1
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MacMahon T, Kelly YP. Zonisamide-induced distal renal tubular acidosis and critical hypokalaemia. BMJ Case Rep 2023; 16:16/4/e254615. [PMID: 37041041 PMCID: PMC10105998 DOI: 10.1136/bcr-2023-254615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023] Open
Abstract
A woman in her 20s presented with rapidly progressive muscle weakness and a 1-month preceding history of fatigability, nausea and vomiting. She was found to have critical hypokalaemia (K+ 1.8 mmol/L), a prolonged corrected QT interval (581 ms) and a normal anion gap metabolic acidosis (pH 7.15) due to zonisamide-induced distal (type 1) renal tubular acidosis. She was admitted to the intensive care unit for potassium replacement and alkali therapy. Clinical and biochemical improvement ensued, and she was discharged after a 27-day inpatient stay.
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Affiliation(s)
- Thomas MacMahon
- Intensive Care Unit, Tallaght University Hospital, Dublin, Ireland
| | - Yvelynne P Kelly
- Intensive Care Unit, Tallaght University Hospital, Dublin, Ireland
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2
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Russo DS, Eugenio CS, Balestrin IG, Rodrigues CG, Rosa RG, Teixeira C, Kelly YP, Vieira SRR. Comparison of hemodynamic instability among continuous, intermittent and hybrid renal replacement therapy in acute kidney injury: A systematic review of randomized clinical trials. J Crit Care 2022; 69:153998. [PMID: 35124346 DOI: 10.1016/j.jcrc.2022.153998] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 01/10/2022] [Accepted: 01/19/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE To compare hemodynamic instability during continuous, intermittent and hybrid renal replacement therapy (RRT) in critically ill patients, and its association with renal recovery and mortality. MATERIALS AND METHODS The search was conducted in accordance with the PRISMA guidelines which was registered at the PROSPERO Database (CRD42018086504). Randomized clinical trials (RCTs) involving critically ill patients with acute kidney injury (AKI) treated with continuous, intermittent or hybrid RRT were included. The search was performed using PubMed, Embase and Cochrane databases. RESULTS Out of 3442 citations retrieved, 12 RCTs were included in the systematic analysis, representing 1419 patients. Most studies (n = 8) did not report differences in hemodynamic parameters across different RTT modalities. The incidence of hypotensive episodes varied from 5 to 60% among the studies. Punctual differences on heart rate and blood pressure were observed among studies. However, studies presented high heterogeneity in terms of outcome definitions and measurement, thus making the conduction of meta-analysis impossible. CONCLUSIONS There is very few information available regarding hemodynamic tolerance of renal replacement therapy methods. A better standardization of hemodynamic tolerance and further reports are needed before conclusions can be drawn.
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Affiliation(s)
- Diana Silva Russo
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | | | | | | | | | - Cassiano Teixeira
- Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil.
| | - Yvelynne P Kelly
- Division of Renal Medicine, Brigham and Women's Hospital, United States of America
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3
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Kelly YP, Mistry K, Ahmed S, Shaykevich S, Desai S, Lipsitz SR, Leaf DE, Mandel EI, Robinson E, McMahon G, Czarnecki PG, Charytan DM, Waikar SS, Mendu ML. Controlled Study of Decision-Making Algorithms for Kidney Replacement Therapy Initiation in Acute Kidney Injury. Clin J Am Soc Nephrol 2022; 17:194-204. [PMID: 34911731 PMCID: PMC8823944 DOI: 10.2215/cjn.02060221] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 12/08/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES AKI requiring KRT is associated with high mortality and utilization. We evaluated the use of an AKI Standardized Clinical Assessment and Management Plan (SCAMP) on patient outcomes, including mortality, hospital length of stay, and intensive care unit length of stay. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a 12-month controlled study in the intensive care units of a large academic tertiary medical center. We alternated use of the AKI-SCAMP with use of a "sham" control form in 4- to 6-week blocks. The primary outcome was risk of inpatient mortality. Prespecified secondary outcomes included 30- and 60-day mortality, hospital length of stay, and intensive care unit length of stay. Generalized estimating equations were used to estimate the effect of the AKI-SCAMP on mortality and length of stay. RESULTS There were 122 patients in the AKI-SCAMP group and 102 patients in the control group. There was no significant difference in inpatient mortality associated with AKI-SCAMP use (41% versus 47% control). AKI-SCAMP use was associated with significantly reduced intensive care unit length of stay (mean, 8; 95% confidence interval, 8 to 9 days versus mean, 12; 95% confidence interval, 10 to 13 days; P<0.001) and hospital length of stay (mean, 25; 95% confidence interval, 22 to 29 days versus mean, 30; 95% confidence interval, 27 to 34 days; P=0.02). Patients in the AKI-SCAMP group were less likely to receive KRT in the context of physician-perceived treatment futility than those in the control group (2% versus 7%; P=0.003). CONCLUSIONS Use of the AKI-SCAMP tool for AKI KRT was not significantly associated with inpatient mortality, but was associated with reduced intensive care unit length of stay, hospital length of stay, and use of KRT in cases of physician-perceived treatment futility. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Acute Kidney Injury Standardized Clinical Assessment and Management Plan for Renal Replacement Initiation, NCT03368183. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_02_07_CJN02060221.mp3.
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Affiliation(s)
- Yvelynne P. Kelly
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kavita Mistry
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Salman Ahmed
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shimon Shaykevich
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sonali Desai
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of the Chief Medical Officer, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stuart R. Lipsitz
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ernest I. Mandel
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emily Robinson
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gearoid McMahon
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Peter G. Czarnecki
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - David M. Charytan
- Nephrology Division, New York University Grossman School of Medicine, New York, New York
| | - Sushrut S. Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Mallika L. Mendu
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of the Chief Medical Officer, Brigham and Women's Hospital, Boston, Massachusetts
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4
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Kirwan M, Munshi R, O'Keeffe H, Judge C, Coyle M, Deasy E, Kelly YP, Lavin PJ, Donnelly M, D'Arcy DM. Exploring population pharmacokinetic models in patients treated with vancomycin during continuous venovenous haemodiafiltration (CVVHDF). Crit Care 2021; 25:443. [PMID: 34930430 PMCID: PMC8691013 DOI: 10.1186/s13054-021-03863-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Therapeutic antibiotic dose monitoring can be particularly challenging in septic patients requiring renal replacement therapy. Our aim was to conduct an exploratory population pharmacokinetic (PK) analysis on PK of vancomycin following intermittent infusion in critically ill patients receiving continuous venovenous haemodiafiltration (CVVHDF); focussing on the influence of dialysis-related covariates. METHODS This was a retrospective single-centre tertiary level intensive care unit (ICU) study, which included patients treated concurrently with vancomycin and CVVHDF between January 2015 and July 2016. We extracted clinical, laboratory and dialysis data from the electronic healthcare record (EHR), using strict inclusion criteria. A population PK analysis was conducted with a one-compartment model using the PMetrics population PK modelling package. A base structural model was developed, with further analyses including clinical and dialysis-related data to improve model prediction through covariate inclusion. The final selected model simulated patient concentrations using probability of target attainment (PTA) plots to investigate the probability of different dosing regimens achieving target therapeutic concentrations. RESULTS A total of 106 vancomycin dosing intervals (155 levels) in 24 patients were examined. An acceptable 1-compartment base model was produced (Plots of observed vs. population predicted concentrations (Obs-Pred) R2 = 0.78). No continuous covariates explored resulted in a clear improvement over the base model. Inclusion of anticoagulation modality and vasopressor use as categorical covariates resulted in similar PK parameter estimates, with a trend towards lower parameter estimate variability when using regional citrate anti-coagulation or without vasopressor use. Simulations using PTA plots suggested that a 2 g loading dose followed by 750 mg 12 hourly as maintenance dose, commencing 12 h after loading, is required to achieve adequate early target trough concentrations of at least 15 mg/L. CONCLUSIONS PTA simulations suggest that acceptable trough vancomycin concentrations can be achieved early in treatment with a 2 g loading dose and maintenance dose of 750 mg 12 hourly for critically ill patients on CVVHDF.
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Affiliation(s)
- Marcus Kirwan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, Ireland.,Department of Pharmacy, Tallaght University Hospital, Dublin 24, Ireland
| | - Reema Munshi
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, Ireland.,Department of Clinical Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Hannah O'Keeffe
- Department of Nephrology, Tallaght University Hospital, Dublin 24, Ireland
| | - Conor Judge
- Department of Nephrology, Tallaght University Hospital, Dublin 24, Ireland
| | - Mary Coyle
- Department of Pharmacy, Tallaght University Hospital, Dublin 24, Ireland
| | - Evelyn Deasy
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, Ireland.,Department of Pharmacy, Tallaght University Hospital, Dublin 24, Ireland
| | - Yvelynne P Kelly
- Department of Critical Care, Tallaght University Hospital, Dublin 24, Ireland.
| | - Peter J Lavin
- Department of Nephrology, Tallaght University Hospital, Dublin 24, Ireland
| | - Maria Donnelly
- Department of Critical Care, Tallaght University Hospital, Dublin 24, Ireland
| | - Deirdre M D'Arcy
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, Ireland
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5
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Tolan NV, Ahmed S, Terebo T, Virk ZM, Petrides AK, Ransohoff JR, Demetriou CA, Kelly YP, Melanson SE, Mendu ML. The Impact of Outpatient Laboratory Alerting Mechanisms in Patients with AKI. Kidney360 2021; 2:1560-1568. [PMID: 35372977 PMCID: PMC8785781 DOI: 10.34067/kid.0003312021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/14/2021] [Indexed: 02/04/2023]
Abstract
Background AKI is an abrupt decrease in kidney function associated with significant morbidity and mortality. Electronic notifications of AKI have been utilized in patients who are hospitalized, but their efficacy in the outpatient setting is unclear. Methods We evaluated the effect of two outpatient interventions: an automated comment on increasing creatinine results (intervention I; 6 months; n=159) along with an email to the provider (intervention II; 3 months; n=105), compared with a control (baseline; 6 months; n=176). A comment was generated if a patient's creatinine increased by >0.5 mg/dl (previous creatinine ≤2.0 mg/dl) or by 50% (previous creatinine >2.0 mg/dl) within 180 days. Process measures included documentation of AKI and clinical actions. Clinical outcomes were defined as recovery from AKI within 7 days, prolonged AKI from 8 to 89 days, and progression to CKD with in 120 days. Results Providers were more likely to document AKI in interventions I (P=0.004; OR, 2.80; 95% CI, 1.38 to 5.67) and II (P=0.01; OR, 2.66; 95% CI, 1.21 to 5.81). Providers were also more likely to discontinue nephrotoxins in intervention II (P<0.001; OR, 4.88; 95% CI, 2.27 to 10.50). The median time to follow-up creatinine trended shorter among patients with AKI documented (21 versus 42 days; P=0.11). There were no significant differences in clinical outcomes. Conclusions An automated comment was associated with improved documented recognition of AKI and the additive intervention of an email alert was associated with increased discontinuation of nephrotoxins, but neither improved clinical outcomes. Translation of these findings into improved outcomes may require corresponding standardization of clinical practice protocols for managing AKI.
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Affiliation(s)
- Nicole V. Tolan
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Salman Ahmed
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Tolumofe Terebo
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Athena K. Petrides
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jaime R. Ransohoff
- Department of Epidemiology, Bloomberg School of Public Health, Baltimore, Maryland
| | - Christiana A. Demetriou
- Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus
- The Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Yvelynne P. Kelly
- Department of Critical Care Medicine, St. James Hospital, Dublin, Ireland
| | - Stacy E.F. Melanson
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Mallika L. Mendu
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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6
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Kelly YP, Sharma S, Mothi SS, McCausland FR, Mendu ML, McMahon GM, Palevsky PM, Waikar SS. Hypocalcemia is associated with hypotension during CRRT: A secondary analysis of the Acute Renal Failure Trial Network Study. J Crit Care 2021; 65:261-267. [PMID: 34274834 DOI: 10.1016/j.jcrc.2021.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/22/2021] [Accepted: 07/06/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE We investigated the effect of potentially modifiable continuous renal replacement therapy (CRRT)-related treatment factors on the risk of severe hypotension. MATERIALS AND METHODS We carried out a secondary statistical analysis of the Acute Renal Failure Trial Network (ATN) trial. The primary exposures of interest were CRRT treatment dose, ultrafiltration rate, blood flow rate, ionized calcium level and type of anti-coagulation used. The primary outcome was severe hypotension, defined as vasopressor-inotropic score > 18 and calculated based on treatment doses of vasopressor and inotropic agents. RESULTS Of 1124 individuals enrolled in the ATN Trial, 786 were managed with CRRT. 265/786 (33.7%) patients experienced severe hypotension during the trial. A serum ionized calcium <1.02 mmol/l was associated with a higher risk of severe hypotension compared to a serum calcium >1.02 mmol/l (hazard ratio 2.9; 95% CI 1.5-5.7). There was no significant difference in the risk of hypotension associated with other CRRT treatment factors. CONCLUSIONS Of the CRRT treatment factors studied, hypocalcemia with a serum ionized calcium <1.02 mmol/l was associated with a significantly increased risk of treatment-associated hypotension. Further studies will be required to assess whether treatment targets for serum calcium improve the risk of hypotension during CRRT.
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Affiliation(s)
- Yvelynne P Kelly
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America; Department of Critical Care Medicine, St. James's Hospital, James's Street, Dublin 8, Ireland.
| | - Shilpa Sharma
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Suraj S Mothi
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Finnian R McCausland
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Mallika L Mendu
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Gearoid M McMahon
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Paul M Palevsky
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine and Kidney Medicine Section, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
| | - Sushrut S Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, 650 Albany Street, EBRC 526, Boston, MA 02118, United States of America
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Kielty JM, Ryan P, Sexton D, Kelly YP. Hypokalaemic paralysis as the initial clinical presentation of Sjogren's syndrome induced distal renal tubular acidosis. BMJ Case Rep 2021; 14:14/5/e241300. [PMID: 33958361 PMCID: PMC8103831 DOI: 10.1136/bcr-2020-241300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
A 41-year-old woman presented by ambulance with a 1-day history of new-onset paralysis and nausea and vomiting ongoing for 48 hours. She had no history of any similar episodes. Biochemical analysis showed profound hypokalaemia with a non-anion gap metabolic acidosis. Her initial serum chloride was within the normal range. She had significant electrocardiographic changes on admission with ST depression, U waves and a prolonged QT interval. Urinary anion gap supported the diagnosis of a distal renal tubular acidosis. Subsequent connective tissue disease serology confirmed previously undiagnosed Sjogren's syndrome. Successful recovery for this patient required multidisciplinary input from the intensive care, nephrology and neurology teams.
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Affiliation(s)
- Jennifer M Kielty
- Anaesthesiology and Intensive Care Medicine, Saint James's Hospital, Dublin, Ireland
| | - Paul Ryan
- Medicine, Saint James's Hospital, Dublin, Ireland
| | - Donal Sexton
- Nephrology, Saint James's Hospital, Dublin, Ireland.,Trinity Health Kidney Centre, Trinity College Dublin School of Medicine, Dublin, Ireland
| | - Yvelynne P Kelly
- Intensive Care Medicine, Saint James's Hospital, Dublin, Ireland
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8
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Sharma S, Kelly YP, Palevsky PM, Waikar SS. Intensity of Renal Replacement Therapy and Duration of Mechanical Ventilation: Secondary Analysis of the Acute Renal Failure Trial Network Study. Chest 2020; 158:1473-1481. [PMID: 32470389 DOI: 10.1016/j.chest.2020.05.542] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 05/06/2020] [Accepted: 05/19/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Randomized clinical trials have failed to show benefit from increasing intensity of renal replacement therapy (RRT) for acute kidney injury, but continue to be frequently used. In addition, intensive RRT is associated with an increase in adverse events potentially secondary to small solute losses, such as phosphate. We hypothesized that, compared with less-intensive RRT, intensive RRT would lead to longer duration of mechanical ventilation. RESEARCH QUESTION Does more-intensive renal replacement therapy in critically ill patients with acute kidney injury increase time to extubation from mechanical ventilation when compared with less-intensive therapy? STUDY DESIGN AND METHODS The Acute Renal Failure Trial Network study was a randomized multicenter trial of more-intensive (hemodialysis or sustained low-efficiency dialysis six times per week or continuous venovenous hemodiafiltration at 35 mL/kg per hour) vs less-intensive (hemodialysis or sustained low-efficiency dialysis three times per week or continuous venovenous hemodiafiltration at 20 mL/kg per hour) RRT in critically ill patients with acute kidney injury. Of 1124 patients, 907 who were supported by mechanical ventilation on study initiation were included in this Cox-proportional hazards analysis. The primary outcome was the time to first successful extubation off mechanical ventilation. RESULTS Patients who were assigned randomly to more-intensive RRT had a 33.3% lower hazard rate of successful extubation (hazard ratio, 0.67; 95% CI, 0.52-0.88; P < .001) when compared with patients who were assigned to less-intensive RRT. Patients who were assigned to more-intensive RRT had, on average, 2.07 ventilator-free days, compared with 3.08 days in those who were assigned to less-intensive RRT (P < .001) over 14 days from start of the study. INTERPRETATION Critically ill mechanically ventilated patients who were assigned randomly to more-intensive RRT had longer duration of mechanical ventilation compared with those who were assigned to less-intensive RRT. The reasons for this, such as excessive phosphate loss from more-intensive RRT, deserve further study to optimize the safety and effectiveness of CRRT delivery. This was a post hoc analysis of the Acute Renal Failure Trial Network study; clinical trial registration of the original trial is NCT00076219.
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Affiliation(s)
- Shilpa Sharma
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA; Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, CA.
| | - Yvelynne P Kelly
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Paul M Palevsky
- Renal Section, Veterans Affairs Pittsburgh Healthcare System, and the Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Sushrut S Waikar
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, MA
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Ahmed S, Kelly YP, Behera TR, Zelen MH, Kuye I, Blakey R, Goldstein SA, Wasfy JH, Erskine A, Licurse A, Mendu ML. Utility, Appropriateness, and Content of Electronic Consultations Across Medical Subspecialties. Ann Intern Med 2020; 172:641-647. [PMID: 32283548 DOI: 10.7326/m19-3852] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Electronic consultations (e-consults) can facilitate patient access to specialists, minimize travel, and reduce unnecessary in-person visits. However, metrics to enable study of e-consults and their effect on processes and patient care are lacking. OBJECTIVE To assess novel metrics of e-consult appropriateness and utility. DESIGN Retrospective cohort study. SETTING Primary and specialty care practices at 2 large academic and 2 community hospitals of an integrated health system. PARTICIPANTS Patients with e-consult requests to 5 specialties-hematology, infectious disease, dermatology, rheumatology, and psychiatry-between October 2017 and November 2018. MEASUREMENTS The appropriateness of e-consult inquiries was assessed by review of medical records and defined as meeting the following 4 criteria: not answerable by reviewing evidence-based summary sources ("point-of-care resource test"), not merely requesting logistic information, having appropriate clinical urgency, and having appropriate patient complexity. Interrater agreement in assessments of e-consult appropriateness was assessed by the κ statistic. Utility of e-consults was assessed by the rate of avoided visits (AVs), defined by the absence of an in-person visit to the same specialty within 120 days. RESULTS Overall, 6512 eligible e-consults were made by 1096 referring providers to 121 specialist consultants. Inquiries were characterized as diagnostic, therapeutic, for provider education, or at the request of the patient. Most consultations were answered within 1 day, with variation across specialties (73.1% for psychiatry to 87.8% for infectious disease). Overall, 70.2% of e-consults met all 4 criteria for appropriateness; the frequency of unmet criteria varied among specialties. Raters agreed on the appropriateness of 94% of e-consults (κ = 0.57 [95% CI, 0.36 to 0.79]), indicating moderate agreement. The overall rate of AVs across the 5 specialties was 81.2%; the highest rate was in psychiatry (92.6%) and the lowest in dermatology (61.9%). LIMITATION Generalizability is unknown outside a single integrated health system, where requesting and consulting providers share a common electronic health record. CONCLUSION Novel metrics to assess the appropriateness and utility of e-consults provide meaningful insight into practice, provide a rubric for comparison in future studies in additional settings, and suggest areas to improve resource use and patient care. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Salman Ahmed
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.A., Y.P.K.)
| | - Yvelynne P Kelly
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.A., Y.P.K.)
| | | | - Michelle H Zelen
- Partners Enterprise Data and Digital Health, Boston, Massachusetts (M.H.Z., R.B., A.E., A.L.)
| | - Ifedayo Kuye
- Brigham and Women's Hospital, Boston, Massachusetts (I.K.)
| | - Ryan Blakey
- Partners Enterprise Data and Digital Health, Boston, Massachusetts (M.H.Z., R.B., A.E., A.L.)
| | - Susan A Goldstein
- Massachusetts General Hospital and Massachusetts General Physicians Organization, Boston, Massachusetts (S.A.G.)
| | - Jason H Wasfy
- Partners HealthCare Center for Population Health Management, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts (J.H.W.)
| | - Alistair Erskine
- Partners Enterprise Data and Digital Health, Boston, Massachusetts (M.H.Z., R.B., A.E., A.L.)
| | - Adam Licurse
- Partners Enterprise Data and Digital Health, Boston, Massachusetts (M.H.Z., R.B., A.E., A.L.)
| | - Mallika L Mendu
- Brigham and Women's Hospital, Harvard Medical School, and Partners HealthCare Center for Population Health Management, Boston, Massachusetts (M.L.M.)
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Kelly YP, Kuperman GJ, Steele DJR, Mendu ML. Interoperability and Patient Electronic Health Record Accessibility: Opportunities to Improve Care Delivery for Dialysis Patients. Am J Kidney Dis 2020; 76:427-430. [PMID: 31973909 DOI: 10.1053/j.ajkd.2019.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/23/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Yvelynne P Kelly
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA.
| | - Gilad J Kuperman
- Division of Health Informatics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David J R Steele
- Division of Renal Medicine, Massachusetts General Hospital, Boston, MA
| | - Mallika L Mendu
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
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Kelly YP, Mendu ML. Vascular access for renal replacement therapy in acute kidney injury: Are nontunneled catheters the right choice? Semin Dial 2019; 32:406-410. [DOI: 10.1111/sdi.12836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Yvelynne P. Kelly
- Division of Renal Medicine Brigham and Women’s Hospital Boston MA USA
| | - Mallika L. Mendu
- Division of Renal Medicine Brigham and Women’s Hospital Boston MA USA
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Kelly YP, Waikar SS, Mendu ML. When to stop renal replacement therapy in anticipation of renal recovery in AKI: The need for consensus guidelines. Semin Dial 2019; 32:205-209. [DOI: 10.1111/sdi.12773] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Yvelynne P. Kelly
- Division of Renal Medicine, Harvard Medical School Brigham and Women's Hospital Boston Massachusetts
| | - Sushrut S. Waikar
- Division of Renal Medicine, Harvard Medical School Brigham and Women's Hospital Boston Massachusetts
| | - Mallika L. Mendu
- Division of Renal Medicine, Harvard Medical School Brigham and Women's Hospital Boston Massachusetts
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Kelly YP, Patil A, Wallis L, Murray S, Kant S, Kaballo MA, Casserly L, Doyle B, Dorman A, O'Kelly P, Conlon PJ. Outcomes of kidney transplantation in Alport syndrome compared with other forms of renal disease. Ren Fail 2016; 39:290-293. [PMID: 27917694 PMCID: PMC6014522 DOI: 10.1080/0886022x.2016.1262266] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Introduction: Alport syndrome is an inherited renal disease characterized by hematuria, renal failure, hearing loss and a lamellated glomerular basement membrane. Patients with Alport syndrome who undergo renal transplantation have been shown to have patient and graft survival rates similar to or better than those of patients with other renal diseases. Methods: In this national case series, based in Beaumont Hospital Dublin, we studied the cohort of patients who underwent renal transplantation over the past 33 years, recorded prospectively in the Irish Renal Transplant Registry, and categorized them according to the presence or absence of Alport syndrome. The main outcomes assessed were patient and renal allograft survival. Results: Fifty-one patients diagnosed with Alport syndrome in Beaumont Hospital received 62 transplants between 1982 and 2014. The comparison group of non-Alport patients comprised 3430 patients for 3865 transplants. Twenty-year Alport patient survival rate was 70.2%, compared to 44.8% for patients with other renal diseases (p = .01). Factors associated with patient survival included younger age at transplantation as well as differences in recipient sex, donor age, cold ischemia time, and episodes of acute rejection. Twenty-year graft survival was 46.8% for patients with Alport syndrome compared to 30.2% for those with non-Alport disease (p = .11). Conclusions: Adjusting for baseline differences between the groups, patients with end-stage kidney disease (ESKD) due to Alport syndrome have similar patient and graft survival to those with other causes of ESKD. This indicates that early diagnosis and management can lead to favorable outcomes for this patient cohort.
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Affiliation(s)
- Yvelynne P Kelly
- a Department of Nephrology , Beaumont Hospital , Dublin , Ireland
| | - Anish Patil
- b Royal College of Surgeons in Ireland , Dublin , Ireland
| | - Luke Wallis
- b Royal College of Surgeons in Ireland , Dublin , Ireland
| | - Susan Murray
- c Department of Nephrology , University Hospital Galway , Galway , Ireland
| | - Saumitra Kant
- d Department of Nephrology , Cork University Hospital , Cork , Ireland
| | - Mohammed A Kaballo
- e Department of Nephrology , University Hospital Limerick , Dooradoyle , Limerick , Ireland
| | - Liam Casserly
- e Department of Nephrology , University Hospital Limerick , Dooradoyle , Limerick , Ireland
| | - Brendan Doyle
- f Department of Pathology , Beaumont Hospital , Dublin , Ireland
| | - Anthony Dorman
- f Department of Pathology , Beaumont Hospital , Dublin , Ireland
| | - Patrick O'Kelly
- a Department of Nephrology , Beaumont Hospital , Dublin , Ireland
| | - Peter J Conlon
- a Department of Nephrology , Beaumont Hospital , Dublin , Ireland.,b Royal College of Surgeons in Ireland , Dublin , Ireland
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Kelly YP, Moran SM, Kelly DM, Wong L, Little MA, Clarkson MR. FP161ANCA AND ANTI−GBM DOUBLE POSITIVITY: A CASE SERIES. Nephrol Dial Transplant 2015. [DOI: 10.1093/ndt/gfv171.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kelly YP, Eustace JA. Perinephric haematoma causing refractory hypertension in a 17-year-old male. Case Rep Nephrol Urol 2012. [PMID: 23197967 PMCID: PMC3482078 DOI: 10.1159/000342241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
New-onset arterial hypertension is a well-recognised complication of kidney trauma. Cases have been described in young healthy athletes with hypertension arising years after sports-related trauma. The pathophysiology of this disease is thought to arise from intrarenal arterial stenosis resulting from rapid deceleration during the initial injury. This leads to arterial obstruction and ischaemia with increased secretion of renin, eventually leading to elevated blood pressure. Though hypertension in these cases is generally gradual in onset and long-standing, it can also rise acutely, leading to malignant hypertension. We present the case of a 17-year-old male who presented with refractory hypertension following blunt trauma to his left kidney during a recent sporting injury. This is followed by a discussion of the relevant literature in this area to date, highlighting the key challenges involved in the management of these patients.
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Affiliation(s)
- Y P Kelly
- Department of Nephrology, Cork University Hospital, Cork, Ireland
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