1
|
Wang B, Peng M, Wei H, Liu C, Wang J, Jiang L, Fang F, Wang Y, Shen Y. The benefits of early continuous renal replacement therapy in critically ill patients with acute kidney injury at high-altitude areas: a retrospective multi-center cohort study. Sci Rep 2023; 13:14882. [PMID: 37689800 PMCID: PMC10492831 DOI: 10.1038/s41598-023-42003-6] [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: 03/12/2023] [Accepted: 09/04/2023] [Indexed: 09/11/2023] Open
Abstract
Severe hypoxia would aggravate the acute kidney injury (AKI) in high-altitude areas and continuous renal replacement therapy (CRRT) has been used to treat critically ill patients with AKI. However, the characteristics and outcomes of CRRT in critically ill patients at AKI in high altitudes and the optimal timing of CRRT initiation remain unclear. 1124 patients were diagnosed with AKI and treated with CRRT in the ICU, comprising a high-altitude group (n = 648) and low-altitude group (n = 476). Compared with the low-altitude group, patients with AKI at high altitude showed longer CRRT (4.8 vs. 3.7, P = 0.036) and more rapid progression of AKI stages (P < 0.01), but without any significant minor or major bleeding episodes (P > 0.05). Referring to the analysis of survival and kidney recovery curves, a higher mortality but a lower possibility of renal recovery was observed in the high-altitude group (P < 0.001). However, in the high-altitude group, the survival rate of early CRRT initiation was significantly higher than that of delayed CRRT initiation (P < 0.001). The findings showed poorer clinical outcomes in patients undergoing CRRT for AKI at high altitudes. CRRT at high altitudes was unlikely to increase the adverse events. Moreover, early CRRT initiation might reduce the mortality and promote renal recovery in high-altitude patients.
Collapse
Affiliation(s)
- Bowen Wang
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
| | - Mengjia Peng
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
| | - Hui Wei
- Intensive Care Center, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, Chengdu, 610041, Sichuan, China
| | - Chang Liu
- Intensive Care Center, People's Hospital of Tibet Autonomous Region, Lhasa, 850000, Tibet, China
| | - Juan Wang
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
| | - Liheng Jiang
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
| | - Fei Fang
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
| | - Yuliang Wang
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China.
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China.
| | - Yuandi Shen
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China.
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China.
- Department of Emergency, Naval Medical Center of PLA, Shanghai, 200052, China.
| |
Collapse
|
2
|
Oxygen Extraction and Mortality in Patients Undergoing Chronic Haemodialysis Treatment: A Multicentre Study. J Clin Med 2022; 12:jcm12010138. [PMID: 36614939 PMCID: PMC9821439 DOI: 10.3390/jcm12010138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/17/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
Patients on haemodialysis (HD) suffer a high mortality rate linked to developing subclinical hypoxic parenchymal stress during HD sessions. The oxygen extraction ratio (OER), an estimate of the oxygen claimed by peripheral tissues, might represent a new prognostic factor in HD patients. This study evaluated whether the intradialytic change in OER (ΔOER) identified patients with higher mortality risks. We enrolled chronic HD patients with permanent central venous catheters with available central venous oxygen saturation (ScvO2) measurements; the arterial oxygen saturation was measured with peripheral oximeters (SpO2). We measured OER before and after HD at enrolment; deaths were recorded during two-years of follow-up. In 101 patients (age: 72.9 ± 13.6 years, HD vintage: 9.6 ± 16.6 years), 44 deaths were recorded during 11.6 ± 7.5 months of follow-up. Patients were divided into two groups according to a 40% ΔOER threshold (ΔOER < 40%, n = 56; ΔOER ≥ 40%, n = 45). The ΔOER ≥ 40% group showed a higher incidence of death (60% vs. 30%; p = 0.005). The survival curve (log-rank-test: p = 0.0001) and multivariate analysis (p = 0.0002) confirmed a ΔOER ≥ 40% as a mortality risk factor. This study showed the intradialytic ΔOER ≥ 40% was a mortality risk factor able to highlight critical hypoxic damage. Using a ΔOER ≥ 40% could be clinically applicable to characterise the most fragile patients.
Collapse
|
3
|
Dias GF, Tozoni SS, Bohnen G, van Spitzenbergen BAK, Grobe N, Nakao LS, Pecoits-Filho R, Kotanko P, Moreno-Amaral AN. Effect of hypoxia and uremia on oxidative stress on erythrocytes from hemodialysis patients. Cell Biochem Funct 2022; 40:856-864. [PMID: 36121199 DOI: 10.1002/cbf.3746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/02/2022] [Accepted: 09/05/2022] [Indexed: 12/15/2022]
Abstract
Oxidative stress (OS) is essential in uremia-associated comorbidities, including renal anemia. Complications experienced by hemodialysis (HD) patients, such as hypoxemia and uremic toxins accumulation, induce OS and premature death of red blood cells (RBC). We aimed to characterize reactive oxygen species (ROS) production and antioxidant pathways in HD-RBC and RBC from healthy controls (CON-RBC) and evaluate the role of uremia and hypoxia in these pathways. ROS production, xanthine oxidase (XO) and superoxide dismutase (SOD) activities, glutathione (GSH), and heme oxygenase-1 (HO-1) levels were measured using flow cytometry or spectrophotometry in CON-RBC and HD-RBC (pre- and post-HD), at baseline and after 24 h incubation with uremic serum (S-HD) and/or under hypoxic conditions (5% O2 ). Ketoprofen was used to inhibit RBC uremic toxins uptake. HD-RBC showed higher ROS levels and lower XO activity than CON-RBC, particularly post-HD. GSH levels were lower, while SOD activity and HO-1 levels of HD-RBC were higher than control. Hypoxia per se triggered ROS production in CON-RBC and HD-RBC. S-HD, on top of hypoxia, increased ROS levels. Inhibition of uremic toxins uptake attenuated ROS of CON and HD-RBC under hypoxia and uremia. CON-RBC in uremia and hypoxia showed lower GSH levels than cells in normoxia and non-uremic conditions. Redox mechanisms of HD-RBC are altered and prone to oxidation. Uremic toxins and hypoxia play a role in unbalancing these systems. Hypoxia and uremia participate in the pathogenesis of OS in HD-RBC and might induce RBC death and thus compound anemia.
Collapse
Affiliation(s)
- Gabriela F Dias
- Anemia and Immunology Research Laboratory (LabAIRe), Pontifícia Universidade Católica do Paraná, Curitiba, Brazil.,Renal Research Institute, New York, New York, USA
| | - Sara S Tozoni
- Anemia and Immunology Research Laboratory (LabAIRe), Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
| | - Gabriela Bohnen
- Anemia and Immunology Research Laboratory (LabAIRe), Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
| | | | - Nadja Grobe
- Renal Research Institute, New York, New York, USA
| | - Lia S Nakao
- Universidade Federal do Paraná, Curitiba, Brazil
| | - Roberto Pecoits-Filho
- Anemia and Immunology Research Laboratory (LabAIRe), Pontifícia Universidade Católica do Paraná, Curitiba, Brazil.,Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Peter Kotanko
- Renal Research Institute, New York, New York, USA.,Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andréa N Moreno-Amaral
- Anemia and Immunology Research Laboratory (LabAIRe), Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
| |
Collapse
|
4
|
Wang B, Li ZL, Zhang YL, Wen Y, Gao YM, Liu BC. Hypoxia and chronic kidney disease. EBioMedicine 2022; 77:103942. [PMID: 35290825 PMCID: PMC8921539 DOI: 10.1016/j.ebiom.2022.103942] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/22/2022] [Accepted: 03/01/2022] [Indexed: 12/12/2022] Open
Abstract
Hypoxia is an inherent pathophysiological characteristic of chronic kidney disease (CKD), which is closely associated with the development of renal inflammation and fibrosis, as well as CKD-related complications such as anaemia, cardiovascular events, and sarcopenia. This review outlined the characteristics of oxygen supply in the kidney, changes in oxygen metabolism and factors leading to hypoxia in CKD. Mechanistically, we discussed how hypoxia contributes to renal injury as well as complications associated with CKD. Furthermore, we also discussed the potential therapeutic approaches that target chronic hypoxia, as well as the challenges in the study of oxygen homeostasis imbalance in CKD.
Collapse
Affiliation(s)
- Bin Wang
- Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
| | - Zuo-Lin Li
- Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
| | - Yi-Lin Zhang
- Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
| | - Yi Wen
- Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
| | - Yue-Ming Gao
- Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
| | - Bi-Cheng Liu
- Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China.
| |
Collapse
|
5
|
Pethő Á, Piecha D, Mészáros T, Urbanics R, Moore C, Canaud B, Rosivall L, Mollnes TE, Steppan S, Szénási G, Szebeni J, Dézsi L. A porcine model of hemodialyzer reactions: roles of complement activation and rinsing back of extracorporeal blood. Ren Fail 2021; 43:1609-1620. [PMID: 34882053 PMCID: PMC8667923 DOI: 10.1080/0886022x.2021.2007127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Hemodialysis reactions (HDRs) resemble complement-activation-related pseudoallergy (CARPA) to certain i.v. drugs, for which pigs provide a sensitive model. On this basis, to better understand the mechanism of human HDRs, we subjected pigs to hemodialysis using polysulfone (FX CorDiax 40, Fresenius) or cellulose triacetate (SureFlux-15UX, Nipro) dialyzers, or Dialysis exchange-set without membranes, as control. Experimental endpoints included typical biomarkers of porcine CARPA; pulmonary arterial pressure (PAP), blood cell counts, plasma sC5b-9 and thromboxane-B2 levels. Hemodialysis (60 min) was followed by reinfusion of extracorporeal blood into the circulation, and finally, an intravenous bolus injection of the complement activator zymosan. The data indicated low-extent steady rise of sC5b-9 along with transient leukopenia, secondary leukocytosis and thrombocytopenia in the two dialyzer groups, consistent with moderate complement activation. Surprisingly, small changes in baseline PAP and plasma thromboxane-B2 levels during hemodialysis switched into 30%-70% sharp rises in all three groups resulting in synchronous spikes within minutes after blood reinfusion. These observations suggest limited complement activation by dialyzer membranes, on which a membrane-independent second immune stimulus was superimposed, and caused pathophysiological changes also characteristic of HDRs. Thus, the porcine CARPA model raises the hypothesis that a second "hit" on anaphylatoxin-sensitized immune cells may be a key contributor to HDRs.
Collapse
Affiliation(s)
- Ákos Pethő
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Dorothea Piecha
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | | | | | - Christoph Moore
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Bernard Canaud
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany.,School of Medicine, Montpellier University, Montpellier, France
| | - László Rosivall
- International Nephrology Research and Training Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Tom Eirik Mollnes
- Department of Immunology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Research Laboratory, Nordland Hospital Bodø and Faculty of Health Sciences and TREC, University of Tromsø, Tromsø, Norway.,Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sonja Steppan
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Gábor Szénási
- International Nephrology Research and Training Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - János Szebeni
- SeroScience Ltd, Budapest, Hungary.,Nanomedicine Research and Education Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - László Dézsi
- SeroScience Ltd, Budapest, Hungary.,Nanomedicine Research and Education Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
| |
Collapse
|
6
|
Canaud B, Stephens MP, Nikam M, Etter M, Collins A. Multitargeted interventions to reduce dialysis-induced systemic stress. Clin Kidney J 2021; 14:i72-i84. [PMID: 34987787 PMCID: PMC8711765 DOI: 10.1093/ckj/sfab192] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Indexed: 11/13/2022] Open
Abstract
Hemodialysis (HD) is a life-sustaining therapy as well as an intermittent and repetitive stress condition for the patient. In ridding the blood of unwanted substances and excess fluid from the blood, the extracorporeal procedure simultaneously induces persistent physiological changes that adversely affect several organs. Dialysis patients experience this systemic stress condition usually thrice weekly and sometimes more frequently depending on the treatment schedule. Dialysis-induced systemic stress results from multifactorial components that include treatment schedule (i.e. modality, treatment time), hemodynamic management (i.e. ultrafiltration, weight loss), intensity of solute fluxes, osmotic and electrolytic shifts and interaction of blood with components of the extracorporeal circuit. Intradialytic morbidity (i.e. hypovolemia, intradialytic hypotension, hypoxia) is the clinical expression of this systemic stress that may act as a disease modifier, resulting in multiorgan injury and long-term morbidity. Thus, while lifesaving, HD exposes the patient to several systemic stressors, both hemodynamic and non-hemodynamic in origin. In addition, a combination of cardiocirculatory stress, greatly conditioned by the switch from hypervolemia to hypovolemia, hypoxemia and electrolyte changes may create pro-arrhythmogenic conditions. Moreover, contact of blood with components of the extracorporeal circuit directly activate circulating cells (i.e. macrophages-monocytes or platelets) and protein systems (i.e. coagulation, complement, contact phase kallikrein-kinin system), leading to induction of pro-inflammatory cytokines and resulting in chronic low-grade inflammation, further contributing to poor outcomes. The multifactorial, repetitive HD-induced stress that globally reduces tissue perfusion and oxygenation could have deleterious long-term consequences on the functionality of vital organs such as heart, brain, liver and kidney. In this article, we summarize the multisystemic pathophysiological consequences of the main circulatory stress factors. Strategies to mitigate their effects to provide more cardioprotective and personalized dialytic therapies are proposed to reduce the systemic burden of HD.
Collapse
Affiliation(s)
- Bernard Canaud
- Montpellier University, Montpellier, France
- Global Medical Office, FMC Deutschland, Bad Homburg, Germany
| | - Melanie P Stephens
- MSL & Medical Strategies for Innovative Therapies, Fresenius Medical Care, Waltham, MA, USA
| | - Milind Nikam
- Global Medical Office, Fresenius Medical Care, Hong Kong
| | - Michael Etter
- Global Medical Office, Fresenius Medical Care, Hong Kong
| | - Allan Collins
- Global Medical Office, Fresenius Medical Care, Waltham, MA, USA
| |
Collapse
|