Timing of renal replacement therapy and long-term risk of chronic kidney disease and death in intensive care patients with acute kidney injury

Incidence, risk factors and clinical outcomes of septic acute renal injury in cancer patients with sepsis admitted to the ICU: A retrospective study

Background

The purpose of this study was to clarify the incidence, risk factors, and clinical outcomes of septic acute kidney injury (AKI) in cancer patients with sepsis admitted to the intensive care unit (ICU).

Methods

A total of 356 cancer patients admitted to the ICU due to sepsis from January 2016 to October 2021 were analyzed retrospectively. According to the incidence of septic AKI, all patients were divided into the non-AKI group (n = 279) and the AKI group (n = 77). The clinical data after ICU admission were compared between the above two groups, and the risk factors and the clinical outcomes of septic AKI in the ICU were identified.

Results

The incidence of septic AKI in all patients was 21.6% (77/356). LASSO regression and logistic regression all showed that lactate, sequential organ failure assessment (SOFA) score and septic shock were closely related to the occurrence of septic AKI. In terms of clinical outcomes after ICU admission, the rate of mechanical ventilation (MV) and continuous renal replacement therapy (CRRT), MV time, hospitalization time and 28-day mortality in the ICU were significantly higher in the septic AKI group than in the non-septic AKI group. Among the three subgroups of septic AKI (AKI combined with septic shock, septic cardiac dysfunction or acute respiratory failure), the mortality of patients in the subgroup of AKI combined with septic shock was significantly higher than others. CRRT has no significant effect on the short-term outcome of these patients.

Conclusion

Lactate level, SOFA score and septic shock were closely related to the occurrence of septic AKI in the ICU. The clinical outcomes within 28 days after ICU admission of cancer patients with septic AKI were worse than those without septic AKI. The short-term outcome was worse in patients with septic AKI complicated with septic shock. CRRT does not have any significant effect on the short-term prognosis of cancer patients with septic AKI in the ICU.

Disease Severity Determines Timing of Initiating Continuous Renal Replacement Therapies: A Systematic Review and Meta-Analysis

Background: Timing of initiating continuous renal replacement therapies (CRRTs) among the patients with acute kidney injury (AKI) in intensive care units (ICU) has been discussed over decades, but the definition of early and late CRRT initiation is still unclear. Methods: The English language randomized controlled trials (RCTs) and cohort studies were searched through MEDLINE, EMBASE, and Cochrane Library on July 19, 2019, by the two researchers independently. The study characteristics; early and late definitions; outcomes, such as all-cause, in-hospital, 28- or 30-, 60-, 90-day mortality; and renal recovery were extracted from the 18 eligible studies. Pooled relative risk ratios (RRs) and 95% CIs were estimated with the fixed effects model and random effects model as appropriate. This study is registered with PROSPERO (CRD 42020158653). Results: Eighteen studies including 3,914 patients showed benefit in earlier CRRT (n = 1,882) over later CRRT (n = 2,032) in all-cause mortality (RR 0.78, 95% CI 0.66-0.92), in-hospital mortality (RR 0.81, 95% CI 0.67-0.99), and 28- or 30-day mortality (RR 0.81, 95% CI 0.74-0.88), but in 60- and 90-day mortalities, no significant benefit was observed. The subgroup analysis showed significant benefit in the disease-severity-based subgroups on early CRRT initiation in terms of in-hospital mortality and 28- or 30-day mortality rather than the time-based subgroups. Moreover, early CRRT was found to have beneficial effects on renal recovery after CRRT (RR 1.21, 95% CI 1.01-1.45). Conclusions: Overall, compared with late CRRT, early CRRT is beneficial for short-term survival and renal recovery, especially when the timing was defined based on the disease severity. CRRT initiation on Acute Kidney Injury Network (AKIN) stage 1 or Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease (RIFLE)-Risk or less may lead to a better prognosis.

Renal replacement therapy in critically ill patients with acute kidney injury: 2020 nephrologist's perspective

Renal replacement therapies (RRT) as support for acute kidney injury in critically ill patients have become a routine and essential practice in their management, resulting in the widespread use of various techniques among these patients, such as intermittent hemodialysis (IHD), extended hemodialysis and continuous RRT (CRRT). In this review we aim to summarize current evidence of indication, choice of modality, timing of initiation, dosing and technical aspects of RRT. We carried out a narrative review based on guidelines, consensus documents by main working groups and the latest relevant clinical trials on RRT in the critically ill. We did not find enough evidence of any RRT modality having superior benefits in terms of patient survival, length of intensive care unit/hospital stay or renal outcomes among critically ill patients, in spite of optimization of clinical indication, modality, timing of initiation and intensity of initial therapy. This is still a controverted matter, since only early start of high-flux CRRT has been proven beneficial over IHD among hemodynamically unstable postoperative patients. Our objective is to portrait current RRT practices in multidisciplinary management of critically ill patients by intensive care and nephrology professionals. Implication of a nephrologist in the assessment of hemodynamic status, coexisting medical conditions, renal outcome expectations and management of resources could potentially have benefits at the time of RRT selection and troubleshooting.

Early versus standard renal replacement therapy after left ventricular assist device implantation

OBJECTIVES

Renal function may improve after left ventricular assist device (LVAD) implant, however, some patients develop postoperative acute kidney injury (AKI). Randomized trials showed benefit for early renal replacement therapy (RRT) in critically ill patients with AKI, but this practice has not been studied in LVAD patients.

METHODS

We performed a single-center, retrospective cohort study of all adults (>18 years) who underwent LVAD placement from 1/2010 to 12/2018. We collected preoperative, hemodynamic, echocardiographic, intraoperative, and postoperative data. AKI was defined according to Kidney Disease: Improving Global Outcomes definition. Early (E) RRT was considered treatment at AKI stage II or below. Standard (S) RRT was considered treatment at AKI stage III. Outcomes and Kaplan-Meier analysis were compared between groups.

RESULTS

A total of 184 patients were included (mean age 56.10 years, 81% males, 30.4% African-American race). A total of 71 (38.6%) developed AKI and 17 (9.24%) needed RRT (11 E vs 6 S). A total of 11 remained hemodialysis-dependent at discharge (5 [45.5%] in E vs 6 [100%] in S, P = .043). There was a trend toward shorter intensive care unit stay and ventilation time in E group, and overall hospital stay was significantly less in the E group (48.18 ± 25.95 vs 94.00 ± 53.07 days, P = .028). Thirty-day mortality was similar between groups (E 18% vs S 16%, P = .9), but there was a trend toward improved overall survival in the E group.

CONCLUSION

This is the first study to examine early initiation of RRT after LVAD implant. Early RRT was associated with shorter hospital stay, lower need for permanent RRT, and a trend toward improved survival. This practice may provide significant cost savings and should be examined further.

Comparison between watchful waiting strategy and early initiation of renal replacement therapy in the critically ill acute kidney injury population: an updated systematic review and meta-analysis

BACKGROUND

The optimal timing of renal replacement therapy (RRT) initiation is debatable. Many articles in this field enrolled trials not based on acute kidney injury. The safety of the watchful waiting strategy has not been fully discussed, and late RRT initiation criteria vary across studies. The effect of early RRT initiation in the AKI population with high plasma neutrophil gelatinase-associated lipocalin (NGAL) has not been examined yet.

METHODS

In accordance with PRISMA guidelines, the PubMed, Embase, and Cochrane databases were systemically searched for randomized controlled trials (RCTs). Trials not conducted in the AKI population were excluded. Data of study characteristics, primary outcome (all-cause mortality), and related secondary outcomes [mechanical ventilation (MV) days, length of hospital stay, RRT days, and length of ICU stay] were extracted. The outcomes were compared between early and late RRT groups by estimating the pooled odds ratio (OR) for binary outcomes and the weighted mean difference for continuous outcomes. Prospective trials were also examined and analyzed using the same method.

RESULTS

Nine RCTs with 1938 patients were included. Early RRT did not provide a survival benefit (pooled OR, 0.88; 95% confidence interval [CI] 0.62-1.27). However, the early RRT group had significantly fewer MV days (pooled mean difference, - 3.98 days; 95% CI - 7.81 to - 0.15 days). Subgroup analysis showed that RCTs enrolling the surgical population (P = .001) and the AKI population with high plasma NGAL (P = .031) had favorable outcomes regarding RRT days in the early initiation group. Moreover, 6 of 9 RCTs were selected for examining the safety of the watchful waiting strategy, and no significant differences were found in primary and secondary outcomes between the early and late RRT groups.

CONCLUSIONS

Overall, early RRT initiation did not provide a survival benefit, but a possible benefit of fewer MV days was detected. Early RRT might also provide the benefit of shorter MV or RRT support in the surgical population and in AKI patients with high plasma NGAL. Depending on the conventional indication for RRT initiation, the watchful waiting strategy is safe on the basis of all primary and secondary outcomes.

Cordyceps militaris Improves Chronic Kidney Disease by Affecting TLR4/NF-κB Redox Signaling Pathway

Cordyceps militaris may show good promise in protecting against chronic kidney disease (CKD) but the molecular mechanism remains unclear. CKD risk is associated with the Toll-like receptor 4/nuclear factor-kappa B (TLR4/NF-κB) signaling pathway. Cordycepin is the main component of Cordyceps militaris and may affect the TLR4/NF-κB pathway. Cordycepin was prepared by preparative HPLC. CKD patients were assigned into Cordyceps militaris (COG, 100 mg daily) and placebo (CG) groups. Cordycepin activity was measured using human embryo kidney cells (HEK293T). Biochemical indices, the levels of TLR4, NF-κB, cyclooxygenase-2 (COX2), tumor necrosis factor-alpha (TNF-α), and interleukin-1 beta (IL-1β), were measured by real-time qRT-PCR, or ELISA kits and or Western blot. After 3-month treatment, cordycepin reduced the levels of urinal protein, blood urea nitrogen (BUN), and creatinine by 36.7%±8.6%, 12.5%±3.2%, and 18.3%±6.6%, respectively (P < 0.05). Cordyceps militaris improved lipid profile and redox capacity of CKD patients by reducing the serum levels of TG, TC, and LDL-C by 12.8%±3.6%, 15.7%±4.1%, and 16.5%±4.4% and increasing the HDL-C level by 10.1%±1.4% in the COG group when compared with the CG group, respectively (P < 0.05). The serum levels of cystatin-C (Cys-C), myeloperoxidase (MPO), and malondialdehyde (MDA) were reduced by 14.0%±3.8%, 26.9%±12.3%, and 19.7%±7.9% while nitric oxide (NO) and superoxide dismutase (SOD) were increased by 12.5%±2.9% and 25.3%±13.4% in the COG group when compared with the CG group, respectively (P < 0.05). Cordycepin reduced the levels of TLR4, NF-κB, COX2, TNF-α, and IL-1β in HEK293T cells too (P < 0.05). However, cordycepin could not affect the levels anymore if TLR4 was silenced. Cordyceps militaris protected against CKD progression by affecting the TLR4/NF-κB lipid and redox signaling pathway via cordycepin.

Sepsis associated acute kidney injury

Sepsis is defined as organ dysfunction resulting from the host's deleterious response to infection. One of the most common organs affected is the kidneys, resulting in sepsis associated acute kidney injury (SA-AKI) that contributes to the morbidity and mortality of sepsis. A growing body of knowledge has illuminated the clinical risk factors, pathobiology, response to treatment, and elements of renal recovery that have advanced our ability to prevent, detect, and treat SA-AKI. Despite these advances, SA-AKI remains an important concern and clinical burden, and further study is needed to reduce the acute and chronic consequences. This review summarizes the relevant evidence, with a focus on the risk factors, early recognition and diagnosis, treatment, and long term consequences of SA-AKI. In addition to literature pertaining to SA-AKI specifically, pertinent sepsis and acute kidney injury literature relevant to SA-AKI was included.

Derivation and validation of plasma endostatin for predicting renal recovery from acute kidney injury: a prospective validation study

BACKGROUND

Acute kidney injury (AKI) is associated with high morbidity and mortality in surgical patients. Nonrecovery from AKI may increase mortality and early risk stratification seems key to improving clinical outcomes. The aim of the current study was to explore and validate the value of endostatin for predicting failure to recover from AKI.

METHODS

We conducted a prospective cohort study of 198 patients without known chronic kidney disease who underwent noncardiac major surgery and developed new-onset AKI in the first 48 h after admission to the ICU. The biomarkers of plasma endostatin, neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C were detected immediately after AKI diagnosis. The primary endpoint was nonrecovery from AKI (within 7 days). Cutoff values of the biomarkers for predicting nonrecovery were determined in a derivation cohort (105 AKI patients). Predictive accuracy was then analyzed in a validation cohort (93 AKI patients).

RESULTS

Seventy-six of 198 (38.4%) patients failed to recover from AKI onset, with 41 in the derivation cohort and 35 in the validation cohort. Compared with NGAL and cystatin C, endostatin showed a better prediction for nonrecovery, with an area under the receiver operating characteristic curve (AUC) of 0.776 (95% confidence interval (CI) 0.654-0.892, p < 0.001) and an optimal cutoff value of 63.7 ng/ml. The predictive ability for nonrecovery was greatly improved by the prediction model combining endostatin with clinical risk factors of Sequential Organ Failure Assessment (SOFA) score and AKI classification, with an AUC of 0.887 (95% CI 0.766-0.958, p < 0.001). The value of the endostatin-clinical risk prediction model was superior to the NGAL-clinical risk and cystatin C-clinical risk prediction models in predicting failure to recover from AKI, which was supported by net reclassification improvement and integrated discrimination improvement. Further, the endostatin-clinical risk prediction model achieved sensitivity and specificity of 94.6% (76.8-99.1) and 72.7% (57.2-85.0), respectively, when validated in the validation cohort.

CONCLUSION

Plasma endostatin shows a useful value for predicting failure to recover from AKI. The predictive ability can be greatly improved when endostatin is combined with the SOFA score and AKI classification.

Acute kidney injury: Epidemiology, outcomes, complications, and therapeutic strategies

Acute kidney injury (AKI) is one of the most common serious complications for all hospital admissions, with its incidence increasing among hospitalized patients, particularly those in the intensive care unit. Despite significant improvements in critical care and dialysis technology, AKI is associated with an increased risk of short- and long-term mortality, prolonged hospital stays, and dialysis dependence. These risks are particularly relevant for critically ill patients with AKI severe enough to require renal replacement therapy (RRT). No specific pharmacologic treatment has been established to treat AKI. Hence, the mainstay treatment for patients with AKI is RRT even though there are still several problematic issues regarding its use including RRT modality, dose, and timing. Recently, the impact of AKI on an increased risk of progression to chronic kidney disease (CKD) and end-stage renal disease requiring dialysis or transplantation is attracting increased attention.