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Zhou Y, Zhang S, Chen Z, Zhang X, Feng Y, Xu R. The association between serum phosphate and length of hospital stay and all-cause mortality in adult patients: a cross-sectional study. Nutr J 2024; 23:81. [PMID: 39026252 PMCID: PMC11256428 DOI: 10.1186/s12937-024-00982-w] [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: 12/20/2023] [Accepted: 07/08/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Data is limited on the prevalence of hypophosphatemia in general hospitalized patients, and its association with length of hospital stay (LOS) and mortality remained unclear. We aimed to investigate the prevalence of admission phosphate abnormality and the association between serum phosphate level and length of hospital stay and all-cause mortality in adult patients. METHODS This was a multi-center retrospective study based on real-world data. Participants were classified into five groups according to serum phosphate level (inorganic phosphorus, iP) within 48 h after admission: G1, iP < 0.64 mmol/L; G2, iP 0.64-0.8 mmol/L; G3, iP 0.8-1.16 mmol/L; G4, iP 1.16-1.45 mmol/L; and G5, iP ≥ 1.45 mmol/L, respectively. Both LOS and in-hospital mortality were considered as outcomes. Clinical information, including age, sex, primary diagnosis, co-morbidity, and phosphate-metabolism related parameters, were also abstracted from medical records. RESULTS A total number of 23,479 adult patients (14,073 males and 9,406 females, aged 57.7 ± 16.8 y) were included in the study. The prevalence of hypophosphatemia was 4.74%. An "L-shaped" non-linear association was determined between serum phosphate level and LOS and the inflection point was 1.16 mmol/L in serum phosphate level. Compared with patients in G4, patients in G1, G2 or G3 were significantly associated with longer LOS after full adjustment of covariates. Each 0.1 mmol/L decrease in serum phosphate level to the left side of the inflection point led to 0.64 days increase in LOS [95% confidence interval (CI): 0.46, 0.81; p for trend < 0.001]. But there was no association between serum phosphate and LOS where serum levels of phosphate ≥ 1.16 mmol/L. Multivariable logistic regression analysis showed that adjusted all-cause in-hospital mortality was 3.08-fold greater in patients in G1 than those in G4 (95% CI: 1.52, 6.25; p for trend = 0.001). Similarly, no significant association with either LOS or mortality were found in patients in G5, comparing with G4. CONCLUSIONS Hypophosphatemia, but not hyperphosphatemia, was associated with LOS and all-cause mortality in adult inpatients. It is meaningful to monitor serum levels of phosphate to facilitate early diagnosis and intervention.
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Affiliation(s)
- Yiquan Zhou
- Department of Clinical Nutrition, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Shuyi Zhang
- Intensive Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Zhiqi Chen
- Department of Clinical Nutrition, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Xiaomin Zhang
- Department of Clinical Nutrition, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Yi Feng
- Department of Clinical Nutrition Center, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China.
| | - Renying Xu
- Department of Clinical Nutrition, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China.
- Department of Nutrition, College of Health Science and Technology, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
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Dimski T, Brandenburger T, Vollmer C, Kindgen-Milles D. A safe and effective protocol for postdilution hemofiltration with regional citrate anticoagulation. BMC Nephrol 2024; 25:218. [PMID: 38982339 PMCID: PMC11234626 DOI: 10.1186/s12882-024-03659-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] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 07/01/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) is recommended during continuous renal replacement therapy. Compared to systemic anticoagulation, RCA provides a longer filter lifespan with the risk of metabolic alkalosis and impaired calcium homeostasis. Surprisingly, most RCA protocols are designed for continuous veno-venous hemodialysis or hemodiafiltration. Effective protocols for continuous veno-venous hemofiltration (CVVH) are rare, although CVVH is a standard treatment for high-molecular-weight clearance. Therefore, we evaluated a new RCA protocol for postdilution CVVH. METHODS This is a monocentric prospective interventional study to evaluate a new RCA protocol for postdilution CVVH. We recruited surgical patients with stage III acute kidney injury who needed renal replacement therapy. We recorded dialysis and RCA data and hemodynamic and laboratory parameters during treatment sessions of 72 h. The primary endpoint was filter patency at 72 h. The major safety parameters were metabolic alkalosis and severe hypocalcemia at any time. RESULTS We included 38 patients who underwent 66 treatment sessions. The mean filter lifespan was 66 ± 12 h, and 44 of 66 (66%) filters were patent at 72 h. After censoring for non-CVVH-related cessation of treatment, 83% of all filters were patent at 72 h. The delivered dialysis dose was 28 ± 5 ml/kgBW/h. The serum levels of creatinine, urea and beta2-microglobulin decreased significantly from day 0 to day 3. Metabolic alkalosis occurred in one patient. An iCa++ below 1.0 mmol/L occurred in four patients. Citrate accumulation did not occur. CONCLUSIONS We describe a safe, effective, and easy-to-use RCA protocol for postdilution CVVH. This protocol provides a long and sustained filter lifespan without serious adverse effects. The risk of metabolic alkalosis and hypocalcemia is low. Using this protocol, a recommended dialysis dose can be safely administered with effective clearance of low- and middle-molecular-weight molecules. TRIAL REGISTRATION The study was approved by the medical ethics committee of Heinrich-Heine University Duesseldorf (No. 2018-82KFogU). The trial was registered in the local study register of the university (No: 2018044660) on 07/04/2018 and was retrospectively registered at ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT03969966) on 31/05/2019.
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Affiliation(s)
- Thomas Dimski
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany.
| | - Timo Brandenburger
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany
| | - Christian Vollmer
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany
| | - Detlef Kindgen-Milles
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany
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Lee YH, Lee S, Seo YJ, Jung J, Lee J, Park JY, Ban TH, Park WY, Lee SW, Kim K, Kim KM, Kim H, Choi JY, Cho JH, Kim YC, Lim JH. Phosphate level predicts mortality in acute kidney injury patients undergoing continuous kidney replacement therapy and has a U-shaped association with mortality in patients with high disease severity: a multicenter retrospective study. Kidney Res Clin Pract 2024; 43:492-504. [PMID: 38934034 PMCID: PMC11237324 DOI: 10.23876/j.krcp.23.311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/21/2024] [Accepted: 03/08/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND This study investigated the association between serum phosphate level and mortality in acute kidney injury (AKI) patients undergoing continuous kidney replacement therapy (CKRT) and evaluated whether this association differed according to disease severity. METHODS Data from eight tertiary hospitals in Korea were retrospectively analyzed. The patients were classified into four groups (low, normal, high, and very high) based on their serum phosphate level at baseline. The association between serum phosphate level and mortality was then analyzed, with further subgroup analysis being conducted according to disease severity. RESULTS Among the 3,290 patients identified, 166, 955, 1,307, and 862 were in the low, normal, high, and very high phosphate groups, respectively. The 90-day mortality rate was 63.9% and was highest in the very high group (76.3%). Both the high and very high groups showed a significantly higher 90-day mortality rate than did the normal phosphate group (high: hazard ratio [HR], 1.35, 95% confidence interval [CI], 1.21-1.51, p < 0.001; very high: HR, 2.01, 95% CI, 1.78-2.27, p < 0.001). The low group also exhibited a higher 90-day mortality rate than did the normal group among those with high disease severity (HR, 1.47; 95% CI, 1.09-1.99; p = 0.01) but not among those with low disease severity. CONCLUSION High serum phosphate level predicted increased mortality in AKI patients undergoing CKRT, and low phosphate level was associated with increased mortality in patients with high disease severity. Therefore, serum phosphate levels should be carefully considered in critically ill patients with AKI.
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Affiliation(s)
- Young Hwan Lee
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University School of Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Soyoung Lee
- Division of Nephrology, Department of Internal Medicine, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Republic of Korea
| | - Yu Jin Seo
- Department of Statistics, Kyungpook National University, Daegu, Republic of Korea
| | - Jiyun Jung
- Data Management and Statistics Institute, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
- Research Center for Chronic Disease and Environmental Medicine, Dongguk University College of Medicine, Gyeongju, Republic of Korea
| | - Jangwook Lee
- Research Center for Chronic Disease and Environmental Medicine, Dongguk University College of Medicine, Gyeongju, Republic of Korea
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Jae Yoon Park
- Research Center for Chronic Disease and Environmental Medicine, Dongguk University College of Medicine, Gyeongju, Republic of Korea
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
- Department of Internal Medicine, Dongguk University College of Medicine, Gyeongju, Republic of Korea
| | - Tae Hyun Ban
- Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Woo Yeong Park
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Sung Woo Lee
- Department of Internal Medicine, Uijeongbu Eulji University Medical Center, Uijeongbu, Republic of Korea
| | - Kipyo Kim
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Kyeong Min Kim
- Division of Nephrology, Department of Internal Medicine, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Republic of Korea
| | - Hyosang Kim
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University School of Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Jang-Hee Cho
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University School of Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeong-Hoon Lim
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University School of Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
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Guan X, Chen D, Xu Y. Clinical practice guidelines for nutritional assessment and monitoring of adult ICU patients in China. JOURNAL OF INTENSIVE MEDICINE 2024; 4:137-159. [PMID: 38681796 PMCID: PMC11043647 DOI: 10.1016/j.jointm.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 05/01/2024]
Abstract
The Chinese Society of Critical Care Medicine (CSCCM) has developed clinical practice guidelines for nutrition assessment and monitoring for patients in adult intensive care units (ICUs) in China. This guideline focuses on nutrition evaluation and metabolic monitoring to achieve optimal and personalized nutrition therapy for critically ill patients. This guideline was developed by experts in critical care medicine and evidence-based medicine methodology and was developed after a thorough review of the system and a summary of relevant trials or studies published from 2000 to July 2023. A total of 18 recommendations were formed and consensus was reached through discussions and reviews by expert groups in critical care medicine, parenteral and enteral nutrition, and surgery. The recommendations are based on currently available evidence and cover several key fields, including screening and assessment, evaluation and assessment of enteral feeding intolerance, metabolic and nutritional measurement and monitoring during nutrition therapy, and organ function evaluation related to nutrition supply. Each question was analyzed according to the Population, Intervention, Comparison, and Outcome (PICO) principle. In addition, interpretations were provided for four questions that did not reach a consensus but may have potential clinical and research value. The plan is to update this nutrition assessment and monitoring guideline using the international guideline update method within 3-5 years.
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Affiliation(s)
- Xiangdong Guan
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuan Xu
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, Beijing, China
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Serpa Neto A, Naorungroj T, Gallagher M, Bellomo R. Impact of Intensity of Continuous Renal Replacement Therapy on Duration of Ventilation in Critically Ill Patients: A Secondary Analysis of the RENAL Trial. Blood Purif 2023; 52:888-897. [PMID: 37852200 DOI: 10.1159/000533687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/11/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION More intensive renal replacement therapy (RRT) has been associated with prolonged mechanical ventilation (MV). However, such finding may be dependent on RRT modality. We hypothesized that, when using continuous renal replacement therapy (CRRT), RRT intensity would not be associated with prolonged MV. METHODS In a secondary analysis of the Randomized Evaluation of Normal versus Augmented Level (RENAL) Replacement trial comparing different CRRT intensities, we applied Fine-Gray competing risk analysis with time to successful extubation within 28 days as primary outcome. RESULTS We studied 531 patients in the higher intensity and 551 in the lower intensity group. Higher intensity patients had more hypophosphatemia (66.7 vs. 58.1%; p = 0.004) and more days with hypophosphatemia (2.2 ± 2.8 vs. 1.6 ± 2.2; p < 0.001). There was no difference in the number of patients extubated within 28 days (60.1% vs. 62.4%; adjusted subdistribution hazard ratio [SHR], 0.95 [95% CI, 0.86 to 1.06]) or time to extubation (8 [5-16] vs. 8 [5-15] days; adjusted median difference, 0.65 [95% CI, -0.41 to 1.70]). Among patients from the upper tertile of days with hypophosphatemia, higher intensity CRRT was associated with a lower chance of successful extubation within 28 days (SHR, 0.67 [95% CI, 0.55 to 0.82]; p for heterogeneity = 0.013). CONCLUSIONS In the RENAL trial, higher intensity CRRT was not associated with delayed extubation. However, it was associated with a greater rate of hypophosphatemia and more days with hypophosphatemia was associated with a lower chance of successful extubation.
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Affiliation(s)
- Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, Victoria, Australia
- Department of Critical Care Medicine Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Faculty of Medicine, Mahidol University, Bangkok, Thailand
| | - Martin Gallagher
- Department of Nephrology, The George Institute for Global Health and University of Sydney, Sydney, New South Wales, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Di Mario F, Sabatino A, Regolisti G, Pacchiarini MC, Greco P, Maccari C, Vizzini G, Italiano C, Pistolesi V, Morabito S, Fiaccadori E. Simplified regional citrate anticoagulation protocol for CVVH, CVVHDF and SLED focused on the prevention of KRT-related hypophosphatemia while optimizing acid-base balance. Nephrol Dial Transplant 2023; 38:2298-2309. [PMID: 37037771 PMCID: PMC10547235 DOI: 10.1093/ndt/gfad068] [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: 10/20/2022] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Hypophosphatemia is a common electrolyte disorder in critically ill patients undergoing prolonged kidney replacement therapy (KRT). We evaluated the efficacy and safety of a simplified regional citrate anticoagulation (RCA) protocol for continuous venovenous hemofiltration (CVVH), continuous venovenous hemodiafiltration (CVVHDF) and sustained low-efficiency dialysis filtration (SLED-f). We aimed at preventing KRT-related hypophosphatemia while optimizing acid-base equilibrium. METHODS KRT was performed by the Prismax system (Baxter) and polyacrylonitrile AN69 filters (ST 150, 1.5 m2, Baxter), combining a 18 mmol/L pre-dilution citrate solution (Regiocit 18/0, Baxter) with a phosphate-containing solution (HPO42- 1.0 mmol/L, HCO3- 22.0 mmol/L; Biphozyl, Baxter). When needed, phosphate loss was replaced with sodium glycerophosphate pentahydrate (Glycophos™ 20 mmol/20 mL, Fresenius Kabi Norge AS, Halden, Norway). Serum citrate measurements were scheduled during each treatment. We analyzed data from three consecutive daily 8-h SLED-f sessions, as well as single 72-h CVVH or 72-h CVVHDF sessions. We used analysis of variance (ANOVA) for repeated measures to evaluate differences in variables means (i.e. serum phosphate, citrate). Because some patients received phosphate supplementation, we performed analysis of covariance (ANCOVA) for repeated measures modelling phosphate supplementation as a covariate. RESULTS Forty-seven patients with acute kidney injury (AKI) or end stage kidney disease (ESKD) requiring KRT were included [11 CVVH, 11 CVVHDF and 25 SLED-f sessions; mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score 25 ± 7.0]. Interruptions for irreversible filter clotting were negligible. The overall incidence of hypophosphatemia (s-P levels <2.5 mg/dL) was 6.6%, and s-P levels were kept in the normality range irrespective of baseline values and the KRT modality. The acid-base balance was preserved, with no episode of citrate accumulation. CONCLUSIONS Our data obtained with a new simplified RCA protocol suggest that it is effective and safe for CVVH, CVVHDF and SLED, allowing to prevent KRT-related hypophosphatemia and maintain the acid-base balance without citrate accumulation. TRIAL REGISTRATION NCT03976440 (registered 6 June 2019).
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Affiliation(s)
- Francesca Di Mario
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Alice Sabatino
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Giuseppe Regolisti
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
- UO Clinica e Immunologia Medica, Azienda Ospedaliero-Universitaria, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Maria Chiara Pacchiarini
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Paolo Greco
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Caterina Maccari
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Giuseppe Vizzini
- Laboratorio di Immunopatologia Renale “Luigi Migone”, Università degli Studi di Parma, Parma, Italy
| | - Chiara Italiano
- Laboratorio di Immunopatologia Renale “Luigi Migone”, Università degli Studi di Parma, Parma, Italy
| | - Valentina Pistolesi
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, “Sapienza” Università̀ di Roma, Rome, Italy
| | - Santo Morabito
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, “Sapienza” Università̀ di Roma, Rome, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
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Lima W, Calderaro DC, Passos R, Côrte M, Leal JA, Mayrink MO, Ferreira G. Lower mean phosphate independently predicts mortality in critically ill patients: Results from a prospective cohort study. J Crit Care 2023; 75:154273. [PMID: 36739201 DOI: 10.1016/j.jcrc.2023.154273] [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: 12/21/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
PURPOSE To evaluate lower mean phosphate as a prognostic tool in critically ill patients. METHODS This is a prospective single-center cohort study including adult patients (> 18 years) with a length of intensive care unit (ICU) stay of at least 24 h. Phosphatemia was evaluated within 1 h of ICU admission and once daily. Mean phosphate, calculated by the simple arithmetic mean of daily phosphate measurements, was proposed and tested. Standard severity scores were applied. Multivariate and survival analyses were performed. RESULTS A total of 317 patients were included, of whom 111 (35%) presented hypophosphatemia. Hypophosphatemia associated with surgical conditions, nutritional therapy, hypovitaminosis D, hyperparathyroidism, mechanical ventilation (need and duration), and ICU and hospital length of stay were evaluated. Admission APACHE II and SOFA (ICU days 1, 3, and 7) scores and ICU and in-hospital mortality were greater in the hypophosphatemia group than control group. Higher APACHE II (RR: 1.1; 95%CI: 1.01-1.2; p = 0.045) and lower mean phosphate (RR: 0.02; 95%CI: 0.001-0.09; p = 0.044) independently predicted ICU and in-hospital mortality. CONCLUSIONS Hypophosphatemia is frequent in the ICU, and was associated with unfavorable outcomes. This study introduces the importance of longitudinal monitoring of phosphate levels, since lower mean phosphate is an independent predictor of mortality in critically ill patients.
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Affiliation(s)
- Washington Lima
- Nutrition and Diet Service, Governador Israel Pinheiro Hospital - Instituto de Previdência Servidor do Estado de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Débora Cerqueira Calderaro
- Musculoskeletal System Department, Falculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Rogério Passos
- Intensive Care Unit, São Rafael Hospital, Salvador, Bahia, Brazil.
| | - Margaret Côrte
- Speech Therapy Nucleus, Governador Israel Pinheiro Hospital - Instituto de Previdência do Servidor do Estado de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Jose Adalberto Leal
- Nutrition and Diet Service, Governador Israel Pinheiro Hospital - Instituto de Previdência Servidor do Estado de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | | | - Gilda Ferreira
- Musculoskeletal System Department, Falculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Boer W, Verbrugghe W, Hoste E, Jacobs R, Jorens PG. Unapparent systemic effects of regional anticoagulation with citrate in continuous renal replacement therapy: a narrative review. Ann Intensive Care 2023; 13:16. [PMID: 36899104 PMCID: PMC10006386 DOI: 10.1186/s13613-023-01113-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/20/2023] [Indexed: 03/12/2023] Open
Abstract
The use of citrate, through reversible binding of calcium, has become the preferred choice for anticoagulation in continuous renal replacement therapy in the critically ill patient. Though generally considered as very efficacious in acute kidney injury, this type of anticoagulation can cause acid-base disorders as well as citrate accumulation and overload, phenomena which have been well described. The purpose of this narrative review is to provide an overview of some other, non-anticoagulation effects of citrate chelation during its use as anticoagulant. We highlight the effects seen on the calcium balance and hormonal status, phosphate and magnesium balance, as well as oxidative stress resulting from these unapparent effects. As most of these data on these non-anticoagulation effects have been obtained in small observational studies, new and larger studies documenting both short- and long-term effects should be undertaken. Subsequent future guidelines for citrate-based continuous renal replacement therapy should take not only the metabolic but also these unapparent effects into account.
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Affiliation(s)
- Willem Boer
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine & Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium.
| | - Walter Verbrugghe
- Department of Critical Care Medicine, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Eric Hoste
- Intensive Care Unit, Department of Internal Medicine and Paediatrics, Ghent University Hospital, Ghent, and Research Foundation Flanders (FWO), Ghent University, Brussels, Belgium
| | - Rita Jacobs
- Department of Critical Care Medicine, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Philippe G Jorens
- Department of Critical Care Medicine, Antwerp University Hospital, LEMP, University of Antwerp, Edegem, Belgium
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Teixeira JP, Mayer KP, Griffin BR, George N, Jenkins N, Pal CA, González-Seguel F, Neyra JA. Intensive Care Unit-Acquired Weakness in Patients With Acute Kidney Injury: A Contemporary Review. Am J Kidney Dis 2023; 81:336-351. [PMID: 36332719 PMCID: PMC9974577 DOI: 10.1053/j.ajkd.2022.08.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 08/31/2022] [Indexed: 11/06/2022]
Abstract
Acute kidney injury (AKI) and intensive care unit-acquired weakness (ICU-AW) are 2 frequent complications of critical illness that, until recently, have been considered unrelated processes. The adverse impact of AKI on ICU mortality is clear, but its relationship with muscle weakness-a major source of ICU morbidity-has not been fully elucidated. Furthermore, improving ICU survival rates have refocused the field of intensive care toward improving long-term functional outcomes of ICU survivors. We begin our review with the epidemiology of AKI in the ICU and of ICU-AW, highlighting emerging data suggesting that AKI and AKI treated with kidney replacement therapy (AKI-KRT) may independently contribute to the development of ICU-AW. We then delve into human and animal data exploring the pathophysiologic mechanisms linking AKI and acute KRT to muscle wasting, including altered amino acid and protein metabolism, inflammatory signaling, and deleterious removal of micronutrients by KRT. We next discuss the currently available interventions that may mitigate the risk of ICU-AW in patients with AKI and AKI-KRT. We conclude that additional studies are needed to better characterize the epidemiologic and pathophysiologic relationship between AKI, AKI-KRT, and ICU-AW and to prospectively test interventions to improve the long-term functional status and quality of life of AKI survivors.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico; Center for Adult Critical Care, University of New Mexico, Albuquerque, New Mexico.
| | - Kirby P Mayer
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, Kentucky
| | - Benjamin R Griffin
- Division of Nephrology, Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Naomi George
- Center for Adult Critical Care, University of New Mexico, Albuquerque, New Mexico; Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Nathaniel Jenkins
- Department of Health and Human Physiology, University of Iowa, Iowa City, Iowa
| | - C Anil Pal
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Felipe González-Seguel
- Servicio de Medicina Física y Rehabilitación, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
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10
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Erfurt S, Lehmann R, Matyukhin I, Marahrens B, Patschan S, Patschan D. Stratification of Acute Kidney Injury Risk, Disease Severity, and Outcomes by Electrolyte Disturbances. J Clin Med Res 2023; 15:59-67. [PMID: 36895624 PMCID: PMC9990720 DOI: 10.14740/jocmr4832] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/28/2023] [Indexed: 03/06/2023] Open
Abstract
Acute kidney injury (AKI) affects up to 30% of all hospitalized patients in Central Europe and the USA. New biomarker molecules have been identified in recent years; most studies performed so far however aimed to identify markers for diagnostic purposes. Serum electrolytes such as sodium and potassium are quantified in more or less all hospitalized patients. Aim of the article is to review the literature on the AKI predictive role of four distinct serum electrolytes in evolving/progressing AKI. The following databases were searched for references: PubMed, Web of Science, Cochrane Library, and Scopus. The period lasted from 2010 until 2022. The following terms were utilized: "AKI" AND "sodium" OR "potassium" OR "calcium" OR "phosphate" AND "risk" OR "dialysis" OR "recovery of kidney function" OR "renal recovery" OR "kidney recovery" OR "outcome". Finally, 17 references were selected. The included studies were mostly retrospective in nature. Particularly, hyponatremia has been shown to be associated with an overall poor clinical outcome. The association between dysnatremia and AKI is anything but consistent. Hyperkalemia and potassium variability are most likely AKI predictive. Serum calcium and AKI risk are associated in a U-shaped manner. Higher phosphate levels potentially predict AKI in non-coronavirus disease 2019 (COVID-19) patients. The literature suggests that admission electrolytes can offer valuable information about AKI onset during follow-up. Limited data are however available on follow-up characteristics such as the need for dialysis or the chance of renal recovery. These aspects are of particular interest from the nephrologist's perspective.
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Affiliation(s)
- Stefan Erfurt
- Department of Internal Medicine I - Cardiology, Nephrology and Internal Intensive Medicine, Brandenburg University Hospital, Brandenburg Medical School (Theodor Fontane), Brandenburg an der Havel, Germany
| | - Rebecca Lehmann
- Department of Internal Medicine I - Cardiology, Nephrology and Internal Intensive Medicine, Brandenburg University Hospital, Brandenburg Medical School (Theodor Fontane), Brandenburg an der Havel, Germany
| | - Igor Matyukhin
- Department of Internal Medicine I - Cardiology, Nephrology and Internal Intensive Medicine, Brandenburg University Hospital, Brandenburg Medical School (Theodor Fontane), Brandenburg an der Havel, Germany
| | - Benedikt Marahrens
- Department of Internal Medicine I - Cardiology, Nephrology and Internal Intensive Medicine, Brandenburg University Hospital, Brandenburg Medical School (Theodor Fontane), Brandenburg an der Havel, Germany
| | - Susann Patschan
- Department of Internal Medicine I - Cardiology, Nephrology and Internal Intensive Medicine, Brandenburg University Hospital, Brandenburg Medical School (Theodor Fontane), Brandenburg an der Havel, Germany
| | - Daniel Patschan
- Department of Internal Medicine I - Cardiology, Nephrology and Internal Intensive Medicine, Brandenburg University Hospital, Brandenburg Medical School (Theodor Fontane), Brandenburg an der Havel, Germany
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11
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Teixeira JP, Neyra JA, Tolwani A. Continuous KRT: A Contemporary Review. Clin J Am Soc Nephrol 2023; 18:256-269. [PMID: 35981873 PMCID: PMC10103212 DOI: 10.2215/cjn.04350422] [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
AKI is a common complication of critical illness and is associated with substantial morbidity and risk of death. Continuous KRT comprises a spectrum of dialysis modalities preferably used to provide kidney support to patients with AKI who are hemodynamically unstable and critically ill. The various continuous KRT modalities are distinguished by different mechanisms of solute transport and use of dialysate and/or replacement solutions. Considerable variation exists in the application of continuous KRT due to a lack of standardization in how the treatments are prescribed, delivered, and optimized to improve patient outcomes. In this manuscript, we present an overview of the therapy, recent clinical trials, and outcome studies. We review the indications for continuous KRT and the technical aspects of the treatment, including continuous KRT modality, vascular access, dosing of continuous KRT, anticoagulation, volume management, nutrition, and continuous KRT complications. Finally, we highlight the need for close collaboration of a multidisciplinary team and development of quality assurance programs for the provision of high-quality and effective continuous KRT.
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Affiliation(s)
- J. Pedro Teixeira
- Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Javier A. Neyra
- Division of Nephrology, Bone, and Mineral Metabolism, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashita Tolwani
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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12
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Di Mario F, Regolisti G, Maggiore U, Pacchiarini MC, Menegazzo B, Greco P, Maccari C, Zambrano C, Cantarelli C, Pistolesi V, Morabito S, Fiaccadori E. Hypophosphatemia in critically ill patients undergoing Sustained Low-Efficiency Dialysis with standard dialysis solutions. Nephrol Dial Transplant 2022; 37:2505-2513. [PMID: 35481705 DOI: 10.1093/ndt/gfac159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In patients admitted to the Intensive Care Unit (ICU), Kidney Replacement Therapy (KRT) is an important risk factor for hypophosphataemia. However, studies addressing the development of hypophosphatemia during prolonged intermittent KRT modalities are lacking. Thus, we evaluated the incidence of hypophosphatemia during Sustained Low-Efficiency Dialysis (SLED) in ICU patients; we also examined the determinants of post-SLED serum phosphate level (s-P) and the relation between s-P and phosphate supplementation and ICU mortality. METHODS We conducted a retrospective analysis on a cohort of critically ill patients with severe renal failure and KRT need, who underwent at least three consecutive SLED sessions at 24-72 h time intervals with daily monitoring of s-P concentration. SLED with Regional Citrate Anticoagulation (RCA) was performed with either conventional dialysis machines or continuous-KRT monitors and standard dialysis solutions. When deemed necessary by the attending physician, intravenous phosphate supplementation was provided by sodium glycerophosphate pentahydrate. We used mixed-effect models to examine the determinants of s-P and Cox proportional hazards regression models with time-varying covariates to examine the adjusted relation between s-P, intravenous phosphate supplementation and ICU mortality. RESULTS We included 65 patients [mean age 68 years (SD 10.0); mean Acute Physiology and Chronic Health Evaluation II score 25 (range 9-40)] who underwent 195 SLED sessions. The mean s-P before the start of the first SLED session (baseline s-P) was 5.6 ± 2.1 mg/dL (range 1.5-12.3). Serum phosphate levels at the end of each SLED decreased with increasing age, SLED duration and number of SLED sessions (P < .05 for all). The frequency of hypophosphatemia increased after the first through the third SLED session (P = .012). Intravenous phosphate supplementation was scheduled after 12/45 (26.7%) SLED sessions complicated by hypophosphataemia. The overall ICU mortality was 23.1% (15/65). In Cox regression models, after adjusting for potential confounders and for current s-P, intravenous phosphate supplementation was associated with a decrease in ICU mortality [adjusted hazard ratio: 0.24 (95% confidence interval: 0.06 to 0.89; P = 0.033)]. CONCLUSIONS Hypophosphatemia is a frequent complication in critically ill patients undergoing SLED with standard dialysis solutions, that worsens with increasing SLED treatment intensity. In patients undergoing daily SLED, phosphate supplementation is strongly associated with reduced ICU mortality.
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Affiliation(s)
- Francesca Di Mario
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Giuseppe Regolisti
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy.,UO Clinica e Immunologia Medica, Azienda Ospedaliero-Universitaria, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Umberto Maggiore
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Maria Chiara Pacchiarini
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Brenda Menegazzo
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Paolo Greco
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Caterina Maccari
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Cristina Zambrano
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Chiara Cantarelli
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Valentina Pistolesi
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università di Roma, Rome, Italy
| | - Santo Morabito
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università di Roma, Rome, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
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13
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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: 23] [Impact Index Per Article: 11.5] [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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14
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Gautam SC, Lim J, Jaar BG. Complications Associated with Continuous RRT. KIDNEY360 2022; 3:1980-1990. [PMID: 36514412 PMCID: PMC9717642 DOI: 10.34067/kid.0000792022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 09/06/2022] [Indexed: 01/12/2023]
Abstract
Continuous renal replacement therapy (CRRT) is a form of renal replacement therapy that is used in modern intensive care units (ICUs) to help manage acute kidney injury (AKI), end stage kidney disease (ESKD), poisonings, and some electrolyte disorders. CRRT has transformed the care of patients in the ICU over the past several decades. In this setting, it is important to recognize CRRT-associated complications but also up-to-date management of these complications. Some of these complications are minor, but others may be more significant and even life-threatening. Some CRRT complications may be related to dialysis factors and others to specific patient factors. Our overarching goal in this article is to review and discuss the most significant CRRT-related complications at the different stage of management of CRRT. With the advent of newer solutions, there have been newer complications as well.
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Affiliation(s)
- Samir C. Gautam
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jonathan Lim
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland,Nephrology Center of Maryland, Baltimore, Maryland
| | - Bernard G. Jaar
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland,Nephrology Center of Maryland, Baltimore, Maryland,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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15
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Thompson Bastin ML, Stromberg AJ, Nerusu SN, Liu LJ, Mayer KP, Liu KD, Bagshaw SM, Wald R, Morris PE, Neyra JA. Association of Phosphate-Containing versus Phosphate-Free Solutions on Ventilator Days in Patients Requiring Continuous Kidney Replacement Therapy. Clin J Am Soc Nephrol 2022; 17:634-642. [PMID: 35477673 PMCID: PMC9269583 DOI: 10.2215/cjn.12410921] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 03/22/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Hypophosphatemia is commonly observed in patients receiving continuous KRT. Patients who develop hypophosphatemia may be at risk of respiratory and neuromuscular dysfunction and therefore subject to prolongation of ventilator support. We evaluated the association of phosphate-containing versus phosphate-free continuous KRT solutions with ventilator dependence in critically ill patients receiving continuous KRT. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our study was a single-center, retrospective, pre-post cohort study of adult patients receiving continuous KRT and mechanical ventilation during their intensive care unit stay. Zero-inflated negative binomial regression with and without propensity score matching was used to model our primary outcome: ventilator-free days at 28 days. Intensive care unit and hospital lengths of stay as well as hospital mortality were analyzed with a t test or a chi-squared test, as appropriate. RESULTS We identified 992 eligible patients, of whom 649 (65%) received phosphate-containing solutions and 343 (35%) received phosphate-free solutions. In multivariable models, patients receiving phosphate-containing continuous KRT solutions had 12% (95% confidence interval, 0.17 to 0.47) more ventilator-free days at 28 days. Patients exposed to phosphate-containing versus phosphate-free solutions had 17% (95% confidence interval, -0.08 to -0.30) fewer days in the intensive care unit and 20% (95% confidence interval, - 0.12 to -0.32) fewer days in the hospital. Concordant results were observed for ventilator-free days at 28 days in the propensity score matched analysis. There was no difference in hospital mortality between the groups. CONCLUSIONS The use of phosphate-containing versus phosphate-free continuous KRT solutions was independently associated with fewer ventilator days and shorter stay in the intensive care unit.
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Affiliation(s)
- Melissa L. Thompson Bastin
- Department of Pharmacy Services, University of Kentucky Medical Center, Lexington, Kentucky,Department of Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky
| | | | | | - Lucas J. Liu
- Department of Computer Science, University of Kentucky, Lexington, Kentucky
| | - Kirby P. Mayer
- Department of Physical Therapy, University of Kentucky, Lexington, Kentucky
| | - Kathleen D. Liu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California,Division of Nephrology, Department of Anesthesia, University of California, San Francisco, California
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Peter E. Morris
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, Lexington, Kentucky
| | - Javier A. Neyra
- Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
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16
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Associations between Phosphate Concentrations and Hospital Mortality in Critically Ill Patients Receiving Mechanical Ventilation. J Clin Med 2022; 11:jcm11071897. [PMID: 35407502 PMCID: PMC8999466 DOI: 10.3390/jcm11071897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/24/2022] [Accepted: 03/26/2022] [Indexed: 02/04/2023] Open
Abstract
Phosphate concentrations change continuously throughout hospitalization; however, it is unclear which available phosphate measures are most clinically important for predicting hospital mortality. Therefore, we investigated phosphate concentrations in association with hospital mortality following admission to the intensive care unit. We retrospectively enrolled all adult patients receiving mechanical ventilation. Phosphate concentrations were divided into three categories: initially measured phosphate (iP); maximum−minimum phosphate values (ΔP); and phosphate arithmetic average (Pmean). In total, 175 patients were enrolled. The hospital mortality rate was 32.6%, and the most common primary diagnosis was respiratory failure. In multivariable logistic regression analyses, the odds ratios for hospital mortality in association with ΔP and Pmean values were 1.56 and 2.13, respectively (p < 0.0001). According to the obtained receiver operating characteristic curve, ΔP (0.75) and Pmean (0.72) each showed a fair predictive power for hospital mortality. In evaluating relative risks, we found that higher concentrations of Pmean and ΔP were each associated with a higher hospital mortality. ΔP and Pmean values were significantly associated with hospital mortality in critically ill patients, compared to iP. These findings showed that throughout hospitalization, it is important to reduce phosphate level fluctuations and maintain appropriate phosphate concentrations through consistent monitoring and corrections.
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17
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Molecular Mechanisms and Biomarkers Associated with Chemotherapy-Induced AKI. Int J Mol Sci 2022; 23:ijms23052638. [PMID: 35269781 PMCID: PMC8910619 DOI: 10.3390/ijms23052638] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 12/10/2022] Open
Abstract
Acute kidney injury (AKI) is a life-threatening condition characterized by a rapid and transient decrease in kidney function. AKI is part of an array of conditions collectively defined as acute kidney diseases (AKD). In AKD, persistent kidney damage and dysfunction lead to chronic kidney disease (CKD) over time. A variety of insults can trigger AKI; however, chemotherapy-associated nephrotoxicity is increasingly recognized as a significant side effect of chemotherapy. New biomarkers are urgently needed to identify patients at high risk of developing chemotherapy-associated nephrotoxicity and subsequent AKI. However, a lack of understanding of cellular mechanisms that trigger chemotherapy-related nephrotoxicity has hindered the identification of effective biomarkers to date. In this review, we aim to (1) describe the known and potential mechanisms related to chemotherapy-induced AKI; (2) summarize the available biomarkers for early AKI detection, and (3) raise awareness of chemotherapy-induced AKI.
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18
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Wozniak H, Dos Santos Rocha A, Beckmann TS, Larpin C, Buetti N, Quintard H, Pugin J, Heidegger CP. Hypophosphatemia on ICU Admission Is Associated with an Increased Length of Stay in the ICU and Time under Mechanical Ventilation. J Clin Med 2022; 11:jcm11030581. [PMID: 35160032 PMCID: PMC8836766 DOI: 10.3390/jcm11030581] [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: 12/29/2021] [Revised: 01/21/2022] [Accepted: 01/22/2022] [Indexed: 01/14/2023] Open
Abstract
Hypophosphatemia is frequently observed in the ICU and is associated with several impairments such as respiratory failure or infections. We hypothesized that hypophosphatemia on ICU admission is associated with a prolonged duration of mechanical ventilation and ICU length of stay (LOS), particularly in COVID-19 patients. This cross-sectional study analyzed data from 1226 patients hospitalized in the ICU of the Geneva University Hospitals from August 2020 to April 2021. Patients were categorized as having hypophosphatemia (phosphatemia ≤ 0.8 mmol/L) or non-hypophosphatemia (phosphatemia > 0.8 mmol/L) on ICU admission. Linear regressions were performed to investigate the association between hypophosphatemia on ICU admission and ICU LOS and duration of mechanical ventilation. Overall, 250 (20%) patients presented hypophosphatemia on ICU admission. In the univariable analysis, hypophosphatemic patients had longer ICU LOS than non-hypophosphatemic patients, 7.4 days (±10.4) versus 5.6 days (±8.3), (p < 0.01). Hypophosphatemia on ICU admission was associated with a prolonged duration of mechanical ventilation, 7.4 days (±11.2) versus 5.6 days (±8.9), (p < 0.01). These associations were confirmed in the multivariable analysis (p < 0.01). In the subgroup of COVID-19 patients, a significant association between hypophosphatemia and ICU LOS and duration of mechanical ventilation was also observed. In conclusion, hypophosphatemia on ICU admission is associated with a longer ICU LOS and time under mechanical ventilation, both in the general ICU population and in COVID-19 patients.
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Affiliation(s)
- Hannah Wozniak
- Division of Intensive Care, Department of Acute Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.L.); (H.Q.); (J.P.)
- Correspondence: (H.W.); (C.P.H.)
| | - André Dos Santos Rocha
- Division of Anesthesiology, Department of Acute Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (A.D.S.R.); (T.S.B.)
| | - Tal Sarah Beckmann
- Division of Anesthesiology, Department of Acute Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (A.D.S.R.); (T.S.B.)
| | - Christophe Larpin
- Division of Intensive Care, Department of Acute Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.L.); (H.Q.); (J.P.)
| | - Niccolò Buetti
- Infection Control Program, World Health Organization Collaborating Centre on Patient Safety, Faculty of Medicine, 1205 Geneva, Switzerland;
| | - Hervé Quintard
- Division of Intensive Care, Department of Acute Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.L.); (H.Q.); (J.P.)
| | - Jérôme Pugin
- Division of Intensive Care, Department of Acute Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.L.); (H.Q.); (J.P.)
| | - Claudia Paula Heidegger
- Division of Intensive Care, Department of Acute Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.L.); (H.Q.); (J.P.)
- Correspondence: (H.W.); (C.P.H.)
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19
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Abstract
Uremic encephalopathy encompasses a wide range of central nervous system abnormalities associated with poor kidney function occurring with either progressive chronic kidney disease or acute kidney injury. The syndrome is likely caused by retention of uremic solutes, alterations in hormonal metabolism, changes in electrolyte and acid-base homeostasis, as well as changes in vascular reactivity, blood-brain barrier transport, and inflammation. There are no defining clinical, laboratory, or imaging findings, and the diagnosis is often made retrospectively when symptoms improve after dialysis or transplantation. The diagnosis is also made difficult because of the many confounding and overlapping conditions seen in patients with chronic kidney disease and acute kidney injury. Thus, institution of kidney replacement therapy should be considered as a trial to improve symptoms in the right clinical context. Neurological symptoms that do not improve after improvement in clearance should prompt a search for other explanations. Further knowledge linking possible uremic retention solutes with neurological symptoms is needed to better understand this syndrome as well as to develop more tailored treatments that aim to improve cognitive function.
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20
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Hong Y, Wang XH, Xiong YT, Li J, Liu CF. Association Between Admission Serum Phosphate Level and All-Cause Mortality Among Patients with Spontaneous Intracerebral Hemorrhage. Risk Manag Healthc Policy 2021; 14:3739-3746. [PMID: 34526830 PMCID: PMC8435619 DOI: 10.2147/rmhp.s317615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/01/2021] [Indexed: 02/04/2023] Open
Abstract
Background Hypophosphatemia was reported to frequently occur in patients with nontraumatic intracranial hemorrhage (ICH); however, the correlation between hypophosphatemia and outcomes of ICH remains unclear. This study aimed to examine the association between admission serum phosphate and all-cause mortality among patients with mild–moderate spontaneous ICH (sICH). Methods A total of 851 patients with sICH were enrolled. Serum phosphate was acquired within 24 hours on admission, and participants were divided according to phosphate quartiles. The primary outcome was all-cause mortality within 90 days, and univariate and multivariate models were employed to estimate the mortality risk. Results There were significant differences among sICH patients with different phosphate quartiles in terms of age, diastolic blood pressure (DBP), activated partial thromboplastin time (APTT), platelet count, and incidence of respiratory failure events on admission (P < 0.05). Log rank test showed a significant difference in the mortality risk among sICH patients with each phosphate quartile. Univariate Cox regression analysis revealed that age, smoking, DBP, APTT, NIH stroke scale (NIHSS) score, hematoma volume and serum phosphate might be associated with the 90-day all-cause mortality in patients with sICH (P < 0.05). Multivariable Cox regression analysis showed that the crude mortality was 4.3-fold greater in sICH patients with serum phosphate Q1 than those with Q4 (P < 0.001), and remained 3.18-fold higher after adjusting for age, smoking, DBP, APTT, NIHSS score, hematoma volume and early withdrawal of life-sustaining therapy (P = 0.011). Representative operating curve (ROC) analysis showed that admission serum phosphate was predictable for all-cause mortality within 90 days in patients with sICH (area under the ROC = 0.628, P < 0.001). Conclusion Low admission serum phosphate is strongly associated with a high risk of mortality in patients with mild–moderate sICH, and hypophosphatemia may be a prognostic marker for all-cause mortality in patients with mild–moderate sICH.
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Affiliation(s)
- Yu Hong
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, People's Republic of China.,Department of Neurology, Affiliated Yixing People's Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People's Republic of China
| | - Xian-Hui Wang
- Department of Neurology, Taicang First People's Hospital, Taicang, Jiangsu, 215400, People's Republic of China
| | - Yi-Tong Xiong
- Department of Neurology, Affiliated Yixing People's Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People's Republic of China
| | - Jie Li
- Department of Neurology, Affiliated Yixing People's Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People's Republic of China
| | - Chun-Feng Liu
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, People's Republic of China
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21
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Kells M, Gregas M, Wolfe BE, Garber AK, Kelly-Weeder S. Factors associated with refeeding hypophosphatemia in adolescents and young adults hospitalized with anorexia nervosa. Nutr Clin Pract 2021; 37:470-478. [PMID: 34494697 DOI: 10.1002/ncp.10772] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Refeeding hypophosphatemia (RH) in individuals with anorexia nervosa (AN) is a potentially fatal complication of nutrition restoration; yet, little is known about risk. This retrospective cohort study examined factors found in hospitalized youth with AN that may contribute to RH. METHODS We reviewed medical records of 300 individuals diagnosed with AN admitted between the years of 2010 and 2016. Logistic regression examined factors associated with RH. Multivariate regression examined factors associated with phosphorus nadir. RESULTS For 300 participants, the mean (SD) age was 15.5 (2.5) years, 88.3% were White, and 88.3% were female. Participants lost an average of 11.3 (9.7) kg of body weight and were 82% (12.1) of median body mass index (BMI). Age (P = .022), nasogastric (NG) tube feeding (P = .054), weight gain (P = .003), potassium level (P = .001), and magnesium level (P = .024) were contributors to RH. Odds of RH were 13.7 times higher for each unit reduction in magnesium, 9.2 times higher for each unit reduction in potassium, three times higher in those who received NG feeding, 1.5 times higher for each kg of weight gain, and 1.2 times higher for each year of age. Regarding phosphorus nadir, serum magnesium level (P < .001) and admission BMI (P = .002) contributed significantly. CONCLUSION The results indicate that age, NG feeding, weight gain, electrolyte abnormalities, and BMI on admission are potential indicators of the development of RH in youth. This study identifies clinical risk factors associated with RH and may guide further investigation.
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Affiliation(s)
- Meredith Kells
- Boston Children's Hospital, Division of Adolescent/Young Adult Medicine, Boston, Massachusetts, USA.,Department of Psychiatry and Behavioral Neuroscience, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Matt Gregas
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts, USA
| | - Barbara E Wolfe
- College of Nursing, University of Rhode Island, Kingston, Rhode Island, USA
| | - Andrea K Garber
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Susan Kelly-Weeder
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts, USA
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22
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Yessayan L, Sohaney R, Puri V, Wagner B, Riddle A, Dickinson S, Napolitano L, Heung M, Humes D, Szamosfalvi B. Regional citrate anticoagulation "non-shock" protocol with pre-calculated flow settings for patients with at least 6 L/hour liver citrate clearance. BMC Nephrol 2021; 22:244. [PMID: 34215201 PMCID: PMC8249839 DOI: 10.1186/s12882-021-02443-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) for the prevention of clotting of the extracorporeal blood circuit during continuous kidney replacement therapy (CKRT) has been employed in limited fashion because of the complexity and complications associated with certain protocols. Hypertonic citrate infusion to achieve circuit anticoagulation results in variable systemic citrate- and sodium load and increases the risk of citrate accumulation and hypernatremia. The practice of "single starting calcium infusion rate for all patients" puts patients at risk for clinically significant hypocalcemia if filter effluent calcium losses exceed replacement. A fixed citrate to blood flow ratio, personalized effluent and pre-calculated calcium infusion dosing based on tables derived through kinetic analysis enable providers to use continuous veno-venous hemo-diafiltration (CVVHDF)-RCA in patients with liver citrate clearance of at least 6 L/h. METHODS This was a single-center prospective observational study conducted in intensive care unit patients triaged to be treated with the novel pre-calculated CVVHDF-RCA "Non-shock" protocol. RCA efficacy outcomes were time to first hemofilter loss and circuit ionized calcium (iCa) levels. Safety outcomes were surrogate of citrate accumulation (TCa/iCa ratio) and the incidence of acid-base and electrolyte complications. RESULTS Of 53 patients included in the study, 31 (59%) had acute kidney injury and 12 (22.6%) had the diagnosis of cirrhosis at the start of CVVHDF-RCA. The median first hemofilter life censored for causes other than clotting exceeded 70 h. The cumulative incidence of hypernatremia (Na > 148 mM), metabolic alkalosis (HCO3- > 30 mM), hypocalcemia (iCa < 0.9 mM) and hypercalcemia (iCa > 1.5 mM) were 1/47 (1%), 0/50 (0%), 1/53 (2%), 1/53 (2%) respectively and were not clinically significant. The median (25th-75th percentile) of the highest TCa/iCa ratio for every 24-h interval on CKRT was 1.99 (1.91-2.13). CONCLUSIONS The fixed citrate to blood flow ratio, as opposed to a titration approach, achieves adequate circuit iCa (< 0.4 mm/L) for any hematocrit level and plasma flow. The personalized dosing approach for calcium supplementation based on pre-calculated effluent calcium losses as opposed to the practice of "one starting dose for all" reduces the risk of clinically significant hypocalcemia. The fixed flow settings achieve clinically desirable steady state systemic electrolyte levels.
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Affiliation(s)
- Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA.
| | - Ryann Sohaney
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Vidhit Puri
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Benjamin Wagner
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Amy Riddle
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Sharon Dickinson
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Lena Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - David Humes
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Balazs Szamosfalvi
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA.
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23
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Al Harbi SA, Al-Dorzi HM, Al Meshari AM, Tamim H, Abdukahil SAI, Sadat M, Arabi Y. Association between phosphate disturbances and mortality among critically ill patients with sepsis or septic shock. BMC Pharmacol Toxicol 2021; 22:30. [PMID: 34049590 PMCID: PMC8161900 DOI: 10.1186/s40360-021-00487-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/30/2021] [Indexed: 11/11/2022] Open
Abstract
Objective The aim of this study is to examine the association of hypophosphatemia and hyperphosphatemia on the first day of ICU admission with mortality in septic critically ill patients. Methods In this retrospective cohort study, all adult patients who were admitted to the medical-surgical ICUs between 2014 and 2017 with sepsis or septic shock were categorized as having hypophosphatemia, normophosphatemia and hyperphosphatemia based on day 1 serum phosphate values. We compared the clinical characteristics and outcomes between the three groups. We used multivariate analysis to examine the association of hypophosphatemia and hyperphosphatemia with these outcomes. Results Of the 1422 patients enrolled in the study, 188 (13%) had hypophosphatemia, 865 (61%) normophosphatemia and 369 (26%) had hyperphosphatemia. The patients in the hyperphosphatemia group had significantly lower GCS, higher APACHE II scores, higher serum creatinine, increased use of vasopressors, and required more mechanical ventilation with lower PaO2/FiO2 ratio compared with the other two groups. In addition, the hyperphosphatemia group showed significantly higher ICU and hospital mortality in comparison with the other two groups. Conclusion Hyperphosphatemia and not hypophosphatemia on the first ICU admission day was associated with an increase in the ICU and hospital mortality in septic critically ill patients.
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Affiliation(s)
- Shmeylan A Al Harbi
- Pharmaceutical Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hasan M Al-Dorzi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Hani Tamim
- Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Department of Internal Medicine, American University of Beirut- Medical Center, Beirut, Lebanon
| | - Sheryl Ann I Abdukahil
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Musharaf Sadat
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Yaseen Arabi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. .,Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia. .,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
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24
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Valente A, Jesus J, Breda J, Dinis A, Correia A, Godinho J, Oliveira T, Garagarza C. Dietary Advice in Hemodialysis Patients: Impact of a Telehealth Approach During the COVID-19 Pandemic. J Ren Nutr 2021; 32:319-325. [PMID: 34147308 PMCID: PMC8098055 DOI: 10.1053/j.jrn.2021.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 04/18/2021] [Accepted: 04/25/2021] [Indexed: 12/27/2022] Open
Abstract
Objective The purpose of this study was to assess the effect of a telehealth-delivered nutritional intervention via telephone in maintenance hemodialysis (HD) patients during the coronavirus outbreak. Methods This was a multicenter, observational, prospective, and longitudinal study of 156 patients undergoing maintenance HD from 15 dialysis units conducted during the COVID-19 pandemic. We assigned patients to receive dietary counseling through a phone call, according to their biochemical and nutritional parameters. Dry weight, intradialytic weight gain percentage (%IDWG), body mass index, potassium, phosphorus, calcium, calcium/phosphorus product, normalized protein catabolic rate, albumin, and hemoglobin were recorded at baseline and 1 month after nutrition counseling. Results The prevalence of hyperkalemia and hyperphosphatemia decreased significantly after dietary advice. A statistically significant reduction in serum potassium and phosphorus levels was observed in patients receiving counseling for hyperkalemia and hyperphosphatemia. In addition, there was a statistically significant decrease in the prevalence of hypophosphatemia. We also observed a significant decrease in %IDWG, although no statistically significant differences were detected in patients with high %IDWG. The data demonstrated statistically significant differences in potassium and phosphorus values when the person receiving the phone contact was the patient or the caregiver. The main statistically significant differences in hypophosphatemia %IDWG were only observed when contact was made directly with the patient. No differences were observed when the contact was made through nursing homes. Conclusion Our results suggest that telehealth-delivered dietary interventions can improve the clinical and nutritional parameters of HD patients. Consequently, this strategy may be effective for promoting continuous nutritional monitoring in these patients, in particular when conducting a face-to-face option is not crucial.
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Affiliation(s)
- Ana Valente
- Nutrition Department, Nephrocare, Lisbon, Portugal.
| | - Joana Jesus
- Nutrition Department, Nephrocare, Lisbon, Portugal
| | - Joana Breda
- Nutrition Department, Nephrocare, Lisbon, Portugal
| | - Ana Dinis
- Nutrition Department, Nephrocare, Lisbon, Portugal
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25
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Sin JCK, Laupland KB, Ramanan M, Tabah A. Phosphate abnormalities and outcomes among admissions to the intensive care unit: A retrospective multicentre cohort study. J Crit Care 2021; 64:154-159. [PMID: 33906104 DOI: 10.1016/j.jcrc.2021.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/01/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE We investigated the effect of serum phosphate abnormalities at intensive care unit (ICU) admission on risk of death and length of stay in critically ill patients. MATERIALS AND METHODS A retrospective cohort of patients admitted to three adult ICUs in Queensland, Australia from April 2014 to 2019 was studied. Hypophosphataemia, normophosphataemia and hyperphosphataemia were defined as serum phosphate level of <0.8, 0.8-1.5 and >1.5 mmol/L respectively. Univariable and logistic regression analyses were performed to investigate the association between the phosphate groups and the risk of death. MEASUREMENTS AND MAIN RESULTS We included 13,155 patients in the analysis, of which 1424 (10.8%) patients had hypophosphataemia and 2544 (19.3%) hyperphosphataemia. The mean admission phosphate level was 1.25 (SD, ±0.43) mmol/L. Both hypophosphatemia (OR 1.29; 95% CI, 1.02-1.64; p = 0.034) and hyperphosphataemia (OR 1.39; 95% CI, 1.15-1.68; p = 0.001) at admission were independently associated with increased risk of death after adjusting for covariables using logistic regression analysis. CONCLUSION Hypophosphatemia and hyperphosphatemia were both independently associated with an increased case fatality rate and ICU length of stay in a large multicentre ICU cohort.
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Affiliation(s)
- Jeremy Cheuk Kin Sin
- Department of Anaesthesia, Redcliffe Hospital, Redcliffe, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, Caboolture and the Prince Charles Hospitals, Brisbane, Queensland, Australia; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, Redcliffe Hospital, Redcliffe, Queensland, Australia.
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26
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Wang H, Zhang L, Liao W, Huang J, Xu J, Yang J, Chen C, He Z. Hyperphosphatemia rather than hypophosphatemia indicates a poor prognosis in patients with sepsis. Clin Biochem 2021; 91:9-15. [PMID: 33600802 DOI: 10.1016/j.clinbiochem.2021.01.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/14/2021] [Accepted: 01/29/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Sepsis is the leading cause of hospitalization and death in the intensive care unit. It is vital to identify high-risk patients with poor prognosis in the early stages of sepsis. We aimed to investigate the prognostic value of serum phosphorus levels for sepsis. METHODS The data of 4767 patients with sepsis were collected from the Multiparameter Intelligent Monitoring in Intensive Care III database. The Locally Weighted Scatterplot Smoothing technique and Kaplan-Meier analysis were used to test the crude relationship between serum phosphorus levels and mortality or overall survival. The multivariable logistic regression was used to further analyze the relationship between serum phosphorus levels and in-hospital mortality. The subgroup analysis was performed according to renal failure, use of vasopressin and the Sequential Organ Failure Assessment (SOFA) score. RESULTS Only hyperphosphatemia significantly correlated with in-hospital mortality [odds ratio (OR) 1.48; 95% confidence interval (CI) 1.19-1.85], while the correlation between hypophosphatemia and in-hospital mortality was not significant (OR 0.91; 95% CI 0.70-1.19). The interactions between serum phosphorus and renal failure, use of vasopressin or the SOFA score were not significant. CONCLUSIONS Hyperphosphatemia rather than hypophosphatemia indicates a poor prognosis in patients with sepsis.
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Affiliation(s)
- Huabin Wang
- Division of Hematology/Oncology, Department of Pediatrics, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China; Department of Pediatric Intensive Care Unit, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China
| | - Lidan Zhang
- Division of Hematology/Oncology, Department of Pediatrics, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China; Department of Pediatric Intensive Care Unit, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China
| | - Wenhua Liao
- Department of Intensive Care Unit, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou 510000, China
| | - Junbin Huang
- Division of Hematology/Oncology, Department of Pediatrics, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China; Department of Pediatric Intensive Care Unit, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China
| | - Jiannan Xu
- Center of Digestive Disease, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China
| | - Jing Yang
- Division of Hematology/Oncology, Department of Pediatrics, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China; Department of Pediatric Intensive Care Unit, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China
| | - Chun Chen
- Division of Hematology/Oncology, Department of Pediatrics, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China.
| | - Zhijie He
- Department of Intensive Care Unit, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou 510000, China.
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Fiaccadori E, Sabatino A, Barazzoni R, Carrero JJ, Cupisti A, De Waele E, Jonckheer J, Singer P, Cuerda C. ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease. Clin Nutr 2021; 40:1644-1668. [PMID: 33640205 DOI: 10.1016/j.clnu.2021.01.028] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute kidney disease (AKD) - which includes acute kidney injury (AKI) - and chronic kidney disease (CKD) are highly prevalent among hospitalized patients, including those in nephrology and medicine wards, surgical wards, and intensive care units (ICU), and they have important metabolic and nutritional consequences. Moreover, in case kidney replacement therapy (KRT) is started, whatever is the modality used, the possible impact on nutritional profiles, substrate balance, and nutritional treatment processes cannot be neglected. The present guideline is aimed at providing evidence-based recommendations for clinical nutrition in hospitalized patients with AKD and CKD. Due to the significant heterogeneity of this patient population as well as the paucity of high-quality evidence data, the present guideline is to be intended as a basic framework of both evidence and - in most cases - expert opinions, aggregated in a structured consensus process, in order to update the two previous ESPEN Guidelines on Enteral (2006) and Parenteral (2009) Nutrition in Adult Renal Failure. Nutritional care for patients with stable CKD (i.e., controlled protein content diets/low protein diets with or without amino acid/ketoanalogue integration in outpatients up to CKD stages four and five), nutrition in kidney transplantation, and pediatric kidney disease will not be addressed in the present guideline.
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Affiliation(s)
- Enrico Fiaccadori
- Nephrology Unit, Parma University Hospital, & Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Alice Sabatino
- Nephrology Unit, Parma University Hospital, & Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Rocco Barazzoni
- Internal Medicine, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Adamasco Cupisti
- Nephrology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Elisabeth De Waele
- Intensive Care, University Hospital Brussels (UZB), Department of Nutrition, UZ Brussel, Faculty of Medicine and Pharmacy, Vrije Unversiteit Brussel (VUB), Bruxelles, Belgium
| | | | - Pierre Singer
- General Intensive Care Department and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañon, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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28
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Chazot G, Lemoine S, Kocevar G, Kalbacher E, Sappey-Marinier D, Rouvière O, Juillard L. Intracellular Phosphate and ATP Depletion Measured by Magnetic Resonance Spectroscopy in Patients Receiving Maintenance Hemodialysis. J Am Soc Nephrol 2021; 32:229-237. [PMID: 33093193 PMCID: PMC7894675 DOI: 10.1681/asn.2020050716] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 09/13/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The precise origin of phosphate that is removed during hemodialysis remains unclear; only a minority comes from the extracellular space. One possibility is that the remaining phosphate originates from the intracellular compartment, but there have been no available data from direct assessment of intracellular phosphate in patients undergoing hemodialysis. METHODS We used phosphorus magnetic resonance spectroscopy to quantify intracellular inorganic phosphate (Pi), phosphocreatine (PCr), and βATP. In our pilot, single-center, prospective study, 11 patients with ESKD underwent phosphorus (31P) magnetic resonance spectroscopy examination during a 4-hour hemodialysis treatment. Spectra were acquired every 152 seconds during the hemodialysis session. The primary outcome was a change in the PCr-Pi ratio during the session. RESULTS During the first hour of hemodialysis, mean phosphatemia decreased significantly (-41%; P<0.001); thereafter, it decreased more slowly until the end of the session. We found a significant increase in the PCr-Pi ratio (+23%; P=0.001) during dialysis, indicating a reduction in intracellular Pi concentration. The PCr-βATP ratio increased significantly (+31%; P=0.001) over a similar time period, indicating a reduction in βATP. The change of the PCr-βATP ratio was significantly correlated to the change of depurated Pi. CONCLUSIONS Phosphorus magnetic resonance spectroscopy examination of patients with ESKD during hemodialysis treatment confirmed that depurated Pi originates from the intracellular compartment. This finding raises the possibility that excessive dialytic depuration of phosphate might adversely affect the intracellular availability of high-energy phosphates and ultimately, cellular metabolism. Further studies are needed to investigate the relationship between objective and subjective effects of hemodialysis and decreases of intracellular Pi and βATP content. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Intracellular Phosphate Concentration Evolution During Hemodialysis by MR Spectroscopy (CIPHEMO), NCT03119818.
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Affiliation(s)
- Guillaume Chazot
- Service de néphrologie et d’exploration fonctionnelle rénale, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Sandrine Lemoine
- Service de néphrologie et d’exploration fonctionnelle rénale, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France,CARMEN U1060 Institut National de la Santé et de la Recherche Médicale (Cardiovascular Metabolisme Nutrition), Université de Lyon, Université Claude Bernard, INSA de Lyon, Bron, France
| | - Gabriel Kocevar
- CREATIS (Centre de Recherche et d'Applications en Traitement de l'Image et du Signal) Unité Mixte de Recherche 5220 Centre National de la Recherche Scientifique and U1206 Institut National de la Santé et de la Recherche Médicale, Université de Lyon, Université Claude Bernard, INSA (Institut National Des Sciences Appliquées) de Lyon, Villeurbanne, France
| | - Emilie Kalbacher
- Service de néphrologie et d’exploration fonctionnelle rénale, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Dominique Sappey-Marinier
- CREATIS (Centre de Recherche et d'Applications en Traitement de l'Image et du Signal) Unité Mixte de Recherche 5220 Centre National de la Recherche Scientifique and U1206 Institut National de la Santé et de la Recherche Médicale, Université de Lyon, Université Claude Bernard, INSA (Institut National Des Sciences Appliquées) de Lyon, Villeurbanne, France,CERMEP-Imagerie du vivant (Centre d'Etude et de Recherche Médicale par Emission de Positons), Université de Lyon, Bron, France
| | - Olivier Rouvière
- Service de radiologie, Hôpital Édouard-Herriot, Hospices Civils de Lyon, Lyon, France,Labtau U1032 Institut National de la Santé et de la Recherche Médicale, Université de Lyon, Université Claude Bernard, Villeurbanne, France
| | - Laurent Juillard
- Service de néphrologie et d’exploration fonctionnelle rénale, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France,CARMEN U1060 Institut National de la Santé et de la Recherche Médicale (Cardiovascular Metabolisme Nutrition), Université de Lyon, Université Claude Bernard, INSA de Lyon, Bron, France
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29
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Reintam Blaser A, Gunst J, Ichai C, Casaer MP, Benstoem C, Besch G, Dauger S, Fruhwald SM, Hiesmayr M, Joannes-Boyau O, Malbrain MLNG, Perez MH, Schaller SJ, de Man A, Starkopf J, Tamme K, Wernerman J, Berger MM. Hypophosphatemia in critically ill adults and children - A systematic review. Clin Nutr 2020; 40:1744-1754. [PMID: 33268142 DOI: 10.1016/j.clnu.2020.09.045] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Phosphate is the main intracellular anion essential for numerous biological processes. Symptoms of hypophosphatemia are non-specific, yet potentially life-threatening. This systematic review process was initiated to gain a global insight into hypophosphatemia, associated morbidity and treatments. METHODS A systematic review was conducted (PROSPERO CRD42020163191). Nine clinically relevant questions were generated, seven for adult and two for pediatric critically ill patients, and prevalence of hypophosphatemia was assessed in both groups. We identified trials through systematic searches of Medline, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. Quality assessment was performed using the Cochrane risk of bias tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies. RESULTS For all research questions, we identified 2727 titles in total, assessed 399 full texts, and retained 82 full texts for evidence synthesis, with 20 of them identified for several research questions. Only 3 randomized controlled trials were identified with two of them published only in abstract form, as well as 28 prospective and 31 retrospective studies, and 20 case reports. Relevant risk of bias regarding selection and comparability was identified for most of the studies. No meta-analysis could be performed. The prevalence of hypophosphatemia varied substantially in critically ill adults and children, but no study assessed consecutive admissions to intensive care. In both critically ill adults and children, several studies report that hypophosphatemia is associated with worse outcome (prolonged length of stay and the need for respiratory support, and higher mortality). However, there was insufficient evidence regarding the optimal threshold upon which hypophosphatemia becomes critical and requires treatment. We found no studies regarding the optimal frequency of phosphate measurements, and regarding the time window to correct hypophosphatemia. In adults, nutrient restriction on top of phosphate repletion in patients with refeeding syndrome may improve survival, although evidence is weak. CONCLUSIONS Evidence on the definition, outcome and treatment of clinically relevant hypophosphatemia in critically ill adults and children is scarce and does not allow answering clinically relevant questions. High quality clinical research is crucial for the development of respective guidelines.
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Affiliation(s)
- Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Estonia; Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Jan Gunst
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, B-3000 Leuven, Belgium.
| | - Carole Ichai
- Mixed Intensive Care Unit, Université Côte d'Azur, Nice, France.
| | - Michael P Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, B-3000 Leuven, Belgium.
| | - Carina Benstoem
- Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, Aachen, Germany.
| | - Guillaume Besch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France.
| | - Stéphane Dauger
- Pediatric Intensive Care Unit, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Sonja M Fruhwald
- Department of Anesthesiology and Intensive Care Medicine, Division of Anesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria.
| | - Michael Hiesmayr
- Cardiac Thoracic Vascular Anaesthesia and Intensive Care, Medical University Vienna, Waehringerguertel 18-20, 1090 Vienna, Austria.
| | - Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation SUD, Hôpital Magellan, CHU de Bordeaux, Bordeaux, France.
| | - Manu L N G Malbrain
- Department Intensive Care Medicine, University Hospital Brussel (UZB), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Jette, Brussels, Belgium.
| | - Maria-Helena Perez
- Paediatric Intensive Care Unit, Department of Paediatrics, Division Women-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland.
| | - Stefan J Schaller
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine, Berlin, Germany.
| | | | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, University of Tartu, Estonia.
| | - Kadri Tamme
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, University of Tartu, Estonia.
| | - Jan Wernerman
- Department of Perioperative Medicine, Karolinska University Hospital Huddinge, CLINTEC Karolinska Institutet, Stockholm, Sweden.
| | - Mette M Berger
- Service of Adult Intensive care & Burns, Lausanne University Hospital, Lausanne, Switzerland.
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30
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Protein-Energy Wasting Assessment and Clinical Outcomes in Patients with Acute Kidney Injury: A Systematic Review with Meta-Analysis. Nutrients 2020; 12:nu12092809. [PMID: 32933198 PMCID: PMC7551057 DOI: 10.3390/nu12092809] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/23/2020] [Accepted: 09/10/2020] [Indexed: 12/13/2022] Open
Abstract
Nutritional assessment is essential to identify patients with acute kidney injury (AKI) who are protein-energy wasting (PEW) and at risk of poor clinical outcomes. This systematic review aimed to investigate the relationship of nutritional assessments for PEW with clinical outcomes in patients with AKI. A systematic search was performed in PubMed, Scopus, and Cochrane Library databases using search terms related to PEW, nutrition assessment, and AKI to identify prospective cohort studies that involved AKI adult patients with at least one nutritional assessment performed and reported relevant clinical outcomes, such as mortality, length of stay, and renal outcomes associated with the nutritional parameters. Seventeen studies reporting eight nutritional parameters for PEW assessment were identified and mortality was the main clinical outcome reported. A meta-analysis showed that PEW assessed using subjective global assessment (SGA) was associated with greater mortality risk (RR: 1.99, 95% CI: 1.36–2.91). Individual nutrition parameters, such as serum chemistry, body mass, muscle mass, and dietary intakes, were not consistently associated with mortality. In conclusion, SGA is a valid tool for PEW assessment in patients with AKI, while other nutrition parameters in isolation had limited validity for PEW assessment.
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31
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Cho AJ, Lee YK, Park HC. Impact of electrolyte-rich dialysate during continuous renal replacement therapy on serum phosphate and potassium in ICU patients. PLoS One 2020; 15:e0238867. [PMID: 32915900 PMCID: PMC7485827 DOI: 10.1371/journal.pone.0238867] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/25/2020] [Indexed: 12/04/2022] Open
Abstract
Background Hypophosphatemia and hypokalemia occur frequently during continuous renal replacement therapy (CRRT). We evaluated serum phosphate and potassium levels in patients administered three different types of dialysis solution. Methods The study population consisted of 324 intensive care unit patients who underwent CRRT between January 2015 and December 2018. Patients were divided into three groups: group 1 (n = 105) received Hemosol B0 (no potassium or phosphate); group 2 (n = 78) received Hemosol B0 and potassium-containing solution (MultiBic); and group 3 (n = 141) received phosphate- and potassium-containing solution (Phoxilium), Hemosol B2, Prismasol 2, and Prismasol 4. A different protocol was followed in each group. Results The incidence rate of hypophosphatemia was 55% lower in group 3 compared to group 1 (incidence rate ratio (IRR) 0.45, 95% confidence interval (CI): 0.33 to 0.61) and 61% lower compared to group 2 (IRR 0.39, 95% CI: 0.29 to 0.53). Group 3 also had a 50% lower incidence rate of hypokalemia compared to group 1 (IRR 0.50, 95% CI: 0.29 to 0.88). The negative slope in phosphate level in group 3 was greater than that in group 1 (ß = 0.19, 95% CI: 0.02 to 0.37, p = 0.032), while the negative slope in the potassium level was greater in group 2 than in group 1(ß = 0.10, 95% CI: 0.03 to 0.17, p = 0.008). Additional intravenous calcium was not used in any case, and most cases of acid-base disturbances were well controlled. Conclusions The use of phosphate- and potassium-containing with a proper CRRT protocol prevented decreases in serum phosphate and potassium levels, thus also preventing hypophosphatemia and hypokalemia, and additional replacement during CRRT.
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Affiliation(s)
- AJin Cho
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Young-Ki Lee
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Hayne Cho Park
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
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32
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Sin JCK, King L, Ballard E, Llewellyn S, Laupland KB, Tabah A. Hypophosphatemia and Outcomes in ICU: A Systematic Review and Meta-Analysis. J Intensive Care Med 2020; 36:1025-1035. [PMID: 32783487 DOI: 10.1177/0885066620940274] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE Hypophosphatemia is reported in up to 5% of hospitalized patients and ranges from 20% to 80% in critically ill patients. The consequences of hypophosphatemia for critically ill patients remain controversial. We evaluated the effect of hypophosphatemia on mortality and length of stay in intensive care unit (ICU) patients. METHODS MEDLINE, EMBASE, Cochrane Library (Reviews and Trials), and PubMed were searched for articles in English. The primary outcome was mortality and secondary outcome was length of stay. The quality of evidence was graded using a modified Newcastle-Ottawa Scale. RESULTS Our search yielded 828 articles and ultimately included 12 studies with 7626 participants in the analysis. Hypophosphatemia was associated with increased hospital length of stay (2.19 days [95% CI, 1.74-2.64]) and ICU length of stay (2.22 days [95% CI, 1.00-3.44]) but not mortality (risk ratio: 1.13 [95% CI, 0.98-1.31]; P = .09). CONCLUSIONS Hypophosphatemia in ICU was associated with increased hospital and ICU length of stay but not all-cause mortality. Hypophosphatemia appears to be a marker of disease severity. Limited number of available studies and varied study designs did not allow for the ascertainment of the effect of severe hypophosphatemia on patient mortality.
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Affiliation(s)
- Jeremy Cheuk Kin Sin
- Intensive Care Unit, 60077Redcliffe Hospital, Redcliffe, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Lillian King
- Intensive Care Unit, 60077Redcliffe Hospital, Redcliffe, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Emma Ballard
- 56362QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Stacey Llewellyn
- 56362QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Kevin B Laupland
- 550021Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Queensland University of Technology, Brisbane, Queensland, Australia
| | - Alexis Tabah
- Intensive Care Unit, 60077Redcliffe Hospital, Redcliffe, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Krebs ED, Chancellor WZ, Beller JP, Mehaffey JH, Hawkins RB, Sawyer RG, Yarboro LT, Ailawadi G, Teman NR. Long-term Implications of Tracheostomy in Cardiac Surgery Patients: Decannulation and Mortality. Ann Thorac Surg 2020; 111:594-599. [PMID: 32619618 DOI: 10.1016/j.athoracsur.2020.05.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/01/2020] [Accepted: 05/07/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The long-term implications of tracheostomy in cardiac surgical patients are largely unknown. We sought to investigate outcomes including decannulation and long-term mortality in a population of post-cardiac surgery patients. METHODS All patients undergoing cardiac surgery at a single institution between 1997 and 2016 were evaluated for postoperative tracheostomy placement, time to decannulation, and mortality. Patients were stratified by tracheostomy placement, as well as by successful decannulation for comparison. Kaplan-Meier analysis identified time to decannulation and mortality and a Fine-Gray's competing risk regression, accounting for mortality, identified predictors of time to decannulation. RESULTS Of 14,600 total cardiac surgery patients, only 309 required tracheostomy. Patients with tracheostomy had high rates of perioperative comorbidities, including 60% with heart failure and 24% with postoperative stroke. Tracheostomy patients had high short-term and long-term mortality, with a median survival of 152 days, 1-year survival of 41%, and 5-year survival of 29.1%. Patients remained with tracheostomy in place for a median of 59 days, with a 1-year decannulation rate of 80% in living patients. Patients with older age (hazard ratio 0.98, P = .01), chronic lung disease (hazard ratio 0.66, P = .03), and preoperative or postoperative dialysis (hazard ratio 0.45, P < .01) were less likely to have their tracheostomy removed. CONCLUSIONS Tracheostomy is associated with poor long-term survival of cardiac surgery patients. However, patients who do survive have a short duration of tracheostomy with almost all surviving patients eventually decannulated. This finding provides valuable information for pre-procedural counseling for these high-risk patients and their families.
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Affiliation(s)
- Elizabeth D Krebs
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
| | - William Z Chancellor
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Jared P Beller
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan
| | - Leora T Yarboro
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Nicholas R Teman
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
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34
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Sharma S, Kelly YP, Palevsky PM, Waikar SS. Intensity of Renal Replacement Therapy and Duration of Mechanical Ventilation: Secondary Analysis of the Acute Renal Failure Trial Network Study. Chest 2020; 158:1473-1481. [PMID: 32470389 DOI: 10.1016/j.chest.2020.05.542] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 05/06/2020] [Accepted: 05/19/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Randomized clinical trials have failed to show benefit from increasing intensity of renal replacement therapy (RRT) for acute kidney injury, but continue to be frequently used. In addition, intensive RRT is associated with an increase in adverse events potentially secondary to small solute losses, such as phosphate. We hypothesized that, compared with less-intensive RRT, intensive RRT would lead to longer duration of mechanical ventilation. RESEARCH QUESTION Does more-intensive renal replacement therapy in critically ill patients with acute kidney injury increase time to extubation from mechanical ventilation when compared with less-intensive therapy? STUDY DESIGN AND METHODS The Acute Renal Failure Trial Network study was a randomized multicenter trial of more-intensive (hemodialysis or sustained low-efficiency dialysis six times per week or continuous venovenous hemodiafiltration at 35 mL/kg per hour) vs less-intensive (hemodialysis or sustained low-efficiency dialysis three times per week or continuous venovenous hemodiafiltration at 20 mL/kg per hour) RRT in critically ill patients with acute kidney injury. Of 1124 patients, 907 who were supported by mechanical ventilation on study initiation were included in this Cox-proportional hazards analysis. The primary outcome was the time to first successful extubation off mechanical ventilation. RESULTS Patients who were assigned randomly to more-intensive RRT had a 33.3% lower hazard rate of successful extubation (hazard ratio, 0.67; 95% CI, 0.52-0.88; P < .001) when compared with patients who were assigned to less-intensive RRT. Patients who were assigned to more-intensive RRT had, on average, 2.07 ventilator-free days, compared with 3.08 days in those who were assigned to less-intensive RRT (P < .001) over 14 days from start of the study. INTERPRETATION Critically ill mechanically ventilated patients who were assigned randomly to more-intensive RRT had longer duration of mechanical ventilation compared with those who were assigned to less-intensive RRT. The reasons for this, such as excessive phosphate loss from more-intensive RRT, deserve further study to optimize the safety and effectiveness of CRRT delivery. This was a post hoc analysis of the Acute Renal Failure Trial Network study; clinical trial registration of the original trial is NCT00076219.
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Affiliation(s)
- Shilpa Sharma
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA; Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, CA.
| | - Yvelynne P Kelly
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Paul M Palevsky
- Renal Section, Veterans Affairs Pittsburgh Healthcare System, and the Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Sushrut S Waikar
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, MA
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35
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Schiffl H. Intensity of renal replacement therapy and outcomes in critically ill patients with acute kidney injury: Critical appraisal of the dosing recommendations. Ther Apher Dial 2020; 24:620-627. [PMID: 31904909 DOI: 10.1111/1744-9987.13471] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 11/17/2019] [Accepted: 01/03/2020] [Indexed: 11/27/2022]
Abstract
The current care of critically ill patients with severe acute kidney injury requiring dialysis (AKI-D) is limited to supportive management in which renal replacement therapy (RRT) plays a central role. Renal replacement techniques are invasive bioincompatible procedures and are therefore associated with complications that may prove harmful to fragile patients. Inexperience with the standards and lacking or misinterpreted recommendations for the delivery of the RRT dose increases the risk of serious complications. Neither the optimal doses of intermittent or continuous RRTs nor the minimal or maximal effective doses are known. The Kidney Disease Improving Global outcomes (KDIGO) AKI guidelines for RRT dosing recommendations are inflexible, based on limited research, and may be at least partially outdated. High-intensity therapy may be associated with clinically relevant alterations in systemic and renal hemodynamics, profound electrolyte imbalances, the loss of nutrients or thermal energy, and underdosing of antimicrobial agents. However, higher doses of continuous renal replacement therapy (CRRT) may confer a survival benefit for certain subgroups of intensive care patients with severe AKI. Lower CRRT doses than the recommended adequate dosage may not lead to negative health outcomes, at least in Asian patients. Future research should evaluate the demand-capacity concept, recognizing that the delivery of the RRT dose is dynamic and should be modified in response to patient-related factors. There is a need for large-scale studies evaluating whether precision RRT dose modifications may improve patient-centered outcomes in subgroups of critically ill patients.
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Affiliation(s)
- Helmut Schiffl
- Department of Internal Medicine IV, Section of Nephrology, University Hospital Munich, Munich, Germany
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36
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Han SA, Park HY, Kim HW, Choi JI, Kang DY, Kim HL, Chung JH, Shin BC. Severe Hypophosphatemia-Induced Acute Toxic-Metabolic Encephalopathy in Continuous Renal Replacement Therapy. Electrolyte Blood Press 2019; 17:62-65. [PMID: 31969925 PMCID: PMC6962441 DOI: 10.5049/ebp.2019.17.2.62] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/02/2019] [Accepted: 12/09/2019] [Indexed: 11/23/2022] Open
Abstract
Acute toxic-metabolic encephalopathy (TME) is an acute condition of global cerebral dysfunction in the absence of primary structural brain disease. Severe hypophosphatemia leads to muscle weakness and involves the diaphragm but hypophosphatemia-induced TME is very rare. Herein, we report the case of a 43-year-old woman with encephalopathy with severe hypophosphatemia during continuous renal replacement therapy. She presented with features of oliguric acute kidney injury on diabetic kidney disease due to volume depletion. At admission, her mental status was alert but gradually changed to stupor mentation during continuous renal replacement therapy. Her phosphate level was less than 0.41 mEq/L and Glasgow coma scale decreased from 15 to 5. After phosphate intravenous replacement and administration of phosphate-containing replacement solution, the phosphate level increased to 2.97 mEq/L and mental state returned to alert state. This case demonstrates that the level of phosphorus should be observed during continuous renal replacement therapy.
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Affiliation(s)
- Sun Ae Han
- Department of Internal Medicine, Chosun University Medical School, Gwangju, Korea
| | - Ha Yeol Park
- Department of Internal Medicine, Chosun University Medical School, Gwangju, Korea
| | - Hyun Woo Kim
- Department of Internal Medicine, Chosun University Medical School, Gwangju, Korea
| | - Jong In Choi
- Department of Internal Medicine, Chosun University Medical School, Gwangju, Korea
| | - Da Yeong Kang
- Department of Internal Medicine, Chosun University Medical School, Gwangju, Korea
| | - Hyun Lee Kim
- Department of Internal Medicine, Chosun University Medical School, Gwangju, Korea
| | - Jong Hoon Chung
- Department of Internal Medicine, Chosun University Medical School, Gwangju, Korea
| | - Byung Chul Shin
- Department of Internal Medicine, Chosun University Medical School, Gwangju, Korea
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Pistolesi V, Zeppilli L, Fiaccadori E, Regolisti G, Tritapepe L, Morabito S. Hypophosphatemia in critically ill patients with acute kidney injury on renal replacement therapies. J Nephrol 2019; 32:895-908. [PMID: 31515724 DOI: 10.1007/s40620-019-00648-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/06/2019] [Indexed: 02/08/2023]
Abstract
Hypophosphatemia is a common but often underestimated electrolyte derangement among intensive care unit (ICU) patients. Low phosphate levels can lead to cellular dysfunction with potentially relevant clinical manifestations (e.g., muscle weakness, respiratory failure, lethargy, confusion, arrhythmias). In critically ill patients with severe acute kidney injury (AKI) renal replacement therapies (RRTs) represent a well-known risk factor for hypophosphatemia, especially if the most intensive and prolonged modalities of RRT, such as continuous RRT or prolonged intermittent RRT, are used. Currently, no evidence-based specific guidelines are available for the treatment of hypophosphatemia in the critically ill; however, considering the potentially negative impact of hypophosphatemia on morbidity and mortality, strategies aimed at reducing its incidence and severity should be timely implemented in the ICUs. In the clinical setting of critically ill patients on RRT, the most appropriate strategy could be to anticipate the onset of RRT-related hypophosphatemia by implementing the use of phosphate-containing solutions for RRT through specifically designed protocols. The present review is aimed at summarizing the most relevant evidence concerning epidemiology, prognostic impact, prevention and treatment of hypophosphatemia in critically ill patients with AKI on RRT, with a specific focus on RRT-induced hypophosphatemia.
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Affiliation(s)
- Valentina Pistolesi
- UO Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università di Roma, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Laura Zeppilli
- UO Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università di Roma, Viale del Policlinico, 155, 00161, Rome, Italy.,UOC Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Giuseppe Regolisti
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Luigi Tritapepe
- UO Anestesia e Terapia Intensiva in Cardiochirurgia, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università di Roma, Rome, Italy
| | - Santo Morabito
- UO Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università di Roma, Viale del Policlinico, 155, 00161, Rome, Italy
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Murugan R, Kerti SJ, Chang CCH, Gallagher M, Clermont G, Palevsky PM, Kellum JA, Bellomo R. Association of Net Ultrafiltration Rate With Mortality Among Critically Ill Adults With Acute Kidney Injury Receiving Continuous Venovenous Hemodiafiltration: A Secondary Analysis of the Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy Trial. JAMA Netw Open 2019; 2:e195418. [PMID: 31173127 PMCID: PMC6563576 DOI: 10.1001/jamanetworkopen.2019.5418] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
IMPORTANCE Net ultrafiltration (NUF) is frequently used to treat fluid overload among critically ill patients, but whether the rate of NUF affects outcomes is unclear. OBJECTIVE To examine the association of NUF with survival among critically ill patients with acute kidney injury being treated with continuous venovenous hemodiafiltration. DESIGN, SETTING, AND PARTICIPANTS The Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy trial was conducted between December 30, 2005, and November 28, 2008, at 35 intensive care units in Australia and New Zealand among critically ill adults with acute kidney injury who were being treated with continuous venovenous hemodiafiltration. This secondary analysis began in May 2018 and concluded in January 2019. EXPOSURES Net ultrafiltration rate, defined as the volume of fluid removed per hour adjusted for patient body weight. MAIN OUTCOMES AND MEASURES Risk-adjusted 90-day survival. RESULTS Of 1434 patients, the median (interquartile range) age was 67.3 (56.9-76.3) years; 924 participants (64.4%) were male; median (interquartile range) Acute Physiology and Chronic Health Evaluation III score was 100 (84-118); and 634 patients (44.2%) died. Using tertiles, 3 groups were defined: high, NUF rate greater than 1.75 mL/kg/h; middle, NUF rate from 1.01 to 1.75 mL/kg/h; and low, NUF rate less than 1.01 mL/kg/h. The high-tertile group compared with the low-tertile group was not associated with death from day 0 to 6. However, death occurred in 51 patients (14.7%) in the high-tertile group vs 30 patients (8.6%) in the low-tertile group from day 7 to 12 (adjusted hazard ratio [aHR], 1.51; 95% CI, 1.13-2.02); 45 patients (15.3%) in the high-tertile group vs 25 patients (7.9%) in the low-tertile group from day 13 to 26 (aHR, 1.52; 95% CI, 1.11-2.07); and 48 patients (19.2%) in the high-tertile group vs 29 patients (9.9%) in the low-tertile group from day 27 to 90 (aHR, 1.66; 95% CI, 1.16-2.39). Every 0.5-mL/kg/h increase in NUF rate was associated with increased mortality (3-6 days: aHR, 1.05; 95% CI, 1.00-1.11; 7-12 days: aHR, 1.08; 95% CI, 1.02-1.15; 13-26 days: aHR, 1.11; 95% CI, 1.04-1.18; 27-90 days: aHR, 1.13; 95% CI, 1.05-1.22). Using longitudinal analyses, increase in NUF rate was associated with lower survival (β = .056; P < .001). Hypophosphatemia was more frequent among patients in the high-tertile group compared with patients in the middle-tertile group and patients in the low-tertile group (high: 308 of 477 patients at risk [64.6%]; middle: 293 of 472 patients at risk [62.1%]; low: 247 of 466 patients at risk [53.0%]; P < .001). Cardiac arrhythmias requiring treatment occurred among all groups: high, 176 patients (36.8%); middle: 175 patients (36.5%); and low: 147 patients (30.8%) (P = .08). CONCLUSIONS AND RELEVANCE Among critically ill patients, NUF rates greater than 1.75 mL/kg/h compared with NUF rates less than 1.01 mL/kg/h were associated with lower survival. Residual confounding may be present from unmeasured risk factors, and randomized clinical trials are required to confirm these findings. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00221013.
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Affiliation(s)
- Raghavan Murugan
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Samantha J. Kerti
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Chung-Chou H. Chang
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Martin Gallagher
- The George Institute for Global Health and University of Sydney, Sydney, New South Wales, Australia
| | - Gilles Clermont
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paul M. Palevsky
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Renal Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - John A. Kellum
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, Austin Hospital, The University of Melbourne, Melbourne, Victoria, Australia
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Wang L, Xiao C, Chen L, Zhang X, Kou Q. Impact of hypophosphatemia on outcome of patients in intensive care unit: a retrospective cohort study. BMC Anesthesiol 2019; 19:86. [PMID: 31122196 PMCID: PMC6533764 DOI: 10.1186/s12871-019-0746-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/26/2019] [Indexed: 01/29/2023] Open
Abstract
Background Hypophosphatemia generally occurs in Intensive Care Units (ICUs), but its impact is often ignored. The aim of this study was to investigate whether hypophosphatemia can be a risk factor for ICU 28-day mortality. Methods A single-center retrospective cohort study was conducted by collecting data from 1073 patients admitted to general ICU and then presented to the Sixth Affiliated Hospital, Sun Yat-sen University (Guangzhou City, Guangdong Province, China) from 1 January 2016 to 31 December 2017. The patients were divided into a normal control group (serum phosphate levels 0.80–1.60 mmol/L) and a hypophosphatemia group (serum phosphate levels < 0.80 mmol/L), based on the concentration of phosphorus at the time of ICU admission. The association between phosphate levels and ICU 28-day mortality was evaluated by binary logistic regression analysis. Multivariate logistic regression was employed to predict the ICU 28-day mortality. Results The cohort included 946 patients with a median phosphate concentration of 0.77 mmol/L (interquartile range 0.55–1.03 mmol/L). Patients with hypophosphatemia had a higher ICU 28-day mortality than the normal control group (33.3% vs 24.0%, P < 0.05). Patients with hypophosphatemia had a longer ICU and hospital stays, and prolonged duration of mechanical ventilation (all P < 0.05). Hypophosphatemia was an independent risk factor for ICU 28-day mortality (adjusted OR = 1.5, 95% CI = 1.1–2.1, P = 0.01) in the multivariate logistic regression analysis. Conclusions Hypophosphatemia at admission is an independent risk factor for 28-day mortality in general ICU patients. Trial registration The medical study was approved by the Institutional Ethics Committee of the Six Affiliated Hospital, Sun Yat-sen University (Approval number: 2017ZSLYEC-110). No consent was given as the data were analyzed anonymously.
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Affiliation(s)
- Lichun Wang
- Department of Intensive Care Unit, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510655, China
| | - Chaoxing Xiao
- Department of Intensive Care Unit, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510655, China
| | - Lei Chen
- Department of Intensive Care Unit, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510655, China
| | - Xiaofei Zhang
- Department of Intensive Care Unit, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510655, China
| | - Qiuye Kou
- Department of Intensive Care Unit, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510655, China.
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Song YH, Seo EH, Yoo YS, Jo YI. Phosphate supplementation for hypophosphatemia during continuous renal replacement therapy in adults. Ren Fail 2019; 41:72-79. [PMID: 30909778 PMCID: PMC6442196 DOI: 10.1080/0886022x.2018.1561374] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Hypophosphatemia is common during continuous renal replacement therapy (CRRT) in critically ill patients and can cause generalized muscle weakness, prolonged respiratory failure, and myocardial dysfunction. This study aimed to investigate the efficacy and safety of adding phosphate to the dialysate and replacement solutions to treat hypophosphatemia occurring in intensive CRRT in critically ill patients. Methods: We retrospectively analyzed 73 patients treated with intensive CRRT (effluent flow ≥35 ml/kg/hr) in the intensive care unit. The control group (group 1, n = 22) received no phosphate supplementation. The treatment groups received dialysate and replacement solution phosphate supplementation at 2.0 mmol/L (group 2, n = 26) or 3.0 mmol/L (group 3, n = 25). Results: The CRRT-induced hypophosphatemia incidence was 59.0%. Correction of hypophosphatemia with phosphate supplementation changed the mean serum phosphorus levels to 1.24 ± 0.37 and 1.44 ± 0.31 mmol/L in groups 2 and 3, respectively (p = .02). The time required for correction was 1.65 ± 0.80 and 1.39 ± 1.43 days for groups 2 and 3, respectively and was significantly longer in group 2 (p = .02). After supplementation, hypophosphatemia, and hyperphosphatemia both occurred in 7% of group 2. Group 3 developed no hypophosphatemia, but 20% developed hyperphosphatemia. The serum phosphate levels in hyperphosphatemia cases returned to normal within 2.0 days (group 2) and 1.0 day (group 3) after stopping phosphate supplementation. Conclusion: Phosphate supplementation effectively corrected CRRT-induced hypophosphatemia in critically ill patients with an acute kidney injury. The use of 2 mmol/L phosphate is appropriate in patients with CRRT-induced hypophosphatemia, but a different concentration could be required to prevent hypophosphatemia at the start of CRRT.
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Affiliation(s)
- Young-Hye Song
- a Dialysis Center , Konkuk University Medical Center , Seoul , Korea
| | - Eun-Hye Seo
- b Department of Cellular and Molecular Medicine , Konkuk University School of Medicine , Seoul , Korea
| | - Yang-Sook Yoo
- c College of Nursing , The Catholic University of Korea , Seoul , Korea
| | - Young-Il Jo
- a Dialysis Center , Konkuk University Medical Center , Seoul , Korea.,d Division of Nephrology , Konkuk University School of Medicine , Seoul , Korea
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Druml W, Joannidis M, John S, Jörres A, Schmitz M, Kielstein J, Kindgen-Milles D, Oppert M, Schwenger V, Willam C, Zarbock A. [Metabolic management and nutrition in critically ill patients with renal dysfunction : Recommendations from the renal section of the DGIIN, ÖGIAIN, and DIVI]. Med Klin Intensivmed Notfmed 2018; 113:393-400. [PMID: 29725741 DOI: 10.1007/s00063-018-0427-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/19/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Intensive care patients with renal failure or insufficiency comprise a heterogeneous group of subjects with widely differing metabolic patterns and nutritional requirements. They include subjects with various stages of acute kidney injury (AKI), acute-on-chronic renal failure (A-CKD), without/with renal replacement therapy (RRT), chronic kidney disease (CKD), and subjects on regular hemodialysis or peritoneal dialysis therapy (HD/PD). GOALS Development of recommendations by the renal section of DGIIN (Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichische Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) for the metabolic management and the planning, indication, implementation, and monitoring of nutrition therapy in this heterogeneous group of patients. MATERIALS AND METHODS The recommendations are based on recent evidence and current recommendations of DGEM (Deutsche Gesellschaft für Ernährungsmedizin), ASPEN (American Society for Parenteral and Enteral Nutrition) and ESPEN (European Society for Clinical Nutrition and Metabolism) and also the KDGIO (Kidney Disease: Improving Global Outcomes) clinical practice guidelines for AKI and the expert knowledge and clinical experience of the authors. RESULTS Nutrition support in these patient groups is not fundamentally different from that in other disease states but must consider the multiple variations in metabolism and nutrient requirements. Nutrition therapy must be adapted to the stage of disease and especially, in those patients on RRT. Nutritional needs can differ widely between patients but also in the same patient during the course of the disease. CONCLUSIONS Thus, the patient with renal failure requires an individualized approach in nutrition support and because of the altered metabolism of many nutrients and intolerances for electrolytes and fluids, the nutrition support in patients with renal insufficiency requires close clinical and laboratory monitoring.
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Affiliation(s)
- W Druml
- Klinik für Innere Medizin III, Abteilung für Nephrologie, Allgemeines Krankenhaus Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - M Joannidis
- Gemeinsame Einrichtung Internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - S John
- Abteilung Internistische Intensivmedizin, Medizinische Klinik 8, Paracelsus Medizinische Privatuniverstität Nürnberg, Universität Erlangen-Nürnberg, Klinikum Nürnberg-Süd, Nürnberg, Deutschland
| | - A Jörres
- Medizinische Klinik I für Nephrologie, Transplantationsmedizin und internistische Intensivmedizin, Klinikum der Universität Witten/Herdecke, Köln-Merheim, Deutschland
| | - M Schmitz
- Klinik für Nephrologie, Städtisches Klinikum Solingen, Solingen, Deutschland
| | - J Kielstein
- Medizinische Klinik V, Nephrologie | Rheumatologie | Blutreinigungsverfahren, Städtisches Klinikum Braunschweig, Braunschweig, Deutschland
| | - D Kindgen-Milles
- Klinik für Anästhesiologie Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
- Medizinische Klinik, Abteilung Klinische Pharmakologie und Pharmakoepidemiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Oppert
- Klinik für Notfall- und internistische Intensivmedizin, Klinikum Ernst von Bergmann, Potsdam, Deutschland
| | - V Schwenger
- Klinik für Nieren‑, Hochdruck- und Autoimmunerkrankungen, Klinikum Stuttgart, Stuttgart, Deutschland
| | - C Willam
- Medizinische Klinik 4, Nephrologie und Hypertensiologie, Erlangen, Deutschland
| | - A Zarbock
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
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Federspiel CK, Itenov TS, Thormar K, Liu KD, Bestle MH. Hypophosphatemia and duration of respiratory failure and mortality in critically ill patients. Acta Anaesthesiol Scand 2018; 62:1098-1104. [PMID: 29687440 DOI: 10.1111/aas.13136] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 03/13/2018] [Accepted: 03/30/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hypophosphatemia has been associated with prolonged duration of respiratory failure and increased mortality in critically ill patients, but there is very limited evidence supporting the negative effects of low phosphate. We examined the association between hypophosphatemia at ICU admission and time to successful weaning and 28-day mortality. METHODS This was a cohort study that included all mechanically ventilated adult patients admitted to the ICU in 2013 at Nordsjaellands Hospital. Hypophosphatemia was defined as a serum level below 0.80 mmol/L. Multivariate Cox-regression was used to evaluate the effect of hypophosphatemia on mechanical ventilation and 28-day mortality. Multiple imputation was used to adjust for missing values. RESULTS A total of patients were admitted during the study period, of whom 190 were eligible. 122 (64.2%) had serum phosphate levels measured during the first 24 hours of admission, of whom 25 (20.5%) were found to be hypophosphatemic. About 74% of patients were successfully weaned from the ventilator within 28 days. Hypophosphatemia was not associated with this outcome (HR: 0.56; 95% CI: 0.30-1.04; P = .067). All-cause 28-day mortality was 32.6%. Hypophosphatemia was also not associated with 28-day mortality (HR: 1.64; 95% CI: 0.65-4.17; P = .447). Similar results were present in supplementary analysis where missing data were included by means of multiple imputation. CONCLUSION Hypophosphatemia at ICU admission was not associated with prolonged respiratory failure nor mortality. Further studies are warranted, where phosphate is measured systematically on all patients to elucidate the effect of low phosphate on relevant outcomes.
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Affiliation(s)
- C K Federspiel
- Department of Anaesthesiology, Nordsjaellands Hospital, Hillerød, University of Copenhagen, Hillerød, Denmark
| | - T S Itenov
- Department of Anaesthesiology, Nordsjaellands Hospital, Hillerød, University of Copenhagen, Hillerød, Denmark
| | - K Thormar
- Department of Anaesthesiology, Landspítali Háskólasjúkrahús, Reykjavík, Iceland
| | - K D Liu
- Departments of Medicine and Anesthesia, University of California, San Francisco, CA, USA
| | - M H Bestle
- Department of Anaesthesiology, Nordsjaellands Hospital, Hillerød, University of Copenhagen, Hillerød, Denmark
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[Extracorporeal renal replacement therapy in acute kidney injury : Recommendations from the renal section of the DGIIN, ÖGIAIN and DIVI]. Med Klin Intensivmed Notfmed 2018; 113:370-376. [PMID: 29546449 DOI: 10.1007/s00063-018-0418-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/27/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication in intensive care unit (ICU) patients. The incidence of AKI in ICU patients exceeds 50% and the associated morbidity and mortality rates increase with severity of AKI. In addition, long-term consequences of AKI are underestimated and several studies show impaired long-term outcome after AKI. In about 5-25% of ICU patients with AKI renal replacement therapy (RRT) is required. OBJECTIVES To assist in indication, timing, modality and application of renal replacement therapy of adult patients, current recommendations from the renal sections of the DGIIN (Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin) are stated. MATERIALS AND METHODS The recommendations stated in this paper are based on the current KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, recommendations from the 17th Acute Disease Quality Initiative (ADQI) Consensus Group, the French Intensive Care Society (SRLF) with the French Society of Anesthesia Intensive Care (SFAR) and the expert knowledge and clinical experience of the authors. RESULTS Today, different treatment modalities for RRT are available. Although continuous RRT and intermittent dialysis therapy as well as continuous dialysis therapy have comparable outcomes, differences exist with respect to practical application as well as health-economic aspects. Individualized risk stratification might be helpful to choose the right time to start and the right treatment modality for patients.
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Miller CJ, Doepker BA, Springer AN, Exline MC, Phillips G, Murphy CV. Impact of Serum Phosphate in Mechanically Ventilated Patients With Severe Sepsis and Septic Shock. J Intensive Care Med 2018. [DOI: 10.1177/0885066618762753] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Hypo- and hyperphosphatemia are common in severe sepsis and septic shock. Published outcome data in patients with phosphate derangements primarily focus on hypophosphatemia and the general critically ill population. This study aimed to determine the impact of serum phosphate on clinical outcomes in patients with severe sepsis and septic shock. Methods: A retrospective cohort analysis of adult mechanically ventilated patients with severe sepsis or septic shock was performed. Patients were randomly selected from an internal intensive care unit (ICU) database at an academic medical center in the United States and screened for inclusion and exclusion criteria. Time-weighted phosphate was calculated using all phosphate measurements obtained during ICU admission. The associations between time-weighted phosphate and duration of mechanical ventilation, 28-day mortality, and ICU and hospital length of stay were evaluated using linear or logistic regression as appropriate. Results: One-hundred ninety-seven patients were evaluated: 33 were categorized as hypophosphatemia, 123 as normophosphatemia, and 41 as hyperphosphatemia. Patients with time-weighted hyperphosphatemia had a higher Simplified Acute Physiology Score III score and incidence of septic shock. Significantly higher rates of 28-day mortality were observed among those with time-weighted phosphate levels above 3.5 mg/dL. However, both time-weighted hypo- and hyperphosphatemia were associated with decreased duration of mechanical ventilation. For every 0.5 mg/dL increase in time-weighted phosphate referent values from 4.0 to 6.0, the duration of mechanical ventilation decreased by 8% to 26%. For every 0.5 mg/dL decrease in time-weighted phosphate referent values from 3.0 to 1.0, significant decreases in duration of mechanical ventilation ranged from 14% to 41%. Conclusion: Time-weighted hyperphosphatemia may be associated with increased mortality in mechanically ventilated patients with severe sepsis or septic shock. However, time-weighted hypo- and hyperphosphatemia were associated with decreased duration of mechanical ventilation. Future studies should further describe the impact of hypo- and hyperphosphatemia on clinical outcomes among critically ill patients with severe sepsis or septic shock.
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Affiliation(s)
| | - Bruce A. Doepker
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Andrew N. Springer
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Matthew C. Exline
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gary Phillips
- Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Claire V. Murphy
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Heung M, Mueller BA. Prevention of hypophosphatemia during continuous renal replacement therapy-An overlooked problem. Semin Dial 2018; 31:213-218. [PMID: 29405468 DOI: 10.1111/sdi.12677] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hypophosphatemia is a common and potentially serious complication occurring during continuous renal replacement therapy (CRRT). Phosphate supplementation is required in the vast majority of patients undergoing CRRT, particularly beyond the first 48 hours. Supplementation can be provided either as a standalone oral or parenteral treatment or as an additive to CRRT solutions. Each approach has advantages and disadvantages, and clinicians must weigh the individual factors most relevant in their practice setting. Currently there are no consensus protocols for phosphate replacement in CRRT, and many centers replete phosphate in response to hypophosphatemia as opposed to pre-emptively. Repletion protocols have also been challenged in recent years by shortages in injectable phosphate solutions. More recently a commercially available phosphate-containing CRRT solution was approved in the United States, but there has been limited clinical experience with this product. In this review, we present recommendations for phosphate repletion in CRRT to prevent hypophosphatemia, and describe our experience using phosphate-containing CRRT solutions.
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Affiliation(s)
- Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Bruce A Mueller
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
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Kim SY, Kim YN, Shin HS, Jung Y, Rim H. The influence of hypophosphatemia on outcomes of low- and high-intensity continuous renal replacement therapy in critically ill patients with acute kidney injury. Kidney Res Clin Pract 2017; 36:240-249. [PMID: 28904875 PMCID: PMC5592891 DOI: 10.23876/j.krcp.2017.36.3.240] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/19/2017] [Accepted: 04/20/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess the role of hypophosphatemia in major clinical outcomes of patients treated with low- or high-intensity continuous renal replacement therapy (CRRT). METHODS We performed a retrospective analysis of data collected from 492 patients. We divided patients into two CRRT groups based on treatment intensity (greater than or equal to or less than 40 mL/kg/hour of effluent generation) and measured serum phosphate level daily during CRRT. RESULTS We obtained a total of 1,440 phosphate measurements on days 0, 1, and 2 and identified 39 patients (7.9%), 74 patients (15.0%), and 114 patients (23.1%) with hypophosphatemia on each of these respective days. In patients treated with low-intensity CRRT, there were 23 episodes of hypophosphatemia/1,000 patient days, compared with 83 episodes/1,000 patient days in patients who received high-intensity CRRT (P < 0.01). Multiple Cox proportional hazards analysis showed that Acute Physiology and Chronic Health Evaluation (APACHE) III score, utilization of vasoactive drugs, and arterial pH on the second day of CRRT were significant predictors of mortality, while serum phosphate level was not a significant contributor to mortality. CONCLUSION APACHE score, use of vasoactive drugs, and arterial pH on the second CRRT day were identified as significant predictors of mortality. Hypophosphatemia might not be a major risk factor of increased mortality in patients treated with CRRT.
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Affiliation(s)
- Soo Young Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Ye Na Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Ho Sik Shin
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Yeonsoon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Hark Rim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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Broman M, Wilsson AMJ, Hansson F, Klarin B. Analysis of Hypo- and Hyperphosphatemia in an Intensive Care Unit Cohort. Anesth Analg 2017; 124:1897-1905. [DOI: 10.1213/ane.0000000000002077] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Aziz F, Chaudhary K. Life threatening nutritional deficiencies in a dialysis patient. Hemodial Int 2017; 21:E50-E53. [DOI: 10.1111/hdi.12529] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Fahad Aziz
- Division of Nephrology; University of Missouri Health Science Center; Columbia Missouri 65212
| | - Kunal Chaudhary
- Division of Nephrology; University of Missouri Health Science Center; Columbia Missouri 65212
- Nephrology Section; Harry S Truman Veterans' Hospital; Columbia Missouri 65212
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Lim C, Tan HK, Kaushik M. Hypophosphatemia in critically ill patients with acute kidney injury treated with hemodialysis is associated with adverse events. Clin Kidney J 2017; 10:341-347. [PMID: 28616212 PMCID: PMC5466083 DOI: 10.1093/ckj/sfw120] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/05/2016] [Accepted: 09/29/2016] [Indexed: 02/07/2023] Open
Abstract
Background. Hypophosphatemia in critically ill patients may be exacerbated by renal replacement therapy (RRT). We aimed to identify risk factors and adverse outcomes associated with hypophosphatemia in intensive care patients treated with RRT for acute kidney injury (AKI). Methods. This was a secondary analysis of data from a single-center prospective cohort study of medical and surgical intensive care patients with RRT for AKI between 18 December 2010 and 3 April 2013. Demographic, comorbidity, laboratory and RRT data were retrieved from patient case notes and electronic medical records. Outcomes assessed were hypophosphatemia (serum phosphate <0.94 mmol/L) during RRT, intensive care unit (ICU) mortality, and duration of mechanical ventilation and vasopressor support. Results. Among 96 patients who received acute RRT, 25 (26.0%) developed hypophosphatemia. On multivariate logistic regression, serum phosphate at RRT initiation [adjusted odds ratio (OR) 0.29, 95% confidence interval (CI) (0.09, 0.91), P = 0.03] was independently associated with hypophosphatemia during acute RRT. Patients with hypophosphatemia during RRT required longer ventilatory support [median 12 (interquartile range: 8, 17) days versus 5 (3, 9) days, P < 0.001] and vasopressor support [5 (4, 15) days versus 2 (2, 6) days, P = 0.003] compared with those without hypophosphatemia but there was no significant difference in ICU mortality [5 patients (20.0%) versus 24 patients (33.8%), P = 0.20]. Hypophosphatemia during RRT was independently associated with prolonged mechanical ventilation (≥7 days) [adjusted OR 14.0, 95% CI (1.37, 143.90), P = 0.03]. Conclusion. Hypophosphatemia is common during acute RRT for critically ill patients and was associated with adverse clinical outcomes.
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Affiliation(s)
- Cynthia Lim
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Han Khim Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
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Jung SY, Kim H, Park S, Jhee JH, Yun HR, Kim H, Kee YK, Yoon CY, Oh HJ, Chang TI, Park JT, Yoo TH, Kang SW, Lee H, Kim DK, Han SH. Electrolyte and mineral disturbances in septic acute kidney injury patients undergoing continuous renal replacement therapy. Medicine (Baltimore) 2016; 95:e4542. [PMID: 27603344 PMCID: PMC5023866 DOI: 10.1097/md.0000000000004542] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Electrolyte and mineral disturbances remain a major concern in patients undergoing continuous renal replacement therapy (CRRT); however, it is not clear whether those imbalances are associated with adverse outcomes in patients with septic acute kidney injury (AKI) undergoing CRRT. We conducted a post-hoc analysis of data from a prospective randomized controlled trial. A total of 210 patients with a mean age of 62.2 years (136 [64.8%] males) in 2 hospitals were enrolled. Levels of sodium, potassium, calcium, and phosphate measured before (0 hour) and 24 hours after CRRT initiation. Before starting CRRT, at least 1 deficiency and excess in electrolytes or minerals were observed in 126 (60.0%) and 188 (67.6%) patients, respectively. The excess in these parameters was greatly improved, whereas hypokalemia and hypophosphatemia became more prevalent at 24 hours after CRRT. However, 1 and 2 or more deficiencies in those parameters at the 2 time points were not associated with mortality. However, during 28 days, 89 (71.2%) deaths occurred in patients with phosphate levels at 0 hour of ≥4.5 mg/dL as compared with 49 (57.6%) in patients with phosphate levels <4.5 mg/dL. The 90-day mortality was also significantly higher in patients with hyperphosphatemia. Similarly, in 184 patients who survived at 24 hours after CRRT, hyperphosphatemia conferred a 2.2-fold and 2.6-fold increased risk of 28- and 90-day mortality, respectively. The results remained unaltered when the serum phosphate level was analyzed as a continuous variable. Electrolyte and mineral disturbances are common, and hyperphosphatemia may predict poor prognosis in septic AKI patients undergoing CRRT.
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Affiliation(s)
- Su-Young Jung
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of South Korea
| | - Hyunwook Kim
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of South Korea
| | - Seohyun Park
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of South Korea
| | - Jong Hyun Jhee
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of South Korea
| | - Hae-Ryong Yun
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of South Korea
| | - Hyoungnae Kim
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of South Korea
| | - Youn Kyung Kee
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of South Korea
| | - Chang-Yun Yoon
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of South Korea
| | - Hyung Jung Oh
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of South Korea
| | - Tae Ik Chang
- Department of Internal Medicine, NHIS Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do
| | - Jung Tak Park
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of South Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of South Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of South Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of South Korea
- Correspondence: Seung Hyeok Han, Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Yonsei-ro, Seodaemun-gu, Seoul, Republic of South Korea (e-mail: )
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