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Surjit A, Prasannan B, Abraham J, Balagopal A, Unni VN. Acute Kidney Injury in Patients Undergoing Extracorporeal Membrane Oxygenation: A Retrospective Cohort Study. Indian J Crit Care Med 2024; 28:26-29. [PMID: 38510762 PMCID: PMC10949276 DOI: 10.5005/jp-journals-10071-24612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/06/2023] [Indexed: 03/22/2024] Open
Abstract
Aims and background Extracorporeal membrane oxygenation (ECMO) is a mode of extracorporeal therapy to support oxygenation of patients with severe cardiac or respiratory failure. Studies have shown that acute kidney injury (AKI) can worsen the outcome in these patients. This study aims to assess the incidence and outcome of AKI in patients on ECMO support. Materials and methods This retrospective study included 64 patients who underwent ECMO for more than 24 hours. Patients who died within 48 hours of initiation of ECMO and patients with end-stage renal disease (ESRD) on maintenance hemodialysis were excluded. Acute kidney injury was diagnosed and categorized according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Results Of the 64 patients studied, 38 patients (59.38%) developed AKI and 17 patients (44.73%) among them developed AKI within 24 hours of initiation of ECMO. Age, Acute Physiology and Chronic Health Evaluation (APACHE-II) score, hypertension, use of nephrotoxic agents, inotropic support, and poor cardiac function were the risk factors associated with the development of AKI. Diabetes mellitus, type of ECMO used, and duration of ECMO were not found to be risk factors for AKI. Renal replacement therapy was initiated in 31 patients (81.58%). The overall mortality in the whole group was 67.19%, while it was 81.58% among the patients with AKI. Conclusion Acute kidney injury was found to be an independent risk factor for mortality in patients on ECMO. Early identification of the risk factors for AKI and management may help to improve the survival rate. Clinical significance The occurrence of AKI among patients on ECMO support increases the risk of mortality significantly. Hence, measures to prevent AKI, as well as early detection and appropriate management of AKI, would improve patient outcomes. How to cite this article Surjit A, Prasannan B, Abraham J, Balagopal A, Unni VA. Acute Kidney Injury in Patients Undergoing Extracorporeal Membrane Oxygenation: A Retrospective Cohort Study. Indian J Crit Care Med 2024;28(1):26-29.
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Affiliation(s)
- Aswin Surjit
- Department of Internal Medicine, Aster Medcity, Kochi, Kerala, India
| | - Bipi Prasannan
- Department of Nephrology, Aster Medcity, Kochi, Kerala, India
| | - Jobin Abraham
- Department of Critical Care, Aster Medcity, Kochi, Kerala, India
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Agapito Fonseca J, Gameiro J, Marques F, Lopes JA. Timing of Initiation of Renal Replacement Therapy in Sepsis-Associated Acute Kidney Injury. J Clin Med 2020; 9:jcm9051413. [PMID: 32397637 PMCID: PMC7290350 DOI: 10.3390/jcm9051413] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/01/2020] [Accepted: 05/07/2020] [Indexed: 12/12/2022] Open
Abstract
Sepsis-associated acute kidney injury (SA-AKI) is a major issue in medical, surgical and intensive care settings and is an independent risk factor for increased mortality, as well as hospital length of stay and cost. SA-AKI encompasses a proper pathophysiology where renal and systemic inflammation play an essential role, surpassing the classic concept of acute tubular necrosis. No specific treatment has been defined yet, and renal replacement therapy (RRT) remains the cornerstone supportive therapy for the most severe cases. The timing to start RRT, however, remains controversial, with early and late strategies providing conflicting results. This article provides a comprehensive review on the available evidence on the timing to start RRT in patients with SA-AKI.
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Subbarayan B, Vivek V, Kuppuswamy MK. Renal replacement therapy during extracorporeal membrane oxygenation. Indian J Thorac Cardiovasc Surg 2020; 37:261-266. [PMID: 33967450 DOI: 10.1007/s12055-019-00920-0] [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: 10/16/2019] [Revised: 12/21/2019] [Accepted: 12/26/2019] [Indexed: 11/25/2022] Open
Abstract
The use of extracorporeal membrane oxygenator (ECMO) has significantly increased in the past 20 years. There is a high incidence of acute kidney injury (AKI) in the group of patients on ECMO, with need for continuous renal replacement therapy (CRRT) in most of them. This article will review the basics of CRRT, its indications, the technical aspects of incorporating CRRT with ECMO circuit, data on clinical aspects, and outcomes.
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Xiao L, Jia L, Li R, Zhang Y, Ji H, Faramand A. Early versus late initiation of renal replacement therapy for acute kidney injury in critically ill patients: A systematic review and meta-analysis. PLoS One 2019; 14:e0223493. [PMID: 31647828 PMCID: PMC6812871 DOI: 10.1371/journal.pone.0223493] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 09/22/2019] [Indexed: 02/06/2023] Open
Abstract
Background Acute kidney injury is associated with high mortality, and is the most frequent complication encountered in patients residing in the intensive care unit. Although renal replacement therapy (RRT) is the standard of care for acute kidney injury, the optimal timing for initiation is still unknown. Methods We conducted a systemic review and meta-analysis of randomized controlled trials evaluating early versus late initiation of RRT in critically ill patients with acute kidney injury. We searched MEDLINE, Embase, and CENTRAL databases from inception to October 15, 2018. We screened studies and extracted data from published reported independently. The primary outcome was short-term mortality. Results A total of 2242 patients were included from 11 trials. No statistically significant effect was found for early versus late initiation of RRT on short-term mortality (risk ratio [RR] 0.99, 95% CI 0.84–1.17, p = 0.93) or long-term mortality (RR 0.98, 95% CI 0.85–1.13, p = 0.76). There were also no statistically significant effects on ICU length of stay, hospital length of stay, recovery of renal function, and renal replacement therapy dependence. Early initiation of RRT decreased the risk of metabolic acidosis (RR 0.65, 95% CI 0.43–0.99, p = 0.04), but increased the risk of hypotension (RR 1.24, 95% CI 1.08–1.43, p = 0.003). Conclusions In critically ill patients with acute kidney injury, early compared with late initiation of RRT is not associated with favorable mortality outcomes, although it appears to reduce the risk of metabolic acidosis.
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Affiliation(s)
- Li Xiao
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China,Chengdu, Sichuan, China
| | - Lu Jia
- Shanxi Provincial People’s Hospital, Taiyuan, China
| | - Rongshan Li
- Shanxi Provincial People’s Hospital, Taiyuan, China
| | - Yu Zhang
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Hongming Ji
- Shanxi Provincial People’s Hospital, Taiyuan, China
- * E-mail:
| | - Andrew Faramand
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
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Renal replacement therapy: Time to give up on early initiation? No. Anaesth Crit Care Pain Med 2019; 37:505-506. [PMID: 30573206 DOI: 10.1016/j.accpm.2018.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Impact of Early versus Late Initiation of Renal Replacement Therapy in Patients with Cardiac Surgery-Associated Acute Kidney Injury: Meta-Analysis with Trial Sequential Analysis of Randomized Controlled Trials. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6942829. [PMID: 30662912 PMCID: PMC6312615 DOI: 10.1155/2018/6942829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/09/2018] [Accepted: 11/15/2018] [Indexed: 12/29/2022]
Abstract
Background Previous studies have examined the effect of the initiation time of renal replacement therapy (RRT) in patients with cardiac surgery-associated acute kidney injury (CSA-AKI), but the findings remain controversial. The aim of this meta-analysis was to systematically and quantitatively compare the impact of early versus late initiation of RRT on the outcome of patients with CSA-AKI. Methods Four databases (PubMed, the Cochrane Library, ISI Web of Knowledge, and Embase) were systematically searched from inception to June 2018 for randomized clinical trials (RCTs). Two investigators independently performed the literature search, study selection, data extraction, and quality evaluation. Meta-analysis and trial sequential analysis (TSA) were used to examine the impact of RRT initiation time on all-cause mortality (primary outcome). The Grading of Recommendations Assessment Development and Evaluation (GRADE) was used to evaluate the level of evidence. Results We identified 4 RCTs with 355 patients that were eligible for inclusion. Pooled analyses indicated no difference in mortality for patients receiving early and late initiation of RRT (relative risk [RR] = 0.61, 95% confidence interval [CI] = 0.33 to 1.12). However, the results were not confirmed by TSA. Similarly, early RRT did not reduce the length of stay (LOS) in the intensive care unit (ICU) (mean difference [MD] = -1.04; 95% CI = -3.34 to 1.27) or the LOS in the hospital (MD = -1.57; 95% CI = -4.62 to 1.48). Analysis using GRADE indicated the certainty of the body of evidence was very low for a benefit from early initiation of RRT. Conclusion Early initiation of RRT had no beneficial impacts on outcomes in patients with CSA-AKI. Future larger and more adequately powered prospective RCTs are needed to verify the benefit of reduced mortality associated with early initiation of RRT. Trial Registration This trial is registered with PROSPERO registration number CRD42018084465, registered on 11 February 2018.
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Lumlertgul N, Peerapornratana S, Trakarnvanich T, Pongsittisak W, Surasit K, Chuasuwan A, Tankee P, Tiranathanagul K, Praditpornsilpa K, Tungsanga K, Eiam-Ong S, Kellum JA, Srisawat N. Early versus standard initiation of renal replacement therapy in furosemide stress test non-responsive acute kidney injury patients (the FST trial). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:101. [PMID: 29673370 PMCID: PMC5909278 DOI: 10.1186/s13054-018-2021-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 03/27/2018] [Indexed: 03/24/2023]
Abstract
Background The timing of initiation of renal replacement therapy (RRT) in severe acute kidney injury (AKI) remains controversial, with early initiation resulting in unnecessary therapy for some patients while expectant therapy may delay RRT for other patients. The furosemide stress test (FST) has been shown to predict the need for RRT and therefore could be used to exclude low-risk patients from enrollment in trials of RRT timing. We conducted this multicenter pilot study to determine whether FST could be used to screen patients at high risk for RRT and to determine the feasibility of incorporating FST into a trial of early initiation of RRT. Methods FST was performed using intravenous furosemide (1 mg/kg in furosemide-naive patients or 1.5 mg/kg in previous furosemide users). FST-nonresponsive patients (urine output less than 200 mL in 2 h) were then randomized to early (initiation within 6 h) or standard (initiation by urgent indication) RRT. Results FST was completed in all patients (100%). Only 6/44 (13.6%) FST-responsive patients ultimately received RRT while 47/60 (78.3%) nonresponders randomized to standard RRT either received RRT or died (P < 0.001). Among 118 FST-nonresponsive patients, 98.3% in the early RRT arm and 75% in the standard RRT arm received RRT. The adherence to the protocol was 94.8% and 100% in the early and standard RRT group, respectively. We observed no differences in 28-day mortality (62.1 versus 58.3%, P = 0.68), 7-day fluid balance, or RRT dependence at day 28. However, hypophosphatemia occurred more frequently in the early RRT arm (P = 0.002). Conclusion The furosemide stress test appears to be feasible and effective in identifying patients for randomization to different RRT initiation times. Our findings should guide implementation of large-scale randomized controlled trials for the timing of RRT initiation. Trial registration clinicaltrials.gov, NCT02730117. Registered 6 April 2016. Electronic supplementary material The online version of this article (10.1186/s13054-018-2021-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nuttha Lumlertgul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sadudee Peerapornratana
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Thananda Trakarnvanich
- Renal Division, Department of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Wanjak Pongsittisak
- Renal Division, Department of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | | | | | | | - Khajohn Tiranathanagul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kriang Tungsanga
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - John A Kellum
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. .,Excellence center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand. .,The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Guerci P, Claudot JL, Novy E, Settembre N, Lalot JM, Losser MR. Immediate postoperative plasma neutrophil gelatinase-associated lipocalin to predict acute kidney injury after major open abdominal aortic surgery: A prospective observational study. Anaesth Crit Care Pain Med 2017; 37:327-334. [PMID: 29033359 DOI: 10.1016/j.accpm.2017.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 09/28/2017] [Accepted: 09/29/2017] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Plasma neutrophil gelatinase-associated lipocalin (pNGAL) has been used as a biomarker in acute kidney injury (AKI). AKI is a common postoperative complication of aortic surgery. We sought to evaluate the performance of the immediately postoperative pNGAL level in comparison with the serum creatinine (SCr) level in predicting AKI and the need for renal replacement therapy (RRT). PATIENTS AND METHODS Prospective non-interventional study in a university hospital. Fifty patients undergoing elective or emergent major intra-abdominal aortic surgery were included. Comparisons between groups of patients with or without postoperative AKI, according to KDIGO staging, were made. Performance of NGAL was determined by examining the area under receiver operating characteristic (AUROC) curve. RESULTS The incidence of AKI was 36%. At H+2, pNGAL values in AKI and non-AKI patients, respectively, were 221 [133-278] versus 50 [50-90] ng/mL (P<0.0001), and SCr values were 115 [96-178] versus 90 [72-99] μmol/L (P<0.0008). The AUROC of pNGAL for prediction of AKI was 0.90 (95% CI: 0.81-0.98) with an optimal cutoff of 112ng/mL, a sensitivity of 83%, specificity of 84%, and positive and negative predictive values of 75% and 90%, respectively. SCr produced an AUROC curve of 0.79 (0.65-0.92) at a cutoff of 110μmol/L. The diagnostic performance of pNGAL was significantly better than that of SCr (P=0.039). PNGAL at H+2 better predicted the RRT requirement [0.96 (0.90-1.0)] compared to SCr [0.86 (0.73-0.98)], but this difference was not statistically significant. CONCLUSIONS A 2-hour postoperative determination of pNGAL outperformed SCr level in predicting postoperative AKI after major aortic surgery.
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Affiliation(s)
- Philippe Guerci
- Department of Anaesthesiology and Critical Care Medicine, Intensive Care Unit J.M.-Picard, University Hospital of Nancy - Brabois, Institut Lorrain du Cœur et des Vaisseaux Louis-Mathieu, 5, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
| | - Jean-Louis Claudot
- Department of Anaesthesiology and Critical Care Medicine, Intensive Care Unit J.M.-Picard, University Hospital of Nancy - Brabois, Institut Lorrain du Cœur et des Vaisseaux Louis-Mathieu, 5, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
| | - Emmanuel Novy
- Department of Anaesthesiology and Critical Care Medicine, Intensive Care Unit J.M.-Picard, University Hospital of Nancy - Brabois, Institut Lorrain du Cœur et des Vaisseaux Louis-Mathieu, 5, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
| | - Nicla Settembre
- Department of Vascular Surgery, University Hospital of Nancy - Brabois, 5, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
| | - Jean-Marc Lalot
- Department of Anaesthesiology and Critical Care Medicine, Intensive Care Unit J.M.-Picard, University Hospital of Nancy - Brabois, Institut Lorrain du Cœur et des Vaisseaux Louis-Mathieu, 5, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
| | - Marie-Reine Losser
- Department of Anaesthesiology and Critical Care Medicine, Intensive Care Unit J.M.-Picard, University Hospital of Nancy - Brabois, Institut Lorrain du Cœur et des Vaisseaux Louis-Mathieu, 5, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
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