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Koraishy FM, Mallipattu SK. Dialysis resource allocation in critical care: the impact of the COVID-19 pandemic and the promise of big data analytics. FRONTIERS IN NEPHROLOGY 2023; 3:1266967. [PMID: 37965069 PMCID: PMC10641281 DOI: 10.3389/fneph.2023.1266967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/05/2023] [Indexed: 11/16/2023]
Abstract
The COVID-19 pandemic resulted in an unprecedented burden on intensive care units (ICUs). With increased demands and limited supply, critical care resources, including dialysis machines, became scarce, leading to the undertaking of value-based cost-effectiveness analyses and the rationing of resources to deliver patient care of the highest quality. A high proportion of COVID-19 patients admitted to the ICU required dialysis, resulting in a major burden on resources such as dialysis machines, nursing staff, technicians, and consumables such as dialysis filters and solutions and anticoagulation medications. Artificial intelligence (AI)-based big data analytics are now being utilized in multiple data-driven healthcare services, including the optimization of healthcare system utilization. Numerous factors can impact dialysis resource allocation to critically ill patients, especially during public health emergencies, but currently, resource allocation is determined using a small number of traditional factors. Smart analytics that take into account all the relevant healthcare information in the hospital system and patient outcomes can lead to improved resource allocation, cost-effectiveness, and quality of care. In this review, we discuss dialysis resource utilization in critical care, the impact of the COVID-19 pandemic, and how AI can improve resource utilization in future public health emergencies. Research in this area should be an important priority.
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Affiliation(s)
- Farrukh M. Koraishy
- Division of Nephrology, Department of Medicine, Stony Brook University Hospital, , Stony Brook, NY, United States
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Teixeira JP, Saa L, Kaucher KA, Villanueva RD, Shieh M, Baca CR, Harmon B, Owen ZJ, Mendez Majalca I, Schmidt DW, Singh N, Shaffi SK, Xu ZQ, Roha T, Mitchell JA, Demirjian S, Argyropoulos CP. Rapid implementation of an emergency on-site CKRT dialysate production system during the COVID-19 pandemic. BMC Nephrol 2023; 24:245. [PMID: 37608357 PMCID: PMC10463836 DOI: 10.1186/s12882-023-03260-9] [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: 02/04/2023] [Accepted: 06/29/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND On December 29, 2021, during the delta wave of the Coronavirus Disease 2019 (COVID-19) pandemic, the stock of premanufactured solutions used for continuous kidney replacement therapy (CKRT) at the University of New Mexico Hospital (UNMH) was nearly exhausted with no resupply anticipated due to supply chain disruptions. Within hours, a backup plan, devised and tested 18 months prior, to locally produce CKRT dialysate was implemented. This report describes the emergency implementation and outcomes of this on-site CKRT dialysate production system. METHODS This is a single-center retrospective case series and narrative report describing and reporting the outcomes of the implementation of an on-site CKRT dialysate production system. All adults treated with locally produced CKRT dialysate in December 2021 and January 2022 at UNMH were included. CKRT dialysate was produced locally using intermittent hemodialysis machines, hemodialysis concentrate, sterile parenteral nutrition bags, and connectors made of 3-D printed biocompatible rigid material. Outcomes analyzed included dialysate testing for composition and microbiologic contamination, CKRT prescription components, patient mortality, sequential organ failure assessment (SOFA) scores, and catheter-associated bloodstream infections (CLABSIs). RESULTS Over 13 days, 22 patients were treated with 3,645 L of locally produced dialysate with a mean dose of 20.0 mL/kg/h. Fluid sample testing at 48 h revealed appropriate electrolyte composition and endotoxin levels and bacterial colony counts at or below the lower limit of detection. No CLABSIs occurred within 7 days of exposure to locally produced dialysate. In-hospital mortality was 81.8% and 28-day mortality was 68.2%, though illness severity was high, with a mean SOFA score of 14.5. CONCLUSIONS Though producing CKRT fluid with IHD machines is not novel, this report represents the first description of the rapid and successful implementation of a backup plan for local CKRT dialysate production at a large academic medical center in the U.S. during the COVID-19 pandemic. Though conclusions are limited by the retrospective design and limited sample size of our analysis, our experience could serve as a guide for other centers navigating similar severe supply constraints in the future.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
- Center for Adult Critical Care, UNM Hospital, Albuquerque, NM, USA.
- Acute Dialysis and CRRT Program, UNM Hospital, Albuquerque, NM, USA.
| | - Lisa Saa
- Department of Internal Medicine, UNM School of Medicine, Albuquerque, NM, USA
| | | | | | - Michelle Shieh
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
- Center for Adult Critical Care, UNM Hospital, Albuquerque, NM, USA
| | - Crystal R Baca
- Acute Dialysis and CRRT Program, UNM Hospital, Albuquerque, NM, USA
| | - Brittany Harmon
- Acute Dialysis and CRRT Program, UNM Hospital, Albuquerque, NM, USA
| | - Zanna J Owen
- Acute Dialysis and CRRT Program, UNM Hospital, Albuquerque, NM, USA
| | | | - Darren W Schmidt
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Namita Singh
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Saeed K Shaffi
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Zhi Q Xu
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
- Acute Dialysis and CRRT Program, UNM Hospital, Albuquerque, NM, USA
| | - Thomas Roha
- Center for Adult Critical Care, UNM Hospital, Albuquerque, NM, USA
| | - Jessica A Mitchell
- Center for Adult Critical Care, UNM Hospital, Albuquerque, NM, USA
- Department of Emergency Medicine, UNM School of Medicine, Albuquerque, NM, USA
| | - Sevag Demirjian
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH, USA
| | - Christos P Argyropoulos
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
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Santos J, Grigorian A, Kuza C, Emigh B, Jeng J, Qazi A, Nguyen NT, Nahmias J. Development and Validation of a Renal Replacement after Trauma Scoring Tool. J Am Coll Surg 2023; 237:79-86. [PMID: 36847387 DOI: 10.1097/xcs.0000000000000667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Stress on the healthcare system requires careful allocation of resources such as renal replacement therapy (RRT). The COVID-19 pandemic generated difficulty securing access to RRT for trauma patients. We sought to develop a renal replacement after trauma (RAT) scoring tool to help identify trauma patients who may require RRT during their hospitalization. STUDY DESIGN The 2017 to 2020 TQIP database was divided into a derivation (2017 to 2018 data) and validation (2019 to 2020 data) set. A 3-step methodology was used. Adult trauma patients admitted from the emergency department to the operating room or ICU were included. Patients with chronic kidney disease, transfers from another hospital, and emergency department death were excluded. Multiple logistic regression models were created to determine the risk for RRT in trauma patients. The weighted average and relative impact of each independent predictor was used to derive a RAT score, which was validated using area under receiver operating characteristic curve (AUROC). RESULTS From 398,873 patients in the derivation and 409,037 patients in the validation set, 11 independent predictors of RRT were included in the RAT score derived with scores ranging from 0 to 11. The AUROC for the derivation set was 0.85. The rate of RRT increased to 1.1%, 3.3%, and 20% at scores of 6, 8, and 10, respectively. The validation set AUROC was 0.83. CONCLUSIONS RAT is a novel and validated scoring tool to help predict the need for RRT in trauma patients. With future improvements including baseline renal function and other variables, the RAT tool may help prepare for the allocation of RRT machines/staff during times of limited resources.
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Affiliation(s)
- Jeffrey Santos
- From the Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine, Orange, CA (Santos, Grigorian, Jeng, Qazi)
| | - Areg Grigorian
- From the Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine, Orange, CA (Santos, Grigorian, Jeng, Qazi)
| | - Catherine Kuza
- the Department of Anesthesiology, University of Southern California, Los Angeles, CA (Kuza)
| | - Brent Emigh
- the Warren Alpert Medical School of Brown University, Providence, RI (Emigh)
| | - James Jeng
- From the Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine, Orange, CA (Santos, Grigorian, Jeng, Qazi)
| | - Alliya Qazi
- From the Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine, Orange, CA (Santos, Grigorian, Jeng, Qazi)
| | - Ninh T Nguyen
- the Division of Gastrointestinal Surgery, University of California, Irvine, Orange, CA (Nguyen)
| | - Jeffry Nahmias
- From the Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine, Orange, CA (Santos, Grigorian, Jeng, Qazi)
- the Department of Anesthesiology, University of Southern California, Los Angeles, CA (Kuza)
- the Warren Alpert Medical School of Brown University, Providence, RI (Emigh)
- the Division of Gastrointestinal Surgery, University of California, Irvine, Orange, CA (Nguyen)
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Intensive Care and Organ Support Related Mortality in Patients With COVID-19: A Systematic Review and Meta-Analysis. Crit Care Explor 2023; 5:e0876. [PMID: 36890875 PMCID: PMC9988289 DOI: 10.1097/cce.0000000000000876] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
To perform a systematic review and meta-analysis to generate estimates of mortality in patients with COVID-19 that required hospitalization, ICU admission, and organ support. DATA SOURCES A systematic search of PubMed, Embase, and the Cochrane databases was conducted up to December 31, 2021. STUDY SELECTION Previously peer-reviewed observational studies that reported ICU, mechanical ventilation (MV), renal replacement therapy (RRT) or extracorporeal membrane oxygenation (ECMO)-related mortality among greater than or equal to 100 individual patients. DATA EXTRACTION Random-effects meta-analysis was used to generate pooled estimates of case fatality rates (CFRs) for in-hospital, ICU, MV, RRT, and ECMO-related mortality. ICU-related mortality was additionally analyzed by the study country of origin. Sensitivity analyses of CFR were assessed based on completeness of follow-up data, by year, and when only studies judged to be of high quality were included. DATA SYNTHESIS One hundred fifty-seven studies evaluating 948,309 patients were included. The CFR for in-hospital mortality, ICU mortality, MV, RRT, and ECMO were 25.9% (95% CI: 24.0-27.8%), 37.3% (95% CI: 34.6-40.1%), 51.6% (95% CI: 46.1-57.0%), 66.1% (95% CI: 59.7-72.2%), and 58.0% (95% CI: 46.9-68.9%), respectively. MV (52.7%, 95% CI: 47.5-58.0% vs 31.3%, 95% CI: 16.1-48.9%; p = 0.023) and RRT-related mortality (66.7%, 95% CI: 60.1-73.0% vs 50.3%, 95% CI: 42.4-58.2%; p = 0.003) decreased from 2020 to 2021. CONCLUSIONS We present updated estimates of CFR for patients hospitalized and requiring intensive care for the management of COVID-19. Although mortality remain high and varies considerably worldwide, we found the CFR in patients supported with MV significantly improved since 2020.
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Samaan F, Carneiro de Paula E, de Lima Souza FBG, Mendes LFC, Rossi PRG, Freitas RAP, Nakagawa FT, Maciel AT, Aranha S, Osawa E, Konigsfeld HP, da Silva RG, de Souza RBC, Coutinho SM, Vieira TD, Thomaz KDB, Flato EMS, da Silva RC, Andrade LV, Badaoui M, Badaoui EP, Goes MÂ, do Amaral SH, Cunha K, Muniz IM, Sampaio JS, Durão Junior MDS, Zanetta DMT, Burdmann EA. COVID-19-associated acute kidney injury patients treated with renal replacement therapy in the intensive care unit: A multicenter study in São Paulo, Brazil. PLoS One 2022; 17:e0261958. [PMID: 35030179 PMCID: PMC8759670 DOI: 10.1371/journal.pone.0261958] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/15/2021] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Multicenter studies involving patients with acute kidney injury (AKI) associated with the disease caused by the new coronavirus (COVID-19) and treated with renal replacement therapy (RRT) in developing countries are scarce. The objectives of this study were to evaluate the demographic profile, clinical picture, risk factors for mortality, and outcomes of critically ill patients with AKI requiring dialysis (AKI-RRT) and with COVID-19 in the megalopolis of São Paulo, Brazil. METHODS This multicenter, retrospective, observational study was conducted in the intensive care units of 13 public and private hospitals in the metropolitan region of the municipality of São Paulo. Patients hospitalized in an intensive care unit, aged ≥ 18 years, and treated with RRT due to COVID-19-associated AKI were included. RESULTS The study group consisted of 375 patients (age 64.1 years, 68.8% male). Most (62.1%) had two or more comorbidities: 68.8%, arterial hypertension; 45.3%, diabetes; 36.3%, anemia; 30.9%, obesity; 18.7%, chronic kidney disease; 15.7%, coronary artery disease; 10.4%, heart failure; and 8.5%, chronic obstructive pulmonary disease. Death occurred in 72.5% of the study population (272 patients). Among the 103 survivors, 22.3% (23 patients) were discharged on RRT. In a multiple regression analysis, the independent factors associated with death were the number of organ dysfunctions at admission and RRT efficiency. CONCLUSION AKI-RRT associated with COVID-19 occurred in patients with an elevated burden of comorbidities and was associated with high mortality (72.5%). The number of organ dysfunctions during hospitalization and RRT efficiency were independent factors associated with mortality. A meaningful portion of survivors was discharged while dependent on RRT (22.3%).
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Affiliation(s)
- Farid Samaan
- Department of High Complexity Patients, Grupo NotreDame Intermédica, São Paulo, Brazil
- Nephrology Division, University of São Paulo Medical School, São Paulo, Brazil
- Nephrology Division, Federal University of São Paulo, São Paulo, Brazil
- Planning and Evaluation Group, São Paulo State Health Department, São Paulo, Brazil
| | | | | | | | | | | | | | | | - Sylvia Aranha
- Imed Research Group, São Camilo Pompeia Hospital, São Paulo, Brazil
| | - Eduardo Osawa
- Imed Research Group, São Camilo Pompeia Hospital, São Paulo, Brazil
| | - Henrique Pinheiro Konigsfeld
- Nephrology Division, Santa Cruz Hospital, São Paulo, Brazil
- Nephrology Division, Sepaco Hospital, São Paulo, Brazil
| | - Riberto Garcia da Silva
- Nephrology Division, Santa Cruz Hospital, São Paulo, Brazil
- Nephrology Division, Sepaco Hospital, São Paulo, Brazil
| | | | - Saurus Mayer Coutinho
- Nephrology Division, Santa Cruz Hospital, São Paulo, Brazil
- Nephrology Division, Sepaco Hospital, São Paulo, Brazil
| | - Tales Dantas Vieira
- Department of High Complexity Patients, Grupo NotreDame Intermédica, São Paulo, Brazil
- Nephrology Division, Cruzeiro do Sul Hospital, Osasco, São Paulo, Brazil
| | | | | | | | - Lucas Vicente Andrade
- Department of General Surgery, Ipiranga Hospital Care Management Unit, São Paulo, Brazil
| | - Muna Badaoui
- Nephrology Division, University of São Paulo Medical School, São Paulo, Brazil
- Nephrology Division, Vila Nova Brasilândia Hospital, São Paulo, Brazil
| | - Eduardo Pogetti Badaoui
- Nephrology Division, University of São Paulo Medical School, São Paulo, Brazil
- Nephrology Division, Vila Nova Brasilândia Hospital, São Paulo, Brazil
| | - Miguel Ângelo Goes
- Department of High Complexity Patients, Grupo NotreDame Intermédica, São Paulo, Brazil
- Nephrology Division, Federal University of São Paulo, São Paulo, Brazil
| | - Sergio Henrique do Amaral
- Department of High Complexity Patients, Grupo NotreDame Intermédica, São Paulo, Brazil
- Medical Board, Bosque da Saúde Hospital, São Paulo, Brazil
| | - Karlla Cunha
- Department of High Complexity Patients, Grupo NotreDame Intermédica, São Paulo, Brazil
- Medical Board, Bosque da Saúde Hospital, São Paulo, Brazil
| | - Inês Marin Muniz
- Department of High Complexity Patients, Grupo NotreDame Intermédica, São Paulo, Brazil
| | - Jacqueline Siqueira Sampaio
- Department of High Complexity Patients, Grupo NotreDame Intermédica, São Paulo, Brazil
- Medical Board, Intermédica Guarulhos Hospital, Guarulhos, São Paulo, Brazil
| | - Marcelino de Souza Durão Junior
- Nephrology Division, Federal University of São Paulo, São Paulo, Brazil
- Nephrology Division, São Paulo Hospital, São Paulo, Brazil
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