Norepinephrine and hospital mortality in critically ill patients undergoing continuous renal replacement therapy

Development and Validation of a Prognostic Model to Predict the Risk of In-hospital Death in Patients With Acute Kidney Injury Undergoing Continuous Renal Replacement Therapy After Acute Type a Aortic Dissection

Background

This study aimed to construct a model to predict the risk of in-hospital death in patients with acute renal injury (AKI) receiving continuous renal replacement therapy (CRRT) after acute type A aortic dissection (ATAAD) surgery.

Methods

We reviewed the data of patients with AKI undergoing CRRT after ATAAD surgery. The patients were divided into survival and nonsurvival groups based on their vital status at hospital discharge. The data were analyzed using univariate and multivariate logistic regression analyses. Establish a risk prediction model using a nomogram and its discriminative ability was validated using C statistic and the receiver operating characteristic (ROC) curve. Its calibration ability was tested using a calibration curve, 10-fold cross-validation and Hosmer–Lemeshow test.

Results

Among 175 patients, in-hospital death occurred in 61 (34.9%) patients. The following variables were incorporated in predicting in-hospital death: age > 65 years, lactic acid 12 h after CRRT, liver dysfunction, and permanent neurological dysfunction. The risk model revealed good discrimination (C statistic = 0.868, 95% CI: 0.806–0.930; a bootstrap-corrected C statistic of 0.859, the area under the ROC = 0.868). The calibration curve showed good consistency between predicted and actual probabilities (via 1,000 bootstrap samples, mean absolute error = 2.2%; Hosmer–Lemeshow test, P = 0.846). The 10-fold cross validation of the nomogram showed that the average misdiagnosis rate was 16.64%.

Conclusion

The proposed model could be used to predict the probability of in-hospital death in patients undergoing CRRT for AKI after ATAAD surgery. It had the potential to assist doctors to identify the gravity of the situation and make the targeted therapeutic measures.

GDF-15 Predicts In-Hospital Mortality of Critically Ill Patients with Acute Kidney Injury Requiring Continuous Renal Replacement Therapy: A Multicenter Prospective Study

Growth differentiation factor-15 (GDF-15) is a stress-responsive cytokine. This study evaluated the association between GDF-15 and in-hospital mortality among patients with severe acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). Among the multicenter prospective CRRT cohort between 2017 and 2019, 66 patients whose blood sample was available were analyzed. Patients were divided into three groups according to the GDF-15 concentrations. The median GDF-15 level was 7865.5 pg/mL (496.9 pg/mL in the healthy control patients). Baseline characteristics were not different among tertile groups except the severity scores and serum lactate level, which were higher in the third tertile. After adjusting for confounding factors, the patients with higher GDF-15 had significantly increased risk of mortality (second tertile: adjusted hazards ratio [aHR], 3.67; 95% confidence interval [CI], 1.05-12.76; p = 0.041; third tertile: aHR, 6.81; 95% CI, 1.98-23.44; p = 0.002). Furthermore, GDF-15 predicted in-hospital mortality (area under the curve, 0.710; 95% CI, 0.585-0.815) better than APACHE II and SOFA scores. Serum GDF-15 concentration was elevated in AKI patients requiring CRRT, higher in more severe patients. GDF-15 is a better independent predictor for in-hospital mortality of critically ill AKI patients than the traditional risk scoring system such as APACHE II and SOFA scores.

Acute kidney injury: Incidence, risk factors, and outcomes in severe COVID-19 patients

Background

COVID-19 is a multisystemic disorder that frequently causes acute kidney injury (AKI). However, the precise clinical and biochemical variables associated with AKI progression in patients with severe COVID-19 remain unclear.

Methods

We performed a retrospective study on 278 hospitalized patients who were admitted to the ward and intensive care unit (ICU) with COVID-19 between March 2020 and June 2020, at the University Hospital, São Paulo, Brazil. Patients aged ≥ 18 years with COVID-19 confirmed on RT-PCR were included. AKI was defined according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. We evaluated the incidence of AKI, several clinical variables, medicines used, and outcomes in two sub-groups: COVID-19 patients with AKI (Cov-AKI), and COVID-19 patients without AKI (non-AKI). Univariate and multivariate analyses were performed.

Results

First, an elevated incidence of AKI (71.2%) was identified, distributed across different stages of the KDIGO criteria. We further observed higher levels of creatinine, C-reactive protein (CRP), leukocytes, neutrophils, monocytes, and neutrophil-to-lymphocyte ratio (NLR) in the Cov-AKI group than in the non-AKI group, at hospital admission. On univariate analysis, Cov-AKI was associated with older age (>62 years), hypertension, CRP, MCV, leucocytes, neutrophils, NLR, combined hydroxychloroquine and azithromycin treatment, use of mechanical ventilation, and vasoactive drugs. Multivariate analysis showed that hypertension and the use of vasoactive drugs were independently associated with a risk of higher AKI in COVID-19 patients. Finally, we preferentially found an altered erythrocyte and leukocyte cellular profile in the Cov-AKI group compared to the non-AKI group, at hospital discharge.

Conclusions

In our study, the development of AKI in patients with severe COVID-19 was related to inflammatory blood markers and therapy with hydroxychloroquine/azithromycin, with vasopressor requirement and hypertension considered potential risk factors. Thus, attention to the protocol, hypertension, and some blood markers may help assist doctors with decision-making for the management of COVID-19 patients with AKI.

Continuous renal replacement therapy in patients with HIV/AIDS

Background

Acute kidney injury (AKI) is a common complication among human immunodeficiency virus (HIV)-infected patients resulting in increased morbidity and mortality. Continuous renal replacement therapy (CRRT) is a useful method and instrument in critically ill patients with fluid overload and metabolic disarray, especially in those who are unable to tolerate the intermittent hemodialysis. However, the epidemiology, influence factors of CRRT and mortality in patients with HIV/AIDS are still unclear in China. This study aims to study the HIV-infected patients admitted in Intensive Care Unit (ICU) and explore the influence factors correlated with CRRT and their prognosis.

Methods

We performed a retrospective case-control study in the ICU of the Beijing Ditan Hospital Capital Medical University. From June 1, 2005 to May 31, 2017, 225 cases were enrolled in this clinical study.

Results

122 (54.2%) patients were diagnosed with AKI during their stay in ICU, the number and percentage of AKI stage 1, 2 and 3 were 38 (31.1%), 21(17.2%) and 63(51.7%), respectively. 26.2% of AKI patients received CRRT during the stay of ICU. 56.25% CRRT patients died in ICU. The 28-day mortality was 62.5%, and the 90-day mortality was 75%. By univariate logistics analysis, it showed that higher likelihood of diagnosis for respiratory failure (OR = 7.333,95% CI 1.467–36.664, p = 0.015), higher likelihood of diagnosis for septic shock (OR = 1.005,95% CI 1.001–1.01, p = 0.018), and higher likelihood to use vasoactive agents (OR = 10.667,95% CI 1.743–65.271, p = 0.001), longer mechanical ventilation duration (OR = 1.011,95% CI 1.002–1.019, p = 0.011), higher likelihood for diagnosis for PCP (OR = 7.50,95% CI 1.288–43.687, p = 0.025), higher SOFA score at ICU admission (OR = 1.183,95% CI 1.012–1.383, p = 0.035), longer duration of CRRT (OR = 1.014,95% CI 1.001–1.028, p = 0.034) contributed to a higher mortality at ICU. The Cox Analysis for the cumulative survival of AKI 3 patients between the CRRT and non-CRRT groups shows no significant differences (p = 0.595).

Conclusions

There is a high incidence of AKI in HIV-infected patients admitted in our ICU. Patients with severe AKI were more prone to be admitted for CRRT and have a consequent poor prognosis.

Development of a new mortality scoring system for acute kidney injury with continuous renal replacement therapy

AIM

On the basis of the worst outcomes of patients undergoing continuous renal replacement therapy (CRRT) in intensive care unit, previously developed mortality prediction model, Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II) and the Sequential Organ Failure Assessment (SOFA) needs to be modified.

METHODS

A total of 828 patients who underwent CRRT were recruited. Mortality prediction model was developed for the prediction of death within 7 days after starting the CRRT. Based on regression analysis, modified scores were assigned to each variable which were originally used in the APACHE II and SOFA scoring models. Additionally, a new abbreviated Mortality Scoring system for AKI with CRRT (MOSAIC) was developed after stepwise selection analysis.

RESULTS

We used all the variables included in the APACHE II and SOFA scoring models. The prediction powers indicated by C-statistics were 0.686 and 0.683 for 7-day mortality by the APACHE II and SOFA systems, respectively. After modification of these models, the prediction powers increased up to 0.752 for the APACHE II and 0.724 for the SOFA systems. Using multivariate analysis, seven significant variables were selected in the MOSAIC model wherein its C-statistic value was 0.772. These models also showed good performance with 0.720, 0.734 and 0.773 of C-statistics in the modified APACHE II, modified SOFA and MOSAIC scoring models in the external validation cohort (n = 497).

CONCLUSION

The modified APACHE II/SOFA and newly developed MOSAIC models could be more useful tool for predicting mortality for patients receiving CRRT.

Norepinephrine Administration Is Associated with Higher Mortality in Dialysis Requiring Acute Kidney Injury Patients with Septic Shock

(1) Background: Norepinephrine (NE) is the first-line vasoactive agent used in septic shock patients; however, the effect of norepinephrine on dialysis-required septic acute kidney injury (AKI-D) patients is uncertain. (2) Methods: To evaluate the impact of NE on 90-day mortality and renal recovery in septic AKI-D patients, we enrolled patients in intensive care units from 30 hospitals in Taiwan. (3) Results: 372 patients were enrolled and were divided into norepinephrine users and non-users. After adjustment by Inverse probability of treatment weighted (IPTW), there was no significant difference of baseline comorbidities between the two groups. NE users had significantly higher 90-day mortality rate and using NE is a strong predictor of 90-day mortality in the multivariate Cox regression (HR = 1.497, p = 0.027) after adjustment. The generalized additive model disclosed norepinephrine alone exerted a dose–dependent effect on 90-day mortality, while other vasoactive agents were not. (4) Conclusion: Using norepinephrine in septic AKI-D patients is associated with higher 90-day mortality and the effect is dose-dependent. Further study to explore the potential mechanism is needed.

Heart rate is associated with mortality in patients undergoing continuous renal replacement therapy

BACKGROUND

Heart rate (HR) is an essential vital sign based on the finding that HR beyond its normal range is associated with several conditions or diseases, including high mortality in several clinical settings. Nevertheless, the clinical implications of HR remain unresolved in patients undergoing continuous renal replacement therapy (CRRT).

METHODS

This retrospective cohort study included 828 patients who underwent CRRT due to acute kidney injury between 2010 and 2014. HR and other baseline parameters at the time of CRRT initiation were retrieved. The odds ratio (OR) of 30-day mortality was calculated using a multivariate logistic model.

RESULTS

CRRT significantly lowered the HR of patients such that the pre- and post-CRRT HRs (average 6 hours) were 107 beats/min and 103 beats/min, respectively (P < 0.001). When we explored the relationship with 30-day mortality, only HR at the time of CRRT initiation, but not pre- or post-CRRT HR, had a significant relationship with mortality outcome. Based on this result, we divided patients into quartiles of HR at the time of CRRT initiation. Mortality OR in the 4th quartile HR group was 2.6 (1.78-3.92) compared with the 1st quartile HR group. This relationship remained consistent despite adjusting for 28 baseline covariates: OR, 1.7 (1.09-2.76); P = 0.020. However, HR was not associated with the weaning rate from CRRT.

CONCLUSION

High HR at the time of CRRT initiation is subsequently related with high mortality. These results can be a basis for a future predictive model of CRRT-related mortality.