Long-term outcomes in acute kidney injury patients who underwent continuous renal replacement therapy: a single-center experience

Dialysis decision in critically ill patients in intensive care unit

The 2012 Kidney Disease Improving Global Outcomes guidelines clearly define emergent indications for kidney replacement therapy; however, whether dialysis should be initiated in critically ill patients without these indications remains unclear. This review briefly summarizes the results of recent landmark trials and discusses their limitations originating from a criteria-based approach at a single time point. Moreover, a personalized approach based on each patient's demand-capacity balance and its future benefits as a platform for kidney support therapy in critically ill patients are discussed.

Worsening or improving hypoalbuminemia during continuous renal replacement therapy is predictive of patient outcome: a single-center retrospective study

Background

Hypoalbuminemia at the initiation of continuous renal replacement therapy (CRRT) is a risk factor for poor patient outcomes. However, it is unknown whether the patterns of changes in serum albumin levels during CRRT can be used to predict patient outcomes.

Methods

This retrospective study analyzed data that had been consecutively collected from January 2016 to December 2020 at the Third Affiliated Hospital. We included patients with acute kidney injury who received CRRT for ≥ 72 h. We divided the patients into four groups based on their serum albumin levels (albumin ≥ 3.0 g/dL or < 3.0 g/dL) at the initiation and termination of CRRT.

Results

The 793 patients in this study were categorized into the following albumin groups: persistently low, 299 patients (37.7%); increasing, 85 patients (10.4%); decreasing, 195 patients (24.6%); and persistently high, 214 patients (27.1%). In-hospital mortality rates were highest in the persistently low and decreasing groups, followed by the increasing and persistently high groups. The hazard ratio for in-hospital mortality was 0.481 (0.340–0.680) in the increasing group compared to the persistently low group; it was 1.911 (1.394–2.620) in the decreasing group compared to the persistently high group. The length of ICU stay was 3.55 days longer in the persistently low group than in the persistently high group.

Conclusions

Serum albumin levels changed during CRRT, and monitoring of patterns of change in serum albumin levels is useful for predicting in-hospital mortality and the length of ICU stay.

Factors Associated with In-Hospital Mortality after Continuous Renal Replacement Therapy for Critically Ill Patients: A Systematic Review and Meta-Analysis

Continuous renal replacement therapy (CRRT) is a broadly-accepted treatment for critically ill patients with acute kidney injury to optimize fluid and electrolyte management. Despite intensive dialysis care, there is a high mortality rate among these patients. There is uncertainty regarding the factors associated with in-hospital mortality among patients requiring CRRT. This review evaluates how various risk factors influence the in-hospital mortality of critically ill patients who require CRRT. Five databases were surveyed to gather relevant publications up to 30 June 2020. We identified 752 works, of which we retrieved 38 in full text. Finally, six cohort studies that evaluated 1190 patients were eligible. The in-hospital mortality rate in these studies ranged from 38.6 to 62.4%. Our meta-analysis results showed that older age, lower body mass index, higher APACHE II and SOFA scores, lower systolic and diastolic blood pressure, decreased serum creatinine level, and increased serum sodium level were significantly associated with increased in-hospital mortality in critically ill patients who received CRRT. These results suggest that there are multiple modifiable factors that influence the risk of in-hospital mortality in critically ill patients undergoing CRRT. Further, healthcare professionals should take more care when CRRT is performed on older adults.

A meta-analysis of clinical predictors for renal recovery and overall mortality in acute kidney injury requiring continuous renal replacement therapy

PURPOSE

To determine clinical predictors for continuous renal replacement therapy (CRRT) discontinuation in patients with acute kidney injury (AKI).

MATERIALS AND METHODS

Ovid MEDLINE, EMBASE, and Cochrane Library were searched. The protocol is registered on researchregistry.com (reviewregistry909). Our criteria included non-end-stage kidney disease adults who required CRRT for AKI. Renal recovery was defined by CRRT discontinuation. Risk of bias was assessed using ROBINS-I tool.

RESULTS

We classified our analyses into renal recovery cohort and overall mortality cohort. All studies were observational. For renal recovery cohort, increasing urine output at time of CRRT discontinuation, elevated initial SOFA score and serum creatinine at CRRT initiation were predictive of renal recovery with OR 1.021 (95%CI = 1.011-1.031), 0.869 (95%CI = 0.811-0.932) and 0.995 (95%CI = 0.996-0.999), respectively. For overall mortality cohort, age and presence of sepsis were significantly associated with overall mortality with OR of 1.028 (95%CI = 1.008-1.048) and 2.160 (95%CI = 0.973-1.932), respectively.

CONCLUSIONS

Urine output at CRRT discontinuation, lower initial SOFA score, and lower serum creatinine levels at CRRT initiation were associated with higher likelihood of renal recovery. Increasing age and the presence of sepsis were associated with increased overall mortality from AKI on CRRT. However, there were limited data on co-morbidities which might preclude their inclusion in our analysis.

Combined use of GM2AP and TCP1-eta urinary levels predicts recovery from intrinsic acute kidney injury

Deficient recovery from acute kidney injury (AKI) has immediate and long-term health, clinical and economic consequences. Pre-emptive recovery estimation may improve nephrology referral, optimize decision making, enrollment in trials, and provide key information for subsequent clinical handling and follow-up. For this purpose, new biomarkers are needed that predict outcome during the AKI episode. We hypothesized that damage pattern-specific biomarkers are expected to more closely associate to outcome within distinct subpopulations (i.e. those affected by specific pathological processes determining a specific outcome), as biomarker pleiotropy (i.e. associated to phenomena unrelated to AKI) introduced by unselected, heterogeneous populations may blur statistics. A panel of urinary biomarkers was measured in patients with AKI and their capacity to associate to normal or abnormal recovery was studied in the whole cohort or after sub-classification by AKI etiology, namely pre-renal and intrinsic AKI. A combination of urinary GM2AP and TCP1-eta best associates with recovery from AKI, specifically within the sub-population of renal AKI patients. This two-step strategy generates a multidimensional space in which patients with specific characteristics (i.e. renal AKI patients with good or bad prognosis) can be identified based on a collection of biomarkers working serially, applying pathophysiology-driven criteria to estimate AKI recovery, to facilitate pre-emptive and personalized handling.