Hypernatremia: Epidemiology and Predictive Role in Emerging and Established Acute Kidney Injury

Hypernatremia (plasma sodium > 145 mmol/L) reflects impaired water balance, and affected patients can suffer from severe neurologic symptoms. Hyponatremia, on the other hand, is the most frequent electrolyte disorder in hospitals. It may be diagnosed in acute kidney injury (AKI), but hyponatremia prior to the diagnosis of AKI has also predictive or prognostic value in the short term. Aim of the article was to summarize data on both, epidemiology and outcomes of in-hospital acquired hypernatremia ("In-hospital acquired" refers to the diagnosis of either hypo- or hypernatremia in patients, who did not exhibit any of these electrolyte imbalances upon admission to the hospital). It also aimed to discuss its predictive role in patients with emerging or established AKI. Five databases were searched for references: PubMed, Medline, Google Scholar, Scopus, and Cochrane Library. Studies published between 2000 and 2023 were screened. The following keywords were used: "hypernatremia", "mortality", "pathophysiology", "acute kidney injury", "AKI", "risk prediction", "kidney replacement therapy", "KRT", "renal replacement therapy", "RRT", "hyponatremia", and "heart failure". A total of 16 studies were deemed eligible for inclusion. Among these, 13 studies had a retrospective design, two investigations were published as secondary analyses from prospective trial cohorts, and one study was prospective in nature. Out of the 16 studies, 11 focused on the epidemiology and outcomes of hypernatremia, while five investigations were related to AKI and/or AKI-associated endpoints. The prevalence of hypernatremia diagnosed during hospitalization varied from 1.9% to 6.8%, with one exception where it was 30.8%. All studies demonstrated associations between hypernatremia and mortality, even over extended periods after discharge. In AKI patients, hypernatremia shows potential for predicting in-hospital death. In conclusion, hypernatremic individuals are at higher risk of death during in-hospital therapy. Also, the electrolyte disorder potentially qualifies as a future biomarker for AKI onset and AKI-associated mortality.

Socioeconomic Influences on the Outcomes of Dialysis-Requiring Acute Kidney Injury in Brazil

Introduction

Although research suggests that socioeconomic deprivation is linked to a higher incidence of acute kidney injury (AKI) and worse outcomes in high-income countries, there is limited knowledge about these epidemiologic factors in developing countries. In addition, the impact of medical institution administration (private versus public) on AKI outcomes remains to be determined.

Methods

We studied 15,186 pediatric and adult patients with dialysis-requiring AKI (AKI-D) admitted to private and public hospitals in Rio de Janeiro, Brazil. According to Brazil's demographic census, socioeconomic indicators were derived from patient zip codes. Propensity score matching analysis and a mixed-effect Cox regression were used to assess the impact of socioeconomic indicators and hospital governance on patient survival.

Results

Crude mortality rates were higher in private hospitals than in public hospitals (71.8% vs. 59.5%, P < 0.001) and were associated with significant differences in age (75 years, interquartile range [IQR]: 61-83 vs. 53 years, IQR: 31-66), baseline renal function (prevalence of chronic kidney disease [CKD]: 33.2% vs. 23%, P < 0.001), comorbidities (Charlson score: 2.03 ± 0.87 vs. 1.72 ± 0.75, P < 0.001), and severity of presentation (mechanical ventilation: 76.5% vs. 58% and vasopressors: 72.8% vs. 50.5%, P < 0.001). After adjustments and propensity score matching, we found no effect of different hospital administrations or socioeconomic factors on mortality. Baseline characteristics and the severity of presentation primarily influenced AKI-D prognosis.

Conclusions

Despite significant racial and socioeconomic differences in hospital governance, these indicators had no independent influence on mortality. Future epidemiologic studies should investigate these relevant assumptions to allow healthcare systems to manage this severe syndrome promptly.

Hospital mortality and prognostic factors in critically ill patients with acute kidney injury and cancer undergoing continuous renal replacement therapy

BACKGROUND

Whether continuous renal replacement therapy (CRRT) should be applied to critically ill patients with both acute kidney injury (AKI) and cancer remains controversial because of poor expected outcomes. The present study determined prognostic factors for all-cause in-hospital mortality in patients with AKI and cancer undergoing CRRT.

METHODS

We included 471 patients with AKI and cancer who underwent CRRT at the intensive care unit of a Korean tertiary hospital from 2013 to 2020, and classified them by malignancy type. The primary outcomes were 28-day all-cause mortality rate and prognostic factors for in-hospital mortality. The secondary outcome was renal replacement therapy (RRT) dependency at hospital discharge.

RESULTS

The 28-day mortality rates were 58.8% and 82% in the solid and hematologic malignancy groups, respectively. Body mass index (BMI), presence of oliguria, Sequential Organ Failure Assessment (SOFA) score, and albumin level were common predictors of 28-day mortality in the solid and hematologic malignancy groups. A high heart rate and the presence of severe acidosis were prognostic factors only in the solid malignancy group. Among the survivors, the proportion with RRT dependency was 25.0% and 33.3% in the solid and hematologic malignancy groups, respectively.

CONCLUSION

The 28-day mortality rate of cancer patients with AKI undergoing CRRT was high in both the solid and hematologic malignancy groups. BMI, presence of oliguria, SOFA score, and albumin level were common predictors of 28-day mortality in the solid and hematologic malignancy groups, but a high heart rate and severe acidosis were prognostic factors only in the solid malignancy group.

Critically ill cancer patient's resuscitation: a Belgian/French societies' consensus conference

To respond to the legitimate questions raised by the application of invasive methods of monitoring and life-support techniques in cancer patients admitted in the ICU, the European Lung Cancer Working Party and the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique, set up a consensus conference. The methodology involved a systematic literature review, experts' opinion and a final consensus conference about nine predefined questions1. Which triage criteria, in terms of complications and considering the underlying neoplastic disease and possible therapeutic limitations, should be used to guide admission of cancer patient to intensive care units?2. Which ventilatory support [High Flow Oxygenation, Non-invasive Ventilation (NIV), Invasive Mechanical Ventilation (IMV), Extra-Corporeal Membrane Oxygenation (ECMO)] should be used, for which complications and in which environment?3. Which support should be used for extra-renal purification, in which conditions and environment?4. Which haemodynamic support should be used, for which complications, and in which environment?5. Which benefit of cardiopulmonary resuscitation in cancer patients and for which complications?6. Which intensive monitoring in the context of oncologic treatment (surgery, anti-cancer treatment …)?7. What specific considerations should be taken into account in the intensive care unit?8. Based on which criteria, in terms of benefit and complications and taking into account the neoplastic disease, patients hospitalized in an intensive care unit (or equivalent) should receive cellular elements derived from the blood (red blood cells, white blood cells and platelets)?9. Which training is required for critical care doctors in charge of cancer patients?

Association of Acute Kidney Injury Receiving Kidney Replacement Therapy With Prognosis of Critically Ill Patients With and Without Cancer: A Retrospective Study

OBJECTIVES

To assess outcomes of cancer patients receiving kidney replacement therapy due to acute kidney injury in ICUs and compare these with other patient groups receiving kidney replacement therapy in ICUs.

DESIGN

Retrospective registry analysis.

SETTING

Prospectively collected database of 296,424 ICU patients.

PATIENTS

Patients with and without solid cancer with acute kidney injury necessitating kidney replacement therapy were identified and compared with those without acute kidney injury necessitating kidney replacement therapy.

INTERVENTIONS

Descriptive statistics were used to ascertain prevalence of acute kidney injury necessitating kidney replacement therapy and solid cancer in ICU patients. Association of acute kidney injury necessitating kidney replacement therapy and cancer with prognosis was assessed using logistic regression analysis. To compare the attributable mortality of acute kidney injury necessitating kidney replacement therapy, 20,154 noncancer patients and 2,411 cancer patients without acute kidney injury necessitating kidney replacement therapy were matched with 12,827 noncancer patients and 1,079 cancer patients with acute kidney injury necessitating kidney replacement therapy.

MEASUREMENTS AND MAIN RESULTS

Thirty-five thousand three hundred fifty-six ICU patients (11.9%) had solid cancer. Acute kidney injury necessitating kidney replacement therapy was present in 1,408 (4.0%) cancer patients and 13,637 (5.2%) noncancer patients. Crude ICU and hospital mortality was higher in the cancer group (646 [45.9%] vs 4,674 [34.3%], p < 0.001, and 787 [55.9%] vs 5,935 [43.5%], p < 0.001). In multivariable logistic regression analyses, odds ratio (95% CI) for hospital mortality was 1.73 (1.62-1.85) for cancer compared with no cancer 3.57 (3.32-3.83) for acute kidney injury necessitating kidney replacement therapy and 1.07 (0.86-1.33) for their interaction. In the matched subcohort, attributable hospital mortality of acute kidney injury necessitating kidney replacement therapy was 56.7% in noncancer patients and 48.0% in cancer patients.

CONCLUSIONS

Occurrence rate of acute kidney injury necessitating kidney replacement therapy and prognosis in ICU patients with solid cancer are comparable with other ICU patient groups. In cancer, acute kidney injury necessitating kidney replacement therapy is associated with higher crude hospital mortality. However, the specific attributable mortality conveyed by acute kidney injury necessitating kidney replacement therapy is actually lower in cancer patients than in noncancer patients. Diagnosis of cancer per se does not justify withholding kidney replacement therapy.

The effect of the underlying malignancy on short- and medium-term survival of critically ill patients admitted to the intensive care unit: a retrospective analysis based on propensity score matching

Background

Advances in oncology led to a substantial increase in the number of patients requiring admission to the ICU. It is significant to confirm which cancer critical patients can benefit from the ICU care like noncancer patients.

Methods

An observational retrospective cohort study using intensive care unit (ICU) admissions of Medical Information Mart for Intensive Care III from the Beth Israel Deaconess Medical Center in Boston, MA, USA between 2001 and 2012 was conducted. Propensity score matching was used to reduce the imbalance between two matched cohorts. ICU patients with cancer were compared with those without cancer in terms of patients’ characteristics and survival.

Results

There were 38,508 adult patients admitted to ICUs during the period. The median age was 65 years (IQR, 52–77) and 8308 (21.6%) had an underlying malignancy diagnosis. The noncancer group had a significant survive advantage at the point of 28-day, 90-day, 365-day and 1095-day after ICU admission compared with cancer group (P < 0.001 for all) after PSM. Subgroup analysis showed that the diagnosis of malignancy didn’t decrease 28-day and 90-day survive when patients’ age ≥ 65-year, patients in surgical intensive care unit or cardiac surgery recovery unit or traumatic surgical intensive care unit, elective admissions, patients with renal replacement therapy or vasopressor support (P > 0.05 for all).

Conclusions

Malignancy is a common diagnosis among ICU patients. Patients without cancer have a survive advantage compared with patients with cancer in the short- and medium-term. However, in selected groups, cancer critical patients can benefit from the ICU care service like noncancer patients in the short-term.

Acute kidney injury in the patient with cancer

Dramatic advances in the care of patients with cancer have led to significant improvement in outcomes and survival. However, renal manifestations of the underlying cancer as well as the effects of anti-neoplastic therapies leave patients with significant morbidity and chronic kidney disease risks. The most common renal manifestations associated with cancer include acute kidney injury (AKI) in the setting of multiple myeloma, tumor lysis syndrome, post-hematopoietic stem cell therapy, and AKI associated with chemotherapy. Knowledge of specific risk factors, modification of risk and careful attention to rapid AKI diagnosis are critical for improving outcomes.

Survival of patients with cancer starting chronic dialysis: Data from kidney and cancer registries in lower Normandy

AIM

Cancer and chronic kidney disease are known to be associated. The way in which a history of cancer can influence outcome in dialysis is not well described. This work aimed to evaluate survival of cancer patients starting chronic dialysis after their diagnosis of cancer.

METHODS

We merged data from cancer registries and a dialysis registry, and explored patients' charts.

RESULTS

Between January 2001 and December 2008, 74 patients with incident cancer in the two-counties-study-area (Calvados and Manche) started chronic dialysis after their diagnosis of cancer. Survival of these incident dialysis patients with a previous diagnosis of cancer was respectively 80.9% (confidence interval 69.9; 88.2) and 68.3% (confidence interval 56.3%; 77.7%) at 1 and 2 years. Only 29 of the 74 patients (39.2%) were still alive at the end of the observation period; median participation time was 2.8 years (1^st and 3^rd quartiles: 1.3-4.4). Survival of patients with cancer was not different to that of non-cancer dialysis patients matched for age and sex, except in patients with haematological malignancies who had a poorer outcome. In a multivariate stratified Cox model, the history of cancer before dialysis start was not associated with death, after adjustment on diabetes.

CONCLUSION

In our study, survival in dialysis was not different among patients with a history of cancer compared to matched patients without malignancy. We can hypothesize that only some selected patients with cancer have access to dialysis. Studies in ESRD patients with cancer should be performed to evaluate access to dialysis in that population.

Plasma neutrophil gelatinase-associated lipocalin and factors related to acute kidney injury and mortality in critically ill cancer patients

Rationale

Acute kidney injury (AKI) is a frequent complication in critically ill cancer patients.

Objectives

To assess plasma neutrophil gelatinase-associated lipocalin (NGAL) levels and risks factors associated with AKI and mortality.

Methods

We recruited 96 critically ill cancer patients and followed them prospectively. Plasma NGAL levels were determined at intensive care unit (ICU) admission and at 48 hours. We generated receiver operating characteristic curves to assess the ability of NGAL to predict AKI. Logistic regression analysis was performed to determine risks factors associated with AKI. Cox-regression analysis was performed to evaluate 6-month mortality.

Measurements and main results

From 96 patients, 60 (63%) developed AKI and 33 (55%) were classified as stages 2 and 3. In patients without AKI at admission, plasma NGAL levels revealed an area under the curve (AUC) = 0.522 for all AKI stages and an AUC = 0.573 for stages 2 and 3 AKI (85% sensitivity and 67% specificity for a 50.66 ng/mL cutoff). We identified sequential organ failure assessment (SOFA) score (without renal parameters) at admission as an independent factor for developing stages 2 and 3 AKI, and haemoglobin as a protective factor. We observed that metastatic disease, dobutamine use and stage 3 AKI were independent factors associated with 6-month mortality.

Conclusions

In our cohort of critically ill cancer patients, NGAL did not predict AKI. SOFA score was a risk factor for developing AKI, and haemoglobin level was a protective factor for developing AKI. The independent factors associated with 6-month mortality included metastatic disease, dobutamine use, lactate and stage 3 AKI.

Use of regional citrate anticoagulation for continuous venovenous hemodialysis in critically ill cancer patients with acute kidney injury

PURPOSE

This study aimed to evaluate the safety and efficacy of a regional citrate anticoagulation (RCA) protocol for continuous venovenous hemodialysis (CVVHD) in cancer patients with acute kidney injury (AKI) in the intensive care unit (ICU) setting.

MATERIAL AND METHODS

One hundred twenty two consecutive ICU cancer patients with AKI treated with citrate-based CVVHD were prospectively evaluated in this prospective observational study.

RESULTS

A total of 7198 h of CVVHD therapy (250 filters) were performed. Patients were 61.3 ± 15.7 years old, 78% had solid cancer and the main AKI cause was sepsis (50%). The in-hospital mortality was 78.7%. Systemic ionized calcium (SCai) was 4.35 (4.10-4.60) mg/dL, severe hypocalcemia (SCai <3.6 mg/dL) was observed in 4.3% of procedures and post-filter ionized calcium was 1.60 (1.40-1.80) mg/dL. Median filter patency was 24.8 (11-43) hours. Factors related to filter clotting were: no tumor evidence (OR 0.44, CI 0.18-0.99); genitourinary tumor (OR 1.83, CI 1.18-2.81); platelets number (each 10,000/mm³) (OR 1.02, CI 1.00-1.04); International Normatized Ratio (INR) (OR 0.59, CI 0.41-0.85) and citrate dose (each 10 mL/h) (OR 0.88, CI 0.82-0.95).

CONCLUSION

Filter patency was relatively short and clotting was associated with active cancer disease, genitourinary tumor, lower citrate dose and lower INR.

The Incidence of and Risk Factors for Postintubation Hypotension in the Immunocompromised Critically Ill Adult

OBJECTIVES

Our primary aim was to ascertain the frequency of postintubation hypotension in immunocompromised critically ill adults with secondary aims of arriving at potential risk factors for the development of postintubation hypotension and its impact on patient-related outcomes.

METHODS

Critically ill adult patients (≥18 years) were included from January 1, 2010, to December 31, 2014. We defined immunocompromised as patients with any solid organ or nonsolid organ malignancy or transplant, whether solid organ or not, requiring current chemotherapy. Postintubation hypotension was defined as a decrease in systolic blood pressure to less than 90 mm Hg or a decrease in mean arterial pressure to less than 65 mm Hg or the initiation of any vasopressor medication. Patients were then stratified based on development of postintubation hypotension. Potential risk factors and intensive care unit (ICU) outcome metrics were electronically captured by a validated data mart system.

RESULTS

The final cohort included 269 patients. Postintubation hypotension occurred in 141 (52%; 95% confidence interval: 46-58) patients. Several risk factors predicted postintubation hypotension on univariate analysis; however, only Acute Physiology and Chronic Health Evaluation III score in the first 24 hours, preintubation shock status, and preintubation hemodynamic instability remained significant on all 4 multivariate analyses. Patients developing postintubation hypotension had higher ICU and hospital mortality (54 [38%] vs 31 [24%], P = .01; 69 [49%] vs 47 [37%], P = .04).

CONCLUSION

Based on previous literature, we found a higher frequency of postintubation hypotension in the immunocompromised than in the nonimmunocompromised critically ill adult patients. Acute Physiology and Chronic Health Evaluation III score in the first 24 hours, preintubation shock status, and preintubation hemodynamic instability were significant predictors on multivariate analyses. Postintubation hypotension led to higher ICU and hospital mortality in those experiencing this complication.

Critical Care Prognosis and Outcomes in Patients with Cancer

Advances in cancer treatment and patient survival are associated with increasing number of these patients requiring intensive care. Over the last 2 decades, there has been a steady improvement in the outcomes of critically ill patients with cancer. This review provides data on the use of the intensive care unit (ICU) and short and long-term outcomes of critically ill patients with cancer, the ICU system practices that influence patients outcomes, and the role of the different clinical variables in predicting the prognosis of these patients.

Critical care of patients with cancer

Answer questions and earn CME/CNE The increasing prevalence of patients living with cancer in conjunction with the rapid progress in cancer therapy will lead to a growing number of patients with cancer who will require intensive care treatment. Fortunately, the development of more effective oncologic therapies, advances in critical care, and improvements in patient selection have led to an increased survival of critically ill patients with cancer. As a consequence, critical care has become an important cornerstone in the continuum of modern cancer care. Although, in many aspects, critical care for patients with cancer does not differ from intensive care for other seriously ill patients, there are several challenging issues that are unique to this patient population and require special knowledge and skills. The optimal management of critically ill patients with cancer necessitates expertise in oncology, critical care, and palliative medicine. Cancer specialists therefore have to be familiar with key principles of intensive care for critically ill patients with cancer. This review provides an overview of the state-of-the-art in the individualized management of critically ill patients with cancer. CA Cancer J Clin 2016;66:496-517. © 2016 American Cancer Society.

Short-term and medium-term survival of critically ill patients with solid tumours admitted to the intensive care unit: a retrospective analysis

OBJECTIVES

Patients with cancer frequently require unplanned admission to the intensive care unit (ICU). Our objectives were to assess hospital and 180-day mortality in patients with a non-haematological malignancy and unplanned ICU admission and to identify which factors present on admission were the best predictors of mortality.

DESIGN

Retrospective review of all patients with a diagnosis of solid tumours following unplanned admission to the ICU between 1 August 2008 and 31 July 2012.

SETTING

Single centre tertiary care hospital in London (UK).

PARTICIPANTS

300 adult patients with non-haematological solid tumours requiring unplanned admission to the ICU.

INTERVENTIONS

None.

PRIMARY AND SECONDARY OUTCOMES

Hospital and 180-day survival.

RESULTS

300 patients were admitted to the ICU (median age 66.5 years; 61.7% men). Survival to hospital discharge and 180 days were 69% and 47.8%, respectively. Greater number of failed organ systems on admission was associated with significantly worse hospital survival (p<0.001) but not with 180-day survival (p=0.24). In multivariate analysis, predictors of hospital mortality were the presence of metastases (OR 1.97, 95% CI 1.08 to 3.59), Acute Physiology and Chronic Health Evaluation II (APACHE II) Score (OR 1.07, 95% CI 1.01 to 1.13) and a Glasgow Coma Scale Score <7 on admission to ICU (OR 5.21, 95% CI 1.65 to 16.43). Predictors of worse 180-day survival were the presence of metastases (OR 2.82, 95% CI 1.57 to 5.06), APACHE II Score (OR 1.07, 95% CI 1.01 to 1.13) and sepsis (OR 1.92, 95% CI 1.09 to 3.38).

CONCLUSIONS

Short-term and medium-term survival in patients with solid tumours admitted to ICU is better than previously reported, suggesting that the presence of cancer alone should not be a barrier to ICU admission.

Acute kidney injury in hematological patients

PURPOSE OF REVIEW

The present article reviews the recent literature on the main aspects of acute kidney injury (AKI) developing in patients with hematological malignancies admitted to ICU.

RECENT FINDINGS

Up to two thirds of critically ill patients with hematological malignancies develop AKI. Current mortality rates range from 40 to 60% for most patients with hematological malignancies, except for recipients of allogeneic hematopoietic stem cell transplantation in whom outcomes remain very poor. Renal function recovery occurs in most patients with AKI, but is dependent on the underlying causes. AKI is usually multifactorial, resulting from causes common to other ICU patients and related to the underlying malignancy or its treatment. New targeted therapies and treatment strategies are potentially associated with AKI. Management of these patients requires a high degree of suspicion, close monitoring of metabolic parameters, and use of preventive strategies to limit risk of AKI or to mitigate its severity.

SUMMARY

AKI is a frequent and severe complication in critically ill patients with hematological malignancies. As the clinical management is complex, close collaboration with hematologists is paramount.

Continuous Renal Replacement Therapy for Acute Renal Failure in Patients with Cancer: A Well-Tolerated Adjunct Treatment

Introduction

Acute renal failure (ARF) has a poor prognosis in patients with cancer requiring intensive care unit (ICU) admission. Our aim is finding prognostic factors for hospital mortality in patients with cancer with ARF requiring renal replacement therapy (RRT).

Methods

In this retrospective study, all patients with cancer with ARF treated with continuous venovenous filtration (CVVHDF) in the ICU of the Institut Jules Bordet, between January 1, 2003 and December 31, 2012, were included.

Results

One hundred and three patients are assessed: men/women 69/34, median age 62 years, solid/hematologic tumors 68/35, median SAPS II 56. Mortality rate was 63%. Seven patients required chronic renal dialysis. After multivariate analysis, two variables were statistically associated with hospital mortality: more than one organ failure (including kidney) (OR 5.918; 95% CI 2.184–16.038; p < 0.001) and low albumin level (OR 3.341; 95% CI 1.229–9.077; p = 0.02). Only minor complications related to CVVHDF have been documented.

Conclusion

Despite the poor prognosis associated with ARF, CVVHDF is an effective and tolerable renal replacement technique in patients with cancer admitted to the ICU. Multiple organ failure and hypoalbuminemia, two independent prognostic factors for hospital mortality have to be considered when deciding for introducing RRT.

Acute kidney injury in critically ill cancer patients: an update

Patients with cancer represent a growing group among actual ICU admissions (up to 20 %). Due to their increased susceptibility to infectious and noninfectious complications related to the underlying cancer itself or its treatment, these patients frequently develop acute kidney injury (AKI). A wide variety of definitions for AKI are still used in the cancer literature, despite existing guidelines on definitions and staging of AKI. Alternative diagnostic investigations such as Cystatin C and urinary biomarkers are discussed briefly. This review summarizes the literature between 2010 and 2015 on epidemiology and prognosis of AKI in this population. Overall, the causes of AKI in the setting of malignancy are similar to those in other clinical settings, including preexisting chronic kidney disease. In addition, nephrotoxicity induced by the anticancer treatments including the more recently introduced targeted therapies is increasingly observed. However, data are sometimes difficult to interpret because they are often presented from the oncological rather than from the nephrological point of view. Because the development of the acute tumor lysis syndrome is one of the major causes of AKI in patients with a high tumor burden or a high cell turnover, the diagnosis, risk factors, and preventive measures of the syndrome will be discussed. Finally, we will briefly discuss renal replacement therapy modalities and the emergence of chronic kidney disease in the growing subgroup of critically ill post-AKI survivors.

Intensive care unit prognostic factors in critically ill patients with advanced solid tumors: a 3-year retrospective study

Background

The objective of this study was to identify risk factors predicting prognosis of critically ill medical patients with advanced solid tumors in the intensive care unit (ICU).

Methods

We retrospectively analyzed all ICU unplanned medical admissions to the ICU of patients with advanced solid cancer in Tianjin Medical University Cancer Institute and Hospital between October 1, 2012 and March 1, 2015. Approval was obtained from the Ethical Commission of Tianjin Medical University Cancer Institute and Hospital to review and publish information from patients’ records.

Results

One hundred and forty-one patients with full code status met the criteria for inclusion from among 813 ICU admissions. ICU mortality was 14.9 % and in-hospital mortality was 29.8 %. The major reasons for unplanned ICU admission were respiratory failure (38.3 %) and severe sepsis or septic shock (27.7 %). The ICU mortality in patients who required vasopressors, mechanical ventilation or renal replacement therapy for >24 h was 25, 25.9 and 40 %, respectively. The mean overall survival was 28.6 months. After adjusting for hypertension, type of solid cancer, intervention time, need for mechanical ventilation and Acute Physiology and Chronic Health Evaluation II score, only Sepsis-related Organ Failure Assessment (SOFA) score on day 7 of ICU treatment remained a significant predictor of ICU mortality (adjusted odds ratio 1.612, 95 % confidence interval 1.137–2.285, P = 0.007).

Conclusions

We suggest broadening the criteria for ICU admission. The patients should be allowed an ICU trial consisting of unlimited ICU support, including invasive hemodynamic monitoring, mechanical ventilation and renal replacement therapy. An interdisciplinary meeting, including an ethics consultation, should be held to make end-of-life decisions if the SOFA score on day 7 shows clinical deterioration with no available therapeutic options.

Evaluation of Intermittent Hemodialysis in Critically Ill Cancer Patients with Acute Kidney Injury Using Single-Pass Batch Equipment

BACKGROUND

Data on renal replacement therapy (RRT) in cancer patients with acute kidney injury (AKI) in the intensive care unit (ICU) is scarce. The aim of this study was to assess the safety and the adequacy of intermittent hemodialysis (IHD) in critically ill cancer patients with AKI.

METHODS AND FINDINGS

In this observational prospective cohort study, 149 ICU cancer patients with AKI were treated with 448 single-pass batch IHD procedures and evaluated from June 2010 to June 2012. Primary outcomes were IHD complications (hypotension and clotting) and adequacy. A multiple logistic regression was performed in order to identify factors associated with IHD complications (hypotension and clotting). Patients were 62.2 ± 14.3 years old, 86.6% had a solid cancer, sepsis was the main AKI cause (51%) and in-hospital mortality was 59.7%. RRT session time was 240 (180-300) min, blood/dialysate flow was 250 (200-300) mL/min and UF was 1000 (0-2000) ml. Hypotension occurred in 25% of the sessions. Independent risk factors (RF) for hypotension were dialysate conductivity (each ms/cm, OR 0.81, CI 0.69-0.95), initial mean arterial pressure (each 10 mmHg, OR 0.49, CI 0.40-0.61) and SOFA score (OR 1.16, CI 1.03-1.30). Clotting and malfunctioning catheters (MC) occurred in 23.8% and 29.2% of the procedures, respectively. Independent RF for clotting were heparin use (OR 0.57, CI 0.33-0.99), MC (OR 3.59, CI 2.24-5.77) and RRT system pressure increase over 25% (OR 2.15, CI 1.61-4.17). Post RRT blood tests were urea 71 (49-104) mg/dL, creatinine 2.71 (2.10-3.8) mg/dL, bicarbonate 24.1 (22.5-25.5) mEq/L and K 3.8 (3.5-4.1) mEq/L.

CONCLUSION

IHD for critically ill patients with cancer and AKI offered acceptable hemodynamic stability and provided adequate metabolic control.

Outcomes of acute kidney injury patients with and without cancer

Incidence of AKI in hospitalized patients with cancer is increasing, but there have been few studies on AKI in patients with cancer. We conducted a retrospective cohort study in a South Korean tertiary care hospital. A total of 2211 consecutive patients (without cancer 61.5%; with cancer 38.5%) were included over a 140-month period. Predictors of all-cause death were examined using the Kaplan-Meier method and the Cox proportional hazards model. The main contributing factors of AKI were sepsis (31.1%) and ischemia (52.7%). AKI was multifactorial in 78% of patients with cancer and in 71% of patients without cancer. Hospital mortality rates were higher in patients with cancer (42.8%) than in patients without cancer (22.5%) (p = 0.014). In multivariate analyses, diabetes mellitus (DM) and cancer diagnosis were associated with hospital mortality. Cancer diagnosis was independently associated with mortality [odds ratio = 3.010 (95% confidence interval, 2.340-3.873), p = 0.001]. Kaplan-Meier analysis revealed that subjects with DM and cancer (n = 146) had lower survival rates than subjects with DM and without cancer (n = 687) (log rank test, p = 0.001). The presence of DM and cancer was independently associated with mortality in AKI patients both with and without cancer. Studies are warranted to determine whether proactive measures may limit AKI and improve outcomes.

Survival in solid cancer patients following intensive care unit admission

PURPOSE

One in seven patients admitted to intensive care units (ICU) has a cancer diagnosis but evidence on their expected outcomes after admission has not been synthesised.

METHODS

Systematic literature review of solid cancer adult patients admitted to ICU from 2000 onwards using EMBASE and MEDLINE electronic databases.

RESULTS

There were 48 papers identified that reported survival in ICU patients with solid cancers. ICU mortality was reported in 35 studies comprising a total sample of 25,339 patients and ranging from 4.5 to 85 %. The average mortality of the distribution of reported mortality rates within ICU was 31.2 % (95 % CI 24.0-39.0 %). Hospital mortality was reported in 31 studies across a total sample of 74,061 patients. The average hospital mortality was 38.2 % (33.8-42.7 %) and ranged from 4.6 to 76.8 %. Poorer physiological score, invasive mechanical ventilation and poor functional status were associated with higher mortality.

CONCLUSIONS

Several factors have been associated with poor survival in ICU cancer patients; however, primary research is still needed to describe outcomes in cancer patients with sufficient case mix and treatment details to be of prognostic value to clinicians.

Renal replacement therapy in the ICU: comparison of clinical features and outcomes of patients with acute kidney injury and dialysis-dependent end-stage renal disease

BACKGROUND

The goal of this study is to study clinical features and outcomes of the patients who had renal replacement therapy (RRT) in the intensive care unit (ICU) between 2000 and 2007.

METHODS

We retrospectively studied 222 patients.

RESULTS

Overall ICU mortality and invasive mechanical ventilation (IMV) rates were 58.1 and 61.3 %. The mean APACHE II score was 27.6 ± 8.3. Chronic dialysis (CD) patients formed 45.5 % of the study population. Acute kidney injury (AKI) patients had higher rates of IMV (73 vs. 51.5 %, p = 0.002), cancer (27.8 vs. 7.9 %, p ≤ 0.001) and mortality (67.8 vs. 50.5 %, p = 0.010) than CD patients. AKI patients with normal kidney function (NKF) before ICU admission had poorer prognosis than acute-on-chronic kidney disease (CKD) and CD patients (78.6, 51 and 50.5 %, respectively, p ≤ 0.001). Multivariate analysis showed that IMV (OR, 14.8; 95 % CI, 5.47-40.05; p ≤ 0.001) and having NKF before hospitalization (OR, 2.8; 95 % CI, 1.04-7.37; p = 0.041) were predictors of overall ICU mortality. Additionally, IMV is found as a prognostic factor for both AKI (OR, 18.7; 95 % CI, 4.48-77.72; p ≤ 0.001) and CD patients (OR, 8.14; 95 % CI, 2.01-33.04; p = 0.003), but APACHE II score is meaningful only for CD patients (OR, 1.13; 95 % CI, 1.02-1.26; p = 0.024). The areas under the ROC curves for APACHE II score were 0.52 (95 % CI, 0.39-0.66) for AKI and 0.78 (95 % CI, 0.55-0.89) for CD patients.

CONCLUSION

The observed ICU mortality among patients requiring RRT is high and IMV is associated with mortality. AKI patients have increased mortality compared to CD patients. AKI patients with past NKF have poorer prognosis than acute-on-CKD and CD patients.

Acute kidney injury in the cancer patient

Acute kidney injury (AKI) is a frequent and significant complication of cancer and cancer therapy. Cancer patients frequently encounter risk factors for AKI including older age, CKD, prerenal conditions, sepsis, exposure to nephrotoxins, and obstructive physiology. AKI can also be secondary to paraneoplastic conditions, including glomerulonephritis and microangiopathic processes. This complication can have significant consequences, including effects on patients' ability to continue to receive therapy for their malignancy. This review will serve to summarize potential etiologies of AKI that present in patients with cancer as well as to highlight specific patient populations, such as the critically ill cancer patient.

Prognosis of AKI in malignant diseases with and without sepsis

Background

AKI significantly worsens prognosis of hospitalized patients. This is particularly the case in patients with sepsis. The risk for aquiring sepsis is significantly increased in malignant diseases. Aim of the present retrospective study was to analyze outcomes of tumor patients with sepsis and AKI.

Methods

One-thousand and seventeen patients, treated at the ICU of the Department of Nephrology and Rheumatology of the University Hospital Göttingen from 2009 to 2011 were retrospectively analyzed for mortality, sepsis, AKI, need for renal replacement therapy (dialysis) and malignancies.

Results

AKI occurred significantly more frequent in septic than in non-septic patients and in tumor as oposed to non-tumor patients. Mortaliy rates were higher in the respective latter groups. Mortality increased even further if patients suffered from a malignant disease with sepsis and AKI. Mortality rates peaked if dialysis treatment became mandatory. In non-solid tumors 100% of the patients died if they suffered drom sepsis and AKI. This was not the case in solid malignancies (mortality rate 56%).

Conclusions

We conclude that prognosis of tumor patients with AKI and sepsis is very poor. Mortality increases to almost 70% if diaylsis therapy is initiated. Non-solid tumors are associated with a 100% mortality if sepsis and AKI conincide.

Intensive care for the cancer patient - unique clinical and ethical challenges and outcome prediction in the critically ill cancer patient

With the rising number of cancer cases and increasing survival times, cancer patients with critical illness are increasingly presenting to the intensive care unit. This article considers the unique challenges they pose in terms of oncological-specific disease processes and treatment and reviews current trends in outcome prediction. We also consider the ethical standpoints surrounding the treatment of patients for whom there may be no cure and their subsequent transition to palliative care, should it become necessary.

Outcome of critically ill patients with hematological malignancies

The prognosis for patients with hematological malignancies (HMs) admitted to the intensive care unit (ICU) is poor. The objective of this study was to evaluate the clinical characteristics and hospital outcomes of critically ill patients with HMs admitted to an oncological ICU. This is a prospective, observational cohort study. A total of 102 patients with HMs admitted to ICU from January 2008 to April 2011 were included. Univariate and multivariate logistic regressions were used to identify factors associated with hospital mortality. During the study period, 3,776 patients with HM were admitted to the Department of Hematology of the Instituto Nacional de Cancerología located in Mexico City, Mexico. After being evaluated by the intensivist, 102 (2.68 %) patients were admitted to the ICU. The ICU mortality rates for patients who had two or less organ system failures and for those with three or more organ system dysfunctions were 20 % (5/25) and 70.1 % (54/77), respectively (P < 0.0001). A multivariate analysis identified independent prognostic factors of in-hospital death as neutropenia at the time of ICU admission (odds ratio (OR), 4.24; 95 % confidence interval (CI), 1.36-13.19, P = 0.012), the need for vasopressors (OR, 4.49; 95 % CI, 1.07-18.79, P = 0.040), need for invasive mechanical ventilation (OR, 4.49; 95 % CI, 1.07-18.79, P = 0.040), and serum creatinine >106 μmol/L (OR, 3.21; 95 % CI, 1.05-9.85, P = 0.041). The ICU and hospital mortality rates were 46.1 and 57.8 %, respectively. The independent prognostic factors of in-hospital death were the need for invasive mechanical ventilation, the need for vasopressors, serum creatinine >106 μmol/L, and neutropenia at the time of ICU admission.

Predicting hospital mortality in critically ill cancer patients according to acute kidney injury severity

BACKGROUND

Acute kidney injury (AKI) is a frequent complication in hospitalized patients, especially in those in intensive care units (ICU). The RIFLE classification might be a valid prognostic factor for critically ill cancer patients. The present study aims to evaluate the discriminatory capacity of RIFLE versus other general prognostic scores in predicting hospital mortality in critically ill cancer patients.

METHODS

This is a single-center study conducted in a cancer-specialized ICU in Brazil. All of the 288 patients hospitalized from May 2006 to June 2008 were included. RIFLE classification, APACHE II, SOFA, and SAPS II scores were calculated and the area under receiver operating characteristic (AROC) curves and logistic multiple regression were performed using hospital mortality as the outcome.

RESULTS

AKI, defined by RIFLE criteria, was observed in 156 (54.2%) patients. The distribution of patients with any degree of AKI was: risk, n = 96 (33.3%); injury, n = 30 (10.4%), and failure, n = 30 (10.4%). Mortality was 13.6% for non-AKI patients, 49% for RIFLE 'R' patients, 62.3% for RIFLE 'I' patients, and 86.8% for RIFLE 'F' patients (p = 0.0006). Logistic regression analysis showed that RIFLE criteria, APACHE II, SOFA, and SAPS II were independent factors for mortality in this population. The discrimination of RIFLE was good (AROC 0.801, 95% CI 0.748-0.854) but inferior compared to those of APACHE II (AROC 0.940, 95% CI 0.915-0.966), SOFA (AROC 0.910, 95% CI 0.876-0.943), and SAPS II (AROC 0.869, 95% CI 0.827-0.912).

CONCLUSION

AKI is a frequent complication in ICU patients with cancer. RIFLE was inferior to commonly used prognostic scores for predicting mortality in this cohort of patients.