Sustained low efficiency dialysis in the continuous mode (C-SLED): dialysis efficacy, clinical outcomes, and survival predictors in critically ill cancer patients

Socioeconomic Influences on the Outcomes of Dialysis-Requiring Acute Kidney Injury in Brazil

Introduction

Although research suggests that socioeconomic deprivation is linked to a higher incidence of acute kidney injury (AKI) and worse outcomes in high-income countries, there is limited knowledge about these epidemiologic factors in developing countries. In addition, the impact of medical institution administration (private versus public) on AKI outcomes remains to be determined.

Methods

We studied 15,186 pediatric and adult patients with dialysis-requiring AKI (AKI-D) admitted to private and public hospitals in Rio de Janeiro, Brazil. According to Brazil's demographic census, socioeconomic indicators were derived from patient zip codes. Propensity score matching analysis and a mixed-effect Cox regression were used to assess the impact of socioeconomic indicators and hospital governance on patient survival.

Results

Crude mortality rates were higher in private hospitals than in public hospitals (71.8% vs. 59.5%, P < 0.001) and were associated with significant differences in age (75 years, interquartile range [IQR]: 61-83 vs. 53 years, IQR: 31-66), baseline renal function (prevalence of chronic kidney disease [CKD]: 33.2% vs. 23%, P < 0.001), comorbidities (Charlson score: 2.03 ± 0.87 vs. 1.72 ± 0.75, P < 0.001), and severity of presentation (mechanical ventilation: 76.5% vs. 58% and vasopressors: 72.8% vs. 50.5%, P < 0.001). After adjustments and propensity score matching, we found no effect of different hospital administrations or socioeconomic factors on mortality. Baseline characteristics and the severity of presentation primarily influenced AKI-D prognosis.

Conclusions

Despite significant racial and socioeconomic differences in hospital governance, these indicators had no independent influence on mortality. Future epidemiologic studies should investigate these relevant assumptions to allow healthcare systems to manage this severe syndrome promptly.

Sustained Low Efficiency Dialysis in Critically Ill Children With Acute Kidney Injury: Single-Center Observational Cohort in a Resource-Limited Setting

OBJECTIVES

To evaluate use of sustained low efficiency dialysis (SLED) in critically ill children with acute kidney injury in a resource-limited setting.

DESIGN

Observational database cohort study (December 2016 to January 2020).

SETTING

PICU of a tertiary hospital in India.

PATIENTS

Critically ill children undergoing SLED were included in the study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic and clinical data, prescription variables, hemodynamic status, complications, kidney, and patient outcomes of all children undergoing SLED in the PICU were analyzed. A total of 33 children received 103 sessions of SLED. The median (interquartile range, IQR) age and weight of children who received SLED were 9 years (4.5-12.8 yr) and 26 kg (15.2-34 kg), respectively. The most common diagnosis was sepsis with septic shock in 17 patients, and the mean (± sd ) Pediatric Risk of Mortality III score at admission was 11.8 (±6.4). The median (IQR) number and mean (± sd ) duration of inotropes per session were 3 hours (2-4 hr) and 96 (±82) hours, respectively. Of 103 sessions, the most common indication for SLED was oligoanuria with fluid overload and the need for creating space for fluid and nutritional support in 45 sessions (44%). The mean (± sd ) duration of SLED was 6.4 (±1.3) hours with 72 of 103 sessions requiring priming. The mean (± sd ) ultrafiltration rate per session achieved was 4.6 (±3) mL/kg/hr. There was significant decrease in urea and creatinine by end of SLED compared with the start, with mean change in urea and serum creatinine being 32.36 mg/dL (95% CI, 18.53-46.18 mg/dL) ( p < 0.001) and 0.70 mg/dL (95% CI, 0.35-1.06 mg/dL) ( p < 0.001), respectively. Complications were observed in 44 of 103 sessions, most common being intradialytic hypotension (21/103) and bleeding at the catheter site (21/103). Despite complications in one third of the sessions, only nine sessions were prematurely stopped, and 23 of 33 patients receiving SLED survived.

CONCLUSION

In critically ill children, our experience with SLED is that it is feasible and provides a viable form of kidney replacement therapy in a resource-limited setting.

Hospital mortality and prognostic factors in critically ill patients with acute kidney injury and cancer undergoing continuous renal replacement therapy

BACKGROUND

Whether continuous renal replacement therapy (CRRT) should be applied to critically ill patients with both acute kidney injury (AKI) and cancer remains controversial because of poor expected outcomes. The present study determined prognostic factors for all-cause in-hospital mortality in patients with AKI and cancer undergoing CRRT.

METHODS

We included 471 patients with AKI and cancer who underwent CRRT at the intensive care unit of a Korean tertiary hospital from 2013 to 2020, and classified them by malignancy type. The primary outcomes were 28-day all-cause mortality rate and prognostic factors for in-hospital mortality. The secondary outcome was renal replacement therapy (RRT) dependency at hospital discharge.

RESULTS

The 28-day mortality rates were 58.8% and 82% in the solid and hematologic malignancy groups, respectively. Body mass index (BMI), presence of oliguria, Sequential Organ Failure Assessment (SOFA) score, and albumin level were common predictors of 28-day mortality in the solid and hematologic malignancy groups. A high heart rate and the presence of severe acidosis were prognostic factors only in the solid malignancy group. Among the survivors, the proportion with RRT dependency was 25.0% and 33.3% in the solid and hematologic malignancy groups, respectively.

CONCLUSION

The 28-day mortality rate of cancer patients with AKI undergoing CRRT was high in both the solid and hematologic malignancy groups. BMI, presence of oliguria, SOFA score, and albumin level were common predictors of 28-day mortality in the solid and hematologic malignancy groups, but a high heart rate and severe acidosis were prognostic factors only in the solid malignancy group.

A real-world prospective study on dialysis-requiring acute kidney injury

Background

Current information about acute kidney injury (AKI) epidemiology in developing nations derives mainly from isolated centers, with few quality multicentric epidemiological studies. Our objective was to describe a large cohort of patients with dialysis-requiring AKI derived from ordinary clinical practice within a large metropolitan area of an emerging country, assessing the impact of age and several clinical predictors on patient survival across the spectrum of human life.

Methods

We analyzed registries drawn from 170 hospitals and medical facilities in Rio de Janeiro, Brazil, in an eleven-year period (2002–2012). The study cohort was comprised of 17,158 pediatric and adult patients. Data were analyzed through hierarchical logistic regression models and mixed-effects Cox regression for survival comparison across age strata.

Results

Severe AKI was mainly hospital-acquired (72.6%), occurred predominantly in the intensive care unit (ICU) (84.9%), and was associated with multiple organ failure (median SOFA score, 11; IQR, 6–13). The median age was 75 years (IQR, 59–83; range, 0–106 years). Community-acquired pneumonia was the most frequent admission diagnosis (23.8%), and sepsis was the overwhelming precipitating cause (72.1%). Mortality was 71.6% and was higher at the age extremes. Poor outcomes were driven by age, mechanical ventilation, vasopressor support, liver dysfunction, type 1 cardiorenal syndrome, the number of failing organs, sepsis at admission, later sepsis, the Charlson score, and ICU admission. Community-acquired AKI, male gender, and pre-existing chronic kidney disease were associated with better outcomes.

Conclusions

Our study adds robust information about the real-world epidemiology of dialysis-requiring AKI with considerable clinical detail. AKI is a heterogeneous syndrome with variable clinical presentations and outcomes, including differences in the age of presentation, comorbidities, frailty state, precipitation causes, and associated diseases. In the cohort studied, AKI characteristics bore more similarities to upper-income countries as opposed to the pattern traditionally associated with resource-limited economies.

The Rate and Risk Factors of Acute Kidney Injury among Cancer Patients’ Admissions in Palestine: A Single-Center Study

Introduction. Acute kidney injury (AKI) remains a critical issue for cancer patients despite recent treatment improvements. This study aimed to assess the incidence of AKI in cancer patients and its related risk factors. Methods. A Retrospective cohort study was conducted at tertiary hospitals in the period 2016–2018. A data abstraction sheet was used to collect related variables from patients’ records. During admission, the incidence of AKI was assessed using creatinine measurements. RIFLE criteria were used to classify it into five categories of severity: risk, injury, failure, loss, and end-stage renal disease. Results. Using RIFLE (Risk, Injury, Failure, Loss, and End-stage renal disease) criteria, 6.9% of admissions were complicated with AKI. The severity of these fell into the categories of risk, injury, and failure, 3.3%, 1.7%, and 1.9%, respectively. In the multivariate model, the odds for developing AKI was significantly higher for patients with congestive heart failure (AOR = 17.1, 95% CI 1.7–80.1), chronic kidney disease (adjusted OR = 6.8, 95% CI 1.4–32.2 ( $P$ value 0.017)), sepsis (AOR = 4.4, 95% CI 1.9–10.1), hypercalcemia (AOR = 8.4, 95% CI 1.3–46.1), and admission to the ICU (AOR = 5.8, 95% CI 2.1–16.2). In addition, the mortality rate was nearly seven times higher for patients complicated by AKI (relative risk = 7.6, 95% CI 3.2–18.2). Conclusion. AKI was significantly associated with congestive heart failure, chronic kidney disease, sepsis, ICU admission, and hypercalcemia in cancer patients, resulting in poorer outcomes and higher mortality rates. AKI assessment for hospitalized cancer patients should be performed regularly, especially for patients at increased risk.

Critically ill cancer patient's resuscitation: a Belgian/French societies' consensus conference

To respond to the legitimate questions raised by the application of invasive methods of monitoring and life-support techniques in cancer patients admitted in the ICU, the European Lung Cancer Working Party and the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique, set up a consensus conference. The methodology involved a systematic literature review, experts' opinion and a final consensus conference about nine predefined questions1. Which triage criteria, in terms of complications and considering the underlying neoplastic disease and possible therapeutic limitations, should be used to guide admission of cancer patient to intensive care units?2. Which ventilatory support [High Flow Oxygenation, Non-invasive Ventilation (NIV), Invasive Mechanical Ventilation (IMV), Extra-Corporeal Membrane Oxygenation (ECMO)] should be used, for which complications and in which environment?3. Which support should be used for extra-renal purification, in which conditions and environment?4. Which haemodynamic support should be used, for which complications, and in which environment?5. Which benefit of cardiopulmonary resuscitation in cancer patients and for which complications?6. Which intensive monitoring in the context of oncologic treatment (surgery, anti-cancer treatment …)?7. What specific considerations should be taken into account in the intensive care unit?8. Based on which criteria, in terms of benefit and complications and taking into account the neoplastic disease, patients hospitalized in an intensive care unit (or equivalent) should receive cellular elements derived from the blood (red blood cells, white blood cells and platelets)?9. Which training is required for critical care doctors in charge of cancer patients?

Determinants of Outcomes of Acute Kidney Injury: Clinical Predictors and Beyond

Acute kidney injury (AKI) is a common clinical syndrome characterized by rapid impairment of kidney function. The incidence of AKI and its severe form AKI requiring dialysis (AKI-D) has been increasing over the years. AKI etiology may be multifactorial and is substantially associated with increased morbidity and mortality. The outcome of AKI-D can vary from partial or complete recovery to transitioning to chronic kidney disease, end stage kidney disease, or even death. Predicting outcomes of patients with AKI is crucial as it may allow clinicians to guide policy regarding adequate management of this problem and offer the best long-term options to their patients in advance. In this manuscript, we will review the current evidence regarding the determinants of AKI outcomes, focusing on AKI-D.

Renal Replacement Therapy in Patients With Stage IV Cancer Admitted to the Intensive Care Unit With Acute Kidney Injury at a Comprehensive Cancer Center Was Not Associated With Survival

INTRODUCTION

In patients with advanced cancer, prolongation of life with treatment often incurs substantial emotional and financial expense. Among hospitalized patients with cancer since acute kidney injury (AKI) is known to be associated with much higher odds for hospital mortality, we investigated whether renal replacement therapy (RRT) use in the intensive care unit (ICU) was a significant independent predictor of worse outcomes.

METHODS

We retrospectively reviewed patients admitted in 2005 to 2014 who were diagnosed with stage IV solid tumors, had AKI, and a nephrology consult. The main outcomes were survival times from the landmark time points, inpatient mortality, and longer term survival after hospital discharge. Logistic regression and Cox proportional regression were used to compare inpatient mortality and longer term survival between RRT and non-RRT groups. Propensity score-matched landmark survival analyses were performed with 2 landmark time points chosen at day 2 and at day 7 from ICU admission.

RESULTS

Of the 465 patients with stage IV cancer admitted to the ICU with AKI, 176 needed RRT. In the multivariate logistic regression model after adjusting for baseline serum albumin and baseline maximum Sequential Organ Failure Assessment (SOFA), the patients who received RRT were not significantly different from non-RRT patients in inpatient mortality (odds ratio: 1.004 [95% confidence interval: 0.598-1.684], P = .9892). In total, 189 patients were evaluated for the impact of RRT on long-term survival and concluded that RRT was not significantly associated with long-term survival after discharge for patients who discharged alive. Landmark analyses at day 2 and day 7 confirmed the same findings.

CONCLUSIONS

Our study found that receiving RRT in the ICU was not significantly associated with inpatient mortality, survival times from the landmark time points, and long-term survival after discharge for patients with stage IV cancer with AKI.

Onconephrology: An Evolving Field

This column is supplied by Ala Abudayyeh, MD, an internal medicine physician and associate professor of nephrology at The University of Texas MD Anderson Cancer Center in Houston, Texas. Dr. Abudayyeh earned her medical degree at the University of Texas-Houston Medical School and completed both her internal medicine residency and nephrology fellowship at Baylor College of Medicine in Houston. She is board certified in internal medicine and nephrology and joined the University of Texas MD Anderson Cancer Center in 2012.

Acute kidney injury in cancer patients: A nationwide survey in China

Cancer patients have a high risk for acute kidney injury (AKI); however, the incidence, severity, and risk factors of malignancy-related AKI (MR-AKI) are unclear. This study aimed to assess MR-AKI risk factors and provide reliable data for AKI prevention, diagnosis, and management in China. This cross-sectional study analysed data from 44 academic and local hospitals in China. AKI patients were identified based on 2 screening criteria: the 2012 Kidney Disease: Improving Global Outcomes-AKI definition and the expanded screening criteria for patients with no repeated serum creatinine (SCr) test within 7 days and those who recovered from AKI. Patients whose SCr level increased or decreased by 50% during hospitalization, compared with that at admission, were considered to have AKI according to the expanded criteria. A total of 7,604 AKI patients were enrolled (1,418 with MR-AKI). Patient characteristics were compared between the MR-AKI and non-MR-AKI groups. Multivariate logistic models were used to statistically assess risk factors. The proportions of MR-AKI patients in academic and local hospitals were 20.2% and 14.1%, respectively. The incidence of MR-AKI was higher in mid-China (the affluent region), elderly patients, and groups with higher per capita gross domestic product. Among MR-AKI cases, gastrointestinal cancer (50.1%) was the most common malignancy, followed by cancers of the reproductive (15.3%), haematological (13.1%), respiratory (11.8%), and other systems (8.3%), and cancers of unknown classification (1.4%). Of 268 hospital deaths, respiratory, haematological, gastrointestinal, reproductive, other system, and unknown classification cancers accounted for 29.3%, 18.8%, 18.6%, 12.9%, 16.9%, and 20.0%, respectively. Increased age, advanced AKI stage at peak, level of per capita gross domestic product, geographic region, and renal replacement therapy indication were risk factors for hospital mortality in patients with gastrointestinal MR-AKI, whereas cardiovascular disease history, AKI stage at peak, and geographic region were risk factors for mortality in patients with reproductive MR-AKI. The incidence and mortality of MR-AKI vary by hospital, economic level, age, geographic region, and malignancy type. High MR-AKI incidence was associated with gastrointestinal cancers and higher level of medical care provided by academic hospitals in affluent regions such as Beijing, Shanghai, and other provincial-level cities. Elderly patients with advanced gastrointestinal cancer in mid-China showed the highest incidence of MR-AKI and in-hospital mortality, and thus require special attention.

Use of regional citrate anticoagulation for continuous venovenous hemodialysis in critically ill cancer patients with acute kidney injury

PURPOSE

This study aimed to evaluate the safety and efficacy of a regional citrate anticoagulation (RCA) protocol for continuous venovenous hemodialysis (CVVHD) in cancer patients with acute kidney injury (AKI) in the intensive care unit (ICU) setting.

MATERIAL AND METHODS

One hundred twenty two consecutive ICU cancer patients with AKI treated with citrate-based CVVHD were prospectively evaluated in this prospective observational study.

RESULTS

A total of 7198 h of CVVHD therapy (250 filters) were performed. Patients were 61.3 ± 15.7 years old, 78% had solid cancer and the main AKI cause was sepsis (50%). The in-hospital mortality was 78.7%. Systemic ionized calcium (SCai) was 4.35 (4.10-4.60) mg/dL, severe hypocalcemia (SCai <3.6 mg/dL) was observed in 4.3% of procedures and post-filter ionized calcium was 1.60 (1.40-1.80) mg/dL. Median filter patency was 24.8 (11-43) hours. Factors related to filter clotting were: no tumor evidence (OR 0.44, CI 0.18-0.99); genitourinary tumor (OR 1.83, CI 1.18-2.81); platelets number (each 10,000/mm³) (OR 1.02, CI 1.00-1.04); International Normatized Ratio (INR) (OR 0.59, CI 0.41-0.85) and citrate dose (each 10 mL/h) (OR 0.88, CI 0.82-0.95).

CONCLUSION

Filter patency was relatively short and clotting was associated with active cancer disease, genitourinary tumor, lower citrate dose and lower INR.

Prevention and Therapy of Acute Kidney Injury in the Developing World

Timely recognition of patients at risk or with possible acute kidney injury (AKI) is essential for early intervention to minimize further damage and improve outcome. Initial management of patients with suspected and persistent AKI should include thorough clinical assessment of all patients with AKI to identify reversible factors, including fluid volume status, potential nephrotoxins, and an assessment of the underlying health of the kidney. Based on these assessments, early interventions to provide appropriate and adequate fluid resuscitation while avoiding fluid overload, removal of nephrotoxins, and adjustment of drug doses according to the level of kidney function derangement are important. The judicious use of diuretics for fluid overload and/or in cardiac decompensated patients and introduction of early enteral nutritional support need to be considered to improve outcomes in AKI. Although these basic principles are well recognized, their application in clinical practice in low resource settings is often limited due to lack of education, availability of resources, and lack of trained personnel, which limits access to care. We report the consensus recommendations of the 18th Acute Dialysis Quality Initiative meeting in Hyderabad, India, on strategies to evaluate patients with suspected AKI and initiate measures for prevention and management to improve outcomes, particularly in low resource settings. These recomendations provide a framework for caregivers, who are often primary care physicians, nurses, and other allied healthcare personnel, to manage patients with AKI in resource poor countries.

Continuous Renal Replacement Therapy for Acute Renal Failure in Patients with Cancer: A Well-Tolerated Adjunct Treatment

Introduction

Acute renal failure (ARF) has a poor prognosis in patients with cancer requiring intensive care unit (ICU) admission. Our aim is finding prognostic factors for hospital mortality in patients with cancer with ARF requiring renal replacement therapy (RRT).

Methods

In this retrospective study, all patients with cancer with ARF treated with continuous venovenous filtration (CVVHDF) in the ICU of the Institut Jules Bordet, between January 1, 2003 and December 31, 2012, were included.

Results

One hundred and three patients are assessed: men/women 69/34, median age 62 years, solid/hematologic tumors 68/35, median SAPS II 56. Mortality rate was 63%. Seven patients required chronic renal dialysis. After multivariate analysis, two variables were statistically associated with hospital mortality: more than one organ failure (including kidney) (OR 5.918; 95% CI 2.184–16.038; p < 0.001) and low albumin level (OR 3.341; 95% CI 1.229–9.077; p = 0.02). Only minor complications related to CVVHDF have been documented.

Conclusion

Despite the poor prognosis associated with ARF, CVVHDF is an effective and tolerable renal replacement technique in patients with cancer admitted to the ICU. Multiple organ failure and hypoalbuminemia, two independent prognostic factors for hospital mortality have to be considered when deciding for introducing RRT.

Acute kidney injury in critically ill cancer patients: an update

Patients with cancer represent a growing group among actual ICU admissions (up to 20 %). Due to their increased susceptibility to infectious and noninfectious complications related to the underlying cancer itself or its treatment, these patients frequently develop acute kidney injury (AKI). A wide variety of definitions for AKI are still used in the cancer literature, despite existing guidelines on definitions and staging of AKI. Alternative diagnostic investigations such as Cystatin C and urinary biomarkers are discussed briefly. This review summarizes the literature between 2010 and 2015 on epidemiology and prognosis of AKI in this population. Overall, the causes of AKI in the setting of malignancy are similar to those in other clinical settings, including preexisting chronic kidney disease. In addition, nephrotoxicity induced by the anticancer treatments including the more recently introduced targeted therapies is increasingly observed. However, data are sometimes difficult to interpret because they are often presented from the oncological rather than from the nephrological point of view. Because the development of the acute tumor lysis syndrome is one of the major causes of AKI in patients with a high tumor burden or a high cell turnover, the diagnosis, risk factors, and preventive measures of the syndrome will be discussed. Finally, we will briefly discuss renal replacement therapy modalities and the emergence of chronic kidney disease in the growing subgroup of critically ill post-AKI survivors.

Evaluation of Intermittent Hemodialysis in Critically Ill Cancer Patients with Acute Kidney Injury Using Single-Pass Batch Equipment

BACKGROUND

Data on renal replacement therapy (RRT) in cancer patients with acute kidney injury (AKI) in the intensive care unit (ICU) is scarce. The aim of this study was to assess the safety and the adequacy of intermittent hemodialysis (IHD) in critically ill cancer patients with AKI.

METHODS AND FINDINGS

In this observational prospective cohort study, 149 ICU cancer patients with AKI were treated with 448 single-pass batch IHD procedures and evaluated from June 2010 to June 2012. Primary outcomes were IHD complications (hypotension and clotting) and adequacy. A multiple logistic regression was performed in order to identify factors associated with IHD complications (hypotension and clotting). Patients were 62.2 ± 14.3 years old, 86.6% had a solid cancer, sepsis was the main AKI cause (51%) and in-hospital mortality was 59.7%. RRT session time was 240 (180-300) min, blood/dialysate flow was 250 (200-300) mL/min and UF was 1000 (0-2000) ml. Hypotension occurred in 25% of the sessions. Independent risk factors (RF) for hypotension were dialysate conductivity (each ms/cm, OR 0.81, CI 0.69-0.95), initial mean arterial pressure (each 10 mmHg, OR 0.49, CI 0.40-0.61) and SOFA score (OR 1.16, CI 1.03-1.30). Clotting and malfunctioning catheters (MC) occurred in 23.8% and 29.2% of the procedures, respectively. Independent RF for clotting were heparin use (OR 0.57, CI 0.33-0.99), MC (OR 3.59, CI 2.24-5.77) and RRT system pressure increase over 25% (OR 2.15, CI 1.61-4.17). Post RRT blood tests were urea 71 (49-104) mg/dL, creatinine 2.71 (2.10-3.8) mg/dL, bicarbonate 24.1 (22.5-25.5) mEq/L and K 3.8 (3.5-4.1) mEq/L.

CONCLUSION

IHD for critically ill patients with cancer and AKI offered acceptable hemodynamic stability and provided adequate metabolic control.

Nutritional risk assessment in critically ill cancer patients: systematic review

Objective

To systematically review the main methods for nutritional risk assessment used in critically ill cancer patients and present the methods that better assess risks and predict relevant clinical outcomes in this group of patients, as well as to discuss the pros and cons of these methods according to the current literature.

Methods

The study consisted of a systematic review based on analysis of manuscripts retrieved from the PubMed, LILACS and SciELO databases by searching for the key words “nutritional risk assessment”, “critically ill” and “cancer”.

Results

Only 6 (17.7%) of 34 initially retrieved papers met the inclusion criteria and were selected for the review. The main outcomes of these studies were that resting energy expenditure was associated with undernourishment and overfeeding. The high Patient-Generated Subjective Global Assessment score was significantly associated with low food intake, weight loss and malnutrition. In terms of biochemical markers, higher levels of creatinine, albumin and urea were significantly associated with lower mortality. The worst survival was found for patients with worse Eastern Cooperative Oncologic Group - performance status, high Glasgow Prognostic Score, low albumin, high Patient-Generated Subjective Global Assessment score and high alkaline phosphatase levels. Geriatric Nutritional Risk Index values < 87 were significantly associated with mortality. A high Prognostic Inflammatory and Nutritional Index score was associated with abnormal nutritional status in critically ill cancer patients. Among the reviewed studies that examined weight and body mass index alone, no significant clinical outcome was found.

Conclusion

None of the methods reviewed helped to define risk among these patients. Therefore, assessment by a combination of weight loss and serum measurements, preferably in combination with other methods using scores such as Eastern Cooperative Oncologic Group - performance status, Glasgow Prognostic Score and Patient-Generated Subjective Global Assessment, is suggested given that their use is simple, feasible and useful in such cases.

Incidence rate, clinical correlates, and outcomes of AKI in patients admitted to a comprehensive cancer center

BACKGROUND AND OBJECTIVES

Incidence of AKI in hospitalized patients with cancer is increasing, but reports are scant. The objective of this study was to determine incidence rate, clinical correlates, and outcomes of AKI in patients admitted to a cancer center.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Cross-sectional analysis of prospectively collected data on 3558 patients admitted to the University of Texas M.D. Anderson Cancer Center over 3 months in 2006.

RESULTS

Using modified RIFLE (Risk, Injury, Failure, Loss, ESRD) criteria, 12% of patients admitted to the hospital had AKI, with severity in the Risk, Injury, and Failure categories of 68%, 21%, and 11%, respectively. AKI occurred in 45% of patients during the first 2 days and in 55% thereafter. Dialysis was required in 4% of patients and nephrology consultation in 10%. In the multivariate model, the odds ratio (OR) for developing AKI was significantly higher for diabetes (OR, 1.89; 95% confidence interval [CI], 1.51-2.36), chemotherapy (OR, 1.61; 95% CI, 1.26-2.05), intravenous contrast (OR, 4.55; 95% CI, 3.51-5.89), hyponatremia (OR, 1.97; 95% CI, 1.57-2.47), and antibiotics (OR, 1.52; 95% CI, 1.15-2.02). In patients with AKI, length of stay (100%), cost (106%), and odds for mortality (4.7-fold) were significantly greater.

CONCLUSION

The rate of AKI in patients admitted to a comprehensive cancer center was higher than the rate in most noncancer settings; was correlated significantly with diabetes, hyponatremia, intravenous contrast, chemotherapy, and antibiotics; and was associated with poorer clinical outcomes. AKI developed in many patients after admission. Studies are warranted to determine whether proactive measures may limit AKI and improve outcomes.

Onconephrology: the latest frontier in the war against kidney disease

Renal diseases in patients with cancer have many unique features, and often these diseases require specialized approaches. Newer cancer therapy has increased cancer cure rate and survival time, but such benefit is not fully realized, partly because of therapy-associated toxicities. Fluid and electrolyte abnormalities are very common in patients with cancer, as are acute and chronic kidney injury. With the evolving complexities of newer cancer therapies, a comprehensive team approach is becoming necessary. It is essential for nephrologists to be informed and involved in cancer care. Many nephrologists caring for patients with cancer in the United States have recently met and formed a focus group, the OncoNephrology Forum, under the American Society of Nephrology. This update addresses what is clinically unique about onconephrology, the objectives and functions of the newly formed forum, and the potential of onconephrology becoming a subspecialty in nephrology.

Onco-nephrology: AKI in the cancer patient

AKI is common in patients with cancer, and it causes interruptions in therapy and increased hospital length of stay, cost, and mortality. Although cancer patients are susceptible to all of the usual causes of AKI in patients without cancer, there are a number of AKI syndromes that occur more frequently or are unique to this patient population. AKI also confers substantially increased risk of short-term death, and the ability to reverse AKI portends a better outcome in some cancers, such as multiple myeloma. Several trends in oncology, including increased survival, better supportive care, older patients who have received multiple chemotherapy regimens, and new therapeutic options, are driving an increase in the numbers of cancer patients who develop AKI. As a result, nephrologists should be increasingly familiar with the diagnosis, management, and treatment of AKI in this setting. Here, we summarize recent data on epidemiology of AKI in cancer patients, describe the most common AKI syndromes in this population, and highlight emerging areas in the growing field of onconephrology.

Clinical management of SIADH

Hyponatremia is the most frequent electrolyte disorder and the syndrome of inappropriate antidiuretic hormone secretion (SIADH) accounts for approximately one-third of all cases. In the diagnosis of SIADH it is important to ascertain the euvolemic state of extracellular fluid volume, both clinically and by laboratory measurements. SIADH should be treated to cure symptoms. While this is undisputed in the presence of grave or advanced symptoms, the clinical role and the indications for treatment in the presence of mild to moderate symptoms are currently unclear. Therapeutic modalities include nonspecific measures and means (fluid restriction, hypertonic saline, urea, demeclocycline), with fluid restriction and hypertonic saline commonly used. Recently vasopressin receptor antagonists, called vaptans, have been introduced as specific and direct therapy of SIADH. Although clinical experience with vaptans is limited at this time, they appear advantageous to patients because there is no need for fluid restriction and the correction of hyponatremia can be achieved comfortably and within a short time. Vaptans also appear to be beneficial for physicians and staff because of their efficiency and reliability. The side effects are thirst, polydipsia and frequency of urination. In any therapy of chronic SIADH it is important to limit the daily increase of serum sodium to less than 8-10 mmol/liter because higher correction rates have been associated with osmotic demyelination. In the case of vaptan treatment, the first 24 h are critical for prevention of an overly rapid correction of hyponatremia and the serum sodium should be measured after 0, 6, 24 and 48 h of treatment. Discontinuation of any vaptan therapy for longer than 5 or 6 days should be monitored to prevent hyponatremic relapse. It may be necessary to taper the vaptan dose or restrict fluid intake or both.

Continuing education: alternative approaches to optimizing antimicrobial pharmacodynamics in critically ill patients

Critical illness results in a constellation of physiologic changes that subsequently impact antibiotic pharmacokinetic and pharmacodynamic parameters. These changes can result in poorly treated infections that in turn lead to longer intensive care unit (ICU) and hospital stays, prolonged use of mechanical ventilation, and higher mortality rates. Research has expanded our understanding of antibiotic pharmacodynamics among ICU patients, and some investigators and clinicians have questioned traditional antibiotic dosing schemes among this population. Alternative dosing strategies to optimize antibiotic pharmacodynamics of aminoglycosides, beta-lactams, fluoroquinolones, and vancomycin have been explored. Appropriate duration of exposure to beta-lactam antibiotics has been recognized as an important parameter associated with successful treatment outcomes. To maximize this exposure, continuous infusions over a 24-hour period have resulted in higher clinical response rates and improved surrogate markers of infection. Equally as promising is the alternative of extending the infusion time to increase exposure while maintaining the same daily beta-lactam dose and frequency. Data from clinical trials have suggested that the area under the concentration-time curve to minimum inhibitory concentration ratio for aminoglycosides, fluoroquinolones, and vancomycin is a better correlate for successful treatment outcomes. Optimizing antibiotic pharmacodynamics by changing dosage methods should be considered in ICU patients to improve treatment response and success.

Costs and outcomes of acute kidney injury in critically ill patients with cancer

BACKGROUND

Acute kidney injury (AKI) is a common complication in critically ill patients with cancer. The RIFLE criteria define three levels of AKI based on the percent increase in serum creatinine (Scr) from baseline: risk (> or = 50%), injury (> or = 100%), and failure (> or = 200% or requiring dialysis). The utility of the RIFLE criteria in critically ill patients with cancer is not known.

OBJECTIVE

To examine the incidence, outcomes, and costs associated with AKI in critically ill patients with cancer.

METHODS

We retrospectively analyzed all patients admitted to a single-center ICU over a 13-month period with a baseline Scr < or = 1.5 mg/dL (n = 2,398). Kaplan-Meier estimates for survival by RIFLE category were calculated. Logistic regression was used to determine the association of AKI on 60-day mortality. A log-linear regression model was used for economic analysis. Costs were assessed by hospital charges from the provider's perspective.

RESULTS

For the risk, injury, and failure categories of AKI, incidence rates were 6%, 2.8%, and 3.7%; 60-day survival estimates were 62%, 45%, and 14%; and adjusted odds ratios for 60-day mortality were 2.3, 3, and 14.3, respectively (P < or = 0.001 compared to patients without AKI). Hematologic malignancy and hematopoietic cell transplant were not associated with mortality in the adjusted analysis. Hospital cost increased by 0.16% per 1% increase in creatinine and by 21% for patients requiring dialysis.

LIMITATIONS

Retrospective analysis. Single-center study. No adjustment by cost-to-charge ratios.

CONCLUSIONS

AKI is associated with higher mortality and costs in critically ill patients with cancer.

Electrolyte disturbances and acute kidney injury in patients with cancer

The interrelation between kidney disease and cancer is complex and reciprocal. Among the most frequent cancer-associated kidney diseases are the electrolyte and acid-base disturbances, which occur frequently and often are associated with an ominous prognosis, and acute kidney injury. Tumor lysis syndrome is a potentially life-threatening condition that frequently occurs in patients with a high tumor burden and high cellular turnover after cytotoxic therapy (including steroids in steroid-sensitive hematologic malignancies). Electrolyte and acid-base disturbances are the consequence of neoplastic spread, anticancer treatment, or, more rarely, paraneoplastic phenomena of all types of tumors. This article reviews hyponatremia and hypernatremia, hypokalemia and hyperkalemia, hypomagnesemia, hypercalcemia and hypocalcemia, hypophosphatemia, and the most important disturbances in acid-base balance in cancer patients. Acute kidney injury (AKI) is a frequent occurrence in cancer patients and has the potential to substantially alter the outcome of patients with cancer and jeopardize their chances of receiving optimal cancer treatment and a potential cure. As in many other circumstances, the etiology of AKI in cancer patients is multifactorial. Initiation and/or continuation of dialysis in the AKI cancer patient should be based on the general clinical condition and overall life expectancy and the personal patient expectations on quality of life after eventual recovery.

Sustained Low-Efficiency Daily Dialysis as Renal Replacement Therapy for the Critically Ill

Understanding proper management of acute kidney injury (AKI) is important given that studies consistently demonstrate an increasing incidence rate of AKI in the critically ill. AKI carries a significant risk for mortality, which only increases if dialysis becomes a necessary treatment. It is not clear whether modalities other than conventional intermittent hemodialysis improve outcomes in AKI. Sustained low-efficiency daily dialysis (SLEDD) is a more recent extracorporeal treatment whose distinguishing characteristic is its hybrid integration of both continuous and intermittent hemodialysis modalities. Besides providing comparable hemodynamic stability through its decreased blood flow rate and extended hours of use, SLEDD is less complicated, is less expensive, and is convenient for staff and patient. As a result, its use in critical care is on the rise.