Acute renal failure according to the RIFLE and AKIN criteria: a multicenter study

Adverse Events and Drug Resistance in Critically Ill Patients Treated with Colistimethate Sodium: A Review of the Literature

The adverse events related to sodium colistimethate have had variability regarding the prevalence of nephrotoxicity, neurotoxicity, and less frequent respiratory depression. In recent years, its use has been relevant due to the increase of multidrug-resistant bacteria since it is considered the last-line drug, being its main adverse event and reason for discrepancies between authors' nephrotoxicity. The indiscriminate use of antibiotic therapy has generated multiple mechanisms of resistance, the most common being related to Colistin, the bactericidal escape effect. Based on the search criteria, no randomized clinical trials were identified showing safety and efficacy with the use of Colistin, inferring that the application of the appropriate dose is governed by expert opinion and retrospective and prospective observational studies, which confounding factors such as the severity of the patient and the predisposition to develop acute renal failure are constant. In this review, we focus on identifying the mechanism of nephrotoxicity and bacterial resistance, where much remains to be known.

The Cost-Effectiveness of Continuous Versus Intermittent Renal Replacement Therapies in Acute Kidney Injury: Perspective of the Social Services for the Elderly in Argentina

BACKGROUND

Acute kidney injury (AKI) is a public health problem that affects millions of hospitalized patients worldwide. In Argentina, evidence suggests that its incidence has risen in recent years. When severe, AKI may require a renal replacement therapy (RRT) where continuous RRT (CRRT) and intermittent RRT (IRRT) are plausible options for patients in the intensive care unit.

OBJECTIVE

To evaluate the cost utility of CRRT versus IRRT for the National Institute of Social Services for Retirees and Pensioners, the largest social security health insurance for elders in Argentina.

METHODS

This was a model-based cost-utility analysis. Long-term costs and health outcomes were estimated for a hypothetical cohort with a Markov model. Parameters used were obtained from published literature and validated with local experts. Local costs were estimated and expressed in $AR of 2016. Several sensitivity analyses were run to analyze the impact of uncertainty on results.

RESULTS

Continuous RRT dominated IRRT by cumulating over the model more quality-adjusted life years and less costs. Total discounted quality-adjusted life years for both cohorts were 1049 and 1034, respectively, and total costs were $95 362 and $103 871. Cost-effectiveness (CE) results reflect these differences in favor of CRRT with a deterministic cost-saving incremental CE ratio and a probability of CRRT being CE of 65.4%, considering a CE threshold of 1 gross domestic product per capita.

CONCLUSIONS

Continuous RRT for patients with AKI eligible for CRRT or IRRT would probably be a cost-effective intervention for the National Institute of Social Services for Retirees and Pensioners' view. Nevertheless, there is considerable uncertainty around results, mainly due to the lack of adequate controlled studies and local data on the prognosis of these patients in Argentina.

Attempts to Limit Opioid Prescribing in Critically Ill Patients: Not So Easy, Not So Fast

OBJECTIVE

To discuss why opioids have been considered the long-standing first-line therapy for treating acute, severe nociceptive pain in critically ill patients and discuss considerations for limiting opioid overuse in the intensive care unit setting.

DATA SOURCES

Articles were identified through searches of PubMed and EMBASE from database inception until December 2018. Additional references were located through a review of the bibliographies of articles and clinical practice guidelines.

STUDY SELECTION AND DATA EXTRACTION

Original research articles excluding case reports were included if they concerned nonopioid agents for pain management in critically ill patients. The focus was on studies not included in the most recent pain management guidelines.

DATA SYNTHESIS

Ten studies were retrieved. Nonopioid therapies or opioid-sparing therapies have been touted as possible alternatives for critically ill patients, but they have particular adverse effects concerns in critically ill patients, often lack parenteral dosage forms, and frequently require dose adjustment or avoidance in patients with renal or hepatic dysfunction. Relevance to Patient Care and Clinical Practice: There is a well-recognized opioid epidemic that has been the subject of much discussion. Attempts to control the epidemic have focused on limiting opioid prescribing and using nonopioid alternatives, but there are special considerations when treating severe pain in critically ill patients that often preclude nonopioid analgesics.

CONCLUSIONS

There continues to be an unmet need for medications that are as effective as opioids for severe nociceptive pain in critically ill patients but without the adverse effect and abuse concerns. Until such medications are available, clinicians need to optimize prescribing of opioid and nonopioid analgesics.

Incidence, timing and outcome of AKI in critically ill patients varies with the definition used and the addition of urine output criteria

Background

Acute kidney injury (AKI) is a serious complication of critical illness with both attributed morbidity and mortality at short-term and long-term. The incidence of AKI reported in critically ill patients varies substantially with the population evaluated and the definitions used. We aimed to assess which of the AKI definitions (RIFLE, AKIN or KDIGO) with or without urine output criteria recognizes AKI most frequently and quickest. Additionally, we conducted a review on the comparison of incidence proportions of varying AKI definitions in populations of critically ill patients.

Methods

We included all patients with index admissions to our intensive care unit (ICU) from January 1^st, 2014 until June 11^th, 2014 to determine the incidence and onset of AKI by RIFLE, AKIN and KDIGO during the first 7 days of ICU admission. We conducted a sensitive search using PubMed evaluating the comparison of RIFLE, AKIN and KDIGO in critically ill patients

Results

AKI incidence proportions were 15, 21 and 20% respectively using serum creatinine criteria of RIFLE, AKIN and KDIGO. Adding urine output criteria increased AKI incidence proportions to 35, 38 and 38% using RIFLE, AKIN and KDIGO definitions. Urine output criteria detected AKI in patients without AKI at ICU admission in a median of 13 h (IQR 7–22 h; using RIFLE definition) after admission compared to a median of 24 h using serum creatinine criteria (IQR24-48 h). In the literature a large heterogeneity exists in patients included, AKI definition used, reference or baseline serum creatinine used, and whether urine output in the staging of AKI is used.

Conclusion

AKIN and KDIGO criteria detect more patients with AKI compared to RIFLE criteria. Addition of urine output criteria detect patients with AKI 11 h earlier than serum creatinine criteria and may double AKI incidences in critically ill patients. This could explain the large heterogeneity observed in literature.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-017-0487-8) contains supplementary material, which is available to authorized users.