W, Zhu R, Xu Q, Yang R, Huo Y, Zhang Q, Liu H, Zhu W, Zhang Q, Li R. Renal hemodynamic evaluation protocol based on the pathophysiological mechanism of acute kidney injury: Critical Care UltraSound Guided-A (KI)BCDE. Ren Fail 2023; 45:2284842. [PMID: 37994455 PMCID: PMC11001348 DOI: 10.1080/0886022x.2023.2284842] [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: 05/02/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023] Open
Abstract
The multiple etiological characteristics of acute kidney injury (AKI) have brought great challenges to its clinical diagnosis and treatment. Renal injury in critically ill patients always indicates hemodynamic injury. The Critical Care UltraSound Guided (CCUSG)-A(KI)BCDE protocol developed by the Chinese Critical Ultrasound Study Group (CCUSG), respectively, includes A(KI) diagnosis and risk assessment and uses B-mode ultrasound, Color doppler ultrasound, spectral Doppler ultrasound, and contrast Enhanced ultrasound to obtain the hemodynamic characteristics of the kidney so that the pathophysiological mechanism of the occurrence and progression of AKI can be captured and the prognosis of AKI can be predicted combined with other clinical information; therefore, the corresponding intervention and treatment strategies can be formulated to achieve targeted, protocolized, and individualized therapy.
Collapse
Affiliation(s)
- Lixia Liu
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Dawei Liu
- Department of Intensive Care Department, Peking Union Medical College Hospital, Beijing, China
| | - Zhenjie Hu
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaoting Wang
- Department of Intensive Care Department, Peking Union Medical College Hospital, Beijing, China
| | - Yangong Chao
- Department of Critical Care Medicine, The First Affiliated Hospital of Tsinghua University, Beijing, China
| | - Jun Wu
- Department of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wanhong Yin
- Department of Intensive Care, West China Hospital, Sichuan University, Chengdu, China
| | - Hongmin Zhang
- Department of Intensive Care Department, Peking Union Medical College Hospital, Beijing, China
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Wei He
- Department of Intensive Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Ran Zhu
- Department of Intensive Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Qianghong Xu
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, China
| | - Rongli Yang
- Department of Critical Care Medicine, The Central Hospital of Dalian, Dalian, China
| | - Yan Huo
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qian Zhang
- Department of Intensive Care Medicine, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Haitao Liu
- Department of Critical Care Medicine, The Fourth Hospital of Harbin Medical University, Harbin, China
| | - Weihua Zhu
- Department of Intensive Care Medicine, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Qian Zhang
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Rong Li
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | | |
Collapse
|
8
|
Yu Y, Gong Y, Hu B, Ouyang B, Pan A, Liu J, Liu F, Shang XL, Yang XH, Tu G, Wang C, Ma S, Fang W, Liu L, Liu J, Chen D. Expert consensus on blood pressure management in critically ill patients. JOURNAL OF INTENSIVE MEDICINE 2023; 3:185-203. [PMID: 37533806 PMCID: PMC10391579 DOI: 10.1016/j.jointm.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Yuetian Yu
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
| | - Ye Gong
- Department of Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
| | - Bin Ouyang
- Department of Critical Care Medicine, The First Affiliated Hospital of SunYatsen University, Guangzhou 510080, Guangdong, China
| | - Aijun Pan
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei 230001, Anhui, China
| | - Jinglun Liu
- Department of Emergency Medicine and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Fen Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi, China
| | - Xiu-Ling Shang
- Department of Critical Care Medicine, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou 350001 Fujian, China
| | - Xiang-Hong Yang
- Department of Intensive Care Unit, Emergency & Intensive Care Unit Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310014 Zhejiang, China
| | - Guowei Tu
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Changsong Wang
- Department of Critical Care Medicine, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang, China
| | - Shaolin Ma
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Wei Fang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong First Medical University, Jinan, 250014 Shandong, China
| | - Ling Liu
- Department of Critical Care Medicine, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009 Jiangsu, China
| | - Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| |
Collapse
|
9
|
Murugan R, Chang CCH, Raza M, Nikravangolsefid N, Huang DT, Palevsky PM, Kashani K. Restrictive versus Liberal Rate of Extracorporeal Volume Removal Evaluation in Acute Kidney Injury (RELIEVE-AKI): a pilot clinical trial protocol. BMJ Open 2023; 13:e075960. [PMID: 37419639 PMCID: PMC10335418 DOI: 10.1136/bmjopen-2023-075960] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/21/2023] [Indexed: 07/09/2023] Open
Abstract
INTRODUCTION Observational studies have linked slower and faster net ultrafiltration (UFNET) rates during kidney replacement therapy (KRT) with mortality in critically ill patients with acute kidney injury (AKI) and fluid overload. To inform the design of a larger randomised trial of patient-centered outcomes, we conduct a feasibility study to examine restrictive and liberal approaches to UFNET during continuous KRT (CKRT). METHODS AND ANALYSIS This study is an investigator-initiated, unblinded, 2-arm, comparative-effectiveness, stepped-wedged, cluster randomised trial among 112 critically ill patients with AKI treated with CKRT in 10 intensive care units (ICUs) across 2 hospital systems. In the first 6 months, all ICUs started with a liberal UFNET rate strategy. Thereafter, one ICU is randomised to the restrictive UFNET rate strategy every 2 months. In the liberal group, the UFNET rate is maintained between 2.0 and 5.0 mL/kg/hour; in the restrictive group, the UFNET rate is maintained between 0.5 and 1.5 mL/kg/hour. The three coprimary feasibility outcomes are (1) between-group separation in mean delivered UFNET rates; (2) protocol adherence; and (3) patient recruitment rate. Secondary outcomes include daily and cumulative fluid balance, KRT and mechanical ventilation duration, organ failure-free days, ICU and hospital length of stay, hospital mortality and KRT dependence at hospital discharge. Safety endpoints include haemodynamics, electrolyte imbalance, CKRT circuit issues, organ dysfunction related to fluid overload, secondary infections and thrombotic and haematological complications. ETHICS AND DISSEMINATION The University of Pittsburgh Human Research Protection Office approved the study, and an independent Data and Safety Monitoring Board monitors the study. A grant from the United States National Institute of Diabetes and Digestive and Kidney Diseases sponsors the study. The trial results will be submitted for publication in peer-reviewed journals and presented at scientific conferences. TRIAL REGISTRATION NUMBER This trial has been prospectively registered with clinicaltrials.gov (NCT05306964). Protocol version identifier and date: 1.5; 13 June 2023.
Collapse
Affiliation(s)
- Raghavan Murugan
- Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chung-Chou H Chang
- Biostatistics and Data Management Core, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Maham Raza
- Multidisciplinary Acute Care Research Organization, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Nasrin Nikravangolsefid
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, New York, USA
| | - David T Huang
- Multidisciplinary Acute Care Research Organization, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Paul M Palevsky
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Kidney Medicine Section, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, New York, USA
| |
Collapse
|
10
|
Liang Z, Yue S, Zhong J, Wu J, Chen C. Associations of systolic blood pressure and in-hospital mortality in critically ill patients with acute kidney injury. Int Urol Nephrol 2023:10.1007/s11255-023-03510-7. [PMID: 36840802 DOI: 10.1007/s11255-023-03510-7] [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: 11/08/2022] [Accepted: 02/06/2023] [Indexed: 02/26/2023]
Abstract
PURPOSE Although systolic blood pressure (SBP) is associated with acute renal injury (AKI), the relationship between baseline SBP and prognosis in critically ill patients with AKI is unclear. We aimed to assess the linearity and profile of the relationship between SBP at intensive care unit (ICU) admission and in-hospital mortality in these patients. METHODS Data of AKI patients in the ICU settings were extracted from the Medical Information Mart for Intensive Care III database. The association between seven SBP categories (< 100, 100-109, 110-119, 120-129, 130-139, 140-149, and ≥ 150 mmHg) and all-cause in-hospital mortality was assessed by Cox proportional hazard models. Restricted cubic spline analysis for the multivariate Cox model was performed to explore the shape of the relationship between SBP and mortality. RESULTS A total of 24,202 patients with AKI were included in this study. A typically U-shaped relationship was found between SBP at admission and in-hospital mortality. Among all SBP categories, the lowest risk of death was observed in patients with SBP around 110-119 mmHg, whereas the highest was noted in patients with extremely low SBP (< 100 mmHg), followed by those with extremely high SBP (≥ 150 mmHg). SBP showed a significant interaction with vasopressor use and AKI stage in relation to the risk of in-hospital mortality. CONCLUSIONS SBP upon admission showed a non-linear association with all-cause in-hospital mortality in critically ill patients with AKI. Patients with low or high SBP show an increased risk of mortality compared to patients with normal SBP.
Collapse
Affiliation(s)
- Zheng Liang
- The First Clinical Medical College of Jinan University, Guangzhou, 510632, China.,Department of Vasculocardiology, The Affiliated Hospital of Guangdong Medical University, Zhanjiang, 524001, China
| | - Suru Yue
- Clinical Research Service Center, The Affiliated Hospital of Guangdong Medical University, Zhanjiang, 524001, Guangdong, China
| | - Jianfeng Zhong
- Department of Vasculocardiology, The Affiliated Hospital of Guangdong Medical University, Zhanjiang, 524001, China
| | - Jiayuan Wu
- Clinical Research Service Center, The Affiliated Hospital of Guangdong Medical University, Zhanjiang, 524001, Guangdong, China.
| | - Can Chen
- The First Clinical Medical College of Jinan University, Guangzhou, 510632, China.
| |
Collapse
|
11
|
Kim SG, Yun D, Lee J, Kim YC, Kim DK, Oh KH, Joo KW, Kim YS, Han SS. Impact of intradialytic hypotension on mortality following the transition from continuous renal replacement therapy to intermittent hemodialysis. Acute Crit Care 2023; 38:86-94. [PMID: 36442470 PMCID: PMC10030245 DOI: 10.4266/acc.2022.00948] [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: 08/01/2022] [Revised: 09/27/2022] [Accepted: 10/14/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The transition of dialysis modalities from continuous renal replacement therapy (CRRT) to intermittent hemodialysis (iHD) is frequently conducted during the recovery phase of critically ill patients with acute kidney injury. Herein, we addressed the occurrence of intradialytic hypotension (IDH) after this transition, and its association with the mortality risk. METHODS A total of 541 patients with acute kidney injury who attempted to transition from CRRT to iHD at Seoul National University Hospital, Korea from 2010 to 2020 were retrospectively collected. IDH was defined as a discontinuation of dialysis because of hemodynamic instability plus a nadir systolic blood pressure <90 mm Hg or a decrease in systolic blood pressure ≥30 mm Hg during the first session of iHD. Odds ratios (ORs) of outcomes, such as in-hospital mortality and weaning from RRT, were measured using a logistic regression model after adjusting for multiple variables. RESULTS IDH occurred in 197 patients (36%), and their mortality rate (44%) was higher than that of those without IDH (19%; OR, 2.64; 95% confidence interval [CI], 1.70-4.08). For patients exhibiting IDH, the iHD sessions delayed successful weaning from RRT (OR, 0.62; 95% CI, 0.43-0.90) compared with sessions on those without IDH. Factors such as low blood pressure, high pulse rate, low urine output, use of mechanical ventilations and vasopressors, and hypoalbuminemia were associated with IDH risk. CONCLUSIONS IDH occurrence following the transition from CRRT to iHD is associated with high mortality and delayed weaning from RRT.
Collapse
Affiliation(s)
- Seong Geun Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Donghwan Yun
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jinwoo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
12
|
Deng J, Li L, Feng Y, Yang J. Comprehensive Management of Blood Pressure in Patients with Septic AKI. J Clin Med 2023; 12:jcm12031018. [PMID: 36769666 PMCID: PMC9917880 DOI: 10.3390/jcm12031018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/31/2023] Open
Abstract
Acute kidney injury (AKI) is one of the serious complications of sepsis in clinical practice, and is an important cause of prolonged hospitalization, death, increased medical costs, and a huge medical burden to society. The pathogenesis of AKI associated with sepsis is relatively complex and includes hemodynamic abnormalities due to inflammatory response, oxidative stress, and shock, which subsequently cause a decrease in renal perfusion pressure and eventually lead to ischemia and hypoxia in renal tissue. Active clinical correction of hypotension can effectively improve renal microcirculatory disorders and promote the recovery of renal function. Furthermore, it has been found that in patients with a previous history of hypertension, small changes in blood pressure may be even more deleterious for kidney function. Therefore, the management of blood pressure in patients with sepsis-related AKI will directly affect the short-term and long-term renal function prognosis. This review summarizes the pathophysiological mechanisms of microcirculatory disorders affecting renal function, fluid management, vasopressor, the clinical blood pressure target, and kidney replacement therapy to provide a reference for the clinical management of sepsis-related AKI, thereby promoting the recovery of renal function for the purpose of improving patient prognosis.
Collapse
Affiliation(s)
- Junhui Deng
- Department of Nephrology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 400120, China
| | - Lina Li
- Department of Nephrology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 400120, China
| | - Yuanjun Feng
- Department of Renal Rheumatology, Space Hospital Affiliated to Zunyi Medical University, Zunyi 563002, China
| | - Jurong Yang
- Department of Nephrology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 400120, China
- Correspondence: or
| |
Collapse
|
13
|
Kompotiatis P, Shawwa K, Jentzer JC, Wiley BM, Kashani KB. Echocardiographic parameters and hemodynamic instability at the initiation of continuous kidney replacement therapy. J Nephrol 2023; 36:173-181. [PMID: 35849262 DOI: 10.1007/s40620-022-01400-2] [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: 04/27/2022] [Accepted: 07/06/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Investigate the association of echocardiographic parameters with hemodynamic instability after initiating continuous kidney replacement therapy (CKRT) in a cohort of intensive care unit (ICU) patients requiring CKRT. METHODS Historical cohort study of consecutive adults admitted to the ICU at a tertiary care hospital from December 2006 through November 2015 who underwent CKRT and had an echocardiogram done within seven days before CKRT initiation. The primary outcome was hypotension within one hour of CKRT initiation. RESULTS We included 980 patients, 804 (82%) with acute kidney injury (AKI) and 176 (18%) with end-stage kidney disease (ESKD). Median patient age was 63 (± 14) years, and median Sequential Organ Failure Assessment (SOFA) score on the day of CKRT initiation was 12 (IQR 10-14). Multivariable analysis showed that Left (OR 2.01, 95% CI 1.04-3.86), and Right (OR 1.5, 95% CI 1.04-2.25) moderate and severe ventricular enlargement, Vasoactive-Inotropic Score (VIS) one hour before CKRT initiation (OR 1.18 per 10 units increase, 95% CI 1.09-1.28) and high bicarbonate fluid replacement (OR 2.52, 95% CI 1.01-6.2) were associated with hypotension after CKRT initiation. CONCLUSION Right and left ventricular enlargement are risk factors associated with hypotension after CKRT initiation.
Collapse
Affiliation(s)
- Panagiotis Kompotiatis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Khaled Shawwa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
14
|
Wu HHL, Athwal VS, Kalra PA, Chinnadurai R. COVID-19 and hepatorenal syndrome. World J Gastroenterol 2022; 28:5666-5678. [PMID: 36338894 PMCID: PMC9627428 DOI: 10.3748/wjg.v28.i39.5666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 09/21/2022] [Accepted: 10/02/2022] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a highly infectious disease which emerged into a global pandemic. Although it primarily causes respiratory symptoms for affected patients, COVID-19 was shown to have multi-organ manifestations. Elevated liver enzymes appear to be commonly observed during the course of COVID-19, and there have been numerous reports of liver injury secondary to COVID-19 infection. It has been established that patients with pre-existing chronic liver disease (CLD) are more likely to have poorer outcomes following COVID-19 infection compared to those without CLD. Co-morbidities such as diabetes, hypertension, obesity, cardiovascular and chronic kidney disease frequently co-exist in individuals living with CLD, and a substantial population may also live with some degree of frailty. The mechanisms of how COVID-19 induces liver injury have been postulated. Hepatorenal syndrome (HRS) is the occurrence of kidney dysfunction in patients with severe CLD/fulminant liver failure in the absence of another identifiable cause, and is usually a marker of severe decompensated liver disease. Select reports of HRS following acute COVID-19 infection have been presented, although the risk factors and pathophysiological mechanisms leading to HRS in COVID-19 infection or following COVID-19 treatment remain largely unestablished due to the relative lack and novelty of published data. Evidence discussing the management of HRS in high-dependency care and intensive care contexts is only emerging. In this article, we provide an overview on the speculative pathophysiological mechanisms of COVID-19 induced HRS and propose strategies for clinical diagnosis and management to optimize outcomes in this scenario.
Collapse
Affiliation(s)
- Henry H L Wu
- Renal Research, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney 2065, New South Wales, Australia
| | - Varinder S Athwal
- Faculty of Biology, Medicine & Health (Division of Diabetes, Metabolism & Gastroenterology), The University of Manchester, Manchester M13 9PL, United Kingdom
| | - Philip A Kalra
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, United Kingdom
| | - Rajkumar Chinnadurai
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, United Kingdom
| |
Collapse
|
15
|
Shawwa K, Kompotiatis P, Sakhuja A, McCarthy P, Kashani KB. Prolonged exposure to continuous renal replacement therapy in patients with acute kidney injury. J Nephrol 2022; 35:585-595. [PMID: 34160782 PMCID: PMC8695624 DOI: 10.1007/s40620-021-01097-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/10/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Little is known about the process of deciding to discontinue continuous renal replacement therapy (CRRT) in patients with acute kidney injury (AKI) and the impact of CRRT duration on outcomes. METHODS We report the clinical parameters of prolonged CRRT exposure and predictors of doubling of serum creatinine or need for dialysis at 90 days after CRRT with propensity score matching, including covariates that were likely to influence patients in the prolonged CRRT group. RESULTS Among 104 survey responders, most use urine output (87%) to guide CRRT discontinuation, 24% use improvement in clinical or hemodynamic status. In the cohort study, of 854 included patients, 465 participated in the assessment of kidney recovery. Patients with prolonged CRRT had higher SOFA scores (11.9 vs. 11.2) and were more likely to be mechanically ventilated (99% vs. 84%) at CRRT initiation compared to patients without prolonged CRRT, p-value < 0.05. In multivariable logistic regression, daily urine output and cumulative fluid balance leading to CRRT discontinuation or day seven were independently associated with lower [OR 0.87 per 200 ml/day increase] and higher odds [OR 1.03 per 1-L increase] of requiring prolonged CRRT, respectively. After propensity score matching, prolonged exposure to CRRT was independently associated with increased risk of doubling serum creatinine or dialysis at 90 days, OR 3.1 (95% CI 1.23-8.3 p = 0.017). CONCLUSIONS Resolution of critical illness and signs of kidney recovery are important factors when considering CRRT discontinuation. Prolonged CRRT exposure may be associated with less chance of kidney recovery among survivors.
Collapse
Affiliation(s)
- Khaled Shawwa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA,Section of Nephrology, Department of Medicine, West Virginia University, Morgantown, WV, USA
| | - Panagiotis Kompotiatis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Ankit Sakhuja
- Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Paul McCarthy
- Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Kianoush B. Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA,Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
16
|
Thongprayoon C, Cheungpasitporn W, Radhakrishnan Y, Petnak T, Qureshi F, Mao MA, Kashani KB. Impact of hypoalbuminemia on mortality in critically ill patients requiring continuous renal replacement therapy. J Crit Care 2021; 68:72-75. [PMID: 34929529 DOI: 10.1016/j.jcrc.2021.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/30/2021] [Accepted: 12/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to assess the association of hypoalbuminemia with mortality in critically ill patients requiring continuous renal replacement therapy (CRRT). METHODS This is a retrospective cohort study of critically ill patients receiving CRRT from December 2006 through November 2015 in a tertiary referral hospital in the United States. We used logistic regression to assess serum albumin at CRRT initiation as predictors for 90-day mortality. RESULTS A total of 911 patients requiring CRRT were included in this study. The mean serum albumin at CRRT initiation was 3.0 ± 0.7 g/dL. The 90-day mortality was 57%. Serum albumin levels of ≤2.4, 2.5-2.9, 3.0-3.4, and ≥ 3.5 g/dL were noted in 24%, 29%, 24%, and 23% of patients, respectively. In adjusted analysis, serum albumin ≤2.4 g/dL compared with serum albumin of ≥3.5 g/dL was significantly associated with higher 90-day mortality with OR of 1.57 (95% CI 1.02-2.42). Serum albumin 2.5-2.9 and 3.0-3.4 g/dL were not associated with higher mortality. Sensitivity analysis in patients requiring CRRT in the setting of acute kidney injury showed consistent results. CONCLUSION Approximately three out of four patients had hypoalbuminemia (<3.5 g/dL) at CRRT initiation. However, only severe hypoalbuminemia <2.5 g/dL was significantly associated with higher mortality.
Collapse
Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yeshwanter Radhakrishnan
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tananchai Petnak
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Pulmonary Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Fawad Qureshi
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - 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, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Petnak T, Thongprayoon C, Cheungpasitporn W, Shawwa K, Mao MA, Kashani KB. The Prognostic Importance of Serum Sodium for Mortality among Critically Ill Patients Requiring Continuous Renal Replacement Therapy. Nephron Clin Pract 2021; 146:153-159. [PMID: 34794149 DOI: 10.1159/000519686] [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: 07/28/2021] [Accepted: 09/15/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Serum sodium derangement is common in critically ill patients requiring continuous renal replacement therapy (CRRT). We aimed to assess the association between serum sodium before and during CRRT with mortality. METHODS This is a historical cohort study of 1,520 critically ill patients receiving CRRT from December 2006 through November 2015 in a tertiary hospital in the United States. Using logistic regression analysis, we used serum sodium before CRRT, mean serum sodium, and serum sodium changes during CRRT to predict 90-day mortality after CRRT initiation. RESULTS Compared with the normal serum sodium levels, the odds ratio (OR) of 90-day mortality in patients with serum sodium before CRRT of 143-147 and ≥148 mmol/L were 1.45 (95% CI 1.03-2.05) and 2.24 (95% CI 1.33-3.87), respectively. There was no significant increase in 90-day mortality in serum sodium of ≤137 mmol/L. During CRRT, the mean serum sodium levels of ≤137 (OR 1.41; 95% CI 1.01-1.98) and ≥143 mmol/L (OR 1.52; 95% CI 1.14-2.03) were associated with higher 90-day mortality. The greater serum sodium changes during CRRT were associated with higher 90-mortality (OR 1.35; 95% CI 1.21-1.51 per 5-mmol/L increase). CONCLUSION Before CRRT initiation, hypernatremia and during CRRT, hypo- and hypernatremia were associated with increased mortality.
Collapse
Affiliation(s)
- Tananchai Petnak
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Pulmonary and Pulmonary Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA,
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Khaled Shawwa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida, USA
| | - Kianoush B Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
19
|
Gao L, Bian Y, Cao S, Sang W, Zhang Q, Yuan Q, Xu F, Chen Y. Development and Validation of a Simple-to-Use Nomogram for Predicting In-Hospital Mortality in Patients With Acute Heart Failure Undergoing Continuous Renal Replacement Therapy. Front Med (Lausanne) 2021; 8:678252. [PMID: 34805193 PMCID: PMC8595094 DOI: 10.3389/fmed.2021.678252] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 09/27/2021] [Indexed: 12/28/2022] Open
Abstract
Background: Patients with acute heart failure (AHF) who require continuous renal replacement therapy (CRRT) have a high risk of in-hospital mortality. It is clinically important to screen high-risk patients using a model or scoring system. This study aimed to develop and validate a simple-to-use nomogram consisting of independent prognostic variables for the prediction of in-hospital mortality in patients with AHF undergoing CRRT. Methods: We collected clinical data for 121 patients with a diagnosis of AHF who underwent CRRT in an AHF unit between September 2011 and August 2020 and from 105 patients in the medical information mart for intensive care III (MIMIC-III) database. The nomogram model was created using a visual processing logistic regression model and verified using the standard method. Results: Patient age, days after admission, lactic acid level, blood glucose concentration, and diastolic blood pressure were the significant prognostic factors in the logistic regression analyses and were included in our model (named D-GLAD) as predictors. The resulting model containing the above-mentioned five factors had good discrimination ability in both the training group (C-index, 0.829) and the validation group (C-index, 0.740). The calibration and clinical effectiveness showed the nomogram to be accurate for the prediction of in-hospital mortality in both the training and validation cohort when compared with other models. The in-hospital mortality rates in the low-risk, moderate-risk, and high-risk groups were 14.46, 40.74, and 71.91%, respectively. Conclusion: The nomogram allowed the optimal prediction of in-hospital mortality in adults with AHF undergoing CRRT. Using this simple-to-use model, the in-hospital mortality risk can be determined for an individual patient and could be useful for the early identification of high-risk patients. An online version of the D-GLAD model can be accessed at https://ahfcrrt-d-glad.shinyapps.io/DynNomapp/. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT0751838.
Collapse
Affiliation(s)
- Luyao Gao
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Chest Pain Center, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Yuan Bian
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Chest Pain Center, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Shengchuan Cao
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Chest Pain Center, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Wentao Sang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Chest Pain Center, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Qun Zhang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Chest Pain Center, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Qiuhuan Yuan
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Chest Pain Center, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Feng Xu
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Chest Pain Center, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Yuguo Chen
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Chest Pain Center, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| |
Collapse
|
20
|
Wald R, Siew ED. Survival and kidney recovery among recipients of continuous renal replacement therapy. Semin Dial 2021; 34:495-500. [PMID: 34533863 DOI: 10.1111/sdi.13016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 06/21/2021] [Accepted: 06/25/2021] [Indexed: 12/15/2022]
Abstract
Continuous renal replacement therapy (CRRT) is widely used in the care of critically ill patients with acute kidney injury (AKI). Despite hopeful trends suggested by recent studies, mortality among CRRT recipients with severe AKI remains extremely high. Moreover, CRRT does not confer a reduction in mortality in trials comparing CRRT to intermittent RRT modalities. Among AKI survivors, some preliminary studies suggest a higher likelihood of kidney recovery and dialysis independence in CRRT recipients. AKI survivors are at risk for a broad array of adverse outcomes; strategies that may mitigate these risks are discussed.
Collapse
Affiliation(s)
- Ron Wald
- Division of Nephrology, St. Michael's Hospital, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Medicine and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for AKI (VIP-AKI), Tennessee Valley Health System, Nashville Veterans Affairs Hospital, Nashville, Tennessee, USA
| |
Collapse
|
21
|
Lv J, Wang H, Sun B, Gao Y, Zhang Z, Pei H. Serum Albumin Before CRRT Was Associated With the 28- and 90-Day Mortality of Critically Ill Patients With Acute Kidney Injury and Treated With Continuous Renal Replacement Therapy. Front Nutr 2021; 8:717918. [PMID: 34513902 PMCID: PMC8425552 DOI: 10.3389/fnut.2021.717918] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Although low serum albumin (ALB) may worsen acute kidney injury (AKI), additional study is needed to establish the connection between ALB and the prognosis of critically ill patients with AKI and treated with continuous renal replacement therapy (CRRT). Methods:A secondary analysis of a bi-center, retrospective, and observational study, such as critically ill patients with AKI and treated with CRRT from January 2009 to September 2016. The univariate analysis, multi-factor regression analysis, sensitivity analysis, and curve-fitting analysis were applied to explore the association of ALB with the 28 and 90 days mortality of critically ill patients with AKI and treated with CRRT, and the removal efficiency of serum phosphorus. Results: From January 2009 to September 2016, 1,132 cases with AKI and treated with CRRT met the inclusion criteria and enrolled in this study. We found that the higher ALB before CRRT, the lower the 28- and 90-day mortality of patients with AKI and treated with CRRT, the higher removal efficiency of serum phosphorus, the adjusted hazard ratio (HR) value for 28-day mortality in the four models were separately 0.92 (0.90, 0.95), 0.91 (0.89, 0.94), 0.92 (0.89, 0.95), and 0.92 (0.89, 0.95); the adjusted HR value for 90 day mortality in the four models were 0.91 (0.89, 0.94), 0.92 (0.89, 0.95), 0.92 (0.89, 0.95), and 0.92 (0.89, 0.96); the adjusted OR value for the removal efficiency of serum phosphorus in the four models were separately -0.04 (-0.07, -0.01), -0.05 (-0.08, -0.01), -0.04 (-0.08, -0.01), and -0.04 (-0.08, -0.01). The sensitivity analysis and curve-fitting analysis also showed that ALB before CRRT was correlated with the 28 and 90 days mortality of critically ill patients with AKI and treated with CRRT and the removal efficiency of serum phosphorus. Conclusion: The higher the serum ALB before CRRT, the lower the mortality of critically ill patients with AKI and treated with CRRT, and the higher the clearance efficiency of serum phosphorus.
Collapse
Affiliation(s)
- Junhua Lv
- Emergency Department, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hai Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Baoni Sun
- Emergency Department, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yanxia Gao
- Emergency Department, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhenglinag Zhang
- Emergency Department, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Honghong Pei
- Emergency Department, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| |
Collapse
|
22
|
Early restrictive fluid balance is associated with lower hospital mortality independent of acute disease severity in critically ill patients on CRRT. Sci Rep 2021; 11:18216. [PMID: 34521957 PMCID: PMC8440636 DOI: 10.1038/s41598-021-97888-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/10/2021] [Indexed: 11/24/2022] Open
Abstract
Fluid overload (FO) with coincident acute kidney injury has been associated with increased mortality. However, it is unclear whether FO is an independent determinant of mortality for disease severity. We aimed to explore whether the development of fluid balance (FB) during the first 72 h of continuous renal replacement therapy (CRRT) is independently associated with hospital mortality. All patients admitted to a single centre ICU requiring CRRT for at least 24 h between years 2010–2019 were included. Extracted data included patient demographics and clinical parameters including daily cumulative fluid balance (FBcum), lactate, SOFA score and vasoactive requirement at the initiation and during the first 72 h of CRRT. 399 patients were included in the analysis. Hospital survivors had a significantly lower FBcum at CRRT initiation compared to non-survivors (median 1382 versus 3265 ml; p = 0.003). Hourly fluid balance per bodyweight (FBnet) was lower in survivors at 0–24, 24–48 and 48–72 h after initiation of CRRT (p < 0.008 for all comparisons). In the survival analysis (analyzed with counting process model) significant time-dependent explanatory variables for hospital mortality were FBnet (per ml/kg/h: HR: 1.319, 95% CI 1.038–1.677, p = 0.02), lactate (HR: 1.086, 95% CI 1.030–1.145, p = 0.002) and SOFA score (per ml/kg/h: HR: 1.084, 95% CI 1.025–1.146, p = 0.005) during the first 72 h of CRRT. Even after careful adjustment for repeated measures of disease severity, FBnet during the first 72 h of CRRT remains independently associated with hospital mortality, in critically ill patients with AKI.
Collapse
|
23
|
Kang MW, Kim S, Kim YC, Kim DK, Oh KH, Joo KW, Kim YS, Han SS. Machine learning model to predict hypotension after starting continuous renal replacement therapy. Sci Rep 2021; 11:17169. [PMID: 34433892 PMCID: PMC8387375 DOI: 10.1038/s41598-021-96727-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/13/2021] [Indexed: 12/20/2022] Open
Abstract
Hypotension after starting continuous renal replacement therapy (CRRT) is associated with worse outcomes compared with normotension, but it is difficult to predict because several factors have interactive and complex effects on the risk. The present study applied machine learning algorithms to develop models to predict hypotension after initiating CRRT. Among 2349 adult patients who started CRRT due to acute kidney injury, 70% and 30% were randomly assigned into the training and testing sets, respectively. Hypotension was defined as a reduction in mean arterial pressure (MAP) ≥ 20 mmHg from the initial value within 6 h. The area under the receiver operating characteristic curves (AUROCs) in machine learning models, such as support vector machine (SVM), deep neural network (DNN), light gradient boosting machine (LGBM), and extreme gradient boosting machine (XGB) were compared with those in disease-severity scores such as the Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation II. The XGB model showed the highest AUROC (0.828 [0.796-0.861]), and the DNN and LGBM models followed with AUROCs of 0.822 (0.789-0.856) and 0.813 (0.780-0.847), respectively; all machine learning AUROC values were higher than those obtained from disease-severity scores (AUROCs < 0.6). Although other definitions of hypotension were used such as a reduction of MAP ≥ 30 mmHg or a reduction occurring within 1 h, the AUROCs of machine learning models were higher than those of disease-severity scores. Machine learning models successfully predict hypotension after starting CRRT and can serve as the basis of systems to predict hypotension before starting CRRT.
Collapse
Affiliation(s)
- Min Woo Kang
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Seonmi Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
| |
Collapse
|
24
|
Kelly YP, Sharma S, Mothi SS, McCausland FR, Mendu ML, McMahon GM, Palevsky PM, Waikar SS. Hypocalcemia is associated with hypotension during CRRT: A secondary analysis of the Acute Renal Failure Trial Network Study. J Crit Care 2021; 65:261-267. [PMID: 34274834 DOI: 10.1016/j.jcrc.2021.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/22/2021] [Accepted: 07/06/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE We investigated the effect of potentially modifiable continuous renal replacement therapy (CRRT)-related treatment factors on the risk of severe hypotension. MATERIALS AND METHODS We carried out a secondary statistical analysis of the Acute Renal Failure Trial Network (ATN) trial. The primary exposures of interest were CRRT treatment dose, ultrafiltration rate, blood flow rate, ionized calcium level and type of anti-coagulation used. The primary outcome was severe hypotension, defined as vasopressor-inotropic score > 18 and calculated based on treatment doses of vasopressor and inotropic agents. RESULTS Of 1124 individuals enrolled in the ATN Trial, 786 were managed with CRRT. 265/786 (33.7%) patients experienced severe hypotension during the trial. A serum ionized calcium <1.02 mmol/l was associated with a higher risk of severe hypotension compared to a serum calcium >1.02 mmol/l (hazard ratio 2.9; 95% CI 1.5-5.7). There was no significant difference in the risk of hypotension associated with other CRRT treatment factors. CONCLUSIONS Of the CRRT treatment factors studied, hypocalcemia with a serum ionized calcium <1.02 mmol/l was associated with a significantly increased risk of treatment-associated hypotension. Further studies will be required to assess whether treatment targets for serum calcium improve the risk of hypotension during CRRT.
Collapse
Affiliation(s)
- Yvelynne P Kelly
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America; Department of Critical Care Medicine, St. James's Hospital, James's Street, Dublin 8, Ireland.
| | - Shilpa Sharma
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Suraj S Mothi
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Finnian R McCausland
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Mallika L Mendu
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Gearoid M McMahon
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Paul M Palevsky
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine and Kidney Medicine Section, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
| | - Sushrut S Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, 650 Albany Street, EBRC 526, Boston, MA 02118, United States of America
| |
Collapse
|
25
|
Murugan R, Bellomo R, Palevsky PM, Kellum JA. Ultrafiltration in critically ill patients treated with kidney replacement therapy. Nat Rev Nephrol 2021; 17:262-276. [PMID: 33177700 PMCID: PMC9826716 DOI: 10.1038/s41581-020-00358-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2020] [Indexed: 01/30/2023]
Abstract
Management of fluid overload is one of the most challenging problems in the care of critically ill patients with oliguric acute kidney injury. Various clinical practice guidelines support fluid removal using ultrafiltration during kidney replacement therapy. However, ultrafiltration is associated with considerable risks. Emerging evidence from observational studies suggests that both slow and fast rates of net fluid removal (that is, net ultrafiltration (UFNET)) during continuous kidney replacement therapy are associated with increased mortality compared with moderate UFNET rates. In addition, fast UFNET rates are associated with an increased risk of cardiac arrhythmias. Experimental studies in patients with kidney failure who were treated with intermittent haemodialysis suggest that fast UFNET rates are also associated with ischaemic injury to the heart, brain, kidney and gut. The UFNET rate should be prescribed based on patient body weight in millilitres per kilogramme per hour with close monitoring of patient haemodynamics and fluid balance. Dialysate cooling and sodium modelling may prevent haemodynamic instability and facilitate large volumes of fluid removal in patients with kidney failure who are treated with intermittent haemodialysis, but the effects of this strategy on organ injury are less well studied in critically ill patients treated with continuous kidney replacement therapy. Randomized trials are required to examine whether moderate UFNET rates are associated with a reduced risk of haemodynamic instability, organ injury and improved outcomes in critically ill patients.
Collapse
Affiliation(s)
- Raghavan Murugan
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The University of Melbourne, Austin Hospital, Melbourne, Victoria, Australia
| | - Paul M Palevsky
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John A Kellum
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
26
|
Abstract
Emerging evidence from observational studies suggests that both slower and faster net ultrafiltration rates during kidney replacement therapy are associated with increased mortality in critically ill patients with acute kidney injury and fluid overload. Faster rates are associated with ischemic organ injury. The net ultrafiltration rate should be prescribed based on patient body weight in milliliters per kilogram per hour, with close monitoring of patient hemodynamics and fluid balance. Randomized trials are required to examine whether moderate net ultrafiltration rates compared with slower and faster rates are associated with reduced risk of hemodynamic instability, organ injury, and improved outcomes.
Collapse
Affiliation(s)
- Vikram Balakumar
- Department of Critical Care Medicine, Mercy Hospitals, Springfield, MO, USA; Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. https://twitter.com/vikrambalakumar
| | - Raghavan Murugan
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, University of Pittsburgh, 3347 Forbes Avenue, Suite 220, Room 206, Pittsburgh, PA 15261, USA.
| |
Collapse
|
27
|
Kim Y, Yun D, Kwon S, Jin K, Han S, Kim DK, Oh KH, Joo KW, Kim YS, Kim S, Han SS. Target value of mean arterial pressure in patients undergoing continuous renal replacement therapy due to acute kidney injury. BMC Nephrol 2021; 22:20. [PMID: 33422032 PMCID: PMC7796677 DOI: 10.1186/s12882-020-02227-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/25/2020] [Indexed: 12/14/2022] Open
Abstract
Background Although patients undergoing continuous renal replacement therapy (CRRT) due to acute kidney injury (AKI) frequently have instability in mean arterial pressure (MAP), no consensus exists on the target value of MAP related to high mortality after CRRT. Methods A total of 2,292 patients who underwent CRRT due to AKI in three referral hospitals were retrospectively reviewed. The MAPs were divided into tertiles, and the 3rd tertile group served as a reference in the analyses. The major outcome was all-cause mortality during the intensive care unit period. The odds ratio (OR) of mortality was calculated using logistic regression after adjustment for multiple covariates. The nonlinear relationship regression model was applied to determine the threshold value of MAP related to increasing mortality. Results The mean value of MAP was 80.7 ± 17.3 mmHg at the time of CRRT initiation. The median intensive care unit stay was 5 days (interquartile range, 2–12 days), and during this time, 1,227 (55.5%) patients died. The 1st tertile group of MAP showed an elevated risk of mortality compared with the 3rd tertile group (adjusted OR, 1.28 [1.03–1.60]; P = 0.029). In the nonlinear regression analysis, the threshold value of MAP was calculated as 82.7 mmHg. Patients with MAP < 82.7 mmHg had a higher mortality rate than those with ≥ 82.7 mmHg (adjusted OR, 1.21 [1.01–1.45]; P = 0.037). Conclusions Low MAP at CRRT initiation is associated with a high risk of mortality, particularly when it is < 82.7 mmHg. This value may be used for risk classification and as a potential therapeutic target. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-020-02227-4.
Collapse
Affiliation(s)
- Yaerim Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Donghwan Yun
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, Korea
| | - Soie Kwon
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, Korea
| | - Kyubok Jin
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Seungyeup Han
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, Korea. .,Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Korea.
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, Korea.
| |
Collapse
|
28
|
Modeling acid-base balance during continuous kidney replacement therapy. J Clin Monit Comput 2021; 36:179-189. [PMID: 33389356 DOI: 10.1007/s10877-020-00635-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
Clinical studies have suggested that use of bicarbonate-containing substitution and dialysis fluids during continuous kidney replacement therapy may result in excessive increases in the carbon dioxide concentration of blood; however, the technical parameters governing such changes are unclear. The current work used a mathematical model of acid-base chemistry of blood to predict its composition within and exiting the extracorporeal circuit during continuous veno-venous hemofiltration (CVVH) and continuous veno-venous hemodiafiltration (CVVHDF). Model predictions showed that a total substitution fluid infusion rate of 2 L/h (33% predilution) with a bicarbonate concentration of 32 mEq/L during CVVH at a blood flow rate of 200 mL/min resulted in only modest increases in plasma bicarbonate concentration by 2.0 mEq/L and partial pressure of dissolved carbon dioxide by 4.4 mmHg in blood exiting the extracorporeal circuit. The relative increase in bicarbonate concentration (9.7%) was similar to that in partial pressure of dissolved carbon dioxide (8.2%), resulting in no significant change in plasma pH in the blood exiting the CVVH circuit. The changes in plasma acid-base levels were larger with a higher infusion rate of substitution fluid but smaller with a higher blood flow rate or use of substitution fluid with a lower bicarbonate concentration (22 mEq/L). Under comparable flow conditions and substitution fluid composition, model predicted changes in acid-base levels during CVVHDF were similar, but smaller, than those during CVVH. The described mathematical model can predict the effect of operating conditions on acid-base balance within and exiting the extracorporeal circuit during continuous kidney replacement therapy.
Collapse
|
29
|
Wu CY, Lin YC, Chen CC. A Case Series: Continuous Kidney Replacement Therapy in Neonates With Low Body Weight. Front Pediatr 2021; 9:769220. [PMID: 34869123 PMCID: PMC8635746 DOI: 10.3389/fped.2021.769220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Emerging data indicate that acute kidney injury (AKI) may contribute to a worse prognosis in the infant population. Kidney replacement therapy (KRT) can be used to treat patients with AKI; however, this technique is challenging in patients in the neonatal intensive care units (NICUs) due to the low body weights and blood volumes in this population. Peritoneal dialysis (PD) is a potential modality since it is technically less challenging. However, PD has been associated with several disadvantages, including poor fluid status control, catheter-associated leakage, and peritonitis. Unfortunately, these complications can cause the temporary cessation of PD. Continuous kidney replacement therapy (CKRT) may represent a suitable alternative for PD. CKRT may be technically feasible in infants; however, little is known about the application of CKRT in neonates with low body weights. In this report, we discuss three cases of CKRT who were treated in the NICU at a tertiary medical center in southern Taiwan. We selected an adequate catheter diameter and achieved vascular access via an internal jugular vein or umbilical vein. The prescription of an appropriate dose of heparin was then used to prolong the circuit life of the CKRT. The maintenance of circuit durability in neonates with low body weight remains problematic. We hope that our experience can assist with the future clinical management of CKRT in neonates with low body weight.
Collapse
Affiliation(s)
- Chen-Yu Wu
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yung-Chieh Lin
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Pediatrics, College of Medicine, National Cheng-Kung University, Tainan, Taiwan
| | - Chih-Chia Chen
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Cheng-Kung University, Tainan, Taiwan
| |
Collapse
|
30
|
Shawwa K, Kompotiatis P, Bobart SA, Mara KC, Wiley BM, Jentzer JC, Kashani KB. New-onset atrial fibrillation in patients with acute kidney injury on continuous renal replacement therapy. J Crit Care 2020; 62:157-163. [PMID: 33383309 DOI: 10.1016/j.jcrc.2020.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/21/2020] [Accepted: 12/11/2020] [Indexed: 02/09/2023]
Abstract
PURPOSE The mortality of critically ill patients with acute kidney injury (AKI) who require continuous renal replacement therapy (CRRT) remains high. We assessed the incidence and predictors of new-onset atrial fibrillation (NOAF) in this population and its impact on outcomes. MATERIALS AND METHODS This is a retrospective cohort study of adult intensive care units (ICU) patients who had AKI and received CRRT from December 2006 through November 2015 in a tertiary academic medical center. Cox proportional hazard model was used to evaluate the impact of NOAF on overall mortality. RESULTS Out of 1398 screened patients, NOAF occurred in 193 (14%) cases. NOAF occurring on CRRT was independently associated with an increased hazard of death at follow-up (HR: 1.26; 95% CI: 1.03-1.56), compared to the group who did not have NOAF. In the multivariable analysis using time-dependent covariates, higher potassium (HR 1.24, 95%CI: 1.01-1.54) and bicarbonate (HR 0.95, 95%CI: 0.92-0.98) levels were associated with increased and decreased risk of NOAF on CRRT, respectively. CONCLUSIONS NOAF in critically ill patients with AKI receiving CRRT is common and carries an unfavorable prognosis. Prospective studies are required to elucidate modifiable risk factors for NOAF occurring on CRRT.
Collapse
Affiliation(s)
- Khaled Shawwa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Panagiotis Kompotiatis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shane A Bobart
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kristin C Mara
- Department of Health Science Research, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
31
|
Shawwa K, Kompotiatis P, Wiley BM, Jentzer JC, Kashani KB. Change in right ventricular systolic function after continuous renal replacement therapy initiation and renal recovery. J Crit Care 2020; 62:82-87. [PMID: 33290930 DOI: 10.1016/j.jcrc.2020.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/03/2020] [Accepted: 11/27/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To describe the associations between right ventricular (RV) function and outcomes of patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). METHODS This is a retrospective study, conducted 2006-2015 at an academic hospital in USA. We included patients with AKI requiring CRRT who had paired echocardiograms within 2 weeks before and after CRRT initiation. We defined improvement in RV systolic function as 2-point improvement on the semiquantitative scale. RESULTS The cohort included 201 patients. The mean(±SD) age was 59(±16) years with 83(41%) female. The median time of the pre and post echocardiograms relative to CRRT initiation were - 1 day (IQR-3;0) prior to and 3 days (IQR1;7) after CRRT initiation. Thirty-one (15%) patients showed an improvement in their RV function. Using a multivariable logistic regression model, improvement in RV systolic function was associated with lower odds of major adverse kidney events (composite of mortality, need for dialysis or persistently elevated serum creatinine) at 90 days with odds ratio (OR) of 0.37(95%CI:0.17-0.84, p.016). Positive cumulative fluid balance was associated with lower odds of improvement in RV function (OR 0.95 per 1-l increase, p 0.045). CONCLUSION Serial assessment of RV function among patients with AKI requiring CRRT could provide prognostic value.
Collapse
Affiliation(s)
- Khaled Shawwa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Panagiotis Kompotiatis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
32
|
Lee HJ, Son YJ. Factors Associated with In-Hospital Mortality after Continuous Renal Replacement Therapy for Critically Ill Patients: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E8781. [PMID: 33256008 PMCID: PMC7730748 DOI: 10.3390/ijerph17238781] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 12/15/2022]
Abstract
Continuous renal replacement therapy (CRRT) is a broadly-accepted treatment for critically ill patients with acute kidney injury to optimize fluid and electrolyte management. Despite intensive dialysis care, there is a high mortality rate among these patients. There is uncertainty regarding the factors associated with in-hospital mortality among patients requiring CRRT. This review evaluates how various risk factors influence the in-hospital mortality of critically ill patients who require CRRT. Five databases were surveyed to gather relevant publications up to 30 June 2020. We identified 752 works, of which we retrieved 38 in full text. Finally, six cohort studies that evaluated 1190 patients were eligible. The in-hospital mortality rate in these studies ranged from 38.6 to 62.4%. Our meta-analysis results showed that older age, lower body mass index, higher APACHE II and SOFA scores, lower systolic and diastolic blood pressure, decreased serum creatinine level, and increased serum sodium level were significantly associated with increased in-hospital mortality in critically ill patients who received CRRT. These results suggest that there are multiple modifiable factors that influence the risk of in-hospital mortality in critically ill patients undergoing CRRT. Further, healthcare professionals should take more care when CRRT is performed on older adults.
Collapse
Affiliation(s)
- Hyeon-Ju Lee
- Department of Nursing, Tongmyong University, Busan 48520, Korea;
| | - Youn-Jung Son
- Red Cross College of Nursing, Chung-Ang University, Seoul 06974, Korea
| |
Collapse
|
33
|
Jentzer JC, Bihorac A, Brusca SB, Del Rio-Pertuz G, Kashani K, Kazory A, Kellum JA, Mao M, Moriyama B, Morrow DA, Patel HN, Rali AS, van Diepen S, Solomon MA. Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives. J Am Coll Cardiol 2020; 76:1084-1101. [PMID: 32854844 PMCID: PMC11032174 DOI: 10.1016/j.jacc.2020.06.070] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) and cardiorenal syndrome (CRS) are increasingly prevalent in hospitalized patients with cardiovascular disease and remain associated with poor short- and long-term outcomes. There are no specific therapies to reduce mortality related to either AKI or CRS, apart from supportive care and volume status management. Acute renal replacement therapies (RRTs), including ultrafiltration, intermittent hemodialysis, and continuous RRT are used to manage complications of medically refractory AKI and CRS and may restore normal electrolyte, acid-base, and fluid balance before renal recovery. Patients who require acute RRT have a significant risk of mortality and long-term dialysis dependence, emphasizing the importance of appropriate patient selection. Despite the growing use of RRT in the cardiac intensive care unit, there are few resources for the cardiovascular specialist that integrate the epidemiology, diagnostic workup, and medical management of AKI and CRS with an overview of indications, multidisciplinary team management, and transition off of RRT.
Collapse
Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Azra Bihorac
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida
| | - Samuel B Brusca
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Gaspar Del Rio-Pertuz
- Department of Critical Care Medicine and Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Amir Kazory
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida
| | - John A Kellum
- Department of Critical Care Medicine and Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | - Brad Moriyama
- Department of Critical Care Medicine, Special Volunteer, National Institutes of Health, Bethesda, Maryland
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hena N Patel
- Division of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Aniket S Rali
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland; Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| |
Collapse
|
34
|
McCoy IE, Chertow GM. AKI-A Relevant Safety End Point? Am J Kidney Dis 2020; 75:508-512. [PMID: 32037098 DOI: 10.1053/j.ajkd.2019.11.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/25/2019] [Indexed: 12/22/2022]
Abstract
Acute kidney injury (AKI) is a common outcome evaluated in clinical studies, often as a safety end point in a variety of cardiovascular, kidney disease, and other clinical trials. AKI end points that include modest increases in serum creatinine levels from baseline may not associate with patient-centered outcomes such as initiation of dialysis, sustained decline in kidney function, or death. Surprisingly, data from several randomized controlled trials have suggested that in certain settings, the development of AKI may be associated with favorable outcomes. AKI safety end points that are nonspecific and may not associate with patient-centered outcomes could result in beneficial therapies being inappropriately withheld or never developed for commercial use. We review several issues related to commonly used AKI definitions and suggest that future work in AKI use more patient-centered AKI end points such as major adverse kidney events at 30 days or other later time points.
Collapse
Affiliation(s)
- Ian E McCoy
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA.
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| |
Collapse
|