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Chander S, Luhana S, Sadarat F, Parkash O, Rahaman Z, Wang HY, Kiran F, Lohana AC, Sapna F, Kumari R. Mortality and mode of dialysis: meta-analysis and systematic review. BMC Nephrol 2024; 25:1. [PMID: 38172835 PMCID: PMC10763097 DOI: 10.1186/s12882-023-03435-4] [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: 04/07/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The global use of kidney replacement therapy (KRT) has increased, mirroring the incidence of acute kidney injury and chronic kidney disease. Despite its growing clinical usage, patient outcomes with KRT modalities remain controversial. In this meta-analysis, we sought to compare the mortality outcomes of patients with any kidney disease requiring peritoneal dialysis (PD), hemodialysis (HD), or continuous renal replacement therapy (CRRT). METHODS The investigation was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed (MEDLINE), Cochrane Library, and Embase databases were screened for randomized trials and observational studies comparing mortality rates with different KRT modalities in patients with acute or chronic kidney failure. A random-effects model was applied to compute the risk ratio (RR) and 95% confidence intervals (95%CI) with CRRT vs. HD, CRRT vs. PD, and HD vs. PD. Heterogeneity was assessed using I2 statistics, and sensitivity using leave-one-out analysis. RESULTS Fifteen eligible studies were identified, allowing comparisons of mortality risk with different dialytic modalities. The relative risk was non-significant in CRRT vs. PD [RR = 0.95, (95%CI 0.53, 1.73), p = 0.92 from 4 studies] and HD vs. CRRT [RR = 1.10, (95%CI 0.95, 1.27), p = 0.21 from five studies] comparisons. The findings remained unchanged in the leave-one-out sensitivity analysis. Although PD was associated with lower mortality risk than HD [RR = 0.78, (95%CI 0.62, 0.97), p = 0.03], the significance was lost with the exclusion of 4 out of 5 included studies. CONCLUSION The current evidence indicates that while patients receiving CRRT may have similar mortality risks compared to those receiving HD or PD, PD may be associated with lower mortality risk compared to HD. However, high heterogeneity among the included studies limits the generalizability of our findings. High-quality studies comparing mortality outcomes with different dialytic modalities in CKD are necessary for a more robust safety and efficacy evaluation.
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Affiliation(s)
- Subhash Chander
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Sindhu Luhana
- Department of Medicine, AGA khan University Hospital, Karachi, Pakistan
| | - Fnu Sadarat
- Department of Medicine, University at Buffalo, New York, USA
| | - Om Parkash
- Department of Medicine, Montefiore Medical Centre, Wakefield, New York, USA
| | - Zubair Rahaman
- Department of Medicine, University at Buffalo, New York, USA
| | - Hong Yu Wang
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Fnu Kiran
- Department of Pathology, Northwell Health Staten Island University Hospital, New York, USA
| | - Abhi Chand Lohana
- Department of Medicine, WVU, Camden Clark Medical Centre, Parkersburg, WV, USA
| | - Fnu Sapna
- Department of Pathology, Albert Einstein School of Medicine, Montefiore Medical Centre, New York, USA
| | - Roopa Kumari
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, USA
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Wang E, Kim S, Wang A, Jiang W, Shah A. Peritoneal dialysis in the setting of acute brain injury: an underappreciated modality. Hosp Pract (1995) 2023; 51:175-183. [PMID: 37491156 DOI: 10.1080/21548331.2023.2241340] [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: 04/01/2023] [Revised: 07/12/2023] [Accepted: 07/24/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION Dialysis is complicated in the setting of acute brain injury (ABI) due to several factors including acute solute shifts, acid base changes, need for anticoagulation, and changes in intracranial pressure. For these reasons, continuous renal replacement therapy (CRRT) is often the chosen modality for renal replacement needs in these patients. Peritoneal dialysis (PD) is less discussed but shares many of the benefits often attributed to CRRT. We describe, from both nephrology and neurosurgical perspectives, a case successfully managed with PD. CASE A 25-year-old male with history of end-stage kidney disease (ESKD) secondary to focal segmental glomerulosclerosis on continuous cycling PD for 5 years presented to the hospital with headache and altered mental status. Initial imaging revealed a large intraventricular hemorrhage extending to the fourth ventricle. He underwent an emergent right depressive hemicraniectomy and clot evacuation. Post-operative imaging revealed worsening cerebral edema, intraventricular hemorrhage, and hydrocephalus. The decision was made to continue PD, noting that it retains many of the benefits of CRRT (which it is in fact, a form of) which he tolerated well until the need for a percutaneous gastrostomy tube arose. He was transiently transitioned to hemodialysis but returned to PD once his gastrostomy healed. He continued PD for 1 year without complication and eventually received a kidney transplant. DISCUSSION In managing patients with ABI undergoing dialysis, a number of considerations must be undertaken including avoidance of hypotension to maintain cerebral perfusion pressure and minimize ischemia reperfusion injury, avoidance of anticoagulants that can precipitate or worsen bleeding, the potential for cerebral edema due to rapid solute clearance and osmotic dissipation of therapeutic hypernatremia, and the mitigation of intracellular acidosis from bicarbonate delivery. Although underutilized, PD may potentially serve as a viable option for dialysis in the setting of ABI as demonstrated by the case presented.
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Affiliation(s)
- Elaina Wang
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Steven Kim
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Aaron Wang
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Winston Jiang
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Ankur Shah
- Warren Alpert Medical School, Brown University, Providence, RI, USA
- Division of Kidney Disease and Hypertension, Rhode Island Hospital, Providence, RI, USA
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Gupta V, Kapoor S, Makkar V, Chhabra ST, Aslam N, Mohan B, Kumar R, Pandey V, Prashar H, Kaur G, Grover S, Sethi S, Kaur S, Ralhan S, Wander GS. Managing patients of shock and acute kidney injury in tertiary care cardiac ICU: Experience with continuous renal replacement therapy. Indian Heart J 2021; 73:594-598. [PMID: 34627575 PMCID: PMC8514416 DOI: 10.1016/j.ihj.2021.08.003] [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] [Received: 02/20/2021] [Revised: 07/18/2021] [Accepted: 08/04/2021] [Indexed: 12/05/2022] Open
Abstract
Background Clinical experience on details of CRRT initiation and outcomes in cardiac intensive care unit (CICU) patients is not available from developing countries like India. This study shares the 5-year clinical experience of managing CICU patients requiring CRRT in a tertiary care cardiac center of North India. Materials and methods Medical records of all CICU patients with acute kidney injury (AKI) managed by CRRT from October 2011 to September 2016 at tertiary referral center in North India were retrospectively reviewed. Multiple logistic regression analysis was used to identify predictors of post-CRRT mortality. Results A total of 630 patients received CRRT during the study period. Most commonly AKI developed in patients with acute coronary syndrome (30.2 %) with cardiogenic shock. 55.9 % of the CRRT patients were >60 years of age, and/or on multiple supports in ICU including, mechanical ventilation, high doses of inotropes & vasopressors and other cardiovascular support. Of those on CRRT, 130 (20.6 %) patients had died, 215 (34.1 %) were discharged and 285 (45.2 %) could not complete the desired course. Multivariate regression analysis showed independent association of mortality with high vasoactive-inotropic score, single CRRT cycle and low mean arterial pressure in CRRT patients. Conclusion About 34.1 % of patients receiving CRRT were alive at discharge, emphasizing the feasibility and utility of CRRT as a promising modality in this population for improving outcomes.
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Affiliation(s)
- Vivek Gupta
- Department of Cardiac Anaesthesia & Intensive Care, Hero DMC Heart Institute, Ludhiana, Punjab, 141001, India.
| | - Samir Kapoor
- Department of Cardiovascular & Thoracic Surgery, Hero DMC Heart Institute, Ludhiana, Punjab, 141001, India
| | - Vikas Makkar
- Department of Nephrology, Dayanand Medical College & Hospital, Ludhiana, Punjab, 141001, India
| | | | - Naved Aslam
- Department of Cardiology, Hero DMC Heart Institute Ludhiana, Punjab, 141001, India
| | - Bishav Mohan
- Department of Cardiology, Hero DMC Heart Institute Ludhiana, Punjab, 141001, India
| | - Rajiv Kumar
- Department of Cardiovascular & Thoracic Surgery, Hero DMC Heart Institute, Ludhiana, Punjab, 141001, India
| | - Vijita Pandey
- Department of Cardiac Anaesthesia & Intensive Care, Hero DMC Heart Institute, Ludhiana, Punjab, 141001, India
| | - Himani Prashar
- Department of Cardiac Anaesthesia & Intensive Care, Hero DMC Heart Institute, Ludhiana, Punjab, 141001, India
| | - Gurkirat Kaur
- Department of Cardiac Anaesthesia & Intensive Care, Hero DMC Heart Institute, Ludhiana, Punjab, 141001, India
| | - Suvir Grover
- Department of Cardiac Anaesthesia & Intensive Care, Hero DMC Heart Institute, Ludhiana, Punjab, 141001, India
| | - Suman Sethi
- Department of Nephrology, Dayanand Medical College & Hospital, Ludhiana, Punjab, 141001, India
| | - Simran Kaur
- Department of Nephrology, Dayanand Medical College & Hospital, Ludhiana, Punjab, 141001, India
| | - Sarju Ralhan
- Department of Cardiovascular & Thoracic Surgery, Hero DMC Heart Institute, Ludhiana, Punjab, 141001, India
| | - G S Wander
- Department of Cardiology, Hero DMC Heart Institute Ludhiana, Punjab, 141001, India
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Jaryal A, Vikrant S, Gupta D. Epidemiology and outcomes of dialysis requiring acute kidney injury: A single-center study. Ther Apher Dial 2021; 26:594-600. [PMID: 34538021 DOI: 10.1111/1744-9987.13739] [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: 07/08/2021] [Revised: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Acute kidney injury (AKI) is a common diagnosis in hospitalized patients. Dialysis requiring AKI (AKI-D) is associated with adverse outcomes. This study aims to know the clinical profile and short-term outcomes at 3 months, in patients with AKI-D, at our center. METHODS A prospective observational study was done of all the patients admitted with AKI-D for 2 years, from July 2018 to June 2020. We recorded clinical parameters at baseline and postdischarge follow-up at 3 months. RESULTS One hundred twenty-eight patients had AKI-D over 2 years. Then, 116 (90.6%) patients had community-acquired AKI (CAAKI), and 12 (9.4%) patients had hospital-acquired AKI. The underlying causes of AKI-D were: toxins in 48 (37.5%), sepsis in 31 (24.2%), acute kidney disease in 15 (11.7%), acute gastroenteritis (AGE) in 9 (7%), and cardiogenic shock in 7 (5.5%) patients. The mean values of intact parathyroid hormone (available in 32% of patients) were 268 pg/mL. Intermittent hemodialysis was the commonest mode of dialysis (85.2%). A kidney biopsy was done in 23 (18%) patients. The most common diagnosis on kidney biopsy was glomerulonephritis (GN) in 12 patients (crescentic GN-9 and IgA nephropathy-3), followed by acute tubule-interstitial nephritis in 6 patients. In-hospital mortality was 29.7%. Overall, 39% regained serum creatinine in the normal range at 3 months, 36.7% died, 14.1% reached chronic kidney disease (CKD), 7.8% lost to follow-up, and 2.3% had reached end-stage renal disease. CONCLUSION The majority of AKI-D at our center was CAAKI. A significant chunk of AKI-D (68.7%) was caused by preventable causes like toxins, sepsis, and AGE. Dysregulation of mineral metabolism was conspicuous. In chemical toxin vs. biological toxins and undifferentiated sepsis vs. the identifiable cause of sepsis, formers had significantly more in-hospital mortality than the latter ones. AKI-D is associated with high in-hospital mortality, total mortality, and risk of progression to CKD at 3 months.
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Affiliation(s)
- Ajay Jaryal
- Department of Nephrology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Sanjay Vikrant
- Department of Nephrology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Dalip Gupta
- Department of Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
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