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Needleman L, Hughes MS, Fatehi P, Sellmeyer DE. Regional citrate anticoagulation with continuous renal replacement therapy as a cause of hypercalcemia. Arch Osteoporos 2024; 19:78. [PMID: 39180669 DOI: 10.1007/s11657-024-01434-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 07/26/2024] [Indexed: 08/26/2024]
Abstract
CLINICAL RELEVANCE Awareness of the causes of hypercalcemia is essential for timely diagnosis of calcium disorders and optimal treatment. Citrate is commonly used as an anticoagulant during continuous renal replacement therapy (CRRT). Accumulation of citrate in the systemic circulation during CRRT may induce several metabolic disturbances, including total hypercalcemia and ionized hypocalcemia. The aim of the present study is to increase awareness of citrate accumulation and toxicity as a cause of hypercalcemia by relating three cases and reviewing the pathophysiology and clinical implications. OBSERVATIONS We utilized electronic health records to examine the clinical cases and outlined key studies to review the consequences of citrate toxicity and general approaches to management. CONCLUSIONS Citrate toxicity is associated with high mortality. A safe threshold for tolerating hypercalcemia during citrate anticoagulation is not clearly defined, and whether citrate toxicity independently increases mortality has not been resolved. Greater attention to citrate toxicity as a cause of hypercalcemia may lead to earlier detection, help to optimize the management of systemic calcium levels, and foster interest in future clinical studies.
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Affiliation(s)
- Leor Needleman
- Department of Medicine, Division of Endocrinology, Gerontology and Metabolism, Stanford University, Stanford, CA, 94305, USA
| | - Michael S Hughes
- Department of Medicine, Division of Endocrinology, Gerontology and Metabolism, Stanford University, Stanford, CA, 94305, USA
| | - Pedram Fatehi
- Department of Medicine, Division of Nephrology, Stanford University, Stanford, CA, 94305, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, 94305, USA
| | - Deborah E Sellmeyer
- Department of Medicine, Division of Endocrinology, Gerontology and Metabolism, Stanford University, Stanford, CA, 94305, USA.
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2
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Fernández J, Blasi A, Hidalgo E, Karvellas CJ. Bridging the critically ill patient with acute to chronic liver failure to liver transplantation. Am J Transplant 2024; 24:1348-1361. [PMID: 38548058 DOI: 10.1016/j.ajt.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024]
Abstract
Liver transplantation (LT) has emerged as an effective therapy for severe forms of acute-on-chronic liver failure (ACLF), an entity characterized by the development of multiorgan failure and high short-term mortality. The aim of critical care management of ACLF patients is to rapidly treat precipitating events and aggressively support failing organs to ensure that patients may successfully undergo LT or, less frequently, recover. Malnutrition and sarcopenia are frequently present, adversely impacting the prognosis of these patients. Management of critical care patients with ACLF is complex and requires the participation of different specialties. Once the patient is stabilized, a rapid evaluation for salvage LT should be performed because the time window for LT is often narrow. The development of sepsis and prolonged organ support may preclude LT or diminish its chances of success. The current review describes strategies to bridge severe ACLF patients to LT, highlights the minimal evaluation required for listing and the currently suggested contraindications to proceed with LT, and addresses different aspects of management during the perioperative and early posttransplant period.
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Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain; EF Clif, EASL-CLIF Consortium, Barcelona, Spain.
| | - Annabel Blasi
- Anesthesiology Department, Hospital Clínic, and University of Barcelona, Spain
| | - Ernest Hidalgo
- Hepatolobiliary Surgery Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada; Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
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3
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Zhao X, Gao J, Kou K, Wang X, Gao X, Wang Y, Zhou H, Li F. Causal effects of plasma metabolites on chronic kidney diseases and renal function: a bidirectional Mendelian randomization study. Front Endocrinol (Lausanne) 2024; 15:1429159. [PMID: 39129920 PMCID: PMC11310041 DOI: 10.3389/fendo.2024.1429159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 07/12/2024] [Indexed: 08/13/2024] Open
Abstract
Background Despite the potential demonstrated by targeted plasma metabolite modulators in halting the progression of chronic kidney disease (CKD), a lingering uncertainty persists concerning the causal relationship between distinct plasma metabolites and the onset and progression of CKD. Methods A genome-wide association study was conducted on 1,091 metabolites and 309 metabolite ratios derived from a cohort of 8,299 unrelated individuals of European descent. Employing a bidirectional two-sample Mendelian randomization (MR) analysis in conjunction with colocalization analysis, we systematically investigated the associations between these metabolites and three phenotypes: CKD, creatinine-estimated glomerular filtration rate (creatinine-eGFR), and urine albumin creatinine ratio (UACR). In the MR analysis, the primary analytical approach employed was inverse variance weighting (IVW), and sensitivity analysis was executed utilizing the MR-Egger method and MR-pleiotropy residual sum and outlier (MR-PRESSO). Heterogeneity was carefully evaluated through Cochrane's Q test. To ensure the robustness of our MR results, the leave-one-out method was implemented, and the strength of causal relationships was subjected to scrutiny via Bonferroni correction. Results Our thorough MR analysis involving 1,400 plasma metabolites and three clinical phenotypes yielded a discerning identification of 21 plasma metabolites significantly associated with diverse outcomes. Specifically, in the forward MR analysis, 6 plasma metabolites were determined to be causally associated with CKD, 16 with creatinine-eGFR, and 7 with UACR. Substantiated by robust evidence from colocalization analysis, 6 plasma metabolites shared causal variants with CKD, 16 with creatinine-eGFR, and 7 with UACR. In the reverse analysis, a diminished creatinine-eGFR was linked to elevated levels of nine plasma metabolites. Notably, no discernible associations were observed between other plasma metabolites and CKD, creatinine-eGFR, and UACR. Importantly, our analysis detected no evidence of horizontal pleiotropy. Conclusion This study elucidates specific plasma metabolites causally associated with CKD and renal functions, providing potential targets for intervention. These findings contribute to an enriched understanding of the genetic underpinnings of CKD and renal functions, paving the way for precision medicine applications and therapeutic strategies aimed at impeding disease progression.
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Affiliation(s)
- Xiaodong Zhao
- Department of Urology, The First Hospital of Jilin University, Changchun, China
| | - Jialin Gao
- Department of Urology, The First Hospital of Jilin University, Changchun, China
| | - Kai Kou
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xi Wang
- Department of Endocrinology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin Gao
- Department of Urology, The First Hospital of Jilin University, Changchun, China
| | - Yishu Wang
- Key Laboratory of Pathobiology, Ministry of Education, Jilin University, Changchun, China
| | - Honglan Zhou
- Department of Urology, The First Hospital of Jilin University, Changchun, China
| | - Faping Li
- Department of Urology, The First Hospital of Jilin University, Changchun, China
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4
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Grolleau F, Petit F, Gaudry S, Diard É, Quenot JP, Dreyfuss D, Tran VT, Porcher R. Personalizing renal replacement therapy initiation in the intensive care unit: a reinforcement learning-based strategy with external validation on the AKIKI randomized controlled trials. J Am Med Inform Assoc 2024; 31:1074-1083. [PMID: 38452293 PMCID: PMC11031229 DOI: 10.1093/jamia/ocae004] [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: 09/13/2023] [Revised: 12/13/2023] [Accepted: 01/16/2024] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVE The timely initiation of renal replacement therapy (RRT) for acute kidney injury (AKI) requires sequential decision-making tailored to individuals' evolving characteristics. To learn and validate optimal strategies for RRT initiation, we used reinforcement learning on clinical data from routine care and randomized controlled trials. MATERIALS AND METHODS We used the MIMIC-III database for development and AKIKI trials for validation. Participants were adult ICU patients with severe AKI receiving mechanical ventilation or catecholamine infusion. We used a doubly robust estimator to learn when to start RRT after the occurrence of severe AKI for three days in a row. We developed a "crude strategy" maximizing the population-level hospital-free days at day 60 (HFD60) and a "stringent strategy" recommending RRT when there is significant evidence of benefit for an individual. For validation, we evaluated the causal effects of implementing our learned strategies versus following current best practices on HFD60. RESULTS We included 3748 patients in the development set and 1068 in the validation set. Through external validation, the crude and stringent strategies yielded an average difference of 13.7 [95% CI -5.3 to 35.7] and 14.9 [95% CI -3.2 to 39.2] HFD60, respectively, compared to current best practices. The stringent strategy led to initiating RRT within 3 days in 14% of patients versus 38% under best practices. DISCUSSION Implementing our strategies could improve the average number of days that ICU patients spend alive and outside the hospital while sparing RRT for many. CONCLUSION We developed and validated a practical and interpretable dynamic decision support system for RRT initiation in the ICU.
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Affiliation(s)
- François Grolleau
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, F-75004, France
- Centre d’Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, Paris, F-75004, France
| | - François Petit
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, F-75004, France
| | - Stéphane Gaudry
- Service de Réanimation Médico-Chirurgicale, AP-HP, Hôpital Avicenne, Université Sorbonne Paris Nord, Bobigny, 93430, France
- Health Care Simulation Center, UFR SMBH, Sorbonne Paris Cité, Bobigny, 93017, France
- INSERM UMR S1155, Sorbonne Université, CORAKID, Hôpital Tenon, Paris, 75020, France
| | - Élise Diard
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, F-75004, France
- Centre d’Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, Paris, F-75004, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, 21000, France
- Lipness Team, INSERM Research Center, LNC-UMR1231 and LabEx LipSTIC, Dijon, 21000, France
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, 21000, France
| | - Didier Dreyfuss
- INSERM UMR S1155, Sorbonne Université, CORAKID, Hôpital Tenon, Paris, 75020, France
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Hôpital Louis Mourier, AP-HP, Université Paris-Cité, Paris, F-75018, France
| | - Viet-Thi Tran
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, F-75004, France
- Centre d’Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, Paris, F-75004, France
| | - Raphaël Porcher
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, F-75004, France
- Centre d’Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, Paris, F-75004, France
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Gao Y, Lu X, Zhang G, Liu C, Sun S, Mao W, Jiang G, Zhou Y, Zhang N, Tao S, Chen M, Chen S, Zhang L. DRD4 alleviates acute kidney injury by suppressing ISG15/NOX4 axis-associated oxidative stress. Redox Biol 2024; 70:103078. [PMID: 38354631 PMCID: PMC10876914 DOI: 10.1016/j.redox.2024.103078] [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: 11/21/2023] [Revised: 01/30/2024] [Accepted: 02/05/2024] [Indexed: 02/16/2024] Open
Abstract
Acute kidney injury (AKI) is a life-threatening health condition associated with increasing morbidity and mortality. Despite extensive research on the mechanisms underlying AKI, effective clinical tools for prediction and treatment remain scarce. Oxidative stress and mitochondrial damage play a critical role in AKI and dopamine D4 receptor (DRD4) has been confirmed to be associated with oxidative stress. In this study, we hypothesized that DRD4 could attenuate AKI through its antioxidative and antiapoptotic effects. In vivo, DRD4 was remarkably decreased in the kidneys of mice subjected to ischemia/reperfusion injury (IRI) or cisplatin treatment. Notably, DRD4 significantly attenuated nephrotoxicity by suppressing oxidative stress and enhancing mitochondrial bioenergetics through the downregulation of reactive oxygen species (ROS) generation and NADPH oxidase 4 (NOX4) expression. In vitro, DRD4 demonstrated the ability to ameliorate oxidative stress-induced apoptosis in HK-2 cells subjected to hypoxia/reoxygenation- or cisplatin treatment. Transcriptome sequencing revealed that, mechanistically, DRD4 reduced the expression of its downstream target, interferon-stimulated gene 15 (ISG15), suppressing NOX4 ISGylation, enhancing the ubiquitination of NOX4, leading to its degradation, and ultimately counteracting oxidative stress-induced AKI. Altogether, these findings underscore the significance of DRD4 in AKI and elucidate DRD4 as a potential protectant against IRI or cisplatin-induced nephrotoxicity.
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Affiliation(s)
- Yue Gao
- Surgical Research Center, Institute of Urology, Medical School of Southeast University, Nanjing, China; Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Xun Lu
- Surgical Research Center, Institute of Urology, Medical School of Southeast University, Nanjing, China; Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Guangyuan Zhang
- Surgical Research Center, Institute of Urology, Medical School of Southeast University, Nanjing, China; Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Chunhui Liu
- Surgical Research Center, Institute of Urology, Medical School of Southeast University, Nanjing, China; Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Si Sun
- Surgical Research Center, Institute of Urology, Medical School of Southeast University, Nanjing, China; Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Weipu Mao
- Surgical Research Center, Institute of Urology, Medical School of Southeast University, Nanjing, China; Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Guiya Jiang
- Surgical Research Center, Institute of Urology, Medical School of Southeast University, Nanjing, China; Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Yu Zhou
- Surgical Research Center, Institute of Urology, Medical School of Southeast University, Nanjing, China
| | - Nieke Zhang
- Surgical Research Center, Institute of Urology, Medical School of Southeast University, Nanjing, China; Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Shuchun Tao
- Surgical Research Center, Institute of Urology, Medical School of Southeast University, Nanjing, China; Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Ming Chen
- Surgical Research Center, Institute of Urology, Medical School of Southeast University, Nanjing, China; Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China.
| | - Shuqiu Chen
- Surgical Research Center, Institute of Urology, Medical School of Southeast University, Nanjing, China; Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China.
| | - Lei Zhang
- Surgical Research Center, Institute of Urology, Medical School of Southeast University, Nanjing, China; Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China.
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6
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Wang Q, Liu Y, Zhang Y, Zhang S, Zhao M, Peng Z, Xu H, Huang H. Characterization of macrophages in ischemia-reperfusion injury-induced acute kidney injury based on single-cell RNA-Seq and bulk RNA-Seq analysis. Int Immunopharmacol 2024; 130:111754. [PMID: 38428147 DOI: 10.1016/j.intimp.2024.111754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/13/2024] [Accepted: 02/21/2024] [Indexed: 03/03/2024]
Abstract
Acute kidney injury (AKI) is a complex disease, with macrophages playing a vital role in its progression. However, the mechanism of macrophage function remains unclear and strategies targeting macrophages in AKI are controversial. To address this issue, we used single-cell RNA-seq analysis to identify macrophage sub-types involved in ischemia-reperfusion-induced AKI, and then screened for associated hub genes using intersecting bulk RNA-seq data. The single-cell and bulk RNA-seq datasets were obtained from the Gene Expression Omnibus (GEO) database. Screening of differentially-expressed genes (DEGs) and pseudo-bulk DEG analyses were used to identify common hub genes. Pseudotime and trajectory analyses were performed to investigate the progression of cell differentiation. CellChat analysis was performed to reveal the crosstalk between cell clusters. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analyses were used to identify enriched pathways in the cell clusters. Immunofluorescence and RT-PCR were preformed to validate the expression of the identified hub genes. Four hub genes, Vim, S100a6, Ier3, and Ccr1, were identified in the infiltrated macrophages between normal samples and those 3 days after ischemia-reperfusion renal injury (IRI); all were associated with the progression of IRI-induced AKI. Increased expression of Vim, S100a6, Ier3, and Ccr1 in infiltrated macrophages may be associated with inflammatory responses and may mediate crosstalk between macrophages and renal tubular epithelial cells under IRI conditions. Our results reveal that Ier3 may be critical in AKI, and that Vim, S100a6, Ier3, and Ccr1 may act as novel biomarkers and potential therapeutic targets for IRI-induced AKI.
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Affiliation(s)
- Qin Wang
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yuxing Liu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China; Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
| | - Yan Zhang
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China; Hunan Key Laboratory of Organ Fibrosis, Central South University, Changsha, China
| | - Siyuan Zhang
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Meifang Zhao
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China; Hunan Key Laboratory of Organ Fibrosis, Central South University, Changsha, China
| | - Zhangzhe Peng
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China; Hunan Key Laboratory of Organ Fibrosis, Central South University, Changsha, China.
| | - Hui Xu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China; Hunan Key Laboratory of Organ Fibrosis, Central South University, Changsha, China.
| | - Hao Huang
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China; Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China; Hunan Key Laboratory of Organ Fibrosis, Central South University, Changsha, China.
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7
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Rambaud T, Hajage D, Dreyfuss D, Lebbah S, Martin-Lefevre L, Louis G, Moschietto S, Titeca-Beauport D, La Combe B, Pons B, De Prost N, Besset S, Combes A, Robine A, Beuzelin M, Badie J, Chevrel G, Bohe J, Coupez E, Chudeau N, Barbar S, Vinsonneau C, Forel JM, Thevenin D, Boulet E, Lakhal K, Aissaoui N, Grange S, Leone M, Lacave G, Nseir S, Poirson F, Mayaux J, Ashenoune K, Geri G, Klouche K, Thiery G, Argaud L, Rozec B, Cadoz C, Andreu P, Reignier J, Ricard JD, Quenot JP, Sonneville R, Gaudry S. Renal replacement therapy initiation strategies in comatose patients with severe acute kidney injury: a secondary analysis of a multicenter randomized controlled trial. Intensive Care Med 2024; 50:385-394. [PMID: 38407824 DOI: 10.1007/s00134-024-07339-1] [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: 10/18/2023] [Accepted: 01/29/2024] [Indexed: 02/27/2024]
Abstract
PURPOSE The effect of renal replacement therapy (RRT) in comatose patients with acute kidney injury (AKI) remains unclear. We compared two RRT initiation strategies on the probability of awakening in comatose patients with severe AKI. METHODS We conducted a post hoc analysis of a trial comparing two delayed RRT initiation strategies in patients with severe AKI. Patients were monitored until they had oliguria for more than 72 h and/or blood urea nitrogen higher than 112 mg/dL and then randomized to a delayed strategy (RRT initiated after randomization) or a more-delayed one (RRT initiated if complication occurred or when blood urea nitrogen exceeded 140 mg/dL). We included only comatose patients (Richmond Agitation-Sedation scale [RASS] < - 3), irrespective of sedation, at randomization. A multi-state model was built, defining five mutually exclusive states: death, coma (RASS < - 3), incomplete awakening (RASS [- 3; - 2]), awakening (RASS [- 1; + 1] two consecutive days), and agitation (RASS > + 1). Primary outcome was the transition from coma to awakening during 28 days after randomization. RESULTS A total of 168 comatose patients (90 delayed and 78 more-delayed) underwent randomization. The transition intensity from coma to awakening was lower in the more-delayed group (hazard ratio [HR] = 0.36 [0.17-0.78]; p = 0.010). Time spent awake was 10.11 days [8.11-12.15] and 7.63 days [5.57-9.64] in the delayed and the more-delayed groups, respectively. Two sensitivity analyses were performed based on sedation status and sedation practices across centers, yielding comparable results. CONCLUSION In comatose patients with severe AKI, a more-delayed RRT initiation strategy resulted in a lower chance of transitioning from coma to awakening.
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Affiliation(s)
- Thomas Rambaud
- Département de Réanimation Médico-Chirurgicale, APHP Hôpital Avicenne, Bobigny, France
- Département de Médecine Intensive Réanimation Neuro, APHP Hôpital Pitié-Salpêtrière, Paris, France
| | - David Hajage
- Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Pitié Salpêtrière, 75013, Paris, France
| | - Didier Dreyfuss
- Common and Rare Kidney Diseases, Sorbonne Université, INSERM, UMR-S 1155, Paris, France
| | - Saïd Lebbah
- Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Pitié Salpêtrière, 75013, Paris, France
| | | | - Guillaume Louis
- Réanimation Polyvalente, CHR Metz-Thionville Hôpital de Mercy, Metz, France
| | | | | | | | - Bertrand Pons
- Réanimation, CHU Pointe-à-Pitre/Abymes, Pointe-a-Pitre, France
| | | | - Sébastien Besset
- Médecine Intensive-Réanimation, APHP, Hôpital Louis Mourier, Colombes, France
| | - Alain Combes
- Service de Réanimation Médicale, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Adrien Robine
- Réanimation Soins Continus, CH de Bourg-en-Bresse - Fleyriat, 01012, Bourg-en-Bresse, France
| | | | - Julio Badie
- Réanimation Polyvalente, Hôpital Nord Franche-Comte CH Belfort, Belfort, France
| | - Guillaume Chevrel
- Réanimation Polyvalente, CH Sud Francilien, Corbeil Essonnes, France
| | - Julien Bohe
- Anesthésie Réanimation Médicale et Chirurgicale, CH Lyon Sud Pierre Benite, Lyon, France
| | - Elisabeth Coupez
- Réanimation Polyvalente, Hôpital G. Montpied, Clermont Ferrand, France
| | - Nicolas Chudeau
- Réanimation Médico-Chirurgicale, CH du Mans, Le Mans, France
| | | | | | | | | | - Eric Boulet
- Réanimation et USC, GH Carnelle Portes de l'Oise, 95260, Beaumont Sur Oise, France
| | - Karim Lakhal
- Réanimation Chirurgicale Polyvalente, Hôpital Nord Laennec, Nantes, France
| | - Nadia Aissaoui
- Réanimation Médicale, Hôpital Georges Pompidou, Paris, France
| | | | - Marc Leone
- Anesthésie Réanimation, Hôpital Nord, Marseille, France
| | - Guillaume Lacave
- Réanimation Médico-Chirurgicale, Hôpital André Mignot, Versailles, France
| | - Saad Nseir
- Réanimation Médicale, CHRU de Lille, Hôpital Roger Salengro, Lille, France
| | - Florent Poirson
- Département de Réanimation Médico-Chirurgicale, APHP Hôpital Avicenne, Bobigny, France
| | - Julien Mayaux
- Pneumologie et Réanimation Médicale, Hôpital Pitié Salpêtrière, Paris, France
| | | | - Guillaume Geri
- Réanimation Médico-Chirurgicale, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - Kada Klouche
- Médecine Intensive Réanimation,, Hôpital Lapeyronnie, Montpellier, France
| | - Guillaume Thiery
- Réanimation Médicale, CHU Saint Etienne, Saint Priest en Jarez, France
| | - Laurent Argaud
- Réanimation Médicale, Hôpital Edouard Herriot, Lyon, France
| | | | - Cyril Cadoz
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Pascal Andreu
- Médecine Intensive Réanimation, Hôtel Dieu, Nantes, France
| | | | - Jean-Damien Ricard
- Médecine Intensive-Réanimation, APHP, Hôpital Louis Mourier, Colombes, France
- Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
- NSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Romain Sonneville
- Médecine Intensive-Réanimation, AP-HP. Nord, Hôpital Bichat - Claude Bernard, Paris, France
- Université Paris Cité, INSERM UMR1137, IAME, 75018, Paris, France
| | - Stéphane Gaudry
- Département de Réanimation Médico-Chirurgicale, APHP Hôpital Avicenne, Bobigny, France.
- Common and Rare Kidney Diseases, Sorbonne Université, INSERM, UMR-S 1155, Paris, France.
- Health Care Simulation Center, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France.
- Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Bobigny, France.
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8
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Penaud V, Duburcq T, Bureau C, Salmon Gandonnière C, Arrestier R, Henri S, Dres M, Jacquier S, Prost ND, Giraud R, Ricard JD, Roux D, Uhel F, Legouis D, Verney C. Kidney Increase Natriuresis but Not Glomerular Filtration Under Veno-venous ECMO, a Retrospective Study. J Intensive Care Med 2024; 39:146-152. [PMID: 37632128 DOI: 10.1177/08850666231195755] [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] [Indexed: 08/27/2023]
Abstract
PURPOSE Acute kidney injury is a frequent complication of acute respiratory distress syndrome (ARDS). We aim to study the evolution of kidney function in patients presenting severe ARDS and requiring veno-venous extracorporeal membrane oxygenation (VV ECMO). METHODS We conducted a multicenter retrospective study, including adult patients requiring VV ECMO for ARDS. The primary outcome was the evolution of the serum creatinine level after VV ECMO initiation. Secondary outcomes were change in urine output, and urine biochemical parameters after VV ECMO initiation. RESULTS One hundred and two patients were included. VV ECMO was initiated after a median of 6 days of mechanical ventilation, mainly for ARDS caused by COVID-19 (73%). Serum creatinine level did not significantly differ after VV ECMO initiation (P = .20). VV ECMO was associated with a significant increase in daily urine output (+6.6 mL/kg/day, [3.8;9.3] P < .001), even after adjustment for potential confounding factors; with an increase in natriuresis. The increase in urine output under VV ECMO was associated with a reduced risk of receiving kidney replacement therapy (OR 0.4 [0.2;0.8], P = .026). CONCLUSIONS VV ECMO initiation in severe ARDS is associated with an increase in daily urine output and natriuresis, without change in glomerular filtration rate.
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Affiliation(s)
- Victor Penaud
- Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
| | | | - Côme Bureau
- Médecine Intensive et Réanimation - R3S, AP-HP, Hôpital Pitié-Salpêtrière, Paris Sorbonne Université, Paris, France
- Sorbonne Université, INSERM_1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Charlotte Salmon Gandonnière
- Université François Rabelais, CHRU de Tours, Médecine Intensive Réanimation, INSERM CIC 1415, CRICS-TriggerSep Research Network, Tours, France
| | - Romain Arrestier
- Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, Université Paris Est Créteil, Créteil, France
| | - Samuel Henri
- Médecine Intensive Réanimation, CHU Lille, Lille, France
| | - Martin Dres
- Médecine Intensive et Réanimation - R3S, AP-HP, Hôpital Pitié-Salpêtrière, Paris Sorbonne Université, Paris, France
- Sorbonne Université, INSERM_1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Sophie Jacquier
- Université François Rabelais, CHRU de Tours, Médecine Intensive Réanimation, INSERM CIC 1415, CRICS-TriggerSep Research Network, Tours, France
| | - Nicolas De Prost
- Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, Université Paris Est Créteil, Créteil, France
| | - Raphael Giraud
- Département de Soins Intensifs, Hôpitaux Universitaires de Genève, Genève, Suisse
| | - Jean-Damien Ricard
- Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
- Université Paris Cité, UMR1137 IAME, INSERM, Paris, France
| | - Damien Roux
- Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
- Université Paris Cité, INSERM UMR-S1151, CNRS UMR-S8253, Institut Necker-Enfants Malades, Paris, France
| | - Fabrice Uhel
- Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
- Université Paris Cité, INSERM UMR-S1151, CNRS UMR-S8253, Institut Necker-Enfants Malades, Paris, France
| | - David Legouis
- Département de Soins Intensifs, Hôpitaux Universitaires de Genève, Genève, Suisse
- Département de physiologie cellulaire, Faculté de Médecine, Université de Genève, Genève, Suisse
| | - Charles Verney
- Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
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9
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Wald R, Gaudry S, da Costa BR, Adhikari NKJ, Bellomo R, Du B, Gallagher MP, Hoste EA, Lamontagne F, Joannidis M, Liu KD, McAuley DF, McGuinness SP, Nichol AD, Ostermann M, Palevsky PM, Qiu H, Pettilä V, Schneider AG, Smith OM, Vaara ST, Weir M, Dreyfuss D, Bagshaw SM. Initiation of continuous renal replacement therapy versus intermittent hemodialysis in critically ill patients with severe acute kidney injury: a secondary analysis of STARRT-AKI trial. Intensive Care Med 2023; 49:1305-1316. [PMID: 37815560 DOI: 10.1007/s00134-023-07211-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/22/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND There is controversy regarding the optimal renal-replacement therapy (RRT) modality for critically ill patients with acute kidney injury (AKI). METHODS We conducted a secondary analysis of the STandard versus Accelerated Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial to compare outcomes among patients who initiated RRT with either continuous renal replacement therapy (CRRT) or intermittent hemodialysis (IHD). We generated a propensity score for the likelihood of receiving CRRT and used inverse probability of treatment with overlap-weighting to address baseline inter-group differences. The primary outcome was a composite of death or RRT dependence at 90-days after randomization. RESULTS We identified 1590 trial participants who initially received CRRT and 606 who initially received IHD. The composite outcome of death or RRT dependence at 90-days occurred in 823 (51.8%) patients who commenced CRRT and 329 (54.3%) patients who commenced IHD (unadjusted odds ratio (OR) 0.90; 95% confidence interval (CI) 0.75-1.09). After balancing baseline characteristics with overlap weighting, initial receipt of CRRT was associated with a lower risk of death or RRT dependence at 90-days compared with initial receipt of IHD (OR 0.81; 95% CI 0.66-0.99). This association was predominantly driven by a lower risk of RRT dependence at 90-days (OR 0.61; 95% CI 0.39-0.94). CONCLUSIONS In critically ill patients with severe AKI, initiation of CRRT, as compared to IHD, was associated with a significant reduction in the composite outcome of death or RRT dependence at 90-days.
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Affiliation(s)
- Ron Wald
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Li Ka Shing Knowledge Institute, Toronto, ON, Canada.
| | - Stephane Gaudry
- AP-HP, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France
- UMR S1155, French National Institute of Health and Medical Research (INSERM), CORAKID, Hôpital Tenon, Sorbonne Université, 75020, Paris, France
| | - Bruno R da Costa
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
- School of Medicine, The University of Melbourne, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Bin Du
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Martin P Gallagher
- The George Institute for Global Health, University of New South Wales, Kensington, NSW, Australia
| | - Eric A Hoste
- Intensive Care Unit, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - François Lamontagne
- Department of Medicine, Université de Sherbrooke, Centre de Recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Kathleen D Liu
- Division of Intensive Care and Nephrology, University of California San Francisco, San Francisco, CA, USA
| | - Daniel F McAuley
- The Regional Intensive Care Unit, The Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Royal Victoria Hospital, Belfast, UK
| | - Shay P McGuinness
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland and Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Alistair D Nichol
- Department of Critical Care Medicine, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin, Ireland
- Monash University, Melbourne, Australia
| | - Marlies Ostermann
- Department of Critical Care Medicine, King's College London, Guy's & St Thomas Hospital, London, UK
| | - Paul M Palevsky
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Kidney Medicine Section, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital Southeast University, Nanjing, China
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antoine G Schneider
- Department of Critical Care Medicine Centre, Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Orla M Smith
- Department of Critical Care, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Suvi T Vaara
- Department of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Matthew Weir
- Division of Nephrology, London Health Sciences Centre, London, ON, Canada
| | - Didier Dreyfuss
- UMR S1155, French National Institute of Health and Medical Research (INSERM), CORAKID, Hôpital Tenon, Sorbonne Université, 75020, Paris, France
- Service de Médecine Intensive Réanimation, Sorbonne Université, Hôpital Louis Mourier, Assistance Publique, Université de Paris-Cité, Paris, France
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
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10
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Gaudry S, Chaïbi K, Dreyfuss D. Renal Replacement Therapy in a World of Constraints: Lessons from the COVID-19 Pandemic. Am J Respir Crit Care Med 2023; 208:639-640. [PMID: 37437531 PMCID: PMC10492245 DOI: 10.1164/rccm.202305-0926le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/12/2023] [Indexed: 07/14/2023] Open
Affiliation(s)
- Stephane Gaudry
- Service de Réanimation Médico-Chirurgicale, Assistance Publique–Hôpitaux de Paris, Hôpital Avicenne, Bobigny, France
- French National Institute of Health and Medical Research, UMR_S1155, CORAKID, Hôpital Tenon, Paris, France
- UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France
| | - Khalil Chaïbi
- Service de Réanimation Médico-Chirurgicale, Assistance Publique–Hôpitaux de Paris, Hôpital Avicenne, Bobigny, France
- French National Institute of Health and Medical Research, UMR_S1155, CORAKID, Hôpital Tenon, Paris, France
- UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France
| | - Didier Dreyfuss
- French National Institute of Health and Medical Research, UMR_S1155, CORAKID, Hôpital Tenon, Paris, France
- Service de Médecine Intensive Réanimation, Hôpital Louis Mourier, Assistance Publique–Hôpitaux de Paris, Colombes, France; and
- Université Paris Cité, Paris, France
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11
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Karvellas CJ, Gustot T, Fernandez J. Management of the acute on chronic liver failure in the intensive care unit. Liver Int 2023. [PMID: 37365997 DOI: 10.1111/liv.15659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/01/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.
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Affiliation(s)
- Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
| | - Thierry Gustot
- Department of Gastroenterology, Hepato-Pancreatology and Digestive Oncology, H.U.B., CUB Hôpital Erasme, Brussels, Belgium
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Barcelona, Spain
- EF CLIF, EASL-CLIF Consortium, Barcelona, Spain
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12
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Chaïbi K, Dreyfuss D, Gaudry S. Debate: Intermittent Hemodialysis versus Continuous Kidney Replacement Therapy in the Critically Ill Patient: The Choice Should Be Evidence Based. Clin J Am Soc Nephrol 2023; 18:661-667. [PMID: 36723298 PMCID: PMC10278838 DOI: 10.2215/cjn.0000000000000104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 02/02/2023]
Abstract
Kidney replacement therapy (KRT) plays a major role in the treatment of severe AKI. Intermittent hemodialysis (HD) and continuous KRT (CKRT) are the main modalities in critically ill patients with AKI. CKRT is the preferred modality in many countries because of its alleged superiority on both hemodynamic tolerance and on kidney function recovery. In fact, randomized controlled trials (RCTs) comparing the two modalities have not shown any actual benefit of one technique over the other on mortality, hemodynamics, or kidney function recovery. Those RCTs were conducted more than 15 years ago. Major progress was eventually made leading to much lower mortality rates in recent studies than in previous studies. In addition, those RCTs included a noticeable proportion of patients who could have recovered without ever receiving KRT, as demonstrated by several recent studies. In the absence of evidence of clinical superiority of one KRT modality, the choice must be addressed not only regarding clinical outcome but also resources and logistics. Conclusions of health technology assessments and study reports were heterogeneous and conflicting concerning cost-effectiveness of intermittent HD versus CKRT. All these considerations justify a reevaluation of the issue in new RCTs that take into account recent knowledge on KRT initiation and management. Pending results of such study, the choice should be guided mainly by organizational considerations in each unit and without condemning any modality in the absence of proof.
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Affiliation(s)
- Khalil Chaïbi
- AP-HP, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, Bobigny, France
- French National Institute of Health and Medical Research (INSERM), UMR_S1155, CORAKID, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Didier Dreyfuss
- French National Institute of Health and Medical Research (INSERM), UMR_S1155, CORAKID, Hôpital Tenon, Sorbonne Université, Paris, France
- Service de Médecine Intensive Réanimation, Hôpital Louis Mourier, Assistance Publique, Colombes, France
- Université de Paris-Cité, Paris, France
| | - Stéphane Gaudry
- AP-HP, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, Bobigny, France
- French National Institute of Health and Medical Research (INSERM), UMR_S1155, CORAKID, Hôpital Tenon, Sorbonne Université, Paris, France
- Health Care Simulation Center, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France
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13
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Reverter E, Toapanta D, Bassegoda O, Zapatero J, Fernandez J. Critical Care Management of Acute-on-Chronic Liver Failure: Certainties and Unknowns. Semin Liver Dis 2023; 43:206-217. [PMID: 37369227 DOI: 10.1055/s-0043-1769907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Intensive care unit (ICU) admission is frequently required in patients with decompensated cirrhosis for organ support. This entity, known as acute-on-chronic liver failure (ACLF), is associated with high short-term mortality. ICU management of ACLF is complex, as these patients are prone to develop new organ failures and infectious or bleeding complications. Poor nutritional status, lack of effective liver support systems, and shortage of liver donors are also factors that contribute to increase their mortality. ICU therapy parallels that applied in the general ICU population in some complications but has differential characteristics in others. This review describes the current knowledge on critical care management of patients with ACLF including organ support, prognostic assessment, early liver transplantation, and futility rules. Certainties and knowledge gaps in this area are also discussed.
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Affiliation(s)
- Enric Reverter
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - David Toapanta
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Octavi Bassegoda
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Juliana Zapatero
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
- European Foundation for the Study of Chronic Liver Failure, EASL-CLIF, Consortium, Barcelona, Spain
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14
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Gao Y, Li M, Jiang M, Zhang Y, Wu C, Ji X. Hemolysis performance analysis and a novel estimation model of roller pump system. Comput Biol Med 2023; 159:106842. [PMID: 37062254 DOI: 10.1016/j.compbiomed.2023.106842] [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: 02/11/2023] [Revised: 03/14/2023] [Accepted: 03/30/2023] [Indexed: 04/18/2023]
Abstract
OBJECTIVE Hemolysis performance is a crucial criterion for roller pumps utilized in life supporting system. In this study, the factor of hemolysis for roller pumps was selected as the target, and an estimation formulation was built to evaluate its hemolysis. METHODS Several models were proposed and then simulated with the assistant of Computational fluid dynamics (CFD) framework. The hemolysis performance was calculated using the power law model based on CFD and the estimation model in accordance with geometry parameters proposed in this study. The results of the in vitro experiments were compared with the simulation results. Power law model with the lowest error was utilized in following analysis. RESULTS As indicated by the simulation result, the rotary speed most significantly affected the hemolysis performance of roller blood pumps, followed by roller number and diameter of tube. The index of hemolysis (IH) for roller blood pumps at a rotary speed of 20-100 rpm ranged from 8.73E-7 to 8.07E-5. The relative error of the estimation model (4.93%) was lower than of the power law model (6.78%). CONCLUSION The IH led by pumps shows a significant, nonlinear relationship with the rotary speed. The design of multiple rollers design is harmful for hemolysis performance and larger diameter of tube exhibits decreased hemolysis at constant flow rate. An estimation formula was proposed with lower relative error for roller pump with the same shell set, which exhibited reduced computation and elevated convenience. And it can be utilized in hemolysis estimation of roller pumps potentially.
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Affiliation(s)
- Yuan Gao
- School of Instrumentation and Optoelectronic Engineering, Beihang University, Beijing, 100191, China; Research Institute for Frontier Science, Beihang University, Beijing, 100191, China
| | - Ming Li
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Miaowen Jiang
- School of Instrumentation and Optoelectronic Engineering, Beihang University, Beijing, 100191, China; Research Institute for Frontier Science, Beihang University, Beijing, 100191, China
| | - Yang Zhang
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Chuanjie Wu
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Xunming Ji
- School of Instrumentation and Optoelectronic Engineering, Beihang University, Beijing, 100191, China; Research Institute for Frontier Science, Beihang University, Beijing, 100191, China; China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
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15
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Yan J, Wang Y, Zhang J, Liu X, Yu L, He Z. Rapidly Blocking the Calcium Overload/ROS Production Feedback Loop to Alleviate Acute Kidney Injury via Microenvironment-Responsive BAPTA-AM/BAC Co-Delivery Nanosystem. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2023; 19:e2206936. [PMID: 36719986 DOI: 10.1002/smll.202206936] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/14/2023] [Indexed: 06/18/2023]
Abstract
Calcium overload and ROS overproduction, two major triggers of acute kidney injury (AKI), are self-amplifying and mutually reinforcing, forming a complicated cascading feedback loop that induces kidney cell "suicide" and ultimately renal failure. There are currently no clinically effective drugs for the treatment of AKI, excluding adjuvant therapy. In this study, a porous silicon-based nanocarrier rich in disulfide bond skeleton (<50 nm) is developed that enables efficient co-loading of the hydrophilic drug borane amino complex and the hydrophobic drug BAPTA-AM, with its outer layer sealed by the renal tubule-targeting peptide PEG-LTH. Once targeted to the kidney injured site, the nanocarrier structure collapses in the high glutathione environment of the early stage of AKI, releasing the drugs. Under the action of the slightly acidic inflammatory environment and intracellular esterase, the released drugs produce hydrogen and BAPTA, which can rapidly eliminate the excess ROS and overloaded Ca2+ , blocking endoplasmic reticulum/mitochondrial apoptosis pathway (ATF4-CHOP-Bax axis, Casp-12-Casp-3 axis, Cyt-C-Casp-3 axis) and inflammatory pathway (TNF-α-NF-κB axis) from the source, thus rescuing the renal cells in the "critical survival" state and further restoring the kidney function. Overall, this nanoparticle shows substantial clinical promise as a potential therapeutic strategy for I/R injury-related diseases.
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Affiliation(s)
- Jiahui Yan
- Frontiers Science Center for Deep Ocean Multispheres and Earth Systems, and Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, Qingdao, 266100, P. R. China
- College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao, 266100, P. R. China
| | - Yanan Wang
- Frontiers Science Center for Deep Ocean Multispheres and Earth Systems, and Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, Qingdao, 266100, P. R. China
- College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao, 266100, P. R. China
| | - Jingwen Zhang
- Frontiers Science Center for Deep Ocean Multispheres and Earth Systems, and Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, Qingdao, 266100, P. R. China
- College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao, 266100, P. R. China
| | - Xiaohu Liu
- Frontiers Science Center for Deep Ocean Multispheres and Earth Systems, and Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, Qingdao, 266100, P. R. China
- College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao, 266100, P. R. China
| | - Liangmin Yu
- Frontiers Science Center for Deep Ocean Multispheres and Earth Systems, and Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, Qingdao, 266100, P. R. China
- College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao, 266100, P. R. China
| | - Zhiyu He
- Frontiers Science Center for Deep Ocean Multispheres and Earth Systems, and Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, Qingdao, 266100, P. R. China
- College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao, 266100, P. R. China
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16
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Chaïbi K, Ehooman F, Pons B, Martin-Lefevre L, Boulet E, Boyer A, Chevrel G, Lerolle N, Carpentier D, de Prost N, Lautrette A, Bretagnol A, Mayaux J, Nseir S, Megarbane B, Thirion M, Forel JM, Maizel J, Yonis H, Markowicz P, Thiery G, Schortgen F, Couchoud C, Dreyfuss D, Gaudry S. Long-term outcomes after severe acute kidney injury in critically ill patients: the SALTO study. Ann Intensive Care 2023; 13:18. [PMID: 36907976 PMCID: PMC10008759 DOI: 10.1186/s13613-023-01108-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: 09/25/2022] [Accepted: 02/07/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND The extent of the consequences of an episode of severe acute kidney injury (AKI) on long-term outcome of critically ill patients remain debated. We conducted a prospective follow-up of patients included in a large multicenter clinical trial of renal replacement therapy (RRT) initiation strategy during severe AKI (the Artificial Kidney Initiation in Kidney Injury, AKIKI) to investigate long-term survival, renal outcome and health related quality of life (HRQOL). We also assessed the influence of RRT initiation strategy on these outcomes. RESULTS Follow-up of patients extended from 60 days to a median of 3.35 years [interquartile range (IQR), 1.89 to 4.09] after the end of initial study. Of the 619 patients included in the AKIKI trial, 316 survived after 60 days. The overall survival rate at 3 years from inclusion was 39.4% (95% CI 35.4 to 43.4). A total of 46 patients (on the 175 with available data on long-term kidney function) experienced worsening of renal function (WRF) at the time of follow-up [overall incidence of 26%, cumulative incidence at 4 years: 20.6% (CI 95% 13.0 to 28.3)]. Fifteen patients required chronic dialysis (5% of patients who survived after day 90). Among the 226 long-term survivors, 80 (35%) answered the EQ-5D questionnaire. The median index value reported was 0.67 (IQR 0.40 to 1.00) indicating a noticeable alteration of quality of life. Initiation strategy for RRT had no effect on any long-term outcome. CONCLUSION Severe AKI in critically ill patients was associated with a high proportion of death within the first 2 months but less so during long-term follow-up. A quarter of long-term survivors experienced a WRF and suffered from a noticeable impairment of quality of life. Renal replacement therapy initiation strategy was not associated with mortality outcome.
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Affiliation(s)
- Khalil Chaïbi
- Service de Réanimation Médico-Chirurgicale, AP-HP, Hôpital Avicenne, 125 rue de Stalingrad, 93000, Bobigny, France.,UMR_S1155, French National Institute of Health and Medical Research (INSERM), CORAKID, Hôpital Tenon, Sorbonne Université, 75020, Paris, France
| | - Franck Ehooman
- UMR_S1155, French National Institute of Health and Medical Research (INSERM), CORAKID, Hôpital Tenon, Sorbonne Université, 75020, Paris, France.,Service Anesthésie Réanimation Hôpital Privé Claude Gallien, Quincy-Sous-Sénart, France
| | - Bertrand Pons
- Service de Réanimation, CHU de Pointe à Pitre-Abymes, CHU de la Guadeloupe, France
| | | | - Eric Boulet
- Réanimation polyvalente, CH René Dubos, Pontoise, France
| | - Alexandre Boyer
- Réanimation médicale CHU Bordeaux, Hôpital Pellegrin, Bordeaux, France
| | - Guillaume Chevrel
- Service de réanimation, Centre Hospitalier Sud Francilien, Corbeil Essonne, France
| | - Nicolas Lerolle
- Département de réanimation médicale et médecine hyperbare, CHU Angers, Universitéd'Angers, Angers, France
| | | | - Nicolas de Prost
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, DHU A-TVB, Service de réanimation médicale, Créteil, France.,CARMAS research group and UPEC-Université Paris-Est Créteil Val de Marne, Créteil, France
| | - Alexandre Lautrette
- Réanimation médicale, Hôpital Gabriel Montpied, CHU de Clermont-Ferrand, Clermont- Ferrand, France
| | - Anne Bretagnol
- Réanimation médico-chirurgicale, Hôpital de La Source, Centre Hospitalier Régional d'Orléans, BP 6709, 45067, Orléans Cedex, France
| | - Julien Mayaux
- Service de Pneumologie et Réanimation Médicale, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Saad Nseir
- Centre de Réanimation, Faculté de Médecine, CHU de Lille, Université de Lille, 59000, Lille, France
| | - Bruno Megarbane
- Réanimation Médicale et Toxicologique, Hôpital Lariboisière, INSERM U1144, Université Paris-Diderot, Paris, France
| | - Marina Thirion
- Réanimation polyvalente, CH Victor Dupouy, 95107, Argenteuil Cedex, France
| | - Jean-Marie Forel
- Service de réanimation des Détresses respiratoires aiguës et infections sévères, Hôpital Nord Marseille, Marseille, France
| | - Julien Maizel
- Service de réanimation médicale INSERM U1088, Centre hospitalier universitaire de picardie, Amiens, France
| | - Hodane Yonis
- Réanimation médicale, Hôpital de la Croix Rousse, Lyon, France
| | | | - Guillaume Thiery
- Réanimation médicale, CHU Saint Etienne, 42270, Saint Priest en Jarez, France
| | - Frédérique Schortgen
- Centre Hospitalier Intercommunal, Service de Réanimation Polyvalente Adulte, Créteil, France
| | - Cécile Couchoud
- REIN registry, Agence de la biomédecine, Saint Denis La Plaine, France
| | - Didier Dreyfuss
- UMR_S1155, French National Institute of Health and Medical Research (INSERM), CORAKID, Hôpital Tenon, Sorbonne Université, 75020, Paris, France.,Service de Médecine Intensive Réanimation, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, Paris, France.,Université Paris-Cité, Paris, France
| | - Stephane Gaudry
- Service de Réanimation Médico-Chirurgicale, AP-HP, Hôpital Avicenne, 125 rue de Stalingrad, 93000, Bobigny, France. .,UMR_S1155, French National Institute of Health and Medical Research (INSERM), CORAKID, Hôpital Tenon, Sorbonne Université, 75020, Paris, France.
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17
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See KC, Lau YH. Acute management of pneumonia in adult patients. Singapore Med J 2023; 64:209-216. [PMID: 36876626 PMCID: PMC10071852 DOI: 10.4103/singaporemedj.smj-2022-050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Affiliation(s)
- Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore
| | - Yie Hui Lau
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
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18
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Chan RJ, Helmeczi W, Canney M, Clark EG. Management of Intermittent Hemodialysis in the Critically Ill Patient. Clin J Am Soc Nephrol 2023; 18:245-255. [PMID: 35840348 PMCID: PMC10103228 DOI: 10.2215/cjn.04000422] [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] [Indexed: 11/23/2022]
Abstract
Intermittent hemodialysis remains a cornerstone of extracorporeal KRT in the intensive care unit, either as a first-line therapy for AKI or a second-line therapy when patients transition from a continuous or prolonged intermittent therapy. Intermittent hemodialysis is usually provided 3 days per week in this setting on the basis that no clinical benefits have been demonstrated with more frequent hemodialysis. This should not detract from the importance of continually assessing and refining the hemodialysis prescription (including the need for extra treatments) according to dynamic changes in extracellular volume and other parameters, and ensuring that an adequate dose of hemodialysis is being delivered to the patient. Compared with other KRT modalities, the cardinal challenge encountered during intermittent hemodialysis is hemodynamic instability. This phenomenon occurs when reductions in intravascular volume, as a consequence of ultrafiltration and/or osmotic shifts, outpace compensatory plasma refilling from the extravascular space. Myocardial stunning, triggered by intermittent hemodialysis, and independent of ultrafiltration, may also contribute. The hemodynamic effect of intermittent hemodialysis is likely magnified in patients who are critically ill due to an inability to mount sufficient compensatory physiologic responses in the context of multiorgan dysfunction. Of the many interventions that have undergone testing to mitigate hemodynamic instability related to KRT, the best evidence exists for cooling the dialysate and raising the dialysate sodium concentration. Unfortunately, the evidence supporting routine use of these and other interventions is weak owing to poor study quality and limited sample sizes. Intermittent hemodialysis will continue to be an important and commonly used KRT modality for AKI in patients with critical illness, especially in jurisdictions where resources are limited. There is an urgent need to harmonize the definition of hemodynamic instability related to KRT in clinical trials and robustly test strategies to combat it in this vulnerable patient population.
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Affiliation(s)
- Ryan J. Chan
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Wryan Helmeczi
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mark Canney
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Edward G. Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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19
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Královcová M, Karvunidis T, Matějovič M. Critical care for multimorbid patients. VNITRNI LEKARSTVI 2023; 69:166-172. [PMID: 37468311 DOI: 10.36290/vnl.2023.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Multimorbidity - the simultaneous presence of several chronic diseases - is very common in the critically ill patients. Its prevalence is roughly 40-85 % and continues to increase further. Certain chronic diseases such as diabetes, obesity, chronic heart, pulmonary, liver or kidney disease and malignancy are associated with higher risk of developing serious acute complications and therefore the possible need for intensive care. This review summarizes and discusses selected specifics of critical care for multimorbid patients.
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20
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Tauber FJ, Slesarenko V. Early career scientists converse on the future of soft robotics. Front Robot AI 2023; 10:1129827. [PMID: 36909362 PMCID: PMC9994530 DOI: 10.3389/frobt.2023.1129827] [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: 12/22/2022] [Accepted: 02/09/2023] [Indexed: 02/24/2023] Open
Abstract
During the recent decade, we have witnessed an extraordinary flourishing of soft robotics. Rekindled interest in soft robots is partially associated with the advances in manufacturing techniques that enable the fabrication of sophisticated multi-material robotic bodies with dimensions ranging across multiple length scales. In recent manuscripts, a reader might find peculiar-looking soft robots capable of grasping, walking, or swimming. However, the growth in publication numbers does not always reflect the real progress in the field since many manuscripts employ very similar ideas and just tweak soft body geometries. Therefore, we unreservedly agree with the sentiment that future research must move beyond "soft for soft's sake." Soft robotics is an undoubtedly fascinating field, but it requires a critical assessment of the limitations and challenges, enabling us to spotlight the areas and directions where soft robots will have the best leverage over their traditional counterparts. In this perspective paper, we discuss the current state of robotic research related to such important aspects as energy autonomy, electronic-free logic, and sustainability. The goal is to critically look at perspectives of soft robotics from two opposite points of view provided by early career researchers and highlight the most promising future direction, that is, in our opinion, the employment of soft robotic technologies for soft bio-inspired artificial organs.
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Affiliation(s)
- Falk J Tauber
- Cluster of Excellence livMatS, FIT-Freiburg Center for Interactive Materials and Bioinspired Technologies, University of Freiburg, Freiburg im Breisgau, Germany.,Plant Biomechanics Group (PBG) Freiburg, Botanic Garden of the University of Freiburg, Freiburg im Breisgau, Germany
| | - Viacheslav Slesarenko
- Cluster of Excellence livMatS, FIT-Freiburg Center for Interactive Materials and Bioinspired Technologies, University of Freiburg, Freiburg im Breisgau, Germany
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21
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Qi W, Liu J, Li A. Regional Citrate Anticoagulation or Heparin Anticoagulation for Renal Replacement Therapy in Patients With Liver Failure: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2023; 29:10760296231174001. [PMID: 37186766 DOI: 10.1177/10760296231174001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
In patients with liver failure complicated by acute kidney injury, renal replacement therapy (RRT) is often required to improve the internal environment. The use of anticoagulants for RRT in patients with liver failure remains controversial. We searched the PubMed, Embase, Cochrane Library, and Web of Science databases for studies. The methodological quality of the included studies was assessed using the Methodological Index for Nonrandomized Studies. A meta-analysis was performed using R software (version 3.5.1) and Review Manager (version 5.3.5). During RRT, 348 patients from 9 studies received regional citrate anticoagulation (RCA), and 127 patients from 5 studies received heparin anticoagulation (including heparin and LMWH). Among patients who received RCA, the incidence of citrate accumulation, metabolic acidosis, and metabolic alkalosis were 5.3% (95% confidence interval [CI]: 0%-25.3%), 26.4% (95% CI: 0-76.9), and 1.8% (95% CI: 0-6.8), respectively. The potassium, phosphorus, total bilirubin (TBIL), and creatinine levels were lower, whereas the serum pH, bicarbonate, base excess levels, and total calcium/ionized calcium ratio were higher after treatment than before treatment. Among patients who received heparin anticoagulation, the TBIL levels were lower, whereas the activated partial thromboplastin clotting time and D-dimer levels were higher after treatment than before treatment. The mortality rates in the RCA and heparin anticoagulation groups were 58.9% (95% CI: 39.2-77.3) and 47.4% (95% CI: 31.1-63.7), respectively. No statistical difference in mortality was observed between the 2 groups. For patients with liver failure, the administration of RCA or heparin for anticoagulation during RRT under strict monitoring may be safe and effective.
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Affiliation(s)
- Wenqian Qi
- Intensive Care Unit, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Jingyuan Liu
- Intensive Care Unit, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Ang Li
- Intensive Care Unit, Beijing Ditan Hospital, Capital Medical University, Beijing, China
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22
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Flamm SL, Wong F, Ahn J, Kamath PS. AGA Clinical Practice Update on the Evaluation and Management of Acute Kidney Injury in Patients With Cirrhosis: Expert Review. Clin Gastroenterol Hepatol 2022; 20:2707-2716. [PMID: 36075500 DOI: 10.1016/j.cgh.2022.08.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/15/2022] [Accepted: 08/18/2022] [Indexed: 02/07/2023]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available published evidence and expert advice regarding the clinical management of patients with suspected acute kidney injury in patients with cirrhosis. METHODS This article provides practical advice for the management of patients with cirrhosis and acute kidney injury based on the best available published evidence. This best practice document is not based on a formal systematic review. This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through the standard procedures of Clinical Gastroenterology & Hepatology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Since systematic reviews were not performed, these BPA statements do not carry formal ratings of the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: Acute kidney injury (AKI) should be diagnosed when the serum creatinine increases by ≥0.3 mg/dL within 48 hours or is ≥50% from baseline or when the urine output is reduced below 0.5 mL/kg/h for >6 hours. BEST PRACTICE ADVICE 2: Preventive measures against the development of AKI in cirrhosis include (1) avoidance of potentially nephrotoxic medications like nonsteroidal anti-inflammatory drugs (NSAIDs), (2) avoidance of excessive or unmonitored diuretics or nonselective beta-blockade, (3) avoidance of large-volume paracentesis without albumin replacement, and (4) counseling patients to avoid alcohol use. BEST PRACTICE ADVICE 3: (A) Investigation is directed to determining the cause of AKI, which can be due to hypovolemic causes (volume responsive, and the most common cause of AKI in patients with cirrhosis); acute tubular necrosis; hepatorenal syndrome with AKI (HRS-AKI) (a functional renal failure that persists despite volume repletion); HRS with acute kidney disease, a type of functional renal failure of <3 months- duration in which criteria for HRS-AKI are not met; or postrenal, which occurs only rarely. (B) The specific type of AKI should be identified through a careful history, physical examination, blood biochemistry, urine microscopic examination, urine chemistry (Na+ and urea) and selected urinary biomarkers, and renal ultrasound. BEST PRACTICE ADVICE 4: A rigorous search for infection is required in all patients with AKI. A diagnostic paracentesis should be carried out to evaluate for spontaneous bacterial peritonitis; blood and urine cultures and chest radiograph are also required. There is no role for routine prophylactic antibiotics in patients with AKI, but broad-spectrum antibiotics should be started whenever infection is strongly suspected. BEST PRACTICE ADVICE 5: When AKI is diagnosed, diuretics and nonselective beta-blockers should be held, NSAIDs discontinued, the precipitating cause of AKI treated, and fluid losses replaced, administering albumin 1 g/kg/d for 2 days if the serum creatinine shows doubling from baseline. Urine output, vital signs, and when indicated, echocardiography or CVP (if there is a pre-existing central line) should be used to monitor fluid status. BEST PRACTICE ADVICE 6: When the serum creatinine remains higher than twice the baseline value despite these measures, treatment of HRS-AKI should be initiated with albumin at a dose of 1 g/kg intravenously on day 1 followed by 20-40 g daily along with vasoactive agents (terlipressin; if terlipressin is not available, either a combination of octreotide and midodrine; or norepinephrine, depending on institutional preferences) and continued either until 24 hours following the return of the serum creatinine level to within ≤0.3 mg/dL of baseline for 2 consecutive days or for a total of 14 days of therapy. BEST PRACTICE ADVICE 7: Terlipressin should be initiated as a bolus dose of 1 mg every 4-6 hours (total 4-6 mg/d). The dose should be increased to a maximum of 2 mg every 4-6 hours (total 8-12 mg/d) if there is no reduction in serum creatinine at day 3 of therapy by at least 25% compared to the baseline value. Alternatively, clinicians can administer terlipressin by continuous intravenous infusion at a lower starting dose of 2 mg/d, which may reduce ischemic side effects and increase the dose gradually every 24-48 hours up to a maximum dose of 12 mg/d, or reversal of HRS. As per Food and Drug Administration restrictions, terlipressin should not be used in patients with a serum creatinine ≥5 mg/dL, or oxygen saturation of <90%. BEST PRACTICE ADVICE 8: Oral midodrine when used should be initiated at doses of 7.5 mg and titrated upward to 12.5 mg 3 times daily with octreotide (starting with 100 μg and titrating upward to 200 μg subcutaneously 3 times daily). BEST PRACTICE ADVICE 9: Norepinephrine should be used as a continuous intravenous infusion at a starting dose of 0.5 mg/h and the dose increased every 4 hours by 0.5 mg/h to a maximum of 3 mg/h with the goal of increasing the mean arterial pressure by ≥10 mm Hg and/or the urine output to >50 mL/h for at least 4 hours. BEST PRACTICE ADVICE 10: The risks of ischemic side effects of terlipressin and norepinephrine include angina and ischemia of fingers, skin, and intestine. These side effects may be lowered by starting at the lowest dose and gradually titrating upward. BEST PRACTICE ADVICE 11: Fluid status should be closely monitored because of the risk of pulmonary edema with excessive use of albumin. BEST PRACTICE ADVICE 12: Renal replacement therapy (RRT) may be used in the management of (A) AKI secondary to acute tubular necrosis; (B) HRS-AKI in potential candidates for liver transplantation (that is, RRT should not be used in patients with HRS-AKI who are not candidates for liver transplantation); and (C) AKI of uncertain etiology in which the need for RRT may be considered on an individual basis. BEST PRACTICE ADVICE 13: Transjugular intrahepatic portosystemic shunts should not be used as a specific treatment of HRS-AKI. BEST PRACTICE ADVICE 14: Liver transplantation is the most effective treatment for HRS-AKI. Pharmacotherapy for HRS-AKI before proceeding with liver transplantation may be associated with better post-liver transplantation outcomes. Selected patients with HRS-AKI may require simultaneous liver kidney transplantation based on updated Organ Procurement and Transplantation Network listing criteria.
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Affiliation(s)
- Steven L Flamm
- Division of Gastroenterology and Hepatology, Rush University Medical College, Chicago, Illinois
| | - Florence Wong
- Division of Gastroenterology and Hepatology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joseph Ahn
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.
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Wald R, Beaubien-Souligny W, Chanchlani R, Clark EG, Neyra JA, Ostermann M, Silver SA, Vaara S, Zarbock A, Bagshaw SM. Delivering optimal renal replacement therapy to critically ill patients with acute kidney injury. Intensive Care Med 2022; 48:1368-1381. [PMID: 36066597 DOI: 10.1007/s00134-022-06851-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
Critical illness is often complicated by acute kidney injury (AKI). In patients with severe AKI, renal replacement therapy (RRT) is deployed to address metabolic dysfunction and volume excess until kidney function recovers. This review is intended to provide a comprehensive update on key aspects of RRT prescription and delivery to critically ill patients. Recently completed trials have enhanced the evidence base regarding several RRT practices, most notably the timing of RRT initiation and anticoagulation for continuous therapies. Better evidence is still needed to clarify several aspects of care including optimal targets for ultrafiltration and effective strategies for RRT weaning and discontinuation.
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Affiliation(s)
- Ron Wald
- Division of Nephrology, St. Michael's Hospital and the University of Toronto, 61 Queen Street East, 9-140, Toronto, ON, M5C 2T2, Canada. .,Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
| | | | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Javier A Neyra
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marlies Ostermann
- Department of Critical Care Medicine, Guys and St. Thomas Hospital, London, UK
| | - Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada
| | - Suvi Vaara
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, Muenster, Germany
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
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24
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A Bayesian reanalysis of the Standard versus Accelerated Initiation of Renal-Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial. Crit Care 2022; 26:255. [PMID: 36008827 PMCID: PMC9404618 DOI: 10.1186/s13054-022-04120-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/05/2022] [Indexed: 12/03/2022] Open
Abstract
Abstract
Background
Timing of initiation of kidney-replacement therapy (KRT) in critically ill patients remains controversial. The Standard versus Accelerated Initiation of Renal-Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial compared two strategies of KRT initiation (accelerated versus standard) in critically ill patients with acute kidney injury and found neutral results for 90-day all-cause mortality. Probabilistic exploration of the trial endpoints may enable greater understanding of the trial findings. We aimed to perform a reanalysis using a Bayesian framework.
Methods
We performed a secondary analysis of all 2927 patients randomized in multi-national STARRT-AKI trial, performed at 168 centers in 15 countries. The primary endpoint, 90-day all-cause mortality, was evaluated using hierarchical Bayesian logistic regression. A spectrum of priors includes optimistic, neutral, and pessimistic priors, along with priors informed from earlier clinical trials. Secondary endpoints (KRT-free days and hospital-free days) were assessed using zero–one inflated beta regression.
Results
The posterior probability of benefit comparing an accelerated versus a standard KRT initiation strategy for the primary endpoint suggested no important difference, regardless of the prior used (absolute difference of 0.13% [95% credible interval [CrI] − 3.30%; 3.40%], − 0.39% [95% CrI − 3.46%; 3.00%], and 0.64% [95% CrI − 2.53%; 3.88%] for neutral, optimistic, and pessimistic priors, respectively). There was a very low probability that the effect size was equal or larger than a consensus-defined minimal clinically important difference. Patients allocated to the accelerated strategy had a lower number of KRT-free days (median absolute difference of − 3.55 days [95% CrI − 6.38; − 0.48]), with a probability that the accelerated strategy was associated with more KRT-free days of 0.008. Hospital-free days were similar between strategies, with the accelerated strategy having a median absolute difference of 0.48 more hospital-free days (95% CrI − 1.87; 2.72) compared with the standard strategy and the probability that the accelerated strategy had more hospital-free days was 0.66.
Conclusions
In a Bayesian reanalysis of the STARRT-AKI trial, we found very low probability that an accelerated strategy has clinically important benefits compared with the standard strategy. Patients receiving the accelerated strategy probably have fewer days alive and KRT-free. These findings do not support the adoption of an accelerated strategy of KRT initiation.
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25
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Genovesi S, Regolisti G, Burlacu A, Covic A, Combe C, Mitra S, Basile C. The conundrum of the complex relationship between acute kidney injury and cardiac arrhythmias. Nephrol Dial Transplant 2022; 38:1097-1112. [PMID: 35777072 DOI: 10.1093/ndt/gfac210] [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: 04/06/2022] [Indexed: 11/13/2022] Open
Abstract
Acute kidney injury (AKI) is defined by a rapid increase in serum creatinine levels, reduced urine output, or both. Death may occur in 16%-49% of patients admitted to an intensive care unit with severe AKI. Complex arrhythmias are a potentially serious complication in AKI patients with pre-existing or AKI-induced heart damage and myocardial dysfunction, fluid overload, and especially electrolyte and acid-base disorders representing the pathogenetic mechanisms of arrhythmogenesis. Cardiac arrhythmias, in turn, increase the risk of poor renal outcomes, including AKI. Arrhythmic risk in AKI patients receiving kidney replacement treatment may be reduced by modifying dialysis/replacement fluid composition. The most common arrhythmia observed in AKI patients is atrial fibrillation. Severe hyperkalemia, sometimes combined with hypocalcemia, causes severe bradyarrhythmias in this clinical setting. Although the likelihood of life-threatening ventricular arrhythmias is reportedly low, the combination of cardiac ischemia and specific electrolyte or acid-base abnormalities may increase this risk, particularly in AKI patients who require kidney replacement treatment. The purpose of this review is to summarize the available epidemiological, pathophysiological, and prognostic evidence aiming to clarify the complex relationships between AKI and cardiac arrhythmias.
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Affiliation(s)
- Simonetta Genovesi
- School of Medicine and Surgery, University of Milano - Bicocca, Nephrology Clinic, Monza, Italy.,Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Giuseppe Regolisti
- Clinica e Immunologia Medica -Azienda Ospedaliero-Universitaria e Università degli Studi di Parma, Parma, Italy
| | - Alexandru Burlacu
- Department of Interventional Cardiology - Cardiovascular Diseases Institute, and 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Adrian Covic
- Nephrology Clinic, Dialysis, and Renal Transplant Center - 'C.I. Parhon' University Hospital, and 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Christian Combe
- Service de Néphrologie Transplantation Dialyse Aphérèse, Centre Hospitalier Universitaire de Bordeaux, and Unité INSERM 1026, Université de Bordeaux, Bordeaux, France
| | - Sandip Mitra
- Department of Nephrology, Manchester Academy of Health Sciences Centre, Manchester University Hospitals Foundation Trust, Oxford Road, Manchester, UK
| | - Carlo Basile
- Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
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Vodovar D, Mégarbane B. Extracorporeal Kidney-Replacement Therapy for Acute Kidney Injury. N Engl J Med 2022; 386:2250. [PMID: 35675191 DOI: 10.1056/nejmc2204453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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COUP-TFII in Kidneys, from Embryos to Sick Adults. Diagnostics (Basel) 2022; 12:diagnostics12051181. [PMID: 35626336 PMCID: PMC9139597 DOI: 10.3390/diagnostics12051181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/02/2022] [Accepted: 05/06/2022] [Indexed: 11/16/2022] Open
Abstract
Chicken ovalbumin upstream promoter-transcription factor II (COUP-TFII) is an orphan nuclear hormone receptor of unknown ligands. This molecule has two interesting features: (1) it is a developmental gene, and (2) it is a potential hormone receptor. Here, we describe the possible roles of COUP-TFII in the organogenesis of the kidneys and protection from adult renal diseases, primarily in mouse models. COUP-TFII is highly expressed in embryos, including primordial kidneys, and is essential for the formation of metanephric mesenchyme and the survival of renal precursor cells. Although the expression levels of COUP-TFII are low and its functions are unknown in healthy adults, it serves as a reno-protectant molecule against acute kidney injury. These are good examples of how developmental genes exhibit novel functions in the etiology of adult diseases. We also discuss the ongoing research on the roles of COUP-TFII in podocyte development and diabetic kidney disease. In addition, the identification of potential ligands suggests that COUP-TFII might be a novel therapeutic target for renal diseases in the future.
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