1
|
Mohd Rozi NA, Mohd Tahir NA, Mohd Saffian S, Makmor-Bakry M, Mohamad Yusof A, Mustafar R, M Saud MN. Therapeutic drug monitoring-guided piperacillin dosing in critically ill patients undergoing continuous renal replacement therapy: a systematic review. J Antimicrob Chemother 2024:dkae332. [PMID: 39321326 DOI: 10.1093/jac/dkae332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 09/05/2024] [Indexed: 09/27/2024] Open
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) complicates antibiotic dosing in critically ill patients due to altered pharmacokinetics. The optimal dosing of piperacillin remains unclear. Therapeutic drug monitoring (TDM) can personalize piperacillin therapy and improve outcomes. OBJECTIVES This review investigates the effects of TDM-guided piperacillin dosing on pharmacokinetic target attainment and clinical outcomes in CRRT patients, analyses correlations with clinical outcomes, provides optimal dosing strategies for piperacillin and identifies future research areas. METHODS A systematic search of PubMed, Scopus and Web of Science was conducted until December 2023, identifying studies on piperacillin pharmacokinetics and clinical outcomes in adult CRRT patients. Data on study characteristics, piperacillin exposures, TDM use, target attainment rates, mortality and length of stay were extracted. The risk of bias was assessed using the Newcastle-Ottawa Scale. RESULTS Eleven observational studies were included. High pharmacokinetic variability was evident, with piperacillin target non-attainment in up to 74% of cases without TDM. Two studies with routine TDM showed increased target attainment rates of 80%-100%. Mortality ranged from 17% to 56%, with supratherapeutic concentrations (≥100 mg/L) associated with higher mortality. The impact of optimized piperacillin exposures on outcomes was inconclusive. Most studies demonstrated a low risk of bias. CONCLUSIONS TDM-guided piperacillin dosing in CRRT patients improved target attainment rates (≥80%). Mortality rates ranged from 17% to 56%, with inconsistent correlations between drug exposures and survival. Supratherapeutic concentrations were linked to higher mortality. Standardized TDM protocols are needed. Future research should establish clear exposure-response relationships and the impact of TDM on clinical outcomes.
Collapse
Affiliation(s)
- Nazatul Adhwa Mohd Rozi
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Aziz, 50300 Kuala Lumpur, Malaysia
| | - Nor Asyikin Mohd Tahir
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Aziz, 50300 Kuala Lumpur, Malaysia
| | - Shamin Mohd Saffian
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Aziz, 50300 Kuala Lumpur, Malaysia
| | - Mohd Makmor-Bakry
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Aziz, 50300 Kuala Lumpur, Malaysia
- Faculty of Pharmacy, Universitas Airlangga, PQMM+9Q6, Gedung Nanizar Zaman Joenoes Kampus C UNAIR, Jl. Mulyorejo, Mulyorejo, Surabaya, East Java 60115, Indonesia
| | - Aliza Mohamad Yusof
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine and Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif Kuala Lumpur, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Ruslinda Mustafar
- Department of Medicine, Faculty of Medicine and Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif Kuala Lumpur, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Muhammad Nordin M Saud
- Department of Pharmacy, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif Kuala Lumpur, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia
| |
Collapse
|
2
|
Phongphithakchai A, Sirisuksan T, Konwai S, Praditau-Krit S, Boonsrirat U. Successful Application of a Hemoperfusion Machine in Separated System CRRT: Evaluating Effectiveness and Safety in Critically Ill Patients With AKI in Resource-Limited Settings. Semin Dial 2024; 37:380-385. [PMID: 38770941 DOI: 10.1111/sdi.13210] [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: 11/12/2023] [Revised: 03/10/2024] [Accepted: 05/06/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND It is imperative to note that integrated system continuous renal replacement therapy (CRRT) necessitates a sophisticated and costly apparatus, potentially limiting its availability within resource-limited settings. The introduction of a separated system for continuous veno-venous hemofiltration (CVVH), characterized by uncomplicated setup procedures with a hemoperfusion machine, holds promise as a feasible alternative to CRRT for critically ill patients with acute kidney injury (AKI). METHODS We aimed to retrospectively analyze the effectiveness and safety of separated CRRT applied from a hemoperfusion machine in critically ill patients with AKI during the January 2015 to December 2021 period. We also examine the in-hospital mortality rate and multivariate logistic regression analysis to uncover the factors that affect mortality. RESULTS We included a total of 129 critically ill patients who received separated system CRRT. The SOFA score at CRRT initiation was 12.6 ± 3.8. The fluid accumulation at the day of CRRT initiation was 3900 mL (622-8172 mL) All patients received pre- and postdilution CVVH. The mean prescribed CRRT dose was 22.4 ± 3.1 mL/kg/h. We found no serious complications including circuit explosion and air embolism. The in-hospital mortality rate was 68.9%. High SOFA score and positive fluid accumulation at CRRT initiation serve as predictors of survival. CONCLUSIONS Separated system CRRT using a hemoperfusion machine provides a simplified system to operate and is proven to be effective and safe in real-life practice, especially in resource-limited areas.
Collapse
Affiliation(s)
- Atthaphong Phongphithakchai
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Thiti Sirisuksan
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Sirihatai Konwai
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Suntornwit Praditau-Krit
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Ussanee Boonsrirat
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| |
Collapse
|
3
|
Lee GB, Lee JW, Yoon SH, Hwang WM, Yun SR, Koh DH, Park Y. Plasma presepsin for mortality prediction in patients with sepsis-associated acute kidney injury requiring continuous kidney replacement therapy. Kidney Res Clin Pract 2024; 43:457-468. [PMID: 38934036 PMCID: PMC11237336 DOI: 10.23876/j.krcp.23.301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/20/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND The reliability of presepsin as a biomarker of sepsis may be reduced in patients with acute kidney injury (AKI) requiring continuous kidney replacement therapy (CKRT). This study analyzed the utility of plasma presepsin values in predicting mortality in patients with AKI requiring CKRT, particularly those with sepsis-associated AKI. METHODS This single-center retrospective study included 57 patients who underwent CKRT, with plasma presepsin measurements, from April 2022 to March 2023; 35 had sepsis-associated AKI. The predictive values of plasma presepsin, as well as Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, for 28-day mortality were analyzed using receiver operating characteristic curves. Multivariate Cox regression analysis was performed to identify risk factors for 28-day mortality in the sepsis-associated AKI subgroup. RESULTS Overall, plasma presepsin showed a lower area under the curve value (0.636; 95% confidence interval [CI], 0.491-0.781) than the APACHE II (0.663; 95% CI, 0.521-0.804) and SOFA (0.731; 95% CI, 0.599-0.863) scores did. However, in sepsis-associated AKI, the area under the curve increased to 0.799 (95% CI, 0.653-0.946), which was higher than that of the APACHE II (0.638; 95% CI, 0.450-0.826) and SOFA (0.697; 95% CI, 0.519-0.875) scores. In the multivariate Cox regression analysis, a high presepsin level was an independent risk factor for 28-day mortality in sepsis-associated AKI (hazard ratio, 3.437; p = 0.03). CONCLUSION Presepsin is a potential prognostic marker in patients with sepsis-associated AKI requiring CKRT.
Collapse
Affiliation(s)
- Gi-Beop Lee
- Division of Nephrology, Department of Internal Medicine, Konyang University Hospital, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Ji Won Lee
- Division of Nephrology, Department of Internal Medicine, Konyang University Hospital, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Se-Hee Yoon
- Division of Nephrology, Department of Internal Medicine, Konyang University Hospital, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Won Min Hwang
- Division of Nephrology, Department of Internal Medicine, Konyang University Hospital, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Sung-Ro Yun
- Division of Nephrology, Department of Internal Medicine, Konyang University Hospital, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Dong Hoon Koh
- Department of Urology, Konyang University Hospital, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Yohan Park
- Division of Nephrology, Department of Internal Medicine, Konyang University Hospital, College of Medicine, Konyang University, Daejeon, Republic of Korea
| |
Collapse
|
4
|
Park CH, Koh HB, Lee JH, Jung HY, Ha J, Kim HW, Park JT, Han SH, Kang SW, Yoo TH. Volume control strategy and patient survival in sepsis-associated acute kidney injury receiving continuous renal replacement therapy: a randomized controlled trial with secondary analysis. Sci Rep 2024; 14:14284. [PMID: 38902283 PMCID: PMC11190228 DOI: 10.1038/s41598-024-64224-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 06/06/2024] [Indexed: 06/22/2024] Open
Abstract
Optimal strategy for volume control and the clinical implication of achieved volume control are unknown in patients with sepsis-associated acute kidney injury (AKI) receiving continuous renal replacement therapy (CRRT). This randomized controlled trial aimed to compare the survival according to conventional or bioelectrical impedance analysis (BIA)-guided volume control strategy in patients with sepsis-associated AKI receiving CRRT. We also compared patient survival according to achieved volume accumulation rate ([cumulative fluid balance during 3 days × 100]/fluid overload measured by BIA at enrollment) as a post-hoc analysis. We randomly assigned patients to conventional volume control strategy (n = 39) or to BIA-guided volume control strategy (n = 34). There were no differences in 28-day mortality (HR, 1.19; 95% CI, 0.63-2.23) or 90-day mortality (HR, 0.99; 95% CI 0.57-1.75) between conventional and BIA-guided volume control group. In the secondary analysis, achieved volume accumulation rate was significantly associated with patient survival. Compared with the achieved volume accumulation rate of ≤ - 50%, the HRs (95% CIs) for the risk of 90-day mortality were 1.21 (0.29-5.01), 0.55 (0.12-2.48), and 7.18 (1.58-32.51) in that of - 50-0%, 1-50%, and > 50%, respectively. Hence, BIA-guided volume control in patients with sepsis-associated AKI receiving CRRT did not improve patient outcomes. In the secondary analysis, achieved volume accumulation rate was associated with patient survival.
Collapse
Affiliation(s)
- Cheol Ho Park
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee Byung Koh
- Department of Internal Medicine, International Saint Mary's Hospital, Catholic Kwandong University, Incheon, Republic of Korea
| | - Jin Hyeog Lee
- Department of Internal Medicine, International Saint Mary's Hospital, Catholic Kwandong University, Incheon, Republic of Korea
| | - Hui-Yun Jung
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joohyung Ha
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyung Woo Kim
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Tak Park
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
5
|
Prasad G, Deepankar P, Choudhary MK, Ahmad A, Ram B, Kumar N, Patel PS. Clinical Profile and Short-Term Outcomes of Acute Kidney Injury in Elderly Patients in a Tertiary Care Center. Cureus 2024; 16:e62690. [PMID: 39036153 PMCID: PMC11259520 DOI: 10.7759/cureus.62690] [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: 04/03/2024] [Accepted: 06/08/2024] [Indexed: 07/23/2024] Open
Abstract
Background Acute kidney injury (AKI) is a common and serious condition affecting elderly patients. Despite its significance, comprehensive research focusing specifically on the clinical profile and short-term outcomes of AKI in this vulnerable population is lacking. Objective This study aimed to evaluate the clinical profile and short-term outcomes of AKI in elderly patients admitted to a tertiary care center. Methods A prospective observational study was conducted from December 2023 to March 2024, involving 75 elderly patients (aged ≥65 years) diagnosed with AKI. Baseline demographic data, clinical profiles, laboratory investigations, mortality rate among elderly patients diagnosed with AKI within 30 days of diagnosis, and short-term outcomes were recorded and analyzed. Descriptive statistics and appropriate statistical tests were used for the data analysis. Results The study cohort had a mean age of 72.6 years. Hypertension was present in 55 patients (73.3%), and diabetes mellitus was observed in 30 patients (40.0%). Prerenal causes of AKI were identified in 40 patients (53.3%), while acute tubular necrosis was found in 25 patients (33.3%). Stage 2 AKI was the most common, affecting 35 patients (46.7%). Out of the 75 patients, 15 patients (20.0%) succumbed to AKI within the study period. Deceased patients had longer hospital stays, with a median of 16 days compared to 10 days for survivors. ICU admission was required for 13 of the deceased patients (86.7%), compared to 32 of the surviving patients (53.3%). The need for renal replacement therapy was higher among the deceased patients, with 11 out of 15 patients (73.3%) requiring it, compared to 19 out of 60 surviving patients (31.7%). Renal function recovery was notably lower in the deceased patients. Conclusion AKI in elderly patients was associated with significant morbidity and mortality, highlighting the need for early recognition, appropriate management, and preventive strategies. A comprehensive evaluation of the clinical profile and short-term outcomes of AKI in the elderly population provides valuable insights for optimizing patient care and improving outcomes.
Collapse
Affiliation(s)
- Govind Prasad
- Department of General Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Praphull Deepankar
- Department of General Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Manoj Kumar Choudhary
- Department of General Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Arshad Ahmad
- Department of General Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Bhim Ram
- Department of General Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Naresh Kumar
- Department of General Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Prem S Patel
- Department of Nephrology, Indira Gandhi Institute of Medical Sciences, Patna, IND
| |
Collapse
|
6
|
Han S, Kim MJ, Ko HJ, Lee EJ, Kim HR, Jeon JW, Ham YR, Na KR, Lee KW, Lee SI, Choi DE, Park H. Diagnostic and Prognostic Roles of C-Reactive Protein, Procalcitonin, and Presepsin in Acute Kidney Injury Patients Initiating Continuous Renal Replacement Therapy. Diagnostics (Basel) 2023; 13:diagnostics13040777. [PMID: 36832265 PMCID: PMC9955569 DOI: 10.3390/diagnostics13040777] [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: 12/14/2022] [Revised: 02/11/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
For reducing the high mortality rate of severe acute kidney injury (AKI) patients initiating continuous renal replacement therapy (CRRT), diagnosing sepsis and predicting prognosis are essential. However, with reduced renal function, biomarkers for diagnosing sepsis and predicting prognosis are unclear. This study aimed to assess whether C-reactive protein (CRP), procalcitonin, and presepsin could be used to diagnose sepsis and predict mortality in patients with impaired renal function initiating CRRT. This was a single-center, retrospective study involving 127 patients who initiated CRRT. Patients were divided into sepsis and non-sepsis groups according to the SEPSIS-3 criteria. Of the 127 patients, 90 were in the sepsis group and 37 were in the non-sepsis group. Cox regression analysis was performed to determine the association between the biomarkers (CRP, procalcitonin, and presepsin) and survival. CRP and procalcitonin were superior to presepsin for diagnosing sepsis. Presepsin was closely related to the estimated glomerular filtration rate (eGFR) (r = -0.251, p = 0.004). These biomarkers were also evaluated as prognostic markers. Procalcitonin levels ≥3 ng/mL and CRP levels ≥31 mg/L were associated with higher all-cause mortality using Kaplan-Meier curve analysis. (log-rank test p = 0.017 and p = 0.014, respectively). In addition, procalcitonin levels ≥3 ng/mL and CRP levels ≥31 mg/L were associated with higher mortality in univariate Cox proportional hazards model analysis. In conclusion, a higher lactic acid, sequential organ failure assessment score, eGFR, and a lower albumin level have prognostic value to predict mortality in patients with sepsis initiating CRRT. Moreover, among these biomarkers, procalcitonin and CRP are significant factors for predicting the survival of AKI patients with sepsis-initiating CRRT.
Collapse
Affiliation(s)
- Suyeon Han
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Moo-Jun Kim
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Ho-Joon Ko
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Eu-Jin Lee
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Hae-Ri Kim
- Department of Nephrology, Chungnam National University Sejong Hospital, Sejong 30099, Republic of Korea
| | - Jae-Wan Jeon
- Department of Nephrology, Chungnam National University Sejong Hospital, Sejong 30099, Republic of Korea
| | - Young-Rok Ham
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Ki-Ryang Na
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Kang-Wook Lee
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Song-I. Lee
- Department of Pulmonary and Critical Care Medicine, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
- Correspondence: (S.-I.L.); (D.-E.C.)
| | - Dae-Eun Choi
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
- Department of Medical Science, Medical School, Chungnam National University, Daejeon 35015, Republic of Korea
- Correspondence: (S.-I.L.); (D.-E.C.)
| | - Heyrim Park
- Department of Medical Science, Medical School, Chungnam National University, Daejeon 35015, Republic of Korea
| |
Collapse
|
7
|
Kim IY, Kim S, Ye BM, Kim MJ, Kim SR, Lee DW, Lee SB. Procalcitonin decrease predicts survival and recovery from dialysis at 28 days in patients with sepsis-induced acute kidney injury receiving continuous renal replacement therapy. PLoS One 2022; 17:e0279561. [PMID: 36574383 PMCID: PMC9794048 DOI: 10.1371/journal.pone.0279561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/09/2022] [Indexed: 12/28/2022] Open
Abstract
Procalcitonin (PCT) is a biomarker for diagnosing infections and guiding antibiotic therapy. In this study, we investigated whether PCT can predict survival and recovery at 28 days in critically ill patients with sepsis-induced acute kidney injury (SIAKI) receiving continuous renal replacement therapy (CRRT). We examined 649 patients with SIAKI who underwent CRRT in our intensive care unit. In a multivariable Cox regression analysis, a single PCT level at CRRT initiation was not associated with survival in all patients. However, the higher % PCT decrease over 72 hours after CRRT initiation was independently associated with the higher chance of 28-day survival (per 10% decrease, hazard ratio [HR] for mortality: 0.87, 95% confidence interval [CI]: 0.85-0.89; P < 0.001). Among the survivors, the % PCT decrease over 72 hours after CRRT initiation, not a single PCT level at CRRT initiation, was independently associated with recovery from dialysis (per 10% decrease, HR for renal recovery: 1.28, 95% CI:1.21-1.36; P < 0.001). This study demonstrated that the higher % PCT decrease was independently associated with the higher chance of survival and recovery from dialysis at 28 days in critically ill patients with SIAKI receiving CRRT. Thus, a decrease in the PCT level, not a single PCT level at CRRT initiation, could be a valuable tool for predicting prognosis in these patients.
Collapse
Affiliation(s)
- Il Young Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Suji Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Byung Min Ye
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Min Jeong Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Seo Rin Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Dong Won Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Soo Bong Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
- * E-mail:
| |
Collapse
|
8
|
Li L, Bai M, Zhang Q, Sun S. Characteristics and predictors of ICU-mortality in critically ill patients with hyperlactatemia requiring CRRT: A retrospective cohort study. Int J Artif Organs 2022; 45:973-980. [PMID: 36151706 DOI: 10.1177/03913988221126728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hyperlactatemia is a common complication in critically ill patients with high morbidity and mortality. Hyperlactatemia patients who require continuous renal replacement therapy (CRRT) constitute a subgroup with increased mortality risk. The clinical significance of serum lactate in these patients was not well understood and clearance of lactate using CRRT shown no survival benefits. The aim of this study is to investigate the incidence and non-lactate risk factors for ICU mortality in hyperlactatemia patients who underwent CRRT. METHOD Hyperlactatemia patients with a serum lactate level >2 μmol/L who underwent CRRT between January, 2014 and May, 2021 were retrospectively investigated. Demographic characteristics and clinical data were collected from the electronic medical record system. The primary endpoint was predictors for ICU mortality which were identified by using multivariate logistic regression analysis. RESULTS A total of 178 eligible patients were finally included with a mean age of 56.6 ± 17.9 years and a median APACHE II score of 18 (IQR (14-22)). The multivariate regression results showed that male gender (OR 0.55 (95%CI 0.27-1.12), p = 0.1), mechanical ventilation (OR 2.60 (95%CI 1.27-5.34), p = 0.008), history of hypertension (OR 2.40 (95%CI 1.12-5.14), p = 0.02), SOFA score (OR 1.16 (95%CI 1.05-1.28), p = 0.002), AST (OR 1.0005 (95%CI 0.99-1.001), p = 0.08), and PT (OR 1.08 (95%CI 0.99-1.17), p = 0.06) were independently associated with ICU mortality. After adjusting for age, illness severity (APACHE II score), and serum lactate level, the statistical significances of SOFA score (OR 1.16 (95%CI 1.04-1.29), p = 0.005), hypertension (OR 2.25 (95%CI 1.02-4.95), p = 0.04), and mechanical ventilation (OR 2.54 (95%CI 1.22-5.25), p = 0.01) were not affected. The overall ICU mortality was 58.4% (104/178). CONCLUSION The hyperlactatemia patients who underwent CRRT were at increased ICU mortality. Gender, AST, PT, SOFA score, history of hypertension, and mechanical ventilation were independent predictors for ICU mortality. Future studies with prospectively design, large sample size, and subgroup analyses are warranted to validate these findings.
Collapse
Affiliation(s)
- Lu Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China.,Department of Nephrology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qiaona Zhang
- Department of Nephrology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| |
Collapse
|
9
|
Zhang M, Li J. Continuous Renal Replacement Therapy for Hypertension Complicated by Refractory Heart Failure: An Analysis of Safety and Nursing Highlights. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:7951744. [PMID: 36158122 PMCID: PMC9492330 DOI: 10.1155/2022/7951744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/27/2022] [Indexed: 11/21/2022]
Abstract
Objective This research is aimed at analyzing the safety profile and nursing highlights of continuous renal replacement therapy (CRRT) for hypertension (HT) complicated by refractory heart failure (RHF). Methods Sixty-six HT + RHF patients admitted between March 2018 and December 2021 were enrolled and assigned to two groups: a CRRT group with 33 cases treated with CRRT and a control group with 33 cases intervened by routine treatment. The therapeutic effect and alterations of cardiac function (CF) indexes were observed in both cohorts. Besides, statistics were made in terms of serum B-type natriuretic peptide (BNP), C-reactive protein (CRP) and mean arterial pressure (MAP) concentrations, time of asthma relief, heart rate recovery (HRR), edema resolution, and hospitalization, as well as incidence of adverse reactions (ARs). Finally, pre- and posttreatment psychological quality and pain of both cohorts of subjects were assessed using the self-rating anxiety and depression scale (SAS and SDS) and visual analogue scale (VAS), respectively. Results CRRT group exhibited higher overall response rate and better CF than control group (P < 0.05), with lower BNP, CRP, and MAP levels, and shorter time of asthma relief, HRR, edema resolution, and hospitalization (P < 0.05); the incidence of ARs was similar (P > 0.05); for both groups, the scores of SAS, SDS, and VAS reduced statistically after treatment (P < 0.05). Conclusion CRRT can effectively improve the therapeutic effect and CF of patients with HT complicated by RHF, to protect the health and safety of patients.
Collapse
Affiliation(s)
- Miaoli Zhang
- Department of Fourth Cardiovascular Medicine, The Affiliated Chuzhou Hospital of Anhui Medical University, The First People's Hospital of Chuzhou, Chuzhou, Anhui 239000, China
| | - Jingfeng Li
- Department of Fourth Cardiovascular Medicine, The Affiliated Chuzhou Hospital of Anhui Medical University, The First People's Hospital of Chuzhou, Chuzhou, Anhui 239000, China
| |
Collapse
|
10
|
Predictors of Mortality in Adults with Acute Kidney Injury Requiring Dialysis: A Cohort Analysis. Int J Nephrol 2022; 2022:7418955. [PMID: 36132538 PMCID: PMC9484972 DOI: 10.1155/2022/7418955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 08/25/2022] [Indexed: 02/05/2023] Open
Abstract
Introduction Acute kidney injury (AKI) requiring renal replacement therapy is accompanied by considerable mortality. This present study evaluated predictors of mortality at initiation of hemodialysis (HD) in AKI patients in Goma (in the Democratic Republic of the Congo (DRC)). Methods A single-centre cohort survey evaluated the clinical profile and survival rates of AKI patients admitted to HD in the only HD centre in Goma, North Kivu province (DRC). Data were collected from patients who underwent HD for AKI. Patient demographics, comorbidities, clinical presentation, laboratory tests, and mortality were reviewed and analyzed. The survival study used the Kaplan–Meier curve. Predictors of mortality were evaluated using Cox regression. Results Of the 131 eligible patients, the mean age was 43.69 ± 16.56 years (range: 18–90 years). Men represented 54.96% of the cohort. The overall HD mortality rate was 25.19% (n = 33). In multivariate analysis, independent predictors of mortality in AKI stage 3 patients admitted to HD were as follows: age ≥ 60 years (adjusted hazard ratio (AHR) = 15.89; 95% CI: 3.98–63.40; p < 0.0001), traditional herbal medicine intake (AHR = 5.10; 95% CI: 2.10–12.38; p < 0.0001), HIV infection (AHR = 5.55; 95% CI: 1.48–20.73; p=0.011), anemia (AHR = 9.57; 95% CI: 2.08–43.87; p=0.004), hyperkalemia (AHR = 6.23; 95% CI: 1.26–30.72; p=0.025), respiratory distress (AHR = 4.66; 95% CI: 2.07–10.50; p < 0.0001), and coma (AHR = 11.39; 95% CI: 3.51–36.89; p < 0.0001). Conclusion Initiation of hemodialysis with AKI has improved survival in patients with different complications.
Collapse
|
11
|
Tiglis M, Peride I, Florea IA, Niculae A, Petcu LC, Neagu TP, Checherita IA, Grintescu IM. Overview of Renal Replacement Therapy Use in a General Intensive Care Unit. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:2453. [PMID: 35206640 PMCID: PMC8878091 DOI: 10.3390/ijerph19042453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/03/2022] [Accepted: 02/19/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Population-based studies regarding renal replacement therapy (RRT) used in critical care populations are useful to understand the trend and impact of medical care interventions. We describe the use of RRT and associated outcomes (mortality and length of intensive care stay) in a level 1 hospital. DESIGN A retrospective descriptive observational study. PATIENTS Critically ill patients admitted to the ICU from 1 January to 31 December 2018. INTERVENTIONS Age, gender, ward of admission, primary organ dysfunction at admission, length of hospital stay (LOS), mechanical ventilation, APACHE, SOFA and ISS scores, the use of vasopressors, transfusion, RRT and the number of RRT sessions were extracted. RESULTS 1703 critically ill patients were divided into two groups: the RRT-group (238 patients) and the non-RRT group (1465 patients). The mean age was 63.58 ± 17.52 (SD) in the final ICU studied patients (64.72 ± 16.64 SD in the RRT-group), 60.5% being male. Patients admitted from general surgery ward needing RRT were 41.4%. The specific scores, the use of vasopressors, transfusions and mortality were higher in the RRT-group. The ICU LOS was superior in the RRT-group, regardless of the primary organ dysfunction. CONCLUSIONS RRT was practiced in 13.9% of patients (especially after age of 61), with mortality being the outcome for 66.8% of the RRT-group patients. All analyzed data were higher in the RRT group, especially for multiple trauma and surgical patients, or patients presenting cardiac or renal dysfunctions at admission. We found significant increased ISS scores in the RRT-group, a significant association between the need of vasopressors or transfusion requirement and RRT use, and an association in the number of RRT sessions and LOS (p < 0.001).
Collapse
Affiliation(s)
- Mirela Tiglis
- Department of Anesthesia and Intensive Care, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (M.T.); (I.A.F.); (I.M.G.)
- Clinical Department No. 14, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Ileana Peride
- Clinical Department No. 3, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.P.); (A.N.); (I.A.C.)
| | - Iulia Alexandra Florea
- Department of Anesthesia and Intensive Care, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (M.T.); (I.A.F.); (I.M.G.)
| | - Andrei Niculae
- Clinical Department No. 3, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.P.); (A.N.); (I.A.C.)
| | - Lucian Cristian Petcu
- Department of Biophysics and Biostatistics, Faculty of Dentistry, “Ovidius” University, 900684 Constanta, Romania;
| | - Tiberiu Paul Neagu
- Clinical Department No. 11, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Ionel Alexandru Checherita
- Clinical Department No. 3, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.P.); (A.N.); (I.A.C.)
| | - Ioana Marina Grintescu
- Department of Anesthesia and Intensive Care, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (M.T.); (I.A.F.); (I.M.G.)
- Clinical Department No. 14, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| |
Collapse
|
12
|
Thongprayoon C, Radhakrishnan Y, Cheungpasitporn W, Petnak T, Qureshi F, Mao MA, Kashani KB. Association of Serum Phosphate Derangement With Mortality in Patients on Continuous Renal Replacement Therapy. Can J Kidney Health Dis 2022; 9:20543581221114697. [PMID: 35923184 PMCID: PMC9340369 DOI: 10.1177/20543581221114697] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background: There is limited evidence on the association of serum phosphate with
mortality in patients receiving continuous renal replacement therapy
(CRRT). Objective: To assess the association of serum phosphate with mortality in critically ill
patients requiring CRRT for acute kidney injury (AKI). Design: A cohort study. Setting: A tertiary referral hospital in the United States. Patients: Acute kidney injury patients receiving CRRT from 2006 through 2015 in
intensive care units. Measurements: (1) Serum phosphate before CRRT and (2) mean serum phosphate during CRRT were
categorized into 3 groups; ≤2.4 (hypophosphatemia), 2.5 to 4.5 (normal serum
phosphate group), and ≥4.6 (hyperphosphatemia) mg/dL. Methods: Multivariable logistic regression was used to assess the association between
serum phosphate and 90-day mortality. Results: A total of 1108 patients were included in this study. Of these, 55% died
within 90 days after CRRT initiation. Before CRRT, 3%, 30%, and 66% had
hypophosphatemia, normophosphatemia, and hyperphosphatemia, respectively.
Before CRRT, both hypophosphatemia and hyperphosphatemia were significantly
associated with higher 90-day mortality with the adjusted odds ratio (OR) of
2.22 (95% confidence interval [CI]: [1.03, 4.78]) and 1.62 (95% CI: [1.21,
2.18]), respectively. During CRRT, 3%, 85%, and 12% had mean serum phosphate
in hypophosphatemia, normophosphatemia, and hyperphosphatemia range. During
CRRT, hyperphosphatemia was significantly associated with higher 90-day
mortality with adjusted OR of 2.22 (95% CI: [1.45, 3.38]). Limitations: Single center, observational design, lack of information regarding causes of
serum phosphate derangement. Conclusion: Most CRRT patients had hyperphosphatemia before CRRT initiation but maintain
normal serum phosphate during CRRT. Before CRRT, hypo- and
hyperphosphatemia, and during CRRT, hyperphosphatemia predicted higher
mortality. Trial registration: Not registered.
Collapse
Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yeshwanter Radhakrishnan
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tananchai Petnak
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Pulmonary and Pulmonary Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Fawad Qureshi
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael A. Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL, USA
| | - Kianoush B. Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
13
|
Thongprayoon C, Cheungpasitporn W, Radhakrishnan Y, Petnak T, Qureshi F, Mao MA, Kashani KB. Impact of hypoalbuminemia on mortality in critically ill patients requiring continuous renal replacement therapy. J Crit Care 2021; 68:72-75. [PMID: 34929529 DOI: 10.1016/j.jcrc.2021.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/30/2021] [Accepted: 12/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to assess the association of hypoalbuminemia with mortality in critically ill patients requiring continuous renal replacement therapy (CRRT). METHODS This is a retrospective cohort study of critically ill patients receiving CRRT from December 2006 through November 2015 in a tertiary referral hospital in the United States. We used logistic regression to assess serum albumin at CRRT initiation as predictors for 90-day mortality. RESULTS A total of 911 patients requiring CRRT were included in this study. The mean serum albumin at CRRT initiation was 3.0 ± 0.7 g/dL. The 90-day mortality was 57%. Serum albumin levels of ≤2.4, 2.5-2.9, 3.0-3.4, and ≥ 3.5 g/dL were noted in 24%, 29%, 24%, and 23% of patients, respectively. In adjusted analysis, serum albumin ≤2.4 g/dL compared with serum albumin of ≥3.5 g/dL was significantly associated with higher 90-day mortality with OR of 1.57 (95% CI 1.02-2.42). Serum albumin 2.5-2.9 and 3.0-3.4 g/dL were not associated with higher mortality. Sensitivity analysis in patients requiring CRRT in the setting of acute kidney injury showed consistent results. CONCLUSION Approximately three out of four patients had hypoalbuminemia (<3.5 g/dL) at CRRT initiation. However, only severe hypoalbuminemia <2.5 g/dL was significantly associated with higher mortality.
Collapse
Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yeshwanter Radhakrishnan
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tananchai Petnak
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Pulmonary Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Fawad Qureshi
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
14
|
Kim HW, Kim S, Ohn JH, Kim NH, Lee J, Kim ES, Lim Y, Cho JH, Park HS, Ryu J, Kim SW. Role of bicarbonate and volume therapy in the prevention of acute kidney injury in rhabdomyolysis: a retrospective propensity score-matched cohort study. Kidney Res Clin Pract 2021; 41:310-321. [PMID: 34974654 PMCID: PMC9184844 DOI: 10.23876/j.krcp.21.093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 10/10/2021] [Indexed: 11/20/2022] Open
Abstract
Background Although bicarbonate has traditionally been used to treat patients with rhabdomyolysis at high risk of acute kidney injury (AKI), it is unclear whether this is beneficial. This study compared bicarbonate therapy to non-bicarbonate therapy for the prevention of AKI and mortality in rhabdomyolysis patients. Methods In a propensity score-matched cohort study, patients with a creatine kinase (CK) level of >1,000 U/L during hospitalization were divided into bicarbonate and non-bicarbonate groups. Patients were subgrouped based on low-volume (<3 mL/kg/hr) or high-volume (≥3 mL/kg/hr) fluid resuscitation in the first 72 hours. Logistic regression analyses were used to identify the impacts of bicarbonate use and fluid resuscitation on AKI risk and need for dialysis. The Kaplan-Meier method was used to estimate survival. Volume overload and electrolyte imbalances were assessed. Results Among 4,077 patients, we assembled a cohort of 887 pairs of patients treated with and without bicarbonate. Bicarbonate group had a higher incidence of AKI, higher rate of dialysis dependency, higher 30-day mortality, and longer hospital stay than the non-bicarbonate group. Further, patients who received high-volume fluid therapy had worse renal outcomes and a higher mortality than those who received low-volume fluids regardless of bicarbonate use. Bicarbonate use, volume overload, and AKI were associated with higher mortality. Volume overload was significantly higher in the bicarbonate group than in the non-bicarbonate group. Conclusion Bicarbonate or high-volume fluid therapy for patients with rhabdomyolysis did not reduce AKI or improve mortality compared to non-bicarbonate or low-volume fluid therapy. Limited use of bicarbonate and adjustment of fluid volume may improve the short- and long-term outcomes of patients with rhabdomyolysis.
Collapse
Affiliation(s)
- Hye Won Kim
- Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.,Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sejoong Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jung Hun Ohn
- Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.,Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Nak-Hyun Kim
- Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.,Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jongchan Lee
- Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.,Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Eun Sun Kim
- Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.,Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yejee Lim
- Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.,Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jae Ho Cho
- Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.,Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hee Sun Park
- Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.,Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jiwon Ryu
- Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.,Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sun-Wook Kim
- Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.,Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| |
Collapse
|