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Glover G, Metaxa V, Ostermann M. Intensive Care Unit Without Walls. Crit Care Clin 2024; 40:549-560. [PMID: 38796227 DOI: 10.1016/j.ccc.2024.03.002] [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] [Indexed: 05/28/2024]
Abstract
Critical illness is a continuum with different phases and trajectories. The "Intensive Care Unit (ICU) without walls" concept refers to a model whereby care is adjusted in response to the patient's needs, priorities, and preferences at each stage from detection, escalation, early decision making, treatment and organ support, followed by recovery and rehabilitation, within which all healthcare staff, and the patient are equal partners. The rapid response system incorporates monitoring and alerting tools, a multidisciplinary critical care outreach team and care bundles, supported with education and training, analytical and governance functions, which combine to optimise outcomes of critically ill patients, independent of location.
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Affiliation(s)
- Guy Glover
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital, Denmark Hill, SE5 9RS, London, UK
| | - Marlies Ostermann
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, UK.
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Neyra JA, Gewin L, Ng JH, Barreto EF, Freshly B, Willett J, Abdel-Rahman EM, McCoy I, Kwong YD, Silver SA, Cerda J, Vijayan A. Challenges in the Care of Patients with AKI Receiving Outpatient Dialysis: AKINow Recovery Workgroup Report. KIDNEY360 2024; 5:274-284. [PMID: 38055734 PMCID: PMC10914193 DOI: 10.34067/kid.0000000000000332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 11/29/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Up to one third of survivors of AKI that required dialysis (AKI-D) during hospitalization remain dialysis dependent at hospital discharge. Of these, 20%-60%, depending on the clinical setting, eventually recover enough kidney function to stop dialysis, and the remainder progress to ESKD. METHODS To describe the challenges facing those still receiving dialysis on discharge, the AKINow Committee conducted a group discussion comprising 59 participants, including physicians, advanced practitioners, nurses, pharmacists, and patients. The discussion was framed by a patient who described gaps in care delivery at different transition points and miscommunication between care team members and the patient. RESULTS Group discussions collected patient perspectives of ( 1 ) being often scared and uncertain about what is happening to and around them and ( 2 ) the importance of effective and timely communication, a comfortable physical setting, and attentive and caring health care providers for a quality health care experience. Provider perspectives included ( 1 ) the recognition of the lack of evidence-based practices and quality indicators, the significant variability in current care models, and the uncertain reimbursement incentives focused on kidney recovery and ( 2 ) the urgency to address communication barriers among hospital providers and outpatient facilities. CONCLUSIONS The workgroup identified key areas for future research and policy change to ( 1 ) improve communication among hospital providers, dialysis units, and patients/care partners; ( 2 ) develop tools for risk classification, subphenotyping, and augmented clinical decision support; ( 3 ) improve education to providers, staff, and patients/care partners; ( 4 ) identify best practices to improve relevant outcomes; ( 5 ) validate quality indicators; and ( 6 ) assess the effect of social determinants of health on outcomes. We urge all stakeholders involved in the process of AKI-D care to align goals and work together to fill knowledge gaps and optimize the care to this highly vulnerable patient population.
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Affiliation(s)
- Javier A. Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Leslie Gewin
- Division of Nephrology, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Jia H. Ng
- Division of Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine, Hempstead, New York
| | | | | | - Jeff Willett
- ASN: American Society of Nephrology, Washington, DC
| | - Emaad M. Abdel-Rahman
- Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Ian McCoy
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
| | - Yuenting D. Kwong
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
| | - Samuel A. Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, Ontario, Canada
| | - Jorge Cerda
- Division of Nephrology, Department of Medicine, Albany Medical College, Albany, New York
| | - Anitha Vijayan
- Division of Nephrology, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
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Giles C, Novakovic M, Hopman W, Barreto EF, Beaubien-Souligny W, Birks P, Neyra JA, Wald R, Silver SA. The Quality of Discharge Summaries After Acute Kidney Injury. Can J Kidney Health Dis 2023; 10:20543581231199018. [PMID: 37781153 PMCID: PMC10540581 DOI: 10.1177/20543581231199018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 07/12/2023] [Indexed: 10/03/2023] Open
Abstract
Background Acute kidney injury (AKI) increases the risk of hospital readmission, chronic kidney disease, and death. Therefore, effective communication in discharge summaries is essential for safe transitions of care. Objective The objectives of this study were to determine the quality of discharge summaries in AKI survivors and identify predictors of higher quality discharge summaries. Design Retrospective chart review. Setting Tertiary care academic center in Ontario, Canada. Patients We examined the discharge summary quality of 300 randomly selected adult patients who survived a hospitalization with AKI at our tertiary care hospital, stratified by AKI severity. We included 150 patients each from 2015 to 2016 and 2018 to 2019, before and after introduction of a post-AKI clinic in 2017. Measurements We reviewed charts for 9 elements of AKI care to create a composite score summarizing discharge summary quality. Methods We used multivariable logistic regression to identify predictors of discharge summary quality. Results The median discharge summary composite score was 4/9 (interquartile range, 2-6). The least frequently mentioned elements were baseline creatinine (n = 55, 18%), AKI-specific follow-up labs (n = 66, 22%), and medication recommendations (n = 80, 27%). The odds of having a higher quality discharge summary (composite score ≥4/9) was greater for every increase in baseline creatinine of 25 μmol/L (adjusted odds ratio [aOR]: 1.27; 95% confidence interval [CI]: 1.03, 1.56), intrarenal etiology (aOR: 2.32; 95% CI: 1.26, 4.27), and increased AKI severity (stage 2 aOR: 2.57; 95% CI: 1.35, 4.91 and stage 3 aOR: 3.36; 95% CI: 1.56, 7.22). There was no association between discharge summary quality and the years before and after introduction of a post-AKI clinic (aOR: 0.77; 95% CI: 0.46, 1.29). Limitations The single-center study design limits generalizability. Conclusions Most discharge summaries are missing key AKI elements, even in patients with severe AKI. These gaps suggest several opportunities exist to improve discharge summary communication following AKI.
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Affiliation(s)
- Cameron Giles
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Milica Novakovic
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Wilma Hopman
- Kingston General Hospital Research Institute, Kingston Health Sciences Centre, ON, Canada
| | | | | | - Peter Birks
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Javier A. Neyra
- Division of Nephrology, Department of Medicine, The University of Alabama at Birmingham, AL, USA
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital, University of Toronto, ON, Canada
| | - Samuel A. Silver
- Division of Nephrology, Department of Medicine, Queen’s University and Kingston Health Sciences Centre, ON, Canada
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Short A, McPeake J, Andonovic M, McFee S, Quasim T, Leyland A, Shaw M, Iwashyna T, MacTavish P. Medication-related problems in critical care survivors: a systematic review. Eur J Hosp Pharm 2023; 30:250-256. [PMID: 37142386 PMCID: PMC10447966 DOI: 10.1136/ejhpharm-2023-003715] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/11/2023] [Indexed: 05/06/2023] Open
Abstract
OBJECTIVES There are numerous, often single centre discussions of assorted medication-related problems after hospital discharge in patients who survive critical illness. However, there has been little synthesis of the incidence of medication-related problems, the classes of medications most often studied, the factors that are associated with greater patient risk of such problems or interventions that can prevent them. METHODS We undertook a systematic review to understand medication management and medication problems in critical care survivors in the hospital discharge period. We searched OVID Medline, Embase, PsychINFO, CINAHL and the Cochrane database (2001-2022). Two reviewers independently screened publications to identify studies that examined medication management at hospital discharge or thereafter in critical care survivors. We included randomised and non-randomised studies. We extracted data independently and in duplicate. Data extracted included medication type, medication-related problems and frequency of medication issues, alongside demographics such as study setting. Cohort study quality was assessed using the Newcastle Ottowa Score checklist. Data were analysed across medication categories. RESULTS The database search initially retrieved 1180 studies; following the removal of duplicates and studies which did not fit the inclusion criteria, 47 papers were included. The quality of studies included varied. The outcomes measured and the timepoints at which data were captured also varied, which impacted the quality of data synthesis. Across the studies included, we found that as many as 80% of critically ill patients experienced medication-related problems in the posthospital discharge period. These issues included inappropriate continuation of newly prescribed drugs such as antipsychotics, gastrointestinal prophylaxis and analgesic medications, as well as inappropriate discontinuation of chronic disease medications, such as secondary prevention cardiac drugs. CONCLUSIONS Following critical illness, a high proportion of patients experience problems with their medications. These changes were present across multiple health systems. Further research is required to understand optimal medicine management across the full recovery trajectory of critical illness. PROSPERO REGISTRATION NUMBER CRD42021255975.
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Affiliation(s)
| | - Joanne McPeake
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Mark Andonovic
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | | | - Tara Quasim
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Alastair Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
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Jeong R, James MT, Quinn RR, Ravani P, Bagshaw SM, Stelfox HT, Pannu N, Clarke A, Wald R, Harrison TG, Niven DJ, Lam NN. Follow-up Care of Critically Ill Patients With Acute Kidney Injury: A Cohort Study. Kidney Med 2023; 5:100685. [PMID: 37538394 PMCID: PMC10394002 DOI: 10.1016/j.xkme.2023.100685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023] Open
Abstract
Rationale & Objective To evaluate follow-up care of critically ill patients with acute kidney injury (AKI). Study Design Retrospective cohort study. Setting & Participants Patients admitted to the intensive care unit (ICU) with AKI in Alberta, Canada from 2005 to 2018, who survived to discharge without kidney replacement therapy or estimated glomerular filtration rate <15 mL/min/1.73 m2. Exposure AKI (defined as ≥50% or ≥0.3 mg/dL serum creatinine increase). Outcomes The primary outcome was the cumulative incidence of an outpatient serum creatinine and urine protein measurement at 3 months postdischarge. Secondary outcomes included an outpatient serum creatinine or urine protein measurement or a nephrologist visit at 3 months postdischarge. Analytical Approach Patients were followed from hospital discharge until the first of each outcome of interest, death, emigration from the province, kidney replacement therapy (maintenance dialysis or kidney transplantation), or end of study period (March 2019). We used non-parametric methods (Aalen-Johansen) to estimate the cumulative incidence functions of outcomes accounting for competing events (death and kidney replacement therapy). Results There were 29,732 critically ill adult patients with AKI. The median age was 68 years (IQR, 57-77), 39% were female, and the median baseline estimated glomerular filtration rate was 72 mL/min/1.73 m2 (IQR, 53-90). The cumulative incidence of having an outpatient creatinine and urine protein measurement at 3 months postdischarge was 25% (95% CI, 25-26). At 3 months postdischarge, 64% (95% CI, 64-65) had an outpatient creatinine measurement, 28% (95% CI, 27-28) had a urine protein measurement, and 5% (95% CI, 4-5) had a nephrologist visit. Limitations We lacked granular data, such as urine output. Conclusions Many critically ill patients with AKI do not receive the recommended follow-up care. Our findings highlight a gap in the transition of care for survivors of critical illness and AKI.
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Affiliation(s)
- Rachel Jeong
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Matthew T. James
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Robert R. Quinn
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Pietro Ravani
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Henry T. Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Neesh Pannu
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Alix Clarke
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital and the University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada
| | - Tyrone G. Harrison
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Daniel J. Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ngan N. Lam
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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McCoy I, Hsu CY. Predicting Outcomes after Discharge from the Hospital on Dialysis. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00160. [PMID: 37265219 PMCID: PMC10356110 DOI: 10.2215/cjn.0000000000000201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Ian McCoy
- Division of Nephrology, School of Medicine, University of California, San Francisco, San Francisco, California
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Ostermann M, Vincent JL. ICU without borders. Crit Care 2023; 27:186. [PMID: 37179324 PMCID: PMC10182543 DOI: 10.1186/s13054-023-04463-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
Critical illness is a continuum, but patient care is often fragmented. Value-based critical care focuses on the overall health of the patient, not on an episode of care. The "ICU without borders" model incorporates a concept where members of the critical care team are involved in the management of patients from the onset of critical illness until recovery and beyond. In this paper, we summarise the potential benefits and challenges to patients, families, staff and the wider healthcare system and list some essential requirements, including a tight governance framework, advanced technologies, investment and trust. We also argue that "ICU without borders" should be viewed as a bi-directional model, allowing extended visiting hours, giving patients and families direct access to experienced critical care staff and offering mutual aid when needed.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Foundation Hospital, NHS Foundation Trust, London, SE1 7EH, UK.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
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Molina Andújar A, Escudero VJ, Piñeiro GJ, Lucas A, Rovira I, Matute P, Ibañez C, Blasco M, Quintana LF, Sandoval E, Sánchez MC, Quintana E, Poch E. Impact of cardiac surgery associated acute kidney injury on 1-year major adverse kidney events. FRONTIERS IN NEPHROLOGY 2023; 3:1059668. [PMID: 37675375 PMCID: PMC10479748 DOI: 10.3389/fneph.2023.1059668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 03/24/2023] [Indexed: 09/08/2023]
Abstract
Background The incidence of acute kidney injury following cardiac surgery (CSA-AKI) is up to 30%, and the risk of chronic kidney disease (CKD) has been found to be higher in these patients compared to the AKI-free population. The aim of our study was to assess the risk of major adverse kidney events (MAKE) [25% or greater decline in estimated glomerular filtration rate (eGFR), new hemodialysis, and death] after cardiac surgery in a Spanish cohort and to evaluate the utility of the score developed by Legouis D et al. (CSA-CKD score) in predicting the occurrence of MAKE. Methods This was a single-center retrospective study of patients who required cardiac surgery with cardiopulmonary bypass (CPB) during 2015, with a 1-year follow-up after the intervention. The inclusion criteria were patients over 18 years old who had undergone cardiac surgery [i.e., valve substitution (VS), coronary artery bypass graft (CABG), or a combination of both procedures]. Results The number of patients with CKD (eGFR < 60 mL/min) increased from 74 (18.3%) to 97 (24%) within 1 year after surgery. The median eGFR declined from 85 to 82 mL/min in the non-CSA-AKI patient group and from 73 to 65 mL/min in those with CSA-AKI (p = 0.024). Fifty-eight patients (1.4%) presented with MAKE at the 1-year follow-up. Multivariate logistic regression analysis showed that the only variable associated with MAKE was CSA-AKI [odds ratio (OR) 2.386 (1.31-4.35), p = 0.004]. The median CSA-CKD score was higher in the MAKE cohort [3 (2-4) vs. 2 (1-3), p < 0.001], but discrimination was poor, with a receiver operating characteristic curve (AUC) value of 0.682 (0.611-0.754). Conclusion Any-stage CSA-AKI is associated with a risk of MAKE after 1 year. Further research into new measures that identify at-risk patients is needed so that appropriate patient follow-up can be carried out.
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Affiliation(s)
- Alícia Molina Andújar
- Nephrology and Kidney Transplantation Department, Hospital Clínic, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | | | - Gaston J. Piñeiro
- Nephrology and Kidney Transplantation Department, Hospital Clínic, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Institut d’investigacions biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Alvaro Lucas
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Irene Rovira
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Anesthesiology Department, Hospital Clinic, Barcelona, Spain
| | - Purificación Matute
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Anesthesiology Department, Hospital Clinic, Barcelona, Spain
| | - Cristina Ibañez
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Anesthesiology Department, Hospital Clinic, Barcelona, Spain
| | - Miquel Blasco
- Nephrology and Kidney Transplantation Department, Hospital Clínic, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Institut d’investigacions biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Luis F. Quintana
- Nephrology and Kidney Transplantation Department, Hospital Clínic, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Institut d’investigacions biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Elena Sandoval
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Cardiovascular Surgery Department, Hospital Clinic, Barcelona, Spain
| | - Marina Chorda Sánchez
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Perfusion Department, Hospital Clinic, Barcelona, Spain
| | - Eduard Quintana
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Cardiovascular Surgery Department, Hospital Clinic, Barcelona, Spain
| | - Esteban Poch
- Nephrology and Kidney Transplantation Department, Hospital Clínic, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Institut d’investigacions biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Lumlertgul N, Wright R, Hutson G, Milicevic JK, Vlachopanos G, Lee KCH, Pirondini L, Gregson J, Sanderson B, Leach R, Camporota L, Barrett NA, Ostermann M. Long-term outcomes in patients who received veno-venous extracorporeal membrane oxygenation and renal replacement therapy: a retrospective cohort study. Ann Intensive Care 2022; 12:70. [PMID: 35870022 PMCID: PMC9308118 DOI: 10.1186/s13613-022-01046-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Background Acute kidney injury (AKI) is a frequent complication in patients with severe respiratory failure receiving extracorporeal membrane oxygenation (ECMO). However, little is known of long-term kidney function in ECMO survivors. We aimed to assess the long-term mortality and kidney outcomes in adult patients treated with veno-venous ECMO (VV-ECMO). Methods This was a single-centre retrospective study of adult patients (≥ 18 years old) who were treated with VV-ECMO at a commissioned ECMO centre in the UK between 1st September 2010, and 30th November 2016. AKI was defined and staged using the serum creatinine and urine output criteria of the Kidney Diseases: Improving Global Outcomes (KDIGO) classification. The primary outcome was 1-year mortality. Secondary outcomes were long-term mortality (up to March 2020), 1-year incidence of end-stage kidney disease (ESKD) or chronic kidney disease (CKD) among AKI patients who received renal replacement therapy (AKI-RRT), AKI patients who did not receive RRT (AKI-no RRT) and patients without AKI (non-AKI). Results A total of 300 patients [57% male; median age 44.5; interquartile range (IQR) 34–54] were included in the final analysis. Past medical histories included diabetes (12%), hypertension (17%), and CKD (2.3%). The main cause of severe respiratory failure was pulmonary infection (72%). AKI occurred in 230 patients (76.7%) and 59.3% received renal replacement therapy (RRT). One-year mortality was 32% in AKI-RRT patients vs. 21.4% in non-AKI patients (p = 0.014). The median follow-up time was 4.35 years. Patients who received RRT had a higher risk of 1-year mortality than those who did not receive RRT (adjusted HR 1.80, 95% CI 1.06, 3.06; p = 0.029). ESKD occurred in 3 patients, all of whom were in the AKI-RRT group. At 1-year, 41.2% of survivors had serum creatinine results available. Among these, CKD was prevalent in 33.3% of AKI-RRT patients vs. 4.3% in non-AKI patients (p = 0.004). Conclusions VV-EMCO patients with AKI-RRT had high long-term mortality. Monitoring of kidney function after hospital discharge was poor. In patients with follow-up creatinine results available, the CKD prevalence was high at 1 year, especially in AKI-RRT patients. More awareness about this serious long-term complication and appropriate follow-up interventions are required. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01046-0.
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Cardiac Surgery Associated AKI Prevention Strategies and Medical Treatment for CSA-AKI. J Clin Med 2021; 10:jcm10225285. [PMID: 34830567 PMCID: PMC8618011 DOI: 10.3390/jcm10225285] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/03/2021] [Accepted: 11/08/2021] [Indexed: 12/29/2022] Open
Abstract
Acute kidney injury (AKI) is common after cardiac surgery. To date, there are no specific pharmacological therapies. In this review, we summarise the existing evidence for prevention and management of cardiac surgery-associated AKI and outline areas for future research. Preoperatively, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should be withheld and nephrotoxins should be avoided to reduce the risk. Intraoperative strategies include goal-directed therapy with individualised blood pressure management and administration of balanced fluids, the use of circuits with biocompatible coatings, application of minimally invasive extracorporeal circulation, and lung protective ventilation. Postoperative management should be in accordance with current KDIGO AKI recommendations.
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